child eating behaviors and caregiver feeding practices in children with autism spectrum disorders

POPULATIONS AT RISK ACROSS THE LIFESPAN: CASE STUDIES

Child Eating Behaviors and CaregiverFeeding Practices in Children withAutism Spectrum DisordersTanja V. E. Kral, PhD,1,2 Margaret C. Souders, PhD, CRNP,1 Victoria H. Tompkins, BA,1 Adriane M.Remiker, BA,3 Whitney T. Eriksen, BSN, RN,1 and Jennifer A. Pinto-Martin, PhD, MPH1,4

1Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; 2Department ofPsychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; 3Department of Cell and DevelopmentalBiology, Weill Cornell Medical College, New York, New York; and 4Department of Biostatistics and Epidemiology, University of PennsylvaniaPerelman School of Medicine, Philadelphia, Pennsylvania

Correspondence to:

Tanja V. E. Kral, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing and Perelman School of Medicine,

308 Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217. E-mail: [email protected]

ABSTRACT Objective: This pilot study compared children with autism spectrum disorders(ASD) and typically developing children (TDC) on weight-related outcomes and caregiver-reportedchild eating behaviors and feeding practices. Design and Sample: Cross-sectional study. Caregiversof 25 children with ASD and 30 TDC, ages 4–6. Methods: Caregivers completed validated question-naires that assessed child eating behaviors and feeding practices. Childrens height, weight, andwaist circumference were measured. Results: Children with ASD, when compared to TDC, showedsignificantly greater abdominal waist circumferences (p = .01) and waist-to-height ratios(p < .001). Children with ASD with atypical oral sensory sensitivity exhibited greater food avoidancebehaviors, including reluctance to eat novel foods (p = .004), being selective about the range offoods they accept (p = .03), and undereating due to negative emotions (p = .02), than children withASD with typical oral sensory sensitivity. Caregivers of children with ASD with atypical oral sensorysensitivity reported using food to regulate negative child emotions to a greater extent than caregiversof children with typical oral sensory sensitivity (p = .02). Discussion: Children with ASD, especiallythose with atypical oral sensory sensitivity, are at increased risk for food avoidance behaviors and mayrequire additional support in several feeding domains.

Key words: autism spectrum disorders, caregiver feeding practices, eating behavior, obesity.

The prevalence of Autism Spectrum Disorders(ASD) has been steadily increasing over the pasttwo decades and is a significant public health con-cern (Autism & Developmental Disabilities Moni-toring Network, 2014). One of the most commonco-occurring problems in children with ASD ischallenging eating behaviors reported by as manyas 90% of caregivers (Ahearn, Castine, Nault, &Green, 2001; DeMeyer, 1979). The core deficits ofASD and their underlying neurobiology may predis-pose children to intrinsic and extrinsic stressorsthat threaten healthy eating behaviors. Conse-

quently, these behaviors put children with ASD atgreat risk for poor dietary patterns and obesity(Curtin, Anderson, Must, & Bandini, 2010). Giventhe convergence of these two pediatric health carepriorities it is critical that public health nursesfocus on these concerns.

Caregivers of individuals with ASD face uniquechallenges when it comes to feeding and daily eat-ing routines, such as increased food selectivity, foodrefusal, and disruptive mealtime behaviors,described by two recent reviews (Kral, Eriksen,Souders, & Pinto-Martin, 2013; Sharp et al., 2013).

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A small number of studies (Ahearn et al., 2001;Klein & Nowak, 1999; Raiten & Massaro, 1986; Wil-liams, Dalrymple, & Neal, 2000) and anecdotal evi-dence/case reports further indicated that childrenwith ASD show aversions or strong preferences tocertain textures, smells, colors, temperatures, andbrand names of foods. These eating behaviors andfood preferences/aversions emerge at a young ageand can adversely impact children’s diet quality,food variety, and their growth and development.The purpose of this pilot study was to gain agreater understanding of caregiver-reported eatingbehaviors, caregiver feeding practices, and growthmeasurements of children with ASD in the earlyyears after a diagnosis.

In a comprehensive narrative review, Cermak,Curtin, and Bandini (Cermak, Curtin, & Bandini,2010) suggested that increased food selectivity inchildren with ASD may be the result of heightenedsensory sensitivity to the texture of certain foods.Preliminary data in typically developing children(TDC) showed that higher taste and smell sensitiv-ity was associated with lower intake of healthyfoods, increased food neophobia (i.e., children’savoidance of novel foods) (Coulthard & Blissett,2009), and higher food selectivity among childrenwith tactile defensiveness (i.e., overreaction toexperiences of touch including touch associatedwith feeding) (Smith, Roux, Naidoo, & Venter,2005). Given the large number of children withASD who experience sensory processing difficulties(Schoen, Miller, Brett-Green, & Nielsen, 2009), it iscrucial for future studies to examine eating behav-iors in children with ASD in the context of theirsensory processing patterns.

Eating difficulties not only pose nutritionalrisks for children with ASD, but they can also put aconsiderable strain on caregivers and their families.While there exists an extensive body of research oncaregiver feeding practices in TDC (e.g., Birch &Fisher, 2000; Fisher & Birch, 2000; Galloway, Fio-rito, Lee, & Birch, 2005; Wardle & Carnell, 2007),we know little about feeding practices used by care-givers of young children with ASD. It is possiblethat caregivers of children with ASD address nutri-tional difficulties in their children by using differentfeeding practices. In TDC, Wardle and colleagues(Wardle, Sanderson, Guthrie, Rapoport, & Plomin,2002) showed that caregiver feeding to regulatechild emotional distress (emotional feeding) and

using food as a reward (instrumental feeding) maylead to children to associate eating with cues otherthan hunger. Together, increased food selectivity inchildren and parental use of highly directive feedingstrategies can put children with ASD at increasedrisk for excess weight gain and overweight/obesityat a young age (Cermak et al., 2010; Fisher &Birch, 2000). Given that children have an innatepreference for calorie-rich, sweet foods (Mennella,2014), an overconsumption of calories can occur ifcoupled with selectivity in the range of acceptablefoods. Conversely, children whose parents consis-tently restrict access to preferred foods have beenshown to become more prone to overeating thesefoods when they become available, resulting inexcess weight gain (Fisher & Birch, 2000).

The primary aim of this pilot study was tocompare children with ASD and TDC, ages 4–6, inweight-related outcomes and caregiver-reportedchild eating behaviors. We hypothesized that chil-dren with ASD would be significantly heavier andwould show greater central adiposity than TDC. Wefurther hypothesized that children with ASD, andthose with atypical oral sensory sensitivity, in par-ticular, would show significantly more food avoid-ance behaviors. A second aim of this study was toexamine feeding practices of caregivers of childrenwith ASD and TDC. We hypothesized that caregiv-ers of children with ASD would exhibit greatermonitoring and greater control over their children’seating compared to caregivers of TDC.

Methods

Design and sampleStudy design. This pilot study used a cross-

sectional design in which 4- and 6-year-oldchildren with ASD were compared to TDC incaregiver-reported eating behaviors and weight-and adiposity-related measures. Caregivers wereasked to complete a series of questionnaires andparticipate in one on-site assessment during whichchildren’s height, weight, and waist circumferencewere measured.

Participants and recruitment. Participantsin this study were 25 children with ASD and 30TDC and their primary caregiver living in thegreater metropolitan area of Philadelphia. Families

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of all racial and ethnic backgrounds were eligible toparticipate in the study. Children with ASD wererecruited via (1) online and e-mail advertisementsthrough autismMatch, an online research registrycreated by the Center for Autism Research (CAR) atThe Children’s Hospital of Philadelphia (CHOP),and (2) flyers posted at Special People in theNortheast (SPIN), a community-based human ser-vice organization in Philadelphia, and at CAR. TDCwere recruited by (1) online advertisement, (2) flyerpostings at local grocery stores and in the commu-nity, and from (3) other ongoing pediatric studiesat the Center for Weight and Eating Disorders(CWED) at the University of Pennsylvania. To beincluded in the study, ASD children were requiredto be between 4 and 6 years of age with a diagnosisof ASD by a community provider, in conjunctionwith having a score ≥12 on the Social Communica-tion Questionnaire (SCQ) – Lifetime Form (Rutter,Bailey, & Lord, 2003). Inclusion criteria for TDCwere no prior diagnosis of ASD and a score <12 onthe SCQ. The SCQ is a validated parent-reportscreening tool for ASD in individuals over age 4whose mental age is at least 2 years (Rutter et al.,2003). The questionnaire consists of 40 itemsinquiring about socialization, communication skills,and atypical behaviors. Children were excludedfrom the study if they had major or chronic medicalconditions known to affect food intake, bodyweight, or growth; were taking psychotropic medi-cations or medications known to affect appetite,food intake, or body weight; were on a strict specialdiet; had significant food allergies; or were lactoseintolerant. Four TDC were excluded from the studydue to scores ≥12 on the SCQ. The age range (4–6 years) was chosen because early childhood is acritical period during which children’s eatingbehaviors are being shaped (Birch & Davison,2001).

Interested caregivers were interviewed by tele-phone to determine whether their children met theinitial inclusion criteria for the study. During thephone interview, caregivers were asked to provideverbal consent to answer both the telephonescreening questions as well as the mailed question-naires. Families who qualified for the study fromthe telephone interview were mailed a question-naire packet along with an informed consent formand asked to complete all questionnaires prior to orduring their on-site study visit at Penn or CHOP.

During the study visit, caregivers received adetailed explanation of study procedures and wereasked to provide voluntary consent to have theirchildren participate in this study by signing theconsent form. Once the signed consent form wasreceived by our staff, the completed questionnaireswere collected and children were invited, in child-friendly language, to participate in body measure-ments. Families were compensated for their partici-pation in the study ($100 in form of a gift card).The study was approved by the Institutional ReviewBoards of the University of Pennsylvania andCHOP.

MeasuresAssessment of height, weight, and waist

circumference. Study visits for children withASD took place at CAR at CHOP; study visits forTDC took place at the CWED at the University ofPennsylvania. During the visit, children’s height,weight, and waist circumference were assessed bytrained research assistants. All measures were takenwith children wearing light clothing and havingtheir shoes removed. Weight was measured on adigital scale (ASD children: SECA 876, Chino, CA;TDC: Tanita BWB-800, Arlington Heights, IL; bothaccurate to 0.1 kg) and height was measured on astadiometer (ASD children: portable stadiometer,SECA 217, Chino, CA; TDC: wall-mounted stadiom-eter, Veder-Root, Elizabethtown, NC; both accurateto 0.1 cm). Children’s abdominal waist circumfer-ence was measured with a nonstretchable fiberglasstape (accurate to 0.1 cm). Measurement techniquesfollowed the methods described in Lohman, Roche,and Martorell (1988). Anthropometric measure-ments were taken in duplicate; the mean was usedin analyses. Child age- and sex-specific BMI per-centiles and z-scores were calculated using the Cen-ter for Disease Control and Prevention GrowthCharts 2000 (Kuczmarski et al., 2002). Childrenwere classified as normal weight (BMI-for-age 5–84th percentile), overweight (BMI-for-age 85–94thpercentile), or obese (BMI-for-age ≥95th percentile)(Ogden et al., 2002). Children’s waist-to-heightratio was calculated as waist circumference dividedby height (Ashwell, Gunn, & Gibson, 2012).

Assessment of child eating behaviors.Eating behaviors of children were assessed by care-giver report using several validated instruments.

Kral et al.: Eating Behaviors of Children with Autism 3

Food neophobia, or children’s reluctance to eatand/or avoidance of novel foods, was assessedusing the modified version (Wardle, Carnell, &Cooke, 2005) of the Child Food Neophobia Scale(Pliner, 1994). The modified version of the scalecontains the following six items: (1) “My child doesnot trust new foods”; (2) “If my child doesn’t knowwhat’s in a food, s/he won’t try it”; (3) “My child isafraid to eat things s/he has never had before”; (4)“My child will eat almost anything”; (5) “My childis very particular about the foods s/he will eat”;and (6) “My child is constantly sampling new anddifferent foods.” Caregivers were asked to indicatetheir responses on a 4-point scale ranging from“strongly disagree” to “strongly agree.” Greaterscores indicate a greater level of food neophobia(Cronbach a = .84).

Caregivers also completed the 35-item ChildEating Behavior Questionnaire (CEBQ), which wasused to assess the following eight dimensions ofchildren’s eating style: (1) children’s responsivenessto food, (2) enjoyment of food, (3) satiety respon-siveness (assesses if food intake is reduced to com-pensate for a prior snack), (4) slowness in eating,(5) fussiness (being highly selective about the rangeof foods that are accepted), (6) emotional overeat-ing (eating more food during negative emotionalstates), (7) emotional undereating (eating less foodduring negative emotional states), and (8) desirefor drinks (Wardle, Guthrie, Sanderson, & Rapo-port, 2001). Caregivers were asked to indicate theirresponses on a 5-point Likert scale ranging from‘never’ to ‘always.’ The questionnaire has showngood internal consistency, test-retest reliability, andstability over time (Ashcroft, Semmler, Carnell, vanJaarsveld, & Wardle, 2008; Carnell & Wardle,2007; Wardle et al., 2001).

Assessment of caregiver feeding prac-tices. Caregivers completed the Child FeedingQuestionnaire (CFQ), which is a 31-item instrumentthat assesses (1) parents’ perceptions of theirresponsibility for child feeding; (2) parents’ percep-tions of their own weight status history; (3) par-ents’ perceptions of their child’s weight statushistory; (4) parents’ concerns about the child’s riskof being overweight; (5) extent to which parentsoversee their child’s eating (monitoring); (6) extentto which parents restrict their child’s access to food(restriction); and (7) parents’ tendency to pressure

their children to eat more food (Birch et al., 2001).For each item, caregivers were asked to indicatetheir response on a 5-point Likert Scale, with eachpoint on the scale represented by a specific wordanchor. The questionnaire showed adequate inter-nal consistency with Cronbach’s alpha coefficientsfor the various subscales ranging from 0.70 to 0.92(Birch et al., 2001).

Caregivers also completed the Parental FeedingStyle Questionnaire (PFSQ), which is a 27-itemcaregiver-report questionnaire that assesses (1)maternal emotional feeding, (2) instrumental feed-ing (using food as reward), (3) prompting/encour-agement to eat, and (4) control over child eating(Wardle et al., 2002). Response options for eachitem range from “I never do” to “I always do” on a5-point Likert Scale. Internal reliability coefficients(Cronbach’s a) ranged from 0.65 to 0.85 and test-retest reliability coefficients ranged from 0.76 to0.83 for the four subscales.

Assessment of child sensory processing.Caregivers were asked to complete the 125-itemSensory Profile Caregiver Questionnaire (Dunn,1999), which measures children’s sensory process-ing abilities across the following nine factors: (1)sensory seeking, (2) emotionally reactive, (3) lowendurance/tone, (4) oral sensory sensitivity, (5)inattention/distractibility, (6) poor registration, (7)sensory sensitivity, (8) sedentary, and (9) finemotor/perceptual. For this study, we limited theanalysis to the oral sensory sensitivity factor only,which is comprised of the following items: “Avoidscertain tastes or food smells that are typically partof children’s diets,” “Will only eat certain tastes,”“Limits self to particular food textures/tempera-tures,” “Picky eater, especially regarding food tex-tures,” “Routinely smells nonfood objects,” “Showsstrong preference for certain smells,” “Shows strongpreference for certain tastes,” “Craves certainfoods,” and “Seeks out certain tastes or smells.”Caregivers were asked to indicate, on a 5-pointscale ranging from ‘always’ (1) to ‘never’ (5), thefrequency with which their child responds to thesesensory experiences. Lower scores correspond tomore frequent child behavioral responses. Childrenwere categorized into “Typical Performance,” “Prob-able Difference,” or “Definite Difference” in oralsensory sensitivity based on the classifications spec-ified by Dunn (Dunn, 1999).


Analytic strategyData were analyzed using the SAS System for Win-dows (Version 9.3; SAS Institute, Cary, NC, USA)and SPSS (Version 20; SPSS Inc., Chicago, IL,USA). We used the Shapiro-Wilk test in conjunctionwith distribution plots and summary statistics toexamine the normality of the distribution of contin-uous variables. For Aims 1 and 2, we used indepen-dent samples t tests for normally distributedcontinuous variables, nonparametric tests for non-normally distributed variables, and Chi-Square andFisher’s Exact tests for categorical variables to com-pare children with ASD and TDC in caregiver-reported eating behaviors, feeding practices, andweight-related measures. In a subgroup analysis, weexamined child eating behaviors and caregiver feed-ing practices by children’s oral sensory sensitivitystatus. In an effort to reduce the number of statisti-cal comparisons, we limited this subgroup analysisto (1) only children with ASD and (2) children with“Typical Performance” (hereinafter referred to as

‘typical oral sensory sensitivity’) and a “Definite Dif-ference” (hereinafter referred to as ‘atypical oralsensory sensitivity’). Descriptive statistics arereported as means (�SDs) for continuous variablesor as percentages for categorical variables unlessotherwise indicated. Reported p values are 2-sidedand p < .05 was considered significant for all tests.

Results

Child characteristicsTable 1 depicts demographic, anthropometric, andsensory sensitivity characteristics of children. Amongchildren with ASD, the majority of children (72%)were male, Caucasian (60%), and non-Hispanic(84%). Among TDC, approximately half of the chil-dren were male (47%) and the majority of them wereAfrican American (83%) and non-Hispanic (97%).

Children with ASD, when compared to TDC,showed a significantly higher waist circumference(56.2 � 7.5 cm vs. 51.9 � 4.0 cm; p = .01), and

TABLE 1. Characteristics (Mean � SD) of Children with Autism Spectrum Disorders (ASD; n = 25) and Typically Develop-ing Children (TDC; n = 30)

Child characteristic ASD TDC P-value

Age (years) 5.0 � 0.9 5.2 � 0.7 .39Sex (male/female) 18 (72%)/7 (28%) 14 (47%)/16 (53%) .06Race (%)Asian 3 (12) 0 (0) <.0001Black or African American 6 (24) 25 (83)White 15 (60) 2 (7)More than one race 1 (4) 3 (10)Ethnicity (%)Hispanic 4 (16) 1 (3) .17Not Hispanic 21 (84) 29 (97)Height (cm) 109.4 � 6.5 112.6 � 7.2 .10Weight (kg) 19.9 � 3.7 20.1 � 3.6 .79BMI (kg/m2) 17.0 � 2.9 15.8 � 1.5 .11BMI z-score 0.75 � 1.39 0.17 � 1.07 .09BMI-for-age percentile 66.1 � 29.9 55.6 � 30.2 .20Weight status (%)Underweight/normal-weight 14 (56) 24 (80) .055Overweight/obese 11 (44) 6 (20)Waist circumference (cm) 56.2 � 7.5 51.9 � 4.0 .01Waist-to-height ratio 0.51 � 0.06 0.46 � 0.03 <.001SCQ total score 17.4 � 5.6 5.9 � 3.3 <.001Oral sensory sensitivity 29.4 � 10.4 39.5 � 8.5 <.001Oral sensory sensitivity classification (%)Typical performance (typical) 10 (40) 25 (83) <.001Probable difference 4 (16) 3 (10)Definite difference (atypical) 11 (44) 2 (7)


waist-to-height ratio (0.51 � 0.06 vs. 0.46 � 0.03;p < .001). Differences in children’s BMI z-scores(ASD: 0.75 � 1.39 vs. TDC: 0.17 � 1.07; p = .09)and percentages of overweight/obesity (ASD: 44%vs. TDC: 20%; p = .055) were not significant. Chil-dren with ASD showed significant differences intheir total score on the SCQ (17.4 � 5.6 vs.5.9 � 3.3; p < .001) and the oral sensory sensitivityfactor (29.4 � 10.4 vs. 39.5 � 8.5; p < .001; lowerscores indicating more frequently endorsed behav-iors related to oral sensory sensitivity).

Child eating behaviorsTable 2 depicts caregiver-reported eating behaviorsfor children. Children with ASD showed signifi-cantly greater food fussiness (p < .001) when com-pared to TDC. Children with ASD and atypical oralsensory sensitivity (N = 11), when compared to chil-dren with ASD with typical oral sensory sensitivity(N = 10), showed significantly greater food avoid-ance behaviors, such as food neophobia (2.9 � 0.1vs. 2.4 � 0.1; p = .004) and food fussiness(4.2 � 0.2 vs. 3.3 � 0.3, p = .03), and greateremotional undereating (3.2 � 0.2 vs. 2.3 � 0.3;p = .02), respectively (Figure 1).

Caregiver feeding practicesCaregivers of children with ASD differed in severalfeeding practices from caregivers of TDC (Table 3).Caregivers of children with ASD reported to engagein significantly higher levels of prompting andencouragement to eat (p = .002), when comparedto caregivers of TDC.

Caregivers of children with ASD and atypicaloral sensory sensitivity (N = 11), when compared to

caregivers of children with ASD and typical oralsensory sensitivity (N = 10), engaged in signifi-cantly greater emotional feeding (2.3 � 0.3 vs.1.4 � 0.2; p = .02). None of the remaining care-giver feeding practices significantly differed by childoral sensory sensitivity status (p > .24).

Discussion

In this study, children with ASD showed signifi-cantly greater waist circumferences and waist-to-height ratios when compared to TDC. Children withASD also showed significantly greater food avoid-ance behaviors, especially those with atypical oralsensory sensitivity. Caregivers of children with ASDappear to address these nutritional challenges byusing feeding practices that differ in severaldomains from caregivers of TDC.

In this study, 44% of children with ASD and20% of TDC were considered overweight or obeseand of those 24% of children with ASD and 13% ofTDC were considered obese (data not shown). Theprevalence of obesity (24%) among the childrenwith ASD in this study is slightly lower than theprevalence rate (30%) reported in a study by Curtinet al. (2010), which was based on data collected inthe 2003–2004 National Survey of Children’sHealth. In that study, determination of children’sobesity status was based on caregiver-reportedrather than measured heights and weights and chil-dren’s ages ranged from 3 to 17 years. Differencesin methods used to determine children’s height andweight (i.e., caregiver-reported vs. measured) anddifferences in children’s age range may account fordifferences in obesity prevalence rates between thetwo studies. National prevalence rates for over-weight and obesity among U.S. children differbased on their race/ethnicity. In 2009–2010, theprevalence of overweight and obesity among chil-dren ages 2–5 years and 6–11 years was estimatedto be 23.8% and 27.6% for non-Hispanic Whitechildren and 28.9% and 42.7% for non-HispanicBlack children, respectively (Ogden, Carroll, Kit, &Flegal, 2012). In this study, the majority of childrenwith ASD were White (60%), while the majority ofTDC were African American (83%). Despite thedemographic differences between groups and theincreased odds of obesity among African Americanchildren (Ogden et al., 2012), children with ASDshowed higher levels of overweight/obesity and sig-

TABLE 2. Caregiver-Reported Eating Behaviors(Mean � SEM) of Children with Autism Spectrum Disor-ders (ASD; n = 25) and Typically Developing Children(TDC; n = 30)

Eating trait ASD TDC P-value

Food neophobia 2.6 � 0.1 2.6 � 0.1 .90Responsiveness to food 2.5 � 0.2 2.3 � 0.1 .39Enjoyment of food 3.4 � 0.1 3.8 � 0.1 .06Satiety responsiveness 3.0 � 0.1 2.9 � 0.1 .60Slowness in eating 3.0 � 0.2 2.7 � 0.1 .07Food fussiness 3.7 � 0.2 2.6 � 0.2 <.001Emotional overeating 2.0 � 0.2 1.7 � 0.1 .19Emotional undereating 2.7 � 0.2 2.5 � 0.1 .25Desire to drink 3.3 � 0.3 3.3 � 0.2 .90


nificantly greater abdominal waist circumferencesand waist-to-height ratios when compared to TDC.The waist-to-height ratio has been recommended asan anthropometric tool predicting cardiovascularrisk in preschool and older children (e.g., Freedmanet al., 2007; Kahn, Imperatore, & Cheng, 2005;Maffeis, Banzato, & Talamini, 2008). In our study,children with ASD averaged a waist-to-height ratiothat exceeded the 0.5 waist-to-height ratio cutoff

value for identifying cumulative cardiovascular riskfactors in preschool children (Campagnolo, Hoff-man, & Vitolo, 2011). Together, these findings sug-gest that children with ASD are at an increased riskfor excess weight gain at an early age, which canhave both immediate and long-term adverse effectson children’s health including, but not limited to,an increased risk for developing cardiovascular dis-ease, type 2 diabetes, stroke, several types of can-cer, and bone and joint problems (e.g.,Anandacoomarasamy, Caterson, Sambrook, Fran-sen, & March, 2008; Calle & Kaaks, 2004; Reaven,Abbasi, & McLaughlin, 2004).

This study further aimed to compare childrenwith ASD and TDC in caregiver-reported child eat-ing behaviors. While our findings showed signifi-cantly greater food fussiness among children withASD, overall there were relatively few differences incaregiver-reported child eating behaviors betweenchildren with ASD and TDC. Children with ASDand TDC did, however, significantly differ in oralsensory sensitivity, which corroborates findingsfrom prior research (Cermak et al., 2010; Watling,Deitz, & White, 2001). Interestingly, when compar-ing children with ASD by their oral sensitivity sta-tus, our data indicate that ASD children with

Food Neophobia

0

1

2

3

4

Typical OralSensory Sensitivity

Atypical OralSensory Sensitivity

P = 0.004 *

Scor

e

Food Fussiness

0

1

2

3

4

5



P = 0.03*

Scor

e

Emotional Overeating

0

1

2

3

4

5



P = 0.07

Scor

e

Emotional Undereating

0

1

2

3

4

5



P = 0.02 *

Scor

eFigure 1. Caregiver-Reported Eating Behaviors (Mean � SEM) of Children with Autism SpectrumDisorders (ASD; n = 25) by Oral Sensory Sensitivity Status

TABLE 3. Caregiver Feeding Practices (Mean � SEM) forChildren with Autism Spectrum Disorders (ASD; n = 25)and Typically Developing Children (TDC; n = 30)

Caregiver feeding practice ASD TDC P-value

Control over eating 3.8 � 0.1 4.0 � 0.1 .10Prompting andencouragementto eat

4.1 � 0.1 3.4 � 0.2 .002

Instrumental feeding 2.2 � 0.2 1.8 � 0.1 .08Emotional feeding 1.9 � 0.2 1.5 � 0.1 .15Perceived responsibility forchild feeding

4.5 � 0.1 4.6 � 0.1 .73

Concern about child weight 2.2 � 0.3 2.2 � 0.3 .77Restriction 3.8 � 0.2 3.3 � 0.2 .07Pressure for child to eatmore food

3.0 � 0.2 3.1 � 0.2 .62

Monitoring 4.4 � 0.1 4.2 � 0.1 .22


atypical oral sensory sensitivity showed significantlygreater food neophobia (e.g., reluctance to eat and/or avoidance of novel foods), greater food fussiness,and increased undereating due to negative emo-tions. Together, these increased food avoidancebehaviors can put children with ASD and atypicaloral sensory sensitivity at an increased risk forpotential nutrient deficiencies, which in turn canadversely affect their growth and development.Future research needs to determine the extent towhich these food avoidance behaviors in childrenmay be food-specific (i.e., apply only to certaintypes of foods or food groups) and if they can bemodified through targeted behavioral interventions.

A second aim of this study was to assess ifcaregivers of children with ASD use child feedingpractices that differ from those used by caregiversof TDC. Our data showed that caregivers of chil-dren with ASD reported to significantly more oftenprompt and encourage their children to eat com-pared to caregivers of TDC. Future research usinglarger samples of children will need to determine ifcaregivers use specific types of foods to try to regu-late their child’s eating. When comparing childrenwith ASD by their oral sensitivity status, our dataindicate that caregivers of children with atypicaloral sensory sensitivity showed significantly greateremotional feeding than caregivers of children withtypical oral sensory sensitivity. This finding,together with the finding that children with ASDand atypical oral sensory sensitivity show greaterlevels of under- and overeating due to negativeemotions, suggests that food plays an importantrole in regulating child feeding in response to nega-tive emotional states among families of childrenwith ASD. Future research is needed to evaluatethe efficacy of behavioral interventions to substitutechild eating and caregiver feeding to regulate nega-tive emotional states in children with other com-forting behaviors that do not involve food andeating.

The strengths of this study include the concur-rent assessment of caregiver-reported child eatingbehaviors and measured child height, weight, andwaist circumference in a unique cohort of children.To our knowledge, this also is the first study tocomprehensively assess feeding practices in caregiv-ers of children with ASD. The study also had sev-eral limitations. First, the skewed distribution ofchildren’s race between groups may have intro-

duced a recruitment bias and attenuated thebetween-group differences in weight-related out-comes due to the higher prevalence of overweightand obesity among African American children. It isalso possible that the racial/ethnic differences mayhave affected caregiver reporting on some question-naires due to cultural differences surrounding fam-ily mealtimes and eating (Skala et al., 2012).Second, the relatively small sample size may haveprecluded us from finding significant differences inchild and caregiver related outcomes, as evident byfindings of several nonstatistically significanttrends. Therefore, before any practice changes canbe implemented, it will be important for futureresearch to study larger samples of children and tostatistically control for between-group differencesin subject characteristics and adjust for multiplecomparisons. Moreover, caregiver-reported ratherthan observed child eating behaviors may be sub-ject to caregiver bias. The completion of numerousquestionnaires likely placed considerable burden oncaregivers and some items may have overlappedbetween questionnaires (e.g., Food Neophobia Scaleand Sensory Profile). Future studies that build onthese preliminary findings should therefore be moreselective in the number of questionnaires that arebeing administered to families and/or may useinterview-based assessment techniques to reducesubject burden. Lastly, due to the communicationdeficits in children with ASD, it is possible thatsome children may have had undiagnosed medicalconditions, which may have impacted their eatingbehaviors or experience of sensory sensitivity.

The findings of this study have importantimplications for public health nurses. First, the highprevalence of feeding difficulties in children withASD warrants a comprehensive gastrointestinal andfeeding history be completed by the nurse/providerat routine health checks. Second, nurses/providersshould complete a thorough physical exam includ-ing abdominal assessment and measurement ofchildren’s heights, weights, and waist circumfer-ences, and determine their BMI-for-age percentilesand waist-to-height ratios. The results of the assess-ment and corresponding weight and cardiovascularhealth status should be shared with the caregiversor individuals with ASD. When necessary nursesshould refer families to a specialty feeding clinicwhere an interdisciplinary team of behavioral psy-chologists, advanced practice nurses, and registered


dieticians can address complex child feeding behav-iors. Lastly, for individuals at risk for overweight/obesity, in particular, nurses can be trained to playa critical role in modeling for parents/caregiversbehaviors that reward healthy food choices and eat-ing behaviors and managing negative child emo-tions with behavioral strategies and nonfoodalternatives.

In sum, the data from this pilot study suggestthat young children with ASD show increasedabdominal waist circumferences and waist-to-height ratios, differences in oral sensory sensitivity,and, for children with atypical oral sensory sensitiv-ity, in particular, greater feeding challenges thanTDC. Caregivers of children with ASD address thesenutritional challenges by using feeding practicesthat differ in several domains from caregivers ofTDC. Public health nurses can take the lead andbuild awareness that all individuals with ASDshould be assessed for their eating behaviors andnutritional status. Moreover, caregivers will needongoing support to prevent maladaptive feedingbehaviors, address sensory sensitivities and pro-mote healthy dietary practices for their family.

Acknowledgments

Financial support: This research was supported bya pilot grant from the Biobehavioral Research Cen-ter at the University of Pennsylvania School ofNursing. We also acknowledge funding supportfrom the Hillman Scholars Program in NursingInnovation.

Conflict of interest: The authors declare thatthey have no conflict of interest.

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