assessment and treatment of feeding problems in … · assessment and treatment of feeding problems...

Assessment and Treatment of Feeding Problems in Children with ASD

WilliamSharp,Ph.D.Director,FeedingDisordersProgramMarcusAutismCenterChildren’sHealthcareofAtlanta|AssistantProfessorDepartmentofPediatricsEmoryUniversitySchoolofMedicine

Marcus Autism Center

LearningObjectives

• DescribefoodselectivityandrelatedmealtimeconcernsinASD

• Identifymedicaloutcomesandnutritionissuesassociatedwithatypicalpatternsofintake

• Recognizepossiblecontributingfactors,focusingonevidenceofgastrointestinal(GI)concernsinASD

• IdentifyappropriateinterventionsforfeedingdisordersinASDbasedontheseverityofthepresentingproblem.Thisincludesparentconsultation/education,nutritionalguidance,behavioraltherapy,medicalinterventions,andintensiveinpatientservices.


AutismSpectrumDisorder(ASD)

• DSM– 5:Neurodevelopmentaldisorder(s)ofunknowngeneticoriginwheresymptomsunfoldoverthefirstfewyearsoflife:–Persistentdeficitsinsocialcommunicationandsocialinteraction–Restrictive,repetitivepatternsofbehavior,interests,oractivities


Volume:AssociatedFactors

• MedicalIssues:§ Congenitaloracquiredrespiratory,cardiac,andgastrointestinal

problems,whichcausedifficultorpainfuleatingexperiences

• Theseinclude:§ Gastroesophageal reflux§ Foodallergies§ Gastroenteritis§ Dysmotility§ Prematurity(withintubation)§ Bronchopulmonary dysplasia§ Shortbowelsyndrome§ Lactoseintolerance

• Feedingproblemsoccursin40-70%ofchildrenwithchronicmedicalconditions(Lukens&Silverman,2014)

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Variety:AssociatedFactors

• AutismSpectrumDisorder(ASD)

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PediatricFeedingDisorders

• Chronicfeedingconcernsgenerallyinvolveeither:– 1)Volume- FoodRefusal– 2)Variety- FoodSelectivity

Severeproblembehaviorsduringmeals:– Crying– Disruptions– Elopement– Aggression– Spitting– Expulsion

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HistoricalBackground

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• Kanner,L.(1943).Autisticdisturbancesofaffectivecontact.TheNervousChild,2,217-250.

• "Foodistheearliestintrusionthatisbroughttothechildfromtheoutsideworld."


ResearchSupport

• Ledford&Gast (2006)– Mostcomprehensivesummaryatthetime– 7descriptivestudiesidentified– N=381childrenwithASD

• Estimatesrangedfrom46%and89%ofchildrenwithASDdisplayingsignificantfeedingproblems– Oftennoidentifiableorganicprecursor

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ResearchSupport

• Limitations– Nocontrolgroupandmostlydescriptivestudies– Involvedbiasedclinicalsample– e.g.,feedingdisordersclinic

– Lackofuniformitydefinitionoffeedingproblem

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• Inclusioncriteria:1. Publishedbetween1980and20112. Focusedonpediatricpopulation(birthto18years)3. Involvedacomparisongroup4. Evaluatedfeedingand/ornutritioninASDa

standardized,replicablemanner5. Presenteddataeitherdescriptively(e.g.,frequency,

percentages)orstatistically(e.g.,tscores)

• Exclusioncriteria:1. Studieswithknownsamplingbias(e.g.,chartreviews

fromfeedingprograms)2. Studiesfocusingondietarymanipulation(e.g.,GFCF)

Sharp et al (2013). Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. Journal of Autism and Developmental Disorders, 43(9): 2159 - 2173.

Fivefold increaseintheoddsofhavingafeedingprobleminASD

FoodSelectivityPreference- carbohydrates,snacks,fats,and/orprocessedfoodRejection- fruitsandvegetables


PickyEatingvs.FoodSelectivity

FoodselectivityinASDisdistinctfrompickyeatingintermsofduration andintensity• Duration - Foodselectivityisachronicconcernthatpersistsovertime– Suarez,Nelson,andCurtis(2013)indicatednochangeinfoodselectivityin52childrenwithASDovera20-monthperiod.

• Intensity– Foodselectivitymorelikelytoinvolvestrongrefusalbehaviors(e.g.,crying,throwingobjects,aggression)

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13Figure1:Lifespanmodeloffoodneophobia asproposedbyDovey etal.(2008)

FoodSelectivityvs.PickyEating

Sharp et al (2013). Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. Journal of Autism and Developmental Disorders, 43(9): 2159 - 2173.


DailyLivingandQualityofLife

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Required to prepare multiple menus for each meal

Disrupted family meals & further limitations in social interactions

Reduced opportunities to eat at restaurants or social occasions

Increased parental stress regarding health and development

Marcus Autism Center 16


ParentReport

• “I’mworriedabouthishealth.Howcanhestayaliveeatingtwofoodsanddrinkingwater?”

• “Ifyoueversawthosemeltdownsyouwouldn’twanttooffernon-preferredfoodeither.”

• “He’llgagandalmostgetphysicallysickjustwatchinguseatsomethinglikespaghettiandmeatsauce.”

• “Myyoungerchildrenwon’teatthefoodtheydon’tlike,butmysonwithautismwon’tevencometothetable.”

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TheParentExperience

• Mealsdescribedasstressful,chaotic,andenergydepleting

• Mealtimeslackpositiveinteractions• Child’sfoodselectivitylimitedotherfamilymembers’foodchoicesduringmeals

• Caregiversreportedceasingfamilymealstoavoidfurtherworry,guilt,andstress.

Marquenie,K.,Rodger,S.,Mangohig,K.,&Cronin,A.(2011);Suarez,Atchison,&Lagerwey (2016)

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Inclusioncriteria:1. Publishedbetween1980and20122. Focusedonpediatricpopulation(birthto

18years)3. Involvedacomparisongroup4. EvaluatedGIconcernsinASDa

standardized,replicablemanner5. Presenteddataeitherdescriptively(e.g.,

frequency,percentages)orstatistically(e.g.,tscores)

Exclusioncriteria:1. Studieswithknownsamplingbias(e.g.,

chartreviewsfromGIclinics)2. Studiesusingahealthycontrolgroup(i.e.,

screeningoutchildrenwithknowngutissues)


McElhanon, B.O., McCracken, C., Karpen, S., Sharp, W.G. (2014) Gastrointestinal Symptoms in Autism Spectrum Disorders: A Meta-analysis. Pediatrics, 133:5 872-883


Otherkeyfindings

• InsufficientdatatoanalyzedataonotherGIconcerns,suchasrefluxorEOE,oftenlinkwithorganicpathology

• Althoughorganicfactorsleadingtodifficultorpainfuleating,suchasgastroesophageal reflux,gastroenteritis,andfoodallergies,oftenprecipitateorplayaroleinthedevelopmentofchronicfeedingconcernsinotherpediatricpopulations,researchhasyettoidentifyaclearGIlink toaccountfortheemergence,maintenance,andtopographyoffeedingproblemsassociatedwithASD.

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Buieetal.(2010)

• AllofthecommongastrointestinalconditionsencounteredbyindividualswithtypicalneurologicdevelopmentarealsopresentinindividualswithASDs.

• ThecommunicationimpairmentscharacteristicofASDsmayleadtounusualpresentationsofgastrointestinaldisorders,includingsleepdisturbancesandproblembehaviors.

• CaregiversandhealthcareprofessionalsshouldbealerttothepresentationofatypicalsignsofcommongastrointestinaldisordersinpatientswithASDs.

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ClinicalImplications

WhenafeedingconcernsispresentinASD:• Animportantfirststepwhenworkingwithanychildwitha

feedingdisorderinvolvesrulingoutthepotentialcontributionoforganicfactors(e.g.,gastroesophagealreflux,foodallergy)thatmaycausepainordiscomfortalongtheGItract.

• Thismayrequireadoptingalowerthresholdforobtainingsubspecialtyconsultation(e.g.pediatricgastroenterologist;allergist)andincreasedrelianceonobjectivetestinginordertorecognizepathologyandfacilitateadiagnosisgivenlimitationsincommunicationoftenobservedinASD(Buie etal.,2010)

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AMeasurementProblem

1) Nouniversallyaccepteddefinition

2) Highvariabilityinitemcontent

3) Nodirectlinkwithactualdietandnutritionalstatus

4) Foodselectivityhasbeenviewedasamonolithicconstruct(e.g.,totalnumberofitemsacceptedorrejected),withoutconsiderationtosymptomseverityordietarydiversity.

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Bandini etal.(2010)

ThreePartDefinitionofFoodSelectivity:• 1)FoodRefusal:Percentageoffoodsofferedthatthechildwillnoteat

• 2)LimitedFoodRepertoire:Numberofuniquefoodsconsumedoverathree-dayperiod

• 3)HighFrequencySingleFoodIntake(HFSFI):Numberofsinglefooditemseaten4to5ormoretimesdaily.

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Bandini etal.(2010)

• 53childrenwithASDvs.58typicallydevelopingchildren(ages3-11years).

• ChildrenwithASD:• 1)Exhibitedgreaterfoodrefusal(rejecting41.7%offooditemsversus18.9%rejectedbypeers)

• 2)Consumedamorelimiteddietaryrepertoire(consuminganaverageof19foodsoverathreedayperiodvs 22.5consumedbypeers)

• HFSFIwasrarelyobservedinbothgroups.

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Frameworkfordefiningfoodselectivitybyseverity

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TheBehavioralPerspective

• Why?– Symptomseverity– Medicalconcernvs.qualityoflifeissue

• How?– Severe ->IntensiveMultidisciplinaryIntervention– Moderate->Outpatient/homeinterventions– Mild->AdaptExistingGuidelinesforIntroducing

Food(e.g.,EllenSatter)

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Parentvs.ChildPerspective

• Parent– Experiencedeater– Flexibilitywithdifferentfoodtypesandtastes– Eatslargeportionsoffoods

• Child– Non-preferredfoodsareaversive/noxious– Preferredfoodscanbecontaminated

• Changeinpresentationandcontactwithnon-preferredfoods

– Highlymotivatedtoavoidcontact

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Involvechildrenintheprocessthroughchoice• Fooditemstotarget• Initialbitevolume• Jumpinvolume• Whichfoodstoaddnext

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DesigningInterventions

• Overarchingphilosophy:– Treatmentinvolvespersistingwithareasonabledemand– Inordertoestablishtractionforbehaviorchange,beginwith“zoneoflikelysuccess”• Cannotreinforce abehaviorislowprobabilityofoccurring

– Andshouldconsiderthecompletetoolboxofantecedentandconsequencebasedstrategies• Ifonlyrelyingonconsequences,maynotbeabletoreplace/overridefunction


Otheraspectsofthemeal…..

• Increasestructureandroutine:– Regularmeal/snackschedule– Mealsinvolveatablewithageappropriateseating

• DifferentialAttention– Provideattentionandpraiseforappropriatemealtimebehaviors-• Acceptingbites,swallowing,eatingproperlywithaspoon,tryinganewfood,orstayingseatedthroughoutthemeal

– Ignoreminorbehaviorproblems• Whining,negativestatementsregardingfood,messyeating(ifageappropriate)

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GeneralBehavioralConcepts

Treatmentmustinvolve:

Escape ExtinctionPersistence

with a Demand

Levels-• Ignoringnegativestatements• Non-removaloftheplate/spoon

Differential Reinforcement

Recognition of

Appropriate Behaviors

Types-• Praiseandattention• Accesstopreferredactivities• Consumptionofpreferredfood• Escape/break

ExposurewithResponsePrevention


DecisionRules

• Makesurebehaviorisstableacrossmeals– After3mealswithfewproblembehaviors,increasethedemand• Addnewfooditem• Increasebitenumber• Increasebitevolume• Increasemeallength

– Ifproblembehaviorspersistacross2meals,reducethedemandandbreakintosmallersteps

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PowerofChoice

• Fooditemstotarget• Initialbitevolume• Jumpinvolume• Whichfoodstoaddnext

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Questions?

References- Feeding• Bandini,L.G.,Anderson,S.E.,Curtin,C.,Cermak,S.,Evans,E.W.,Scampini,R.,Maslin,M.,&Must,A.(2010).Foodselectivityin

childrenwithautismspectrumdisordersandtypicallydevelopingchildren.TheJournalofPediatrics,157(2),259- 264.• BuieT.,Campbell,D.B.,Fuchs,G.J.,Furuta,G.T.,Levy,J.,Vandewater,J.,etal.(2010).Evaluation,diagnosis,andtreatmentof

gastrointestinaldisordersinindividualswithASDs:aconsensusreport.Pediatrics,125(suppl1),S1-18.• CurtinC,AndersonSE,MustA,BandiniL.Theprevalenceofobesityinchildrenwithautism:asecondarydataanalysisusing

nationallyrepresentativedatafromtheNationalSurveyofChildren'sHealth.BMCPediatr.2010Feb23;10:11.doi:10.1186/1471-2431-10-11.

• EganAM,DreyerML,OdarCC,BeckwithM,GarrisonCB.Obesityinyoungchildrenwithautismspectrumdisorders:prevalenceandassociatedfactors.ChildObes. 2013;doi:10.1089/chi.2012.0028.Epub2013Mar13

• Emond,A.,Emmett,P.,Steer,C.,Golding,J.(2010).Feedingsymptoms,dietarypatterns,andgrowthinyoungchildrenwithautismspectrumdisorders.Pediatrics,126(2),337- 342

• Ho,Eaves,&Peabody(1997).NutrientIntakeandObesityinChildrenwithAutism.FocusonAutismandOtherDevelopmentalDisabilities,12(3),187– 192.

• Johnson,C.R.,Handon,B.L.,Mayer-Costa,M.,&Sacco,K.(2008).Eatinghabitsanddietarystatusonyoungchildrenwithautism.JournalofAutismandDevelopmentalDisorders,20,437- 448.

• Kanner,L.(1943).Autisticdisturbancesofaffectivecontact.TheNervousChild,2,217–250.• Ledford,J.R.&Gast,D.L.(2006).Feedingproblemsinchildrenwithautismspectrumdisorders:Areview.FocusonAutismand

OtherDevelopmentalDisabilities,21,153-166.• Lukens,C.T.&Linscheid(2008).Developmentandvalidationofaninventorytoassessmealtimebehaviorproblemsinchildren

withautism.JournalofAutismandDevelopmentalDisorders, 38,342- 352.• Lukens,C.T.&Silverman,A.H.(2014).SystematicReviewofPsychologicalInterventionsforPediatricFeedingProblems.Journal

ofPediatricPsychology.pp.1–15,2014doi:10.1093/jpepsy/jsu040• Manikam,R.,&Perman,J.(2000).Pediatricfeedingdisorders.JournalofClinicalGastroenterology,30,34-46.• Martins,Y.,Young,R.L.,&Robson,D.C.(2008).Feedingandeatingbehaviorsinchildrenwithautismandtypicallydeveloping

children.JournalofAutismandDevelopmentalDisorders,38,1878- 1887.• Mayes,L.,&Volkmar,F.(1993).Nosologyofeatingandgrowthdisordersinearlychildhood.ChildandAdolescentPsychiatric

ClinicsofNorthAmerica,2,15-25.

References- Feeding• McElhanon,B.O.,McCracken,C.,Karpen,S.,Sharp,W.G.(2014)GastrointestinalSymptomsinAutismSpectrumDisorders:A

Meta-analysis.Pediatrics,133:5872-883.• Satter,E.(1990).Thefeedingrelationship:Problemsandinterventions.JournalofPediatrics,117(2Pt2),S181–S189.• Schmitt,L.,Heiss,C.J.,&Campbell,E.E.(2008).Acomparisonofnutrientintakeandeatingbehaviorsofboyswithandwithout

autism.TopicsinClinicalNutrition.23(1),23- 31.• Sharp,W.G.,Berry,R.C.,McCracken,C.,Nuhu,N.N.,Marvel,E.,Saulnier,C.A.,Klin,A.,Jones,W.,&Jaquess,D.L.(2013). Feeding

ProblemsandNutrientIntakeinChildrenwithAutismSpectrumDisorders:AMeta-analysisandComprehensiveReviewoftheLiterature.JournalofAutismandDevelopmentalDisorders,43(9):2159- 2173.

• Sharp,W.G.,Jaquess,D.L.,Morton,J.S.,&Herzinger,C.(2010).Pediatricfeedingdisorders:Aquantitativesynthesisoftreatmentoutcomes.ClinicalChildandFamilyPsychologyReview,13,348-365.

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