doi:10.1111/jpc.

14638

REVIEW ARTICLE

Feeding difficulties in children with autism spectrum disorder:

Aetiology, health impacts and psychotherapeutic interventions
Vincent Zhu1 and Jacqueline Dalby-Payne 1,2

1
Department of General Medicine, Children’s Hospital at Westmead and 2Discipline of Child and Adolescent Health, University of Sydney, Sydney, New
South Wales, Australia

Abstract: Feeding difficulties are common and significant issues for children with autism spectrum disorder and their families. Key features of
autism are intrinsically linked with factors contributing to these children’s feeding difficulties. Following a multidisciplinary assessment to exclude
non-behavioural reasons for the feeding difficulty, there are two mainstay modalities of treatment: operant conditioning and systematic
desensitisation. Currently, evidence points towards operant conditioning as the most efficacious psychotherapy. However, recent research into
cognitive behavioural therapy for older children with feeding difficulties has shown promising results and will be an area to monitor in the coming
years. This review outlines the causes and health impacts and evaluates current evidence supporting the available psychotherapeutic interven-
tions for children with autism spectrum disorder experiencing feeding difficulties.

Key words: autism spectrum disorder; feeding difficulties; selective eating.

Autism spectrum disorder (ASD) is a complex lifelong develop-
mental disorder that involves clinically significant impairment of
social ability in multiple contexts and restricted and repetitive
patterns of behaviour. The prevalence of autism ranges from 1 to
1.5%.1–3 Within the families that have a child with ASD, studies
have shown that up to 67% of the parents believe their child to
have strong food preferences.4,5 As children with ASD are more
likely to exhibit refusal behaviours,6 this results in feeding diffi-
culties that can impact both the child and the family.
Feeding difficulties not only affect the child’s health but have
profound effects on the family’s psychological well-being and
dynamics. These harmful effects necessitate the need for evidence-
Key Points
1 A range of factors may contribute to feeding difficulties, and
medical causes should be identified and managed before
embarking on a behavioural approach to therapy.
2 Studies to date indicate that operant conditioning may be
more effective than systematic desensitisation therapy, but fur-
ther research is required.
3 Cognitive behavioural therapy for older children with feeding
difficulties has shown promising results and will be an area to
monitor in the future.
Correspondence: Dr Jacqueline Dalby-Payne, Department General
Medicine, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead,
NSW 2145, Australia. Fax: +61 29845 0074; email: jacqueline.
dalbypayne@health.nsw.gov.au
Conflict of interest: None declared.
Accepted for publication 28 August 2019.
based management recommendations. Behavioural interventions
have been found to be beneficial for certain types of feeding difficul-
ties;7 however, evidence of the effectiveness of many commonly
recommended interventions is often lacking. Research comparing
behavioural interventions is limited, often small-scaled and highly
dependent on the treatment provider. This review aims to describe
the aetiology of the various types of feeding difficulties, explore the
health and family impacts of restricted eating behaviours and exam-
ine behavioural therapies available for the management of feeding
difficulties in children with ASD.
Aetiology of Feeding Difficulties in ASD
Abnormal feeding behaviours in children with ASD often arise
from the complex interplay of symptoms commonly associated
with autism. The factors for behavioural feeding difficulties in
children with ASD identified by Cumine8 can be grouped into
three main issues: behavioural rigidity, social impairment and
sensory processing difficulties. These three issues identified by
Cumine are also key symptoms of ASD as described in DSM-5.9
They are described in diagnostic criteria: B2 – Insistence on
sameness, inflexible adherence to routines; A3 – Deficits in devel-
oping, maintaining and understanding relationships; and B4 –
Hyper- or hyporeactivity to sensory input. Behavioural rigidity
involves desiring consistency in meal presentation, preparation
and taste. The social impairment mentioned involves anxiety, dis-
ruptive behaviour and deficits for social compliance. The third
issue is sensory-processing difficulties, which affects how the food
and the entire experience of eating are perceived. Appropriate
processing of sensory information allows the brain to be mindful of
useful information while preventing the brain from being inundated
with useless information. An inability to process the myriad of sen-
sory information received during a meal can impact the

Journal of Paediatrics and Child Health (2019) 1

© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
Feeding and autism spectrum disorder
eating experience of children with ASD.10 Twachtman-Reilly et al.
described how deficits in processing auditory, visual, gustatory,
olfactory, tactile, vestibular and proprioceptive sensory information
can lead to difficulties in feeding.11 Hyper-responsiveness in audi-
tory, visual, gustatory, olfactory and tactile senses can lead to an
overstimulating environment or meal, which may invoke a fight or
flight response during mealtimes. Hyporesponsiveness to these five
senses could result in a disinterested child who would rather par-
take in other activities or request more stimulating food. Hyper-
responsiveness and hyporesponsiveness in proprioceptive senses can
cause poor body awareness and difficulties with self-feeding. Vestib-
ular hyper-responsiveness can lead to a child who is uncomfortable
with head movements required to eat certain food, whereas vestib-
ular hyporesponsiveness can lead to a restless child. These three fac-
tors can occur in combination or independently to result in feeding
difficulties in children with ASD. An understanding of how these
factors contribute to an individual child’s feeding behaviour can
assist with guiding management.
Feeding difficulty is an umbrella term for feeding problems
that may present in several ways. Discerning the problems caus-
ing the feeding difficulty is the first step in formulating an initial
management plan. A study by Field et al. of 349 children with
feeding difficulties described five categories: selectivity by texture,
selectivity by type (including food neophobia), food refusal, oral
motor delays and dysphagia.12 The study also demonstrated that
the various feeding problems can coexist. Of the 349 children
studied, 26 had a diagnosis of autism. By far the most common
form of feeding problem in children with ASD was selectivity by
type, found in 62%. In comparison, the prevalence of selectivity
by type was 11% in the Down syndrome and cerebral palsy arm.
Although it is not well established why children with ASD were
presenting with selectivity by type more than five times as often,
it was suggested by Field et al. that this may be due to the differ-
ence in sensory modulation among children with ASD. This the-
ory was demonstrated in further studies that showed poor
olfactory and taste accuracy were related to food selectivity.13,14
This underscores the importance of assessing for differences in
sensory processing during the assessment stage to help guide tai-
loring of the management plan.
Food refusal was defined as the refusal to eat all or most
food to the point of not meeting energy demands, which is
vastly different from having a highly selective diet that may
lead to specific micronutrient deficiencies while sustaining
energy consumption. Of the three children with ASD who had
food refusal, all of them had gastro-oesophageal reflux, thus
highlighting the importance of excluding medical issues in chil-
dren who are exhibiting feeding difficulties, particularly in
cases of food refusal (Box 1).
Health and Psychosocial Impacts of
Feeding Difficulties in Children with ASD
Feeding difficulties in children with ASD can have a significant
impact on the child’s health. As food selectivity is the most
common type of feeding difficulty in children with ASD, they
are at risk of nutritional deficiencies, with resulting diverse
health impacts. Studies have demonstrated that children with
ASD had a greater number of nutritional deficiencies compared
to typically developing children.6,15,16 Vitamin A, vitamin D
2 Journal of Paediatrics and Child Health (2019)
© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
V Zhu and J Dalby-Payne
and calcium deficiencies have been shown to be significantly
more common in children with ASD with feeding difficulties.6
Studies show that, overall, fruit and vegetables was the food
group most often neglected, with simple carbohydrates pre-
ferred.17,18 This preference for simple carbohydrates is thought
to be the main contributor towards a greater tendency for chil-
dren with ASD to be overweight.19 This is concerning as over-
weight and obese children have been shown to be at increased
risk of adulthood obesity20 and its associated risks, such as cor-
onary heart disease.
As the focus of care can often be on medical issues, it is not
uncommon to overlook the impact these feeding difficulties
have on the carers and the other diners in the family.
Ausderau identified four issues experienced by families with
children who have ASD.21 First, families were unable to eat
together at the same time due to attention and consideration
required to feed the affected child. Second, mealtime routines
were adapted to great lengths to engage the child to eat his or
her food. Adaptations included distracting the child with tele-
vision or playing games. Third, many carers were preparing at
least two meals in case the first was refused. The fourth theme
explored by Ausderau was the impact on siblings. Siblings were
required to be a role model and assist with encouraging posi-
tive eating behaviours. It was also reported that siblings some-
times also imitated the negative behaviours, which gave the
carer additional stress.21 Overall, it is evident that feeding diffi-
culties in children with ASD have various impacts on the child
and the family unit. For these reasons, the establishment of a
Box 1 Aetiology
1 Behavioural rigidity
Desiring consistent presentation, preparation and taste
2 Social impairment
Anxiety, disruptive behaviour and deficits for social compliance
3 Sensory-processing difficulties
Affects how food tastes, feel and smell
Box 2 Impacts
1 Nutritional deficiencies
Particularly vitamin A, vitamin D and calcium
2 Weight gain
Likely due to tendency to prefer simple carbohydrates
3 Carer stress
Preparation of multiple meal options
Un-co-operative child
4 Relationship strain on family unit
Family members unable to eat together
Negative influence on siblings
V Zhu and J Dalby-Payne
strategy to deal with feeding difficulties in children with ASD is
paramount (Box 2).
Assessment
To evaluate the cause of the feeding difficulty and to develop a
treatment plan, a multidisciplinary team should ideally be
involved. It is important to remember that it is not uncommon
for children to have multiple causes for their feeding difficulty,12
hence the importance of engaging a multidisciplinary team for
assessment. This team should include a dietitian, medical officer,
speech pathologist, occupational therapist and psychologist or
behavioural therapist. A dietitian’s role is to assess for atypical
growth or nutritional deficiencies in the child’s diet and provide
dietary goals for management. A medical review is crucial to
assess the medical causes of feeding difficulties and complications
such as constipation and clinically evident nutritional deficien-
cies.12,22 Medical causes such as gastro-oesophageal reflux dis-
ease, dysphagia and eosinophilic oesophagitis should always be
considered, particularly in cases where food refusal has been
identified as a factor of the feeding difficulty. A speech patholo-
gist can assess for oro-motor dysfunction. An occupational thera-
pist can examine sensory-processing and motor skills involved
with feeding. The nature and symptoms of the different compo-
nents of hyper-responsiveness and hyporesponsiveness have
been described,11 and an occupational therapist can assess for
these by direct observation of the child, as well as by parent
report. A psychologist will be able to assess for the contribution
of behavioural components such as rigidity and anxiety to the
child’s feeding difficulty. The frequency of multiple causative fac-
tors contributing to a child’s feeding difficulties and the impor-
tance of identifying these factors to formulate appropriate
management strategies makes a multidisciplinary approach
essential.
General Management
Regardless of the cause of the feeding difficulties, it is important
to first address the nutritional requirements of the child. Ade-
quate nutrition is important for growth and development. A child
with an inadequate intake or restricted diet can be supplemented
with specialised child formulas or micronutrient supplements
while the management plan is underway. Medical causes of feed-
ing difficulties should be identified and managed as behavioural
interventions are unlikely to be successful unless they are
addressed. Other medical issues such as neurological deficits or
anatomical abnormalities, which may cause dysphagia, are
diverse and not the most common cause of feeding difficulties in
children with ASD. Their diagnosis and management will require
specialist medical assessment. Children with ASD found to have
dysphagia or oro-motor delay may benefit from therapy with a
speech pathologist. The speech pathologist may work to improve
the muscle co-ordination, recommend an altered diet or teach
behavioural and postural strategies to optimise swallowing.
Where anxiety is seen to be a significant issue, a Cochrane review
in 2009 investigated the benefits of pharmacotherapy in children
with anxiety disorders. The systematic review included 22 short-
term randomised controlled trials (RCTs) on children without
ASD and showed that there was a benefit in treating paediatric
Journal of Paediatrics and Child Health (2019)
© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
Feeding and autism spectrum disorder
anxiety disorders with pharmacotherapy.23 However, a Cochrane
review in 2013 investigated the use of selective serotonin reup-
take inhibitors (SSRIs) for the management of ASD symptoms in
children.24 The review included five RCTs on children with ASD.
Overall, they showed no significant benefit for the management
of core ASD features (problems with behaviour, communication
and social interaction), as well as the non-core aspects, such as
obsessive–compulsive behaviour and self-injurious behaviour.
Unfortunately, not enough data were gathered to make a conclu-
sion of whether or not SSRIs were useful for anxiety or feeding
difficulties in children with ASD. As pharmacotherapy such as
SSRIs has been found to be useful in managing anxiety in chil-
dren, and anxiety is known to contribute to feeding difficulties in
children with autism, SSRIs may be worth considering for the
management of feeding difficulties in children with ASD. Never-
theless, the effectiveness of SSRIs in this particular population is
not clear from current available evidence. As pharmacotherapy
such as SSRIs have been found to be useful in managing anxiety
in children and anxiety is known to contribute to feeding difficul-
ties in children with autism, SSRIs could be considered though
their effectiveness in this particular population is not clear from
current available evidence.
Psychotherapies
Literature review and data gathering
For evidence regarding psychotherapies, multiple databases,
including Cochrane, Medline, PubMed, Embase and PsycINFO,
were used with a combination of the following search terms:
autism, children, feeding, operant conditioning (OC), escape
extinction (EE), positive reinforcement, applied behavioural anal-
ysis (ABA), systematic desensitisation, sequential oral sensory
and cognitive behavioural therapy (CBT).
The search yielded no meta-analyses and very few high-
quality studies. Several RCTs cited involved a small participant
population. Much of the evidence was case reports and case
series. For the purpose of this literature review, single case
reports were excluded, and RCTs and case series were included
with preferences given to higher-quality studies where available.
Operant conditioning
OC is a process of influencing behaviours by reinforcing (reward-
ing) desired behaviours and punishing undesired behaviours.
Positive reinforcement for good feeding behaviours generally
involves provision of a toy, a desired food or praise given either
continuously throughout the meal (non-contingent positive rein-
forcement) at the same time as good behaviour (simultaneous
presentation) or after good behaviour is displayed (differential
positive reinforcement).
A vital aspect of OC is not to provide negative reinforcement –
that is, rewarding behaviour that is undesired, such as allowing a
child to not eat when they cry or engage in other disruptive
behaviours. The practice of avoiding this detrimental response to
negative behaviour is known as EE. A well-known method of EE
for feeding difficulties would be non-removal of the spoon. This
involves holding the spoon in front of the child’s mouth unyield-
ingly until he or she eats the food. This removes the avenue of
3
Feeding and autism spectrum disorder
escape for the child, thus ceasing reinforcement of the negative
behaviour. Numerous studies have shown its benefit in both chil-
dren with and without ASD for feeding difficulties.25–29
ABA utilises OC to promote good feeding behaviour and dis-
courage poor feeding behaviour. It is well established that ABA is
beneficial for the management of behavioural issues in children
with ASD.30 A technical review of 112 studies reports a beneficial
outcome 70% of the time and that approximately two-thirds of
ABA interventions exhibited strong evidence for generalisation to
other aspects of the participant’s life.29 Various ABA techniques
have been shown to be beneficial for many types of feeding diffi-
culties in children with ASD.7,25,30–32 Thus, ABA has been one of
the most favoured psychotherapeutic treatments for feeding diffi-
culties in the past.
Systematic desensitisation
Systemic desensitisation (SD) is centred around the theory that
children with ASD are more likely to have sensory modulation
deficits,33 which may negatively impact their eating experience.10
The Sequential Oral Sensory approach (SOS) is a widely pro-
moted SD programme in Australia for children with ASD and
feeding difficulties. SOS attempts to gradually desensitise a child
to eat a greater range of food at reasonable quantities by logical
and stepwise introduction of food. This would suggest that SOS is
more effective in children who have been assessed to have
hyper-responsive dysfunction; however, there are no published
studies of SOS just targeting children with sensory modulation
deficits. This stepwise introduction of food is significantly differ-
ent from tactics used by OC as it allows the child to lead the pro-
gression of therapy. Children are exposed to their target foods
through sight, touch, play and taste before actual ingestion.
Several studies have been conducted comparing OC and SD
therapy for children with ASD. The largest study was a
randomised clinical trial that involved 68 participants with feed-
ing difficulties, 33 of whom had ASD.34 This study showed that
children in the OC group had a greater increase in total number
of unprocessed fruits and vegetables consumed than the SD
group. Although a control was not used for this study, it is impor-
tant to note that both arms of this study benefited from the inter-
vention. A randomised trial of six children with ASD in 2010
showed that all three children undergoing ABA therapy demon-
strated increased acceptance of food, while all three children receiv-
ing SD had acceptance rates at zero or near zero.35 A case series
involving two typically developing children identified as having
sensory-processing issues showed that sensory integration therapy
(involving sensory desensitisation with escape, similar to SOS) pro-
duced little to no benefit for the children, but then, EE with non-
contingent reinforcement increased the acceptance rate to 96% in
one child and 100% in the other.36 The results of these studies sug-
gest that OC is more effective than SD therapy, but it is important
to note that these are small studies and that further research is
required to fully evaluate their efficacy in children with ASD.
Cognitive behavioural therapy
CBT works by teaching the subject to identify and redirect nega-
tive thoughts and behaviours into more positive alternatives. It
has been shown that children with ASD between the ages of
4 Journal of Paediatrics and Child Health (2019)
© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
V Zhu and J Dalby-Payne
7 and 12 years are able to participate in the basic cognitive tasks
involved in CBT37 and that, with some modification to traditional
CBT, it can an effective therapy for anxiety in children with ASD.38
Despite this, research into the efficacy of CBT to manage feeding dif-
ficulties in children with ASD is limited. A pilot trial was performed
in 2017 utilising CBT over 14 weeks for feeding difficulties in 11 chil-
dren with ASD aged between 8 and 12 with a verbal intelligence
quotient ≥80. CBT was provided on a weekly basis to the carers and
the children, with sessions running for 90 min each. Results of the
study were measured qualitatively with satisfaction questionnaires.
Although it was not clearly established what the needs of the family
were, half of the participants believed the program met all their
needs, 38% believed most of their needs were met, and 12%
believed only a few of their needs were met.39 With these promising
results, we can expect further research into the use of CBT in man-
aging feeding difficulties in older children with ASD in the future.
Conclusion
Feeding difficulties in children with ASD is an important issue
as it adversely impacts the child’s health and the family’s expe-
rience at mealtimes. As there is a variety of causes for feeding
difficulties, a multidisciplinary approach to assessment and
management is essential to formulate an appropriate manage-
ment strategy. Medical causes should be identified and man-
aged before embarking on a behavioural approach to therapy.
Studies examining the use of psychotherapies for managing
selective eating in ASD are limited. Therapy options include OC
and systematic desensitisation for younger children and CBT for
children over 8 year of age. ABA, a form of OC therapy, is a
well-established discipline with the most evidence for its use in
feeding difficulties for children with ASD. Therapies utilising
a systematic desensitisation approach have been gaining pop-
ularity in recent years. Although both ABA and systematic
desensitisation have been shown to be effective therapies for
feeding difficulties in children with ASD, studies overall indicate
that ABA may be more effective. Preliminary results show that
the use of CBT in older children with ASD may be effective for
managing problematic feeding behaviours, and further research
into this form of therapy is warranted. Given the limited evidence
for the efficacy of the various psychotherapeutic treatment
options for managing behavioural feeding difficulties in children
with ASD, further research is required. It is hoped that the result
will be a better understanding of the use of these therapies and
improved nutritional and psychological outcomes for children
with ASD and their families.
Acknowledgement
We thank Wendy Birks, Laura Swift and Jane Pettigrew, Multi-
disciplinary Feeding Team, The Children’s Hospital at Westmead,
for review of manuscript.
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5