speech therapy Archives - Brooklyn Letters

Letting a baby play on an iPad might lead to speech delays, study says

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(CNN) Anyone raising a child today has likely fretted about screen time and wondered about the impact of devices on our kids. Does the technology affect their brains? Does it limit their social development? Could it harm them emotionally? Could it delay when they start talking?

I had never thought about that last question until a new study, released Thursday and being presented at the 2017 Pediatric Academic Societies Meeting, revealed some striking findings.

The study found that the more time children between the ages of six months and two years spent using handheld screens such as smartphones, tablets and electronic games, the more likely they were to experience speech delays.

“I believe it’s the first study to examine mobile media device and communication delay in children,” said Dr. Catherine Birken, the study’s senior investigator and a pediatrician and scientist at the Hospital for Sick Children in Toronto, Ontario. “It’s the first time that we’ve sort of shone a light on this potential issue, but I think the results need to be tempered (because) it’s really a first look.”

In the study, which involved nearly 900 children, parents reported the amount of time their children spent using screens in minutes per day at age 18 months. Researchers then used an infant toddler checklist, a validated screening tool, to assess the children’s language development also at 18 months. They looked at a range of things, including whether the child uses sounds or words to get attention or help and puts words together, and how many words the child uses.

Twenty percent of the children spent an average of 28 minutes a day using screens, the study found. Every 30-minute increase in daily screen time was linked to a 49% increased risk of what the researchers call expressive speech delay, which is using sounds and words. The study did not find any link between use of a handheld device and other areas of communication, such as gestures, body language and, social interaction.

‘We need more definitive research’

Birken, who is also an associate professor of pediatrics at the University of Toronto, stressed that while her study shows there appears to be a relationship between handheld device use and communication delays in young children, much more research is needed to determine if the device use is actually causing the speech delay.

Further research also needs to look into what content the young children are reviewing and whether they are using devices with a parent and/or caregiver present, she said.

“I think in order to actually develop the evidence to inform parents and clinicians about what to recommend, we need more definitive research,” Birken said. “You need trials. You need good evidence, at least longitudinal studies, but this, at least, this finding is identifying an association and it does support the current recommendation” from the American Academy of Pediatrics.

That group recommends no screens at all, other than video-chatting with family, for children younger than 18 months. The noise and activity of a screen can be distracting for a small child and can cause a disconnect between them and their parents, pediatricians have said.

For kids between the ages of 18 to 24 months, the American Academy of Pediatrics moved away last year from recommending a total screen ban for this age group. Instead, it recommends parents choose high-quality programming and watch it with their children to help them understand what exactly they are seeing.

Nearly 40% of children under age 2 have used a mobile device, an increase from just 10% in 2011, according to a 2013 study by Common Sense Media, a nonprofit organization which is focused on helping children, parents and educators navigate the world of media and technology. Those numbers are likely to be even higher today as smartphones have only grown in popularity.

“This is an important study in highlighting some of the potential risks associated with media use, and specifically handheld mobile devices,” said Michael Robb, research director for Common Sense Media. “What’s driving the effect is very important. The negative effects may be due to screen time replacing parent-child interaction (playing, reading, talking, singing, etc.) which are critical for healthy development,” said Robb via email.

Screens are ‘everywhere’

Michelle MacRoy-Higgins and Carlyn Kolker are co-authors of the just released “Time to Talk: What You Need to Know About Your Child’s Speech and Language Development,” which explores how speech develops in babies and young children.

MacRoy-Higgins, who has worked with hundreds of infants, toddlers and young children as a speech-language therapist, said she was not at all surprised by the findings.

“We do know that young kids learn language best through interaction and engagement with other people, and we also know that children who hear less language in their homes have lower vocabularies.”

It may be the case that the more young children are engaged in screen time, then the less time they have to engage with caretakers, parents and siblings, said MacRoy-Higgins, who is also an associate professor in the department of speech-language pathology and audiology at Hunter College.

The first two years are incredibly important for children and their early foundation of language is important for academic success, she said. “Delays can be associated with difficulties learning to read and to write in elementary school so these early years, these first two years, the language influence that kids get is really very, very important and we want our kids to stay on track with their language development, because if they’re not, they’re really at risk for having some difficulties.”

When my first daughter was born in 2006, there was no such thing as an iPhone or an iPad. But today, handheld devices are ubiquitous, which is part of the reason why there is more attention and perhaps concern about the impact they might have on kids, especially babies.

“They are everywhere and we can’t ignore that fact,” said Kolker, a former Bloomberg News and Reuters reporter, who started working on “Time to Talk” with MacRoy-Higgins almost five years ago. “We’re not all going to throw our phones away.”

Devices are a reality today, but parents need to be informed, she said.

“I think what this study shows is how much we really need to delve into what affects they’re having on children, and how a parent, while we may have them and while they may be there, we need to know how exactly we can regulate them,” Kolker said.

The best advice for parents, the co-authors say, is to interact with your child. The best way to teach them language is by interacting with them, talking with them, playing with them, using different vocabulary, pointing things out to them and telling them stories.

“They’re free and they’re easy to do,” said MacRoy-Higgins, a mother of two who said she wanted to write a book because she is constantly approached by fellow parents with questions about their children’s language development. “Sometimes parents want to know ‘What type of toy should I buy?’ … ‘What types of things can I buy to help my child learn?’ and you don’t have to spend a lot of money, just time and engagement is really the easiest thing that you can do.”

But most parents today, even those who are aware of the research, may find it useful to let their baby be preoccupied by a handheld device from time to time and that’s OK, said Kolker, who is also a mom of two.

“Every parent is going to need a device at some moment, a screen or a device, a tablet with their child at some point,” Kolker said. “It’s just going to happen and you can do that without some level of guilt, but I think you need to know that those are effectively tools to help yourself perhaps in a down moment but they aren’t tools that are really going to help your child.”

Queens and Long Island Speech Language Therapy for Children

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queens-liSpeech, Language, Feeding Therapy

Speech therapy services in the convenience of your home. We are experienced therapists providing speech language therapy for children, from babies to adolescents (we are now offering adult speech language therapy!) with a variety of speech language difficulties, including articulation/enunciation difficulties (e.g lisp, tongue thrust, and/or difficulty saying sounds, and more), speech delay (including apraxia, oral motor difficulties, cleft palate), late talkers/expressive and receptive language delay (including multilingual homes), autism spectrum, e.g. Asperger’s, pervasive developmental disorder (PDD-NOS), social language delays, disfluency (stuttering), and feeding delays (including picky eaters, oral motor delays, medically fragile).

Our Licensed Speech & Language Therapists’ qualifications include: – Master’s degree in speech language pathology – New York State and national certification – PROMPT training. We also offer bilingual services/

If you are interested in a licensed speech language therapist (pathologist) coming to your home, please contact us for more information at craig@brooklynletters.com or call us at 347-394-3485.

We work with all ages (babies-adolescents) and all types of speech and language delays and concerns. We not only provide services in Brooklyn and Manhattan but we service neighborhoods in Queens and Long Island such as Springfield Gardens, Laurelton, Bellerose and Hollis  Little Neck, Douglaston, Astoria, Long Island City, Great Neck, Great Neck Plaza, Port Washington, Roslyn, Albertson, North Hills, Flower Hill, and Manorhaven.

We look forward to working with you!

Long Island Speech Language Therapy

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long-islandWe are now offering speech language therapy in the following Long Island towns: Centereach, Farmingville, Selden, Smithtown, Hauppague, Sayville, West Sayville, Bluepoint, Bayport, Oakdale, Bohemia, Patchogue, Medford, Port Jefferson, Port Jefferson Station, Nesconset, Setauket, South Setauket, St. James, East Islip.

Allison, bio. below, moved from Staten Island to Long Island, so she’s now available to work with your child. She is an amazing speech language therapist, and I can personally attest to her work with children before she made the move to Long Island.

-Craig, founder of Brooklyn Letters

Allison Weiss, M.S. CCC-SLP, Speech-Language Pathologist

photoAllison is a NYS licensed speech-language pathologist and Certified Teacher of the Speech and Hearing Handicapped (TSHH). She earned her B.A. and M.S. in Speech Language Pathology from The State University of New York College at Fredonia. Allison holds a Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA). She has 8 years teaching/therapeutic experience in school and naturalistic settings, as well as 6 years of supervisory experience. Allison has gained this experience through her positions in various agencies providing Early Intervention services, as well as in a variety of special education preschool programs including the Rainbow School for Child Development, Milestone School for Child Development, and in her current position with AHRC New York City, as the Clinical Supervisor of Speech Services, working with students ages 3-21, supervising clinicians, and training staff and families on a range of communication topics. She is highly skilled at working with a variety of language, and articulation delays, phonological disorders, social/pragmatic deficits, auditory processing disorders, fluency, and oral-motor difficulties. Over her years as a clinician and supervisor, she developed a passion for working with individuals with Autism Spectrum Disorders and providing them with the language, social skills, and supports necessary to become independent adults. This has led her to become passionate about the funding, programming, and implementation of Augmentative and Alternative Communication (AAC) systems, such as the Picture Exchange Communication System (PECS), in which she has been formally trained, static and dynamic display devices (i.e., Tech Speak, Dynavox, Saltillo, iPad) and American Sign Language (ASL). She is also a Certified Sequential Oral Sensory Feeding provider and has developed a love for treating feeding disorders, through this methodology. Allison prides herself on her ability to effectively collaborate with families, teachers, and other professionals in related fields to encourage effective communication across all environments. She believes that a combination of evidence-based practice, parent/caregiver involvement, and fun is the key to communication success.

Park Slope Speech Language Therapy for Children

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Park Slope Speech Therapy

Park Slope, Brooklyn speech therapy services in the convenience of your home or come to one of our offices!

Speech language services include:

Pronunciation (all ages)
Early Childhood Expressive Language
School Age Expressive Language
Tongue Thrust Therapy
Autism Spectrum Disorder (PDD, Aspergers, etc.)
Social Skills
Listening Difficulties (auditory and language processing)
Picky Eaters and Early Childhood Feeding Delays
Voice (Dysphonia) Therapy
Augmentative and Alternative Therapy (AAC)
Adult Speech Therapy

Our Licensed Speech & Language Therapists’ qualifications include: – Master’s degree in speech language pathology – New York State and national certification – PROMPT training – We offer bilingual services (Spanish, French, Hebrew, or Hungarian).

Here’s our team.

Speech, Language, Feeding Therapy

We are experienced to treat babies to adolescents (we are now offering adult speech language therapy!) with a variety of speech language difficulties, including articulation/enunciation difficulties (e.g lisp, tongue thrust, and/or difficulty saying sounds, and more), speech delay (including apraxia, oral motor difficulties, cleft palate), late talkers/expressive and receptive language delay (including multilingual homes), autism spectrum, e.g. Asperger’s, pervasive developmental disorder (PDD-NOS), social language delays, disfluency (stuttering), and feeding delays (including picky eaters, oral motor delays, medically fragile).

Contact Craig for more information at craig@brooklynletters.com

Autism! by Sarah Stuntebeck, MS, CCC-SLP, and Luke Fortney, MD

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The story of autism spectrum disorders (ASD) is unique compared to other disorders in that few have seen such an unexplained increase over time, strain on personal and health care resources, rise of social activism and advocacy organizations, and controversial treatment approaches. First reported in 1943, autism poses particular challenges for researchers given the numerous potential contributing factors. Although treatable, it is considered an incurable, multifactorial disorder that is influenced by genetic, neurological, environmental, and immunological aspects.1 That being said, recent developments have helped create a better understanding of the heterogeneity of ASD and its variable phenotypes.2

Autism itself is a biologically based disorder of brain development. This neurodevelopmental disorder is characterized by variable degrees of social and language deficits. Children with ASD demonstrate stereotypically restricted and repetitive behavior. Variants of ASD include conditions such as pervasive developmental delay (PDD) and Asperger disorder (AD). A 2012 Centers for Disease Control and Prevention (CDC) report estimates that of all autism diagnoses in the United States, 47% were PDD and 9% were AD.3 Comorbid conditions — such as ADHD on the other hand — are separate but appear to have a higher prevalence in ASD.

The incidence of ASD has increased 10-fold in the last 25 years. In 1990, the estimated prevalence was 5 per 10,000 children. A report published by the U.S. Department of Health and Human Services indicates that among children aged 6-17, prevalence of autism increased from 1.16% in 2007 to 2.00% in 2012,4 although the CDC estimates that one in 110 children now born in the United States has ASD.5

Although there is controversy regarding the various factors that may contribute to ASD prevalence and severity, perhaps the most frustrating aspect of ASD for both parents and health care professionals is that its cause(s) remain unknown. That being said, most experts agree that ASD is a genetically predisposed disorder that seems to require an inciting environmental trigger (or triggers). For most cases of ASD, no single gene or group of genes has been definitively shown to significantly impact its development. However, there is a 90% concordance between identical twins vs 30% in fraternal twins.6

The pathophysiology of autism is — without surprise — not well understood. A genetic cause can be identified in only 20% of ASD cases, involving genes that converge on common pathways that alter synaptic homeostasis.7 There is good evidence to support the understanding that autism is characterized by inflammatory and abnormal neural connections, particularly underconnectivity of cortical systems leading to abnormal interhemispheric communication. With corroborating advanced imaging from fMRI, this abnormal brain function correlates well with many of the stereotypical behaviors seen in ASD.8

One of the most widely debated aspects of ASD is gastrointestinal (GI) dysregulation — specifically conditions known as dysbiosis and increased intestinal permeability. However, the exact cause for increased prevalence of GI abnormalities in ASD is unknown. Up to one-third of children with autism exhibit some form of GI disorder clinically (e.g., constipation, abdominal pain, diarrhea, gastroesophageal reflux disease). The human gut is home to a dynamic and complex community of microbes that can profoundly influence nervous system growth and development.9 Many of the behavioral challenges associated with autism likely can be explained by gut dysfunction, noting that many autistic children have communication barriers and have challenges expressing their discomfort.

One study found that ASD children treated with vancomycin saw an improvement in both abnormal gut bacteria and GI symptoms, while also seeing improvements in autistic behavior.10 Lactulose-mannitol testing reveals that the majority of these children exhibit abnormal intestinal permeability, which is thought to indicate atrophy of the intestinal mucosa and injury to intercellular junctions. This altered intestinal permeability is thought to allow absorption of incompletely digested peptides that behave as receptor agonists leading to abnormal brain-gut neuro-activity that result in behavior changes.11

Along these lines, duodenal biopsies from 25 autistic children show increased lymphocytic proliferation and other immune abnormalities, indicating a possible autoimmune etiology.12 A separate study of 36 autistic children reported significantly higher levels of IgG, IgM, and IgA to food proteins such as casein and lactoglobulin compared to controls.13 An autoimmune etiology in ASD is supported by an epidemiological study showing that families affected by autism had 1.87 relatives with autoimmune disorders, which is significantly more common when compared to the general population, and surprisingly even more common than families affected by other common autoimmune diseases such as lupus and rheumatoid arthritis.14 Another study even found that 36.7% of autistic patients and 21.2% of their direct relatives demonstrated active “leaky gut” syndrome as compared to 5% of controls.15 These findings suggest an inheritable predisposition for ASD that, when triggered by environmental events, may play a key role in prevalence and severity.

The majority of published studies show a statistically significant benefit of a gluten-free/casein-free (GFCF) diet in ASD. However, specific characteristics of best and non-responders to GFCF intervention have not yet been elucidated. That some children benefit from this dietary intervention and others do not is likely due to variable ASD phenotypes.16 One striking case report in the literature reported significant benefits in a child with severe ASD, morbid obesity, and epilepsy, who after limited response to other interventions, was placed on a GFCF-ketogenic diet that used medium-chained triglycerides and a high intake of vegetables. Over the course of a few years, the child’s Autism Rating Score went from severe to non-autistic, her intelligence quotient increased 70 points, and she became seizure-free with normal follow-up EEGs.17 Needless to say, in keeping with the favorable benefit-harm ratio, it is entirely reasonable for families affected by ASD to implement a GFCF diet.

In addition, many studies demonstrate the need to supplement the diet of autistic patients with omega-3 fatty acids, probiotics, vitamins, and minerals in combination with other medical and psychological interventions.18 However, good data showing conclusive clinical benefit of these additions largely are lacking and there have been calls to investigate the likely beneficial role of probiotics in ASD.19

Another popular ASD suspect is thimerisol (ethylmercury), which was previously contained in childhood vaccinations. This, perhaps more than any other aspect of the autism story, has been hotly debated. A review by the FDA found that prior to 1999, the additive sum of childhood vaccinations exceeded EPA limits for safe exposure of methylmercury. Although epidemiological studies have failed to find a connection between the small amounts of mercury in vaccines and incidence of ASD,20 one study demonstrated a 61% associated increase in the rate of autism incidence for every 1000 pounds of mercury released from industrial pollution.21

There is ongoing concern about the growing chemical milieu that children are exposed to early in life. A well-known source of mercury exposure comes from amalgam fillings. However, whether there are any adverse health effects from this remains a subject of debate.22 While mercury is a well-known neurotoxin with no acceptable level of exposure, it is unproven as a significant cause of autism by itself. However, mercury may just be the tip of the iceberg. Children today are exposed to thousands of synthetic chemicals, with at least 200 being known neurotoxins and another 1000 demonstrating neurotoxicity in laboratory tests. According to the CDC’s biomonitoring program, there are more than 100,000 chemicals commonly used every day in household cleaners, solvents, pesticides, food additives, lawn care, and other products. Every year another 1000 chemicals are introduced that do not take into account the mixtures and various combinations of commercial and consumer products to which people are exposed.23

Another alarming study found nearly 300 environmental toxins in the umbilical blood of neonates.24 Animal models show that even low levels of these toxins can negatively affect neurodevelopment. Indirect human evidence points to the sensitivity of the developing brain to lead, mercury, and other toxins. The strongest proof-of-concept evidence comes from research linking ASD to various chemical exposures in early pregnancy.25 Given this information, it is reasonable for parents and practitioners alike to follow the precautionary principle that states, “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically.”26

That being said, it has been postulated that previously undetected inherited metabolic defects predispose those who would eventually be diagnosed with ASD due to impaired detoxification systems that are not adequately able to handle the same low level of toxic exposure as normally developing children. For example, in a study of more than 200 autistic children treated with the chelating agent DMSA, urinary levels of mercury were significantly higher compared to neuro-typical controls.27 Additional studies lend support to the hypothesis that even though children with autism and neuro-typical children both have similar exposures,28 those with ASD exhibit abnormal urinary porphyrin levels, which indicates abnormal mercury metabolism and elimination.29

Although children with ASD may be susceptible to even “normal” levels of mercury exposure, and although there are some data showing increased urinary output of toxic metals with use of chelating agents,30 evidence showing clinically beneficial outcomes from the use of chelating agents such as EDTA and DMSA is lacking.31 What’s more, NIH-funded trials were halted prematurely due to ethical concerns.32 However, there are reasonable lifestyle approaches to help reduce toxic body burden for would-be-mothers and families with young children (see EWG link in resources).

The MMR vaccine has been implicated by many parents as a triggering event for autism. Although there were early concerns, no link between the MMR vaccination and autism has been found.33 In fact, a recent study found that children with ASD have similar levels of antibodies against the MMR vaccine as same-age neuro-typical controls.34 An infamous study published in the Lancet in 1998 that suggested a link in ASD with colitis and MMR vaccination35 was retracted in 2010 by the journal due to serious irregularities.36 An 8-year U.S. federal court process that finally ended in 2010 concluded that ASD was not caused by an adverse reaction to vaccination.37 To the contrary, it is now estimated that MMR vaccinations administered in the United States from 2001-2010 helped prevent more than 16,000 cases of congenital rubella syndrome — a known cause of ASD — which in turn helped prevent more than 6000 new cases of ASD during that 10-year period.38

Study retractions and court rulings have hardly transformed the thinking of many antivaccine advocacy groups. A recent CNN story reported that measles infections, once considered eradicated in the United States, have increased.39 For example, another story by NPR reported that 21 vaccine-skeptical parishioners of a North Texas Church who had not been adequately immunized with MMR were infected in a measles outbreak.40 For reference, it is estimated that 1 of 1000 children ultimately die from measles infections, even with the best of care.39 As a result, there have been calls to set aside philosophical quarrels and instead respond with empathy and open family-centered dialogue to address misinformation and concerns about vaccinations.41

Alternative childhood immunization schedules (ACIS) are one approach for families that refuse standard CDC vaccine schedules. Despite controversy of a well-known ACIS (the Sears alternative vaccine schedule42), a recent survey of 517 families in Washington found that this approach did not predominate, with only 9.4% of parents reporting use of ACIS.43 The real advantage of offering ACIS to concerned parents is not about efficacy or promoting a “better or worse” vaccination schedule, but rather in establishing a trusting relationship while ensuring eventual full immunization and protection for children.

Although the cause(s) of autism are unknown, there are reasonable and effective treatments for ASD. The most common, and arguably the most effective approaches address behavioral, communication, and social deficits. Early screening during routine well-child exams can identify signs of ASD, which in turn should lead to initiation of speech-language therapy (see NICHCY link in resources). Effective services should vary with individual children, depending on the child’s age, cognitive level, language skills, behavioral needs, and family priorities. With some children, it is appropriate to incorporate augmentative and alternative communication (AAC), such as the Picture Exchange Communication System, other high- and low-tech assistive technology tools, and/or sign language. A meta-analysis of single-case research studies indicates strong effects for the use of AAC on communication skills. Although effect sizes should be interpreted cautiously due to the small number of studies, social skills, challenging behaviors, and spelling also appear to be positively affected.44

Although behavioral intervention methods appear to have a positive impact on learning, communication, and behavior in children with ASD, intervention studies suffer from methodological problems that make it difficult to form definitive conclusions regarding efficacy. That being said, there is evidence to support the use of applied behavioral analysis for functional skills development, and there are clear benefits of Lovaas therapy compared to no treatment. Furthermore, increased therapy intensity is known to be more effective than no- or low-intensity therapy. The National Research Council suggests that young children with ASD should receive at least 25 hours of individualized and structured intervention per week, 12 months a year.45 In general though, as no definitive behavioral or developmental intervention improves all symptoms for every child, it is recommended that therapy management be guided by each child’s needs and availability of resources.46

Other common and effective behavioral therapies include Greenspan’s Floortime and Developmental Individual Difference Relationship Model, which incorporates play activities with an emphasis on emotional development. Relationship Development Intervention is a parent-based treatment approach that works to improve social skills, adaptability, and self-awareness skills. Social Communication/Emotional Regulation/Transactional Support uses practices from a variety of other approaches in order to promote child-initiated communication and skills in a variety of settings.

Although there are anecdotal reports of benefits from sensory motor interventions, such as sensory integration therapy or use of a sensory diet, results are limited and inconsistent. A review of auditory integration therapy by the American Speech-Language and Hearing Association concluded that efficacy standards for use by audiologists and speech-language pathologists are not yet available. At this time, families should pursue these therapies with some skepticism until further research can be conducted.47   n

1.         Al-Ayadhi L, et al. Role of proteomics in the discovery of autism biomarkers. J Coll Physicians Surg Pak 2013;23:137-143.

2.         Thompson T. Autism research and services for young children: History, progress, and challenges. J Appl Res Intellect Disabil 2013;26:81-107.

3.         Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders – Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2008. MMWR Surveill Summ 2012;61:10.

4.         Blumberg S, et al. Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011-2012. National Health Statistics Reports 2013;65:1-11.

5.         CDC: National Center on Birth Defects and Developmental Disabilities: How Many Children Have Autism? Available at: www.cdc.gov/ncbddd/features/counting-autism.html. Accessed Sept. 2, 2013.

6.         El-Fishawy P, State MW. The genetics of autism: Key issues, recent findings, and clinical implications. Psychiatr Clin North Am 2010;33:83-105.

7.         Delorme R, et al. Progress toward treatments for synaptic defects in autism. Nat Med 2013;19:685-694.

8.         Minshew NJ, Keller TA. The nature of brain dysfunction in autism: Functional brain imaging studies. Curr Opin Neurol 2010;23:124-130.

9.         Mulle JG, et al. The gut microbiome: A new frontier in autism research. Curr Psychiatry Rep 2013;15:337.

10.       Sandler RH, et al. Short-term benefit from oral vancomycin treatment of regressive-onset autism. J Child Neurol 2000;15:429-435.

11.       Souza NC, et al. Intestinal permeability and nutritional status in developmental disorders. Altern Ther Health Med 2012;18:19-24.

12.       Torrente F, et al. Small intestinal enteropathy with epithelial IgG and complement deposition in children with regressive autism. Mol Psychiatry 2002;7:375-382.

13.       Lucarelli S, et al. Food allergy and infantile autism. Panminerva Med 1995;37:137-141.

14.       Sweeten TL, et al. Increased prevalence of familial autoimmunity in probands with pervasive developmental disorders. Pediatrics 2003;112:e420.

15.       de Magistris L, et al. Alterations of the intestinal barrier in patients with autism spectrum disorders and in their first-degree relatives. J Pediatr Gastroenterol Nutr 2010;51:418-424.

16.       Whiteley P, et al. Gluten- and casein-free dietary intervention for autism spectrum conditions. Front Hum Neurosci 2013;4:344.

17.       Herbert MR, et al. Autism and dietary therapy: Case report and review of the literature. J Child Neurol 2013;28:975-982.

18.       Kawicka A, et al. How nutritional status, diet and dietary supplements can affect autism. A review. Rocz Panstw Zakl Hig 2013;64:1-12.

19.       Critchfield JW, et al. The potential role of probiotics in the management of childhood autism spectrum disorders. Gastroenterol Res Pract 2011;Epub 2011; Oct 26.

20.       Madsen KM, et al. Thimerosal and the occurrence of autism: Negative ecological evidence from Danish population-based data. Pediatrics 2003;112(3 Pt 1):604-606.

21.  Palmer RF, et al. Environmental mercury release, special education rates, and autism disorder: An ecological study of Texas. Health Place 2006;12:203-209.

22.  Park JD, Zheng W. Human exposure and health effects of inorganic elemental mercury. J Prev Med Public Health 2012;45:344-352.

23.  CDC Agency for toxic substances and disease registry. Available at: www.atsdr.cdc.gov/risk/cancer/cancer-laboratory.html. Accessed Sept. 3, 2013.

24.  Environmental Working Group: Body Burden: The Pollution in Newborns. A Benchmark Investigation of Industrial Chemicals, Pollutants, and Pesticides in Umbilical Cord Blood 2005. Available at: www.ewg.org/research/body-burden-pollution-newborns. Accessed Sept. 8, 2013.

25.  Landrigan PJ. What causes autism? Exploring the environmental contribution. Curr Opin Pediatr 2010;22:219-225.

26.  Precautionary Principle. Available at: www.sehn.org/precaution.html. Accessed Sept. 3, 2013.

27.  Bradstreet J, et al. A case-control study of mercury burden in children with autistic spectrum disorders. J Am Phys Surg 2003;8:76-82.

28.  Albizzati A, et al. Normal concentrations of heavy metals in autistic spectrum disorders. Minerva Pediatr 2012;64:27-31.

29.  Woods JS, et al. Urinary porphyrin excretion in neurotypical and autistic children. Environ Health Perspect 2010;118:1450-1457.

30.  Blaucok-Busch E, et al. Efficacy of DMSA therapy in a sample of Arab children with autistic spectrum disorder. Maedica (Buchar) 2012;7:214-221.

31.  Wadman M. Autism study panned by critics. Nature 2008;453:259.

32.  Mitka M. Chelation therapy trials halted. JAMA 2008;300:2236.

33.  Mrozek-Budzyn D, et al. Lack of association between measles-mumps-rubella vaccination and autism in children: A case-control study. Pediatr Infect Dis J 2010;29:397-400.

34.  Gentile I, et al. Response to measles-mumps-rubella vaccine in children with ASD. In Vivo 2013;27:377-382.

35.  Wakefield A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998;351:637-641.

36.       Harris G. Journal retracts 1998 paper linking autism to vaccines. New York Times. Available at: www.nytimes.com/2010/02/03/health/research/03lancet.html?_r=0. Accessed Sept. 8, 2013.

37.       Kirkland A. Credibility battles in the autism litigation. Soc Stud Sci 2012;42:237-261.

38.       Berger BE, et al. Congenital rubella syndrome and autism spectrum disorder prevented by rubella vaccination — United States, 2001-2010. BMC Public Health 2011;11:340.

39.       CNN Health. US measles cases in 2013 may be most in 17 years. Available at: www.cnn.com/2013/09/12/health/worst-measles-year/index.html?hpt=he_c2. Accessed Sept. 3, 2013.

40.       NPR News. Texas megachurch at center of measles outbreak. Available at: www.npr.org/2013/09/01/217746942/texas-megachurch-at-center-of-measles-outbreak. Accessed Sept. 3, 2013.

41.       Holler K, et al. “I’ve heard some things that scare me.” Responding with empathy to parents’ fears of vaccinations. Mo Med 2012;109:10-13.

42.       Offit PA, et al. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics 2009;123:164-169.

43.       Opel DJ, et al. Use of alternative childhood immunization schedules in King County, Washington, USA. Vaccine 2013; Aug 24. pii: S0264-410X(13)01127-4. doi: 10.1016/j.vaccine.2013.08.036. [Epub ahead of print].

44.       Ganz JB, et al. A meta-analysis of single case research studies on aided augmentative and alternative communication systems with individuals with autism spectrum disorders. J Autism Dev Disord 2012;42:60-74.

45.       Educating Children with Autism. Lord & McGee, eds Washington DC. National Academy Press, National Research Council. Division of Behavioral and Social Sciences. 2001.

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47.             American Speech-Language-Hearing Association. Auditory integration training Position Statement. Available at: www.asha.org/policy. Accessed Sept. 8, 2013.

Ms. Stuntebeck is Clinical Assistant Professor, Department of Communication Sciences and Disorders, University of Wisconsin-Madison. Dr. Fortney is Integrative Family Medicine Physician, Meriter Medical Group, Madison, Wisconsin.