Assessment and Treatment of Feeding Problems in Children with ASD
WilliamSharp,Ph.D.Director,FeedingDisordersProgramMarcusAutismCenterChildren’sHealthcareofAtlanta|AssistantProfessorDepartmentofPediatricsEmoryUniversitySchoolofMedicine
Marcus Autism Center
LearningObjectives
• DescribefoodselectivityandrelatedmealtimeconcernsinASD
• Identifymedicaloutcomesandnutritionissuesassociatedwithatypicalpatternsofintake
• Recognizepossiblecontributingfactors,focusingonevidenceofgastrointestinal(GI)concernsinASD
• IdentifyappropriateinterventionsforfeedingdisordersinASDbasedontheseverityofthepresentingproblem.Thisincludesparentconsultation/education,nutritionalguidance,behavioraltherapy,medicalinterventions,andintensiveinpatientservices.
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AutismSpectrumDisorder(ASD)
• DSM– 5:Neurodevelopmentaldisorder(s)ofunknowngeneticoriginwheresymptomsunfoldoverthefirstfewyearsoflife:–Persistentdeficitsinsocialcommunicationandsocialinteraction–Restrictive,repetitivepatternsofbehavior,interests,oractivities
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Volume:AssociatedFactors
• MedicalIssues:§ Congenitaloracquiredrespiratory,cardiac,andgastrointestinal
problems,whichcausedifficultorpainfuleatingexperiences
• Theseinclude:§ Gastroesophageal reflux§ Foodallergies§ Gastroenteritis§ Dysmotility§ Prematurity(withintubation)§ Bronchopulmonary dysplasia§ Shortbowelsyndrome§ Lactoseintolerance
• Feedingproblemsoccursin40-70%ofchildrenwithchronicmedicalconditions(Lukens&Silverman,2014)
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Variety:AssociatedFactors
• AutismSpectrumDisorder(ASD)
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PediatricFeedingDisorders
• Chronicfeedingconcernsgenerallyinvolveeither:– 1)Volume- FoodRefusal– 2)Variety- FoodSelectivity
Severeproblembehaviorsduringmeals:– Crying– Disruptions– Elopement– Aggression– Spitting– Expulsion
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HistoricalBackground
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• Kanner,L.(1943).Autisticdisturbancesofaffectivecontact.TheNervousChild,2,217-250.
• "Foodistheearliestintrusionthatisbroughttothechildfromtheoutsideworld."
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ResearchSupport
• Ledford&Gast (2006)– Mostcomprehensivesummaryatthetime– 7descriptivestudiesidentified– N=381childrenwithASD
• Estimatesrangedfrom46%and89%ofchildrenwithASDdisplayingsignificantfeedingproblems– Oftennoidentifiableorganicprecursor
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ResearchSupport
• Limitations– Nocontrolgroupandmostlydescriptivestudies– Involvedbiasedclinicalsample– e.g.,feedingdisordersclinic
– Lackofuniformitydefinitionoffeedingproblem
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• Inclusioncriteria:1. Publishedbetween1980and20112. Focusedonpediatricpopulation(birthto18years)3. Involvedacomparisongroup4. Evaluatedfeedingand/ornutritioninASDa
standardized,replicablemanner5. Presenteddataeitherdescriptively(e.g.,frequency,
percentages)orstatistically(e.g.,tscores)
• Exclusioncriteria:1. Studieswithknownsamplingbias(e.g.,chartreviews
fromfeedingprograms)2. Studiesfocusingondietarymanipulation(e.g.,GFCF)
Sharp et al (2013). Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. Journal of Autism and Developmental Disorders, 43(9): 2159 - 2173.
Fivefold increaseintheoddsofhavingafeedingprobleminASD
FoodSelectivityPreference- carbohydrates,snacks,fats,and/orprocessedfoodRejection- fruitsandvegetables
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PickyEatingvs.FoodSelectivity
FoodselectivityinASDisdistinctfrompickyeatingintermsofduration andintensity• Duration - Foodselectivityisachronicconcernthatpersistsovertime– Suarez,Nelson,andCurtis(2013)indicatednochangeinfoodselectivityin52childrenwithASDovera20-monthperiod.
• Intensity– Foodselectivitymorelikelytoinvolvestrongrefusalbehaviors(e.g.,crying,throwingobjects,aggression)
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13Figure1:Lifespanmodeloffoodneophobia asproposedbyDovey etal.(2008)
FoodSelectivityvs.PickyEating
Sharp et al (2013). Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. Journal of Autism and Developmental Disorders, 43(9): 2159 - 2173.
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DailyLivingandQualityofLife
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Required to prepare multiple menus for each meal
Disrupted family meals & further limitations in social interactions
Reduced opportunities to eat at restaurants or social occasions
Increased parental stress regarding health and development
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ParentReport
• “I’mworriedabouthishealth.Howcanhestayaliveeatingtwofoodsanddrinkingwater?”
• “Ifyoueversawthosemeltdownsyouwouldn’twanttooffernon-preferredfoodeither.”
• “He’llgagandalmostgetphysicallysickjustwatchinguseatsomethinglikespaghettiandmeatsauce.”
• “Myyoungerchildrenwon’teatthefoodtheydon’tlike,butmysonwithautismwon’tevencometothetable.”
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TheParentExperience
• Mealsdescribedasstressful,chaotic,andenergydepleting
• Mealtimeslackpositiveinteractions• Child’sfoodselectivitylimitedotherfamilymembers’foodchoicesduringmeals
• Caregiversreportedceasingfamilymealstoavoidfurtherworry,guilt,andstress.
Marquenie,K.,Rodger,S.,Mangohig,K.,&Cronin,A.(2011);Suarez,Atchison,&Lagerwey (2016)
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Inclusioncriteria:1. Publishedbetween1980and20122. Focusedonpediatricpopulation(birthto
18years)3. Involvedacomparisongroup4. EvaluatedGIconcernsinASDa
standardized,replicablemanner5. Presenteddataeitherdescriptively(e.g.,
frequency,percentages)orstatistically(e.g.,tscores)
Exclusioncriteria:1. Studieswithknownsamplingbias(e.g.,
chartreviewsfromGIclinics)2. Studiesusingahealthycontrolgroup(i.e.,
screeningoutchildrenwithknowngutissues)
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McElhanon, B.O., McCracken, C., Karpen, S., Sharp, W.G. (2014) Gastrointestinal Symptoms in Autism Spectrum Disorders: A Meta-analysis. Pediatrics, 133:5 872-883
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Otherkeyfindings
• InsufficientdatatoanalyzedataonotherGIconcerns,suchasrefluxorEOE,oftenlinkwithorganicpathology
• Althoughorganicfactorsleadingtodifficultorpainfuleating,suchasgastroesophageal reflux,gastroenteritis,andfoodallergies,oftenprecipitateorplayaroleinthedevelopmentofchronicfeedingconcernsinotherpediatricpopulations,researchhasyettoidentifyaclearGIlink toaccountfortheemergence,maintenance,andtopographyoffeedingproblemsassociatedwithASD.
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Buieetal.(2010)
• AllofthecommongastrointestinalconditionsencounteredbyindividualswithtypicalneurologicdevelopmentarealsopresentinindividualswithASDs.
• ThecommunicationimpairmentscharacteristicofASDsmayleadtounusualpresentationsofgastrointestinaldisorders,includingsleepdisturbancesandproblembehaviors.
• CaregiversandhealthcareprofessionalsshouldbealerttothepresentationofatypicalsignsofcommongastrointestinaldisordersinpatientswithASDs.
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ClinicalImplications
WhenafeedingconcernsispresentinASD:• Animportantfirststepwhenworkingwithanychildwitha
feedingdisorderinvolvesrulingoutthepotentialcontributionoforganicfactors(e.g.,gastroesophagealreflux,foodallergy)thatmaycausepainordiscomfortalongtheGItract.
• Thismayrequireadoptingalowerthresholdforobtainingsubspecialtyconsultation(e.g.pediatricgastroenterologist;allergist)andincreasedrelianceonobjectivetestinginordertorecognizepathologyandfacilitateadiagnosisgivenlimitationsincommunicationoftenobservedinASD(Buie etal.,2010)
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AMeasurementProblem
1) Nouniversallyaccepteddefinition
2) Highvariabilityinitemcontent
3) Nodirectlinkwithactualdietandnutritionalstatus
4) Foodselectivityhasbeenviewedasamonolithicconstruct(e.g.,totalnumberofitemsacceptedorrejected),withoutconsiderationtosymptomseverityordietarydiversity.
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Bandini etal.(2010)
ThreePartDefinitionofFoodSelectivity:• 1)FoodRefusal:Percentageoffoodsofferedthatthechildwillnoteat
• 2)LimitedFoodRepertoire:Numberofuniquefoodsconsumedoverathree-dayperiod
• 3)HighFrequencySingleFoodIntake(HFSFI):Numberofsinglefooditemseaten4to5ormoretimesdaily.
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Bandini etal.(2010)
• 53childrenwithASDvs.58typicallydevelopingchildren(ages3-11years).
• ChildrenwithASD:• 1)Exhibitedgreaterfoodrefusal(rejecting41.7%offooditemsversus18.9%rejectedbypeers)
• 2)Consumedamorelimiteddietaryrepertoire(consuminganaverageof19foodsoverathreedayperiodvs 22.5consumedbypeers)
• HFSFIwasrarelyobservedinbothgroups.
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Frameworkfordefiningfoodselectivitybyseverity
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TheBehavioralPerspective
• Why?– Symptomseverity– Medicalconcernvs.qualityoflifeissue
• How?– Severe ->IntensiveMultidisciplinaryIntervention– Moderate->Outpatient/homeinterventions– Mild->AdaptExistingGuidelinesforIntroducing
Food(e.g.,EllenSatter)
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Parentvs.ChildPerspective
• Parent– Experiencedeater– Flexibilitywithdifferentfoodtypesandtastes– Eatslargeportionsoffoods
• Child– Non-preferredfoodsareaversive/noxious– Preferredfoodscanbecontaminated
• Changeinpresentationandcontactwithnon-preferredfoods
– Highlymotivatedtoavoidcontact
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Involvechildrenintheprocessthroughchoice• Fooditemstotarget• Initialbitevolume• Jumpinvolume• Whichfoodstoaddnext
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DesigningInterventions
• Overarchingphilosophy:– Treatmentinvolvespersistingwithareasonabledemand– Inordertoestablishtractionforbehaviorchange,beginwith“zoneoflikelysuccess”• Cannotreinforce abehaviorislowprobabilityofoccurring
– Andshouldconsiderthecompletetoolboxofantecedentandconsequencebasedstrategies• Ifonlyrelyingonconsequences,maynotbeabletoreplace/overridefunction
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Otheraspectsofthemeal…..
• Increasestructureandroutine:– Regularmeal/snackschedule– Mealsinvolveatablewithageappropriateseating
• DifferentialAttention– Provideattentionandpraiseforappropriatemealtimebehaviors-• Acceptingbites,swallowing,eatingproperlywithaspoon,tryinganewfood,orstayingseatedthroughoutthemeal
– Ignoreminorbehaviorproblems• Whining,negativestatementsregardingfood,messyeating(ifageappropriate)
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GeneralBehavioralConcepts
Treatmentmustinvolve:
Escape ExtinctionPersistence
with a Demand
Levels-• Ignoringnegativestatements• Non-removaloftheplate/spoon
Differential Reinforcement
Recognition of
Appropriate Behaviors
Types-• Praiseandattention• Accesstopreferredactivities• Consumptionofpreferredfood• Escape/break
ExposurewithResponsePrevention
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DecisionRules
• Makesurebehaviorisstableacrossmeals– After3mealswithfewproblembehaviors,increasethedemand• Addnewfooditem• Increasebitenumber• Increasebitevolume• Increasemeallength
– Ifproblembehaviorspersistacross2meals,reducethedemandandbreakintosmallersteps
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PowerofChoice
• Fooditemstotarget• Initialbitevolume• Jumpinvolume• Whichfoodstoaddnext
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Questions?
References- Feeding• Bandini,L.G.,Anderson,S.E.,Curtin,C.,Cermak,S.,Evans,E.W.,Scampini,R.,Maslin,M.,&Must,A.(2010).Foodselectivityin
childrenwithautismspectrumdisordersandtypicallydevelopingchildren.TheJournalofPediatrics,157(2),259- 264.• BuieT.,Campbell,D.B.,Fuchs,G.J.,Furuta,G.T.,Levy,J.,Vandewater,J.,etal.(2010).Evaluation,diagnosis,andtreatmentof
gastrointestinaldisordersinindividualswithASDs:aconsensusreport.Pediatrics,125(suppl1),S1-18.• CurtinC,AndersonSE,MustA,BandiniL.Theprevalenceofobesityinchildrenwithautism:asecondarydataanalysisusing
nationallyrepresentativedatafromtheNationalSurveyofChildren'sHealth.BMCPediatr.2010Feb23;10:11.doi:10.1186/1471-2431-10-11.
• EganAM,DreyerML,OdarCC,BeckwithM,GarrisonCB.Obesityinyoungchildrenwithautismspectrumdisorders:prevalenceandassociatedfactors.ChildObes. 2013;doi:10.1089/chi.2012.0028.Epub2013Mar13
• Emond,A.,Emmett,P.,Steer,C.,Golding,J.(2010).Feedingsymptoms,dietarypatterns,andgrowthinyoungchildrenwithautismspectrumdisorders.Pediatrics,126(2),337- 342
• Ho,Eaves,&Peabody(1997).NutrientIntakeandObesityinChildrenwithAutism.FocusonAutismandOtherDevelopmentalDisabilities,12(3),187– 192.
• Johnson,C.R.,Handon,B.L.,Mayer-Costa,M.,&Sacco,K.(2008).Eatinghabitsanddietarystatusonyoungchildrenwithautism.JournalofAutismandDevelopmentalDisorders,20,437- 448.
• Kanner,L.(1943).Autisticdisturbancesofaffectivecontact.TheNervousChild,2,217–250.• Ledford,J.R.&Gast,D.L.(2006).Feedingproblemsinchildrenwithautismspectrumdisorders:Areview.FocusonAutismand
OtherDevelopmentalDisabilities,21,153-166.• Lukens,C.T.&Linscheid(2008).Developmentandvalidationofaninventorytoassessmealtimebehaviorproblemsinchildren
withautism.JournalofAutismandDevelopmentalDisorders, 38,342- 352.• Lukens,C.T.&Silverman,A.H.(2014).SystematicReviewofPsychologicalInterventionsforPediatricFeedingProblems.Journal
ofPediatricPsychology.pp.1–15,2014doi:10.1093/jpepsy/jsu040• Manikam,R.,&Perman,J.(2000).Pediatricfeedingdisorders.JournalofClinicalGastroenterology,30,34-46.• Martins,Y.,Young,R.L.,&Robson,D.C.(2008).Feedingandeatingbehaviorsinchildrenwithautismandtypicallydeveloping
children.JournalofAutismandDevelopmentalDisorders,38,1878- 1887.• Mayes,L.,&Volkmar,F.(1993).Nosologyofeatingandgrowthdisordersinearlychildhood.ChildandAdolescentPsychiatric
ClinicsofNorthAmerica,2,15-25.
References- Feeding• McElhanon,B.O.,McCracken,C.,Karpen,S.,Sharp,W.G.(2014)GastrointestinalSymptomsinAutismSpectrumDisorders:A
Meta-analysis.Pediatrics,133:5872-883.• Satter,E.(1990).Thefeedingrelationship:Problemsandinterventions.JournalofPediatrics,117(2Pt2),S181–S189.• Schmitt,L.,Heiss,C.J.,&Campbell,E.E.(2008).Acomparisonofnutrientintakeandeatingbehaviorsofboyswithandwithout
autism.TopicsinClinicalNutrition.23(1),23- 31.• Sharp,W.G.,Berry,R.C.,McCracken,C.,Nuhu,N.N.,Marvel,E.,Saulnier,C.A.,Klin,A.,Jones,W.,&Jaquess,D.L.(2013). Feeding
ProblemsandNutrientIntakeinChildrenwithAutismSpectrumDisorders:AMeta-analysisandComprehensiveReviewoftheLiterature.JournalofAutismandDevelopmentalDisorders,43(9):2159- 2173.
• Sharp,W.G.,Jaquess,D.L.,Morton,J.S.,&Herzinger,C.(2010).Pediatricfeedingdisorders:Aquantitativesynthesisoftreatmentoutcomes.ClinicalChildandFamilyPsychologyReview,13,348-365.
