Feeding and eating problems in children and adolescents with autism: A scoping review

In the paper

“Although differentiating “feeding” from “eating” problems is critical for accurate identification and treatment of these issues, the existing literature has failed to do so.”

In the paper

“No common individual characteristics (e.g. cognitive functioning and autism symptom severity) were identified for youth who experience feeding or eating problems.”

• Also stated in: § Lay abstract · plain

  “We found no common characteristics (such as severity of autism symptoms) that best describe autistic youth who experience problems with feeding or eating.”

In the paper

“with almost all studies (91%) investigating feeding problems”

• Also stated in: § Lay abstract · plain

  “Almost all studies we reviewed focused on problems with feeding (selective or picky eating)”

In the paper

“Only 9% of studies examined concern with weight, shape, and/or body image”

• Also stated in: § Lay abstract · plain

  “only a few studies focused on eating disorder symptoms (concern with weight, shape, and/or body image)”

In the paper

“there is a limited understanding as to whether such problems should be attributed to an individual’s autism or whether an additional diagnosis is warranted.”

In the paper

“The total sample of participants with autism was 4215.”

In the paper

“no consensus has been established for how to assess for eating problems in this population.”

In the paper

“psychotherapeutic treatment options that adequately address an autistic person’s eating problems are extremely limited.”

In the paper

“A few studies reported no or marginal differences in food selectivity between youth with autism and controls.”

In the paper

“Some studies used the term “feeding problems” to describe a range of problematic behaviors that occur in the mealtime context (e.g. Aponte & Romanczyk, 2016; Johnson et al., 2014)”

What the sources say

• Not checked yetcites Aponte & Romanczyk, 2016
• Not checked yetcites Johnson et al., 2014

In the paper

“the combination of increased ASD traits and increased FN was linked with increased BMI.”

What the sources say

• Not checked yetcites Wallace et al. (2018)

In the paper

“Significant relationship between foods accepted and age for ASD group.”

What the sources say

• Not checked yetcites Suarez (2017)

In the paper

“However, most studies reported greater food selectivity in autism groups.”

In the paper

“Others used the term “eating problems” to describe pathology related to restricted eating (i.e. failing to gain weight and perceived fear of gaining weight; Råstam et al., 2013).”

What the sources say

• Not checked yetcites Råstam et al., 2013 source

In the paper

“91% of included studies examined “feeding” rather than “eating” problems.”

In the paper

“no clear differentiation was presented in the literature.”

In the paper

“No relationship between foods accepted and ASD symptom severity.”

What the sources say

• Not checked yetcites Suarez (2017)

In the paper

“Only three studies (9%) examined constructs that fit our definition of eating problems.”

In the paper

“86% of studies investigated feeding problems involving selective intake.”

In the paper

“Most often, the terms “feeding” and “eating” problems were used interchangeably to describe a number of related issues.”

In the paper

“In the studies without comparison groups, rates of food selectivity in samples of autistic youth were strikingly high”

In the paper

“Subclinical associations found between FN and ASD traits.”

What the sources say

• Not checked yetcites Wallace et al. (2018)

In the paper

“Children with ASD accepted significantly fewer foods total and fewer foods from each group compared to controls, except snack foods.”

What the sources say

• Not checked yetcites Suarez (2017)

In the paper

“Children with ASD had more FN than peers.”

What the sources say

• Not checked yetcites Wallace et al. (2018)

In the paper

“In general, most studies that compared groups of youth with autism to groups with other disorders and/or typical development found autistic individuals had higher rates of food selectivity.”

In the paper

“Children with ASD accepted significantly fewer foods total and fewer foods from each group compared to controls, except snack foods.”

What the sources say

• Not checked yetcites Suarez (2017)

In the paper

“Likewise, three other studies found autism symptom severity was not significantly related to feeding or eating problems (Schreck & Williams, 2006; Sharp et al., 2013; Suarez, 2017).”

What the sources say

• Not checked yetcites Schreck & Williams, 2006
• Not checked yetcites Sharp et al., 2013
• Not checked yetcites Suarez, 2017

In the paper

“Most (n = 15) examining sensory sensitivity and limited food intake utilized a broad measure of sensitivity (i.e. overall sensory impairment score or more focused but representative score, such as overall oral sensitivity).”

In the paper

“Conversely, the remaining three studies had younger participants (aged 2–12 years) and found no significant relation between feeding and eating problems and measures of adaptive functioning (Martins et al., 2008; Peverill et al., 2019; Postorino et al., 2015).”

What the sources say

• Not checked yetcites Martins et al., 2008
• Not checked yetcites Peverill et al., 2019
• Not checked yetcites Postorino et al., 2015

In the paper

“For instance, two studies (Emond et al., 2010; Kerwin et al., 2005) used author-created measures to assess feeding behaviors”

What the sources say

• Not checked yetcites Emond et al., 2010
• Not checked yetcites Kerwin et al., 2005

In the paper

“it should be noted that most of these studies did not use standardized measures to assess for symptoms of pica.”

In the paper

“Four studies examined symptoms of pica in youth with autism.”

In the paper

“Kuschner and colleagues (2015) found that in a sample of adolescents and young adults with autism, those with food neophobia received significantly lower parent ratings of daily living skills, but scores of social and communication skills did not significantly differ from their peers with autism and without food neophobia.”

What the sources say

• Not checked yetcites Kuschner and colleagues (2015)

In the paper

“Six studies support a relation between ritualistic behaviors and food selectivity.”

In the paper

“Of the 29 studies that investigated selective eating, 69% (n = 20) also examined the presence of sensory sensitivities or aspects of food texture, temperature, smell, or taste in relation to food selectivity.”

In the paper

“Similarly, mixed results were found in the studies examining the relation between feeding and eating problems and adaptive functioning (n = 4).”

In the paper

“In three studies, authors used the comparison score of the Autism Diagnostic Observation Schedule–Second Edition (ADOS-2) as a measure of autism symptom severity and found no significant associations between feeding or eating behaviors and more autism symptoms (Bitsika & Sharpley, 2018; Johnson et al., 2014; Peverill et al., 2019).”

What the sources say

• Not checked yetcites Bitsika & Sharpley, 2018
• Not checked yetcites Johnson et al., 2014
• Not checked yetcites Peverill et al., 2019

In the paper

“In general, these studies suggested food selectivity may be related to sensory impairments”

In the paper

“Laboratory mealtime observations demonstrated similar findings.”

In the paper

“while Mayes and Zickgraf (2019) used a validated measure along with additional qualitative information to characterize the feeding problems (e.g. inedible substances consumed).”

What the sources say

• Not checked yetcites Mayes and Zickgraf (2019)

In the paper

“Kuschner and colleagues (2015) found that in a sample of adolescents and young adults with autism, those with food neophobia received significantly lower parent ratings of daily living skills, but scores of social and communication skills did not significantly differ from their peers with autism and without food neophobia.”

What the sources say

• Not checked yetcites Kuschner and colleagues (2015)

In the paper

“Similarly, a few studies included scores from measures of adaptive functioning and autism symptom severity in their analyses.”

In the paper

“While many more studies reported scores from measures of autism traits in relation to feeding or eating problems, results across studies were evenly split between evidence for and against an association.”

In the paper

“Most studies indicated that food selectivity was a pervasive issue among their samples of autistic youth.”

In the paper

“In addition, most participants from studies that reported cognitive ability had IQs of 70 or higher, so results may not extend to individuals with lower cognitive functioning.”

In the paper

“Although only a handful of studies examined the relation between adaptive functioning and feeding or eating problems, the one study (Kuschner et al., 2015) that provided support for a negative relation (i.e. poor adaptive functioning skills associated with more feeding issues) had a much older sample than the others.”

In the paper

“Consistent with previous reports (e.g. Twachtman-Reilly et al., 2008), the present review identified food selectivity as the most common feeding issue autistic youth experience.”

What the sources say

• Not checked yetcites Twachtman-Reilly et al., 2008

In the paper

“Despite inconsistent terminology to describe the specific feeding and eating problems autistic youth may experience, there is clear evidence that such issues are common in this population.”

In the paper

“Although only a handful of studies examined the relation between adaptive functioning and feeding or eating problems, the one study (Kuschner et al., 2015) that provided support for a negative relation (i.e. poor adaptive functioning skills associated with more feeding issues) had a much older sample than the others.”

What the sources say

• Not checked yetcites Kuschner et al., 2015

In the paper

“Given that most research in this area has used cross-sectional designs, factors that influence the development and maintenance of feeding and eating problems are unknown.”

In the paper

“While some evidence suggests that disordered eating behaviors are present in youth with autism, research on body image in relation to disordered eating in this population is non-existent, despite body image disturbance being an important feature of AN and BN (APA, 2013).”

In the paper

“While many more studies reported scores from measures of autism traits in relation to feeding or eating problems, results across studies were evenly split between evidence for and against an association.”

In the paper

“Of the few studies that reported mean scores of cognitive functioning, there was marked variability across samples, meaning results cannot be directly compared.”

In the paper

“Our finding that only three studies have examined cognitive concerns related to weight, shape, and/or body image in youth with autism highlights the paucity of research in this area.”

In the paper

“While some evidence suggests that disordered eating behaviors are present in youth with autism, research on body image in relation to disordered eating in this population is non-existent, despite body image disturbance being an important feature of AN and BN (APA, 2013).”

In the paper

“Another issue identified in the current review that spans feeding and eating disorders is eating rituals commonly experienced by autistic individuals.”

In the paper

“However, Postorino and colleagues (2015) used several measures to assess autism symptom severity and found those with food selectivity scored significantly higher on the Social Responsiveness Scale (Constantino, 2005) and Social Communication Questionnaire (Rutter et al., 2003).”

What the sources say

• Not checked yetcites Postorino and colleagues (2015)
• Not checked yetcites Constantino, 2005
• Not checked yetcites Rutter et al., 2003

In the paper

“Feeding and eating problems are pervasive problems that affect persons with autism across all ages and cognitive abilities (Råstam, 2008; Vissoker et al., 2015).”

What the sources say

• Not checked yetcites Råstam, 2008
• Not checked yetcites Vissoker et al., 2015

In the paper

“Such high rates of varied eating and feeding problems suggest the difficulties related to eating that autistic youth experience may be complex, pervasive, and heterogeneous in nature.”

In the paper

“When issues such as mealtime behaviors, fear of trying new foods, and eating problems associated with medical disorders (e.g. gastrointestinal disorders) are considered, rates of eating and feeding problems in autistic youth are likely even higher.”

In the paper

“For example, in their sample of 1462 youth, Mayes and Zickgraf (2019) found atypical eating behaviors (e.g. limited food preferences and brand-specific preferences) occur much more often in autistic children (70.4%) compared to children with other disorders (13.1%) and children in the general population (4.8%).”

What the sources say

• Not checked yetcites Mayes and Zickgraf (2019)

In the paper

“existing literature has focused on a broad range of difficulties, including feeding problems, mealtime behaviors, and picky eating.”

In the paper

“All FS children showed at least one sensory factor linked to FS”

What the sources say

• Not checked yetcites Postorino et al. (2015)

In the paper

“Children in FS group had significantly higher ASD symptoms and significantly lower cognitive functioning vs no FS group.”

What the sources say

• Not checked yetcites Postorino et al. (2015)

In the paper

“92% of parents of children with FS observed food refusal in their child.”

What the sources say

• Not checked yetcites Postorino et al. (2015)

In the paper

“In laboratory observation, FS was associated negatively with children’s acceptance of bites (i.e. food offered) and positively with mealtime behavior.”

What the sources say

• Not checked yetcites Sharp et al. (2013)

In the paper

“Increased FS was positively correlated with problem behaviors during the observation”

What the sources say

• Not checked yetcites Sharp et al. (2013)

In the paper

“Autism group showed higher feeding problems, refused more foods, were more likely to require specific utensils/food presentations, and had preference for low texture foods vs controls.”

What the sources say

• Not checked yetcites Schreck et al. (2004)

In the paper

“Children ate only a small variety of presented foods.”

What the sources say

• Not checked yetcites Schreck & Williams (2006)

In the paper

“Autism group showed higher feeding problems, refused more foods, were more likely to require specific utensils/food presentations, and had preference for low texture foods vs controls.”

What the sources say

• Not checked yetcites Schreck et al. (2004)

In the paper

“Prevalence of eating problems was significantly higher in children with ADHD and/or ASD.”

What the sources say

• Not checked yetcites Råstam et al. (2013) source

In the paper

“Feeding or eating problems commonly present early in development; often even before concerns related to autism are identified (Emond et al., 2010).”

What the sources say

• Not checked yetcites Emond et al., 2010

In the paper

“ASD symptom severity was unrelated to feeding data.”

What the sources say

• Not checked yetcites Sharp et al. (2013)

In the paper

“No change in FS level across time-points.”

What the sources say

• Not checked yetcites Suarez et al. (2014)

In the paper

“Restricted variety was primarily related to food presentation (e.g. utensils and food items touching on plate).”

What the sources say

• Not checked yetcites Schreck & Williams (2006)

In the paper

“both disorders are thought to be over-represented in persons with autism (Chial et al., 2003; Matson et al., 2011; Råstam, 2008).”

What the sources say

• Not checked yetcites Chial et al., 2003
• Not checked yetcites Matson et al., 2011
• Not checked yetcites Råstam, 2008

In the paper

“In laboratory observation, FS was associated negatively with children’s acceptance of bites (i.e. food offered) and positively with mealtime behavior.”

What the sources say

• Not checked yetcites Sharp et al. (2013)

In the paper

“41% showed two sensory factors”

What the sources say

• Not checked yetcites Postorino et al. (2015)

In the paper

“Autism group showed higher feeding problems, refused more foods, were more likely to require specific utensils/food presentations, and had preference for low texture foods vs controls.”

What the sources say

• Not checked yetcites Schreck et al. (2004)

In the paper

“Research on eating behaviors in persons with autism is relatively limited (Råstam, 2008)”

What the sources say

• Not checked yetcites Råstam, 2008

In the paper

“eating problems are likely often misattributed to the individual’s autism traits (Mayes et al., 2018).”

What the sources say

• Not checked yetcites Mayes et al., 2018

In the paper

“impulsivity and activity problems were associated with eating problems in boys”

What the sources say

• Not checked yetcites Råstam et al. (2013) source

In the paper

“72% of autistic children ate a narrow variety of foods.”

What the sources say

• Not checked yetcites Schreck et al. (2004)

In the paper

“Autism group showed higher feeding problems, refused more foods, were more likely to require specific utensils/food presentations, and had preference for low texture foods vs controls.”

What the sources say

• Not checked yetcites Schreck et al. (2004)

In the paper

“Children in FS group had significantly higher ASD symptoms and significantly lower cognitive functioning vs no FS group.”

What the sources say

• Not checked yetcites Postorino et al. (2015)

In the paper

“Without treatment, the feeding problems autistic children experience tend to persist into late childhood (Suarez et al., 2014)”

What the sources say

• Not checked yetcites Suarez et al., 2014

In the paper

“impulsivity and activity problems were associated with eating problems in boys”

What the sources say

• Not checked yetcites Råstam et al. (2013) source

In the paper

“Social interaction problems were strongly associated with eating problems in girls”

What the sources say

• Not checked yetcites Råstam et al. (2013) source

In the paper

“Specifically, Bitsika and Sharpley (2018) found approximately 11% of 52 young females with autism endorsed severe eating disturbances (i.e. purging, dieting, and fasting behaviors).”

What the sources say

• Not checked yetcites Bitsika and Sharpley (2018)

In the paper

“the number of foods eaten did not increase”

What the sources say

• Not checked yetcites Bandini et al. (2017)

In the paper

“They found that while food refusal improved over time”

What the sources say

• Not checked yetcites Bandini et al. (2017)

In the paper

“but the same trend was not observed in children and adolescents without autism.”

What the sources say

• Not checked yetcites Beighley and colleagues (2013)

In the paper

“Together, results of the four studies examining selective eating over time suggest variability in patterns of selective eating.”

In the paper

“with limited food preferences being the most common atypical eating behavior.”

What the sources say

• Not checked yetcites Mayes and Zickgraf (2019)

In the paper

“moderate and declining (39%)”

What the sources say

• Not checked yetcites Peverill et al. (2019)

In the paper

“Suarez and colleagues (2014) found no change in food selectivity in children with autism over a 2-year period.”

What the sources say

• Not checked yetcites Suarez and colleagues (2014)

In the paper

“For example, Kalyva (2009) found adolescent females with Asperger’s syndrome were at a significantly higher risk for eating problems compared to age- and body mass index (BMI)-matched peers without Asperger’s syndrome.”

What the sources say

• Not checked yetcites Kalyva (2009)

In the paper

“Taken together, although the proportion of studies examining eating problems in autistic youth is small, preliminary evidence suggests persons with autism may be at higher risk for developing eating problems compared to persons without autism.”

In the paper

“less severe and stable (26%)”

What the sources say

• Not checked yetcites Peverill et al. (2019)

In the paper

“72% showed restricted variety”

What the sources say

• Not checked yetcites Schreck & Williams, 2006

In the paper

“very severe and stable (8%)”

What the sources say

• Not checked yetcites Peverill et al. (2019)

In the paper

“and 15 times more common in the autism group than their typical developing peers”

What the sources say

• Not checked yetcites Mayes and Zickgraf (2019)

In the paper

“Mayes and Zickgraf (2019) found atypical eating behaviors (e.g. limited food preferences, texture sensitivity, and brand-specific preferences) were five times more common in youth with autism than children with other disorders (e.g. ADHD, intellectual disability, language disorder, and learning disability)”

What the sources say

• Not checked yetcites Mayes and Zickgraf (2019)

In the paper

“57% showed food refusal in Schreck & Williams, 2006”

What the sources say

• Not checked yetcites Schreck & Williams, 2006

In the paper

“62% showed food selectivity in Kerwin et al., 2005”

What the sources say

• Not checked yetcites Kerwin et al., 2005

In the paper

“severe and declining (27%)”

What the sources say

• Not checked yetcites Peverill et al. (2019)

In the paper

“autistic children aged 2–12 years were only marginally more likely to exhibit picky eating behavior when compared to age- and gender-matched siblings and children without autism (Martins et al., 2008).”

What the sources say

• Not checked yetcites Martins et al., 2008

In the paper

“with taste and color identified as influential (Hubbard et al., 2014; Nadon et al., 2011; Postorino et al., 2015).”

What the sources say

• Not checked yetcites Hubbard et al., 2014
• Not checked yetcites Nadon et al., 2011
• Not checked yetcites Postorino et al., 2015

In the paper

“although two (Aponte & Romanczyk, 2016; Schreck & Williams, 2006) found no relation between food selectivity and sensory impairments.”

What the sources say

• Not checked yetcites Aponte & Romanczyk, 2016
• Not checked yetcites Schreck & Williams, 2006

In the paper

“Specifically, smoother, consistent textures (e.g. hotdogs) were more likely to be accepted than lumpy/inconsistent textures (e.g. pureed beans).”

What the sources say

• Not checked yetcites Sharp and colleagues (2013)

In the paper

“while nearly 4% had unspecified eating rituals.”

What the sources say

• Not checked yetcites Postorino and colleagues (2015)

In the paper

“Sharp and colleagues (2013) found approximately half their sample of autistic children aged 3–8 years demonstrated selective patterns of eating by type and/or texture.”

What the sources say

• Not checked yetcites Sharp and colleagues (2013)

In the paper

“Specific presentation of food was identified repeatedly as the most common eating ritual (Diolordi et al., 2014; Schreck & Williams, 2006; Williams et al., 2005).”

What the sources say

• Not checked yetcites Diolordi et al., 2014
• Not checked yetcites Schreck & Williams, 2006
• Not checked yetcites Williams et al., 2005

In the paper

“Although Martins et al. (2008) found no difference in eating rituals between autistic children and their siblings without autism”

What the sources say

• Not checked yetcites Martins et al. (2008)

In the paper

“Food selectivity was also linked to more than one sensory factor (Postorino et al., 2015)”

What the sources say

• Not checked yetcites Postorino et al., 2015

In the paper

“Several studies found youth with autism had more ritualistic and/or idiosyncratic eating behaviors (e.g. requiring specific presentation of food, and use of certain utensils) than youth with other disabilities (e.g. ADHD, intellectual disability, and language disorder; Mayes & Zickgraf, 2019; Williams et al., 2005)”

What the sources say

• Not checked yetcites Mayes & Zickgraf, 2019
• Not checked yetcites Williams et al., 2005

In the paper

“Postorino and colleagues (2015) found nearly 13% of autistic children refused food because of brand or packaging”

What the sources say

• Not checked yetcites Postorino and colleagues (2015)

In the paper

“and general population peers (Diolordi et al., 2014; Mayes & Zickgraf, 2019; Williams et al., 2005).”

What the sources say

• Not checked yetcites Diolordi et al., 2014
• Not checked yetcites Mayes & Zickgraf, 2019
• Not checked yetcites Williams et al., 2005