Behavioral Pediatrics Feeding Assessment Scale in Young Children With Autism Spectrum Disorder: Psychometrics and Associations With Child and Parent Variables

Effect of maternal eating behaviors and attitudes towards the feeding process on feeding problems of pre-school age children

BACKGROUND & AIMS

Feeding problems in pre-school children are common and negative maternal feeding practices may even worsen the child's problematic eating behavior. Therefore, investigating the effects of maternal eating behaviors and attitudes towards the feeding process on pre-school children's feeding problems may be helpful for preventing feeding problems. This study sought to investigate the effects of maternal eating behaviors and attitudes towards the feeding process on feeding problems of pre-school children.

METHODS

Mothers of 373 children aged 3-6 were included in this cross-sectional study and data was collected by an online questionnaire including the scales of three-factor eating questionnaire (TFEQ), mother's attitudes towards the feeding process (MATFPS) and behavioral pediatric feeding assessment (BPFAS), as well as demographics and anthropometric measures (height and weight). Spearman's rho test was used to calculate correlation coefficients between the TFEQ, MATFP and BPFA scales. In order to identify independent predictors of child feeding behaviors, a multiple linear regression model was used.

RESULTS

Results showed that uncontrolled eating subscale was positively (r = 0.160, p < 0.001) and cognitive restriction subscale negatively (r = -0.126, p < 0.05) correlated with MATFP. MATFP was also positively correlated with BPFA (r = 0.368, p < 0.001). Regression analysis indicated that BPFA was significantly predicted by MATFP which was the most important contributor of child feeding problems (β = 0.24, t = 4.88, p < 0.001).

CONCLUSIONS

This study indicated that maternal eating behaviors were related to maternal attitudes towards the feeding process and, mothers' attitudes were associated with feeding problems of their pre-school children.

Feeding Behaviors in Infants and Toddlers Later Diagnosed with Autism Spectrum Disorder: A Systematic Review

Children with autism spectrum disorder (ASD) are five times more likely to have feeding difficulties than neurotypical peers, although the majority of evidence describes feeding difficulty in children age 2 years and older. The purpose of this study is to systematically review the literature on feeding characteristics of children age 0-24 months who were later diagnosed with ASD with an emphasis on the measurement tools used to assess these feeding behaviors. We conducted a systematic review of the literature using PRISMA guidelines. Using selected keywords, a search was conducted using PubMed, PsycINFO, and CINAHL databases for relevant articles to identify feeding characteristics in infants and toddlers (age 0-24 months) later diagnosed with ASD. Sixteen studies were selected for this review by two independent reviewers. Among the selected studies, feeding difficulties were reported in all infant oral feeding modalities (breastfeeding, bottle feeding, and complementary feeding) by infants later diagnosed with ASD. However, the evidence was conflicting among studies regarding feeding characteristics, such as sucking differences while breastfeeding, use of the spoon with feedings, and preference of solid food texture, that presented in infants later diagnosed with ASD. A lack of consistent measurement of feeding behaviors in infants later diagnosed with ASD contributes to the difficulty in comparison across studies. Future research should focus on developing targeted, validated instruments for measuring feeding difficulty in this population with emphasis on breastfeeding and bottle feeding difficulty.

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

OBJECTIVE

To examine clinical correlates and prevalence of food selectivity (FS) - i.e., 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 Brief Autism Mealtime Behavior Inventory (BAMBI) and disruptive behavior on 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

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.

Investigating the impact of autistic children's feeding difficulties on caregivers

AIM

The aim of this study was to investigate the influence of children's autism characteristics, sensory profiles and feeding difficulties on caregiver-reported impact at mealtimes.

BACKGROUND

Caregivers of children (5-12 years) with a diagnosis of Autism Spectrum Disorder completed an online survey examining (a) demographic characteristics, (b) children's autism characteristics (Social Communication Questionnaire), (c) sensory profiles (Sensory Profile 2-short form), (d) feeding difficulties (Behavioural Paediatrics Feeding Assessment Scale, BPFAS) and (c) caregiver-reported impact of feeding difficulties (Feeding-Swallowing Impact Survey, FS-IS).

RESULTS

Seventy-eight caregivers completed surveys for 80 children. Children with clinically significant feeding difficulties on the BPFAS (n = 55, 68.8%) had higher levels of caregiver-reported impact on daily activities, worry and feeding difficulties compared to children without clinically significant feeding difficulties (FS-IS; U = 257.000, z = -4.471, p < 0.01). Spearman's rank correlation showed a statistically significant, moderate correlation between BPFAS total frequency score and FS-IS Daily activities score, rs (98) = 0.56, p < 0.01, indicating that as the frequency of feeding difficulties increased, the impact of these feeding difficulties on caregivers also increased. Using multiple regression, a model comprising of the three factors was statistically significant (F[1, 78] = 87.75, p < 0.001, adj. R2  = 0.52), with children's frequency of feeding difficulties the strongest predictor of caregiver-reported impact with a moderate effect size (r = 0.49).

CONCLUSION

Autistic children's feeding difficulties had a greater impact on caregivers than autism or sensory profiles, with the frequency of feeding difficulties and the caregiver impact of these feeding difficulties positively correlated. The findings demonstrate that efforts to understand and address feeding difficulties in autistic children must extend beyond the children to include their families.

A Comparison of Family Management Between Families of Children With Autism Spectrum Disorder and Families of Children With Down Syndrome

INTRODUCTION

This cross-sectional study aimed to (1) compare family management between families of children with autism spectrum disorder (ASD) or Down syndrome and (2) evaluate the contribution of the child (ASD behaviors, feeding difficulties, sleep disturbances), caregiver (mental health) and family (social support) factors to the caregiver's perceived condition management ability and effort.

METHOD

Eighty-five caregivers (56 ASD, 29 Down syndrome) completed quantitative instruments online. Data analysis included independent samples t-tests and multiple linear regression.

RESULTS

There were no significant differences in the dimensions of family management between groups. More ASD behaviors were associated with lower condition management ability and higher condition management effort. Lower perceived social support and higher caregiver age were associated with lower condition management ability.

DISCUSSION

Integrating care into family life may be more challenging when the child has more social differences and behavioral rigidity. Nursing care should include an assessment of family social support.

A Review of the Nutritional Approach and the Role of Dietary Components in Children with Autism Spectrum Disorders in Light of the Latest Scientific Research

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects several areas of mental development. The onset of ASD occurs in the first few years of life, usually before the age of 3 years. Proper nutrition is important to ensure that an individual's nutrient and energy requirements are met, and it can also have a moderating effect on the progression of the disorder. A systematic database search was conducted as a narrative review to determine whether nutrition and specific diets can potentially alter gastrointestinal symptoms and neurobehavioral disorders. Databases such as Science Direct, PubMed, Scopus, Web of Science (WoS), and Google Scholar were searched to find studies published between 2000 and September 2023 on the relationship between ASD, dietary approaches, and the role of dietary components. The review may indicate that despite extensive research into dietary interventions, there is a general lack of conclusive scientific data about the effect of therapeutic diets on ASD; therefore, no definitive recommendation can be made for any specific nutritional therapy as a standard treatment for ASD. An individualized dietary approach and the dietician's role in the therapeutic team are very important elements of every therapy. Parents and caregivers should work with nutrition specialists, such as registered dietitians or healthcare providers, to design meal plans for autistic individuals, especially those who would like to implement an elimination diet.

Patient-Reported Outcome Measures That Describe the Feeding Skills Domain for Pediatric Feeding Disorder: A Clinimetric Review

OBJECTIVES

Pediatric feeding disorder (PFD) is defined as "impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction." Patient-reported outcome measures (PROMs) are tools that complement clinical assessment, but many have limited clinimetric data. This review aimed to assess PROMs that reported on the feeding skills domain for PFD in children.

METHODS

A search strategy across 4 databases was conducted (July 2022). PROMs were included in the review if they described elements of the feeding skills domain of PFD, had criterion/norm-referenced data and/or a standardized assessment procedure, description, or scoring system available, and were applicable to children ≥6 months. PROMs were mapped to the PFD diagnostic domains and aspects of the International Classification of Function (ICF) model. Quality assessment was completed using the COnsensus-based Standards to the selection of health Measurement Instruments methodology.

RESULTS

Overall, 14 PROMs across 22 papers met inclusion criteria. There was variable methodological quality across the tools, with those more recently developed often receiving better scores, particularly where a more rigorous process for tool development and content validity was reported. Most tools captured ICF aspects of impairment (n = 11, eg, biting/chewing) or activity (n = 13, eg, eating a meal), rather than social participation (n = 3, eg, going to a restaurant).

CONCLUSIONS

Using PROMs with strong content validity, and including some measure of social participation, is recommended as part of an assessment battery for PFD. Consideration of the caregiver/child perspective is an essential component of family-centered care.

Investigation of Assessment Tools in the Area of Pediatric Feeding Evaluation: A Mixed-Methods Study

IMPORTANCE

The new diagnostic code for pediatric feeding disorder (PFD) in the International Classification of Diseases, 10th edition, Clinical Modification, requires that occupational therapists and speech-language pathologists (SLPs) use valid and reliable assessment tools that capture the complexity of PFD.

OBJECTIVE

To determine current assessment tools that clinicians are using across the four domains of PFD: (1) medical factors, (2) nutrition factors, (3) feeding skill factors, and (4) psychosocial factors. A secondary objective was to obtain clinicians' perceptions of the assessment tools.

DESIGN

A mixed-methods study using survey research and focus groups.

SETTING

Online survey and virtual focus groups.

PARTICIPANTS

Occupational therapists and SLPs who identified as clinicians who treat PFDs.

RESULTS

The survey revealed that 65% of the clinicians (N = 445) used a nonstandardized assessment tool across the four domains of PFD. The focus groups (n = 26) revealed four resulting themes that expanded the survey results: (1) no one assessment tool works, (2) clinicians rely on self-created assessments, (3) it takes a team and collaboration, and (4) there are many issues with the current assessment of PFD.

CONCLUSIONS AND RELEVANCE

This study reveals the need for clinicians working with children with PFD to use feeding assessment tools with sound psychometric properties. The requirement for occupational therapists and SLPs to evaluate and treat dysphagia and disorders of feeding indicates the need to provide entry-level education on reliable and valid assessment tools that thoroughly evaluate all the domains of PFD. What This Article Adds: This article highlights current assessment tools used by occupational therapists and SLPs treating PFD and the need for more standardized procedures and tools to evaluate children across the four domains of PFD.

Food Selectivity in Children with Autism: Guidelines for Assessment and Clinical Interventions

Autisms Spectrum Disorders (ASD) are characterized by core symptoms (social communication and restricted and repetitive behaviors) and related comorbidities, including sensory anomalies, feeding issues, and challenging behaviors. Children with ASD experience significantly more feeding problems than their peers. In fact, parents and clinicians have to manage daily the burden of various dysfunctional behaviors of children at mealtimes (food refusal, limited variety of food, single food intake, or liquid diet). These dysfunctional behaviors at mealtime depend on different factors that are either medical/sensorial or behavioral. Consequently, a correct assessment is necessary in order to program an effective clinical intervention. The aim of this study is to provide clinicians with a guideline regarding food selectivity concerning possible explanations of the phenomenon, along with a direct/indirect assessment gathering detailed and useful information about target feeding behaviors. Finally, a description of evidence-based sensorial and behavioral strategies useful also for parent-mediated intervention is reported addressing food selectivity in children with ASD.

Short report: The role of oral hypersensitivity in feeding behaviors of young autistic children

LAY ABSTRACT

Feeding problems are common among autistic children and are linked to negative health consequences. Therefore, understanding feeding problems and factors that influence these behaviors is important for developing supports for children and families. While certain sensory processing patterns are commonly associated with feeding problems, less is known about the link between sensory processing and feeding behaviors in autism, as well as how parent behaviors and feelings during mealtime differ based on child sensory preferences. This research examined two groups of young autistic children who were reported to be picky eaters by their parents: those with and those without oral hypersensitivity. Children with oral hypersensitivity had more difficulty with food acceptance and their parents reported more negative feelings around feeding their child. However, the two groups of children (oral hypersensitive and not) did not differ in their medical/oral motor symptoms, mealtime behavior, or parent use of strategies at mealtimes. This research supports the need for personalized treatment strategies based on the child's sensory preferences to support both the child and parent in managing mealtimes.

Assessment of Feeding Behaviors and Parents' Frustrations of Children with Autism Spectrum Disorder in Lebanon: A Case-Control Study

Children with autism spectrum disorder (ASD) exhibit restrictive and repetitive behaviors that affect their eating habits. The purpose of this study is to identify the behavioral feeding problems and eating habits among ASD children compared to typically developed (TD) children age/gender-matched controls, along with their parents'/caregivers' strategies for dealing with them. It included 43 ASD children and 43 TD children aged two to eleven years. The analysis was performed based on two valid questionnaires: the Behavior Pediatrics Feeding Assessment Scale (BPFA) and "My Child Eating Habits" (MCEH). The BPFA and MCEH scores conceded three manifestations that fall into food selectivity and problematic mealtime behavior in both groups of children. Compared to TD children, children with ASD exhibited higher BPFA scores, which indicated food-related behavioral and skill-based problems (p = 0.004). Children with ASD were less likely to consume fruits, vegetables, and milk than TD children, which may lead to nutritional deficiencies (p = 0.003, p = 0.003, and p = 0.010, respectively). Parents of ASD children were concerned about their behavioral problems and expressed their intention of an early intervention. These findings highlight the importance of nutritional clinical routines that incorporate the evaluation of the nutritional status and feeding behaviors of ASD children.

Eating and sleep problems, related factors, and effects on the mental health of the parents in children with autism spectrum disorder

This study aimed to evaluate the frequency of sleep and eating problems in children with autism spectrum disorder (ASD), the factors associated with these problems, and the relationship with the risk of developing depression and anxiety in their parents. In the study, 156 children with ASD and their parents were included. The Brief Autism Mealtime Behavior Inventory (BAMBI), the Children's Sleep Habits Questionnaire (CSHQ), the Hospital Anxiety Depression Scale (HADS) were completed by the parents. The Childhood Autism Rating Scale (CARS) was administered by the researchers to evaluate the severity of ASD in children. The mean age of children was 8.08 ± 2.84, and 87.2% of the children were male. The mean score of CARS was 41.25 ± 6.16, the mean score of BAMBI was 45.67 ± 11.87, and the mean score of CSHQ was 51.67 ± 10.17. According to the CSHQ, 83.3% of the children had sleep problems. The response rate above the cut-off point in the HAD-A subscale was 59.6%, whereas it was 67.3% in the HAD-D subscale. There was a positive correlation between CARS and BAMBI, CSHQ, HAD-A, and HAD-D subscales. There was a positive correlation between BAMBI and CHSQ, HAD-A, and HAD-D subscales. There was a positive correlation between the CSHQ, HAD-A, and HAD-D subscales. There was a negative correlation between the age of the child with ASD, food refusal, and resistance to bedtime. As sleeping and eating problems affect a large portion of children diagnosed with ASD and their caregivers, large population-based studies evaluating both these problems must be designed and carried out to understand factors affecting the prevalence, development, and persistence of sleeping and eating problems and to determine interventions to reduce these issues.

Dealing with food selectivity and mealtime behaviour in school-children with autism: a qualitative study of special education teachers in Japan

Food selectivity in children with autism spectrum disorder (ASD) is a serious issue in special needs schools, and special education teachers face various difficulties in their management of the problem. The aim of this study is to investigate the difficulties that special education teachers face in managing food selectivity in children with ASD. Data were obtained from 12 special education teachers in 2018 via semi-structured in-depth interviews. Thematic analysis was used to identify key conceptions of the participants' experiences, while qualitative analysis of the interview data revealed three major themes. Their personal and professional thoughts and hopes regarding eating habits in children, feelings of uncertainty about their practice, and their interactions with the children and their parents were the key factors behind the difficulties they experience as special education teachers. The findings improve our understanding of the challenges experienced by teachers managing food selectivity in children with ASD. A different conceptualisation of the problem may lead to difficulties in collaboration among the people who are tasked with solving the problem.

Eating Behaviors of Children with Autism-Pilot Study, Part II

Autism spectrum disorder is characterized by social communication deficit and non-normative behavior. The people with autism often experience troubles with feeding. The purpose of this study was to conduct evaluation of the feeding and eating behaviors among children with autism. Patients and Methods: The study group included 41 high-functioning autistic children. The control group consisted of 34 children without the ASD. The questionnaire was used to assess the nutritional status. Results: The children with ASD fuss during mealtimes more frequently, they require entertaining and diverting their attention, they are fed by parents, and they consume their meals away from the table. The significant difference found in the use of utensils and food selectivity works to the disadvantage of the Study Group. Conclusions: The food selectivity occurs significantly more frequently among children with ASD. The feeding and eating problems should be considered on a wider scale. The cooperation of the multidisciplinary and the parents teams should be proposed in the ASD patients care.

Development and application of specific questions to classify a child as food texture sensitive

Understanding food texture sensitivity in children is important in guiding food selection. The objective of this work was to develop a short questionnaire that could be completed by parents in nonclinical settings to provide a categorization for food texture sensitivity in children. This study evaluated the distribution of children as texture sensitive (TS) or non-texture sensitive (NTS) and the predictive validity of these questions to explain rejection of specific food textures. Three sets of survey data were examined, including data from a home-use test (HUT) in children with and without Down syndrome (DS), and lingual tactile sensitivity measured by grating orientation task (GOT). From three parent-completed surveys, the use of the questionnaire yielded a similar distribution of children in the TS category (16-22%) as previously reported. TS children (4-36 months) were more likely to reject specific food textures, including chewy, hard, lumpy, and "tough meat" (p < .05). A higher percentage of children with a diagnosis of DS were TS (36.9%). Children who were TS showed increased negative behaviors to foods and ate less than NTS children. In older children (5-12 years), TS children were fussier than NTS children (p < .001). Lingual tactile sensitivity was not significantly different by TS/NTS categorization (p = .458). This study demonstrated that the use of these five questions specific to food texture provides a useful tool in categorizing a child as TS/NTS, with this information being useful in selecting preferred food textures. Future studies involving these TS questions should perform psychometric assessments and measures of criterion validity using other questionnaires.

Tools available to screen for child feeding dysfunction: A systematic review

INTRODUCTION

The aim of this systematic review is to identify existing pediatric feeding screening tools that have been shown to be valid and reliable in identifying feeding dysfunction in children.

METHOD

A database search produced 5862 relevant articles to be screened based on pre-determined inclusion/exclusion criteria. After full text review of 183 articles, 64 articles were included in the review.

RESULTS

Forty-four studies detailed development and validation of unique feeding screening tools for the pediatric population. The remaining twenty studies were validations studies of already developed screening tools.

DISCUSSION

Multiple screening tools identified were effective in determining feeding dysfunction in children. Several tools employed excellent techniques to measure reliability and validity for diverse pediatric populations. Careful consideration of the tools listed in this review will help practitioners determine the best method for feeding screening in their facility.

Factors Associated with Feeding Problems in Young Children with Gastrointestinal Diseases

Feeding problems are associated with the consumption of a limited amount or restricted variety of foods and often occur in children with gastrointestinal diseases. The majority of studies to date do not use valid and reliable measurements to detect feeding problems. The aim of this cross-sectional study was to assess behavioral and skill-based feeding problems in young children with gastrointestinal diseases by using a well-established parent-reported feeding measure and identify demographic, anthropometric, and environmental factors associated with maladaptive feeding behaviors in this pediatric population. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and self-reported questionnaires assessing mealtime environment and parental feeding practices. It was found that 18.6% of the sample had abnormal Total Frequency Score (TFS) (frequency of problematic feeding behaviors) and 39.5% had abnormal Total Problem Score (TPS) (number of behaviors perceived as problematic by parents). Younger children, with lower body mass index, lower birth weight, and only children were more likely to have feeding problems. The study showed that parent-reported feeding problems are increased in young children with gastrointestinal diseases and are associated with specific aspects of mealtime environment and parental feeding practices.

Feeding Problems in Typically Developing Young Children, a Population-Based Study

Feeding problems have been estimated to occur in approximately 25–45% of normally developing children. The aim of this study was to investigate the prevalence of feeding problems in typically developing young children in Greece. Child feeding behavior, parents’ feelings about their child’s feeding patterns, and parental feeding practices were also explored. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS). Data on 742 healthy, typically developing children aged two to seven years are presented. Overall, the majority of children in the sample showed high frequency of desirable mealtime behaviors and low frequency of undesirable mealtime behaviors. However, a significant proportion of the cohort presented with food neophobia and low consumption of vegetables. When applying test cut-off scores, it was found that 8.2% of the sample had abnormal Total Frequency Score (TFS) and 26.6% had abnormal Total Problem Score (TPS). The study showed that parent-reported feeding problems are quite common in children of typical development in Greece. Moreover, while the majority of the sample displayed a high frequency of favorable behaviors, specific child feeding behaviors are amenable to improvement.

Impact of Disruptive Behavior in Childhood Feeding Difficulties

Pediatric feeding problems occur in 25-40% of all children and disproportionately affect children with health and/or developmental concerns. Children with autism spectrum disorder (ASD) are at particularly high risk for feeding difficulties, though the connection between ASD and feeding problems is not well understood. As issues related to problematic feeding behavior frequently present to outpatient pediatric clinics, there is a need to understand the common factors that contribute to the development of both adaptive and maladaptive feeding behaviors. The current study examined predictors of problematic feeding behavior in children with and without ASD. Parents of children with ASD reported significantly greater child disruptive behavior, parenting stress, child feeding difficulties, and problematic parental feelings and strategies regarding feeding. Child disruptive behavior and parenting stress contributed the most variance in the prediction of child feeding difficulties and the relation between child disruptive behavior and feeding difficulties was partially mediated by parental strategies and feelings.

Parent-delivered interventions used at home to improve eating, drinking and swallowing in children with neurodisability: the FEEDS mixed-methods study

BACKGROUND

Eating, drinking and swallowing difficulties are common in young children with neurodisability. These difficulties may lead to inadequate calorie intake, which affects a child's nutrition, growth and general physical health.

OBJECTIVE

To examine which interventions are available that can be delivered at home by parents to improve eating, drinking and swallowing in young children with neurodisability and are suitable for investigation in pragmatic trials.

DESIGN

This was a mixed-methods study that included focus groups, surveys, an update of published systematic reviews of interventions, a systematic review of measurement properties of existing tools, evidence mapping, evidence synthesis, a Delphi survey and stakeholder workshops.

SETTING

The study was carried out in NHS hospitals, community services, family homes and schools.

PARTICIPANTS

Parents of children who had neurodisability and eating, drinking and swallowing difficulties. Professionals from health and education. Young people with eating, drinking and swallowing difficulties or young people who had previously experienced eating, drinking and swallowing difficulties.

DATA SOURCES

Literature reviews; national surveys of parents and professionals; focus groups with parents, young people and professionals; and stakeholder consultation workshops.

REVIEW METHODS

An update of published systematic reviews of interventions (searched July-August 2017), a mapping review (searched October 2017) and a systematic review of measurement properties using COnsensus-based Standards for the Selection of health status Measurement INstruments (COSMIN) methodology (searched May 2018).

RESULTS

Significant limitations of the available research evidence regarding interventions and tools to measure outcomes were identified. A total of 947 people participated: 400 parents, 475 health professionals, 62 education professionals and 10 young people. The survey showed the wide range of interventions recommended by NHS health professionals, with parents and professionals reporting variability in the provision of these interventions. Parents and professionals considered 19 interventions as relevant because they modified eating, drinking and swallowing difficulties. Parents and professionals considered 10 outcomes as important to measure (including Nutrition, Growth and Health/safety); young people agreed that these were important outcomes. Stakeholder consultation workshops identified that project conclusions and recommendations made sense, were meaningful and were valued by parents and professionals. Parents and health professionals were positive about a proposed Focus on Early Eating, Drinking and Swallowing (FEEDS) toolkit of interventions that, through shared decision-making, could be recommended by health professionals and delivered by families.

LIMITATIONS

The national surveys included large numbers of parents and professionals but, as expected, these were not representative of the UK population of parents of children with eating, drinking and swallowing difficulties. Owing to the limitations of research evidence, pragmatic decisions were made about interventions that might be included in future research and outcomes that might be measured. For instance, the reviews of research found only weak or poor evidence to support the effectiveness of interventions. The review of outcome measures found only limited low-level evidence about their psychometric properties.

CONCLUSIONS

Opportunities and challenges for conducting clinical trials of the effectiveness of the FEEDS toolkit of interventions are described. Parents and professionals thought that implementation of the toolkit as part of usual NHS practice was appropriate. However, this would first require the toolkit to be operationalised through development as a complex intervention, taking account of constituent interventions, delivery strategies, implementation and manualisation. Subsequently, an evaluation of its clinical effectiveness and cost-effectiveness could be undertaken using appropriate research methods.

FUTURE WORK

Initial steps include FEEDS toolkit development and evaluation of its use in clinical practice, and identification of the most robust methods to measure valued outcomes, such as Nutrition and Growth.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10454425.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 22. See the NIHR Journals Library website for further project information.

Detecting Feeding Problems in Young Children with Autism Spectrum Disorder

Feeding problems are prevalent in children with ASD. We investigated whether the Montreal Children’s Hospital Feeding Scale (MCH-FS, Ramsay et al. in Pediatrics and Child Health 16:147–151, 2011) can be used for young children with ASD. Participants (1–6 years) were selected from a clinical ASD sample (n = 80) and a general population sample (n = 1389). Internal consistency was good in both samples. In general, parents of children with ASD reported more feeding problems than those from the population sample. The response patterns on the individual items was highly similar. There was a slight increase in symptoms with age in the population sample, but not in the ASD sample. These results suggest that the MCH-FS can be used in populations that include children with ASD.

A Comparative Analysis of Chewing Function and Feeding Behaviors in Children with Autism

The present study was aimed to compare chewing performance level and feeding behaviors of children with autism to their typically developing peers. A total of 56 children (37 children with autism, 19 typically developing children) participated in the study. Feeding-related characteristics and observational oral-motor characteristics of children were recorded. The Karaduman Chewing Performance Scale (KCPS) was used to assess chewing performance level, the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was used to assess feeding behaviors of children, and the Turkish version of the Feeding/Swallowing Impact Survey (T-FS-IS) was used to evaluate the effect of the child's feeding and swallowing problem on their parents. Results showed that transition time to solid food intake for children with autism was later than typically developing children (p = 0.014), and they had more tongue thrusting (p = 0.009). There were differences between groups in terms of KCPS (p = 0.002), BPFAS (Total frequency score, p = 0.008; Child frequency score, p = 0.017; Parent frequency score, p = 0.021; Restriction score, p = 0.004), and T-FS-IS (Daily activities, p = 0.004; Worry, p = 009; Feeding difficulties, p = 0.031; Total score, p = 0.001). The present study shows that children with autism had worse chewing function and worse mealtime functioning compared to typically developing children. Their parents perceived mealtime behavior as more problematic, and parents' quality of life related to feeding/swallowing disorders was worse compared to parents of typically developing children. The study results reveal the importance of early assessment and intervention of chewing function and feeding behaviors in children with autism.

Neonatal feeding performance is related to feeding outcomes in childhood

AIM

Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment.

STUDY DESIGN

Ninety-one infants (44 preterm infants born ≤32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT).

RESULTS

Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = -0.44), but were not related to BPFAS scores (p = 0.17; r = -0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p < 0.001), but no differences were detected in preterm compared to full-term performance on the BPFAS (p = 0.87) and PediEAT scores (p = 0.27).

DISCUSSION

Neonatal feeding performance is an important predictor of feeding outcomes at 4 years of age. The Neonatal Eating Outcome Assessment has predictive validity, and the Pediatric Eating Assessment Tool has concurrent validity with relationships to another childhood feeding tool.

Associations between autism symptom severity and mealtime behaviors in young children presented with an unfamiliar food

BACKGROUND

Feeding problems are common in children with Autism Spectrum Disorder (ASD), and there are associations between parent reports of child ASD symptom severity and feeding problems. The current study further explores this association between ASD severity and family mealtime behaviors using directly observed naturalistic mealtime interactions.

METHODS AND PROCEDURES

Seventy-three children (M_age = 5.42 years) were presented an unfamiliar food during a videotaped but otherwise typical home meal. Mealtime behavior was assessed through coding of the videotaped meal using the Dyadic Interaction Nomenclature for Eating (DINE) and parent report (Brief ASD Mealtime Behavior Inventory; BAMBI). ASD severity was assessed with the clinician-completed Childhood Autism Rating Scale-Second Edition (CARS-2).

OUTCOMES AND RESULTS

Greater ASD severity was associated with fewer bites of the unfamiliar food, greater disruptive behavior during meals, and greater parental commands to take bites during meals. We found negative associations between limited food variety and food refusal (BAMBI subscales) and child bites of the unfamiliar food, with higher levels of limited food variety and food refusal associated with fewer bites of the unfamiliar food.

CONCLUSIONS AND IMPLICATIONS

Children with more severe ASD may eat less and be more disruptive during meals, despite parent redirection. We also found associations between the BAMBI and DINE which suggest the BAMBI may be a sensitive measure of mealtime behaviors such as food flexibility and food refusal.

Onset, Trajectory, and Pattern of Feeding Difficulties in Toddlers Later Diagnosed with Autism

OBJECTIVE

To examine the emergence and trajectory of feeding difficulties in young children who are later diagnosed with autism spectrum disorder (ASD).

METHODS

The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was administered to a sample of 93 toddlers with an older sibling with ASD-the high-risk group-and 62 toddlers with no known familial ASD-the low-risk group-as part of a larger infant sibling study. The BPFAS was completed by parents at 15, 18, 24, and 36 months of age. At 36 months, participants underwent a diagnostic assessment and were classified into 1 of the following 4 outcome groups: ASD, nontypical development, high-risk typically developing, and low-risk typically developing. The BPFAS was scored for total frequency of feeding difficulties and autism-specific factor scores previously described in the literature.

RESULTS

The frequency of feeding difficulties increased significantly more rapidly in the ASD group between 15 and 36 months of age, and by 36 months, they exhibited a significantly higher total frequency score than all other groups. Analysis of the factor scores revealed a similar pattern for the food acceptance and mealtime behavior domains but no significant differences in the medical/oral motor domain.

CONCLUSION

Feeding difficulties develop significantly more rapidly in children with ASD, with longitudinal monitoring revealing the steeper trajectory earlier than can be detected with cross-sectional analysis. Children with ASD are at risk of health and social consequences of poor feeding behavior that may potentially be minimized if addressed early and appropriately.

Developmental Trajectories of Feeding Problems in Children with Autism Spectrum Disorder

OBJECTIVE

Although feeding problems are a common concern in children with autism spectrum disorder (ASD), few longitudinal studies have examined their persistence over time. The purpose of this study was to examine the developmental progression of feeding problems across four time points in preschoolers with ASD.

METHODS

Group-based trajectory analyses revealed four distinct trajectories of feeding problems in our sample (N = 396).

RESULTS

The majority of children showed levels of feeding problems that were low from the outset and stable (Group 1; 26.3%) or moderate and declining over time (Group 2; 38.9%). A third group (26.5%) showed high levels of feeding problems as preschoolers that declined to the average range by school age. Few participants (8.3%) showed evidence of severe chronic feeding problems. Feeding problems were more highly correlated with general behavior problems than with autism symptom severity.

CONCLUSIONS

Overall, our findings demonstrated that in our sample of children with ASD, most feeding problems remitted over time, but a small subgroup showed chronic feeding problems into school age. It is important to consider and assess feeding problems in ASD against the backdrop of typical development, as many children with ASD may show improvement with age.

Eating behaviour, behavioural problems and sensory profiles of children with avoidant/restrictive food intake disorder (ARFID), autistic spectrum disorders or picky eating: Same or different?

BACKGROUND

Not much is known at present about the behavioural and sensory profiles of children with avoidant/restrictive food intake disorder (ARFID), the newest addition to the eating disorder diagnostic category in DSM-V. Our aims were to examine eating difficulties, behavioural problems and sensory hypersensitivity in ARFID children, relative to typically developing children with no reported feeding, mental or physical health problems, as well as children with autistic spectrum disorders (ASD; typically associated with a high prevalence of eating problems) or Picky Eating (PE).

METHODS

Four hundred and eighty-six parents of children with ARFID (n = 29), ASD (n = 56), PE (n = 143) or no reported difficulties (n = 259) completed (online) the Behavioral Pediatric Feeding Assessment Scale, the Child Eating Behaviour Questionnaire, Strengths and Difficulties Questionnaire, and the Sensory Experiences Questionnaire about the children.

RESULTS

The ARFID, ASD and PE groups had eating difficulties, behavioural problems and sensory hypersensitivity, relative to the typically developing group, and differed significantly on only some of the dimensions assessed. Specifically, the ARFID group had the lowest food-responsiveness and differed significantly from the PE and typically developing (but not from ASD) groups while the ASD group had significantly greater behavioural problems and social and non-social sensitivity than all other groups.

CONCLUSIONS

Notable overlap in eating difficulties, behavioural problems and sensory profiles of children with ARFID, ASD or PE, with more severe aberrations in ARFID (food-responsiveness) and ASD (hypersensitivity and social problems) on specific dimensions, argue for a dimensional approach to improve therapy and management of children with these disorders.

Socio-demographic Determinants and the Family Ability to Care for Children with Avoidant Restrictive Food Intake Disorder (ARFID)

Background: The ability of families to care for avoidant restrictive food intake disorder children is still low. There is only few studies that examined relationship between family factor to ability to care children with avoidant restrictive food intake disorder. The purpose of this study was to identify the influence of socio-demographic factors on the ability of families to represent children with avoidant restrictive food intake disorder.Method: The study design was cross-sectional, and the majority of samples were gathered using the rule of the thumb, totaling 245 participants. The sampling technique used a type of multistage sampling. Data were collected by questionnaire. We then conducted an analysis of the univariate data using frequency distribution, while for the bivariate data, we used the chi-square technique. All of the data was processed using IBM SPSS 23.0 statistics.Results: The results showed that the ability of care from the families (health promotion behavior) of children with avoidant restrictive food intake disorder  was influenced by the socio-demographic factors, namely maternal age (p= 0.010), the number of children (p= 0.047) and education (p= 0.036).Conclusion: Young mothers need appropriate guidance and direction through good health education. Good health education in young mothers can reduce the pressure faced by the mothers when caring for their children with avoidant restrictive food intake disorder. Health promotion behavior is influenced by maternal education and maternal age. Through good mother's education, the mother will be able to provide a good pattern of care to children who experience avoidant restrictive food intake disorder.

Identifying Associations Among Co-Occurring Medical Conditions in Children With Autism Spectrum Disorders

OBJECTIVE

Children with autism spectrum disorder (ASD) have a high prevalence of co-occurring medical conditions, including speech, sleep, and gastrointestinal disorders (constipation and feeding difficulties); developmental delay; attention deficit/hyperactivity disorder; hypotonia; epilepsy; anxiety; disruptive behavior; pica; and eczema. Less is known about whether these commonly coexist in the same children. We sought to determine clinically meaningful, statistically significant associations among co-occurring medical conditions in children with ASD that could lead to better understanding, identification, and treatment of these disorders.

METHODS

We studied 2114 children with ASD aged 17 months to 5years and 1221 children aged 6 to 17years at 15 Autism Speaks Autism Treatment Network Registry sites. Clinician-reported diagnoses and problems were grouped into 12 core conditions. We determined the observed prevalence (O) of co-occurring conditions and the estimated expected prevalence (E) across the network, adjusting for sitevariability in the prevalence of individual conditions. Pvalues were calculated using a Cochran-Mantel-Haenszel test stratified by site. We identified pairs of conditions co-occurring more frequently than expected (O/E >1) and less frequently than expected (O/E <1) and highlighted statisticallysignificant differences.

RESULTS

Among the 66 condition pairs for each age group, we confirmed previously identified associations, such as sleep disorders and anxiety symptoms, in older children. We found some associations not previously described, including feeding with sleep disorders (younger children only), constipation with sleep disorders, feeding with speech disorders, and constipation with speech disorders.

CONCLUSIONS

We have identified new associations among co-occurring medical conditions in children with ASD, offering the potential to examine common pathways.

Parent-report instruments for assessing feeding difficulties in children with neurological impairments: a systematic review

AIM

This study aimed to review the psychometric properties and clinical application of parent-report instruments that assess feeding difficulties in children with neurological impairments.

METHOD

Papers were identified through five electronic databases based on 15 keywords and were included if they met the following criteria: published in English, described the implementation of parent-report instruments, and included children with neurological impairments (either in the report or a related study population).

RESULTS

In total, 1220 relevant abstracts were screened and 22 full-text articles were evaluated. The following six parent-report instruments met the inclusion criteria: (1) Screening Tool of Feeding Problems applied to children, (2) Paediatric Eating Assessment Tool, (3) Paediatric Assessment Scale for Severe Feeding Problems, (4) Montreal Children's Hospital Feeding Scale, (5) Children's Eating Behaviour Inventory, and (6) Behavioural Paediatric Feeding Assessment Scale (BPFAS). Based on comprehensive psychometric testing and consistently good results, the BPFAS was considered the most valid and reliable instrument. The BPFAS also showed good clinical applicability because it was readily available, required a short administration time, and used a simple scoring system.

INTERPRETATION

We reviewed the available parent-report instruments for assessing feeding difficulties in children with neurological impairments. The BPFAS had the best psychometric properties and clinical applicability.

WHAT THIS PAPER ADDS

Six parent-report instruments were suitable for assessing feeding in children with neurological impairments. The Behavioural Paediatric Feeding Assessment Scale (BPFAS) has the strongest psychometric properties. The BPFAS also has good clinical applicability.

Parenting Intervention to Improve Nutrition and Physical Activity for Preschoolers with Type 1 Diabetes: A Feasibility Study

OBJECTIVE

This study reports the feasibility and acceptability of a healthy eating and physical-activity-focused behavioral intervention for parents of young children with type 1 diabetes (T1D).

METHODS

Ten parents of young children (age 2-5 years) with T1D enrolled. The intervention included six behavioral sessions (five by telephone), diabetes nursing consultation, parent coach contact, text messages, and a study website. Analyses explored feasibility, acceptability, and preliminary findings.

RESULTS

There was evidence of high acceptability (mean parent satisfaction = 1.11, very satisfied). Although most participants completed all of the assessments, there were some barriers to data collection devices. The number of participants within the American Diabetes Association recommended glycemic range doubled; there was no significant change in hemoglobin A1c, diet, or physical activity.

CONCLUSION

There was evidence of feasibility and acceptability and initial evidence of change in hypothesized directions. Minor changes were made for the larger randomized controlled trial.

Feasibility of Including Behavioral Feeding Training Within a Parent Intervention for Young Children With Type 1 Diabetes

Young children with T1D frequently display challenging eating behaviors interfering with diabetes management. The current study explored the feasibility and acceptability of a behavioral parent feeding training session with young children with type 1 diabetes. As part of a larger intervention pilot focused on healthy eating and physical activity, 9 young children (M_age = 4.22) with type 1 diabetes (T1D) and their mothers participated in a novel/non-preferred food training session. Parents were taught strategies and then were given an opportunity to use the strategies with their child. The paradigm was video recorded and content was coded for parent and child behavior. Feasibility was high, and all parents rated the feeding session as acceptable. All parents demonstrated using at least one behavioral feeding skill (M = 3.38, SD = 1.60). All 9 (100%) children touched at least one of their non-preferred foods (M = 2.05, SD = 0.75), and 5 (56%) ate at least one novel/non-preferred food (M = 1.65, SD = 0.87). Parents of young children with T1D demonstrated use of parenting skills after receiving brief instructions, with more children than not trying at least one novel/non-preferred food.

Behavioral Phenotype of ASD Preschoolers with Gastrointestinal Symptoms or Food Selectivity

This study investigated the prevalence and type of gastrointestinal (GI) and food selectivity (FS) symptoms in 163 preschoolers with ASD, and their possible links with core ASD features and emotional/behavioural problems. 40.5% of children with ASD had at least one severe GI symptom or FS. Preschoolers with and without GI symptoms and with and without FS were significantly different on several emotional/behavioural problems and restrictive/repetitive behaviours, whereas they did not differ significantly on performance IQ and autistic severity. The GI plus FS group presented with Sleep Problems, Self-injurious Behaviors and Anxiety Problems. Results indicated the need for early identification of GI disturbances and FS in order to design tailored intervention for these symptoms frequently associated to challenging behaviours in ASD.

Co-occurring behavioral difficulties in children with severe feeding problems: A descriptive study

BACKGROUND

Recent literature highlights the association between behavioral difficulties and the presence of feeding problems in children with an Autism Spectrum Disorder (ASD) relative to children with ASD without feeding problems. However, it is not clear to what extent behavior problems (outside of the meal setting) occur in children with feeding problems without comorbid ASD.

AIMS

The purpose is to describe co-occurring behavioral difficulties of a sample of children with severe food refusal/selectivity and examine potential predictors of behavioral difficulties outside of the meal context.

METHOD AND PROCEDURES

The medical charts of fifty-four patients were reviewed and data were collected on the frequency of caregiver coaching and/or behavioral intervention outside of the meal context. Age, presence of developmental delay/autism, and type of feeding problem were examined as potential predictors of behavioral support.

OUTCOME AND RESULTS

Approximately half of the sample received coaching or individualized intervention. The percentage of caregivers who received individualize coaching were similar across groups. Younger age at admission was a predictor of individual caregiver coaching. Presence of delay/ASD, age, and type of feeding problems were not significant predictors for individualized treatment programing.

CONCLUSION AND IMPLICATIONS

These data provide evidence of difficult caregiver-child interactions that occurs outside of the meal context for some children with severe feeding difficulties and suggest that this association may not be exclusive to children with ASD.

An Evaluation of the Children's Report of Sleep Patterns Using Confirmatory and Exploratory Factor Analytic Approaches

OBJECTIVE

To explore the psychometric properties of the Children's Report of Sleep Patterns (CRSP) in school-aged children by conducting a factor analysis of the Sleepiness Scale and the Sleep Disturbances Scales.

METHODS

Participants included 155 children from two elementary schools (Mage = 9.82) who completed the self-report CRSP. A confirmatory factor analysis (CFA) was conducted using the originally hypothesized structure. A subsequent exploratory factor analysis (EFA) was conducted to determine an alternative factor structure.

RESULTS

CFA revealed that the hypothesized factor structure was not supported. The EFA produced an alternative six-factor solution, which supports the conceptualization of three new scales, Restless Legs Report, Sleep Initiation, and Sleep Maintenance/Night Wakings.

CONCLUSION

The revised measure adds increased specificity with scales related to insomnia and restless leg symptoms. Researchers and clinicians interested in using the CRSP should continue to assess its validity by exploring the relationship between the measure and objective measures of sleep behavior.