A Review of Feeding Interventions For Autism Spectrum

A Review of Feeding Interventions For Autism Spectrum

A Review of Feeding Interventions For Autism Spectrum Disorders and Neurodevelopmental
Disabilities across the Lifespan
Jan T. Marson, OTD, OTR/L, BCP & Linda ONeil, M.S., NvLEND
ABSTRACT: Feeding challenges are reported and difficult to manage for individuals with autism spectrum disorders and neurodevelopmental disorders across the lifespan.
Feeding problems are indicated if an individuals feeding behavior interferes with adequate nutritional intake such that weight gain, health, development, and quality of life are
compromised. Although feeding is one of the most difficult daily tasks required of individuals with neurobiological deficit, very little support has been established for
interventions and accommodations for successful feeding. A transdisciplinary approach will be discussed and demonstrated during the poster session. Strategies to address food
refusals, food over-selectivity, disruptive behavior, and sensory issues will be provided. This session will also provide an evidenced-based review of the current literature.
Clinicians, educator, and caretakers could all benefit from information and strategies, as feeding problems tend to be challenges that are stressful, costly, and difficult to manage
across the lifespan. This presentation will not only have implications for diagnostic purposes and can also contribute to intervention strategies that could be applied to a variety
of individuals with autism and related neurodevelopmental disorders.

Surprising: Children with feeding disorders displayed less affectionate touch, more negative touch and more rejection of the mothers touch. (Feldman, 2004). Journal of the American Academy of Child and Adolescent Psychiatry
Treatments such as restrictive diets, vitamin, and mineral and other diet supplements should not be provided indiscriminately to children with autism unless there is explicit evidence indicating the presence of a gastrointestinal disorder
in a specific case. (Ibrahim, 2009). Pediatrics in Review
Children with eating impairments may be more sensitive than children without disabilities to small changes in food consistencies or other characteristics of the food. The therapeutic implication for children with eating impairments
is that cohesive food textures will be easier to manipulate orally than thinner food textures (Tcheremenska, 1994). American Journal of Occupational Therapy.
Children with ASD were compared to gender-matched controls subjects and no diffidence was found in incidence of gastrointestinal symptoms, although children with ASD had higher incidence of constipation and food selectivity.
Treatments such as restrictive diets, vitamin, mineral, and other diet supplements should not be provided indiscriminately to children with autism unless there is explicit evidence indicating the presence of a gastrointestinal disorder
in a specific case (Ibrahim, 2009Mayo Clinic study).
Adaptable or Adapting: A unifying theme emerged reflecting parents experiences of survival and coping with chronic stress. These included fear for their childs survival, impact of stress on the parent-child relationship and stress from demands of extra care of the child with a feeding concern
(Franklin, 2003). Australian Occupational Therapy Journal
Infantile Anorexia bears important consequences for the mother-child relational dynamics. These findings have valuable clinical implications, especially for intervention strategies focused on the infant-mother relationship (Ammaniti, 2010). International Journal of Eating Disorders
Although oral-motor interventions show promise for enhancing feeding/swallowing in pre-term infants, methodological limitations and variations in results across studies warrant careful consideration in their use (Arvedson, 2010).The use of food (purees, ground, mashed, and table food) rather than
chewy tubes or other nonnutritive objects may better promote generalization of chewing skills (Eckman, 2008), American Journal of Occupational Therapy
Organism-Like: A developmental disorder in itself causes a relational and psychological distress in both mother and child, in a developmental phase when social-affective experiences are connected to feeding function as an important organizer in the biological rhythms and a childs development of self (Fabrizi,
2010). Eating and Weight Disorders
Constipation was very common in children with autism probably resulting from poor diet and could reinforce feeding problems by decreasing appetite and decreasing the willingness to try new foods (Field, 2003). Journal of Paediatric Child Health
Regulatory problems in infancy can increase the likelihood of developing behavioral problems in childhood (Hemmi, 2011). Archives of Disease in Childhood

Search Terms

Patient/Client Population

infant, newborn, infant, premature, preschool, pediatric,
paediatric, children, childhood, toddlers, young children,
adolescents, autism, autism spectrum disorder, cerebral
palsy, cleft lip/palate, Down syndrome, failure to thrive,
infantile, a neurodevelopmental disorders, pervasive
developmental disorder


behavioral approach/intervention, behavioural
approach/ intervention biobehavioral approach/
intervention, caregiver/infant interaction during feeding,
dysphagia, eating, eating behavior, feeding, feeding and
eating disorders of childhood, feeding difficulties,
feeding intervention, feeding problems, food refusal,
food selectivity, interdisciplinary, multidisciplinary, oral
motor, parent training, sensory integration /processing /
regulation/sensitivity, swallowing difficulty

Inclusion Criteria

Peer- reviewed scientific literature published in English
Published since 1992. Level I, II, III, evidence and Level IV
evidence in areas without higher level evidence
Explored qualitative literature related to subjects

Exclusion Criteria

Non-peer reviewed research literature. Published prior
to 1992, except for earlier well-designed, classic
literature . Level V evidence . Articles that are already
included as part of a systematic review

Databases and Sites Searched

Medline, CINAHL, PsycInfo, ERIC, Evidence-Based
Medicine ReviewsCochrane Database
of Systematic Reviews, hand searching of bibliographies,
hand searches of journals as needed

Quality Control/Peer Review Process

NvLEND faculty and trainees developed systematic
review questions and the search terms were developed
as part of NvLEND Feeding Team Project.
Searches were conducted during the months of
September October 2012.
Searches were conducted within the disciplines of
NvLEND Feeding Team Project.
Team member disciplines included: child development
feeding specialist, marriage and family therapist,
occupational therapist, two registered dieticians, speech
language pathologist, two child psychiatrists, school
psychologist, a parent of a child with an autism spectrum
disorder, and a parent of a child with a
neurodevelopmental disorder.
Initial review completed and entered into an evidence
Preliminary work to develop a strategic plan for NvLEND
Feeding Clinic.
Long-range goal is to impact services for children with
feeding disorders that supports integration, education,
and leadership throughout the LEND programs.

Emergent: The incidence of pediatric feeding disorders is increasing, and is likely related to the increased survival rates of very early preterm babies. Possible factors related to the increased incidence of feeding disorders in NICU graduates
include: a) association of feeding problems with neurological sequelae of prematurity; b) the high incidence of GI problems in premature babies; and c) effects of early medical interventions (such as ventilation, NG tubes and other procedures) on
the subsequent acquisition of feeding skills.
There is an intriguing inter-relationship between growth, feeding problems and developmental and neuropsychiatric disorders which have yet to be explored systematically. The presence of severe and persistent feeding problems, or atypical
patterns of FTT (Failure to Thrive), in a very young children should alert clinicians to the possibility of an ASD (Keen, 2008). European Child and Adolescent Psychiatry
According to Schreck 2006, the children with ASD accepted less than half of the identified foods. These data also indicate that children with ASD accepted a narrower range of foods than those accepted by their remaining family members.
More interestingly, the results of this study suggested that food acceptance patterns of children with ASD were more likely to be related to their familys food acceptance patterns than specific characteristics of autism.
Patterned: Effective treatment of feeding problems requires direct, objective assessment to identify the precise nature of the problems Ahearn, 2010). Journal of Autism and Developmental Disorders.
According to Glass, 1994, infant feeding is a highly complex and integrated process involving numerous body systems including: state, behavior tactile responses, motoric control, oral motor function, physiologic control, coordination.
American Journal of Occupational Therapy
Nonlinear: Because a childs failure to eat is rarely the result of a single etiology, treatment is typically conducted by an interdisciplinary team (Cooper-Brown, 2008). Developmental Disabilities Research Reviews.
A major limitation in the research evidence-base on feeding disorders is the lack of consistency and agreement in the definitions and categorizations of feeding disorders. From Nicholls and Bryant-Waugh, 2008: Until approaches for
identification, measurement and classification of feeding disorders can be agreed on, studies of epidemiology, treatment, course and prognosis remain difficult. A related problem in the classification of feeding disorders has been the reliance on
an arbitrary distinction between organic causes (i.e. physical, structural or functional abnormalities) vs. nonorganic causes (assumed to be caused by social or psychological factors). The reality is that most cases of feeding disorders include a
variety of interacting variables that cannot be so easily untangled into non-overlapping categories.
Every fifth child with Cerebral Palsy is completely dependent on help during feeding or needed tube feedings. Every fourth child with Cerebral Palsy was undernourished. The use of gastrostomy tube feeding has increased, however, tube
feedings may still be introduced too late (Dahlseng, 2012). ACTA Paediatrica
Complex Perspective: When diagnosing and treating feeding disorders, education and learning models are needed to support the development of expertise by using multi-faceted approaches. Mentoring and dynamic practice environment is
desired to promote a safe and competent clinician and foster the development of expertise (Dulvestein, 2011). Research and Learning Methodologies
Neonatal feeding performance can predict later neurodevelopmental disorders. Therefore, whether the feeding pattern and the pressures develop with time is an important issue in terms of neurological development. (Mizuno, 2005).
Developmental Medicine and Child Neurology
In difficult cases, treatment by one specialty is likely to be ineffective. A comprehensive evaluation of all spheres and by a multidisciplinary team is the most effective way to treat difficult feeding disorders (Wolff, 1994). Infants and Young
The complexity of the childs problematic feeding at presentation. Complex potential etiology coupled with the requirement for therapeutic adaptation for the individual family necessitates an equally complex intervention. The incorporation of
a multifaceted intervention makes it difficult to uncover direct and specific accountability for individual components on the measured outcomes (Dovey, 2012).
Food selectivity is a significant problem for many children with ASDs. Collaboration among registered dieticians, occupational therapists, and psychologists can enhance effectiveness of the dietary intervention. An interdisciplinary team can
provide the following array: an approach in identifying appropriate foods, providing appropriate eating utensils, considering sensory characteristics of the food need to be identified, supports in modifying the environment, incorporating
supportive behavioral interventions and reducing family stress at meals (Cermak, 2010). Journal of the American Dietetic Association
Individualized approaches with multidisciplinary team participation appear to be promising and effective when addressing feeding disorders (Chatoor, 1997). Infant Mental Health Journal

Ammaniti, A., Lucarelli, L., Cimino, S., DOlimpio, F., & Chatoor, I. (2010). Maternal pathology and child risk factors in infantile anorexia. International Journal of Eating Disorders, 43(3), 233-240.
Arvedson, J. C. & Lefton-Greif, M. A. (2007). Ethical and legal challenges in feeding and swallowing intervention for infants and children. Seminars in Speech and Language, 28(3), 232-238.
Cermak, S. A., Curtin, C., & Bandini, L.G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110, 238-246.
Chatoor, I., Getson, P., Menvielle, E., Brasseaux, C., ODonnell, R., Rivera, Y., & Mrazek, D. A. (1997). A feeding scale for research and clinical practice to assess mother-child interactions in the first three years of life. Infant Mental Health Journal, 18(1), 76-91.
Cooper-Brown, L., Copeland, S., Dailey, S., Downey, D., Petersen, M. C., Stimson, C., & Van Dike, D. C. (2008). Feeding and swallowing dysfunction in genetic syndromes. Developmental Disabilities Research Reviews, 14, 147-157.
Dahlseng, M. O., Finbraten, A., Juliusson, P. B., Skranes, J., Anderson, G., & Vik, T. (2012). Feeding problems, growth and nutritional status in children with cerebral palsy. ACTA Paediatrica, 101, 92-98.
Dovey, T. & Martin, C. (2012). A quantitative psychometric evaluation of an intervention for poor dietary variety in children with a feeding problem of clinical significance, Infant Mental Health Journal, 33(2), 148-162.
Eckman, N., Williams, K. E., Riegel, K., & Paul, C. (2008). Teaching chewing: A structured approach. American Journal of Occupational Therapy, 62(5), 514-521.
Fabrizi, A., Costa, A., Lucarelli, L., & Patruno, E. (2010). Comorbidity in specific language disorders and early feeding disorders: Mother-child interactive patterns. Eating and Weight Disorders, 15, e152-e160.
Feldman R., Keren, M., Gross-Rozval, O., & Tyano, S. (2004). Mother-child touch patterns in infant feeding disorders: Relation to maternal, child, and environmental factors. Journal of the American Academy of Child and Adolescent Psychiatry, 43(9), 1089-1097.
Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Paediatric Child Health, 39,299-304.
Franklin, L. & Rodger, S. (2003). Parents perspectives on feeding medically compromised children: Implications for occupational therapy. Australian Occupational Therapy Journal, 50, 137-147.
Glass, R. P, & Wolf, L. S. (1994). A global perspective on feeding assessment in the neonatal intensive care unit. American Journal of Occupational Therapy, 48(6), 514-526.
Hemmi, M. H., Wolke, D., & Schneider, S. (2011). Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: A meta-analysis. Archives of Disease in Childhood, 96,622-629.
Ibrahim, S. H., Voigt, R. G., Katusic, S. K., Weaver, A. L., & Barbaresi, W. J. (2009). Incidence of gastrointestinal symptoms in children with autism: A population-based study. Pediatrics in Review, 124(2), 680-686.
Keen, D. V. (2008). Childhood autism, feeding problems and failure to thrive. European Child and Adolescent Psychiatry, 17, 209-216.
Nicholls, D. & Bryant-Waugh, R. (2008). Eating disorders of infancy and childhood: Definition symptomatology, epidemiology, and comorbidity. Child and Adolescent Psychiatric Clinics of North America, 18, 17-30.
Schreck, K. A. & Williams, K. (2006). Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities, 27, 353-363.
Tcheremenska, A. R., & Gisel, E. G. (1994). Use of substitute food texture for standard eating assessment in children with cerebral palsy and children without disabilities. American Journal of Occupational Therapy, 48(7), 626-632.
Wolff, R. P. & Lierman, C. J. (1994). Management of behavioral feeding problems in young children. Infants and Young Children, 7(1), 14-25.

Most authors agree that the complexity and inter-related factors involved
in feeding disorders demands that these problems be cared for by an
interdisciplinary team. However, in practice, few such teams existand
there is no consensus on how such teams should be structured, or what
disciplines should be included.

Chaos Theory: The two paradigms--linear predictability and chaotic adaptationare
not mutually exclusive. Some aspects of a problem will be predictable and patterned
while others will be emergent, complex, organism-like and surprising. A chaotic
system may appear to be disordered or random, but it is not.
Image courtesy of [email protected] ,father of a child with autism

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