Clinical Correlates and Prevalence of Food Selectivity in Children with Autism Spectrum Disorder.

OBJECTIVE: To examine clinical correlates and prevalence of food selectivity (FS) - ie, self-restricted diet, reluctance to try new foods - in children with autism spectrum disorder (ASD) ascertained from a general outpatient autism clinic. STUDY DESIGN: A multidisciplinary team (pediatric nurse practitioner, psychologist and dietitian) assessed medical and psychosocial histories and dietary habits in 103 children with ASD (mean age = 5.8 ± 2.2 years; range 2-10). Parents rated child mealtime behavior on the Brief Autism Mealtime Behavior Inventory (BAMBI) and disruptive behavior on the Aberrant Behavior Checklist (ABC). Height and weight measurements were collected. Children were classified as FS or no FS based on parent reported intake and mealtime behavior. A 24-hour dietary recall was used to record intake percentages < 80%. Logistic regression and multivariable modeling were used to evaluate clinical correlates with FS. RESULTS: Of 103 children, 45.6% (n = 47) were classified as FS; 54.4% (n = 56) no FS. After adjusting for potential confounders, the odds of FS increased by 1.91 (95% CI: 1.38, 2.64, P < .001) for every half-SD increase in BAMBI total score and by 1.35 (95% CI: 1.05, 1.74, P = .020) for every half-SD increase in ABC Hyperactivity/Noncompliance. No group differences in anthropometrics or nutritional intake were identified. CONCLUSIONS: Food selectivity (FS) in children with ASD was strongly associated with greater severity of disruptive mealtime and hyperactivity/noncompliance behaviors. FS was not associated with anthropometrics or nutritional intake.

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder.

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.

A systematic review of physical guidance procedures as an open-mouth prompt to increase acceptance for children with pediatric feeding disorders.

This article reviews behavioral treatments of pediatric feeding disorders using physical guidance procedures as an open-mouth prompt (i.e., jaw prompt, finger prompt, Nuk prompt, side deposit) to increase food acceptance. We identified 9 articles containing 35 systematic evaluations. We coded participant and study characteristics and assessed the experimental rigor, quality, and outcomes of each evaluation. Of the high-quality research present, the finger prompt variation and side deposit reliably increased acceptance. We found mixed results on the efficacy of the jaw prompt, although it was the most widely researched procedure. Further, authors reported interobserver agreement for 100% of the participants, procedural integrity for 60%, social validity for 80%, fading for 5%, and follow-up for 55%. Based on the invasive nature of physical guidance, we provide recommendations for researchers and clinicians to increase the quality of their treatment evaluations. We discuss limitations, implications for practice, and future research.

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders.

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.

Modified-Bolus Placement as a Therapeutic Tool in the Treatment of Pediatric Feeding Disorders: Analysis From a Retrospective Chart Review.

Purpose Recognizing the need to advance the treatment of pediatric feeding disorders, an emerging area of inquiry focuses on therapeutic techniques that address expulsion and packing possibly associated with oral-motor dysfunction. In the current study, we documented the use of modified-bolus placement in the treatment of pediatric feeding disorders at an intensive, multidisciplinary day-treatment center over a 26-month period. Method The retrospective observational cohort study involved patients admitted for the assessment and treatment of chronic food refusal from August 2013 to October 2015. Results Patients (n = 23) who received modified bolus placement displayed moderate-to-severe oral-motor deficits. Use of modified-bolus placement was associated with reduced expulsion and packing of bites during meals, and treatment gains coincided with a threefold increase in grams consumed per meal. Conclusion Results provide additional support for the potential therapeutic benefits of enhancing bolus placement onto the tongue as a means to improve mealtime performance in children with pediatric feeding disorders when included as an adjunct to more traditional behavioral approaches.

Inappropriate mealtime behavior: the effects of noncontingent access to preferred tangibles on responding in functional analyses.

An understanding of the functional variables associated with inappropriate mealtime behavior (IMB) is critical to developing an effective and efficient treatment for food refusal. To this aim, functional analysis methodology has been modified for the meal context, and previous research has shown that multiple sources of reinforcement maintain IMB. Functional analysis literature, related to severe problem behavior, suggests that access to preferred stimuli may abolish or compete with social reinforcers in some cases. The role of noncontingent access to preferred stimuli during the assessment of IMB has not been evaluated. The purpose of the current study was to examine the effects noncontingent access to preferred toys/activities on IMB in the presence and absence of social consequences. The specific aims were to evaluate: (1) levels of IMB when the spoon is held stationary at the child's lips when preferred tangible stimuli are present noncontingently vs. absent; (2) levels of IMB when social consequences were provided contingent upon IMB when preferred tangible stimuli are present noncontingently vs. absent. For many participants, levels of IMB were reduced with the inclusion of preferred toys/activities; while for one, levels of IMB increased. Possible implications of these findings on functional analyses of IMB will be discussed.