Research in Autism Spectrum Disorders 7 (2013) 5665

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Research in Autism Spectrum Disorders

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Multi-method assessment of feeding problems among children with autism spectrum disorders
William G. Sharp a,b,*, David L. Jaquess a,b, Colleen T. Lukens c
a

The Marcus Autism Center, United States Emory University School of Medicine, United States c The Childrens Hospital of Philadelphia, United States
b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 3 April 2012 Received in revised form 29 June 2012 Accepted 2 July 2012 Keywords: Assessment Autism Children Diet Feeding Food selectivity Pediatric feeding disorders

Estimates suggest that atypical eating is pervasive among children with autism spectrum disorders (ASD); however, much remains unknown regarding the nature and prevalence of feeding problems in this population due to methodological limitations, including lack of adequate assessment methods and empirical evaluation of existing measures. In the current study, a sample of 30 children ages 38 years completed a multi-method assessment battery involving a standardized mealtime observation, a food preference inventory, and the Brief Autism Mealtime Behavior Inventory (BAMBI), which represents the rst attempt to assess the correspondence between direct observation and parent-report measures of feeding concerns and dietary intake in ASD. During the mealtime observation, fourteen participants either rejected (n = 8) or accepted (n = 6) all bites, while the remaining 16 participants demonstrated selective patterns of acceptance by type and/or texture. Among this subgroup, vegetables were the most frequently rejected food type during the behavioral observation. Vegetables were also the most frequently rejected food based on parent report for the sample. Increased food selectivity was positively correlated with problem behaviors during the observation, while ASD symptom severity and growth parameters were unrelated to feeding data. We discuss ndings in relation to clinical and research activities and recommend strategies to achieve more systematic research in this area. 2012 Elsevier Ltd. All rights reserved.

In addition to difculties with communication, social interaction, and behavioral exibility, feeding problems represent a frequent concern reported by caregivers of children with autistic spectrum disorders (ASD) and more recent research suggests that challenging mealtime behaviors may occur at near epidemic levels in this population, with some estimates approaching 90% (see Cermak, Curtin, & Bandini, 2010; Ledford & Gast, 2006; Matson & Fodstad, 2009 for reviews). Food selectivity (i.e., only eating a narrow variety of foods by type, texture, and/or presentation) is the most frequent feeding concern documented among children with ASD, predominately in the form of strong preferences for starches, snack and processed foods and a bias against fruits, vegetables, and proteins (Ahearn, Castine, Nault, & Green, 2001; Field, Garland, & Williams, 2003; Lukens & Linscheid, 2008). Provisional evidence also suggest children with ASD may be at increased risk for nutritional and/or related medical issues related to atypical mealtime behaviors, including vitamin and mineral deciencies (Bandini et al., 2010; Zimmer et al., 2011) and poor bone growth (Hediger et al., 2008). Despite the potential for serious

* Corresponding author at: Pediatric Psychology and Feeding Disorders Program, The Marcus Autism Center, 1920 Briarcliff Road, Atlanta, GA 30329, United States. Tel.: +1 404 785 9469. E-mail addresses: wgsharp@emory.edu, william.sharp@choa.org (W.G. Sharp). 1750-9467/$ see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rasd.2012.07.001

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consequences associated with feeding problems in ASD, much remains unknown regarding the prevalence, etiology, and possible sequelae associated with feeding problems and ASD. Lack of adequate assessment methods has been identied as a signicant barrier to progress in this area (Matson & Fodstad, 2009; Seiverling, Williams, & Sturmey, 2010). Published reports vary widely in outcome measures of mealtime behavior problems and related nutritional concerns, including retrospective chart reviews, study-specic caregiver questionnaires, and less commonly, direct mealtime observation or standardized assessment instruments. Replicating procedures outlined by Munk and Repp (1994) for classifying feeding problems of individuals with physical or developmental disabilities based on direct observation, Ahearn et al. (2001) conducted the only direct observation of mealtime behavior to assess feeding problems among a sample of children with ASD to date. The authors evaluated a group of 30 children ages 314 years with autistic disorder or pervasive developmental disorder-not otherwise specied (PDDNOS), presenting children with three food items from each of four food groups (i.e., fruit, vegetable, protein, and starch) across six sessions (120 bites) and preparing one item at pureed texture per session. Behaviors measured during the observation included food acceptance, expulsion, and disruptive behavior. Ahearn and colleagues reported that more than half of the sample (57%) exhibited food selectivity by type or texture, while more than three quarters (87%) exhibited low to moderate food acceptance. The use of behavioral observation among children with ASD seeking intervention for feeding problems has also been documented in single-subject research literature (see Sharp, Jaquess, Morton, & Herzinger, 2011 for a review). Standardized questionnaires represent an alternative method for evaluating feeding behaviors and dietary intake in ASD. There are, however, relatively few measures developed for pediatric feeding disorders and only one measure the Brief Autism Mealtime Behavior Inventory (BAMBI; Lukens & Linscheid, 2008) specically designed to evaluate mealtime difculties commonly seen in the ASD population; however, additional research is needed to conrm the psychometric utility of the BAMBI, including comparing scores to direct observation of mealtime behaviors, as well as cross validation with an independent sample. A food preference inventory (FPI) is a complimentary parent-report method used to assess dietary variety in children with ASD. This method involves a list of food items across food groups, which caregivers endorse in terms of regularity (e.g., often, sometimes, never) or willingness to consume (e.g., favorite, willingly, with prodding) using a likert-type scale (Willett, 1998). Previous studies utilized the FPI to determine overall patterns of food intake in ASD (Schreck, Williams, & Smith, 2004), as well as design and evaluate interventions targeting food selectivity in this population (Paul, Williams, Riegel, & Gibbons, 2007; Pizzo, Williams, Paul, & Riegel, 2009). Data, however, regarding dietary variety as captured by the FPI has yet to be compared to direct observation and/or standardized questionnaires in the ASD population. In sum, there is a strong need to further develop assessment methods focusing on feeding problems in ASD. The current study seeks to add to this line of research by assessing the correspondence between different assessment tools available to measure feeding concerns among children with ASD, including data derived from a structured mealtime observation, the BAMBI, and a FPI. Descriptive statistics, including mean and variance, are presented and correlations between measures are investigated through exploratory analysis. Through this process, we describe a multi-method assessment battery designed to capture mealtime difculties purportedly unique to this population, including severe food selectivity, ritualistic behavior surrounding eating, and strong emotional responses in response to non-preferred food, with the potential for dissemination among researchers and practitioners in the ASD community. To aide in replication and standardization of procedures, we provide a detailed protocol for conducting a behavioral observation during meals and discuss the pros and cons regarding the use of direct observation versus questionnaires based on pragmatic and logistical concerns. 1. Methods 1.1. Participants Participants were recruited through local early intervention programs, parent support groups, and state and local autism organizations through yers, list serves, and The central inclusion criterion was an ASD diagnosis (i.e., Aspergers Disorder, PDD-NOS, and Autistic Disorder) among children between ages 3 and 8. All participants were diagnosed by professionals not associated with the program (based on caregiver report); however, we used the Social Responsiveness Scale (SRS; Constantino, 2005) parent form to support ASD status. The inclusion criterion required a total SRS score in the mild, moderate, or severe range (T-score > 60). The nal sample included 30 children with ASD between the ages of 3 years and 8 years, 7 months. There were 23 males and 7 females, which is consistent with previous researchers indicating higher rates of autism among males (Cialdella & Mamelle, 1989). Findings from the SRS supported the characterization of the sample as falling on the autism spectrum, with the mean score falling in the severe range (M = 83; SD = 7.8; range: 6891). 1.2. Procedure Upon arriving to the clinic, children were measured to obtain anthropometric parameters (i.e., height, weight), and caregivers completed a battery of questionnaires (outlined below). When these measures were completed, we conducted a structured mealtime observation with each parentchild dyad. Meals occurred in a 100 by 100 room equipped with one way

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mirror and adjacent observation room. The room included a chair, foods, table, feeding utensils (small maroon spoons), and serving tray. We modied procedures used by Ahearn et al. (2001), with the meal involving one food from each of the four basic food groups: peaches (fruit), potato (starch), hot dog (protein), and green beans (vegetable). We selected these foods in consultation with a registered dietician in order to target the presentation of commonly consumed, age-appropriate foods, while also minimizing the possibility that a child would be unable to participate in the mealtime observation due to dietary restrictions [e.g., following a Gluten Free Casein Free (GFCF)]. We presented each food three times at both puree and table texture ( in. in.), with a total of 24 bites during the observation. All bites involved approximately the same volume of food (i.e., about 1 cm3 per bite) and we standardized the order of presentation across items and texture. The presentation of each bite involved a 4-step prompting sequence (independent; verbal; model; physical). A trial began with the presentation of a bite on a plate in front of the child. If the bite was not independently accepted within 5 s, the feeder issued the verbal instruction to take a bite. If the bite was not accepted within 5 s, the feeder modeled taking a bite with a separate spoon while simultaneously issuing the same verbal instruction. If the child did not accept the bite 5 s following the model prompt, the feeder placed the childs hand over the spoon and physically guided the spoon to the childs mouth while simultaneously instructing the child to take a bite. The child received verbal praise in response to accepting a bite (regardless of the step in the prompting sequence). Escape (i.e., removal of the bite of food) was provided in response to any disruptive behavior (e.g., head turning; batting at the plate or spoon; swiping the food or spoon off the table). The feeder neutrally redirected the child back to the table in response to elopement between bites, but discontinued this process following signicant resistance to return to the table (e.g., aggression, opping to the oor) for more than two redirections. In such cases, the protocol involved presenting bites on the table in front of the childs seat using the prompting sequence, while issuing instructions in the direction of the child and removing the bite in response to turning away from the table/food. A break of approximately 20 seconds occurred between bites following either acceptance or disruption. An outline of the protocol is illustrated in Fig. 1. A caregiver served as the feeder throughout the mealtime observation in order to ameliorate possible separation issues or related behavioral concerns that could occur with the introduction of an unfamiliar feeder. Each caregiver completed a brief training session before the meal and they were provided with a script outlining movement through the prompting sequence for reference during the meal. The script also included an introductory paragraph to be read to each child outlining the

Fig. 1. 4-Step prompting sequence + escape during structured mealtime observation.

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structure of the meal (a copy of this script is available upon request). A trained behavioral observer was positioned in the observation room to assist the caregiver with the prompting sequence (when necessary), monitor the timing of bite presentations to ensure proper cadence, and provide immediate feedback for any deviation in the protocol using a wireless communication system (i.e., bug in the ear). With this support in place, caregiver protocol integrity was high (>90%) for the sample of caregivers enrolled in the study. 1.3. Caregiver questionnaires 1.3.1. Demographic/personal history form A background questionnaire included items gathering demographic information (e.g., date of birth, gender), as well as information regarding feeding concerns/dietary habits and previously diagnosed medical, developmental, or mental health issues. 1.3.2. Food preference inventory (FPI) The FPI includes 154 items across seven food categories 30 fruits, 28 vegetables, 36 proteins, 27starches, 8 dairy, 20 miscellaneous/snack (i.e., deserts, fats, and sweets such as cake, cookies, or chips), and 5 combination foods (e.g., lasagna/ ravioli, taco/burrito, or soup/stews). A registered dietician reviewed the list and classied foods into each of these categories based on classications provided by the United States Department of Agriculture. The inventory employs a likert-type scale assessing preference for consumption (e.g., Never, With Prodding, Willing, Favorite). Respondents were also given the option of selecting N/A if an item was not part of the familys regular diet or the child lacked exposure/experience with the food. Consistent with previous research (Bandini et al., 2010; Emond, Emmett, Steer, & Golding, 2010) we derived a food selectivity score by dividing the number of foods a caregiver reported the child never consumed by total number of items (154) multiplied by 100. A food selectivity score for each category was derived using a similar formula, with the number of foods for a certain food type (e.g., fruit) identied as never consumed divided by the total number of items for that category (e.g., 30) multiplied by 100. 1.3.3. Brief autism mealtime behavior inventory (BAMBI; Lukens & Linscheid, 2008) The BAMBI is a parent report checklist designed to measure the extent of mealtime behavior problems observed in children with ASD. The 18 item measure employs a Likert scale for reporting the frequency of behaviors (1 = Never/Rarely to 5 = At Almost Every Meal). The scale yields a total score, as well as scores on three subscales (i.e., Limited Variety, Food Refusal, and Features of Autism). Items on the Limited Variety subscale assess a childs willingness to try new foods and food preference by preparation, texture, or type. The Food Refusal subscale focuses on problem behaviors during meals (e.g., crying, expelling bite, disruptions during meals). Finally, the Feature of Autism subscale includes items that assess inattention, self-injury, and rigid behavior patterns during meals. The authors reported good internal consistency, high testretest reliability, and strong construct and criterion-related validity in the initial validation study. 1.3.4. Social Responsiveness Scale (SRS) parent form (Constantino, 2005) The SRS (parent report form) is a 65-item rating scale measuring severity of ASD symptoms as they occur in natural social settings. The instrument yields a total standard score (T-score), as well as T-scores on 5 subscales focusing on social awareness, social cognition, social communication, social motivation (e.g., anxiety/avoidance), and autistic mannerisms (e.g., preoccupations). Scores from 60 to 75 reect deciencies that are clinically signicant and lead to mild to moderate interference in everyday social interactions consistent with mild to high functioning autism. The scale has demonstrated adequate reliability and validity (see Booker & Starling, 2011 for a review). 1.4. Mealtime observation variables 1.4.1. Acceptance Bite acceptance was dened as the mouth opening and the child (or feeder) depositing the entire bite. Acceptance was converted to percentages by dividing the total number of accepted bites by the number of total bites presented multiplied by 100. Similar to the analysis conducted by Ahearn et al. (2001), the percentage of bites accepted during the meal was also summarized to produce a prole of the overall level of acceptance for the sample (i.e., low, moderate, and high), with group divided into thirds based on the number of bites accepted. Specically, a low level of acceptance was dened as accepting 8 or fewer bites; moderate acceptance was dened as accepting 9 to 16, and acceptance of 17 or more bites was considered high acceptance. Food type and texture was also analyzed to determine the possible pattern of selectivity for the sample. This analysis focused exclusively on children whose intake of bites was variable (i.e., <24 bites and >1 bite). 1.4.2. Disruptions Disruptions included any response that interfered with a bite presentation, such as head turns (turning the head 45 degrees past midline during the presentation of a bite), pushing the spoon, plate, or the feeders hand/arm (i.e., from the elbow through the hand) while the feeder presented the bite. Data on disruptions was converted into a percentage by dividing the total occurrence of the behavior during a session by the number of bites presented multiplied by 100.

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1.4.3. Negative vocalizations Negative vocalization was dened as crying, screaming, whining, swearing, or making negative statements/refusal statements regarding the food or bite presentation at or above normal conversational tone. The percentage of the session involving negative vocalizations was calculated by dividing the duration of negative vocalizations by the total meal duration multiplied by 100. We video-recorded and a trained behavioral observer scored each tape, collecting data on the operationally dened mealtime observation variables and caregiver protocol integrity on computers using an event-recorder computer program. A second member of the research team independently scored 65% of the meal observations, allowing for the calculation of interobserver agreement (total agreements by the total agreements plus disagreements multiplied by 100%). The total interobserver agreement for the sample was 95% for acceptance (range, 72100%), 95% for disruptions (range, 73100%), and 98% for negative vocalization (range, 86100%). 2. Results Participant demographics and medical characteristics are presented in Table 1. The age-referenced body mass index (BMI) for most participants (63.3%) fell in the normal range, while 16.7% were overweight (8595th percentile) and 20% were obese (>95th percentile). No participant had a BMI that was considered underweight (<5th percentile), suggesting that participants were able to maintain (at a minimum) adequate weight for height for their age. Most caregivers (80%) expressed concerns regarding their childs eating habits in response to the general question: Does your child have a problem with feeding?. Many families (40%) reported implementing a special diet to target behavioral concerns, most often in the form of a GFCF diet or use of nutritional supplements. Consistent with an ASD diagnosis, caregivers indicated that communication and speech were the most prominent developmental/mental health concern (reported by 73% of the sample). Less common were concerns regarding attention decit hyperactivity disorder (ADHD) or a learning disorder (LD, 33.3%), followed by anxiety (10%) and mental retardation (MR, 6.7%). Less than half of the sample (42%) had a history of medical concerns, most often involving a food allergy (20%) followed by gastroesophageal reux (13.3%), constipation (13.3%), and enteral feedings (6%). Descriptive statistics from the mealtime observation are presented in Table 2. On average, participants accepted fewer than half of the bites (40.5%) presented during the meal; although there was high variability across the sample (SD = 37.4; range: 0100). The percentage of disruptions (43%) was strongly negatively correlated with acceptance (r = .716, p < .001), which likely reects the format of the meal involving removal of food in response to refusal behaviors. The average duration of negative vocalizations for the sample was <5% of meals and only 33% of participants (n = 10) exhibited this behavior. Similar to disruptions, bite acceptance and negative vocalizations were negatively correlated at a moderate level (r = .385; p < .05), with greater crying observed among children who accepted few or no bites.

Table 1 Participant characteristics. Characteristic Age (in months): Height (inches): Weight (lbs): Body mass index (BMI) M 68.7 44.7 49.9 17.4 n BMI-for-age Normal (584%) Overweight (8595%) Obese (>95%) Gender: male/female Parent reported feeding concerns Parent mediated dietary manipulationa b Gluten free/casein free (GFCF) b Vitamin supplementation b Other Developmental/mental health issues b ADHD/LD b Anxiety disorder b Mental retardation b Speech/language delay Medical issues reporteda b Gastroesophageal reux b Food allergies b Constipation b Past feeding tube
a b

SD 17.3 4.7 14 3.6

Range 36104 3053.2 33.182.5 13.727.4 % 63.3 16.7 20 77/23 80 40 30 30 16.7 81 33.3 10 6.7 73 42 13.3 20 13.3 6

19 5 6 23/7 24 12 9 9 5 25 10 3 2 22 13 4 6 4 2

Total breakdown may exceed total number per category due to multiple dietary, medical or developmental issues per participant. % calculated based on total sample n = 30.

W.G. Sharp et al. / Research in Autism Spectrum Disorders 7 (2013) 5665 Table 2 Behavioral data from mealtime observation (n = 30). Variable % Acceptance % Negative vocalizations % Disruptions M 41.8 3.6 43.0 SD 37 9.1 33.8 Range

61

0100 029.8 0100

Table 3 presents a more detailed analysis of bite acceptance. Eight participants (26.7%) demonstrated high overall acceptance, with 6 children accepting all bites. Seven children (23.3%) displayed a moderate level of acceptance, and half of the sample exhibited low overall acceptance; 8 children accepted no bites. We analyzed patterns of food selectivity by type and texture, focusing on the 16 participants who accepted between 1 and 23 bites. We examined this subgroup based on the rationale that participants who accepted all 24 bites exhibited no issues with selectivity during the meal observation, while participants who rejected all bites appeared highly selective/displayed complete refusal, providing no data regarding specic patterns of preference by type or texture. We conducted an ANOVA comparing mean levels of acceptance by food type (combining both puree and table texture bites), adopting the more conservative Greenhouse-Geisser correction. This analysis revealed a signicant main effect for the average number of bites accepted across food type [F (3, 60) = 5.05; p < .003; h2 p :202]. Post hoc analyses (Bonferroni corrected) indicated that hotdog was signicantly more likely to be accepted compared with green beans (p < .001) and potato (p < .05). There was no signicant difference between bites involving peach compared with other foods, as well as between green beans and potato. Analysis of acceptance of bites by texture indicated that table texture bites were signicantly more likely to be accepted compared with puree presentations (t = 3.6; p = .001; d = 1.3). Table texture hotdog was the most frequently accepted food during the meal observation (91.7% of bites accepted), with each of the 16 participants accepting at least 2 bites of this food. Pureed green beans was the least accepted food (10.4% of bites accepted), with only 3 participants consuming green beans at this texture. Given the notable inuence of food texture on consumption based on the observed pattern and past research in this area (Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005), we compared the mean level of acceptance by food type at each texture using an ANOVA. For table texture foods, we detected a similar main effect regarding the average number of bites accepted across food type [F (3, 60) = 7.4; p < .001; h2 p 2:7], with post hoc analysis indicating hotdog was signicantly more likely to be consumed compared with green beans (p < .001) and potato (p < .001). In contrast, there was no signicant difference in the acceptance of bites by food type at puree texture [F (3, 60) = 1.5; p = 2.3; h2 p :069], possibly related to the low level of acceptance across foods at this texture. Results from the BAMBI and FPI are presented in Table 4. In terms of dietary variety, caregivers identied nearly 40% of foods on the FPI as never consumed, with vegetables identied as the most frequently rejected food. We compared the average percentage of foods identied as never consumed across food groups, conducting an ANOVA utilizing the more
Table 3 Breakdown of acceptance and selectivity. Breakdown of acceptancea High Moderate Low Total participants: Analysis of selectivityb % Acceptance by type: Peaches Hotdog Potato Green Bean % Acceptance by texture: Table Puree % Acceptance by type and texture Peaches Table Peaches Puree Hotdog Table Hotdog Puree Potato Table Potato Puree Green Bean Table Green Bean Puree
a b

n 8 7 15 30 M 45.8 63.5 30.2 23.9 56.8 25.0 63.5 29.2 91.7 35.4 35.4 25.0 37.5 10.4 SD 36.3 20.4 36.6 29.8 26.2 23.9 46.9 36.3 14.9 39.4 42.9 35.5 41.9 26.4

% 26.7 23.3 50.0 100 Range 0100 33100 0100 0100 25100 075 0100 0100 66.7100 0100 0100 0100 0100 0100

High: n = 6 accepted all bites; low: n = 8 accepted no bites. Calculation based on the sample of participants who accepted >1 and <24 bites (n = 16).

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Table 4 Descriptive statistics for the BAMBI and FPI. Variable BAMBI Limited variety Food refusal Autism features FPI % Never consumed Breakdown by food % Fruit % Protein % Starch % Vegetable Mean (St. Dev) 49.4 26.7 11.7 10.9 (10.8) (6.3) (3.9) (3.3) Range 1875 834 521 520 3.986.4 086.7 086.1 088.8 10.796.4

39.9 (23.2) 42.2 42.1 30.6 61.6 (30.3) (25.2) (22.8) (30.0)

Table 5 Pearson correlations (sig. 2-tail) between autism severity, BMI, and feeding measures. SRS total SRS total BMI BAMBI Total BAMBI LV BAMBI FR BAMBI FA FPI never Accept Neg Vocs Disruptions .234 .194 .223 .171 .003 .205 .058 .088 .164 BMI BAMBI total BAMBI LV BAMBI FR BAMBI FA FPI never Accept Neg Vocs

(.213) (.305) .176 (.237) .041 (.367) .209 (.986) .249 (.278) .074 (.757) .017 (.643) .090 (.387) .169

(.351) (.830) .846** (.000) (.267) .764** (.000) .389* (.01) (.185) .736** (.000) .381* (.038) .564* (.001) (.699) .285 (.126) .560** (.001) .150 (.430) .034 (.859) (.929) .101 (.596) .367* (.046) .078 (.682) .280 (.134) .619** (.000) * (.635) .237 (.208) .396 (.030) .133 (.485) 142 (.453) .408* (.025) .385 (.035) (.373) .056 (.770) .282 (.131) .083 (.664) .259 (.166) .414* (.023) .716 (.000) .380 *(.038)

Neg Vocs: negative vocalizations. * p < .05. ** p < .005.

conservative Greenhouse-Geisser correction during the analysis. Findings indicated a signicant main effect for food group, F (3, 116) = 6.4, p < .001, h2 p :157. We used the Bonferroni correction to explore main effects during post hoc analysis, which indicated vegetables were signicantly more likely (p < .001) to be identied as never consumed compared with all other food groups. No other difference between food groups was detected. The BAMBI Limited Variety subscale and the percentage of foods identied as never consumed on the FPI were strongly and positively associated, r = .560, p < .01, suggesting that these measures tap into a similar construct (i.e., restricted dietary intake or food selectivity). Both of these measures were also associated with maladaptive feeding behaviors during the mealtime observation. The Limited Variety subscale was negatively correlated with the number of bites accepted, r = 367, p < .05, and positively correlated with negative vocalizations during the meal, r = .396, p < .05, both at moderate levels. The percentage of foods identied as never consumed on the FPI was strongly and negatively associated with the number of bites accepted, r = .619, p < .001, as well as moderately and positively associated with negative vocalizations, r = .408, p = .05, and disruptions, r = .414, p < .05, during the meal. Correlations between autism severity scores on the SRS, growth status as captured by BMI, and feeding measures are presented in Table 5. The analysis indicated no association between degree of autism severity, feeding behaviors and/or degree of food selectivity; a nding consistent with previous research in this area (Schreck & Williams, 2006). There was also no association between feeding measures and participants growth status. It is also noteworthy that the BAMBI Features of Autism subscale was unrelated to SRS total score or any subscales of the SRS (e.g., Autism Mannerisms), suggesting that the need to further investigate whether this factor captures characteristics and associated features of autism as rst reported by Lukens and Linscheid (2008). In regard to correlations among BAMBI subscales, the Limited Variety factor was positively correlated with both the Food Refusal, r = .389 (p < .05), and the Features of Autism subscales, r = .381 (p < 05), while the Food Refusal subscale was positively correlated with the Features of Autism subscale, r = .564 (p < .01). This pattern is consistent with subscale correlations reported in the initial validation of the BAMBI. 3. Discussion The current study expands the research base regarding the assessment of feeding problems in children with ASD in a number of key areas. Most notably, this represents the rst attempt to assess the correspondence between direct observation and parent-report measures of feeding concerns and dietary intake. Findings suggest indirect measures of food selectivity, as captured by the BAMBIs Limited Variety subscale and the number of foods identied as never consumed on the FPI, are negatively associated with a childs acceptance of bites and positively associated with disruptions during the presentation of

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foods during a structured mealtime observation. This relationship has important implications for guiding the selection of assessment methods for clinical and research purposes based on a number of important considerations. As the traditionally viewed gold standard for assessment, behavioral observation will continue to play an important part in any detailed assessment of feeding concerns among children with ASD. The process of conducting a behavioral observation during meals, however, is complicated by a number of factors, most notably the time requirement, questions regarding meal formatting (e.g., foods, texture, feeders, bite size) and the possibility of eliciting strong emotional responses during the assessment process (described in more detail below). In addition, there is little evidence to assure that clinic-based observations correspond with behaviors that children exhibit in their daily home environments. As such, the use of behavioral observation as the rst-line screening method may be neither feasible nor appropriate across pediatric settings. With the current results indicating measures of food selectivity correspond to behavior during a structured meal, the use of the BAMBI or FPI may hold certain benets in terms of ease of administration, respondent burden, and length, pending more comprehensive validation. The selection of a measure to include in the assessment and screening process may be guided by pragmatic and clinical considerations. For example, the relative brevity of the BAMBI in comparison to the FPI (18 items vs. 154 items, respectively) suggest that it may more readily lend itself for use as an initial screening for feeding concerns among children with ASD. In addition, the items of the BAMBI, assessing food variety, behavioral concerns, and autism symptoms may also be more sensitive to detecting proximate changes in response to intervention not captured by a broad tally of rejected foods, such as a childs willingness to try new foods or remaining seated during meals. Alternatively, the FPI may be utilized when a more detailed analysis of dietary patterns is warranted or longer-term shifts in dietary patterns are an anticipated outcome of clinical or research efforts. Findings also provide further detail regarding the BAMBI as a potential tool for measuring mealtime difculties among children with ASD, including data on two key limitations cited by Lukens and Linscheid (2008) in the initial validation study (i.e., the use of a conrmatory measure of ASD status and the comparison of scores to behavioral data obtained through direct observation). As noted above, the Limited Variety subscale may provide the most clinically salient data from the BAMBI when assessing feeding problems in this population, with this subscale associated with bite acceptance and problem behaviors during the meal. We did not nd a signicant relationship between ASD symptoms and the BAMBI Autism Features subscale and it is unclear why the Food Refusal subscale was unrelated to problem behaviors during the meal observation, suggesting the need to further explore the psychometric properties of this instrument. Together, the available data suggests the BAMBI may serve best as a screening instrument for food selectivity in clinical setting, but not replace the utility of behavioral data to assess challenging behaviors during mealtime. This study also represents one of the few descriptions of a structured mealtime observation (involving a set prompting sequence, standard bite size and pre-selected target foods) utilizing caregivers as the primary feeder available in the assessment literature. Outcomes from the meal observation paralleled results reported by Ahearn et al. (2001), with the majority (73%) of participants demonstrating low to moderate food acceptance, with both food type and texture playing a role in bite acceptance during the meal. This suggests that a structured mealtime observation, as outlined in both the current study and by Ahearn et al., represents a viable tool for clinicians and researchers interested in assessing feeding behaviors in children in ASD. There are a number of aspects of the protocol used in the current study, which should be considered when designing future studies involving a structured meal observation. We used an escape baseline condition during the meal observation, which may not provide a complete representation of a childs behavior during the presentation of clinic foods. With caregivers instructed to remove a bite in response to refusal behaviors, data were unavailable regarding how a child would respond if the feeder persisted with a bite presentation (which is likely to occur at some point during meals with many families). With this in mind, the nding that many children displayed high rates of problem behaviors, including pushing the food away and crying, with nominal demands for consumption further solidies the importance of research and intervention in this area. The type of food presented may have also inuenced outcomes during the meal observation. In contrast to Ahearn et al. (2001), we selected one food (vs. three) from each food group to present during the meal. The lack of multiple food items from each food group limits conclusions that can be drawn regarding specic patterns of selectivity. For example, table texture hot dog was the most frequently accepted food during the meal, while pureed green beans were the least accepted bites. This pattern is consistent with previous reports describing children with ASD as preferring dense, processed foods, while rejecting vegetables (Field et al., 2003; Lukens & Linscheid, 2008); however, it is inconsistent with reports of children with ASD preferring carbohydrates and starches, while rejecting proteins. Expanding the number of food items presented during the meal, as well as including proteins that are not highly processed (e.g., grilled chicken or sh; beans) and starches more often associated with the diet of children with ASD (e.g., French fries; chips or pretzels) may yield a more consistent picture of food preference among children with ASD. In addition, varying the structure of mealtime observations (e.g., parent directed vs. therapist; increased food types and textures; home vs. clinic setting), as well as assessing the impact of texture and bite size modications, would help identify the optimal means for capturing behavioral data. For example, presenting very small bites or pureed textured foods on a spoon (particularly for older children) may have inuenced rates of acceptance or disruptions due to the likely novelty of this presentation method. In doing so, it will be necessary to continue to include alternative measures of dietary diversity (e.g., FFI; 24 h recall) in order to develop a more comprehensive, population level prole of the pattern of food selectivity associated with ASD, as it remains unclear if a mealtime observation is the optimal means to assess food variety given the possibility of idiosyncratic dietary preference in ASD. Throughout this process, it will be important to evaluate each of these factors in terms of the balance between complexity, efciency and incremental validity of feeding measures.

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It is noteworthy that ASD symptom severity was unrelated to feeding measures, highlighting remaining questions regarding the relationship between ASD, food selectivity, and whether restricted patterns of intake are unique to this populations, as rst raised by Williams, Gibbons, & Schreck, 2005. Past research in this area has produced conicting results. Similar to the results of the current study, Schreck and Williams (2006) reported that scores on the Gilliam Autism Rating Scale (GARS, Gilliam, 1995) overall autism quotient was unrelated to dietary diversity, although children with more selective diets tended to live in families with less diverse diets. Lukens and Linscheid (2008), however, reported that certain mealtime behaviors, including rigid and repetitive behavior, abnormal responses to sensory input, and short attention span, appeared unique to children with ASD compared to typically developing peers, resulting in the Features of Autism subscale being included as part of the Brief Autism Mealtime Behavior Inventory (BAMBI). In addition, the Features of Autism subscale was strongly and positively correlated with scores on the GARS, and it was positively correlated with the Limited Variety subscale, which assesses a childs willingness to try new foods and food preference by preparation, texture, or type (higher scores reecting more difculty). Results also highlight the importance of future research to determine the impact of aberrant feeding patterns on growth, development, and nutrition beyond anthropometric parameters in this population. Data from the current study suggests that atypical patterns of intake may not necessarily translate to compromised gross anthropometric parameters (i.e., height, weight, and body-mass index [BMI]), which is consistent with previous research analyzing growth status in ASD (Bandini et al., 2010; Emond et al., 2010). Provisional evidence, however, also suggests that feeding problems in ASD may translate into other indicators of health status, such as documented decits in micronutrient intake (Emond et al., 2010) and poor bone growth (Hediger et al., 2008), which may increase the risk of long-term, chronic diet related diseases among the ASD population. Clearly, additional research is needed to determine the relationship between ASD symptomatology, feeding behaviors, and health status, which will necessitate more detailed diagnostic characterization of ASD samples and increased standardization in the measurement of feeding concerns. Finally, increasing the sample size and including a comparison group in future studies will be critical to determine prevalence rates and aide in the development of normative criteria for identifying feeding problems across assessment methods. While providing preliminary data regarding the relationship between feeding measures, as well as feasibility of a multi-method assessment battery, the small sample size and lack of comparison control likely limits the generalizability of nding, highlighting the need to replicate these procedures with larger cohorts of ASD and typically developing peers. Expanding the range and number of ASD and non-ASD participants will also help attenuate concerns regarding range restriction detected in the current correlation analysis of ASD symptoms and feeding problems, with most SRS scores clustering in the high/severe range. 4. Conclusion Findings from the current study are consistent with previous descriptions of children with ASD as exhibiting preferences for certain foods and displaying strong behavioral responses when presented with non-preferred food (Bowers, 2002; Collins et al., 2003; Field et al., 2003). Data from both direct and indirect assessment methods indicated high rates of food rejection, most notably vegetables. With growing research supporting the use of behavioral intervention as an effective means to expand dietary variety among children with ASD (Laud, Girolami, Boscoe, & Gulotta, 2010; Sharp, Jaquess, Morton, & Miles, 2011), future research is needed to further rene assessment methods in order to increase the identication of feeding problems in this population. Increased standardization of measurement is essential for expanding our knowledge regarding the feeding problems in ASD while also strengthening conclusions from intervention studies targeting mealtime concerns in this population. Acknowledgements This project was funded by a 2008 Applied Research Grant sponsored by the Organization for Autism Research. References
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