Feeding difficulties and their treatment strategies in children with autism spectrum disorder

Abstract

Autism spectrum disorder (ASD) is the most recognized neuropsychiatric disorder of childhood and is characterized by impairments in social interaction and communication as well as restricted, stereotyped behavior. Feeding difficulties are frequent and important in children with ASD and their families. Specific concerns, including those related to food selectivity and food refusal, are more likely addressed than those associated with mealtime.1Bonsall A. Thullen M. Stevenson B.L. Sohl K. Parental feeding concerns for children with autism spectrum disorder: a family-centered analysis.OTJR (Thorofare N J). 2021; 41: 169-174PubMed Google Scholar A survey of nutritional behavior and parental feeding styles in children with ASD showed that such children have different eating and feeding styles compared to those in the control group. Children with ASD were more responsive to food, emotional overeating, enjoyment of food, desire for drinks, emotional undereating, and food selectivity behaviors than controls, whereas the parents of the children with ASD used more emotional, instrumental, and tolerance-controlled feeding styles than those of controls.2Demir A.Ç. Özcan Ö. The nutritional behavior of children with autism spectrum disorder, parental feeding styles, and anthropometric measurements.Nord J Psychiatry. 2022; 76: 64-70Google Scholar Evidence suggests that comorbid feeding problems predispose an individual with ASD toward medical complications. The incidence of chronic feeding problems can result in several medical and developmental implications, including malnutrition, growth retardation, poor academic achievement, and social deficits. Feeding difficulties rapidly develop in children with ASD. The frequency of feeding difficulties significantly and more rapidly increases in children with ASD between 15 and 36 months of age, and by 36 months, they exhibit a significantly higher frequency of feeding difficulties than all other groups.3Ashley K. Steinfeld M.B. Young G.S. Ozonoff S. Onset, trajectory, and pattern of feeding difficulties in toddlers later diagnosed with autism.J Dev Behav Pediatr. 2020; 41: 165-171Crossref PubMed Scopus (4) Google Scholar Children and adolescents with ASD show high rates of gastrointestinal symptoms, food selectivity, mealtime problems, and dietary modification (such as the use of food supplements). The most common gastrointestinal symptoms in these children are abdominal pain and constipation. Children with ASD may experience at least one gastrointestinal symptom weekly, with bowel issues associated with feeding. Gastroesophageal reflux is the most prevalent condition associated with food refusal. The analyses of individual feeding factors showed that feeding difficulties in children with ASD were not due to oral–motor problems but included challenges in food acceptance and mealtime behaviors. These feeding difficulties might be related to social communication deficits. A systematic review revealed that feeding difficulties from selective intake consistently correlate with impaired sensory processing and perception and tend to be positively associated with rigidity and challenging behavior.4Page S.D. Souders M.C. Kral T.V.E. Chao A.M. Pinto-Martin J. Correlates of feeding difficulties among children with autism spectrum disorder: a systematic review.J Autism Dev Disord. 2021 Mar 5; https://doi.org/10.1007/s10803-021-04947-4Crossref PubMed Scopus (6) Google Scholar The associations between children's and parents' eating behaviors are complex in children with ASD and may be related to parenting feeding styles, stressful mealtimes, and neurodevelopmental conditions. A cross-sectional study in Asian children with ASD aged 1–7 years showed that caregiver feeding styles could be authoritarian (34.8%) or indulgent (39.4%); the authoritarian feeding style and Aberrant Behavior Checklist scores of hyperactivity were significantly associated with Behavioral Pediatrics Feeding Assessment Scale severity score.5Kang Y.Q. Teo C.M. Tan M.L. Aw M.M. Chan Y.H. Chong S.C. Pediatr Neonatol.. 2022; 63: 48-56Google Scholar Asian parents tend to apply a more authoritarian parenting style. Authoritative feeding was associated with the consumption of dairy, fruit, and vegetables in children with ASD. Evidence for the benefits of authoritative feeding suggests that interventions to increase children's consumption should be targeted toward increasing caregivers' authoritative feeding behaviors.6Patrick H. Nicklas T.A. Hughes S.O. Morales M. The benefits of authoritative feeding style: caregiver feeding styles and children's food consumption patterns.Appetite. 2005; 44: 243-249Crossref PubMed Scopus (272) Google Scholar Addressing caregiver feeding style aimed at increasing positive parent–child interaction and emotional communication have been associated with larger positive effects. Providing clinicians with a conceptual framework to systematically identify factors that contribute to the feeding challenge construct will ensure the provision of appropriate intervention. A multidisciplinary framework combining medical, oral–motor, behavior, sensory, and environmental issues could help assess feeding challenges observed in ASD. Operant conditioning and systematic desensitization are two mainstay psychotherapeutic interventions in children with ASD who experience feeding difficulties. Current evidence for operant conditioning as the most effective psychotherapy and cognitive behavioral therapy for older children with feeding difficulties has shown promising results.7Zhu V. Dalby-Payne J. Feeding difficulties in children with autism spectrum disorder: aetiology, health impacts and psychotherapeutic interventions.J Paediatr Child Health. 2019; 55: 1304-1308Crossref PubMed Scopus (3) Google Scholar In conclusion, the impact of feeding problems with caregivers and the possible nutritional insufficiency should be considered when assessing the families of children with ASD. Feeding problems in children with ASD appear early and escalate quickly; feeding difficulties are now considered part of the ASD diagnostic phenotype. The poor feeding behaviors of children with ASD can be minimized if addressed early and appropriately. Children with ASD and those who have significant hyperactivity behaviors in the context of parents with an authoritarian feeding style could be predisposed toward problematic feeding behaviors. Families that have children with ASD who present with significant feeding challenges should be followed up by a multidisciplinary team to systematically identify challenges and provide appropriate interventions. The author declares that he has no competing interests.