**1. Introduction**

Feeding issues are prevalent in young children. Feeding will be defined here as the process of in‐ gesting food and drink in social environments where such activities take place. Estimates of problems may range from 13 to 50% in typically developing children, but may be as high as 80% in children with developmental disabilities [1-7]. In 1 to 10% of these children problems may be‐ come chronic and may affect their health and development [1, 8]. Anatomical, metabolic, gastro‐ intestinal, motor or sensory problems may be the cause of or may contribute to some of these feeding problems [8]. A global medical assessment is necessary when feeding problems persist, because some medical symptoms may not be recognized as associated with feeding at first sight, such as asthma. Even if the association remains unclear, a high prevalence of asthmatic children, particularly with nocturnal asthma, have gastro-esophageal reflux (GER) [9]. Both feeding and eating, the processing of food and drink in the mouth and swallowing, are also known as activi‐ ties of daily living (ADL) and studies examining the specific problems of children with Autism Spectrum Disorders (ASD), found that 46 to 89% have feeding problems [10-18].

While these studies are important to determine the nature and extent of such problems, re‐ sults have to be interpreted with caution. First, small and heterogeneous sample sizes do not permit generalization to the entire population of children with ASD. There is also no consen‐ sus regarding the terminology and definitions used to describe these problems, i.e. feeding problem, eating problem, food refusal, selective/picky eating, mealtime problems, etc… Fur‐ thermore, authors use different instruments to measure these problems. Caregiver question‐ naires are the most commonly used tools for this purpose; however, their psychometric properties are not well established. Further, observational studies of these subjects' eating skills or self-reports from them are lacking. This makes it difficult to compare studies or to replicate their results.

© 2013 Nadon et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Despite these methodological limitations, it is clear that feeding problems constitute a fre‐ quent and significant preoccupation for many parents of children with ASD [18]. In support of such concerns, some studies found that children with ASD are more susceptible to feed‐ ing problems than children with other developmental disabilities [19-23]. There is as yet no defined etiology for feeding problems in children with ASD neither is there for the pediatric population in general. Significant associations have been found between oral-motor, gastro‐ intestinal and sensory problems in children with ASD [19, 24-26]. According to Skinner [27], individuals' responses to environmental stimuli shape their behaviors and this interaction constitutes the foundation for learning. When feeding is described as a struggle in the family environment, behavioral approaches such as escape extinction and positive reinforcement are used by professionals and gradually assumed by the caregiver. However, feeding prob‐ lems may also arise from a limited ability to communicate or from poor social and cognitive skills. Eating skills and mealtime manners are learned by observation and imitation, yet these associations have not been correlated with ASD. More recent studies have found simi‐ larities between anorexia nervosa (AN) and ASD, on the basis of global processing deficits, inflexible style of thinking, communication difficulties and impairment of interpersonal functioning and social interactions [28-30]. Hence, treatment approaches used for AN might also be suitable for ASD.

Criterion A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain

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Criterion C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by

*Feeding Behavior Disorder* [32] applies «when the child does not regulate his feeding in ac‐ cordance with physiological feelings of hunger or fullness» and comprises six categories to be described below. The future DSM-V [34] *Avoidant/Restrictive Food Intake Disorder* will in‐ clude a description of three main subtypes that will map onto the first three categories of the DC:0-3R [32]. The reader is referred to the APA DSM-V website for further details on the inclusion criteria [34]. A clarification has been made to consider severe feeding problems, when they exceed what is normally expected with a concurrent medical condition or anoth‐ er mental disorder, which may include ASD [34]. The criterion has been further modified to

The central problem of infantile anorexia is a lack of appetite, as manifested by a lack of interest in eating and food refusal, and issues of control and autonomy that may exist be‐ tween the parent and the child [33, 35]. Parent recall indicates that the child will be easily distracted by environmental stimuli, which interfere with nursing from the bottle or breast from the very first weeks of life. Later, children in this category never complain of hunger and are satisfied with only a few bites. Parents worry when their child does not eat enough and often try different strategies to encourage their child to eat. Early on dis‐ traction manoeuvres may work, but they do not last, and parents are forced to invent new strategies to entice their child to eat. They may coax the child and sometimes use forcefeeding. Despite these efforts the child does not eat enough to maintain normal growth, which may later lead to malnutrition, but will come to attention when the child does not

In contrast to *infantile anorexia,* children with sensory based feeding problems are not lacking in appetite and eat an adequate diet as long as it meets their preferences which are consis‐ tent and stable over time [33]. These food preferences may be based on food texture, taste, smell, temperature or appearance. Sensory aversions may range from mild to severe, with some children refusing only a few items and others a whole food category. The varying in‐

Criterion B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g.

**Table 1.** Diagnostic Criteria for *Feeding Disorder of Infancy or Early Childhood* from the DSM-IV-TR [31]

also include children that do not loose or fail to gain weight.

weight or significant loss of weight over at least 1 month.

Criterion D. The onset is before age 6 years.

**2.1. DC: 0-3R and Proposed DSM-V**

esophageal reflux).

lack of available food.

*2.1.1. Infantile anorexia*

follow his expected growth curve.

*2.1.2. Sensory food aversions*

Considering the impact feeding problems can have on children's health, the stress experi‐ enced by parents, as well as the impact on social participation of child and family, it will be crucial to continue documenting feeding problems in this group, to better understand them and thereby, offer better treatment. Similarly, it will be just as important to provide profes‐ sionals with better guidelines to evaluate feeding problems, as well as to appreciate the con‐ sequences they have on family function.

### **2. Essentials of diagnosis**

The severity of pediatric feeding problems can range from mild to severe. Despite this wide range, there are no clear indicators to determine which problems will be transient and those that will persist over the long term and may have an impact on children's health [1]. The DSM-IV-TR, a classification for psychiatric disorders, describes criteria for *feeding disorder of infancy and early childhood*; however, this particular diagnosis is rarely used in research or clinical practice. There are several reasons for this. A majority of the children who are refer‐ red for feeding problems, in general, do not meet all of the criteria outlined in the DSM-IV-TR (Table 1) [7, 31]. For example, children do not qualify even if they have severe feeding problems but normal weight (e.g. eating foods of poor nutritional value; eating only purees or being tube fed) [7]. It is also not clear which medical or mental conditions, including ASD, would exclude a child from a diagnosis of *feeding disorder of infancy and early childhood*. Other diagnostic classifications and screening criteria appear promising. These are: *Feeding Behav‐ ior Disorder* [32, 33], *Avoidant/Restrictive Food Intake Disorder* [34] and *Feeding Disorder* [35-37], the *Wolfson Diagnostic Criteria* [38] and the framework proposed by Davies et al.[39].

Criterion A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least 1 month.

Criterion B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g. esophageal reflux).

Criterion C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.

Criterion D. The onset is before age 6 years.

Despite these methodological limitations, it is clear that feeding problems constitute a fre‐ quent and significant preoccupation for many parents of children with ASD [18]. In support of such concerns, some studies found that children with ASD are more susceptible to feed‐ ing problems than children with other developmental disabilities [19-23]. There is as yet no defined etiology for feeding problems in children with ASD neither is there for the pediatric population in general. Significant associations have been found between oral-motor, gastro‐ intestinal and sensory problems in children with ASD [19, 24-26]. According to Skinner [27], individuals' responses to environmental stimuli shape their behaviors and this interaction constitutes the foundation for learning. When feeding is described as a struggle in the family environment, behavioral approaches such as escape extinction and positive reinforcement are used by professionals and gradually assumed by the caregiver. However, feeding prob‐ lems may also arise from a limited ability to communicate or from poor social and cognitive skills. Eating skills and mealtime manners are learned by observation and imitation, yet these associations have not been correlated with ASD. More recent studies have found simi‐ larities between anorexia nervosa (AN) and ASD, on the basis of global processing deficits, inflexible style of thinking, communication difficulties and impairment of interpersonal functioning and social interactions [28-30]. Hence, treatment approaches used for AN might

Considering the impact feeding problems can have on children's health, the stress experi‐ enced by parents, as well as the impact on social participation of child and family, it will be crucial to continue documenting feeding problems in this group, to better understand them and thereby, offer better treatment. Similarly, it will be just as important to provide profes‐ sionals with better guidelines to evaluate feeding problems, as well as to appreciate the con‐

The severity of pediatric feeding problems can range from mild to severe. Despite this wide range, there are no clear indicators to determine which problems will be transient and those that will persist over the long term and may have an impact on children's health [1]. The DSM-IV-TR, a classification for psychiatric disorders, describes criteria for *feeding disorder of infancy and early childhood*; however, this particular diagnosis is rarely used in research or clinical practice. There are several reasons for this. A majority of the children who are refer‐ red for feeding problems, in general, do not meet all of the criteria outlined in the DSM-IV-TR (Table 1) [7, 31]. For example, children do not qualify even if they have severe feeding problems but normal weight (e.g. eating foods of poor nutritional value; eating only purees or being tube fed) [7]. It is also not clear which medical or mental conditions, including ASD, would exclude a child from a diagnosis of *feeding disorder of infancy and early childhood*. Other diagnostic classifications and screening criteria appear promising. These are: *Feeding Behav‐ ior Disorder* [32, 33], *Avoidant/Restrictive Food Intake Disorder* [34] and *Feeding Disorder* [35-37],

the *Wolfson Diagnostic Criteria* [38] and the framework proposed by Davies et al.[39].

also be suitable for ASD.

sequences they have on family function.

600 Recent Advances in Autism Spectrum Disorders - Volume I

**2. Essentials of diagnosis**

**Table 1.** Diagnostic Criteria for *Feeding Disorder of Infancy or Early Childhood* from the DSM-IV-TR [31]

#### **2.1. DC: 0-3R and Proposed DSM-V**

*Feeding Behavior Disorder* [32] applies «when the child does not regulate his feeding in ac‐ cordance with physiological feelings of hunger or fullness» and comprises six categories to be described below. The future DSM-V [34] *Avoidant/Restrictive Food Intake Disorder* will in‐ clude a description of three main subtypes that will map onto the first three categories of the DC:0-3R [32]. The reader is referred to the APA DSM-V website for further details on the inclusion criteria [34]. A clarification has been made to consider severe feeding problems, when they exceed what is normally expected with a concurrent medical condition or anoth‐ er mental disorder, which may include ASD [34]. The criterion has been further modified to also include children that do not loose or fail to gain weight.

#### *2.1.1. Infantile anorexia*

The central problem of infantile anorexia is a lack of appetite, as manifested by a lack of interest in eating and food refusal, and issues of control and autonomy that may exist be‐ tween the parent and the child [33, 35]. Parent recall indicates that the child will be easily distracted by environmental stimuli, which interfere with nursing from the bottle or breast from the very first weeks of life. Later, children in this category never complain of hunger and are satisfied with only a few bites. Parents worry when their child does not eat enough and often try different strategies to encourage their child to eat. Early on dis‐ traction manoeuvres may work, but they do not last, and parents are forced to invent new strategies to entice their child to eat. They may coax the child and sometimes use forcefeeding. Despite these efforts the child does not eat enough to maintain normal growth, which may later lead to malnutrition, but will come to attention when the child does not follow his expected growth curve.

#### *2.1.2. Sensory food aversions*

In contrast to *infantile anorexia,* children with sensory based feeding problems are not lacking in appetite and eat an adequate diet as long as it meets their preferences which are consis‐ tent and stable over time [33]. These food preferences may be based on food texture, taste, smell, temperature or appearance. Sensory aversions may range from mild to severe, with some children refusing only a few items and others a whole food category. The varying in‐ tensities of these aversive reactions may lead to food refusals that may get generalized to foods with similar characteristics or to all new foods. Some children are so sensitive to the sensory characteristics of the rejected food that they will not eat any other food that comes in contact with the refused food, or refuse that certain foods be placed in their line of vision, or refuse to eat when others, seated next to them, eat a food that has been rejected or it may trigger an aversive reaction (Figure 1). What distinguishes *Sensory Food Aversions* from nor‐ mal food preferences is the degree of severity of the food refusal and the presence of nutri‐ tional deficiencies or oral-motor delays arising from a lack of exposure to more demanding food textures [33]. Some studies have shown a significant relationship between food selec‐ tivity or mealtime problems and problems with sensory modulation [26, 40].

*2.1.4. Feeding disorder associated with concurrent medical conditions*

medical problems.

*2.1.5. Feeding disorder of state regulation*

may be an early indicator of ASD.

The DC: 0-3R [32] also lists feeding problems that are associated with medical conditions whereas the DSM-V [34] will only deal with mental health issues, not medical problems. Children with medical conditions and associated feeding problems are able to initiate eat‐ ing; however, they may soon show signs of distress and/or fatigue and may not be able to finish their meal [33]. This inability may vary according to the severity of the medical condi‐ tion. Heart and respiratory problems, as well as allergies and gastro-esophageal reflux are frequently associated with this type of feeding disability. Resolving the medical issues often improves the feeding related problems, although the latter may not always be eliminated completely. Several symptoms such as gagging, lack of appetite, food refusals, weight loss or growth faltering, may also be found in conjunction with other medical diagnoses. It is es‐ sential therefore, that children with feeding problems be carefully examined for associated

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This feeding disorder is characterized by its onset in infancy, difficulty in establishing a qui‐ et alert state necessary for feeding, weight loss, and absence of any medical condition that could explain these problems. This disturbance in state regulation, similar to disturbances in sleep or crying, will not be included in the next issue of the DSM-V [34]. Feeding is the first competent motor skill of infants [41] and is also an early indicator of self-regulation [33]. Therefore, specific aspects of feeding problems that also coincide with the behavior charac‐ teristics of ASD, might become 'red flags' for its diagnosis. Infants must be alert and able to maintain a calm state during feeding right from birth, i.e. the infant should not fall asleep at the onset of feeding, be too agitated or too distressed to feed [33]. Infants triple their body weight in the first year of life [41]. Therefore, a child who does not gain weight will not be able to maintain his established growth curve, or tends to cross over into a lower growth curve, which is interpreted as 'losing weight'. Mother and infant are 'mutual caregivers' [42]; the child who engages the mother visually, smiles or babbles and gains weight pro‐ vides feedback to the mother that she is 'doing a good job', whereas a child who is colicky, cries, arches away from the mother and does not seem to eat enough causes the mother to worry and to try to compensate. She may feed the child more frequently than a child who eats well and she will also feed the child longer to compensate for the emerging weight loss [43]. The recent development of the P.O.P.S.I.C.L.E Center Infant and Child Feeding Ques‐ tionnaire© (Parent Organized Partnerships Supporting Infants and Children Learning to Eat), an age-specific questionnaire available on the web, gives parents information regard‐ ing typical feeding development and helps them identify whether referral to a health profes‐ sional (feeding specialist) is indicated [44]. Future studies will need to determine whether the constellation of early weight loss, lack of reciprocity, and distractibility during feeding

**Figure 1.** Children learn about food through exploration with their senses

#### *2.1.3. Feeding disorders associated with insults to the gastrointestinal tract*

This diagnosis, later renamed *posttraumatic feeding disorders* by Chatoor [33], has a sudden onset and results in severe food refusal. Young children with this diagnosis refuse to be fed, and often cry, hyper-extend their trunk and refuse to open their mouth when food is of‐ fered. Posttraumatic feeding problems are the result of a traumatic event or chronic, repeat‐ ed traumatic events that affect the oropharynx or the esophagus. The event may have been aspiration of solid food into the trachea, related to force-feeding, due to medical procedures, such as placement of a nasogastric tube or enteral feeding. The refusal of food may manifest itself in different ways, depending on the type of feeding that is associated with the trauma. Depending further on the situation where the trauma occurred, such as the location or the positioning associated with feeding, the child may show signs of anxiety and marked dis‐ tress at the approach of the bottle or the spoon, or when the food is placed in the mouth. Fear will override any sense of hunger and the effects on the child's health may vary, de‐ pending on the duration and extent of the food refusal, and the adequacy and adaptations made for nutritional compensation. If the food refusal extends over a prolonged period of time, delay in oral-motor skills, or overall development may be the result [33].

#### *2.1.4. Feeding disorder associated with concurrent medical conditions*

The DC: 0-3R [32] also lists feeding problems that are associated with medical conditions whereas the DSM-V [34] will only deal with mental health issues, not medical problems. Children with medical conditions and associated feeding problems are able to initiate eat‐ ing; however, they may soon show signs of distress and/or fatigue and may not be able to finish their meal [33]. This inability may vary according to the severity of the medical condi‐ tion. Heart and respiratory problems, as well as allergies and gastro-esophageal reflux are frequently associated with this type of feeding disability. Resolving the medical issues often improves the feeding related problems, although the latter may not always be eliminated completely. Several symptoms such as gagging, lack of appetite, food refusals, weight loss or growth faltering, may also be found in conjunction with other medical diagnoses. It is es‐ sential therefore, that children with feeding problems be carefully examined for associated medical problems.

#### *2.1.5. Feeding disorder of state regulation*

tensities of these aversive reactions may lead to food refusals that may get generalized to foods with similar characteristics or to all new foods. Some children are so sensitive to the sensory characteristics of the rejected food that they will not eat any other food that comes in contact with the refused food, or refuse that certain foods be placed in their line of vision, or refuse to eat when others, seated next to them, eat a food that has been rejected or it may trigger an aversive reaction (Figure 1). What distinguishes *Sensory Food Aversions* from nor‐ mal food preferences is the degree of severity of the food refusal and the presence of nutri‐ tional deficiencies or oral-motor delays arising from a lack of exposure to more demanding food textures [33]. Some studies have shown a significant relationship between food selec‐

tivity or mealtime problems and problems with sensory modulation [26, 40].

602 Recent Advances in Autism Spectrum Disorders - Volume I

**Figure 1.** Children learn about food through exploration with their senses

*2.1.3. Feeding disorders associated with insults to the gastrointestinal tract*

time, delay in oral-motor skills, or overall development may be the result [33].

This diagnosis, later renamed *posttraumatic feeding disorders* by Chatoor [33], has a sudden onset and results in severe food refusal. Young children with this diagnosis refuse to be fed, and often cry, hyper-extend their trunk and refuse to open their mouth when food is of‐ fered. Posttraumatic feeding problems are the result of a traumatic event or chronic, repeat‐ ed traumatic events that affect the oropharynx or the esophagus. The event may have been aspiration of solid food into the trachea, related to force-feeding, due to medical procedures, such as placement of a nasogastric tube or enteral feeding. The refusal of food may manifest itself in different ways, depending on the type of feeding that is associated with the trauma. Depending further on the situation where the trauma occurred, such as the location or the positioning associated with feeding, the child may show signs of anxiety and marked dis‐ tress at the approach of the bottle or the spoon, or when the food is placed in the mouth. Fear will override any sense of hunger and the effects on the child's health may vary, de‐ pending on the duration and extent of the food refusal, and the adequacy and adaptations made for nutritional compensation. If the food refusal extends over a prolonged period of This feeding disorder is characterized by its onset in infancy, difficulty in establishing a qui‐ et alert state necessary for feeding, weight loss, and absence of any medical condition that could explain these problems. This disturbance in state regulation, similar to disturbances in sleep or crying, will not be included in the next issue of the DSM-V [34]. Feeding is the first competent motor skill of infants [41] and is also an early indicator of self-regulation [33]. Therefore, specific aspects of feeding problems that also coincide with the behavior charac‐ teristics of ASD, might become 'red flags' for its diagnosis. Infants must be alert and able to maintain a calm state during feeding right from birth, i.e. the infant should not fall asleep at the onset of feeding, be too agitated or too distressed to feed [33]. Infants triple their body weight in the first year of life [41]. Therefore, a child who does not gain weight will not be able to maintain his established growth curve, or tends to cross over into a lower growth curve, which is interpreted as 'losing weight'. Mother and infant are 'mutual caregivers' [42]; the child who engages the mother visually, smiles or babbles and gains weight pro‐ vides feedback to the mother that she is 'doing a good job', whereas a child who is colicky, cries, arches away from the mother and does not seem to eat enough causes the mother to worry and to try to compensate. She may feed the child more frequently than a child who eats well and she will also feed the child longer to compensate for the emerging weight loss [43]. The recent development of the P.O.P.S.I.C.L.E Center Infant and Child Feeding Ques‐ tionnaire© (Parent Organized Partnerships Supporting Infants and Children Learning to Eat), an age-specific questionnaire available on the web, gives parents information regard‐ ing typical feeding development and helps them identify whether referral to a health profes‐ sional (feeding specialist) is indicated [44]. Future studies will need to determine whether the constellation of early weight loss, lack of reciprocity, and distractibility during feeding may be an early indicator of ASD.

#### *2.1.6. Feeding disorder of caregiver-infant reciprocity*

Feeding disorders of caregiver-infant reciprocity have their onset in the infant's first year of life and may come to attention through a problem that needs medical attention. The infant's developmental progression shows growth retardation and a lack of age appropriate engage‐ ment with the primary caregiver. Careful examination of the child-family relationships often point toward child neglect that may have its origin in the caregiver's history. These difficult problems will need to be addressed in conjunction with the original feeding problems of the infant [33]. In the DSM-V, this problem will be classifiable under a V code (i.e. a relational problem) [34].

*2.2.2. Learning-dependent food refusal*

change can be expected.

*2.2.3. Selective food refusal*

ry problems in the ASD population.

ther details.

*2.2.5. Fear-based food refusal*

*2.2.4. Appetite-awareness-autonomy-based food refusal*

According to Dovey et al. [35], the feeding disorder defined in this category is «complete‐ ly dependent on the child's experience with it (eating)». Children in this category may have temper tantrums when new foods are offered to them and the usual response of the parent is to take their plate away and replace it with something they know their child will eat. Eventually, parents adapt the family menu to better fit their child's preferences and avoid unfamiliar foods or ones they know will trigger aversive reactions. Children be‐ tween 2 and 6 years of age often refuse to taste new foods, which generally improves as the children get older. Food refusal based on novelty is called food neophobia and is con‐ sidered an evolved behavior from human ancestry that protects the organisms from poi‐ soning, at a time when children begin to leave their parents' supervision and gain more autonomy [35]. Repeated exposure, a positive experience and social influence will help children to overcome food neophobia. Therefore, caregiver education will be the first strategy to use when a learning dependent feeding disorder is suspected and rapid

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Initially the picture of the «selective child» will be similar to learning dependent food refusal but for various reasons will evolve into a significant decrease in dietary variety. Here, expo‐ sure and social facilitation will have little to no effect on food acceptance and the child will not play with food. His diet will rely mostly on hedonic foods, e.g. foods that have a high salt, sugar and fat content. The child may eventually develop gastrointestinal problems as a result of a lack of fiber in his diet. Similar to Chatoor's Sensory Food Aversion category [33], these children have some sensory sensitivities, both tactile and/or oral defensiveness. En‐ largement of dietary variety is a long process for children in this category and needs collabo‐ ration of parents, other caregivers and professionals. Dovey et al. [35] suggest that children in this category be referred for diagnostic work-up because of the high prevalence of senso‐

This category is the same as Infantile Anorexia described earlier by Chatoor and her col‐ leagues [33] and is included in the above classification. The reader is referred to it for fur‐

Fear-Based Food Refusal is also called Food Phobia. This category is identical to Posttrau‐ matic Feeding Disorders of Infancy [33]. Some authors believe that, for many of these chil‐ dren, food phobia might be associated with a more general anxiety or affective disorder [49]. Food refusal in this category can be distinguished from other categories by the intensity of

the emotional reaction when the child is asked to eat the target food.

#### **2.2. Feeding Disorders as classified by Dovey and collaborators**

The classification by Dovey et al. [35, 36] is built on an older classification by Chatoor and Ganiban [45]. Of the five types of feeding disorder, which will be further described below, four are similar to the classifications mentioned above. *Learning-dependant food refusal* is add‐ ed and will include many children seen briefly in clinical practice. In their decision-making model [36, 37], *Autism-Related Food Refusal* is mentioned as a distinct category, but not fur‐ ther elaborated. In an earlier paper Dovey et al. [35] briefly describe feeding problems asso‐ ciated with ASD and touch upon the importance of the cognitive and social aspects of these problems. However, at that time, the authors seemed to include *Autism-Related Food Refusal* in their *selective food refusal* category. For clarity we will present a brief definition of the *Au‐ tism-Related Food Refusal* as a sixth category in this chapter.

#### *2.2.1. Medical complications-related food refusal*

Similar to the *Feeding Disorder Associated with Concurrent Medical Conditions* [32], food refusal is associated with one or more medical conditions. Medical professionals (e.g. gastroenterol‐ ogist, general practitioner, health visitor, etc.) are needed to address these issues. The child may lack developmentally appropriate experiences with food because of major medical in‐ terventions that may have required nasogastric tube feeding which is often followed by gas‐ trostomy feeding until the medical issues are resolved. Periods of longer than 1 week of tube feeding put the child at risk for 'oral deprivation,' i.e. they deprive the child of the daily practice of oral behaviors which in turn seem to have a detrimental effect on the associated brain development [46, 47]. If it occurs in infancy children will experience great difficulty in making the transition to oral feeding. If children have had oral feeding experience before in‐ tubation there will be a transition time where they will have 'to learn to eat' again, but the transition will be shorter than in infants who have not had any feeding experience [46]. Dovey et al. [35] describe these children as not interested in eating but generally as happy to explore and play with food. Food refusal can also be present due to an association of food and/or eating with pain or discomfort. Many children who were tub-fed for extended peri‐ ods will require additional support when making the transition to oral feeding [48].

#### *2.2.2. Learning-dependent food refusal*

*2.1.6. Feeding disorder of caregiver-infant reciprocity*

604 Recent Advances in Autism Spectrum Disorders - Volume I

**2.2. Feeding Disorders as classified by Dovey and collaborators**

*tism-Related Food Refusal* as a sixth category in this chapter.

*2.2.1. Medical complications-related food refusal*

problem) [34].

Feeding disorders of caregiver-infant reciprocity have their onset in the infant's first year of life and may come to attention through a problem that needs medical attention. The infant's developmental progression shows growth retardation and a lack of age appropriate engage‐ ment with the primary caregiver. Careful examination of the child-family relationships often point toward child neglect that may have its origin in the caregiver's history. These difficult problems will need to be addressed in conjunction with the original feeding problems of the infant [33]. In the DSM-V, this problem will be classifiable under a V code (i.e. a relational

The classification by Dovey et al. [35, 36] is built on an older classification by Chatoor and Ganiban [45]. Of the five types of feeding disorder, which will be further described below, four are similar to the classifications mentioned above. *Learning-dependant food refusal* is add‐ ed and will include many children seen briefly in clinical practice. In their decision-making model [36, 37], *Autism-Related Food Refusal* is mentioned as a distinct category, but not fur‐ ther elaborated. In an earlier paper Dovey et al. [35] briefly describe feeding problems asso‐ ciated with ASD and touch upon the importance of the cognitive and social aspects of these problems. However, at that time, the authors seemed to include *Autism-Related Food Refusal* in their *selective food refusal* category. For clarity we will present a brief definition of the *Au‐*

Similar to the *Feeding Disorder Associated with Concurrent Medical Conditions* [32], food refusal is associated with one or more medical conditions. Medical professionals (e.g. gastroenterol‐ ogist, general practitioner, health visitor, etc.) are needed to address these issues. The child may lack developmentally appropriate experiences with food because of major medical in‐ terventions that may have required nasogastric tube feeding which is often followed by gas‐ trostomy feeding until the medical issues are resolved. Periods of longer than 1 week of tube feeding put the child at risk for 'oral deprivation,' i.e. they deprive the child of the daily practice of oral behaviors which in turn seem to have a detrimental effect on the associated brain development [46, 47]. If it occurs in infancy children will experience great difficulty in making the transition to oral feeding. If children have had oral feeding experience before in‐ tubation there will be a transition time where they will have 'to learn to eat' again, but the transition will be shorter than in infants who have not had any feeding experience [46]. Dovey et al. [35] describe these children as not interested in eating but generally as happy to explore and play with food. Food refusal can also be present due to an association of food and/or eating with pain or discomfort. Many children who were tub-fed for extended peri‐

ods will require additional support when making the transition to oral feeding [48].

According to Dovey et al. [35], the feeding disorder defined in this category is «complete‐ ly dependent on the child's experience with it (eating)». Children in this category may have temper tantrums when new foods are offered to them and the usual response of the parent is to take their plate away and replace it with something they know their child will eat. Eventually, parents adapt the family menu to better fit their child's preferences and avoid unfamiliar foods or ones they know will trigger aversive reactions. Children be‐ tween 2 and 6 years of age often refuse to taste new foods, which generally improves as the children get older. Food refusal based on novelty is called food neophobia and is con‐ sidered an evolved behavior from human ancestry that protects the organisms from poi‐ soning, at a time when children begin to leave their parents' supervision and gain more autonomy [35]. Repeated exposure, a positive experience and social influence will help children to overcome food neophobia. Therefore, caregiver education will be the first strategy to use when a learning dependent feeding disorder is suspected and rapid change can be expected.

#### *2.2.3. Selective food refusal*

Initially the picture of the «selective child» will be similar to learning dependent food refusal but for various reasons will evolve into a significant decrease in dietary variety. Here, expo‐ sure and social facilitation will have little to no effect on food acceptance and the child will not play with food. His diet will rely mostly on hedonic foods, e.g. foods that have a high salt, sugar and fat content. The child may eventually develop gastrointestinal problems as a result of a lack of fiber in his diet. Similar to Chatoor's Sensory Food Aversion category [33], these children have some sensory sensitivities, both tactile and/or oral defensiveness. En‐ largement of dietary variety is a long process for children in this category and needs collabo‐ ration of parents, other caregivers and professionals. Dovey et al. [35] suggest that children in this category be referred for diagnostic work-up because of the high prevalence of senso‐ ry problems in the ASD population.

#### *2.2.4. Appetite-awareness-autonomy-based food refusal*

This category is the same as Infantile Anorexia described earlier by Chatoor and her col‐ leagues [33] and is included in the above classification. The reader is referred to it for fur‐ ther details.

#### *2.2.5. Fear-based food refusal*

Fear-Based Food Refusal is also called Food Phobia. This category is identical to Posttrau‐ matic Feeding Disorders of Infancy [33]. Some authors believe that, for many of these chil‐ dren, food phobia might be associated with a more general anxiety or affective disorder [49]. Food refusal in this category can be distinguished from other categories by the intensity of the emotional reaction when the child is asked to eat the target food.

#### *2.2.6. Autism-related food refusal*

Dovey et al. [35] describe children with ASD and feeding problems as having «seemingly illogical rules around what constitutes an acceptable meal». We are not aware of any stud‐ ies that have examined these children's rationale for their eating behaviors and the cogni‐ tive decisions that have led to them. Although, we do not know whether Dovey and collaborators have studied these, they acknowledge that these children must make deci‐ sions whether to eat something or not. This constitutes an important gap in our under‐ standing of these children's feeding behavior and has important consequences on how we treat them. We observe children's behaviors and decide to manipulate them without un‐ derstanding the underlying rationale that has led to these behaviors. An interpretation based on the hyper-systematization theory of Baron-Cohen et al. [50] will be discussed in the intervention section of this chapter. Meanwhile, perhaps one approach would be to study adults with autism and/or higher functioning children with ASD where some com‐ munication and insight is present, in order to access this very challenging domain. Even here, we must be sensitive to the fact that many other domains of ADL might be affected, besides eating, and that children and their family must be treated holistically.

**2.4. Davies and collaborators' framework for classification**

of the quality of the parent-child relationship.

large proportion of children with ASD to be obese [61].

**2.5. Parent reported feeding problems**

with selective eating.

Finally, another convincing argument for a reconceptualization of diagnostic criteria of feed‐ ing problems has been advanced by Davies and collaborators [39], suggesting that feeding problems are the result of a relational disorder of the child in his social context. The authors propose that feeding problems be diagnosed along 6 axes that define 1) a feeding disorder between parent and child, characterized by the child's persistent failure to eat foods in ac‐ cordance with his developmental stage and the cultural or sub-cultural expectations. 2) a character/developmental disorder of parent and/or child, where the feeding relationship may be disrupted due to the caregivers' own psychopathology or life demands, and/or where the child may have a difficult temperament or medical and developmental issues that interfere with feeding, 3) This axis describes medical disorders of parent and/or child, that need to be addressed before feeding problems can be resolved 4) psychosocial stressors need to be identified "through use of the multi-axial diagnosis, to reflect the multi-determined na‐ ture of feeding disorders" 5) global functioning of parent and child will be examined sepa‐ rately for each, and 6) the global parent-infant relationship is classified through assessment

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A systematic literature review of feeding problems reported by parents, shows that many symptoms are similar to those associated with sensory feeding problems [4, 5, 10, 11, 14, 17, 20, 26, 53-55]. The peculiar ways in which sensory input is treated by persons with ASD are well documented in the literature [56-59]. The most frequently mentioned problems are tex‐ ture, color, and smell selectivity, refusal of new foods, and food refusals in general. These problems were not associated with weight loss in a study comparing body mass index be‐ tween typically developing children and those with ASD [60]. One study even reported a

Parents' perception of their child's feeding problem often leads them to seek professional advice. In terms of nutritional deficiency, results vary widely [62-64]. Application of stand‐ ards of reference with different criteria for severity levels may explain these discrepancies [65]. Furthermore, none of the studies reviewed so far have exclusively studied children with clinically significant feeding problems. Within a normally distributed population one would expect some children with, but the majority to be without nutritional deficiencies. Thus, it is not yet possible to determine whether or not children with ASD and severe feed‐ ing problems would also have nutritional deficiencies. Some case studies and larger studies report negative health effects due to selective eating or restrictive diets [66, 67]. Therefore, it is always advisable to refer a child to a qualified nutritional expert when the child presents

Some parents report problems with chewing and abnormal drooling even after the child's developmental age has been taken into account [13, 68]. Nadon et al. [13] compared children with ASD and their typically developing siblings of the same mean age and found that only the children with ASD had problems with eating related drooling, chewing, moving their tongue or swallowing. While parents interpreted these problems as a source of their child's

#### **2.3. The 'Wolfson group' diagnostic criteria of infantile feeding disorders**

The 'Wolfson Group', a collaboration of medical professionals from Israel, has studied infan‐ tile feeding problems for a number of years [38, 51, 52] and has shown considerable success in discriminating between infantile feeding disorders (non-organic) and medically based feeding problems (organic). Levine et al. [38] compared the diagnostic criteria of the Wolf‐ son group to DC: 0-3R [32], and the DSM-IV [31] classifications in a group of children refer‐ red for food refusal. Results discriminated 100%, 77% and 47% respectively. The Wolfson criteria (Table 2) successfully identified a substantial proportion of treatable patients that the two other existing classifications could not identify [38].

1. Persistent food refusal "/>1 month

2. Absence of obvious organic disease leading to food refusal or lack of response to medical treatment of an organic disease

3. Age of onset <2 years, age at presentation <6 years

4. Presence of at least one of the following:

a. Pathological feeding or

b. Anticipatory gagging

**Table 2.** The Wolfson Diagnostic Criteria

#### **2.4. Davies and collaborators' framework for classification**

*2.2.6. Autism-related food refusal*

606 Recent Advances in Autism Spectrum Disorders - Volume I

Dovey et al. [35] describe children with ASD and feeding problems as having «seemingly illogical rules around what constitutes an acceptable meal». We are not aware of any stud‐ ies that have examined these children's rationale for their eating behaviors and the cogni‐ tive decisions that have led to them. Although, we do not know whether Dovey and collaborators have studied these, they acknowledge that these children must make deci‐ sions whether to eat something or not. This constitutes an important gap in our under‐ standing of these children's feeding behavior and has important consequences on how we treat them. We observe children's behaviors and decide to manipulate them without un‐ derstanding the underlying rationale that has led to these behaviors. An interpretation based on the hyper-systematization theory of Baron-Cohen et al. [50] will be discussed in the intervention section of this chapter. Meanwhile, perhaps one approach would be to study adults with autism and/or higher functioning children with ASD where some com‐ munication and insight is present, in order to access this very challenging domain. Even here, we must be sensitive to the fact that many other domains of ADL might be affected,

besides eating, and that children and their family must be treated holistically.

The 'Wolfson Group', a collaboration of medical professionals from Israel, has studied infan‐ tile feeding problems for a number of years [38, 51, 52] and has shown considerable success in discriminating between infantile feeding disorders (non-organic) and medically based feeding problems (organic). Levine et al. [38] compared the diagnostic criteria of the Wolf‐ son group to DC: 0-3R [32], and the DSM-IV [31] classifications in a group of children refer‐ red for food refusal. Results discriminated 100%, 77% and 47% respectively. The Wolfson criteria (Table 2) successfully identified a substantial proportion of treatable patients that the

2. Absence of obvious organic disease leading to food refusal or lack of response to medical treatment of an organic

**2.3. The 'Wolfson group' diagnostic criteria of infantile feeding disorders**

two other existing classifications could not identify [38].

1. Persistent food refusal "/>1 month

3. Age of onset <2 years, age at presentation <6 years

4. Presence of at least one of the following:

**Table 2.** The Wolfson Diagnostic Criteria

a. Pathological feeding or b. Anticipatory gagging

disease

Finally, another convincing argument for a reconceptualization of diagnostic criteria of feed‐ ing problems has been advanced by Davies and collaborators [39], suggesting that feeding problems are the result of a relational disorder of the child in his social context. The authors propose that feeding problems be diagnosed along 6 axes that define 1) a feeding disorder between parent and child, characterized by the child's persistent failure to eat foods in ac‐ cordance with his developmental stage and the cultural or sub-cultural expectations. 2) a character/developmental disorder of parent and/or child, where the feeding relationship may be disrupted due to the caregivers' own psychopathology or life demands, and/or where the child may have a difficult temperament or medical and developmental issues that interfere with feeding, 3) This axis describes medical disorders of parent and/or child, that need to be addressed before feeding problems can be resolved 4) psychosocial stressors need to be identified "through use of the multi-axial diagnosis, to reflect the multi-determined na‐ ture of feeding disorders" 5) global functioning of parent and child will be examined sepa‐ rately for each, and 6) the global parent-infant relationship is classified through assessment of the quality of the parent-child relationship.

#### **2.5. Parent reported feeding problems**

A systematic literature review of feeding problems reported by parents, shows that many symptoms are similar to those associated with sensory feeding problems [4, 5, 10, 11, 14, 17, 20, 26, 53-55]. The peculiar ways in which sensory input is treated by persons with ASD are well documented in the literature [56-59]. The most frequently mentioned problems are tex‐ ture, color, and smell selectivity, refusal of new foods, and food refusals in general. These problems were not associated with weight loss in a study comparing body mass index be‐ tween typically developing children and those with ASD [60]. One study even reported a large proportion of children with ASD to be obese [61].

Parents' perception of their child's feeding problem often leads them to seek professional advice. In terms of nutritional deficiency, results vary widely [62-64]. Application of stand‐ ards of reference with different criteria for severity levels may explain these discrepancies [65]. Furthermore, none of the studies reviewed so far have exclusively studied children with clinically significant feeding problems. Within a normally distributed population one would expect some children with, but the majority to be without nutritional deficiencies. Thus, it is not yet possible to determine whether or not children with ASD and severe feed‐ ing problems would also have nutritional deficiencies. Some case studies and larger studies report negative health effects due to selective eating or restrictive diets [66, 67]. Therefore, it is always advisable to refer a child to a qualified nutritional expert when the child presents with selective eating.

Some parents report problems with chewing and abnormal drooling even after the child's developmental age has been taken into account [13, 68]. Nadon et al. [13] compared children with ASD and their typically developing siblings of the same mean age and found that only the children with ASD had problems with eating related drooling, chewing, moving their tongue or swallowing. While parents interpreted these problems as a source of their child's feeding problem, this study showed that these motor behaviors were associated with tactile sensitivity but independent of mental retardation, attention deficit disorder or hyperactivity that is often present in these children [13]. These oral-motor problems are often overlooked, because it is generally a small group when compared to the whole population of children with ASD. However, careful evaluation may be particularly helpful for this group of chil‐ dren, because specific treatments exist, and have been shown to be effective for other neuro‐ logically based feeding problems [41].

Anticipatory behavior is an early indicator of social engagement. Kanner [69] noted that in‐ fants who later were described as 'autistic' did not reach out to an adult who was engaged in picking them up. Brisson and colleagues [70] made use of this characteristic by studying anticipatory behavior associated with feeding. The authors performed a retrospective re‐ view of home movies of infants, 3 to 6 months of age, who were later diagnosed with au‐ tism, expecting that they would perform poorly on opening their mouth (the anticipatory behavior) in response to an approaching spoon. Results were compared to an age matched typically developing group. While typically developing children, as a group, achieved 79% correct responses, only 46% of the children with autism did so. There was a clear learning curve in both groups, with younger infants showing fewer mouth opening responses than the older ones, and a larger proportion of typically developing infants opening their mouth to an approaching spoon than did infants with autism. These results are consistent with pa‐ rent descriptions that infants were easily distracted when feeding, right from birth, and this behavior may indeed become an early diagnostic indicator, in conjunction with other behav‐ iors that characterize the ASDs.

**Figure 2.** Adapted from the International Classification of Functioning, Disability and Health (ICF)

ities will determine how best to approach his treatment.

Parent questionnaires with interview formats are commonly used [71-74]. These have the advantage that they can cover an extended period of the child's life. As well, documenting the feeding history during the first year of life, and again around 18 months when most of the problems become apparent, sheds light on the evolution of the presenting problems. Pa‐ rents can provide a more complete picture of the child's feeding behaviors because they usu‐ ally provide their child's daily meals. The advantage for the evaluator is that he is not dependent on a single meal observation that may not be representative of the daily routine in the home. It is also very important to get to know parents' motivation for consultation, their perception of the problems and their priorities for resolving them. It is important like‐ wise, to learn what strategies parents have tried to solve the feeding problems and how the child reacted to them [75]. A detailed description of the child's food preferences is in order to determine the adequacy of the nutritional content. As well, common sensory characteris‐ tics of his preferred and non-preferred foods need to be assessed (color, texture, consistency, taste, smell, appearance,…) to better understand the nature of the problem and assist in the formulation of a treatment plan [76]. A sensory profile of the child is essential and, to under‐ stand his way of communicating, his motor abilities, learning strategies, and his cognitive and sensory information processing. It is also important to assess whether the child has a minimal understanding of negotiation, and what his play skills and interests are. These abil‐

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**3.1. Parent questionnaires**

#### **3. Evaluation**

Feeding at mealtimes occurs as the result of the interaction between a child's body functions and structures, his health condition and some contextual factors (i.e. environmental factors as well as personal factors). An illustration of these interactions, using the model of the In‐ ternational Classification of Functioning, Disability and Health (ICF) is illustrated in Figure 2. The complexity of these interactions may be the reason why many investigators devel‐ oped their own assessment tool, because existing ones did not adequately cover the domains to meet the authors' needs [71]. To have a complete picture of a child's problems, it is neces‐ sary to combine various methods of evaluation and to collaborate with professionals who have different domains of expertise.

There are a number of methods and feeding assessments, with varying content as well as different psychometric properties (e.g. caregiver questionnaires, interviews, child observa‐ tions). The following review will be selective and is not intended to be exhaustive. For a more complete review the reader is referred to Nadon et al. [71] and Seiverling, Williams and Sturmey [72]. Other evaluations may be performed using standardized assessments if the child's condition suggests additional problems.

**Figure 2.** Adapted from the International Classification of Functioning, Disability and Health (ICF)

#### **3.1. Parent questionnaires**

feeding problem, this study showed that these motor behaviors were associated with tactile sensitivity but independent of mental retardation, attention deficit disorder or hyperactivity that is often present in these children [13]. These oral-motor problems are often overlooked, because it is generally a small group when compared to the whole population of children with ASD. However, careful evaluation may be particularly helpful for this group of chil‐ dren, because specific treatments exist, and have been shown to be effective for other neuro‐

Anticipatory behavior is an early indicator of social engagement. Kanner [69] noted that in‐ fants who later were described as 'autistic' did not reach out to an adult who was engaged in picking them up. Brisson and colleagues [70] made use of this characteristic by studying anticipatory behavior associated with feeding. The authors performed a retrospective re‐ view of home movies of infants, 3 to 6 months of age, who were later diagnosed with au‐ tism, expecting that they would perform poorly on opening their mouth (the anticipatory behavior) in response to an approaching spoon. Results were compared to an age matched typically developing group. While typically developing children, as a group, achieved 79% correct responses, only 46% of the children with autism did so. There was a clear learning curve in both groups, with younger infants showing fewer mouth opening responses than the older ones, and a larger proportion of typically developing infants opening their mouth to an approaching spoon than did infants with autism. These results are consistent with pa‐ rent descriptions that infants were easily distracted when feeding, right from birth, and this behavior may indeed become an early diagnostic indicator, in conjunction with other behav‐

Feeding at mealtimes occurs as the result of the interaction between a child's body functions and structures, his health condition and some contextual factors (i.e. environmental factors as well as personal factors). An illustration of these interactions, using the model of the In‐ ternational Classification of Functioning, Disability and Health (ICF) is illustrated in Figure 2. The complexity of these interactions may be the reason why many investigators devel‐ oped their own assessment tool, because existing ones did not adequately cover the domains to meet the authors' needs [71]. To have a complete picture of a child's problems, it is neces‐ sary to combine various methods of evaluation and to collaborate with professionals who

There are a number of methods and feeding assessments, with varying content as well as different psychometric properties (e.g. caregiver questionnaires, interviews, child observa‐ tions). The following review will be selective and is not intended to be exhaustive. For a more complete review the reader is referred to Nadon et al. [71] and Seiverling, Williams and Sturmey [72]. Other evaluations may be performed using standardized assessments if

logically based feeding problems [41].

608 Recent Advances in Autism Spectrum Disorders - Volume I

iors that characterize the ASDs.

have different domains of expertise.

the child's condition suggests additional problems.

**3. Evaluation**

Parent questionnaires with interview formats are commonly used [71-74]. These have the advantage that they can cover an extended period of the child's life. As well, documenting the feeding history during the first year of life, and again around 18 months when most of the problems become apparent, sheds light on the evolution of the presenting problems. Pa‐ rents can provide a more complete picture of the child's feeding behaviors because they usu‐ ally provide their child's daily meals. The advantage for the evaluator is that he is not dependent on a single meal observation that may not be representative of the daily routine in the home. It is also very important to get to know parents' motivation for consultation, their perception of the problems and their priorities for resolving them. It is important like‐ wise, to learn what strategies parents have tried to solve the feeding problems and how the child reacted to them [75]. A detailed description of the child's food preferences is in order to determine the adequacy of the nutritional content. As well, common sensory characteris‐ tics of his preferred and non-preferred foods need to be assessed (color, texture, consistency, taste, smell, appearance,…) to better understand the nature of the problem and assist in the formulation of a treatment plan [76]. A sensory profile of the child is essential and, to under‐ stand his way of communicating, his motor abilities, learning strategies, and his cognitive and sensory information processing. It is also important to assess whether the child has a minimal understanding of negotiation, and what his play skills and interests are. These abil‐ ities will determine how best to approach his treatment.

#### **3.2. Mealtime behavior questionnaires**

*The Children's Eating Behavior Inventory* (CEBI-R) [77] covers eating and behavioral prob‐ lems at mealtimes in 2 groups: typically developing children (non-clinic) and a « clinic » group, aged 2 to 12 years. It uses a 5 point Likert scale to identify whether a problem oc‐ curs between « never » and « always », and a dichotomized scale for parents to note whether the behavior is perceived as a problem or not. Construct validity was demon‐ strated by significant differences between the two groups in total eating problems and the number of items perceived as problematic. Internal reliability or item consistency ranged from.58 to.76 using Cronbach's alpha, and test-retest reliability was 84 (parent score) and 87 (total eating problems).

frustration, food amount demandingness, and food type demandingness, for which sub‐ scales were computed. The Feeding Demands Questionnaire showed acceptable internal consistency (.70 to.86). The authors concluded that different demand beliefs influence differ‐

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611

*About Your Child's Eating* (AYCE) [81] was developed to document positive mealtime envi‐ ronment, parent aversion to mealtime and child resistance to eating in a sample of typically developing and a group of chronically ill children, aged 8 to 16 years. The AYCE is scored on a Likert scale from « never » to « nearly every time » describing the frequency of the child's mealtime behaviors, the caregiver's interaction with the child and the caregiver's re‐ action to the meal. While the constructs evaluated would seem to be similar in a group of younger children, validity for the ASD diagnostic group remains to be determined. The AYCE internal consistency is -.24 for child resistance, positive mealtime environment.55, and parent aversion -.37. There is also evidence for convergent validity with the *Family Envi‐*

The *Eating Profile* [13] covers eleven domains (145 items): 1) dietary history of the child, 2) child health, 3) family dietary history, 4) mealtime behaviors of the child, 5) food preferences, 6) au‐ tonomy with respect to eating, 7) behaviors outside of mealtimes, 8) impact on daily life, 9) strategies used to resolve difficulties encountered at mealtimes, 10) communication abilities of the child and 11) socio-economic factors of the family. The psychometric properties of this questionnaire have been studied to a limited degree [13, 82]. It was used to compare sibling mealtime behavior (ASD vs typically developing) in the same family. It showed that although typically developing children also had some mealtime problems (mean of 5.0), children in the same social and physical environment but with ASD, had significantly more such problems (mean of 13.0) than their siblings. Lack of variety of foods, i.e. less than 20 items, an inadequate number of meals, not eating at the table, or not staying seated during the meal, as well as show‐ ing some oral-motor deficits were the most significant differences between the two groups [13]. Even after developmentally related behaviors were excluded the difference between the num‐ ber of mealtime problems in the two groups persisted. These results suggest that the impact of

The *Youth/Adolescent Questionnaire* (YAQ) [83] is a self-report inventory for food frequency with 148 items to determine the nutritional intake of 9 to 18 year-olds and the average food serving frequency of six food groups. It provides an estimate of the average serving frequen‐ cy per day for 6 food groups as well as the average intake over one year. In a validation study a correlation of.54 was achieved between the YAQ and 24-hour food recall interviews [83]. Test-retest reliability ranged from.26 to.58 for nutrients and from.39 to.57 for food groups. A modified version of the YAQ was used with children with ASD to quantify food refusal and food selectivity (i.e. 'High-Frequency Single Food Intake') on a daily basis [64]. Although food frequency questionnaires are known to commonly over-report dietary intake [84], they are useful to analyze children's preferences as it is required when using graduated

*ronment* measure. Other psychometric properties still need to be developed.

the diagnosis on mealtime behavior is greater than that of the environment.

ent feeding practices.

**3.3. Nutritional assessments**

exposure therapies.

The *Brief Autism Mealtime Behavior Inventory* (BAMBI) [73] measures the frequency of meal‐ time behavior problems in children with ASD between the ages of 3 and 11 years. The BAM‐ BI contains 18 questions based on a 3 factor structure that identifies limited variety of foods (8 items), food refusals (5 items) and autistic behaviors (5 items). The BAMBI has good inter‐ nal consistency.88, high inter-rater 0.78 and test-retest reliability 0.87, as well as strong con‐ struct and criterion-related validity [73].

The *Behavioral Pediatric Feeding Assessment Scale* (BPFAS) is a 35 item, standardized caregiver report inventory that was developed for children with feeding problems, 9 months to 8 years of age, but who are otherwise typically developing. The tool has a 5-point Likert scale and caregivers indicate how frequently children show a behavior, i.e. « never happens » to « always happens », parents' frequency of feelings or strategies is noted and a total frequen‐ cy is computed. Higher scores indicate more problems. Internal consistency of the BPFAS is. 88. Test-re-test reliability for the total score is.78 in both normal and clinical samples. The BPFAS was shown to have adequate reliability and validity [78].

The 31-item *Parent Mealtime Action Scale* (PMAS) [75] measures parents' actions regarding their child's mealtime behaviors in nine dimensions: snack limits, positive persuasion, daily fruit and vegetable availability, use of rewards, insistence on eating, snack modeling, special meals, fat reduction and many food choices. Parents also provide three-point ratings (1 = never, 2 = sometimes, 3 = always) how often they use each of these actions in a typical week. The clinician then provides specific recommendations to caregivers regarding actions they can implement to improve their child's feeding. The PMAS was developed with a sample of over 2000 typically developing children [75] but a recent study [79] examined it's applicabil‐ ity with a clinical sample including 49 children with ASD. Mean internal reliability was.62 and convergent validity was demonstrated with expected associations between parent meal‐ time actions measured by the PMAS and some children's feeding problems. The five PMAS dimensions most associated with children's feeding problems were snack limits, insistence on eating, fat reduction, many food choices, and special meals [79].

The *Feeding Demands Questionnaire* is a parent report questionnaire that measures parents' belief how their child should eat [80]. Mothers of 3 to 7-year old children completed the 8 item Feeding Demands Questionnaire, the Child Feeding Questionnaire, measures of de‐ pression and fear of fat. The Feeding Demands Questionnaire revealed 3 factors: anger/ frustration, food amount demandingness, and food type demandingness, for which sub‐ scales were computed. The Feeding Demands Questionnaire showed acceptable internal consistency (.70 to.86). The authors concluded that different demand beliefs influence differ‐ ent feeding practices.

*About Your Child's Eating* (AYCE) [81] was developed to document positive mealtime envi‐ ronment, parent aversion to mealtime and child resistance to eating in a sample of typically developing and a group of chronically ill children, aged 8 to 16 years. The AYCE is scored on a Likert scale from « never » to « nearly every time » describing the frequency of the child's mealtime behaviors, the caregiver's interaction with the child and the caregiver's re‐ action to the meal. While the constructs evaluated would seem to be similar in a group of younger children, validity for the ASD diagnostic group remains to be determined. The AYCE internal consistency is -.24 for child resistance, positive mealtime environment.55, and parent aversion -.37. There is also evidence for convergent validity with the *Family Envi‐ ronment* measure. Other psychometric properties still need to be developed.

The *Eating Profile* [13] covers eleven domains (145 items): 1) dietary history of the child, 2) child health, 3) family dietary history, 4) mealtime behaviors of the child, 5) food preferences, 6) au‐ tonomy with respect to eating, 7) behaviors outside of mealtimes, 8) impact on daily life, 9) strategies used to resolve difficulties encountered at mealtimes, 10) communication abilities of the child and 11) socio-economic factors of the family. The psychometric properties of this questionnaire have been studied to a limited degree [13, 82]. It was used to compare sibling mealtime behavior (ASD vs typically developing) in the same family. It showed that although typically developing children also had some mealtime problems (mean of 5.0), children in the same social and physical environment but with ASD, had significantly more such problems (mean of 13.0) than their siblings. Lack of variety of foods, i.e. less than 20 items, an inadequate number of meals, not eating at the table, or not staying seated during the meal, as well as show‐ ing some oral-motor deficits were the most significant differences between the two groups [13]. Even after developmentally related behaviors were excluded the difference between the num‐ ber of mealtime problems in the two groups persisted. These results suggest that the impact of the diagnosis on mealtime behavior is greater than that of the environment.

#### **3.3. Nutritional assessments**

**3.2. Mealtime behavior questionnaires**

610 Recent Advances in Autism Spectrum Disorders - Volume I

struct and criterion-related validity [73].

BPFAS was shown to have adequate reliability and validity [78].

on eating, fat reduction, many food choices, and special meals [79].

87 (total eating problems).

*The Children's Eating Behavior Inventory* (CEBI-R) [77] covers eating and behavioral prob‐ lems at mealtimes in 2 groups: typically developing children (non-clinic) and a « clinic » group, aged 2 to 12 years. It uses a 5 point Likert scale to identify whether a problem oc‐ curs between « never » and « always », and a dichotomized scale for parents to note whether the behavior is perceived as a problem or not. Construct validity was demon‐ strated by significant differences between the two groups in total eating problems and the number of items perceived as problematic. Internal reliability or item consistency ranged from.58 to.76 using Cronbach's alpha, and test-retest reliability was 84 (parent score) and

The *Brief Autism Mealtime Behavior Inventory* (BAMBI) [73] measures the frequency of meal‐ time behavior problems in children with ASD between the ages of 3 and 11 years. The BAM‐ BI contains 18 questions based on a 3 factor structure that identifies limited variety of foods (8 items), food refusals (5 items) and autistic behaviors (5 items). The BAMBI has good inter‐ nal consistency.88, high inter-rater 0.78 and test-retest reliability 0.87, as well as strong con‐

The *Behavioral Pediatric Feeding Assessment Scale* (BPFAS) is a 35 item, standardized caregiver report inventory that was developed for children with feeding problems, 9 months to 8 years of age, but who are otherwise typically developing. The tool has a 5-point Likert scale and caregivers indicate how frequently children show a behavior, i.e. « never happens » to « always happens », parents' frequency of feelings or strategies is noted and a total frequen‐ cy is computed. Higher scores indicate more problems. Internal consistency of the BPFAS is. 88. Test-re-test reliability for the total score is.78 in both normal and clinical samples. The

The 31-item *Parent Mealtime Action Scale* (PMAS) [75] measures parents' actions regarding their child's mealtime behaviors in nine dimensions: snack limits, positive persuasion, daily fruit and vegetable availability, use of rewards, insistence on eating, snack modeling, special meals, fat reduction and many food choices. Parents also provide three-point ratings (1 = never, 2 = sometimes, 3 = always) how often they use each of these actions in a typical week. The clinician then provides specific recommendations to caregivers regarding actions they can implement to improve their child's feeding. The PMAS was developed with a sample of over 2000 typically developing children [75] but a recent study [79] examined it's applicabil‐ ity with a clinical sample including 49 children with ASD. Mean internal reliability was.62 and convergent validity was demonstrated with expected associations between parent meal‐ time actions measured by the PMAS and some children's feeding problems. The five PMAS dimensions most associated with children's feeding problems were snack limits, insistence

The *Feeding Demands Questionnaire* is a parent report questionnaire that measures parents' belief how their child should eat [80]. Mothers of 3 to 7-year old children completed the 8 item Feeding Demands Questionnaire, the Child Feeding Questionnaire, measures of de‐ pression and fear of fat. The Feeding Demands Questionnaire revealed 3 factors: anger/

The *Youth/Adolescent Questionnaire* (YAQ) [83] is a self-report inventory for food frequency with 148 items to determine the nutritional intake of 9 to 18 year-olds and the average food serving frequency of six food groups. It provides an estimate of the average serving frequen‐ cy per day for 6 food groups as well as the average intake over one year. In a validation study a correlation of.54 was achieved between the YAQ and 24-hour food recall interviews [83]. Test-retest reliability ranged from.26 to.58 for nutrients and from.39 to.57 for food groups. A modified version of the YAQ was used with children with ASD to quantify food refusal and food selectivity (i.e. 'High-Frequency Single Food Intake') on a daily basis [64]. Although food frequency questionnaires are known to commonly over-report dietary intake [84], they are useful to analyze children's preferences as it is required when using graduated exposure therapies.

*Food records* are routinely used by nutritionists to measure energy intake. A systematic review [84] suggests that the 24-hour multiple pass recall conducted over at least a 3-day period that includes weekdays and weekend days, using parents as reporters is the most accurate method for children aged 4 to 11 years and that weighted food records provid‐ ed the best estimates of Estimated Intake for younger children aged 0.5 to 4 years. Cor‐ nish [54] used a three day food record to study a small group of children with ASD, aged 3 to 16 years where 8 had followed a gluten and/or casein free diet for various lengths (1 to 6 months) and 29 consumed a regular diet. Caregivers filled out a 3-day di‐ ary of all foods and drinks consumed. Nutrient intakes in 12 children were lower than recommended in *'Lower Reference Nutrient Intake'* for zinc, calcium, iron, vitamin A, B12 and riboflavin in the regular diet group and in 4 for zinc and calcium in the diet group although these differences were not statistically significant between the 2 groups. The median daily energy intake was 93% of *Estimated Average Requirements* (EAR) in both groups, and did not differ in the contribution of proteins, fats, or carbohydrates. Fruit and vegetable intake was higher and consumption of starches was lower in the diet group. The author notes that parents who followed the exclusion diet found that it iso‐ lated the family socially, food substitutes were difficult to find and costly, meals re‐ quired longer preparation time, and it was very difficult for the child to make the change to the new diet.

Structure, consisting of 'an evaluation of the face and mouth at rest to identify variations from normal, using surface anatomy exclusively', 3) Oral-Facial Sensory Inputs: a subjec‐ tive evaluation of sensory and reflex motor activity produced by stimulation of selected cranial nerves, 4) Oral-Facial Motor Function: a series of voluntary oral facial postures such as puckering the lips or deviating the jaw to the right or left, 5) Ventilation/Phona‐ tion: 'a subjective evaluation of breathing and sound production' and 6) Functional Feed‐ ing Assessment: an 'evaluation of oral-motor skills during specific feeding tasks' examining spoon feeding, biting, chewing, cup- and straw drinking and swallowing. Overall rater agreement, among 3 raters, was 0.83, and overall rater consistency was 0.90. Other psychometric properties such as validity, item consistency and test-retest reli‐ ability still need to be determined. As well, examination of the suitability for the popula‐

Feeding Issues Associated with the Autism Spectrum Disorders

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

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*The Schedule of Oral-Motor Assessment* (SOMA) by Reilly et al. [86] measures the oral-motor and feeding skills of children 8 to 24 months of age. A sample of 127 children constituted the original sample, 90% were typically developing and 10% were children with cerebral palsy. Differently textured foods and liquids are offered to the child in a pre-determined order: liq‐ uid, puree, semi-solids, solids, biscuits and dried fruit and scored in 6 sections. Scores are based on the quality of oral-motor, mandible, lip and tongue movements. Inter-rater reliabil‐ ity was 0.75 and internal consistency 0.85 [87]. The predictive validity was > 95% and sensi‐ tivity >.85 [88]. The age range of the SOMA makes it particularly attractive for use with young children because of the benefits of early intervention [41]. While a diagnosis of ASD may only be confirmed by two years or later, feeding problems are often recognized by pa‐ rents from the first year. Treatment of feeding problems is not dependent on the diagnosis of ASD. Therefore, early intervention may prevent aggravation of feeding problems with

Treatment must take the complete evaluation into account, including the interaction of the person with his familiar environment. Feeding cannot be treated as an isolated problem and the strategies employed should not be limited to mealtimes only. To illustrate: the stress a child experiences during mealtime may decrease his appetite or decrease his tolerance for tactile or olfactory stimuli. Also, if functional analysis reveals environmental contributions to the feeding problems, like inappropriate parental strategies to cope with behavioral issues

Whether the treatment approach will be interdisciplinary or trans-disciplinary [19, 89] collaboration between different professionals is desirable, given the complex nature of feeding problems and the many factors to be considered [21, 39, 90, 91]. The degree of involvement may vary, depending on the expertise of the individuals involved, the etiol‐ ogy of the problem to be addressed or the relationship the professionals have with the

during mealtime, treatment needs to include these routines as well.

tion with ASD will be needed.

time when not treated promptly.

**4. Treatment**

parents [89, 90].

#### **3.4. Direct observations**

Observation of the child's mealtime routine in his familiar environment provides insight into the family's daily life and the accommodations made for coping with problems [74]. The family may be so enmeshed in this routine that it does not always realize how it has adapted to the child's problem and to what extent the child's behavior or the envi‐ ronmental setting may contribute to the maintenance of problems. By making several vis‐ its to the home and by changing different variables (person, environment, social demands, sensory stimuli, liked vs non-liked foods…) the observer gets a clearer picture of the situation. If possible the evaluator should have a discussion with the child regard‐ ing his global understanding of eating and his recognition of any problems. If a home visit is not possible, the parent/caregiver should come to the clinic and bring some of the child's liked and non-liked foods. Familiar plates or utensils can also be brought. Evalua‐ tion will then focus on oral-motor skills, reaction to foods, intensity of food aversions, and acceptability of food modifications. A systematic presentation of foods was used by Ahearn et al. [10] for children with ASD. However, a major criticism with this type of evaluation is that it does not measure the severity or the problem experienced in the home, because the context is far from what the child is used to. It is more likely measur‐ ing the child's reaction to novelty or the influence of different contexts.

*The Multidisciplinary Feeding Profile* (MFP) was developed by Kenny and collaborators [85] with a group of 18 children, 6 to 18 years of age, who had neurological disabilities and were 'dependent feeders.' The evaluation is divided into six sections covering: I) Physical/Neurological factors such as posture, tone and reflex activity, 2) Oral-Facial Structure, consisting of 'an evaluation of the face and mouth at rest to identify variations from normal, using surface anatomy exclusively', 3) Oral-Facial Sensory Inputs: a subjec‐ tive evaluation of sensory and reflex motor activity produced by stimulation of selected cranial nerves, 4) Oral-Facial Motor Function: a series of voluntary oral facial postures such as puckering the lips or deviating the jaw to the right or left, 5) Ventilation/Phona‐ tion: 'a subjective evaluation of breathing and sound production' and 6) Functional Feed‐ ing Assessment: an 'evaluation of oral-motor skills during specific feeding tasks' examining spoon feeding, biting, chewing, cup- and straw drinking and swallowing. Overall rater agreement, among 3 raters, was 0.83, and overall rater consistency was 0.90. Other psychometric properties such as validity, item consistency and test-retest reli‐ ability still need to be determined. As well, examination of the suitability for the popula‐ tion with ASD will be needed.

*The Schedule of Oral-Motor Assessment* (SOMA) by Reilly et al. [86] measures the oral-motor and feeding skills of children 8 to 24 months of age. A sample of 127 children constituted the original sample, 90% were typically developing and 10% were children with cerebral palsy. Differently textured foods and liquids are offered to the child in a pre-determined order: liq‐ uid, puree, semi-solids, solids, biscuits and dried fruit and scored in 6 sections. Scores are based on the quality of oral-motor, mandible, lip and tongue movements. Inter-rater reliabil‐ ity was 0.75 and internal consistency 0.85 [87]. The predictive validity was > 95% and sensi‐ tivity >.85 [88]. The age range of the SOMA makes it particularly attractive for use with young children because of the benefits of early intervention [41]. While a diagnosis of ASD may only be confirmed by two years or later, feeding problems are often recognized by pa‐ rents from the first year. Treatment of feeding problems is not dependent on the diagnosis of ASD. Therefore, early intervention may prevent aggravation of feeding problems with time when not treated promptly.
