Top Clin Nutr

Vol. 25, No. 1, pp. 27–37

Copyright  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

DIETETIC PERSPECTIVES
Eating Problems in Children
With Autism Spectrum
Disorders
Keith E. Williams, PhD, BCBA-D; Laura Seiverling, MA

A variety of eating problems, especially problems with food selectivity, have been reported in
children with autism spectrum disorders (ASDs). A few studies have examined children with and
without ASDs and compared eating problems found in a group of children. Other research has
examined possible etiological factors that lead to eating problems among children with ASDs. This
review discusses these areas of research. While the treatment of eating problems among children
with ASDs can present a clinical challenge to providers, there is a growing literature detailing ef-
fective interventions for the eating problems in this population. Methods of assessment as well
as details of interventions that have been found to effectively treat eating problems among chil-
dren with ASDs are described. Key words: autism, autism spectrum disorder, eating problem,
feeding problem, nutritional deficit

A UTISM SPECTRUM DISORDERS (ASDs)

are neurodevelopmental disorders char-
acterized by 3 core areas of deficit: deficits in
communication; deficits in socialization; and
restrictions in behavior, interests, or activi-
ties. While ASD is more often described in
terms of these 3 areas of deficit, problems
with eating have also characterized ASD since
Leo Kanner’s initial description of infantile
autism1 with the most commonly reported
eating problem involving some form of diet
restriction.
There is not a single etiology responsible
for the characteristics that result in children
being diagnosed with ASD. As a result, chil-
dren with ASD form a very heterogeneous
group, greatly varying in their abilities and
areas of deficit. This fact is critical for profes-
sionals to consider as it implies that each child
with ASD is unique, thus, interventions to
address eating problems must be based upon
the medical history, the level of development,
experience, and other factors specific to the
individual.
The purpose of this article was to review
the current literature regarding eating prob-
lems found among children with ASD and
to provide information on evidence-based in-
terventions for the treatment of these eating
problems. This article does not discuss nutri-
tional treatment of autism, nor does it discuss
specific diets proposed for autism.

TYPES OF EATING PROBLEMS

Author Affiliations: Penn State Hershey Medical
Center, Hershey, Pennsylvania (Dr Williams); and
The Graduate Center and Queens College, City
University of New York, New York (Ms Seiverling).
Disclosure: Neither author has any disclosures.
Corresponding Author: Keith E. Williams, PhD, BCBA-
D, Penn State Hershey Medical Center, 905 W Gov-
ernor Rd, Hershey, PA 17033 (Feedingprogram@hmc.
psu.edu).
Numerous studies have found selective eat-
ing to be a common problem among children
with ASD.2–5 Selective eating extends to vari-
ous dimensions and children with ASD have
been reported to be selective of the type,
texture, brand, temperature, and even color
of foods. While feeding problems are more
27
28 TOPICS IN CLINICAL NUTRITION/JANUARY–MARCH 2010
common among children with special needs
than children with typical development, food
selectivity by type or eating a narrow range
of food that was nutritionally inappropriate
was more prevalent among children with ASD
(62%) than children with either cerebral palsy
(5%) or Down syndrome (14%).6 Although
Field et al found the majority of children with
ASD were food selective by type or texture,
they also found a few children with ASD who
had food refusal, defined as refusal to eat all
or most foods, resulting in insufficient calorie
intake, dysphagia or problems with swallow-
ing, and oral motor problems.
Other feeding problems that have received
less attention in the literature have also been
reported among children with ASD. Both adip-
sia and the failure to consume sufficient flu-
ids, selectivity by the type of fluid, have been
reported in case reports of children with
ASD.7,8 Problems with liquid intake can be
a potentially serious issue, resulting in con-
stipation, diarrhea, vomiting, and restricted
caloric intake resulting due to inadequate
fluids.9 Packing or the retention of food in
the mouth for protracted durations has also
been found among children with ASD.10,11
Packing has been hypothesized not only as a
way of avoiding eating, but also as a result of
oral motor delays. Two studies involving chil-
dren with autism have examined packing, and
each study involved an intervention address-
ing a different reason for packing. Although it
has been speculated that packing is often an
avoidance behavior exhibited to avoid eating,
it is also possible that packing occurs because
the child does not have the requisite oral mo-
tor skills needed to eat higher-texture foods.
Rapid eating or eating at a pace that does
not allow appropriate chewing and swallow-
ing is a common problem among persons
with developmental disabilities.12 The side ef-
fects of rapid eating include vomiting, aspira-
tion, and social stigmatization. Although the
treatment of rapid eating among persons with
developmental disabilities has been reported
in several studies,13,14 the first study involving
adolescents with ASD was published recently
in 2008.15
A COMPARISON OF THE EATING
PROBLEMS IN CHILDREN WITH AND
WITHOUT AUTISM DISORDERS
While there are case studies describing
the treatment of eating problems in children
with ASD and studies describing samples of
children with feeding problems that have in-
cluded children with ASD, few studies have
compared dietary habits and eating behaviors
of children with and without ASD. The study
with the largest sample,4 which compared
children with and without ASD between the
ages of 7 and 10 years, examined differences
in diet variety and the frequency of a range
of eating and mealtime behavior problems be-
tween the 2 groups. For this study, caregivers
of 138 children with ASD and 298 typically
developing children aged 7 to 10 years filled
out 2 questionnaires including the Gilliam
Autism Rating Scale16 and the Children’s Eat-
ing Behavior Inventory.17 In addition, care-
givers completed a food preference inven-
tory, a comprehensive listing of all foods eaten
by the child and family and a personal history
form. The personal history gathered family
demographic information as well as informa-
tion about the child’s developmental and med-
ical history. The findings showed that children
with ASD ate significantly fewer fruits, veg-
etables, proteins, dairy products, and starches
than did children with typical development.
Seventy-two percent of the children with ASD
were reported to eat a narrow variety of foods.
In addition, the caregivers of children with
ASD reported more frequently that their chil-
dren refused foods, required specific utensils,
were particular about how foods were pre-
sented, and had difficulties with food textures
than did caregivers of children with typical de-
velopment. The finding of a more limited diet
variety among children with ASD was repli-
cated in another study which compared nu-
trient intake and eating behaviors between
20 boys with autism and 18 boys without
autism, all of whom were between the ages
of 7 and 10 years.3 This study found that chil-
dren with ASD were more likely to make food
choices on the basis of the texture of the food.
 Eating Problems in Children With Autism Spectrum Disorders
Caregivers of children with ASD reported sig-
nificantly more problems getting their chil-
dren to eat than did caregivers of children
without ASD. In another study 41 children
with ASD were individually matched with
41 typically developing children based upon
their performance on the Vineland Adaptive
Behavior Scale.18 The mothers of these two
groups of children were then asked to com-
plete an eating behaviors questionnaire cre-
ated by the authors from the parent section
of the Behavioral Pediatric Feeding Assess-
ment Scale19 and the Childhood Autism Rat-
ing Scale.20 The results showed that the moth-
ers of children with ASD reported that their
children were more likely to avoid food and
that they exhibited more neophobic eating
behaviors.18
Two recent studies have examined dietary
intake and mealtime behaviors in young chil-
dren with ASD and typically developing chil-
dren. Lockner et al21 collected 3-day diet
records for 20 children with ASD aged 3
to 5 years and 20 typically developing chil-
dren who were age-matched to the children
with ASD. In addition, all parents completed
a survey concerning mealtime behaviors and
supplement use. The results of the survey
showed no significant differences between
groups in nutrient intake. However, parents
of children with ASD did report significantly
more often that their children were picky
eaters and resisted trying new foods. The
parents of children with ASD were also less
likely to report their children were healthy
eaters and that their children liked a variety
of foods. There was also a significant differ-
ence in the use of supplements, with 60%
of children with ASD receiving nonprescrip-
tion vitamin/mineral supplements and only
25% of typically developing children receiv-
ing supplements. The authors suggested that
parental beliefs concerning the inadequacy
of their child’s diet may be responsible for
the use of supplements. Similar findings con-
cerning diet and eating behaviors were re-
ported in a study involving 19 children with
ASD and 15 typically developing children be-
tween the ages of 2 and 4 years.22 Caregivers
29
of these children completed a brief ques-
tionnaire about mealtime behaviors, the Food
Frequency Questionnaire23 and a 24-hour di-
etary recall. While the caregivers of children
with ASD reported more problems with meal-
time behavior, there were no significant dif-
ferences in nutrient intake. It is noteworthy
that these two studies involving preschoolers
found no significant differences in nutrient in-
take between children with and without ASD
since the preschool period of development
has been hypothesized to be a period when
all children have narrower diets.24
CAUSES OF EATING PROBLEMS
Although studies have demonstrated an in-
creased prevalence of selective eating among
children with ASD when compared to other
populations of children, the etiology of this
type of eating problem is unclear. Parents of
children with ASD reported that their children
had greater abnormalities in taste than did par-
ents of children with other special needs,25
but it is not known if children with ASD actu-
ally have greater taste acuity. Recent research
found that children with ASD were less accu-
rate at identifying sour and bitter tastes than
children without ASD, and the researchers hy-
pothesized that this finding was the result
of cortical processing rather than brainstem
dysfunction.26 It has also been speculated that
children with ASD, whose diets often con-
sist largely of carbohydrates, are seeking foods
with a high glycemic index to get the “sugar
high” associated with eating these foods.27
The restriction in interests and activities has
long been a hallmark of ASD and it may be
possible that the narrow diets found among
children with ASD are an extension of this
characteristic.28
All children learn to eat a variety of foods
by repeatedly tasting novel foods. The tasting
of these novel foods is initiated by a range
of social and environmental strategies such
as caregiver’s prompts, modeling by peers,
and exposures to novel foods in numerous
settings, including school. Delays in language
and poor social skills, the core deficits in ASD,
30 TOPICS IN CLINICAL NUTRITION/JANUARY–MARCH 2010
may prevent verbal prompts, modeling, and
other strategies used by caregivers to teach
their children from being as effective in devel-
oping diet variety among children with ASD.
Research has also proposed that children re-
ject foods on the basis of how the foods look,
not how they taste.29 When a child is pre-
sented with a new food, the child must make a
decision of whether to eat or reject that food.
The child utilizes past experiences with other
foods to make this judgment, thus the child
is making an inference about the new food,
a task that may be more difficult for children
with ASD.
Ledford and Gast30 defined feeding prob-
lems among children with ASD as selective
acceptance of food or refusal to eat many
or most foods with no known medical ex-
planation. Although this definition excludes
medical etiologies, the research on feeding
problems has consistently shown that medical
conditions such as gastroesophageal reflux,
constipation, or pulmonary disease may pre-
cipitate or maintain feeding problems.6,31
Most of the children with ASD in the study
by Field et al6 were food-selective by type
and/or texture and did not have comorbid
medical conditions. However, 30% of the chil-
dren with ASD and these feeding problems
did have comorbid medical issues. In addi-
tion, a small number of children with ASD in
this sample were identified as having food re-
fusal and dysphagia. In every child, with these
more severe feeding problems, there was a
comorbid medical problem, most commonly,
gastroesophageal reflux.
ASSESSMENT OF EATING PROBLEMS
The child’s medical status and ability to par-
ticipate in an intervention for an eating prob-
lem is generally determined by the child’s pri-
mary physician, in some cases with the input
of other medical subspecialists. While some
researchers have found the frequency of asso-
ciation of medical conditions and ASD to be
24% to 37%,32,33 others have found only a sus-
pected etiological relationship between med-
ical conditions and autism at 10% to 15%.34
Researchers have also proposed consider-
ation of autism as a neurodevelopmental dis-
order with abdominal features on the basis
of a number of studies reporting gastrointesti-
nal problems in this population.35 A more re-
cent review of the literature found that while
gastrointestinal problems are not uncommon
among children with ASD, there is no evi-
dence to support increased gastrointestinal
symptomatology for this population.36 Al-
though the heterogeneity of the ASD makes
it difficult to find specific relations between
the disorder and medical conditions, a medi-
cal evaluation for each individual referred for
treatment is essential.
While some studies have shown that the
nutritional intake for children with ASD does
not differ significantly from children with typ-
ical development;22,37 other studies have sug-
gested that children with ASD are at risk for
reduced bone cortical thickness, secondary
to their diets and nutritional deficiencies.38
Research has demonstrated that nutritional
deficits stemming from eating problems have
resulted in significant medical issues in chil-
dren with ASD. In 2 separate cases, 8-year-old
boys with autism, 1 of whom ate only French
fries and water while the other ate only fried
potatoes and water, were both diagnosed
with xerophthalmia and corneal erosions, sec-
ondary to vitamin A deficiencies.39,40 A 9-year-
old boy with autism whose diet consisted of
toaster pastries and cola was referred for limb
pain and diagnosed with scurvy, secondary
to vitamin C deficiencies.41 In addition to
case studies, one study examined the iron lev-
els in a sample of 52 children with autism
and 44 children with Asperger syndrome.42
The results showed that among children with
autism, 12% were anemic and 52% were iron
deficient, and among children with Asperger
syndrome, 5% were anemic and 14% were
iron deficient. These examples of deficiencies
in diet point to the importance of nutritional
assessment and micronutrient analysis.
The relationship between growth mea-
sures, such as body mass index (BMI), and
ASD are mixed; one study examined 50 boys
with autism and found that 80% exceeded the
50th percentile for BMI,43 and another study
 Eating Problems in Children With Autism Spectrum Disorders
examined 84 boys with autism and found
that 75% were below the 50th percentile for
BMI.44 No significant differences were found
in height or weight in a study comparing eat-
ing behaviors of children with and without
ASD.4 While many, if not most of children
with ASD, do not have problems with growth,
those referred for eating problems certainly
are at higher risk, and the assessment of an-
thropometrics and calorie requirements are
indicated for these children.
An oral motor assessment is warranted for
some children with ASD. While the most com-
mon eating problem found among children
with ASD is a narrow diet, there are children
who have problems with higher texture and
eat only low-texture foods or in some cases, an
exclusively liquid diet. For these children and
some others, a determination of the oral mo-
tor status is needed to ensure that the child is
a safe oral feeder. An oral motor examination
evaluates oral motor functions such as suck-
ing, chewing, and swallowing, as well as the
child’s oral anatomy including the lips, teeth,
tongue, and palate. This type of assessment of-
ten involves either an occupational therapist
or a speech pathologist. For children who ex-
hibit signs of aspiration or are at risk for as-
piration, an oral motor evaluation is required
and often includes a videofluoroscopy, a ra-
diographic study of swallowing function.
Few questionnaires have been used specif-
ically in the assessment of the eating prob-
lems in children with ASD, as well as several
other questionnaires that have been used to
assess children’s eating more generally. The
Children’s Eating Behavior Inventory evalu-
ates the frequency of 19 eating behaviors with
a 5-point rating scale.17 A more recent instru-
ment is the 18-item Brief Autism Mealtime Be-
havior Inventory, which also evaluates the fre-
quency of these items using a 5-point rating
scale.45 Both of these instructions can provide
information about which specific eating be-
haviors should be targeted for intervention.
The Parent Mealtime Action Scale is a 31-item
scale that measures not only actions taken by
parents during meals but also the frequency
that the parents eat certain foods (eg, fruits
and vegetables) and serve these foods to their
31
children.46 This scale can provide informa-
tion about particular actions that have been
shown to be associated with diet and weight
status. These questionnaires focus on specific
actions or behaviors, which can help guide
the development of interventions.
INTERVENTIONS FOR FEEDING
PROBLEMS
A variety of interventions have been used to
address the feeding problems among children
with ASD. These interventions have typically
consisted of a treatment package of 2 or more
behavioral components. This section will de-
scribe a range of these interventions to pro-
vide examples of the behavioral components
commonly used.
The use of preferred food items to increase
consumption of novel or nonpreferred items
has been used in 2 different types of inter-
vention. The preferred food is presented se-
quentially as a reward for eating the novel or
nonpreferred food whereas, in simultaneous
presentation, both the preferred food and
novel or nonpreferred food are presented to-
gether. Piazza and colleagues47 compared si-
multaneous and sequential presentation of
nonpreferred and preferred foods to reduce
food selectivity in 3 children with autism. Si-
multaneous presentation led to a more rapid
increase in acceptance than sequential pre-
sentation for all participants. Simultaneous
presentation was also used in the treatment
of a 7-year-old child with autism by placing a
novel food (ie, piece of vegetable) on top of
a preferred food48 (ie, corn chip). Vegetable
consumption was also increased in a 14-year-
old boy with autism by serving the vegeta-
bles covered with preferred condiments.49
There are several possible reasons why in-
terventions involving simultaneous presenta-
tion or mixing novel and preferred foods have
been successful. In these interventions, the
new foods were introduced in very small
amounts making the effort required by the
child low, thus increasing the probability the
novel foods would be eaten. In addition, these
interventions may have involved flavor-flavor
32 TOPICS IN CLINICAL NUTRITION/JANUARY–MARCH 2010
conditioning, a form of Pavlovian condition-
ing in which associations are created be-
tween the novel and preferred foods produc-
ing a positive shift in preference for the novel
food.49
Another treatment component that has
been used in feeding interventions is response
cost. In response cost, the child is allowed
to engage in a preferred activity (eg, watch-
ing a video or playing with a toy) prior to
presentation of a demand such as taking a
bite. If the child does not comply with the
request, the preferred activity is removed un-
til the child does comply. In a study de-
scribing the use of response cost, Buckley
and Newchok10 treated a 9-year-old girl with
autism, who ate a narrow diet but exhibited
no difficulty eating any textures. She packed
novel or less preferred foods interfering with
attempts at improving her diet. This study
compared 3 treatments: one involved differ-
ential reinforcement and response cost; an-
other consisted of simultaneous presentation;
and the final consisted of differential rein-
forcement, response cost, and simultaneous
presentation. In the differential reinforcement
and response cost condition, praise was pro-
vided when the child had swallowed her food
and her mouth was empty. She was provided
with a preferred video at the beginning of
the meal, which was turned off if she packed
food and again turned on when she had an
empty mouth. In the simultaneous presenta-
tion condition, a small bite of cookie, a pre-
ferred food, was presented on the spoon with
a bite of a target food. The final condition,
differential reinforcement, response cost, and
simultaneous presentation involved combin-
ing the procedures from both of the other
conditions. While all 3 treatment conditions
resulted in reductions in packing, simultane-
ous presentation was shown to be the most
significant component in the reduction of
packing.
Another approach that has been used suc-
cessfully to introduce novel foods is fading,
gradually increasing the amount the child is
required to eat. To increase diet variety, a
5-year-old boy with autism was initially re-
quired to eat a single bite of novel food be-
fore being provided with a plate of preferred
food.50 Each meal lasted until either the child
consumed the novel food presented or un-
til 30 minutes had elapsed, whichever oc-
curred first. Across the course of treatment,
the amount of novel food was systematically
increased whereas the amount of preferred
food was decreased. Treatment was also ap-
plied from the home to restaurants. Another
study using similar procedures described the
treatment of a 6-year-old child with autism
and severe behaviors who consistently re-
fused to eat.51 As in the previously described
treatment, each meal lasted until either all
of food was consumed or until 30 minutes
elapsed, whichever occurred first. A prompt-
ing sequence consisting of a verbal prompt,
partial physical prompt (placing the child’s
hand on the spoon), and finally hand-over-
hand prompt was also used if the child did
not self-initiate taking bites. While the goal
of treatment was to have the child consume
meals consisting of a fruit, protein, vegetable,
and starch, the initial meal consisted of a sin-
gle spoonful of fruit. Across the course of
treatment, the variety and volume of foods
was systematically increased. In both of these
studies, the response effort (the amount of
food the child was required to eat) was grad-
ually increased on the basis of the child’s
compliance.
Another variant of stimulus fading, or grad-
ually changing a stimulus over time, has been
used to teach children to drink novel liquids
and reduce packing. To replace the consump-
tion of a supplement with milk in a 4-year-old
girl with autism, Luiselli and colleagues9 sub-
stituted a small amount of milk for an equal
amount of supplement. Across the course of
treatment, more of the supplement was re-
placed with milk until the child was drink-
ing only milk. This same strategy was used
to teach a 6-year-old boy with pervasive
developmental disorder to drink milk with
instant breakfast powder. Because the boy
initially only drank water, instant breakfast
powder was mixed with water and eventually
the water was replaced with milk.8
 Eating Problems in Children With Autism Spectrum Disorders
In the treatment of packing in a 4-year-old
boy with autism and 2 other children with-
out ASD, Patel and associates11 evaluated the
manipulation of food textures. Prior to inter-
vention, the children were evaluated by an
occupational therapist who determined that
higher textures would be inappropriate given
the oral motor skills of the 3 children. The
intervention consisted of lowering the food
texture for these children and then gradu-
ally increasing the texture over time. This
intervention, commonly known as texture
fading, has also been used to increase the tex-
ture of foods consumed by children without
ASD.52,53
An intervention based on literature con-
cerning the development of food preferences
has been used in a pair of studies. Food pref-
erences are acquired through repeated expo-
sures to the taste of novel foods over time.54
Repeated taste exposure was used within a
treatment package to increase diet variety
in 2 children with autism.55 The interven-
tion involved offering 4 novel foods in brief
probe meals, during which the children were
praised for eating, but not required to con-
sume them. Foods not eaten in probe meals
were introduced in taste sessions. In a taste
session, the child was offered only a single
pea-sized bite of one food, and the session was
terminated upon consumption of this bite. All
bites were initially small to reduce the effort
required by the children. Multiple taste ses-
sions were conducted to provide the opportu-
nity to taste novel foods multiple times. This
repeated tasting of novel foods resulted in in-
creased consumption of these foods in subse-
quent probe meals, even when the children
were not required to eat. A follow-up study in-
volving this same intervention examined the
number of tastes required before each novel
food was eaten in meals and found that, as
the number of foods added to the child’s
diet increased, the number of tastes before
a child would eat a novel food decreased.56
This finding, although in need of replica-
tion, is important because it demonstrates
that increasing variety becomes easier over
time.
33
A few studies have examined the use of
a high-probability request sequence to treat
feeding problems in children with ASD.57,58
The use of a high-probability request se-
quence, also known as behavioral momen-
tum, involves the presentation of preferred
activities or high-probability responses, prior
to the presentation of nonpreferred ac-
tivities or low-probability responses.30 A
high-probability instructional sequence was
included in a treatment package to increase
compliance to decrease food selectivity in a
4-year-old boy with pervasive developmental
disorder.57 The goal in this procedure was
to get the child to accept pureed fruit, veg-
etable, and protein. This study compared the
effectiveness of a low-probability instruction
condition and a high-probability instruction
condition. In the low-probability phase, the
participant was presented with one spoon-
ful of food placed on a spoon in the bowl.
A verbal prompt, “take a bite,” was presented
2 times before the bite was removed. In the
high-probability phase, the verbal prompt was
delivered with 3 presentations of an empty
spoon preceding the presentation of a spoon
containing food. Prior to treatment, accep-
tance of an empty spoon was demonstrated
to be a high-probability response. Thus, in
the high-probability phase, an instruction to
perform a high-probability response (accept-
ing the empty spoon) was presented prior
to the low-probability response (taking a bite
of new food), whereas in the low-probability
phase, only the instruction to take a bite was
given. In each phase, verbal praise and light
physical touch were presented following ac-
ceptance of the bite of food. All feeding ses-
sions were terminated after presentation of 5
bites of food. Compliance was zero during the
low-probability phase and 100% during the
high-probability phase. Additional new foods
were gradually presented and mealtime length
and volume requirements were also gradually
increased.57
In another study involving the use of a
high-probability instructional sequence, Gen-
try and Luiselli58 trained a mother to con-
duct 2 multicomponent procedures to treat
34 TOPICS IN CLINICAL NUTRITION/JANUARY–MARCH 2010
food selectivity in her 4-year-old son with
pervasive developmental disorder. First the
mother placed 2 preferred foods and 1 non-
preferred food in 3 sections on a paper plate
and presented the child with a “Mystery Mo-
tivator” game in which the child had to spin
a game arrow to determine how many bites
of each food he had to eat. To incorporate
the high-probability instructional sequence,
the mother suggested that the participant eat
the required bites from the preferred foods be-
fore eating the nonpreferred foods. When the
child ate the required bites of nonpreferred
foods, he was given verbal praise and access to
a preferred activity. He was also allowed to eat
the remainder of the food or ask for additional
foods. If the game arrow landed on a ques-
tion mark, the child was immediately given
access to a preferred toy from a gift box and
was allowed to play with the toy at the table.
If the child did not eat the required number
of nonpreferred bites, the mother withheld
praise, had the child stay in his chair for ap-
proximately 5 minutes, and then she allowed
the child to leave the table. The number of re-
quired bites on the “Mystery Motivator” game
was systematically increased after reviewing
data with the child’s mother.
To date, there has been only 1 study ad-
dressing rapid eating in persons with ASD.15
This study involved 3 teenagers who were
able to self-feed and had a history of rapid
food consumption. They were taught to
take bites of food when a pager vibrated.
The teacher provided praise for waiting un-
til the pager vibrated and blocked attempts
to take bites before the pager vibrated. Af-
ter training was completed, the pager prompt
was used during all meals and each of the
teenagers increased the duration of their total
eating time.15
Although the studies described demon-
strate the effectiveness of behaviorally based
treatment for the range of eating problems
found among children with ASD, they consti-
tute only a small selection of the treatment lit-
erature. As the field of behavior analysis con-
tinues to develop and the issues related to
ASDs, such as eating problems, remain a ma-
jor focus of behavior analysis, there will be an
increasing number of treatment approaches
available to professionals to help these chil-
dren with their eating problems. Recent com-
prehensive reviews of the treatment literature
are available.30,59
PARENT TRAINING
Feeding problems can be distressing for
parents who often face difficulty during meal-
time due to child disruptive responses when
presented with novel or nonpreferred foods.
A few studies have involved training care-
givers to implement home-based interven-
tions that address food selectivity. Two of
these studies60,61 reported data on parent/
caregiver performance and provided details
regarding how parents were trained to con-
duct the procedure.
McCartney and associates60 trained the
caregivers of 4 children (3 children with
autism and 1 typically developing child) to
conduct an intervention in the home set-
ting. The intervention included reinforcement
in the form of verbal praise and access to
preferred foods, escape prevention, and fad-
ing to treat food selectivity. The investiga-
tors first presented the parent/caregivers with
a video of therapist-conducted clinic meals.
Then, the therapist reviewed the video with
the parent/caregiver and explained the treat-
ment procedure. Next, the parent/caregiver
observed at least 2 meals through a 1-way
observation mirror and then observed 1
meal within the session room. Prior to each
meal fed by the parent/caregiver, an inves-
tigator reviewed the intervention with the
parent/caregiver. In addition, an investigator
provided feedback following each meal and
provided guidance on how to implement the
treatment procedures as needed. Initially, the
child was required to eat a single bite of
one food. On the basis of the child’s behavior,
the number of bites the child was required to
eat was increased across the course of treat-
ment. All 4 children showed an increase in ac-
ceptance of novel foods and a reduction in in-
appropriate mealtime behavior.
Anderson and McMillan61 used verbal and
written instructions, modeling, videotape
 Eating Problems in Children With Autism Spectrum Disorders
review, and feedback during weekly home vis-
its to train parents to implement differential
reinforcement, escape prevention, and fad-
ing to increase acceptance of pureed fruits
and reduce meal-related problem behavior
in a 5-year-old boy with pervasive develop-
mental disorder and severe intellectual dis-
abilities. Parents were trained to present
both preferred and nonpreferred foods dur-
ing mealtimes. Differential reinforcement in-
volved statements of praise (eg, “good job
taking your bite!”) and access to a preferred
item (ie, milk) when the child accepted a
bite. Escape prevention included presenting
the bite of food to the child until it was ac-
cepted. Fading involved gradually increasing
number of bites of fruit required before meal
termination and changes in the bite number
were based upon the child’s progress. Fol-
lowing intervention, the child consumed age-
appropriate amounts of fruit (approximately
4 oz per meal).
These studies demonstrate that parents
can learn to implement feeding intervention
procedures through various behavioral skills
training packages involving instructions, mod-
eling, rehearsal, and feedback. However, in
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