The Autism MEAL Plan: A parent-training curriculum to manage eating aversions and low intake among children with autism

Abstract

Feeding problems represent a frequent concern reported by caregivers of children with autism spectrum disorders, and growing evidence suggests atypical patterns of intake may place this population at risk of nutritional and/or related medical issues, including chronic vitamin and mineral deficiencies, poor bone growth, and obesity. This combination of factors emphasizes a clear need to identify and disseminate evidence-based treatment of feeding problems associated with autism spectrum disorders. Behavioral intervention represents an effective treatment for chronic feeding concerns in this population; however, evidence has largely been established with trained therapists working in highly structured settings. This pilot study seeks to fill this gap in the literature by describing and evaluating the Autism MEAL Plan, a behaviorally based parent-training curriculum to address feeding problems associated with autism spectrum disorders. We assessed the feasibility of the intervention in terms of program content and study protocol (e.g. recruitment and retention of participants, assessment procedures), as well as efficacy in terms of changes in feeding behaviors. A total of 10 families participated in the treatment condition, and the program was evaluated using a waitlist control design (n = 9), representing the first randomized-control study of a feeding intervention in autism spectrum disorders. Results provide provisional support regarding the utility of the program, including high social validity, parent perception of effectiveness, and reduced levels of caregiver stress following intervention. Implications, limitations, and future directions for this line of research are discussed.

Keywords

autism food selectivity intervention mealtime problems parent training pediatric feeding disorders

Food selectivity (i.e. only eating a narrow variety of foods) has been widely documented among children with autism spectrum disorders (ASD), with dietary patterns often involving strong preferences for starches and snack foods coinciding with a bias against fruits and vegetables (Ahearn et al., 2001; Cornish, 2002; Field et al., 2003). Estimates of atypical intake in ASD reach as high as 90%, suggesting that feeding problems may occur at epidemic levels in this population (see Ledford and Gast, 2006; Matson and Fodstad, 2009; Sharp et al., 2013a for reviews). Children with ASD often exhibit a strong emotional response when presented with nonpreferred food, including crying, disruption, and aggression during meals (Sharp et al., 2013b). There is also evidence that poor dietary diversity in ASD may increase the risk of nutritional and/or related medical issues, including vitamin and mineral deficiencies (Bandini et al., 2010; Zimmer et al., 2012) and poor bone growth (Hediger et al., 2008). Selective eating patterns may also explain increased rates of constipation among children with ASD (Ibrahim et al., 2009) while also portending elevated risk of diet-related diseases (e.g. obesity and cardiovascular disease) into adolescence and adulthood (Ho et al., 1997), both of which are associated with excessive consumption of snack and fats. Together, such high prevalence of feeding problems in ASD combined with the risk of long-term sequelae amplify the need to identify and disseminate evidence-based treatment to remediate these concerns.

Behavioral intervention represents a well-supported treatment for pediatric feeding disorders (Sharp et al., 2011a), and there is growing support that this technology can be applied to address selective eating patterns associated with ASD. Retrospective chart reviews conducted by Laud et al. (2009) and Sharp et al. (2011b) suggest significant improvement in feeding behaviors following behavioral intervention aimed at expanding dietary variety among samples of 46 and 13 children (respectively) treated at intensive feeding programs. Summaries of single-case reports in the extant literature also document uniformly positive outcomes associated with behavioral intervention to address food selectivity in ASD, including significant improvements in the variety and volume of nonpreferred foods (e.g. vegetables) consumed during meals (Ledford and Gast, 2006). Treatment descriptions typically involve both antecedent manipulations and consequence-based procedures combined to maintain the least restrictive environment while promoting contact with the sensory experience of food and exposure to the primary and secondary reinforcement contingent upon eating (Sharp et al., 2011a). Consequence-based procedures include escape extinction (e.g. nonremoval of the spoon or plate), which involves persisting with a feeding demand while ignoring refusal behaviors, as well as differential reinforcement of appropriate mealtime behaviors (e.g. acceptance and swallowing). Antecedent manipulations involve stimulus-fading procedures for introducing variety, texture, and/or volume of food presented during meals, as well as simultaneous and sequential presentation of preferred and nonpreferred food items (Sharp et al., 2011b). Among children with ASD, treatment packages often incorporate these elements with consideration to the unique cognitive and behavioral profile associated with ASD (e.g. resistance to change and heightened sensory defensiveness), such as greater use of antecedent manipulations and shaping to slowly introduce new sensory experiences (taste, texture, and temperature) due to the strong emotional response associated with the introduction of novel foods (Ledford and Gast, 2006).

While the available evidence suggests behavioral intervention represents a promising treatment avenue to address food selectivity among children with ASD, the extant literature primarily involves children working with behavioral therapists in highly structured settings (e.g. inpatient hospital unit and day treatment program), raising questions whether similar improvements can be achieved with less intensive approaches. With relatively few pediatric feeding programs spread out geographically, there is a strong need to develop and evaluate alternative treatment avenues to promote greater access to care. This will also provide an alternative treatment option for children with milder feeding concerns whose presentation does not warrant intensive intervention. Parent training represents a viable candidate for disseminating this technology in such cases, as this mode of treatment has been successfully applied to other widespread childhood concerns, including conduct problems (Sanders et al., 2000), toileting issues (Stark et al., 1990), and anxiety (Creswell and Cartwright-Hatton, 2007). Developing a parent-directed feeding intervention may also hold economical benefits, requiring less frequent and concentrated clinical contact while increasing the likelihood of application and maintenance in the natural environment. Interventions are more effective with involvement of family members and teachers rather than specialists alone (Buschbacher et al., 2004; Horner et al., 2002; Ingersoll and Dvortcsak, 2006), as parent-directed treatment facilitates generalization to the home environment, improves parent–child interactions, and maximizes the amount of intervention children receive (Girolametto and Tannock, 1994). Research also indicates parents of children with ASD can effectively implement continuous treatment, highlighting the potential for parent-directed feeding intervention to approximate outcomes documented with behavioral therapists (Koegel et al., 1996).

Caregiver involvement in treatment may also enhance parent well-being, including increased positive affect (Koegel et al., 1996; Solomon et al., 2008), reduced stress (Symon, 2001), and improved self-efficacy (Feldman and Werner, 2002). This represents a critical issue for caregivers of children with ASD given the hardships and additional stressors placed on family members related to the disorder (Symon, 2001), which include increased stress related to child dependency and physical limitations (Bouma and Schweitzer, 1990), disruptions in daily activities, and long-term child caring responsibilities (Koegel et al., 1992). Chronic feeding difficulties and related dietary concerns also represent an additional source of strain on caregivers (Greer et al., 2008), possible increasing child rearing burden (e.g. preparing multiple menus for each meal), parental stress, and social isolation. Unfortunately, many families also lack social support critical for coping with the stressors in their daily lives (Symon, 2001), suggesting the need to enhance caregiver skills in managing challenging behavior while also increasing interaction with peers. With this in mind, high caregiver involvement in treatment is not only important for the prognosis of the child but may also hold benefits for parents as well.

Although parent-directed interventions represent a promising treatment approach in ASD (Campbell and Kozloff, 2007), only a handful of studies have documented parents as the principal agent of change to address feeding concerns in this population (Najdowski et al., 2003, 2010). More commonly, generalization of treatment gains occurs once improvements in dietary variety and mealtime behaviors have been stabilized with a trained therapist, as detailed by both Laud et al. (2009) and Sharp et al. (2011b). In addition, past research has been limited to individual treatment protocols, raising questions whether similar positive outcomes can also be achieved in a group format using a standardized curriculum. Given that many effective interventions offered for families of children with ASD are costly, time consuming, and may not initially involve parents (Minjares et al., 2011), treatment offered in a group format may represent a unique, cost-efficient alternative for disseminating treatment in the ASD community (McNeil et al., 2005). Given the critical and ubiquitous role parents play in structuring meals in the home setting, developing and evaluating a parent-training curriculum designed to target feeding concerns in ASD also has potential for broad application and rapid distribution. With this backdrop in place, the purpose of this article is to (a) describe a behaviorally based parent-training program—the Autism MEAL Plan—a curriculum specifically developed to assist caregivers to Manage Eating Aversions and Low intake among children with ASD; (b) evaluate the feasibility of the parent-training program including program content and implementation, recruitment and retention of participants, and assessment procedures (Leon et al., 2011); and (c) obtain preliminary outcome data evaluating the social validity and effectiveness of this curriculum using a waitlist control design.

Method

Participant recruitment

Potential participants were recruited to take part in a two-phase project. The first phase of the project focused on methods for evaluating feeding concerns in ASD through the use of a multimethod assessment battery described in detail by Sharp et al. (2013b). Upon completion, the second phase of the project evaluated the feasibility and preliminary outcome data of the Autism MEAL Plan, which is the focus of this study. Recruitment occurred through local early intervention programs, parent support groups, and state and local autism organizations through flyers, list serves, and email. The central inclusion criteria included an ASD diagnosis (i.e. Asperger’s Disorder, Pervasive Developmental Disorder–Not Otherwise Specified, and Autistic Disorder) among children aged between 3 and 8 years. All participants were diagnosed by professionals not associated with the program (based on caregiver report); however, the Social Responsiveness Scale (SRS) parent report form (Constantino, 2005), a rating scale measuring the severity of autism spectrum symptoms (described in the following), was used to confirm ASD status. To be included in this study, participants were required to have a total SRS score in the mild, moderate, or severe range (total standard score (T-score) > 60). The presence of a significant feeding issue was not a requirement of the study, and we did not screen for feeding issues prior to enrollment in the study; however, we understood that the subject matter of the parent-training curriculum was likely to attract families concerned with their child’s mealtime behaviors.

Measures

The assessment battery included a general questionnaire gathering background information (e.g. date of birth and gender), feeding concerns or dietary habits, and previously diagnosed medical, developmental, or mental health issues. Nursing staff also obtained anthropometric parameters (i.e. height and weight) for each child during the first assessment visit to the clinic. To assess the impact of intervention, we selected measures likely to be sensitive to detecting proximate changes in response to intervention as outlined by Sharp et al. (2013b). This included standardized questionnaires assessing the following: (a) general mealtime problems specific to ASD, (b) areas of family life that may be affected by feeding problems (i.e. parent stress), and (c) dietary diversity as captured by a Food Preference Inventory (FPI). In addition, we assessed the social validity of the program as well as parent perception of improvement with a brief questionnaire administered at the completion of the study.

SRS–parent report form

The SRS–parent report form (Constantino, 2005) is a 65-item rating scale measuring the severity of autism spectrum symptoms as they occur in natural social settings. The instrument yields a total score (T-score), as well as T-scores on five subscales focusing on social awareness, social cognition, social communication, social motivation (e.g. anxiety/avoidance), and autistic mannerisms (e.g. preoccupations). Scores from 60 to 75 reflect deficiencies that are clinically significant and lead to mild to moderate interference in everyday social interactions consistent with mild to “high functioning” autism. The scale has demonstrated adequate reliability and validity.

Brief Autism Mealtime Behavior Inventory

The Brief Autism Mealtime Behavior Inventory (BAMBI; Lukens and Linscheid, 2008) is a parent report checklist designed to measure mealtime behavior problems observed in children with ASD. The 18-item measure employs a Likert scale for reporting the frequency of behaviors (1 = Never/Rarely to 5 = At Almost Every Meal). The scale yields a total score, as well as scores on three subscales (i.e. Limited Variety, Food Refusal, and Features of Autism). Items on the Limited Variety subscale assess a child’s willingness to try new foods and food preference by preparation, texture, or type. The Food Refusal subscale focuses on problem behaviors during meals (e.g. crying, expelling bite, and disruptions during meals). Finally, the Features of Autism subscale includes items that assess inattention, self-injury, and rigid behavior patterns during meals. The authors reported good internal consistency, high test–retest reliability, and strong construct and criterion-related validity in the initial validation study.

FPI

The FPI includes 154 items across 7 food categories—30 fruits, 28 vegetables, 36 proteins, 27 starches, 8 dairy, 20 miscellaneous/snack (i.e. deserts, fats, and sweets such as cake, cookies, or chips), and 5 combination foods (e.g. lasagna/ravioli, taco/burrito, or soups/stews). A registered dietician reviewed the list and classified foods into each of these categories based on classifications provided by the United States Department of Agriculture. The inventory employs a Likert-type scale assessing preference for consumption (e.g. Never, With Prodding, Willing, and Favorite). Respondents were also given the option of selecting “N/A” if an item was not part of the family’s regular diet or the child lacked exposure or experience with the food. Consistent with previous research (Sharp et al., 2013b), we derived a food selectivity score by dividing the number of foods a caregiver reported the child “never” consumed by total number of items (154) multiplied by 100. Higher scores reflect greater levels of food selectivity.

Parenting Stress Index–short form

The Parenting Stress Index–short form (PSI-SF; Abidin, 1995) is a screening instrument designed to provide an indication of the overall level of parenting stress an individual is experiencing through self-report. A total stress score is derived, as well as data on three subscales involving 12 items each: Parental Distress (PD), Parent–Child Dysfunctional Interaction (P-CDI), and Difficult Child (DC). Analysis in this study focused exclusively on the total PSI score. Percentile scores from 81 to 84 are considered in the borderline range of clinical severity, while scores of 85 or greater are considered clinically significant. The PSI has been used in pediatric samples and has exhibited high internal reliability.

Social validity and parent perception of improvement

We developed a 10-item posttreatment questionnaire assessing the following: (a) general satisfaction and acceptability of the program (e.g. “Overall, how satisfied were you with the parent group?”) and (b) perceived effectiveness of the intervention to improve behavior during and outside of meals (e.g. “In general, how effective were the behavioral recommendations at improving your child’s mealtime behaviors?”). Items were rated on 5-point Likert-type scale (1 = Quite Dissatisfied/Totally Disagree/Not at All Effective; 5 = Extremely Satisfied/Totally Agree/Extremely Effective), with higher scores reflecting greater levels of satisfaction, perceived improvements/effectiveness, and acceptance of treatment. All items included in the scale are presented with outcome date in the following.

Educational curriculum

The Autism MEAL Plan was modeled after well-established, evidence-based training programs successfully applied to other behavior problems in children (e.g. Neary and Eyberg, 2002; Sanders et al., 2000). The book Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities: Interventions for Professionals and Parents by Williams and Fox (2007) also served as a model for the development of training activities and handouts, as did treatment protocols used with children with ASD in our clinical practice (see Sharp et al., 2011b for a description).

The intervention involved eight, 1-h-long parent-training group sessions. Sessions were didactic in nature, with structured content presented during each meeting (See Table 1 for table of contents). Topics covered in the manual included general behavior management strategies (e.g. routine and consistency, positive attending) applied during meals, specific interventions for feeding problems associated with ASD (e.g. extinction and stimulus fading), and strategies for promoting self-feeding (e.g. graduated prompting and backward chaining). Additional themes emphasized throughout the curriculum included the following: (a) the gradual process of behavior change, (b) the importance of monitoring behaviors (e.g. ABC charts and mealtime data sheets), (c) identifying and concretely defining specific behaviors for intervention (i.e. using operational definitions), (d) using the child’s behavior to guide the course of treatment through the use of decision rules, and (e) the possibility for an increase in problem behavior following the introduction of treatment (i.e. an extinction burst). To encourage caregivers to apply new skills in the home setting, a homework assignment accompanied each lesson, and the first 10 min of each session involved reviewing these assignments, addressing questions or concerns, and providing feedback. We did not, however, collect data regarding completion of homework or fidelity regarding assigned activities.

Table 1.

The Autism MEAL Plan: overview of sessions.

Session	Subject	Content
1	Introduction	Types of eating problems
		Antecedents and consequences that affect feeding
		Modeling
		Parenting stress
		Planning an intervention
		Homework: selecting a target for intervention
2	Structuring meals and monitoring behaviors	Routine and consistency: meal schedules, location, and length
		Monitoring your child’s intake
		Tracking your child’s mealtime behavior: ABC charting and behavioral definitions
		Homework: ABC chart—tracking mealtime interactions
3	Ways to increase appropriate behavior	Positive attending and specific praise
		Tangible rewards
		Homework: catching your child’s good behavior during meals
4	Effective communication	Rules for effective commands
		General strategies for effective communication
		Homework: changing ineffective commands to effective commands worksheet
5	Ways to decrease inappropriate behavior during meals	Selective ignoring and differential attention
		Withdrawing positive reinforcement
		Nonremoval of the spoon and exit criterion
		Homework: practicing selective ignoring
6	Methods of introducing foods	Modifying the bite size, meal variety, and food texture
		Simultaneous presentation and variety fading
		Homework: introducing new foods during a meal
7	Teaching self-feeding skills	Prompting strategies
		Four-step prompting sequence
		Backward chaining
		Homework: implementing the four-step prompting sequence
8	Monitoring and maintaining progress	Tracking progress
		What to look for when problems arise
		Dietary considerations

The sequence of topics initially focused on strategies aimed at establishing conditions favorable for a feeding intervention, including improving meal structure (time, location, and length), age-appropriate seating, and general behavioral management strategies. The families were encouraged to set up these foundational practices in the home setting before introducing new foods (a topic not covered until the sixth week). Families were provided with a three-ring binder during the first session; however, to encourage attendance, therapists distributed lessons on a weekly basis (as opposed to providing the entire manual at the onset of the group) and provided access to missed lessons when a family returned for the next scheduled meeting. Although the curriculum was delivered in a group format using broad examples and principles, participants were encouraged to individualize the strategies to meet the needs of their child. Individualization of intervention was also emphasized when assigning and reviewing completion of homework on a weekly basis.

Childcare was provided for families (if needed) during the educational sessions. The intervention did not involve live feeding activities with parent–child dyads because researchers were evaluating the feasibility of delivering a parent-only education group. We provided the educational curriculum and childcare at no cost and offered two group sessions of the program each week (i.e. morning and evening) in order to accommodate possible scheduling conflicts and to maximize participation. Three families attended the Monday morning session and seven families attended the Wednesday evening session.

The first author (W.G.S.), a behavioral psychologist with expertise in the treatment of pediatric feeding disorders who developed the curriculum, conducted the sessions with assistance from a postdoctoral psychology fellow. A fidelity checklist was utilized to ensure that the clinician covered all topics of the curriculum each week. Both therapists also took detailed notes regarding any new topics (e.g. use of time-out during and outside of meals) introduced during group discussion to ensure this information was disseminated to both cohorts, as well as to provide a reference during program evaluation and revision.

Design and procedure

This study was conducted in compliance with a university-based Institutional Review Board (IRB). Participation in the study was voluntary, with no incentives for participation outside the educational curriculum. We obtained written consent from all participants prior to enrollment. We evaluated treatment using a waitlist control design. During preintervention, all participants participated in the assessment battery described by Sharp et al. (2013b) and, when complete, families were randomly assigned to either receive the treatment condition or to a waitlist control. During the second stage of the project, the treatment group participated in the 8-week educational curriculum. We collected attendance data at each session, including the number of caregivers present. In an effort to boost retention, the waitlist control group received email correspondence involving handouts on nonfeeding-related topics with limited behavioral content (e.g. limiting television watching and toileting recommendations). All participants completed a postintervention assessment battery following completion of the educational curriculum, and the waitlist group was subsequently offered the educational curriculum, followed by a final evaluation.

Statistical analyses

To determine whether there were preexisting differences between the treatment and waitlist control groups, as well as those participants lost to attrition, we compared groups using analysis of variance (ANOVA) on all preintervention dependent measures. We also calculated descriptive statistics (means and standard deviations) to provide a qualitative summary of pre- and postintervention scores for the treatment and waitlist control groups. Finally, to evaluate the degree of change in parenting stress (as captured by the PSI) and feeding behaviors (as reflected by the BAMBI total score and subscales and the FPI selectivity score), we conducted analysis of covariance (ANCOVA) comparing postscores between the treatment group and the waitlist control group on each dependent measure statistically controlling for variation in baseline scores. We also calculated effect size estimates (Cohen’s d) for each outcome variable based on differences between groups using pre/post-change scores and evaluated the magnitude of the treatment effect using conventional standards (0.2 = small, 0.5 = medium, 0.9 = large; Cohen, 1988).

Results

Feasibility outcomes

Study attrition, description of participants, and session attendance

The CONSORT diagram (Figure 1) displays the flow of participants through the study. A total of 30 families completed the first assessment phase (see Sharp et al. (2013b) for sample description) and were assigned to either the treatment condition or the waitlist control condition using computer-generated block randomization to promote equal number of participants in each group (n = 15). Participant attrition, however, impacted the number of families who completed the study, with 19 participants continuing in the study following randomization. Ten families participated in the educational curriculum and completed the second assessment battery. The five families who discontinued participation following random assignment (but before attending a parent-training session) cited scheduling issues as prohibiting further involvement in the study. In the waitlist control condition, nine families returned to complete the second evaluation following the 8-week break. We were unable to contact two of the families, and the remaining four families cited scheduling as a barrier to continued participation in the study. The 11 families lost to attrition were not different on any baseline measures compared to those who completed the study.

Figure 1.

Flow diagram of parent education versus waitlist control.

There were no significant differences between the groups (as well as those lost to attrition) on key baseline characteristics or feeding behaviors (Table 2). The majority of the children in the study were male, representing 15 of the 19 children (79%). The average body mass index (BMI) for age percentile of the sample, calculated based on Center for Disease Control and Prevention’s BMI-for-age growth charts (Kuczmarski et al., 2000) using weight and height obtained during the initial assessment fell within the healthy weight range (5th to 85th percentile). This suggests no growth concerns as a group (i.e. underweight or obesity), which is consistent with research indicating increased risk of feeding problems (e.g. extreme tantrums during meals, severe food selectivity, and ritualistic mealtime behaviors) in ASD and does not necessarily translate into greater risk of compromised growth (Sharp et al., 2013a). Notably, scores on the PSI fell in the clinically significant range for the treatment group and in the borderline range for the waitlist control group, suggesting high levels of stress among caregivers participating in the study. In terms of attendance, 83% of sessions were attended by at least one caregiver from the 10 families in the treatment group. Mothers represented the modal participant, attending 80% of the sessions, while fathers attended 37% of the sessions. Four families had both parents attend at least three sessions.

Table 2.

Baseline characteristics by group.

Characteristic	Treatment (n = 10)	Waitlist (n = 9)	Attrition (n = 11)	p-value(F)
	M (SD)/range	M (SD)/range	M (SD)/range
Male sex, n (%)	8 (80)	7 (78)	8 (73)
Age (in months)	70.8 (20.5)/36–104	64.8 (16.9)/45–94	70 (15.8)/43–93	.73 (.32)
SRS total score	82.4 (8.4)/70–91	80.6 (7.9)/68–91	86.7 (6.6)/78–91	.19 (1.75)
BMI/age %	47 (32.8)/11–93	66.8 (36.4)/9–99	68 (33.6)/6–99	.31 (1.24)
PSI total score	89.3 (7.8)/75–99	79.9 (20.5)/50–99	89 (5.8)/80–95	.49 (.73)
BAMBI total score	51.1 (7.1)/41–61	52.1 (7.8)/36–62	45.6 (14.7)/18–75	.35 (1.09)
BAMBI limited variety	28.2 (5.1)/22–34	28.2 (5.1)/20–34	24.2 (8.4)/8–34	.27 (1.39)
BAMBI food refusal	12.9 (3.5)/8–18	11.9 (3.3)/8–18	10.4 (4.5)/5–21	.33 (1.15)
BAMBI autism features	10.0 (2.1)/7–13	12.0 (3.54)/7–19	11.0 (4.0)/5–20	.44 (.85)
FPI selectivity score	32.6 (22.3)/5–75	37.2 (17.8)/12–63	41.6 (25.8)/4–81	.67 (.42)

SD: standard deviation; SRS: Social Responsiveness Scale; BMI: body mass index; PSI: Parenting Stress Index; BAMBI: Brief Autism Mealtime Behavior Inventory; FPI: Food Preference Inventory.

Social validity and caregiver satisfaction

All families who completed the educational curriculum (treatment and waitlist) were asked to complete the posttreatment satisfaction questionnaire. We administered this questionnaire to both treatment and waitlist groups at the same point in time (e.g. after all participants were exposed to the curriculum), which (in hindsight) reduced the number of treatment families (n = 6) who remained in contact with the study following the additional 8 weeks required for the waitlist group to complete parent training. This resulted in a total of 12 families (63% of the total group) who provided feedback regarding program satisfaction, treatment gains, and social acceptability (Table 3). Ratings for the available families suggest a high degree of social validity associated with Autism MEAL Plan. We also encouraged caregivers to provide a narrative summary regarding their perception of the training program. Feedback included both positive statements (e.g. “Awesome program!”) as well as recommendations for future modifications to the format of the group (e.g. hands-on training with child present and email communication between sessions).

Table 3.

Caregiver ratings of the Autism MEAL Plan post intervention.

Item	Treatment (n = 6)	Waitlist (n = 6)
1. Overall how satisfied are you with the Marcus Feeding Parent Group?	4.2	4.2
2. In general, how effective were the behavioral recommendations in improving your child’s mealtime behavior?	4.2	4.3
3. In general, how effective were the behavioral recommendations in improving your child’s behavior outside of meals?	3.3	4.0
4. At home, my family will continue to use the behavioral recommendations from this program.	4.3	4.8
5. Compared to when we started the program, my child’s feeding/behavior is much improved.	4.0	4.0
6. If a friend was in need of a similar help, would you recommend the Parent Group to him/her?	4.8	4.8
7. Soon after using the intervention, you noticed a change in eating behavior that was much better.	3.0	3.7
8. This is an acceptable intervention for my child’s eating behavior.	4.0	4.5
9. The program improved my child’s eating/target behavior so it is not much different from others.	2.8	3.3
10. At a restaurant, we plan to use the behavioral treatment program.	4.0	4.3

Efficacy outcomes

Upon completion of the Autism MEAL Plan, caregivers in the treatment group reported a significant reduction (F (1, 16) = 7.6, p = .01) in PSI scores compared to the waitlist control group after controlling for preintervention PSI levels (Table 4). The magnitude of this effect fell in the large range by conventional standards (d = 1.1). There were no significant changes detected in terms of feeding behaviors, as captured by the BAMBI total score and the three BAMBI subscales, or dietary variety based on the FPI selectivity score.

Table 4.

Mean (SD) levels of parenting stress and feeding behaviors before and after intervention.

Characteristic	Treatment		Waitlist		p-value (F)
	Pre	Post	Pre	Post
PSI total score	89.3 (7.8)	81.0 (14.1)	79.9 (20.5)	80.3 (24.9)	.01 (7.6)
BAMBI total score	51.1 (7.1)	47.2 (9.6)	52.1 (7.8)	47.2 (12.6)	.79 (.07)
BAMBI limited variety	28.2 (5.1)	26.0 (5.2)	28.2 (5.1)	26.8 (6.6)	.55 (.36)
BAMBI food refusal	12.9 (3.5)	12.6 (4.1)	11.9 (3.3)	11.0 (3.0)	.51 (.46)
BAMBI autism features	10.0 (2.1)	8.6 (2.0)	12.0 (3.54)	9.5 (3.6)	.57 (.34)
FPI selectivity score	32.6 (22.3)	38.8 (27.5)	37.2 (17.8)	37.2 (25.9)	.21 (1.7)

SD: standard deviation; PSI: Parenting Stress Index; BAMBI: Brief Autism Mealtime Behavior Inventory; FPI: Food Preference Inventory.

Discussion

This pilot study describes a parent-training curriculum, entitled the Autism MEAL Plan, aimed at teaching caregivers of children with ASD to develop and implement behaviorally based feeding interventions. This represents a novel approach to address the ubiquity of feeding problems in this population, as previous treatment descriptions either involved intensive intervention occurring at specialized feeding disorder programs or case studies describing individualized protocols. By developing a manual-based curriculum involving minimal clinical contact, we sought to provide an economical alternative with the potential for replication and rapid dissemination in the ASD community. The potential cost-savings benefits of a parent-directed feeding intervention in a group format is highlighted by the reduction in clinical contact associated with the program, with 8 h of group sessions (vs 80 h of individual sessions) required to serve the 10 families in the treatment condition. Preliminary results also support the Autism MEAL Plan as a promising treatment avenue for delivering this technology, with caregiver feedback indicating high overall satisfaction with the program in terms of both content and format of the intervention. Following treatment, caregivers also reported a significant reduction in overall stress, which is consistent with previous research indicating caregiver involvement in treatment has the potential to enhance parent well-being and may also portend increased likelihood of follow-through with a parent-directed feeding intervention. Although parenting stress was not the primary target of intervention, research suggests that the reduction in parenting stress can positively influence the effectiveness of the treatment being implemented, as well as potentially provide additional benefits such as more positive parent–child interactions (Brookman-Frazee, 2004) and improved self-efficacy (Feldman and Werner, 2002). Together, the feasibility information yielded by this pilot study suggests that Autism MEAL Plan may represent an economical and socially valid intervention for feeding problems in ASD, while also providing important guidance for future research in this area outlined in the following (See Table 5 for summary).

Table 5.

Summary of key findings and recommendations for future research.

Findings suggest the Autism MEAL Plan
May lead to a reduction in total parenting stress Represents a socially valid means to disseminate this technology Holds potential cost-savings benefits in terms of total clinical contact
Future research in this area should
Involve direct observation or live feeding activities to assess procedural fidelity and enhance training Include detailed diagnostic characterization to confirm ASD status and determine intellectual status Identify and incorporate feeding screening measures to quantify feeding concerns and determine appropriateness of intervention Increase the number of children exposed to the curriculum while concurrently identifying means to reduce attrition Conduct larger efficacy studies, including determining the external validity of the curriculum to other settings and therapists

ASD: autism spectrum disorders.

Despite positive parent feedback and reduced levels of stress, we did not observe a change in mealtime behaviors (as captured by the BAMBI) or dietary variety. In fact, although not statistically significant, the mean number of foods identified as nonpreferred actually increased for the treatment group following intervention. The lack of improvement in feeding outcomes, which represent the ultimate target of the Autism MEAL Plan, raises important questions regarding the apparent discordance with high social validity, parent perception of effectiveness, and reduced caregiver stress associated with the program. Limitations in study design, including both statistical power and timeframe of measurement, likely account for some of this discrepancy. As noted above, the first half of the intervention focused on foundational behavioral principles (e.g. routine and consistency, selective ignoring), while methods for introducing new foods into meals did not occur until the sixth week. The program also emphasized the use of antecedent manipulations and shaping to slowly introduce new foods. Long-term follow-up, therefore, may be required to detect more distal shifts in dietary intake. This may also help explain the observed increase in the number of nonpreferred foods associated with intervention, as caregivers may have been more likely to present new foods in the home setting, but not yet able to achieve stable rates of acceptance due to the likelihood of an extinction burst and/or the use of stimulus fading and shaping to gradually shift dietary preference.

The study was also limited by the lack of a training manipulation check, raising important questions regarding whether possible protocol drift influenced outcome variables, as well as the curriculum’s effectiveness in promoting skill acquisition. Direct observation represents one method to assess procedural fidelity, providing information regarding parents’ implementation of behavioral strategies as well as their child’s response to intervention. Adding live feeding activities to the curriculum was also recommended by many caregivers during postintervention feedback, suggesting that activities such as coaching, modeling, and/or role plays would enhance the overall training experience for participants. Procedural fidelity could also be assessed by collecting detailed information regarding homework completion, including the extent to which parents used recommended skills outside of the sessions and/or completed weekly assignments. Finally, development of a knowledge test of program content would permit analysis of parents’ acquisition of behavioral principles and effectiveness of the current format in disseminating this information.

Future research should also seek to increase the number of children exposed to the curriculum (and reduce attrition) in order to enhance power and provide a more robust assessment of intervention. Identifying additional methods to maximize retention should be a priority to reduce possible threats to internal validity. Modifying the recruitment process represents one potential avenue to reduce attrition. For example, providing families interested in the study with predetermined days/times for group sessions prior to enrollment (vs following the initial assessment) may help minimize scheduling conflicts. In addition, requiring the presence of feeding concerns as part of the inclusion criteria—possibly through the use of a severity threshold for enrollment (e.g. accepts < four fruits or vegetables)—may help assure participants are highly motivated to participate in an intervention aimed at addressing mealtime difficulties in ASD. Once the study begins, retention and attendance could also be enhanced by increasing engagement with families throughout the study through phone calls and/or email, including providing consultation between sessions as suggested by many participants during postintervention feedback.

Finally, it will be important to better characterize participants through standardized developmental diagnostic testing and feeding evaluation to provide more detailed information regarding ASD symptomatology, level of functioning, and severity of feeding concerns. Enhanced assessment would permit questions regarding what subgroup(s) of children best benefit from this level of intervention, such as establishing a threshold for children appropriate for a parent-directed intervention. This will require the development of a frontline feeding screen tool to quantify the magnitude of mealtime difficulties associated with ASD, as lack of standardized measures represents a significant barrier to research in this area (Matson and Fodstad, 2009). With food selectivity representing a primary feeding concern associated with ASD, dietary diversity, as captured through measures such as the BAMBI’s Limited Variety subscale or the number of foods identified as never consumed on the FPI, should continue to be included in outcome measures of treatment efficacy. In addition, parent performance, knowledge, and application of behavioral principles should be accessed through the use of direct and/or indirect assessment methods. Direct observation of parent–child mealtime interactions would necessitate the identification of a coding system to track and capture both parent and child behavior, which could be modeled after procedural integrity procedures outlined in single-subject research (e.g. Najdowski et al., 2010). Outcomes should also assess more general changes in the family environment, such as changes in parenting stress, family routine (e.g. increased visits to restaurants or social gatherings involving food), parent–child interactions, and child behavior outside the context of meals (e.g. improvements in externalizing behaviors).

With these limitations in mind, this study represents one of the few empirical evaluations of a feeding intervention using a group design (See Sharp et al., 2011a for review) and the only specifically targeting feeding problems in ASD. Furthermore, it involves one of the largest cohorts of children with ASD in the feeding intervention literature, with the exception of retrospective chart reviews of intensive feeding programs (Laud et al., 2009; Sharp et al., 2011b). This highlights the paucity of research in this area despite high prevalence estimates and the potential for long-term health sequelae associated with chronic feeding problems. It also reflects the need for a greater research thrust focusing on feeding problems in ASD in order to address key questions regarding the assessment, long-term consequences, and remediation of atypical patterns of intake in ASD (Sharp et al., 2013a).

In sum, preliminary evidence suggests that the Autism MEAL Plan has the potential to fill an important gap in the treatment literature, providing an alternative option to therapist-driven, clinic interventions for children with milder feeding concerns, which do not warrant admission to an intensive feeding program. Feedback from participants, as well as therapists’ experience implementing the protocol, provides guidance regarding potential modifications to training activities going forward. These include greater use of supplemental learning activities, such as role-playing, video examples, and in vivo coaching. We will be revising and reevaluating the training curriculum with these considerations in mind. Finally, the mechanism(s) responsible for the observed reduction in stress levels should be more fully explored, with potential candidates including enhanced self-efficacy related to skill acquisition and/or increased levels of social support provided by interaction with the clinicians and/or peers.

Footnotes

Funding

This project was funded by a 2008 Applied Research Grant sponsored by the Organization for Autism Research.

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