Table 2.
Studies of feeding and eating issues in children and adolescents with autism.
| Author (year) | N a | Sample characteristics b | Age range (mean, M) | Feeding/eating measure | Control group(s) c | Primary findings |
|---|---|---|---|---|---|---|
| Aponte & Romanczyk (2016) | 38 | AD (58%), AS (11%), PDD-NOS (18%), ASD (13%). Sex: 84% male | 3–12 years (M: 6) | BAMBI, FFQ | None | ASD severity predicted feeding problem scores and duration of negative vocalizations during meal observations. 39% of participants showed low food acceptance. |
| Attlee et al. (2015) | 23 | Autism. Sex: 78% male | 5–16 years (M: NA) | BAMBI, FPI, 3-day food record | None | Participants had mealtime concerns related to limited variety, food refusal, and picky eating. Sample had a high rate of food rejection. |
| Bandini et al. (2010) | 53 | Autism. Sex: 83% male | 3–11 years (M: 6) | FFQ, 3-day food record | TD (58) | Autistic children had significantly more food refusal and limited food repertoire vs controls. |
| Bandini et al. (2017) | 18 | Autism. Sex: 89% male | NA (baseline M: 6; follow-up M: 13) | FFQ, MIOH, 3-day food record | None | Food refusal improved from baseline to follow-up, but repertoire of foods eaten did not. Rates of high food selectivity (FS) decreased from 83% to 44% between time-points. |
| Beighley et al. (2013) | 269 | AD (127), PDD-NOS (82), AS (60). Sex: 70% male | 2–18 years (AD M: 7; PDD-NOS M: 7; AS M:10) | ASD-CC | Atyp Dev (107), TD (149) | Children with ASDs had more FS vs non-ASD groups. There was a downward trend in FS severity across childhood; as children got older FS decreased. |
| Bitsika & Sharpley (2018) | 52 | ASD. Sex: 100% female | 6–17 years (M: 10) | SWEAA | None | 11% of scores from parents and daughters fell into the “usually-always” range. |
| Castro et al. (2016) | 49 | ASD. Sex: 100% male | 4–16 years (M: 10) | BPFAS | TD (49), matched | ASD group had higher levels of overall problematic eating behavior, but did not significantly differ from controls on factor scores (e.g. picky eating, refusal based on food texture, and general refusal). |
| Chistol et al. (2018) | 53 | Autism. Sex: 83% male | 3–11 years (M: 6) | FFQ, Sensory Profile | TD (58) | Autistic children were more likely to demonstrate oral sensory sensitivity. Autistic youth with atypical oral sensory sensitivity refused more foods and demonstrated more restrictive eating behaviors. |
| Curtin et al. (2015) | 53 | Autism. Sex: 83% male | 3–11 years (M: 6) | FFQ, MIOH | TD (58) | Children in autism group were more likely to have high FS and mealtime behavior problems. |
| Diolordi et al. (2014) | 33 | Autism. Sex: 82% male | 2–9 years (two ranges: 2–5.9 years, 6–9.5 years) | CEBI, author-created food frequency measure | TD (35); age-matched | Autistic children showed more eating problems in 6–9.5 years age range. Autism group had more mealtime rituals and generally ate below recommended amounts of all food groups. Overall, eating problems decreased at 1-year follow-up for the autism group. |
| Emond et al. (2010) | 79 | ASD. Sex: NA | 6, 15, 24, 38, and 54 months | Author-created food frequency questionnaires | TD (12,901) | Children with ASD demonstrated feeding symptoms from infancy and had less varied diet from 15 months of age. |
| Hubbard et al. (2014) | 53 | Autism. Sex: 83% male | 3–11 years (M: 6) | FFQ, Sensory Profile | TD (58) | Autistic children refused significantly more foods for more reasons (e.g. taste/smell). Consistency/texture was the most common reason for both groups, but prevalence was much higher in autism (77.4% vs 36.2%) |
| Johnson et al. (2008) | 19 | Autism. Sex: NA | 2–4 years (M: 39.2 months) | Author-created feeding assessment survey, FFQ, 24-h dietary recall | TD (15) | Autistic children had more feeding problems, particularly related to idiosyncratic refusal of foods based on color, texture, and type. Groups did not differ on nutritional status. |
| Johnson et al. (2014) | 256 | Autism (174), AS (21), PDD-NOS (57). Sex: 84% male | 2–11 years (M: 5) | BAMBI, Short Sensory Profile, 3DFR Healthy Eating Index | None | Strong associations between feeding habits and repetitive and ritualistic features, sensory features, and externalizing and internalizing behavior. No association between feeding behaviors and social and communication deficits and IQ. |
| Kalyva (2009) | 56 | AS. Sex: 100% female | 12–18 years (M: 14) | EAT-26 (self and parent report) | TD (56); age- and BMI-matched | AS group showed significantly more eating problems according to self- and mother-report. |
| Kerwin et al. (2005) | 89 | PDD-NOS (51%), AD (39%), AS (9%). Sex: 79% male | 3–17 years (M: 8) | Author-created eating behavior measure, GI symptoms, related behavior | None | Majority of children had unusual eating habits. Only 6.7% of parents indicated their child had a feeding problem. 62% of children had FS, and 29% of the sample exhibited pica. |
| Kral et al. (2015) | 25 | ASD. Sex: 72% male | 4–6 years (M: 5) | Modified Child Neophobia Scale, 35-item CEBQ, CFQ, PFSQ | TD (30) | Autistic children were at increased risk for food avoidance behaviors. ASD group had significantly more food fussiness than controls; those with ASD and oral sensory sensitivity showed more food avoidance, food fussiness, and emotional undereating. |
| Kuschner et al. (2015) | 65 | ASD. Sex: 89% male | 12–28 years (M: 16) | AASP | TD (59) | ASD group was significantly more likely to be food neophobic, more likely to report disliking textured foods, and less likely to enjoy strong tastes vs controls. FS issues appeared to be linked to daily living skills. |
| Malhi et al. (2017) | 63 | ASD. Sex: 91% male | 4–10 years (M: 6) | CEBI, 3-day food record | TD (50); age- and SES-matched | ASD group had significantly more feeding problems and ate significantly fewer food items. Autistic children were 6× more likely to be picky eaters than controls and were particularly averse to eating vegetables and fruits. |
| Marshall et al. (2016) | 33 | ASD. Sex: 76% male | 2–6 years (M: 52 months) | BPFAS, 3-day prospective diet record | Non-medically complex history (35) | Children with ASD showed increased FS; differences between ASD and controls were found predominantly on measures of general behavior rather than feeding behaviors. |
| Martins et al. (2008) | 41 | AD (35), AD or PDD-NOS diagnosis but under CARS cut-off (6). Sex: 83% male | 2–12 years (M: 7) | Author-created eating behavior questionnaire, BPFAS, FNS | TD (41), TD siblings of ASD sample (14); gender- and age-matched | Children with ASDs were marginally more likely to exhibit picky eating than their siblings or matched TD children. Rates of ritualistic feeding behaviors were similar across groups, but children with autism were more likely to have current problematic eating and feeding behaviors. |
| Matson et al. (2009) | 114 | Autism (72), PDD-NOS (40). Sex: 66% male | 3–16 years (M: 8) | ASD-CC | TD (114), Atyp Dev (53) | No significant differences between autism and PDD-NOS group on measures of feeding problems. Significantly higher rates of feeding problems across all items in ASD group vs atypically or typically developing. ASD group showed problems with FS and eating style (pica and rapid eating). |
| Mayes & Zickgraf (2019) | 1462 | Sample 1: Autism (1443). Sex: 79% male; Sample 2: Autism (19). Sex: 51% male | Sample 1: 1–17 years (M: 6). Sample 2: 1–18 years (M: 10) | CASD | Other Disabilities (327), TD (313) | Atypical eating behaviors 5× more common in autism group than other disorder group and 15× more common than typical development group. Limited food preferences were the most common atypical eating behavior in autism group. Most children with autism had 2+ types of atypical eating (e.g. sensitivity to textures and idiosyncratic mealtime rituals). |
| Nadon et al. (2011) | 95 | Autism (61%), PDD-NOS (29%), AS (10%). Sex: 92% male | 3–10 years (M: 7) | Eating Profile, Short Sensory Profile | None | Children with higher sensory problems had significantly more eating problems. Tactile sensitivity, taste and smell sensitivity, and visual/auditory sensitivities were associated with significantly more eating problems. |
| Peverill et al. (2019) | 396 | ASD. Sex: 84% male | 24–60 months; data collected across four time-points | BPFAS | None | Feeding problems followed four distinct trajectories: (1) began low and remained stable; (2) moderate at outset and declined over time; (3) high during preschool which declined to average by school age; and (4) severe, chronic feeding problems. Feeding problems were more highly correlated with general behavior problems than with ASD symptom severity. Few strong predictors of feeding problems were identified. |
| Postorino et al. (2015) | 158 | ASD. Two groups: ASD + FS (79); age- and gender-matched ASD + no FS (79). Sex: 86% male | 3–12 years (M: 7) | Revised FFQ, parent interview | None | 92% of parents of children with FS observed food refusal in their child. All FS children showed at least one sensory factor linked to FS; 41% showed two sensory factors; and 23% showed three sensory factors. Children in FS group had significantly higher ASD symptoms and significantly lower cognitive functioning vs no FS group. |
| Råstam et al. (2013) | 377 | ASD only (89), ASD + ADHD (288). Sex: 74% male | 9 and 12 years | A-TAC Feeding/Eating Module | ADHD only (903), no ASD + no ADHD (11,024) | Prevalence of eating problems was significantly higher in children with ADHD and/or ASD. Social interaction problems were strongly associated with eating problems in girls, and impulsivity and activity problems were associated with eating problems in boys. |
| Schreck & Williams (2006) | 138 | Autism (100), PDD-NOS (47), AS(29). Sex: 88% male | 4–12 years (M: 8) | CEBI, FPI | None | Children ate only a small variety of presented foods. Restricted variety was primarily related to food presentation (e.g. utensils and food items touching on plate). Selectivity was not related to autism symptoms. |
| Schreck et al. (2004) | 138 | Autism. Sex: 88% male | 7–9 years (M: 8) | CEBI, FPI | No autism or PDD diagnosis (298) | 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. 72% of autistic children ate a narrow variety of foods. |
| Sharp et al. (2013) | 30 | ASD. Sex: 77% male | 3–8 years (M: 68 months) | FPI, BAMBI, mealtime observation | None | In laboratory observation, FS was associated negatively with children’s acceptance of bites (i.e. food offered) and positively with mealtime behavior. Increased FS was positively correlated with problem behaviors during the observation, while ASD symptom severity was unrelated to feeding data. |
| Suarez et al. (2014) | 52 | ASD. Sex: 88% male. Follow-up sample ranging from 11 to 21 months | 4–12 years (M: 8) | Author-created FS questionnaire | None | No change in FS level across time-points. There was a stable, significant relationship between FS and sensory over-responsivity; children with higher sensory sensitivities also had higher FS. |
| Suarez (2017) | 31 | ASD. Sex: 90% male | 4–14 years (M: 9) | Laboratory food acceptance | TD (21) | Significant relationship between foods accepted and age for ASD group. Children with ASD accepted significantly fewer foods total and fewer foods from each group compared to controls, except snack foods. No relationship between foods accepted and ASD symptom severity. |
| Wallace et al. (2018) | 37 | ASD. Sex: 89% male | 8–11 years (M: 10) | Child Neophobia Scale | Non-ASD (4564) | Children with ASD had more FN than peers. Subclinical associations found between FN and ASD traits. Higher FN was associated with lower BMI, but the combination of increased ASD traits and increased FN was linked with increased BMI. |
| Williams et al. (2005) | 64 | ASD. Sex: 91% male | 24–129 months | Food frequency questionnaire, 3-day food diary | Special needs (45), TD (69) | No significant differences between groups on types of food consumed or liquid intake. Autistic children had more mealtime behaviors related to insistence on sameness (e.g. utensils and food preparation methods). |
AD: autistic disorder; AS: Asperger’s syndrome; PDD-NOS: pervasive developmental disorder–not otherwise specified; ASD: autism spectrum disorder; NA: not available; GI: gastrointestinal; ADHD: attention-deficit hyperactivity disorder; BAMBI: Brief Autism Mealtime Behavior Inventory (Lukens & Linscheid, 2008); SES: socioeconomic status; FFQ: food frequency questionnaire (checklist to obtain frequency of food and beverage consumption; exact questionnaire varied by study); FPI: food preference inventory (unstandardized measure to ascertain food preferences); TD: typically developing; MIOH: Meals in Our Household Questionnaire (Anderson et al., 2012); FS: food selectivity; ASD-CC: Autism Spectrum Disorder–Comorbidity for Children (Matson & Gonzalez, 2007); Atyp Dev: atypically developing; SWEAA: Swedish Eating Assessment for Autism spectrum disorders (Karlsson et al., 2013); BPFAS: Behavioral Pediatrics Feeding Assessment Scale (Crist & Napier-Phillips, 2001); CEBI: Children’s Eating Behavior Inventory (Archer et al., 1991); 3DFR: 3-day food record (Guenther et al., 2006); IQ: intelligence quotient; EAT-26: Eating Attitudes Test 26 (Garner et al., 1982); BMI: body mass index; CEBQ: Child Eating Behavior Questionnaire (Wardle et al., 2001); CFQ: Child Feeding Questionnaire (Birch et al., 2001); PFSQ: Parental Feeding Style Questionnaire (Wardle et al., 2002); AASP: Adult/Adolescent Sensory Profile (Brown & Dunn, 2002); CARS: Childhood Autism Rating Scales (Schopler et al., 1980); FNS: Food Neophobia Scale (Pliner & Hobden, 1992); CASD: Checklist for Autism Spectrum Disorder (Mayes, 2012); A-TAC: The Autism-Tics, AD/HD and Other Comorbidities Inventory (Larson et al., 2010); FN: food neophobia.
a
Size of ASD sample.
b
Diagnosis: description of diagnosis. AD: autistic disorder, AS: Asperger’s syndrome, PDD-NOS: Pervasive developmental disorder–not otherwise specified, ASD: sample not characterized by specific diagnoses, ASDs: where groups of varying ASD diagnoses were combined.
c
Composition of control group/comparison scores (N = number of subjects).