This second category reflects the family's attitudes in relation to the child's eating habits, with the following subcategories: In all interviews, it was mentioned that the family's dietary preferences and habits closely resembled those of the individuals with ASD. Some of the mothers expressed an interest in healthy eating habits, not only for the individual with ASD but also for the whole family.
These mothers did not report any significant restrictions in their children's dietary habits at any time in their lives.
The mother's attitude regarding new foods also appears to influence the child's eating habits. Some mothers tended to accept the children's refusal to eat even before they tried the food. Other mothers tended not to accept the children's initial refusal to eat the food and invented games to whet their curiosity about it. Another aspect that was emphasized in this category was the importance given by the family to where meals were eaten. Some families would put the child outdoors at mealtimes or feed the child separately from the other members of the family. In relation to this third category, the mothers spoke of attitudes and reactions associated with eating that could affect the children's specific eating pattern.
The following subcategories emerged: Some kinds of food were seen as behavior-altering. The reactions triggered by eating certain food items were described, ranging from behavior modifications to functional alterations in the organism. Behavioral alterations ranged from reactions such as irritation, euphoria, agitation, aggravation of stereotypes, difficulties sleeping and more frequent crying episodes to more distant and evasive behavior, emphasizing the child's difficulty in interacting socially.
These reactions were perceived to be associated with drinking coffee, eating peanuts, chocolate and chocolate-based foods, foods containing gluten, carbonated soft drinks, processed snacks and waffles containing food dyes. The majority of the children suffered some form of modification when they consumed at least two of the above-mentioned foods.
With respect to functional alterations in the organism, bowel regularity was found to be affected by gluten intake, triggering constipation, abdominal swelling due to the intense production of gases, absence of stool formation and the presence of viscous feces. Many of the mothers reported that they had consulted professionals regarding the efficacy of a gluten- and lactose-free diet for autistic children; however, they justified not having complied with the diet for financial reasons despite having been curious to see whether it would result in any change in their children's behavior.
Only one mother stated that she had excluded gluten and lactose routinely from her son's diet and added that she had started him on this diet prior to receiving confirmation of his diagnosis of ASD, because of her son's gastrointestinal symptoms and behavior. After having his bottle of porridge, the child would stay awake and agitated, and this behavior was particularly evident at night because of his inability to sleep. Food used as a bargaining chip. Since feeding was one of the major concerns reported by the mothers, the use of food as a bargaining chip in the relationship with the children was easily noted.
Some of the mothers used this control mechanism with success, since the children ate correctly. In these cases, an incentive was given for the child to finish the meal, e. Nevertheless, in the majority of cases, this bargaining resulted in replacing lunch or dinner with a high-calorie dessert or snack.
In other words, to get the child to eat something, the solution was to let him eat what he wanted such as a sandwich, cookie, creamy chocolate yoghurt, or a soft drink. Strategies used to get food. The children also developed strategies to get their preferred food.
In some cases, behaviors became more disruptive, including aggressive attitudes with crying fits and temper tantrums, aggression and self-mutilation. Reaction to the foods that are rejected. The children's reactions to the foods they reject may influence the family's attitudes.
Reactions such as nausea and vomiting were defined as physiological since they are involuntary; these were among the behaviors shown in response to food texture pieces of vegetables or meat in the blended soup, a solid piece of potato in the mashed potato. In one specific case, this type of behavior was partially modified following desensitization treatment provided by a psychologist specialized in selective eating.
During treatment, the focus of the work was directed at the patient's hypersensitivity to certain textures - vegetables and fruit in general, beans, and juices with residues. At the end of treatment, the mother managed to introduce various food items into the child's diet that had previously triggered the reactions described above and improved his tolerance to textures in various aspects: It was well-sieved pineapple juice, passion fruit juice, grape juice. He wouldn't take mango juice, cashew fruit juice, hog plum juice, any of those with fibers in them.
Mother 6, boy 7 years. Reaction to new kinds of foods. Attempts to introduce different foods may generate reactions to the new foods that may or may not include an outright refusal. These reactions will affect the future behavior of the mothers. Attitudes of resistance were more common. Some children spit out the food, and became irritated and aggressive just from being offered the food. More flexible attitudes were less common.
In these cases, first the child smelled the food and then put a very small piece in their mouth. These children were more likely to accept the food offered. The majority of the mothers reported having stopped breastfeeding early or having had to introduce supplementary feeding because the infant refused to breastfeed.
In a case-control study with ASD cases and matched healthy controls, the reports of the women interviewed suggested that the early weaning of their children may have been related to the onset of the symptoms of ASD. Difficulty with sucking, both from the breast and from a bottle, was reported in cases in which breastfeeding was interrupted or formula milk was introduced at an early stage. As the children grew up, difficulties with sucking may have progressed into chewing and swallowing problems, contributing to their food choices. Other studies have mentioned the occurrence of problems related to the mechanics of chewing and swallowing in children with ASD.
Nevertheless, not all the mothers mentioned difficulties related to sucking, chewing and swallowing, and this may suggest the existence of a subgroup of individuals with ASD with specific abnormalities in the tonicity of the muscles of the face and mouth. Of course, this qualitative study does not allow inferences to be made regarding causality, and it is important to mention that any observations in this respect are in fact mere speculation.
Sensory dysfunction, a common characteristic of ASD, was expressed as hypersensitivity to smells and textures, leading to a refusal to eat certain foods. A study conducted with typical children also showed that the children's eating habits reflected those of their parents. Studies that analyzed the formation of eating habits have shown that the parents exert a significant influence on the development of their children's behavior. Some mothers give in faster to their children's dietary demands and make many exceptions, allowing the children to choose what they want to eat. This permissiveness appears to be supported by the mother's belief that the eating habits of children with ASD are selective and restrictive.
According to Birch, 28 when given the opportunity to choose, our genetic predisposition induces us to reject anything that is new. Also, we tend to choose foods with a sweet or savory taste, foods that are part of a social context and foods that, when eaten, are followed by a positive sensation, e. At the same time, shielded by ASD, parents may give up on their attempts to impose a more rigid dietary education and yield to their children's preferences.
Subjects were excluded if they had a history of hearing impairment and co-morbidities such as Rett-Syndrome. No healthy controls were included in this research. The NFB protocol delivered by the Mente Autism device aims to reduce the abnormal EEG pattern associated with ASD that is characterized by excessive power at low frequency and high-frequency bands, as well as reduced power in the middle-range frequency band.
As previously mentioned, Mente Autism utilizes an auditory feedback in the form of binaural auditory beats. The binaural beats produce a perceptual phenomenon that occurs when two tones of a slightly different frequency are presented separately to the left and right ears resulting in the listener perceiving a single tone that varies in amplitude at a frequency equal to the frequency difference between the two tones The binaural beats delivered by Mente Autism are in the range of delta, theta and beta frequency and are selected accordingly to the user's brain pattern amount and distribution of brain waves.
Changes in the sound volume are controlled by specialized algorithms and the user receives an instant feedback through the earphones. The Mente Autism system presents a mixture of warble tones and binaural beats using a set of generative rules from derived brain activity levels, in order to present multiple frequencies that are hypothesized to alter and help the brain work in more desirable patterns. The protocol aims to promote a self-regulation of the brain activity including also the reduction of the faster high beta waves mostly associated with anxiety and over arousal.
An iPad running current OS and smart card Internet access was provided to all subjects at no cost, although they were advised that they could use their own devices, smart phones and tablets if they desired. The qEEG bands we considered are delta 1. All channels of EEG were acquired with 24 bits resolution at the sampling rate of Hz. The EEG was recorded for 5 min while the subject rested with eyes closed. Prior to the quantification analysis, all EEG signals were examined to remove epochs containing artifacts, such as EEG segments contaminated by horizontal and lateral eye-movement, muscle activity and electrocardiac artifact.
Successive EEG quantification was restricted to those children from whom a minimum of 1 min of artifact-free EEG could be obtained. Each qEEG measure was calculated with the respect to the mean and standard deviation of that measure obtained from an age-regressed normal database using a Z or standard score. The normative database from Neuroguide provided an evaluation of whether the subject's qEEG deviated from the normative sample From the qEEG, we considered the absolute power transformed into z-scores obtained by the power spectrum of each EEG channel.
Multiple ANCOVAs were conducted with treatment as between subject factor, post-scores as dependent variables and pre-tests scores as covariate. Paired t -test were also conducted within the Active and Control groups respectively. Normal distribution of the data was assessed using the Kolmogorov-Smirnov with the Lilliefors Significance Correction and the Shapiro-Wilk tests before further proceeding with the analysis. Paired t -tests were applied for exploring the differences between pre- and post-test scores with regard to absolute z-scores in group and for each frequency band and the effect size was calculated as Cohen's d 21 0.
The ability of a subject to maintain equilibrium was assessed using standard posturography testing in four different conditions [known as the modified Clinical Test of Sensory Integration in Balance or mCTSIB protocol 22 ]: Subjects were instructed to stand upright in a comfortable position, with their arms held loosely and naturally to their sides. Center of Pressure CoP coordinates were acquired at 64 Hz for 20 seconds and then upsampled to 1 kHz before any analysis was performed. No filtering besides the anti-aliasing filtering in the device was applied to the data.
The normality of the distribution of the data was confirmed using the Kolmogorov-Smirnov with the Lilliefors Significance Correction and the Shapiro-Wilk tests.
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Five commonly available and validated questionnaires were used pre and post treatment to determine the status of the participants: Of the 83 subjects that completed the evaluation at the enrollment time, 34 returned for the POST evaluation after the 12 weeks of home based therapy. The dropout reasons were inability or unwillingness to come back for the POST 22 in the Active group and 16 in the Control group , or discontinued treatment because of problems associated with internet connections and technology challenges 2 in the Active group and 9 in the Control group.
No subjects dropped out because of problems of tolerance with the Mente device or treatment. Furthermore, some subjects could not complete some of the testing resulting in a different number of subjects included in the different analysis. Some children could not tolerate the placement of an EEG Cap while others could not stand still for 20 seconds of posturography testing. Because of artifacts from movement and problems with tolerating the EEG cap, 10 subjects were removed from the qEEG analysis.
Therefore, from the entire sample, 24 participants were included in the successive qEEG analysis with their age expressed in months. No gender discrimination was included in the demographics of the posturographic data as once they are normalized there is no gender dependency Demographics of the subjects participating in the study and that were included in the various analysis.
The different number of subjects in the qEEG analysis is due to the exclusion of some subjects due to artifacts in the EEG recordings. The different number of subjects in the BRIEF analysis is due to the removal of the subject with high inconsistency value. We identified 5 subjects who demonstrated significant scores on the Inconsistency scale promoting a further analysis excluding these subjects.
Furthermore, since they are the most complete, the demographics of the posturographic analysis were also used to determine if there were any statistically significant differences among the two groups by calculating the t -tests between the Active and Control groups for each demographic variable. The resulting p -values are also shown, indicating that no differences were present among the two groups pre-treatment. Thirty-four participants completed the pre and post treatment qEEG testing. As stated before, because of artifact from movement and problems with tolerating the EEG cap, 10 subjects were removed from the analysis.
There was some asymmetry in the qEEG results but this was not statistically significant. Three frequency bands demonstrated statistically significant changes pre and post treatment: Our analysis reporting is specific for these areas and also focused on three main region of interest ROIs: Box plots of statistically and substantively significant beta and high beta band widths pre and post treatment. Refer to tables for statistical and substantive significance.
Topographical statistical distribution of the outcomes after 12 weeks period of treatment in eyes closed condition assessed by comparing the Pre- and Post- qEEG separately for the Delta, Beta and High Beta bands, in the Active left side and the Control right side group respectively. Values are expressed in term of absolute Z scores and p values of the paired t -tests.
With the reference to the t values the lower the values, the stronger the reductions of the abnormal Z scores values in the Post- over the Pre- qEEG assessment. With the reference to the values on the respective color-coded bar the red indicates larger values on PRE and blue larger values on POST phase. With the reference to the absolute difference values on the respective color-coded bar the red indicates that the color is Red is higher and Blue is lower.
Pairwise comparisons within the groups Active and Control , carried out for each band of frequency Delta, Beta, High Beta , showed statistically significant results only in the Active group between pre and post scores. Overall changes represented an improvement toward normalization, i.
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Box plots of statistically and substantively significant delta band widths pre and post treatment. The results of the GLM analysis are also shown as the p value between groups pre and post and for each group pre-post. Numerical results of the univariate GLM statistical analysis performed on the posturography data. In bold the results that are statistically significant. In underlined italic the results that are worse POST vs.
Everything else is scaled accordingly. The T-scores obtained were adjusted for age and sex allowing us to combine all subjects independent of gender for our analysis. All the t values that are positive indicate an improvement in symptoms or dysfunctional areas according to the T-scores provided by each questionnaire standardization with the exception of the ATEC that has negative values indicating a worsening of symptoms.
Paired t -tests were calculated to explore the differences between pre- and post-test scores within the groups Active andC , with regard to: For each paired t -tests, an effect size was calculated as Cohen's d Statistically significant results were found in both groups but with different directions of the effects for the single scales: As mentioned previously, T- scores were transformed from the raw individual scores thus allowing a comparison for age and gender.
No statistically significant results were found with the reference to each clinical scale as well as the two composite indexes, RRB and SCI for either the Active or Control groups.
T-scores were transformed from the raw individual scores thus allowing the comparison for age and gender. Among significant results, the direction of the effects pointed toward an improvement of executive function where high T scores indicated clinically relevant observations with the reference to each functional area as described by the individual subscales. Only the Active group had statistically significant differences between pre and post scores and the direction of the effect was toward a reduction of the autistic behaviors.
Only the Active group had statistically significant differences between pre and post scores for the Escape, the Nonsocial Reinforcement and the total score. The direction of the effect was toward a reduction of problematic behaviors. Parents of subjects in the Active group of this investigation reported significant improvements in communication and social skills of their children while the parents of subjects in the Control group did not report much change in these skills. There are no other comparisons represented in the literature. In spite of these difficulties, our main findings represent statistically significant improvements of Delta, Beta and High Beta Frequencies in the Active group after a 12 weeks NFB home treatment with the Mente device.
The various frequency bands of the EEG represent power spectra that are regulated by anatomically homeostatic systems mediated by cortical, thalamic and brainstem processes Changes in the power spectra of the EEG as observed in this investigation reflect a statistically significant change in brain function of the active treatment group as a consequence of the intervention.
We observed similar criteria values in the active treatment group with subsequent improvement after treatment. We have documented non significant brain symmetry differences in all of our subjects Active and Control before treatment with subsequent changes after treatment. Low EEG frequencies tend to decrease with age from childhood to adulthood while high frequencies increase We observed changes in the qEEG frequencies with noted decreases of low EEG frequencies and increases of high frequencies in our Active group after treatment signifying a trend toward normality.
For the most part we did not find statistically significant changes in our Control group after treatment but did find a statistically significant improvement only in the Beta band P3 and T3 leads. Sensory-based interventions SBIs are associated with an improved performance in daily life activities and occupations of people with ASD 36 and although the sham treatment did not affect significant change in general, it does appear that the sham sound had a minor consequence in brain activity.
Sensory stimulation such as sound may be modified by environmental factors in the development of an individual whose brain interacts with the environment with resultant modification of neural circuitry An assessment of Cochrane systematic reviews found that music therapy is associated with evidence of benefits for patients with autism spectrum disorders, although the evidence is low quality with a need for high quality long term clinical trials The presentation of binaural auditory beats can affect psychomotor performance and mood, comprising a dual complex system including spectral complexities that are effective for ASD children The binaural beats associated with the NFB of the Active Mente device are associated with the differences between the Active and Control groups.
Spectral complexity is present due to different frequencies being sent back to the user in the Active group's NFB loop, resulting in the generation of EEG data frequencies. Binaural beats originate in the superior olivary nucleus as a new auditory stimulation produced by listening to different frequencies of sound at each ear Our investigation demonstrated significant changes in the qEEG of various brain areas and no significant changes in others.
The cortical processing evoked by binaural beats is similar in distribution to other acoustic beats that are located mostly to left temporal lobe areas However, multisensory temporal integration in ASD is associated with a wider temporal binding window suggesting that general sound stimulation may bind with other sensory modalities such as proprioception of the head band resulting in an improvement in postural stability Max Sway again for the Control group in the eyes open on hard or compliant surface tests and might have been gone undetected if the instrument used to record the posturography data were not sensitive enough.
Looking at the results in general, we found a decrease in whole body sway in both the Active and Control groups but only the Active group demonstrated statistically significant decreases in sway after treatment. The proprioceptive effect of the headband itself might contribute to central changes independent of sound and should be investigated. This was mainly due to the difficulty in keeping the child in position for the entire duration of the test and obtaining meaningful data without excessive movements or the subject stepping out of position, or opening the eyes.
Some subjects were even jumping up and down on the CAPS force platform, but fortunately this type of abuse did not injure the children nor damage the instrument, because of a designed maximum load of 1, kg. Also the larger area of support allowed subjects to assume their preferred stance without any restrictions.
It would be expected that the more difficult the test, the higher the sway would be. However, this was not always the case: It is expected that people are able to stand better when they can see their environment and these findings in our ASD subjects are alarming. ASD individuals experience the world around them uniquely by using different visual strategies to process social information Clearly, the comparison of the performance of vision strategies and eye movements and gaze following in social settings is quantitatively different in children with developmental delays compared to children without delays Obviously, the role of the eyes in gaze holding plays a central role in social cognition that is impaired in ASD children, suggesting a deficiency in the spatiotemporal networks of the brain The worsening of stability and sway with the eyes open in our subjects may be identified as a biomarker for ASD.
Even the targets that a child looks at before maintaining gaze are different in ASD than typically developing children who look at the eyes and mouth of an individual much more than an autistic child A recent meta-analysis suggests that decreased eye fixation to the eye region of the face may represent a robust biomarker for ASD Interestingly, there are differences in fixation time at eye regions between ASD children who tend to fixate on the right eye for a greater amount of time than the left eye compared to typically developing children that increase left eye fixation over right eye fixation when scanning the face The descriptive characteristics of children and their families are shown in Table 1.
Children with median age of 9. Eighty-nine percent of children had no or only one sibling. From all children, 21 Composite score for leisure time activity was in average Table 2 shows the measurements obtained from daily activity logbook. Time spent in social or solitary play activities Minutes in children with ASD by gender differences. Daily physical and play activities have an important role in the psychosocial development of children. In fact an appropriate activity profile prevents them from isolation in adulthood [ 27 ] and significantly influences the wellbeing of children [ 17 , 28 ].
Nevertheless, there was lack of studies assessing daily activities participation in children with ASD and investigating the impact of individual and environmental factors on their physical activity parameters. Results from the current study indicates that most of the children with ASD do not have adequate physical activity participation since only few of our children met the minimum physical activity criteria. Several studies have discovered that individuals with disabilities are more likely to be inactive and due to abundance of impediments they are less likely to participate in activities when they are compared with the general population [ 29 — 32 ].
Their findings show that ASD and the severity of intellectual impairments place the people with disabilities at a higher risk for sedentariness [ 33 , 34 ]. A number of factors can limit the participation of children with ASD in daily physical activities. Those mainly include lack of positive experiences in exercises, frequent failures, emotional impairments, and low self-esteem [ 34 ].
However, our data showed that such low participation was mostly due to the financial complaints and lack of resources or opportunities as reported by the parents. Moreover, there were other factors e. Interestingly, data from another developing country revealed similar barriers such as financial complaints, lack of knowledge, and perception of the situation in an ASD sample [ 35 ]. Although there are differences in measurement of barriers across previous studies, almost similar patterns of barriers including time limits and financial constraints were reported as leading barriers to activity participation in children with disabilities particularly ASD [ 15 , 36 , 37 ].
Indeed this finding is not limited to ASD and previous data from individuals with other disabilities revealed that disabled people face a number of barriers to PA participation even more than healthy population. Expenditures of the child's medical care impose a financial burden on families with an autistic child and therefore they require more financial resources.
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They also have to limit their productive working times in order to take care of their difficult children, which in turn will further challenge the possibility of secure a financial resource expansion [ 38 ]. One of the important findings of the present study is that children from low-income families show lower level of PA than children from high-income families. Indeed family income is a determinant of health behavior. Children who grow up in a low-income family are more likely to live a sedentary lifestyle and experience more health problems related to physical inactivity compared to children from higher income families [ 39 ].
There are a number of physical and social barriers to physical activity for low-income families including low access to parks and recreational services, traffic conditions and air pollution, lack of relevant alternatives of transportation, and lack of enough social support for physical activity.
On the other hand, low-income families are often less able to overcome these barriers [ 40 ]. Due to financial constraints, there are fewer alternatives available for low-income people; for example, they are not able to spend on a health club or recreation center membership [ 41 ]. It can be expected that the problem is more complicated in families with an ASD child.
Thus, the economically disadvantaged ASD families may show a lower preference to participate in physical activities [ 42 ]. Furthermore, some parents have increasing concerns about their child's health and possibility of an injury, which can explain their lack of interest toward activity participation of their autistic child. The household structure has been identified as another independent correlate of activity participation. Single parents experience a number of work-related or housing problems.
Furthermore, they report lack of time and financial resources as the main impediments to participation in activities [ 32 ]. Our findings provide additional evidence regarding the effect of household structure on the leisure time activity involvement in children with ASD. However, it is not clear if other variables such as presence of a sibling may influence the opportunities to engage in social play and daily social activities inside the family environment. Expectedly children with ASD showed a remarkably low social but high solitary play activity during a typical day.
Indeed this finding may reflect the characteristic of autism itself. A previous research has shown that the characteristics of ASD as social, communicative, and motor impairments increase the likelihood of loneliness and decrease the opportunities for interactions in individuals with ASD [ 32 ]. Previous studies suggested that a lower level of social play activities in addition to autistic character difficulties can have serious developmental and social consequences [ 43 — 45 ].
Examining the apparent role of autism symptom severity, we observed that the children with greater deficits e. These results are in line with previous studies which indicated that there is an inverse correlation between severity of communication impairment and the level of life participation in individuals with disabilities. In fact, previous studies indicated that individuals with more severe motor or physical impairments or cognitive disabilities are at a higher risk of being excluded from daily activities [ 46 , 47 ].
Our findings also indicated that there is a significant age and gender difference in level of physical activity and this is in line with studies of ASD and general population. It can be explained that older children have low opportunities to participate in physical and recreation activities. Furthermore, age may decrease the children motivation to participate in complex motor or physical activities.
We also indicated that gender in favor of males influences the daily physical and play activities of children. Gender differences in ASD characteristics revealed that males with ASD show more stereotypic and repetitive behaviors while there are more communication deficits in female counterparts [ 48 ]. In addition, there is more achievements in motor skills and social competence in boys than girls with ASD [ 49 ].
One can argue that being a girl is associated with poor outcome in physical activity participation in ASD. Several limitations of this study have to be acknowledged. First, the cross-sectional design prevents an understanding of the exact nature of the daily activity participation, particularly with respect to its determinants. Second, while a neurotypical control group was not included, it would be helpful to compare the scores of physical activity participation between neurotypical controls and children with ASD.
Third, the measures solely relied on the parents' or teachers self-report information; thus, recall bias maybe a potential limitation. In conclusion, only a small part of children with ASD are physically active according to activity guideline. Financial concerns, lack of opportunities, and sociodemographic factors are indicated as major limitations of their physical activities. The authors want to thank the children with autism and families who took part in this study. This research was funded by Tehran University of Medical Sciences.
The authors report no actual or potential conflict of interests. National Center for Biotechnology Information , U. Journal List Neurol Res Int v. Published online Jun This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.