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J Dev Phys Disabil (2010) 22:401–413

DOI 10.1007/s10882-010-9206-0
O R I G I N A L A RT I C L E

Assessment of Feeding Problems in Children


with Autism Spectrum Disorders

Laura Seiverling & Keith Williams & Peter Sturmey

Published online: 1 June 2010


# Springer Science+Business Media, LLC 2010

Abstract Feeding problems are common among children with autism spectrum
disorders (ASD), but the assessment of feeding behavior in this population has
received little attention. Currently, two of the most promising psychometric
assessments of feeding problems in children and adolescents with ASD are the
Brief Autism Mealtime Behavior Inventory (BAMBI) (Lukens and Linscheid
Journal of Autism and Developmental Disorders 38:342–352, 2008) and the Parent
Mealtime Action Scale (PMAS) (Hendy et al. Appetite 52:328–339, 2009). The
BAMBI addresses common feeding problems exhibited by children and adolescents
with ASD and the PMAS addresses parent behavior associated with child mealtime
problem behavior. Additionally, there are direct observation measures that assess
feeding problems. The current definition for pediatric feeding problems in the
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revisions
[DSM-IV-TR]; American Psychiatric Association [APA] 2000) is limited and
incomplete when assessing feeding problems in children with ASD; however,
proposed changes to diagnostic criteria may lead to more accurate assessment of
feeding problems in this population.

Keywords Feeding disorders . Autism . Assessment . Functional analysis

When first describing children with autism, Kanner (1943) mentioned that eating
problems, particularly problems involving dietary restrictions, appeared to be
common; indeed, Ledford and Gast (2006) reported that between 46% and 89% of

L. Seiverling
The Graduate Center and Queens College, City University of New York, New York, NY, USA

K. Williams
Penn State Hershey Medical Center, Hershey, PA, USA

P. Sturmey (*)
Queens College, City University of New York, New York, NY, USA
e-mail: psturmey@gmail.com
402 J Dev Phys Disabil (2010) 22:401–413

children with autism spectrum disorder (ASD) exhibit selective acceptance of food
or refusal to eat many or most foods with no known medical explanation. The most
commonly reported and researched feeding problem in children with ASD is food
selectivity (Williams and Seiverling 2010), the insistence on eating a narrow range
of foods (Williams and Foxx 2007). Children may be selective by food type,
temperature, texture, brand, and even color of food. Less commonly reported
problems in those with ASD include liquid avoidance, packing (i.e. retaining food in
the mouth for protracted durations), and rapid eating (i.e. eating at a pace that does
not allow for appropriate chewing and swallowing). Although there is a range of
feeding problems among children with ASD, the assessment of these specific
feeding problems has received little study.

Assessment of Feeding Behavior in Children with ASD

While many children with ASD have no comorbid medical problems, it is critical to
ensure that clinicians identify relevant concurrent medical conditions before
initiating feeding interventions. Clinicians should examine the presence of gastro-
esphageal reflux, oral motor difficulties, and other relevant medical conditions as
well as environmental events, such as choking on a food item and parents removing
non-preferred food following child problem behavior. Behavioral assessments of
feeding problems include: (a) indirect questionnaires, (b) direct-observation, (c)
functional assessments, and (d) functional analyses. These assessments have focused
on child behavior, and in one case, parent behavior (Hendy et al. 2009).

Questionnaires

Questionnaires, completed by parents or caregivers, are routinely used in the


assessment of feeding problems. Researchers have used questionnaires to gather
information regarding the presence of a feeding problem as well as variables
involved in maintaining the feeding problem. These questionnaires have several
benefits. They can be completed quickly in any location, do not require trained
personnel, and may be helpful in identifying possible treatment interventions. While
there are benefits to using questionnaires, there are also limitations including the
accuracy of secondary reports and the correlational nature of questionnaires which
make it impossible to validate that a particular variable(s) is responsible for the
feeding problem. Nevertheless, because of their practicality, questionnaires are often
a good starting point in the assessment of feeding problems. The following
instruments are some of the most common feeding assessments used with children
with ASD, as well as other populations.

Children’s Eating Behavior Inventory

Archer et al. (1991) developed the Children’s Eating Behavior Inventory (CEBI) to
to address the contribution of child, parent, and family factors to eating and mealtime
problems for children from a broad age span who had a variety of developmental
J Dev Phys Disabil (2010) 22:401–413 403

and medical conditions. The authors developed the questionnaire to include single-
parent families and families with only one child. Archer et al. developed the CEBI
using a clinical sample of 110 children recruited from outpatient and mental health
clinics referred for eating and mealtime problems and 206 typically developing
children. The children’s ages ranged from 2 to 12 years. While the children in the
clinical sample included nine children with ASD and 11 children with intellectual
disabilities (ID), it also included children with many other diagnoses.
Archer et al. developed items for the CEBI by reviewing the literature on feeding
problems and interviewing professionals with expertise in eating and mealtime
problems. Twenty-eight items address food preferences, motor skills, and behavioral
compliance of the child. Twelve items address parent behavior and the family system
with regards to parent-child behavioral controls, parental cognitions and feelings
about feeding one’s child, and interactions between family members. The CEBI
evaluates the frequency of 40 mealtime and eating behaviors. Informants rate each
item using five-point frequency Likert scales and report if they consider the item to
be a problem by circling “Yes” or “No” for each item. They reported test-retest
reliabilities of .87 for the total score and .84 for individual items identified as a
problem. Values of Cronbach’s alpha were generally above .7 in three subsamples
but was .58 in a fourth subsample. They also found evidence of criterion group
validity, in that the total score distinguished clinical from non-clinic children and
differences between different subgroups of children. Laud et al. (2009) used the
CEBI as an outcome measure in a treatment study involving 46 children aged 36–
145 months with ASD and severe feeding problems referred for treatment at a
feeding program. The CEBI total eating problems score and several subscales
significantly decreased from admission to discharge, suggesting that the CEBI is a
sensitive measure of change.
The CEBI is useful in that questions address both child and parent behavior
during mealtimes and several studies have now reported acceptable psychometric
properties of the CEBI; however, many of the questions do not address the mealtime
problem behaviors commonly seen in those with ASD. Therefore, other feeding
questionnaires may be more appropriate for use with children with ASD.

Screening Tool of Feeding Problems (STEP)

Matson and Kuhn (2001) developed the STEP to assess the presence of feeding
problems in adults with ID. It has 23-items based on the literature on the assessment
and treatment of feeding problems among persons with ID. The five general
categories assessed include aspiration risk, selectivity, feeding skills, food refusal,
and nutrition related problems. For aspiration risk, questions address vomiting and
rumination (i.e. regurgitation of ingested food). For selectivity, questions examine
selectivity by food type, texture, temperature, feeder, and the meal setting. Questions
regarding feeding skills include items concerning swallowing ability, the ability to
chew, the ability to feed independently, and the need for adaptive feeding equipment.
Food refusal items address mealtime refusal or termination and behaviors such as
spitting out food, self-injury during meals, and aggression associated with mealtime.
Questions addressing nutrition-related problems examine over- and under-eating as
well as pica and food stealing. The person completing the questionnaire rates how
404 J Dev Phys Disabil (2010) 22:401–413

often the behavior occurred during the last month using a three-point Likert-type
frequency and severity scales.
Matson and Kuhn reported that the STEP had moderately high test-retest
reliability. For the full scale test-retest reliability was .72, but ranged from .26 to .79
for individual scales. Internal consistency measures were also modest and was .68
overall and ranged from .27 to .70 for subscales. The authors also reported a
principal components analysis which found eight factors with Eigen values greater
than 1. This factor analysis accounted for 58% of the variance and all but one item
loaded on at least one factor. In a second study, Kuhn and Matson (2002)
demonstrated that the STEP had criterion group validity in that it differentiated
groups of people with pica from rumination. Subsequently, Matson et al. (2008)
reported norms and cutoffs for the STEP.
Researchers have not yet validated the STEP with children with ASD, although it
may provide useful information as it does include a wide range of mealtime and
feeding behaviors. As it was developed based upon the literature concerning feeding
problems in persons with ID, it may be an appropriate measure for many children
with ASD as ASD is often comorbid with ID. The utility and limitations of the STEP
should be examined further in future research, with a focus on validating the use of
the measure with other populations including children with ASD.

Brief Autism Mealtime Behavior Inventory

Lukens and Linscheid (2008) were the first to develop a standardized measure to
examine mealtime behavior specifically in children with ASD. They argued that
measures such as the CEBI and STEP did not include items that address the feeding
problems seen in children with ASD, such as mealtime self-injury, aggression, rituals,
and food selectivity, and that previous measures have not adequately addressed
mealtime behavior of young children. They developed the 18-item Brief Autism
Mealtime Behavior Inventory (BAMBI) by comparing eating behavior of 68 children
with ASD and 40 children without ASD. All children were aged 3 to 11 years. Parents
rate items using 5-point frequency Likert scales and assess their child’s variety of
foods eaten, food refusal, and their child’s demonstration of autism features. Parents
are to think about mealtimes with the child during the last 6 months. They are to rate
items as a “Yes” if they think the item is a problem or “No” if they think it is not a
problem. When constructing the scale, Lukens and Linscheid only retained items from
an initial pool of items that had adequate reliabilities.
The authors conducted a factor analysis with yielded a three-factor solution which
accounted for 45% of the variance. This factor analysis was the basis for three
subscales named Limited Variety, Food Refusal and Features of Autism. Lukens and
Linscheid reported that the full scales had a Cronbach’s alpha of .61 in a pilot sample
and .88 in a larger sample. Cronbach alphas for the three subscales were .87, .76 and
.63. They also reported high reliabilities such as .87 for test-retest reliability and .78
for inter-rated reliability. The authors also reported a variety of validity measures
such as correlations with other psychometric measures and mealtime behavior.
A major benefit of the development of the BAMBI is that it was the first
assessment to address feeding problems commonly seen in the ASD population. This
is particularly beneficial because as discussed, previous assessments were not
J Dev Phys Disabil (2010) 22:401–413 405

developed to address the specific mealtime problem behavior seen in this population.
Additionally, it was developed empirically and thus has strong psychometric
properties. Therefore, this measure may be more efficient and useful compared to
more generic feeding assessments that do not target a particular clinical population.
One significant limitation is that the BAMBI has not been independently validated.

Parent Mealtime Action Scale

Recently, Hendy et al. (2009) developed the Parent Mealtime Action Scale (PMAS)
to identify both child and parent mealtime behavior and the frequency that the
parents eat and serve certain foods. Researchers developed questions for the PMAS
based upon past research and clinical practice. They used three separate samples of
2008 mothers, 541 mothers, and 439 fathers. The 2,988 parents involved in
developing norms for this scale had children ages 2 to 12 years. Using an
exploratory factor analysis and two confirmatory factor analyses, a 31 item
questionnaire with nine subscales was derived. Hendy and colleagues criticized the
use of measures that focus on parent attitudes about feeding their children instead of
focusing on parent mealtime behavior. They claimed that collecting data on parent
mealtime behavior will provide parents with more useful information if they plan to
implement changes in order to improve their children’s eating behavior.
The nine subscales of the PMAS include: snack limits, positive persuasion, daily
fruits and vegetables availability, use of rewards, insistence on eating, snack
modeling, special meals, fat reduction, and many food choices. When parents
complete the PMAS, they are asked how often they show each mealtime action
during a typical week and items are scored using a three-point frequency Likert
scale.
Factor analyses indicated that while fathers tended to use PMAS actions like
insistence on eating, mothers were more likely to report using actions such as setting
snack limits, providing daily access to fruits and vegetables, using fat reduction, and
positive persuasion during mealtime. These scales had moderate to high internal
consistencies (Cronbach alphas were .42 to .81) and moderate to high test retest and
inter-rater reliability (ranged from .51 to .78). In the sample used, Hendy et al. found
that children with healthier diets and weight had parents who provided snack limits,
provided access fruits and vegetables on a daily basis, used fat reduction, positive
persuasion to eat, and insisted on eating during meals and who rarely provided
special meals for the child (i.e. a meal separate from the meal eaten by the family),
modeled snacking, and allowed children too many choices at meal time.
Hendy et al. (2010) recently used the PMAS in order to evaluate parent mealtime
actions that mediate associations between children’s fussy-eating and their weight
and diet. Two hundred and thirty-six children (50 with ASD; 84 with other special
needs; 102 without special needs) referred to a feeding clinic for feeding problems
had their weight measured as body mass index percentile (BMI%). Caregivers filled
out the Child Eating Behavior Questionnaire (Wardle et al. 2001) to assess child
fussiness during meals, rated child diet variety using a food preference inventory of
commonly eaten foods, and rated their own use of four actions in the PMAS: special
meals, insistence on eating, snack modeling, and positive persuasion. Using multiple
regression, Hendy and colleagues found that the parent action of presenting special
406 J Dev Phys Disabil (2010) 22:401–413

meals explained variance in both child diet variety and children’s BMI%. In children
without special needs, variance in children’s BMI% explained by child fussiness was
entirely accounted for by parent presentation of special meals while child diet variety
in all diagnostic groups explained by fussiness was also accounted for by
presentation of special meals. This study using the PMAS demonstrates how
feeding assessments may be helpful in identifying which parental behaviors may
lead to change in child eating behavior.
Although the PMAS was not designed specially to address the feeding needs of
those with ASD, the emphasis on parent behavior during mealtime is a contribution
of this assessment. By comparing the correlates of parent behavior and child feeding
problems, clinicians are provided with helpful information regarding what parent
behavior may be contributing to the child feeding problem as well as what changes
parents can make in order to help make changes in child mealtime behavior. No
previous feeding assessments have emphasized parent mealtime behavior.

Food Preference Inventory

Food preference inventories may also be helpful when screening for feeding
problems and also may help identify which foods to target when implementing
intervention. Researchers have used an inventory in several intervention studies
(Paul et al. 2007; Pizzo et al. 2009). In these studies, researchers used the
inventory to determine which foods to target during intervention by asking parents
to indicate which foods they consumed as well as which foods the child consumed.
Researchers then targeted foods eaten by parents but not eaten by the child during
the intervention. In addition, they used the inventory as an outcome measure for
parents to report the number of foods eaten by the children at 1-month and 3-
month follow-up. The inventory used in these studies was a list of 123 commonly
eaten foods from five different food categories.

Direct Observation

Another way to assess feeding problems involves direct observation of eating


behavior instead of using indirect measures such as questionnaires. Ahearn et al.
(2001) criticized the use of questionnaires and anecdotal evidence when assessing
the presence of feeding problems in children with ASD and argued that in
prevalence studies, subject selection procedures are often not well-specified and
third-party reports can be inaccurate. Due to these limitations with use of indirect
measures, Ahearn et al. adapted Munk and Repp’s (1994) direct assessment and
were the first to use a direct assessment to measure food acceptance in children with
ASD. Ahearn et al. assessed 30 children with ASD ages 3 to 14 years old. They
presented three food items from each of four food groups (i.e. protein, fruit,
vegetables, and starch) across six sessions. One item each session was presented in
puree texture. They presented children with 120 bites during the assessment, with 30
of the bites presented in pureed texture. Ahearn et al. classified low acceptance as
eating 30 or fewer bites and moderate acceptance as acceptance of 31 to 60 bites. To
assess food selectivity, Ahearn et al. analyzed acceptance within food groups.
J Dev Phys Disabil (2010) 22:401–413 407

Researchers found that 87% of children assessed exhibited low or moderate food
acceptance and 57% exhibited particular forms of food selectivity by type (e.g.
eating primarily starches) or texture (e.g. only crunchy foods).
A limitation of this direct observation procedure was the failure to use a
comparison group of typically developing children. It is unclear how children with
typical development would score using the procedure and if their acceptance would
differ from those with ASD. Since the authors presented only three foods from each
of four food categories, they may have overestimated how many children fall into
food selectivity and moderate to low acceptance categories. Further, this direct
observation does not attempt to identify any possible factors that may be related to
low acceptance of foods or food selectivity. Therefore, while this assessment may
assist in identifying whether a child appears to have food selectivity and or low to
moderate acceptance, this direct assessment may be less useful compared to other
indirect measures for designing treatment plans for those with food selectivity and
low acceptance. Future research should compare food acceptance of those with ASD
and those without ASD using this procedure in order to assess validity of this direct
assessment measure.

Functional Assessment

Only one study directly assessed the use of an instrument to assess the functions of
food problems in people with developmental disabilities. Matson et al. (2005)
administered the Questions About Behavioral Function to 125 adults living in an
institutional setting. Almost all had profound ID and were aged from 16 to 84 years.
They screened the participants with the STEP (See above) and the Questions About
Behavioral Function (QABF) (Matson and Vollmer 1995), a 25-item rating scale to
identify the functions of maladaptive behavior. The authors then compared the scores
of each scale measuring different functions broken down by groups of participants
with different feeding problems. For example, they found that participants with
mealtime behavior problems, such as aggression and self-injury and with food
refusal were more likely to demonstrate problem behavior maintained by attention
than people who stole food, demonstrated pica or rumination. In contrast people with
pica and rumination were more likely to show automatically reinforced problem
behavior than other problems. Similarly, those people showing food refusal were
more likely than those in other groups to demonstrate higher scores on the Tangible
scale, indicating that their behavior was maintained by tangible reinforcement.
The QABF is the only available scale to date that has been shown to be useful in
assessing the functions of mealtime-related problem behavior. Future research
should extend this preliminary study to evaluate if it is also useful with children and
adolescents with ASD and feeding problems.

Functional Analyses

Another type of direct observation of eating behavior is functional analysis. A


functional analysis involves the systematic manipulation of antecedent and
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consequent variables to determine their influence on a problem behavior (Skinner


1953). Functional analyses can also be useful in identifying reasons why problematic
feeding behavior may be maintained and in determining function-based treatments to
reduce the particular feeding problem. When using non-experimental methods such
as questionnaires, parents may sometimes report that their child’s mealtime problem
behavior is maintained by a particular variable (e.g. attention) when the behavior is
in fact maintained by another variable (e.g. escape).
Najdowski et al. (2003) and Levin and Carr (2001) conducted functional analyses
of mealtime problem behavior prior to feeding interventions to treat food selectivity
in children with ASD. Najdowski et al.’s (2003) functional analysis involved four
conditions: no interaction, attention, play, and escape conditions. In the no
interaction condition, the child’s mother presented five bites of foods not chosen
during a preference assessment, gave no demands to take bites, and provided no
consequences for food refusal. In the attention condition, again, the mother presented
bites and gave no demands; however, when the child engaged in refusal responses,
the mother delivered attention (e.g. “I know the food is so gross.”). During the play
condition, the mother presented both preferred items and non-preferred items,
provided no consequences for refusal, but did provide non-contingent positive
attention every 30 s. In the escape condition, she provided several prompts to initiate
self-feeding, delivered praise when food was accepted, and removed the plate of
non-preferred foods temporarily contingent on food refusal. Mealtime problem
behavior occurred most frequently in the escape condition indicating that escape
from food or other mealtime-related stimuli negatively reinforced problem behavior.
In Levin and Carr’s (2001) functional analysis, they presented bite-sized portions
of foods identified as either preferred (e.g. items selected during an initial preference
assessment) or non-preferred (i.e. items not selected during the preference
assessment) to the child. If the child consumed a bite, the experimenter praised the
child and offered more bites. If the child did not eat the bite, the experimenter
presented the bite again every 10 s; however, if the child engaged in problem
behavior, the experimenter temporarily removed the food and turned away from the
child. Like Najdowski et al. (2003), researchers identified escape from the demand
of eating non-preferred foods as the function of maladaptive mealtime behavior.
Despite the small number of functional analyses of mealtime problem behavior in
children with ASD escape from non-preferred or new foods appears to be a common
function of mealtime problem behavior, although for some children, escape from
pain or escape from foods with a history of being paired with pain (e.g.
gastroesophageal reflux) may also be an important function. Ahearn (2003)
suggested that if a feeding problem is mild or not maintained by escape, then
escape extinction, a typical treatment component for escape-maintained behavior,
may not be a necessary for intervention. When planning interventions, researchers
may find functional analyses useful in identifying treatment components; however,
functional analyses are time consuming compared to using indirect measures such as
questionnaires. Therefore, the use of indirect assessments such as questionnaires,
despite the mentioned limitations, may be a more appropriate first step in identifying
the presence and possible function of a feeding problem. Nevertheless, when the
function of mealtime problem behavior appears unclear, experimental analyses may
be more helpful than indirect measures.
J Dev Phys Disabil (2010) 22:401–413 409

Comparing Feeding Problems in Those with and Without ASD

Some evidence based on assessment questionnaires suggests that children with ASD
have more feeding problems than other pediatric populations. Shreck et al. (2004)
compared the eating habits of children ages 7 to 10 years with and without ASD.
Caregivers of 298 typically developing children and 138 children with ASD
completed: (a) the CEBI (Archer et al. 1991), (b) the Gilliam Autism Rating Scale
(Gilliam 1995), and (c) a food preference inventory (i.e. a comprehensive list of
foods in which caregivers indicated foods eaten by the child and the family), and (d)
a personal history form (i.e. medical history and demographic information). Shreck
et al. found that children with ASD ate fewer fruits, vegetables, starches, proteins,
and dairy products compared to typically developing children. In addition, compared
to caregivers of typically developing children, caregivers of those with ASD reported
more often that their children refused foods, ate a narrow range of foods, required
special utensils, had difficulty with food texture, and were particular about how
foods were presented.
Bandini et al. (in press) recently reported using the Youth/Adolescent Food
Frequency Questionnaire (YAQ) to assess the differences in eating patterns between
children with ASD and typically developing children. The YAQ is a modification of
the Harvard Food Frequency Questionnaire modified so that parents report their
children’s refusal of 131 foods on a daily basis. They found much higher rates of
food refusal in their sample children with ASD than in their sample of typically
developing children. Other studies have shown that caregivers of children with ASD
are more likely to report that their children make food choices based on texture of
the food and report more problems in getting their children to eat (Schmitt et al.
2008), that their children avoid food and engage in more neophobic eating behavior
(Crist and Napier-Phillips 2001), and that their children are picky eaters and resist
trying new foods (Lockner et al. 2008) compared to caregivers of typically
developing children. Lockner et al. also found that caregivers of children with
ASD were more likely to report the use of nonprescription supplements with their
children compared to caregivers of children with typical development. In a recent
study, Kalyva (2009) found that adolescent girls with Asperger syndrome were at a
higher risk for eating problems such as bulimia, food preoccupation, oral control
issues, and overall eating problems compared to typically developing peers
according to their own reporting and their mothers’ reports.
Several studies have shown that those with ASD exhibit food selectivity more
than other clinical populations. Field et al. (2003) collected records on 349 children,
ages 1 month to 12 years, referred to an interdisciplinary feeding program and found
that food selectivity occurred more frequently among children with ASD compared
to those with other developmental disabilities such as cerebral palsy and Down
syndrome. In a recent study, Fodstad and Matson (2008) compared eating behavior
of adults with ASD and ID to those with ID alone. They administered the STEP
(Matson and Kuhn 2001) to a group of 60 adults with ID with and without ASD and
found that those with ASD and ID were reported to have more severe feeding and
mealtime behavior compared to those with ID alone. Further, similar to the findings
of Field et al. (2003) with children, Fodstad and Matson found that adults with ASD
and ID had more behaviorally-based feeding problems, such as food selectivity and
410 J Dev Phys Disabil (2010) 22:401–413

refusal (e.g. mealtime termination and disruptive behavior associated with


mealtime), compared to those with ID alone. They also found that those with ID
alone showed more feeding skill problems (e.g. chewing and swallowing) compared
to those with ASD and ID. These studies indicate that prevalence of different types
of feeding problems appears to vary across different clinical populations with food
selectivity being more common in those with ASD compared to other clinical
groups.
There are numerous reasons why certain feeding problems, particularly, food
selectivity may occur more frequently in the ASD population compared to those
with other developmental disabilities. First, it may be that their insistence on eating a
narrow range may be an extension of repetitive behavior patterns, a characteristic of
ASD. Further, children with ASD often show difficulties in imitation, generalization,
and communication, which may also be involved in the development and
exacerbation of these feeding problems.

Use of the DSM-IV-TR for ASD and Feeding Problems

Despite Kanner’s (1943) inclusion of aberrant eating behavior as a common feature


of those with ASD in his initial case descriptions, more common diagnostic criteria
include impairments in socialization, communication, and restriction in behavior or
interests (American Psychiatric Association 2000). The Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American
Psychiatric Association [APA] 2000) criteria for Feeding Disorder of Infancy and
Early Childhood (FDIEC) include: (a) persistent failure to eat adequately, as
reflected in significant failure to gain weight or significant weight loss over at least
1 month; (b) absence of a medical condition severe enough to account for the
feeding disturbance, (c) the feeding disturbance is not better accounted for by
another medical disorder or lack of available food; and (d) the onset of the disorder
must be before 6 years of age. In addition, the definition describes associated
features of the disorder as problems with parents’ feeding, parental psychopathology,
and child abuse and neglect. Despite the fact that research has shown feeding
problems to be common among children with ASD (Ledford and Gast 2006), the
utility of the DSM-IV-TR diagnostic criteria for FDIEC appear limited and
incomplete when assessing the feeding problems of this population. For example,
Williams et al. (2009), examined how many children referred to a pediatric feeding
program for feeding problems met criteria for FDIEC as defined by the DSM-IV-TR.
They classified feeding problems of children referred to the clinic into five
categories: (a) food refusal (i.e. failure to consume enough calories to maintain a
weight and height ratio equal or greater to the fifth percentile and children with
adequate growth but who received supplemental tube feeds); (b) selectivity by
texture; (c) selectivity by type; (d) oral-motor delays; and (e) dysphasia (i.e.
problems with swallowing). Williams and colleagues found that out of 234 children
referred to the clinic, only 19 met criteria for FDIEC—1 child with food selectivity
and 18 children with food refusal. Of the children who did not meet the DSM-IV-TR
diagnostic criteria, 62% (133) of children had food selectivity by type, 60% (129) of
children had food selectivity by texture, 12% (25) of children had food refusal, 10%
J Dev Phys Disabil (2010) 22:401–413 411

(21) had oral motor delays; and 1% (2) of children had dysphagia. This sample
included 36 children with ASD, none of whom met the DSM-IV-TR criteria for
FDIEC. All 36 children had either food selectivity by type or texture, which is
consistent with other samples of children with feeding problems which have also
found food selectivity by type or texture were the most prevalent feeding problems
in this population (Field et al. 2003; Fodstad and Matson 2008). As most children
with ASD who have feeding problems do not meet DSM-IV-TR criteria for FDIEC,
the DSM-IV-TR may not be as valuable as other measures when assessing feeding
problems in this population.

Future Directions

Feeding problems appear to be more common in children with ASD compared to


those with typical development. In addition, children with ASD tend to exhibit
certain feeding problems, such as food selectivity by food type and texture, more
than other clinical populations. There is a small but growing literature on assessment
of feeding problems in children with ASD. Although several psychometric measures
are now available they vary considerably in their content and the degree to which
they assess the feeding problems that children with ASD commonly display. At this
time, promising feeding assessments for those with ASD appear to be the BAMBI
(Lukens and Linscheid 2008) and the PMAS (Hendy et al. 2009). The BAMBI was
the first measure developed specifically to address feeding problems in the ASD
population and its development may start a trend in the designing of measures that
address feeding problems exhibited in particular clinical populations. Prior to the
development of the PMAS (Hendy et al. 2009), most feeding assessments
emphasized parent attitudes regarding child behavior. The PMAS, although not
developed to assess feeding problems in those with ASD, measures parent behavior
that may contribute to child mealtime problems and thus, can provide useful
information regarding what parent behavior changes may lead to improved child
mealtime behavior.
One of the limitations of all indirect measures is that it is unknown if the
information they provide is representative of the behaviors that parents and children
actually exhibit in meals. Future research should provide external validation of these
questionnaires by comparing the results of the questionnaires to mealtime
observations. Future research should also evaluate the clinical utility of direct
observation methods and functional analyses in the assessment and treatment of
feeding problems in children with ASD. Further, although researchers and clinicians
recognize the importance of medical evaluation in the assessment of food-related
problems, there have not been any specific protocols developed and evaluated for
physicians to use to identify associated medical problems. Recently, Bandini et al.
(in press) reported that children with ASD are much more likely to have inadequate
nutritional intake than typically developing children. Thus, screening for nutritional
deficiencies should also be part of an initial medical evaluation prior to behavioral
interventions, as this information may play a part in identifying target foods.
Last, as mentioned, the DSM-IV-TR diagnostic criteria for FDIEC are limited
when assessing the feeding problems of children with ASD. The upcoming
412 J Dev Phys Disabil (2010) 22:401–413

Diagnostic and Statistical Manual of Mental Disorders, (5th ed., [DSM-V];


American Psychiatric Association [APA] 2010) will eliminate the diagnosis of
FDIEC and a new diagnosis has been proposed as a replacement. This proposed
diagnosis, Avoidant/Restrictive Food Intake Disorder, should prove to be more
appropriate for the diagnosis of the feeding problems of children with ASD. The
primary criterion for this disorder has been proposed to be “eating or feeding
disturbance as manifested by persistent failure to meet appropriate nutritional and/or
energy needs leading to one or more of the following; significant weight loss (or
failure to gain weight or faltering growth in children), significant nutritional
deficiency, dependence on enteral feeding, or marked interference with psychosocial
functioning”. This diagnosis would seem to be appropriate for the extreme
selectivity commonly found among children with ASD. It could also be used to
diagnose children who have food refusal and are dependent upon supplemental tube
feeds, who were not necessarily included under the DSM-IV criteria. Although the
final diagnostic criteria have not been determined, if adopted as proposed, the
diagnosis of Avoidant/Restrictive Food Intake Disorder will provide a useful tool in
the assessment of the feeding problems common in those with ASD.

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