**5. Discussion**

Much progress has been made in our ability to discriminate between constellations of ap‐ parently similar feeding behaviors, and thereby establish differential diagnoses for chil‐ dren with ASD and feeding problems [33-35, 38, 39]. However, each new insight gained seems to beg new questions that call for an answer. The evaluation and treatment for these feeding problems has experienced a similar evolution. We will discuss these in the same order as the chapter has been presented so far, starting with diagnoses, followed by evaluation and treatment.

#### **5.1. Differential diagnoses**

One of the basic needs for the classification of a problem is the use of a nomenclature that is understood and used consistently by the professionals who work in the same domain. There is still no universal consensus what defines a 'feeding problem, eating problem, food refusal, selective/picky eating, mealtime problems' etc., in terms of their characteristics, duration, and severity. It may be the source of confusion and disagreement in the interpretation of re‐ sults from research. Therefore, such a classification would do much to advance the field, by minimizing the need for defining terms by individual investigators in the course of their work. Consensus building of this type is usually called upon by nationally recognized pro‐ fessional organizations which in the case of feeding problems will need to ensure that as broad a spectrum of professionals is represented in the discussions and formulation of such a classification of this complex topic.

Several classification systems are currently in use. These may contribute to some of the in‐ consistencies of results, but each makes a unique contribution, and so, a comparison may be helpful to conclude the discussion on differential diagnoses. The DC: 0-3R [32], the proposed DSM-V [34] and Dovey et al.' [35] classifications have several advantages over the current DSM-IV-TR classification. These are the addition of the constructs of appetite, self-regula‐ tion, and the sensory and post-traumatic feeding problems. Despite these advances, there will always be children who will not exactly fit these new definitions. It must also be noted that the authors of these classifications do not exclude the possibility that a child may present with more than one diagnosis at a time. Nonetheless, there are still gaps. For exam‐ ple, much attention has been paid to nutritional deficiencies and weight loss, whereas nor‐ mal weight gain or over-weight due to hyper-caloric diets associated with high hedonic value from sugars, fats and salt are not yet covered. These diets are quickly becoming an important societal problem. Certain symptoms and diagnostic criteria sometimes overlap and standardized tools are not yet available, especially for sensory food aversions [124]. The recognition of sensory based feeding problems is new and studies will be needed to validate criteria for sensory based food aversions. It is also not yet clear whether some of these feed‐ ing problems are specific to the population with ASD, if they are an associated condition or a learned behavior complicated by their diagnosis.

#### **5.2. Evaluation**

Use of alternative and augmentative communication such as the *Picture Exchange Communi‐ cation System* (PECS) [123] may enhance communication and understanding of social set‐

Much progress has been made in our ability to discriminate between constellations of ap‐ parently similar feeding behaviors, and thereby establish differential diagnoses for chil‐ dren with ASD and feeding problems [33-35, 38, 39]. However, each new insight gained seems to beg new questions that call for an answer. The evaluation and treatment for these feeding problems has experienced a similar evolution. We will discuss these in the same order as the chapter has been presented so far, starting with diagnoses, followed by

One of the basic needs for the classification of a problem is the use of a nomenclature that is understood and used consistently by the professionals who work in the same domain. There is still no universal consensus what defines a 'feeding problem, eating problem, food refusal, selective/picky eating, mealtime problems' etc., in terms of their characteristics, duration, and severity. It may be the source of confusion and disagreement in the interpretation of re‐ sults from research. Therefore, such a classification would do much to advance the field, by minimizing the need for defining terms by individual investigators in the course of their work. Consensus building of this type is usually called upon by nationally recognized pro‐ fessional organizations which in the case of feeding problems will need to ensure that as broad a spectrum of professionals is represented in the discussions and formulation of such

Several classification systems are currently in use. These may contribute to some of the in‐ consistencies of results, but each makes a unique contribution, and so, a comparison may be helpful to conclude the discussion on differential diagnoses. The DC: 0-3R [32], the proposed DSM-V [34] and Dovey et al.' [35] classifications have several advantages over the current DSM-IV-TR classification. These are the addition of the constructs of appetite, self-regula‐ tion, and the sensory and post-traumatic feeding problems. Despite these advances, there will always be children who will not exactly fit these new definitions. It must also be noted that the authors of these classifications do not exclude the possibility that a child may present with more than one diagnosis at a time. Nonetheless, there are still gaps. For exam‐ ple, much attention has been paid to nutritional deficiencies and weight loss, whereas nor‐ mal weight gain or over-weight due to hyper-caloric diets associated with high hedonic value from sugars, fats and salt are not yet covered. These diets are quickly becoming an important societal problem. Certain symptoms and diagnostic criteria sometimes overlap and standardized tools are not yet available, especially for sensory food aversions [124]. The recognition of sensory based feeding problems is new and studies will be needed to validate

tings between the child and members of the family at mealtimes.

620 Recent Advances in Autism Spectrum Disorders - Volume I

**5. Discussion**

evaluation and treatment.

**5.1. Differential diagnoses**

a classification of this complex topic.

In the section on evaluation we noted that the age ranges of evaluations vary from infancy to late adolescence. New assessments may be needed if the age range for a particular do‐ main is not yet available. While a diagnosis of ASD is often not confirmed until a child is 3 to 4 years old, feeding problems are prevalent and often come to attention in infancy [70]. Treatment of a feeding problem does not depend on a diagnosis of ASD. Therefore, it can be dealt with as early as it comes to attention. Such an approach may prevent the serious longterm consequences in terms of weight gain and brain development [46]. Whether early feed‐ ing behaviors may become predictors for a diagnosis of ASD will need further study. However, inclusion of feeding evaluation at the time of the diagnostic work-up is highly rec‐ ommended for the many reasons that have been stated throughout this chapter.

We proposed the *International Classification of Functioning* (ICF; WHO) as the model for eval‐ uation, in order to ensure that the interactions between the child's body functions and struc‐ tures, his health condition, and some contextual factors (i.e. environmental as well as personal factors) will be included in the global evaluation. As of this writing no standar‐ dized evaluation exists that covers all domains of this model. Some evaluations may cover some domains, e.g. activity/participation and environment, or personal factors and activity/ participation and so, feeding assessments based on all domains have to be accomplished by using several evaluations that in combination cover these domains. Another problem is that some of these evaluations have been developed for typically developing children or children with other diagnoses, and will need to be validated for children with ASD. As stated in the discussion of differential diagnoses, collaboration by an interdisciplinary team to develop a tool comprising all three domains would move the field forward substantially.

Many of the evaluation tools reviewed above are questionnaires and may have satisfacto‐ ry psychometric properties [73, 77, 78], while others have only limited psychometric prop‐ erties [13, 85] and need further development. Questionnaires offer the advantage of describing the child's usual abilities. These behaviors are described by a person who is fa‐ miliar with the child, usually a parent or teacher, and reflects the observer's perception of the child's performance. Direct observations of the child's performance in his familiar en‐ vironment are still lacking. This constitutes a significant gap in the treating professional's knowledge, because the treatment plan will be based on results obtained from a question‐ naire or from contexts unfamiliar to the child.

Evaluation of children's nutritional state is based on caloric and nutrient sufficiency of the diet. These are commonly evaluated by food frequency questionnaires, and by 1, or 3-day food records [84]. Food intake is very individual, depending on the child's age and activi‐ ty level, as well as the cultural environment of the family unit. To judge intake adequacy, results are compared to established national standards such as *Estimated Average Require‐ ments, or National Recommended Intake Standards* (NRIS). Evaluation of nutrient adequacy (vitamins and micronutrients) should be part of a nutritional evaluation. A particular chal‐ lenge is the peculiar eating habits of children with ASD; they may be of normal weight, hence pose no major 'medical problem', but their diet may consist predominantly of sug‐ ars, fats and salt. Such diets may also eventually lead to obesity. To assist parents in their daily mealtime struggles a number of evaluations also focus on parent perceptions of their successes and difficulties [80, 81]. We are not aware of any standardized dietary evalua‐ tion for children with ASD.

rent could not tell, but it upset the family considerably. Therefore, the definition of what is 'normal' or 'abnormal' at different stages of development has not yet been adequately de‐ fined. Despite the extensive use of behavioral and sensory integration techniques in the clin‐ ical environment, research using appropriate controls is still lacking to corroborate results from anecdotal reports [8]. Most of the behavioral approaches are 'patient' centered and so, may not take the whole family unit into account. This point has been particularly empha‐ sized by Davies et al. [39]. With an activity that is so 'family/culture' centered as mealtimes

Feeding Issues Associated with the Autism Spectrum Disorders

http://dx.doi.org/10.5772/53644

623

are, a further challenge will be to integrate the family into our treatment approaches.

lems also seems promising. Further research is needed to support these beginnings.

and Erika Gisel1,2

1 Université de Montréal and Center for Interdisciplinary Rehabilitation Research, Montreal,

2 Faculty of Medicine, School of Physical & Occupational Therapy, McGill University, Canada

[1] Aldridge VK, Dovey TM, Martin CI, Meyer C. Identifying clinically relevant feeding

[2] Bryant-Waugh R, Markham L, Kreipe RE, Walsh BT. Feeding and eating disorders in

problems and disorders. Journal of Child Health Care 2010;14 261-270.

childhood. International Journal of Eating Disorders 2010;43 98-111.

, Debbie Feldman1

\*Address all correspondence to: erika.gisel@mcgill.ca

This literature review has illustrated how common feeding problems are in children with ASD. However, it is not yet definitively established whether these problems are different from the general pediatric population. There is no consensus yet on the terminology to be used to describe these problems, on evaluation methods, and use of different diagnostic classification systems. This makes comparisons of different studies very difficult at present. Some feeding problems are similar to the sensory problems described in the DC: 0-3R. This would justify the use of the sensory integration approach, as well as hierarchic desensitiza‐ tion in the treatment of children with ASD and feeding problems. Updating guidelines for diagnoses and clinical practice will contribute to knowledge translation from research to general practice. Preventive approaches, and teaching parents how to handle feeding prob‐

**6. Conclusion**

**Author details**

Geneviève Nadon1

Quebec, Canada

**References**

Although some standardized sensory evaluations exist [125-127], they cover sensory reac‐ tions in many domains of ADL and so, only a few items deal directly with feeding and eating. Hence, the greatest need in this area is an assessment that will fully cover the sen‐ sory domains associated with feeding and eating. Preliminary data are available from a study by Tessier [124], but now need to be subjected to a full psychometric evaluation. Common sensory characteristics should include color, texture, consistency, taste, smell, shape, size of a bite, and appearance which may have an influence on the variety of foods eaten. A study of how language and social skills affect feeding ability and the cognitive aspects that are involved for or against eating a certain food may be appropriate to in‐ clude, since meals are social events. We are also still lacking self-report studies from indi‐ viduals with ASD who may help us understand the challenges they associate with eating. An update of evaluation guidelines or even new guidelines for clinicians and researchers may well arise from the research suggested in this section and would immediately benefit the population we are trying to serve.

#### **5.3. Treatment**

A combination of treatment strategies, based on a holistic evaluation is, in our opinion, the most promising approach to intervention. Regardless which treatment approaches are chos‐ en, intervention based on the contextual factors suggested by the ICF will facilitate the trans‐ fer to different environments, maintenance of the gains over time and hopefully further improvement. Early parent education may be critical to prevent the establishment of feeding problems but will need further study.

We have seen that careful manipulation of foods, the mealtime environment or the nutrient content of the diet may lead to some success in the acceptance of a new food, but one of the challenges remaining is that success with one food or domain does not necessarily general‐ ize to other foods or domains. Such progress will probably only happen once children's cog‐ nitive decisions/intuitive reactions for acceptance/rejection of foods will be more clearly understood. We have suggested that one approach may be to study the more highly func‐ tioning children with ASD or Asperger's syndrome where some communication skills and insight are present. It may also be helpful to begin work by letting the child determine his food preference to facilitate co-operation.

Typically developing children also go through food jags, i.e. phases where they will only eat a limited variety of foods over an extended period of time. One of the authors (E.G.) recalls a parent telling her that his three-year-old son ate only pasta for three months and once he had his fill he 'returned' to eating the well balanced family diet. What this 'fill' was, the pa‐ rent could not tell, but it upset the family considerably. Therefore, the definition of what is 'normal' or 'abnormal' at different stages of development has not yet been adequately de‐ fined. Despite the extensive use of behavioral and sensory integration techniques in the clin‐ ical environment, research using appropriate controls is still lacking to corroborate results from anecdotal reports [8]. Most of the behavioral approaches are 'patient' centered and so, may not take the whole family unit into account. This point has been particularly empha‐ sized by Davies et al. [39]. With an activity that is so 'family/culture' centered as mealtimes are, a further challenge will be to integrate the family into our treatment approaches.
