In November, OAR’s Board of Directors authorized funding for eight applied autism research studies in 2024. These new grants, totaling $297,569, bring OAR’s total research funding to more than $5 million since 2002. This article is sixth of eight previews to be featured in The OARacle this year.
Autistic children are reported to be five times more likely to experience feeding difficulties than neurotypical children. A 2023 study confirmed that autistic symptoms and feeding difficulties are strongly correlated. Specifically, autistic children are significantly more likely to be underweight or obese, show a greater degree of inadequate intake, and show elevated levels of food selectivity and rigidity.
While practices used in treating feeding difficulties vary, the American Academy of Pediatrics and the World Health Organization recommend responsive feeding. In responsive feeding, the parent acknowledges the child’s acceptance or rejection of food without the use of enticement or rewards, such as supplying access to toys or praise following consumption. If the child refuses to eat or drink, the parent removes the food or drink. For typically developing children, the responsive feeding approach has been associated with decreased fussiness and increased enjoyment during mealtimes per parent reports.
While there is no published research on whether responsive feeding is appropriate for autistic children, some feeding specialists use it. To date, the only evidence-based approach is behavioral intervention. Behavioral feeding focuses on increasing desired feeding behavior with reinforcement—providing rewards—and restricting reinforcement when the behavior is not performed.
In her one-year OAR-funded study, researcher Laura Phipps, Ph.D., will examine both approaches to see which is more effective. The goals of the study, “Feasibility and Efficacy of Assessing Child Preference for Feeding Treatment Using Choice Assessment,” are to:
The study results will provide knowledge for clinicians about which approach may be more effective and to incorporate patient autonomy into treatment without sacrificing effectiveness.
Dr. Phipps is an assistant professor of psychology at the University of Nebraska Medical Center’s Munroe-Meyer Institute. Her research focuses on improving treatment for pediatric feeding disorders. She is the clinical director of a program that provides early intervention therapy for children with autism and feeding difficulties. She also has training and expertise in applied behavior analysis and neurodiversity.
The research team will recruit 10 autistic children and parents from the pediatric feeding and autism center waitlists at the Munroe-Meyer Institute, which serves a diverse group of patients. The children will be between 4 and 12 years old and must engage in disruptive behavior during meals.
Children and parents will attend a one-hour session weekly for three weeks. The child will be taught to touch cards, each with a distinct black-and-white pattern that matches a pattern taped to each of the room’s three doors. The patterns are assigned to study conditions: responsive feeding, behavioral feeding, and no-treatment.
When the child touches a card, they will enter the room for that treatment. After treatment, the researcher will prompt the child to select a new card. In each session, the child will complete at least 10 exposures to each treatment. Parents will implement the procedures and the instructors will communicate via an earbud to guide them as needed.
In responsive feeding treatment, the child’s parent will present the target food and tell the child to take a bite if they want to. If the child indicates that they do not want to, the parent will remove the food and wait for up to two minutes for the child to indicate interest. If the child indicates interest, then the parent will present the same bite and continue until all three bites are presented or until two minutes elapses. If the child consumes a bite, the parent will not provide praise but will provide descriptive statements about the food, such as “the bite made a crunch!” If the child does not participate within two minutes, the session ends.
For behavioral feeding, the parent will present the target food and tell the child that if they take a bite, then they can play. If the child indicates they do not want to complete the task, the parent will keep the food within arm’s reach of the child for up to two minutes and then remind the child that if they take a bite, they can have their toy and tell them that they will wait until the child is ready. While the parent waits, they will engage in a diverted-attention activity, like reading a book, for example. If the child does not participate before time is up, they will not receive the toy. If the child does eat the bite, the parent will provide a reward and praise.
In the no-treatment control condition, the parent will present the target food with no instruction and without giving the child the opportunity to earn a reward. Parents will be asked to remain neutral and not make any statements about the food. There will be no consequences for either appropriate or inappropriate mealtime behavior.
After the child has experienced each of the three conditions, the instructor will begin the preference assessment. The instructor will present all the cards and tell the child to pick the card for the room they want to go to. Once the child selects a card, the parent and child will enter the selected room and complete the corresponding treatment. The child can choose to leave the room after the first bite is presented and make a new choice if they wish.
How long the child spends in each room will serve as a corresponding check of preference in addition to the number of times a child chooses each card. The process will be repeated until the child shows a clear preference or 20 sessions are conducted and preference is not demonstrated, indicated by the child selecting treatments in similar proportions.
Dr. Phipps will compare the effects of the two approaches, using rates of appropriate and inappropriate mealtime behavior. If, for example, negative vocalizations and inappropriate behavior decrease while appropriate behavior, happiness, and approval increase, then the research team can conclude that there is a chance the treatment led to improved behavior.
The preference assessment will be evaluated based on the number of times each child selects a treatment. If a child selects one treatment more than others for three consecutive sessions, then the selected treatment will be considered preferred. If the child does not select one treatment more than others for three consecutive sessions, then no treatments will be considered preferred.
Parents will be asked to indicate their preference for either responsive feeding, behavioral feeding, or neither after the study. They will also be able to provide comments about which components of each approach they liked or disliked and why, as well as how they felt each approach matched with their cultural norms for mealtimes.
This study aims to ameliorate the challenges of pediatric feeding difficulties by examining which treatment techniques are effective as well as evaluating child preference. Having that information could change the standard course of treatment for a child and positively impact their experience with feeding treatment. A range of potential outcomes for this study could have implications for children’s individual treatment experiences as well as future research.
The preference assessment protocol and responsive and behavioral treatment protocols will be available for practitioners and researchers to modify and replicate. This knowledge will serve as a tool for prioritizing patient autonomy and incorporating choice into a child’s daily life.
Strengthening the existing treatment for pediatric feeding difficulties and examining how it can be tailored toward the autistic population is critical because pediatric feeding difficulties are strongly associated with a less healthy quality of life and with exacerbating the social difficulties associated with autism. Mitigating the effects of pediatric feeding difficulties can reduce those challenges.
Sherri Alms is the freelance editor of The OARacle, a role she took on in 2007. She has been a freelance writer and editor for more than 20 years.
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