Swallowing and Feeding Difficulties in Neurodivergent Children: Awareness,Practices,and Challenges Among Indian Speech-Language Pathologists: A Cross-Sectional Survey

Abstract

This cross-sectional survey study examined awareness, assessment practices, management strategies, and perceived challenges among Indian Speech-Language Pathologists (SLPs) working with feeding and swallowing in neurodivergent children. A cross-sectional online survey was conducted with 136 SLPs practicing pediatric dysphagia management across India. While 85.3% of SLPs recognized feeding difficulties in neurodivergent children, only 58.1% provided dysphagia services. Most (72.1%) considered current assessment tools inadequately adapted, and 91.2% reported difficulty obtaining child cooperation. Differentiating sensory from physiological disorders was the primary assessment challenge (80.9%). Sensory integration strategies (36.8%) and adaptive utensils (48.5%) were commonly used, but limited evidence on sensory difficulties (70.6%) and lack of standardized protocols (52.9%) constrained practice. Nearly all respondents demanded enhanced training (95.6%) and standardized guidelines (86.8%). Indian SLPs demonstrate high awareness and commitment to sensory-informed, family-centered care but face significant barriers including inadequate assessment tools, limited evidence, and insufficient interdisciplinary infrastructure.

Keywords

feeding disorders dysphagia neurodevelopmental disorders child health services accessibility

Introduction

Neurodivergence refers to a condition of individuals who have a neurocognitive profile that diverges from the majority (i.e., atypical), whereas neurotypical people are those whose neurocognitive profile is considered aligned with the majority (i.e., typical) (Gaddy & Crow, 2023; Wakefield et al., 2020). There are many forms of neurodivergence, such as, but not limited to, autism, attention deficit hyperactivity disorder (ADHD), Tourette’s syndrome, giftedness, dyslexia, dyscalculia, dyspraxia, and intellectual disability (ID) (Gaddy & Crow, 2023; Matson, 2023; Wakefield et al., 2020).

Children with additional needs are at higher risk for feeding problems than typically developing peers. Feeding difficulties affect 20% to 40% of typically developing children and up to 80% of those with developmental disabilities (Cobbaert & Rose, 2023; Ledford & Gast, 2006). While communication and social skill deficits are often highlighted in autism spectrum disorder, many children also struggle with daily living skills like toileting, dressing, and feeding. Up to 90% of autistic children experience feeding difficulties (Kodak & Piazza, 2008). Recent studies suggest that early feeding issues may serve as an early indicator of autism spectrum disorder (Cobbaert et al., 2024; Kodak & Piazza, 2008). Meal time challenges can be especially stressful for caregivers, leading to mealtime anxiety, family conflict, and reduced quality of life (Gent et al., 2025; Samuel et al., 2023). Some parents even prepare separate meals for their children, avoid restaurants, or go to great lengths to find specific foods their child will eat when they become unavailable (Matson, 2023; Shabnam et al., 2022). Delays in Eating Disorder identification and shared neurocognitive vulnerabilities, such as executive dysfunction (e.g., impaired task-switching and inhibitory control), may underlie these outcomes (Norton et al., 2024).

The assessment of feeding difficulties often includes descriptive analyses of inappropriate mealtime behaviors, involving observation of meals in natural settings to identify antecedents and caregiver-delivered consequences (Borrero et al., 2010; Leon et al., 2016). Descriptive analyses provide useful insights and may indicate a need for medical evaluation or dietary changes. However, they only identify correlational relationships, not causality, so further assessment is required to confirm the functional link. Functional analysis of mealtime behavior systematically manipulates antecedents and consequences to identify reinforcers maintaining problem behavior (Leon et al., 2016). In Antecedent Assessments the children may accept certain foods or drinks under specific conditions. Assessing antecedent variables (e.g., food type, texture, bite size, utensil) can identify these conditions by addressing skill deficits or altering reinforcer effectiveness (Matson, 2023; Sharp & Jaquess, 2009).

While autism spectrum disorder has received the greatest research attention, emerging evidence indicates that feeding difficulties are prevalent across neurodivergent conditions, including ADHD (where impulsivity and inattention affect mealtime routines), intellectual disability (where oral-motor and cognitive factors interact), and dyspraxia (where motor planning difficulties compromise self-feeding skills) (Grot et al., 2024; Norton et al., 2024).

The Indian context presents unique considerations. India’s diverse culinary landscape, characterized by mixed dishes, variable textures (e.g., rice, chapati, dal), and specific mealtime rituals, poses challenges for applying Western-developed assessment instruments. Furthermore, the Rehabilitation Council of India recognizes approximately 12,000 registered SLPs for a population of 1.4 billion, with pediatric dysphagia services concentrated in urban tertiary care centers (Bajaj & Karuppali, 2022; Muneer & Shabnam, 2025). Cultural factors, including extended family involvement in feeding and traditional dietary beliefs, may influence both the presentation of feeding difficulties and caregiver responses (Samuel et al., 2023). To date, no culturally adapted assessment tools or Indian-specific clinical guidelines exist for managing feeding and swallowing difficulties in neurodivergent children.

Improving clinical care and honing diagnostic criteria require better understanding of feeding and swallowing issues in neurodivergent people. The causes underlying these difficulties may become clearer with more investigation into physiological profiles and neuroanatomic correlations. Effective assessment and management are hampered by presentation variability and a lack of established criteria. Insights from this research into contemporary practices and viewpoints of Indian SLPs may provide useful information for identifying care needs, training priorities, and practice requirements for managing feeding and swallowing difficulties in neurodivergent children. Such insights can help guide future research and service development rather than directly establishing evidence-based regimens. The current study aimed to determine the awareness, knowledge and perspectives of Indian Speech-Language Pathologists regarding the assessment and management of Swallowing and Feeding in neurodivergent population. Specifically, this study aimed to answer the following research questions: (1) What is the level of awareness among Indian SLPs regarding feeding and swallowing difficulties in neurodivergent children? (2) What assessment and management practices do Indian SLPs currently employ for this population? (3) What are the perceived challenges and resource needs for improving dysphagia services for neurodivergent children in India?

Methods

A cross-sectional survey design was employed to investigate the awareness, knowledge, and clinical practices of Indian Speech-Language Pathologists (SLPs) regarding swallowing and feeding difficulties in neurodivergent children. Data were collected between May 2025 and August 2025 using a self-administered online questionnaire. The study received ethical approval from the Father Muller Institutional Ethics Committee (FMIEC/CCM/225/2025), and all procedures were conducted in accordance with the Declaration of Helsinki. This study is reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (Altman et al., 2007).

Participants

Eligible participants were Rehabilitation Council of India (RCI) registered SLPs practicing in India with ≥1 year of pediatric dysphagia experience. The online survey included a screening question confirming this criterion. However, five respondents who endorsed the eligibility filter subsequently indicated in the demographic section that they had <1 year experience. These respondents were retained for descriptive reporting (Table 1) but excluded from chi-square analyses involving years of experience as a predictor variable (n = 131 for those analyses). Sensitivity analyses excluding these five respondents entirely did not materially change any reported findings. Invitation emails were sent to 847 registered SLPs; 63 were undeliverable, yielding 784 valid invitations. A total of 157 clinicians initiated the survey, with 136 providing complete responses (completion rate: 86.6%; response rate: 17.3%). The target sample size of 136 was determined a priori using single proportion calculation with the following parameters: estimated proportion of SLPs providing dysphagia services of 50% (conservative estimate based on Rangarathnam & Desai, 2020; Rangarathnam & Desai, 2020), 95% confidence level (z = 1.96), 5% margin of error, yielding a minimum required sample of 96. Accounting for an anticipated 30% incomplete response rate, the target was increased to 136. To characterize the geographic representativeness of the sample, respondents’ reported practice locations were categorized into the six major geographic zones of India (North, South, East, West, Central, and Northeast). The final sample included representation from 18 states, with the highest concentration from South India (n = 74, 54.4%), followed by West (n = 28, 20.6%), North (n = 18, 13.2%), East (n = 10, 7.4%), Central (n = 4, 2.9%), and Northeast (n = 2, 1.5%).

Table 1

Demographic and Practice Characteristics of Participants (N = 136)

Characteristic	Category	n	%
Gender	Female	120	88.2
Gender	Male	16	11.8
Qualification	B.ASLP	98	72.1
	MSc Speech-Language Pathology	18	13.2
	M.ASLP	18	13.2
Work setting*	Academic	38	27.9
	Private Clinic	31	22.8
	Hospital	28	20.6
	NGO	11	8.1
	Early Intervention Center	8	5.9
	Telepractice^a	7	5.1
	Government Setup	6	4.4
Work experience	<1 year	5	3.7
	1–5 years	65	47.8
	6–10 years	45	33.1
	>10 years	21	15.4

Note. *Participants could select multiple work settings; percentages sum to >100%. Abbreviations: B.ASLP = Bachelor of Audiology and Speech-Language Pathology; M.ASLP = Master of Audiology and Speech-Language Pathology; NGO = Non-Governmental Organization

^a‘Telepractice’ as a work setting reflects responses from participants who selected ‘Other’ in Q3 and specified telepractice as their primary practice setting (n = 7).

Survey Development

A structured questionnaire was developed specifically for this study, as no validated instrument existed to assess SLP practices in neurodivergent pediatric dysphagia within the Indian context. Item generation was informed by: a comprehensive review of existing literature on feeding and swallowing difficulties in neurodivergent populations (Cobbaert et al., 2024; Grot et al., 2024; Kodak & Piazza, 2008; Shabnam et al., 2022) and consultations with three senior SLPs specializing in pediatric feeding disorders. Questionnaire structure and response formats were informed by published recommendations for survey design in health professions research (O’Connor, 2021) and by the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (Torrejón-Guirado et al., 2024).The survey was administered in English, which is the medium of instruction for all RCI-recognized SLP training programs in India and the primary language of professional communication among Indian SLPs. All registered SLPs are required to demonstrate English proficiency for licensure. Therefore, language was not expected to be a barrier to comprehension or response. Content validity was established by five experts (three SLPs, one occupational therapist, one pediatric gastroenterologist). Item-Level Content Validity Indices (I-CVIs) ranged from 0.80 to 1.00, and the Scale-Level Content Validity Index (S-CVI/Ave) was 0.94. The survey instrument began with an operational definition of ‘neurodivergent children’ to ensure shared understanding among respondents: children diagnosed with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), intellectual disability, dyslexia, dyspraxia/developmental coordination disorder, Tourette’s syndrome, or other neurodevelopmental conditions characterized by atypical neurological development. This definition was presented on the first page of the questionnaire. The questionnaire comprised five sections: demographics, awareness, assessment practices, management practices, and future perspectives. Internal consistency reliability was acceptable: awareness section α = 0.81, assessment challenges α = 0.79, management challenges α = 0.84. The instrument was pilot-tested with 12 SLPs prior to finalization. Pilot testing was conducted in two phases. Phase 1 (cognitive interviewing) involved six SLPs (three with >5 years pediatric dysphagia experience, three with 1–3 years experience) who completed the survey while verbalizing their thought processes, following established cognitive interviewing protocols (Collins, 2003; Willis, 2004). This identified unclear items, ambiguous terminology, and response option gaps. Phase 2 involved six additional SLPs who completed the survey independently, followed by a debriefing interview assessing item clarity, survey length, and technical functionality. Based on pilot feedback, the following modifications were made: (a) the definition of ‘neurodivergent children’ was added to the survey header; (b) three response options were added to Q14 (assessment tools) based on participant suggestions; (c) the wording of selected questions was revised for clarity and readability; (d) instructions were added to clarify that ‘adaptive feeding bottles/utensils’ could be specified under ‘Other’; and (e) the response scale for confidence items was changed from a 5-point Likert to a 3-point (low/moderate/high) based on participant reports of difficulty discriminating between adjacent options.

Procedures

The questionnaire was administered via Google Forms. Invitation emails included a Participant Information Sheet and required electronic consent. Anonymity was ensured; no identifying information or IP addresses were collected. Three reminders were sent at 21-day intervals. Anonymity was ensured as follows: the survey was hosted on Google Forms with the ‘Collect email addresses’ setting disabled. Participants who wished to receive a copy of the results were instructed to send a separate email to a dedicated study address (not linked to their survey response). No identifying information (including IP addresses or email addresses) was collected within the survey data file. The survey platform did not record respondent email addresses, and we did not cross-reference any external contact information with responses. Therefore, individual responses cannot be traced to any participant.

Data Analysis

Quantitative data were analyzed using SPSS version 26.0 (IBM Corp, 2019) for analysis. Descriptive statistics (frequencies, percentages, means, SDs) were computed, with 95% confidence intervals for key proportions using the Wilson method. Normality of continuous variables (e.g., years of experience, age) was assessed using the Shapiro-Wilk test and visual inspection of Q-Q plots. Associations between demographic variables and clinical practice patterns were examined using chi-square tests of independence with Cramer’s V or phi coefficients for effect sizes. The following associations were prespecified for analysis: (a) confidence level by years of clinical experience; (b) confidence level by highest qualification; (c) confidence level by primary work setting; (d) provision of dysphagia services by work setting; (e) use of instrumental assessment [Video Fluoroscopic Swallowing Study (VFSS)/Fiberoptic Endoscopic Evaluation of Swallowing (FEES), yes/no] by work setting; (f) perception that ‘lack of standardized protocols’ is a major challenge by years of experience; and (g) perception of research base adequacy by qualification and by years of experience. For variables with expected cell counts <5, Fisher’s exact test was employed. Statistical significance was set at p < .05 (two-tailed). Open-ended responses were analyzed using conventional content analysis as described by Hsieh and Shannon (Hsieh & Shannon, 2005). This approach is suitable when existing theory or literature is limited. Two researchers (AM and a research assistant) independently read all open-ended responses to gain immersion. They then generated initial codes inductively, grouped codes into categories, and finally aggregated categories into broader themes. Discrepancies were resolved through consensus discussion with a third researcher. Inter-coder reliability for 20% of responses was strong (κ = 0.84).

Results

Participant Characteristics

A total of 136 Speech-Language Pathologists (SLPs) participated in the study. Table 1 presents demographic characteristics.

For analytic purposes, the 1–3 years (n = 28) and 4–5 years (n = 37) categories were combined into a single 1–5 years category (n = 65) to achieve adequate expected cell frequencies for chi-square analyses.

Awareness of Feeding and Swallowing Disorders

Table 2 summarizes awareness and clinical perspectives. The majority of respondents (n = 116, 85.3%) acknowledged that neurodivergent children experience feeding and swallowing difficulties. However, fewer clinicians (n = 79, 58.1%) reported providing dysphagia-related services. A substantial proportion (n = 98, 72.1%) perceived that swallowing and feeding difficulties remain under-recognized within the SLP field.

Table 2

Awareness of Swallowing and Feeding Difficulties (N = 136)

Variable	Response	n	%
Aware of difficulties in neurodivergent children	Yes	116	85.3
Aware of difficulties in neurodivergent children	No	20	14.7
Provides dysphagia services	Yes	79	58.1
Provides dysphagia services	No	57	41.9
Confidence in assessment/diagnosis	Low	42	30.9
	Moderate	64	47.1
	High	30	22.0
Recognition within SLP field	Adequately recognized	38	27.9
Recognition within SLP field	Under-recognized	98	72.1
Aware of sensory integration role	Yes	110	80.9
Aware of sensory integration role	No	26	19.1
Observed difficulties*	Food selectivity/texture aversion	103	75.7
	Prolonged mealtime	86	63.2
	Oral-motor discoordination	79	58.1
	Coughing/choking	56	41.2
	Food pocketing	39	28.7
	Oral hypersensitivity	34	25.0

Note. *Participants could select multiple options.

Confidence level was significantly associated with years of clinical experience (χ²(4) = 11.23, p = .024, Cramer’s V = 0.20). Post-hoc examination of standardized residuals indicated that clinicians with >10 years of experience were more likely to report high confidence, while those with <1 year were more likely to report low confidence. No significant associations were found between confidence and qualification (χ²(4) = 3.87, p = .42) or work setting (χ²(8) = 7.56, p = .48). Provision of dysphagia services was associated with work setting (χ²(4) = 9.84, p = .043, Cramer’s V = 0.27), with hospital-based SLPs more likely to provide services and those in academic settings less likely.

Assessment Practices

Most respondents (n = 98, 72.1%) believed that current swallowing and feeding evaluation tools are inadequately adapted for neurodivergent children. Additionally, 124 (91.2%) reported difficulty obtaining accurate input or cooperation during assessments.

Table 3 presents assessment components used by SLPs. The assessment tools listed in Table 3 represent three categories: (a) parent-reported measures (e.g., Pedi-EAT, CEBI, BAMBI), which rely on caregiver observations of mealtime behaviors; (b) clinician-administered direct assessments (e.g., oro-motor examination, Functional Feeding Assessment, Early Feeding Skills Assessment); and (c) instrumental assessments (VFSS, FEES). This categorization reflects the survey’s aim to capture the full range of assessment approaches used by SLPs, acknowledging that different tool types serve complementary purposes. However, we note that few of these instruments have been validated specifically for neurodivergent populations. Oro-motor examination was nearly universal, followed by Functional Feeding Assessment and Pedi-EAT. Instrumental assessments were used by approximately half: VFSS and FEES.

Table 3

Assessment Components Used by SLPs (N = 136)

Assessment component	n	%
Oro-motor Examination	130	95.6
Functional Feeding Assessment (FFA)	82	60.3
Pediatric Eating Assessment Tool (Pedi-EAT)	78	57.4
Video Fluoroscopic Swallowing Study (VFSS)	74	54.4
Early Feeding Skills Assessment (EFS)	70	51.5
Parent Mealtime Action Scale (PMAS)	58	42.6
Pediatric Assessment Scale for Severe Feeding Problems (PASSFP)	46	33.8
Children’s Eating Behavior Inventory (CEBI)	44	32.4
Screening Tool of Feeding Problems (STEP-Child)	44	32.4
Brief Assessment of Mealtime Behavior Inventory (BAMBI)	34	25.0
Eating Profile	30	22.1
Neonatal Eating Assessment Tool (Neo-EAT)	16	11.8

Note. Participants could select multiple options. All listed assessment tools were explicitly provided as response options in Q14. No tools were added from open-text responses.

Use of instrumental assessment (VFSS/FEES) was significantly associated with work setting (χ²(4) = 14.32, p = .006, Cramer’s V = 0.32), with hospital-based SLPs more likely to use these tools and private practitioners less likely.

Clinical Characteristics Associated With Feeding Difficulties

Table 4 presents the clinical characteristics that respondents identified as commonly accompanying feeding difficulties in neurodivergent children. These span multiple domains: sensory processing (sensory sensitivities), behavioral presentation (feeding rituals, food refusal/tantrums), oral-motor function (oral-motor coordination difficulties), communication (communication barriers), motor planning (motor coordination issues/dyspraxia), medical comorbidities [Gastro Esophageal Reflex Disease (GERD), constipation], and environmental factors (social/environmental influences). We present these together to reflect the multifactorial nature of pediatric feeding disorders in neurodivergent populations, while acknowledging in the Discussion that these domains require distinct assessment and intervention approaches.

Table 4

Clinical Characteristics Associated With Feeding Difficulties in Neurodivergent Children (N = 136)

Clinical characteristics	N	%
Sensory sensitivities	126	92.6
Feeding rituals/food selectivity	102	75.0
Oral-motor coordination difficulties	102	75.0
Food refusal, tantrums, gagging	102	75.0
Communication barriers	80	58.8
Attention/hyperactivity issues	70	51.5
Motor coordination issues (dyspraxia)	70	51.5
Co-occurring medical issues (GERD, etc.)	62	45.6
Social/environmental influences	58	42.6

Note. Participants could select multiple options.

Respondents employed various methods to assess the impact of behavioral challenges: mealtime observation (n = 58, 42.6%), structured behavioral observation (n = 42, 30.9%), caregiver/parent-mediated assessment (n = 36, 26.5%), and non-real-time video-based analysis (n = 12, 8.8%). Twenty-eight respondents (20.6%) reported using ‘specific behavioral assessments’ without further specification.

Management Practices

All 136 respondents (100%) reported modifying feeding therapy based on the child’s sensory needs. Interdisciplinary collaboration was common: 74 (54.4%) always collaborated with other professionals, 52 (38.2%) frequently collaborated, and 10 (7.4%) occasionally collaborated. Caregiver involvement strategies included: educational and training programs (n = 88, 64.7%), home exercise/feeding plans (n = 34, 25.0%), and regular timed follow-ups (n = 14, 10.3%).

Preferred Management Strategies

Adaptive feeding bottles/utensils were most frequently reported (n = 66, 48.5%), followed by sensory integration strategies (n = 50, 36.8%), non-speech oro-motor exercises (n = 30, 22.1%), and food texture modification (n = 30, 22.1%). Less commonly used approaches included oral placement therapy (n = 8, 5.9%), behavioral modification techniques (n = 4, 2.9%), and neuromuscular electrical stimulation (n = 2, 1.5%). Adaptive feeding bottles/utensils were the most frequently reported management strategy (n = 66, 48.5%). This category emerged from open-text responses to Q21, where participants specified these strategies under ‘Other’. The original closed-ended response options yielded the following frequencies: sensory integration strategies (n = 50, 36.8%), non-speech oro-motor exercises (n = 30, 22.1%), food texture modification (n = 30, 22.1%), oral placement therapy (n = 8, 5.9%), behavioral modification techniques (n = 4, 2.9%), and neuromuscular electrical stimulation (n = 2, 1.5%).

Sources of Clinical Knowledge

Clinical experience was the most frequently cited knowledge source (n = 116, 85.3%), followed by discussions with colleagues (n = 96, 70.6%), seminars/conferences/workshops (n = 76, 55.9%), and expert opinions (n = 74, 54.4%). Journal articles and Indian Speech and Hearing Association (ISHA) Special Interest Groups were each cited by 68 respondents (50.0%).

Challenges in Clinical Practice

Table 5 presents challenges reported by SLPs during the feeding management.

Table 5

Challenges Faced by SLPs in Assessment and Management (N = 136)

Challenge	N	%
Assessment challenges
Differentiating sensory vs. physiological disorders	110	80.9
Limited parental awareness	88	64.7
Lack of child cooperation	76	55.9
Limited access to specialized diagnostic tools	68	50.0
Inconsistent/unclear caregiver reports	68	50.0
Limited multidisciplinary collaboration	62	45.6
Limited clinician knowledge	58	42.6
Management challenges
Limited evidence on sensory difficulties	96	70.6
Difficulty engaging children in therapy	76	55.9
Limited access to interdisciplinary resources	76	55.9
Lack of standardized protocols	72	52.9
Differentiating sensory vs. physiological issues	60	44.1
Resistance from caregivers/families	54	39.7

Note. Participants could select multiple options.

The perception that ‘lack of standardized protocols’ was a major challenge varied significantly by work experience as reported in Table 6, (χ²(3) = 8.91, p = .031, Cramer’s V = 0.26), with clinicians having 6–10 years of experience more likely to endorse this challenge compared to those with >10 years.

Table 6

Summary of Chi-Square Analyses Examining Associations Between Demographic Variables and Clinical Practice Patterns

Association	χ²	df	p-value	Effect size (Cramer’s V/φ)	Interpretation
Confidence level vs. years of clinical experience	11.23	4	.024	V = 0.20	Significant; post-hoc residuals showed clinicians with >10 years more likely to report high confidence, and those with <1 year more likely to report low confidence.
Confidence level vs. highest qualification	3.87	4	.42	V = 0.12	Not significant.
Confidence level vs. primary work setting	7.56	8	.48	V = 0.17	Not significant.
Provision of dysphagia services vs. work setting	9.84	4	.043	V = 0.27	Significant; hospital-based SLPs more likely to provide services, academic setting SLPs less likely.
Use of instrumental assessment vs. work setting	14.32	4	.006	V = 0.32	Significant; hospital-based SLPs more likely to use instrumental tools, private practitioners less likely.
Perception that ‘lack of standardized protocols’ is a major challenge vs. years of experience	8.91	3	.031	V = 0.26	Significant; clinicians with 6–10 years of experience endorsed this challenge more frequently than those with >10 years.
Perception of research base adequacy vs. qualification	2.34	4	.67	V = 0.09	Not significant.
Perception of research base adequacy vs. years of experience	5.12	6	.53	V = 0.14	Not significant.

Notes. All significance tests were two-tailed with α = 0.05.

For all analyses, Fisher’s exact test was used when any expected cell count was <5; no such instances occurred for the associations reported above.

Effect sizes: Cramer’s V (V) values of 0.10, 0.30, and 0.50 are conventionally interpreted as small, medium, and large, respectively.

An overwhelming majority (n = 130, 95.6%; 95% CI [90.6, 98.1]) expressed the need for enhanced training opportunities and resources. Similarly, 118 respondents (86.8%; 95% CI [80.0, 91.5]) indicated an urgent requirement for standardized diagnostic guidelines and management protocols. Regarding the current research base, most respondents characterized it as limited (n = 84, 61.8%; 95% CI [53.3, 69.7]), while 46 (33.8%; 95% CI [26.4, 42.1]) rated it as adequate, and only 6 (4.4%; 95% CI [2.0, 9.5]) considered it extensive. Perception of the research base did not differ significantly by qualification (χ²(4) = 2.34, p = .67) or work experience (χ²(6) = 5.12, p = .53).

Qualitative Findings

Content analysis of open-ended responses (n = 43 respondents provided qualitative comments) revealed three primary categories of responses:

Category 1: Need for Context-Specific Tools

Participants emphasized that Western-developed assessment tools often fail to account for Indian dietary practices and mealtime contexts. One respondent noted: ‘Standardized tools don’t consider Indian food textures like rice, chapati, or mixed dishes. We need adaptations for our cultural context’.

Category 2: Complexity of Differential Diagnosis

Clinicians described difficulty distinguishing between sensory, behavioral, and physiological contributors. A participant commented: ‘The child refuses food – is it sensory aversion, oral-motor difficulty, or simply behavioral? Without clear guidelines, we rely on trial and error’.

Category 3: Desire for Collaborative Networks

Many expressed interest in formal interdisciplinary networks and mentorship opportunities: ‘We need platforms to discuss complex cases with OTs, pediatricians, and more experienced SLPs. Currently, we work in silos’.

Discussion

This study examined the awareness, assessment practices, management strategies, and perceived challenges of Indian Speech-Language Pathologists (SLPs) regarding swallowing and feeding difficulties in neurodivergent children. The findings reveal a complex landscape characterized by high awareness but significant gaps in clinical preparedness, resource accessibility, and evidence-based practice. These results have important implications for clinical training, service delivery, and future research in the Indian context.

Awareness on Feeding and Swallowing Disorders

A substantial majority of participants (85.3%) acknowledged that neurodivergent children experience feeding and swallowing difficulties, consistent with international literature reporting prevalence rates of up to 90% in autistic children (Kodak & Piazza, 2008; Ledford & Gast, 2006). However, the finding that only 58.1% of aware clinicians actually provide dysphagia-related services reveals a critical awareness-to-practice gap. This disconnect may reflect several factors: limited institutional support, inadequate access to assessment tools, or insufficient training in specialized dysphagia management for this population (Tamura et al., 2023).

Confidence levels varied considerably, with nearly one-third of respondents reporting low confidence in assessment and differential diagnosis. The significant association between confidence and clinical experience, where clinicians with >10 years of experience were more likely to report high confidence suggests that competency develops primarily through accumulated clinical exposure rather than through formal training alone. This interpretation is supported by the absence of significant associations between confidence and educational qualification, implying that current academic curricula may not adequately prepare SLPs for the complexities of neurodivergent dysphagia management (Kleinert, 2017; Pergeline et al., 2025).

The perception that swallowing and feeding difficulties remain under-recognized within the broader SLP field (endorsed by 72.1% of respondents) echoes global calls for greater integration of pediatric feeding disorders into professional education and clinical frameworks (Pergeline et al., 2025). This under-recognition may contribute to the marginalization of dysphagia services, particularly in settings where communication disorders receive prioritization over feeding-related concerns.

Encouragingly, 80.9% of participants recognized the role of sensory integration in feeding difficulties, reflecting a paradigm shift toward holistic, neurodiversity-affirming approaches that acknowledge the interplay between sensory processing and oral-motor function (Addison et al., 2012; Tamura et al., 2023). This awareness aligns with contemporary interdisciplinary perspectives advocating for individualized, sensory-responsive interventions, particularly for autistic children and those with related neurodevelopmental conditions.

Assessment Practices and Challenges

The finding that 72.1% of SLPs consider current assessment tools inadequately adapted for neurodivergent children represents a significant concern. Traditional dysphagia assessments, while widely used (e.g., oro-motor examination by 95.6% of respondents), were originally designed for typically developing populations and may not capture the behavioral, sensory, and cognitive heterogeneity characteristic of neurodivergent children (Pergeline et al., 2025; Tamura et al., 2023). The psychometric properties of these tools for children with autism, ADHD, or intellectual disabilities remain largely unexamined, raising questions about diagnostic accuracy and clinical utility.

The near-universal difficulty (91.2%) in obtaining accurate input and cooperation during assessments reflects the behavioral rigidity, sensory sensitivities, and attentional fluctuations common in neurodivergent children (Benjasuwantep et al., 2013; Cermak et al., 2010). These challenges compromise the reliability of structured clinical evaluations and necessitate flexible, child-centered approaches. The varied methods employed by respondents, including mealtime observation (42.6%), caregiver-mediated assessment (26.5%), and video-based analysis (8.8%), suggest that clinicians are adapting creatively to these challenges. However, the absence of standardized protocols for such adaptations may introduce variability and reduce diagnostic consistency.

The significant association between hospital-based practice and greater use of instrumental assessments (VFSS/FEES) likely reflects differential resource availability across settings. Private practitioners and those in community-based settings may lack access to these technologies, potentially compromising their ability to identify aspiration risk and physiological swallowing impairments. This disparity highlights systemic inequities in healthcare infrastructure that warrant attention from policymakers and professional bodies.

The clinical characteristics reported sensory sensitivities (92.6%), feeding rituals (75.0%), and oral-motor difficulties (75.0%) align closely with previously described feeding phenotypes in neurodivergent populations (Cermak et al., 2010; Kleinert, 2017). The co-occurrence of medical issues such as GERD and constipation, noted by 45.6% of respondents, underscores the multifactorial nature of pediatric feeding disorders and the necessity of interdisciplinary collaboration involving gastroenterologists, dietitians, and occupational therapists (Sharp et al., 2017).

Qualitative findings further illuminated these assessment challenges. Participants emphasized the need for context-specific tools that account for Indian dietary practices, a crucial consideration given that Western-developed instruments may not adequately assess feeding difficulties involving rice, chapati, mixed dishes, and culturally specific mealtime routines. This finding has important implications for test adaptation and cultural validation research in the Indian context.

Management Practices and Interdisciplinary Collaboration

The universal adoption of sensory-informed therapy modifications (100% of respondents) represents a significant strength of current Indian practice. This finding suggests that sensory integration principles have been widely embraced, consistent with international recommendations advocating for sensory-responsive interventions in neurodivergent populations (Addison et al., 2012; Goday et al., 2019). The frequent use of adaptive feeding utensils (48.5%) and sensory integration strategies (36.8%) further reflects this orientation.

The high rates of interdisciplinary collaboration with 92.6% collaborating always or frequently aligns with best-practice guidelines emphasizing team-based approaches to pediatric feeding disorders (Arvedson et al., 2019; Sharp et al., 2024). Feeding difficulties in neurodivergent children rarely involve isolated oropharyngeal dysfunction; they typically encompass sensory, behavioral, nutritional, and medical dimensions requiring coordinated input from multiple disciplines (Sharp et al., 2017). The collaborative practices reported by Indian SLPs are therefore encouraging and should be supported through formal interdisciplinary networks and shared care pathways.

Caregiver engagement emerged as a cornerstone of management, with 64.7% of respondents providing educational programs and 25.0% offering structured home exercise plans. This family-centered orientation is critical, as caregiver consistency and reinforcement are essential for generalizing feeding gains beyond clinical settings (Benjasuwantep et al., 2013; Kleinert, 2017). Recent qualitative work with Indian caregivers of children with developmental disabilities has similarly emphasized the importance of collaborative, empowering partnerships between professionals and families (Athaide et al., 2025; Samuel et al., 2023).

The predominance of clinical experience (85.3%) and collegial discussions (70.6%) as knowledge sources, relative to journal articles (50.0%) and textbooks (41.2%), suggests that informal learning networks currently compensate for limited access to formal evidence-based resources. While experiential learning is invaluable, this pattern may indicate barriers to research dissemination, including restricted access to subscription journals, limited time for literature review, or perceptions that published research lacks local applicability (Mukundan, 2008). The moderate utilization of ISHA Special Interest Groups (50.0%) represents an opportunity for professional bodies to enhance knowledge translation through targeted continuing education initiatives.

The limited adoption of behavioral modification techniques (2.9%) and neuromuscular electrical stimulation (1.5%) may reflect several factors: resource constraints, inadequate training, or perceived incompatibility with neurodivergent children’s needs. Given the evidence supporting behavioral interventions for feeding disorders (Sharp et al., 2017), this gap warrants attention in continuing professional development programs.

Challenges and Barriers to Effective Practice

The challenges identified in this study illuminate systemic gaps requiring coordinated action. The most frequently cited assessment challenge difficulty differentiating sensory from physiological disorders (80.9%) reflects the inherent complexity of neurodivergent feeding presentations, where sensory aversion, oral-motor dysfunction, and behavioral resistance may coexist and interact (Adams, 2022; Elsayed et al., 2022). Without clear diagnostic guidelines or validated assessment protocols, clinicians must rely on clinical judgment, which may vary substantially and lead to inconsistent intervention approaches.

Limited parental awareness (64.7%) and inconsistent caregiver reports (50.0%) represent interrelated challenges. Previous research has documented that caregivers of neurodivergent children experience significant mealtime stress and may lack understanding of the underlying causes of feeding difficulties (Gent et al., 2025). This gap necessitates not only caregiver education but also sensitive, collaborative approaches to history-taking that acknowledge family perspectives while gathering clinically relevant information.

In the management domain, the most prevalent challenge limited evidence on sensory difficulties (70.6%) highlights a critical research gap. While sensory integration approaches are widely employed, their evidence base for feeding disorders remains nascent (Elsayed et al., 2022; Moore, 2024). The lack of standardized protocols for neurodivergent children (endorsed by 52.9%) compounds this problem, leaving clinicians to improvise interventions without clear guidance. The association between mid-career experience (6–10 years) and greater concern about protocol absence may reflect this group’s active engagement with complex cases while possessing sufficient experience to recognize evidence limitations.

Limited access to interdisciplinary resources (55.9%) and difficulty engaging children in therapy (55.9%) further constrain effective management. These challenges are interconnected: without occupational therapists to address sensory components, psychologists to manage behavioral resistance, and dietitians to ensure nutritional adequacy, SLPs may struggle to achieve meaningful outcomes. The qualitative theme of working ‘in silos’ poignantly captures this frustration and underscores the need for systemic investment in multidisciplinary teams.

Implications for Training, Policy, and Research

The overwhelming demand for enhanced training (95.6%) and standardized guidelines (86.8%) signals urgent priorities for professional development and policy reform. Undergraduate and postgraduate curricula must expand coverage of neurodivergent pediatric dysphagia, incorporating content on sensory processing, behavioral assessment, and culturally adapted intervention strategies. Continuing education programs should address identified gaps, particularly in differential diagnosis, instrumental assessment, and evidence-based sensory interventions.

At the policy level, professional bodies such as the Rehabilitation Council of India and the Indian Speech and Hearing Association should consider developing context-specific clinical guidelines for neurodivergent feeding disorders. Such guidelines should address assessment tool adaptation, interdisciplinary care pathways, and culturally appropriate intervention protocols. Investment in multidisciplinary feeding clinics, particularly in public healthcare settings, could reduce disparities in access to specialized care.

The research priorities identified by participants particularly the need for standardized diagnostic guidelines and evidence on sensory interventions should inform national research agendas. Collaborative, multi-site studies examining the psychometric properties of assessment tools in Indian neurodivergent populations are urgently needed. Qualitative research exploring family perspectives and mealtime experiences across diverse Indian communities would further enrich the evidence base.

Limitations

Several limitations should be considered when interpreting these findings. The response rate of 17.3%, while consistent with web-based surveys of health professionals, raises the possibility of non-response bias; clinicians with greater interest in pediatric dysphagia may have been overrepresented, potentially inflating estimates of awareness and specialized practice. The sample was predominantly from South India (54.4%), limiting generalizability to other regions where healthcare infrastructure and professional training may differ. Self-reported data are subject to recall bias and social desirability effects; actual practices may deviate from reported practices. The cross-sectional design captures a single time point and cannot establish causal relationships or track practice changes over time. While the questionnaire demonstrated acceptable reliability and content validity, its construct validity requires further examination through factor analysis in larger samples. The English-only survey, while appropriate given that English is the professional medium for Indian SLPs, may have excluded clinicians who serve linguistically diverse rural populations and who may have preferred to respond in regional languages; however, RCI registration requires English proficiency, so the practical impact is likely minimal. We also acknowledge that our sample size calculation was designed for estimation of survey responses rather than for subgroup comparisons; consequently, some subgroup analyses (e.g., by work setting or qualification) may have been underpowered to detect small or moderate associations, and non-significant findings should be interpreted cautiously.

Conclusions

This study provides the first comprehensive examination of Indian SLPs’ practices in managing swallowing and feeding difficulties in neurodivergent children. The findings reveal high awareness and commitment to sensory-informed, collaborative, and family-centered care, alongside significant gaps in assessment tools, evidence-based protocols, and interdisciplinary infrastructure. Addressing these gaps requires coordinated action from educational institutions, professional bodies, policymakers, and researchers. With appropriate investment in training, resources, and context-specific research, Indian SLPs can be better equipped to meet the complex feeding needs of neurodivergent children and their families, ultimately improving developmental outcomes and quality of life.

Supplemental Material

Supplemental Material - Swallowing and Feeding Difficulties in Neurodivergent Children: Awareness, Practices, and Challenges Among Indian Speech-Language Pathologists: A Cross-Sectional Survey

Supplemental Material for Swallowing and Feeding Difficulties in Neurodivergent Children: Awareness, Practices, and Challenges Among Indian Speech-Language Pathologists: A Cross-Sectional Survey by Asif Maitheen, Nehala Moopan M M, Dhiya Fathima Shamsudeen, in Advances in Communication and Swallowing

Footnotes

ORCID iDs

Asif Maitheen

Nehala Moopan M M

Dhiya Fathima Shamsudeen

Authors’ Contributions

Conceptualization: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M M. Data curation: Dhiya Fathima Shamsudeen, Nehala Moopan M M. Funding acquisition: Not applicable. Formal analysis and Investigation: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M. Project administration: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M M. Resources and Software: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M M. Supervision and Visualization: Asif Maitheen. Validation: Asif Maitheen. Writing—original draft: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M M. Writing—review and editing: Asif Maitheen, Dhiya Fathima Shamsudeen, Nehala Moopan M M.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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