Public Health Nursing

0737-1209/© 2014 Wiley Periodicals, Inc.

doi: 10.1111/phn.12146

POPULATIONS AT RISK ACROSS THE LIFESPAN: CASE STUDIES

Child Eating Behaviors and Caregiver

Feeding Practices in Children with
Autism Spectrum Disorders
Tanja V. E. Kral, PhD,1,2 Margaret C. Souders, PhD, CRNP,1 Victoria H. Tompkins, BA,1 Adriane M.
Remiker, BA,3 Whitney T. Eriksen, BSN, RN,1 and Jennifer A. Pinto-Martin, PhD, MPH1,4
1
Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; 2Department of
Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; 3Department of Cell and Developmental
Biology, Weill Cornell Medical College, New York, New York; and 4Department of Biostatistics and Epidemiology, University of Pennsylvania
Perelman School of Medicine, Philadelphia, Pennsylvania

Correspondence to:
Tanja V. E. Kral, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing and Perelman School of Medicine,
308 Claire M. Fagin Hall, 418 Curie Blvd, Philadelphia, PA 19104-4217. E-mail: tkral@nursing.upenn.edu

ABSTRACT Objective: This pilot study compared children with autism spectrum disorders
(ASD) and typically developing children (TDC) on weight-related outcomes and caregiver-reported
child eating behaviors and feeding practices. Design and Sample: Cross-sectional study. Caregivers
of 25 children with ASD and 30 TDC, ages 4–6. Methods: Caregivers completed validated question-
naires that assessed child eating behaviors and feeding practices. Childrens height, weight, and
waist circumference were measured. Results: Children with ASD, when compared to TDC, showed
significantly greater abdominal waist circumferences (p = .01) and waist-to-height ratios
(p < .001). Children with ASD with atypical oral sensory sensitivity exhibited greater food avoidance
behaviors, including reluctance to eat novel foods (p = .004), being selective about the range of
foods they accept (p = .03), and undereating due to negative emotions (p = .02), than children with
ASD with typical oral sensory sensitivity. Caregivers of children with ASD with atypical oral sensory
sensitivity reported using food to regulate negative child emotions to a greater extent than caregivers
of children with typical oral sensory sensitivity (p = .02). Discussion: Children with ASD, especially
those with atypical oral sensory sensitivity, are at increased risk for food avoidance behaviors and may
require additional support in several feeding domains.
Key words: autism spectrum disorders, caregiver feeding practices, eating behavior, obesity.

The prevalence of Autism Spectrum Disorders
(ASD) has been steadily increasing over the past
two decades and is a significant public health con-
cern (Autism & Developmental Disabilities Moni-
toring Network, 2014). One of the most common
co-occurring problems in children with ASD is
challenging eating behaviors reported by as many
as 90% of caregivers (Ahearn, Castine, Nault, &
Green, 2001; DeMeyer, 1979). The core deficits of
ASD and their underlying neurobiology may predis-
pose children to intrinsic and extrinsic stressors
that threaten healthy eating behaviors. Conse-
quently, these behaviors put children with ASD at
great risk for poor dietary patterns and obesity
(Curtin, Anderson, Must, & Bandini, 2010). Given
the convergence of these two pediatric health care
priorities it is critical that public health nurses
focus on these concerns.
Caregivers of individuals with ASD face unique
challenges when it comes to feeding and daily eat-
ing routines, such as increased food selectivity, food
refusal, and disruptive mealtime behaviors,
described by two recent reviews (Kral, Eriksen,
Souders, & Pinto-Martin, 2013; Sharp et al., 2013).

1
2 Public Health Nursing
A small number of studies (Ahearn et al., 2001;
Klein & Nowak, 1999; Raiten & Massaro, 1986; Wil-
liams, Dalrymple, & Neal, 2000) and anecdotal evi-
dence/case reports further indicated that children
with ASD show aversions or strong preferences to
certain textures, smells, colors, temperatures, and
brand names of foods. These eating behaviors and
food preferences/aversions emerge at a young age
and can adversely impact children’s diet quality,
food variety, and their growth and development.
The purpose of this pilot study was to gain a
greater understanding of caregiver-reported eating
behaviors, caregiver feeding practices, and growth
measurements of children with ASD in the early
years after a diagnosis.
In a comprehensive narrative review, Cermak,
Curtin, and Bandini (Cermak, Curtin, & Bandini,
2010) suggested that increased food selectivity in
children with ASD may be the result of heightened
sensory sensitivity to the texture of certain foods.
Preliminary data in typically developing children
(TDC) showed that higher taste and smell sensitiv-
ity was associated with lower intake of healthy
foods, increased food neophobia (i.e., children’s
avoidance of novel foods) (Coulthard & Blissett,
2009), and higher food selectivity among children
with tactile defensiveness (i.e., overreaction to
experiences of touch including touch associated
with feeding) (Smith, Roux, Naidoo, & Venter,
2005). Given the large number of children with
ASD who experience sensory processing difficulties
(Schoen, Miller, Brett-Green, & Nielsen, 2009), it is
crucial for future studies to examine eating behav-
iors in children with ASD in the context of their
sensory processing patterns.
Eating difficulties not only pose nutritional
risks for children with ASD, but they can also put a
considerable strain on caregivers and their families.
While there exists an extensive body of research on
caregiver feeding practices in TDC (e.g., Birch &
Fisher, 2000; Fisher & Birch, 2000; Galloway, Fio-
rito, Lee, & Birch, 2005; Wardle & Carnell, 2007),
we know little about feeding practices used by care-
givers of young children with ASD. It is possible
that caregivers of children with ASD address nutri-
tional difficulties in their children by using different
feeding practices. In TDC, Wardle and colleagues
(Wardle, Sanderson, Guthrie, Rapoport, & Plomin,
2002) showed that caregiver feeding to regulate
child emotional distress (emotional feeding) and
using food as a reward (instrumental feeding) may
lead to children to associate eating with cues other
than hunger. Together, increased food selectivity in
children and parental use of highly directive feeding
strategies can put children with ASD at increased
risk for excess weight gain and overweight/obesity
at a young age (Cermak et al., 2010; Fisher &
Birch, 2000). Given that children have an innate
preference for calorie-rich, sweet foods (Mennella,
2014), an overconsumption of calories can occur if
coupled with selectivity in the range of acceptable
foods. Conversely, children whose parents consis-
tently restrict access to preferred foods have been
shown to become more prone to overeating these
foods when they become available, resulting in
excess weight gain (Fisher & Birch, 2000).
The primary aim of this pilot study was to
compare children with ASD and TDC, ages 4–6, in
weight-related outcomes and caregiver-reported
child eating behaviors. We hypothesized that chil-
dren with ASD would be significantly heavier and
would show greater central adiposity than TDC. We
further hypothesized that children with ASD, and
those with atypical oral sensory sensitivity, in par-
ticular, would show significantly more food avoid-
ance behaviors. A second aim of this study was to
examine feeding practices of caregivers of children
with ASD and TDC. We hypothesized that caregiv-
ers of children with ASD would exhibit greater
monitoring and greater control over their children’s
eating compared to caregivers of TDC.
Methods
Design and sample
Study design. This pilot study used a cross-
sectional design in which 4- and 6-year-old
children with ASD were compared to TDC in
caregiver-reported eating behaviors and weight-
and adiposity-related measures. Caregivers were
asked to complete a series of questionnaires and
participate in one on-site assessment during which
children’s height, weight, and waist circumference
were measured.
Participants and recruitment. Participants
in this study were 25 children with ASD and 30
TDC and their primary caregiver living in the
greater metropolitan area of Philadelphia. Families
 Kral et al.: Eating Behaviors of Children with Autism
of all racial and ethnic backgrounds were eligible to
participate in the study. Children with ASD were
recruited via (1) online and e-mail advertisements
through autismMatch, an online research registry
created by the Center for Autism Research (CAR) at
The Children’s Hospital of Philadelphia (CHOP),
and (2) flyers posted at Special People in the
Northeast (SPIN), a community-based human ser-
vice organization in Philadelphia, and at CAR. TDC
were recruited by (1) online advertisement, (2) flyer
postings at local grocery stores and in the commu-
nity, and from (3) other ongoing pediatric studies
at the Center for Weight and Eating Disorders
(CWED) at the University of Pennsylvania. To be
included in the study, ASD children were required
to be between 4 and 6 years of age with a diagnosis
of ASD by a community provider, in conjunction
with having a score ≥12 on the Social Communica-
tion Questionnaire (SCQ) – Lifetime Form (Rutter,
Bailey, & Lord, 2003). Inclusion criteria for TDC
were no prior diagnosis of ASD and a score <12 on
the SCQ. The SCQ is a validated parent-report
screening tool for ASD in individuals over age 4
whose mental age is at least 2 years (Rutter et al.,
2003). The questionnaire consists of 40 items
inquiring about socialization, communication skills,
and atypical behaviors. Children were excluded
from the study if they had major or chronic medical
conditions known to affect food intake, body
weight, or growth; were taking psychotropic medi-
cations or medications known to affect appetite,
food intake, or body weight; were on a strict special
diet; had significant food allergies; or were lactose
intolerant. Four TDC were excluded from the study
due to scores ≥12 on the SCQ. The age range (4–
6 years) was chosen because early childhood is a
critical period during which children’s eating
behaviors are being shaped (Birch & Davison,
2001).
Interested caregivers were interviewed by tele-
phone to determine whether their children met the
initial inclusion criteria for the study. During the
phone interview, caregivers were asked to provide
verbal consent to answer both the telephone
screening questions as well as the mailed question-
naires. Families who qualified for the study from
the telephone interview were mailed a question-
naire packet along with an informed consent form
and asked to complete all questionnaires prior to or
during their on-site study visit at Penn or CHOP.
3
During the study visit, caregivers received a
detailed explanation of study procedures and were
asked to provide voluntary consent to have their
children participate in this study by signing the
consent form. Once the signed consent form was
received by our staff, the completed questionnaires
were collected and children were invited, in child-
friendly language, to participate in body measure-
ments. Families were compensated for their partici-
pation in the study ($100 in form of a gift card).
The study was approved by the Institutional Review
Boards of the University of Pennsylvania and
CHOP.
Measures
Assessment of height, weight, and waist
circumference. Study visits for children with
ASD took place at CAR at CHOP; study visits for
TDC took place at the CWED at the University of
Pennsylvania. During the visit, children’s height,
weight, and waist circumference were assessed by
trained research assistants. All measures were taken
with children wearing light clothing and having
their shoes removed. Weight was measured on a
digital scale (ASD children: SECA 876, Chino, CA;
TDC: Tanita BWB-800, Arlington Heights, IL; both
accurate to 0.1 kg) and height was measured on a
stadiometer (ASD children: portable stadiometer,
SECA 217, Chino, CA; TDC: wall-mounted stadiom-
eter, Veder-Root, Elizabethtown, NC; both accurate
to 0.1 cm). Children’s abdominal waist circumfer-
ence was measured with a nonstretchable fiberglass
tape (accurate to 0.1 cm). Measurement techniques
followed the methods described in Lohman, Roche,
and Martorell (1988). Anthropometric measure-
ments were taken in duplicate; the mean was used
in analyses. Child age- and sex-specific BMI per-
centiles and z-scores were calculated using the Cen-
ter for Disease Control and Prevention Growth
Charts 2000 (Kuczmarski et al., 2002). Children
were classified as normal weight (BMI-for-age 5–
84th percentile), overweight (BMI-for-age 85–94th
percentile), or obese (BMI-for-age ≥95th percentile)
(Ogden et al., 2002). Children’s waist-to-height
ratio was calculated as waist circumference divided
by height (Ashwell, Gunn, & Gibson, 2012).
Assessment of child eating behaviors.
Eating behaviors of children were assessed by care-
giver report using several validated instruments.
4 Public Health Nursing
Food neophobia, or children’s reluctance to eat
and/or avoidance of novel foods, was assessed
using the modified version (Wardle, Carnell, &
Cooke, 2005) of the Child Food Neophobia Scale
(Pliner, 1994). The modified version of the scale
contains the following six items: (1) “My child does
not trust new foods”; (2) “If my child doesn’t know
what’s in a food, s/he won’t try it”; (3) “My child is
afraid to eat things s/he has never had before”; (4)
“My child will eat almost anything”; (5) “My child
is very particular about the foods s/he will eat”;
and (6) “My child is constantly sampling new and
different foods.” Caregivers were asked to indicate
their responses on a 4-point scale ranging from
“strongly disagree” to “strongly agree.” Greater
scores indicate a greater level of food neophobia
(Cronbach a = .84).
Caregivers also completed the 35-item Child
Eating Behavior Questionnaire (CEBQ), which was
used to assess the following eight dimensions of
children’s eating style: (1) children’s responsiveness
to food, (2) enjoyment of food, (3) satiety respon-
siveness (assesses if food intake is reduced to com-
pensate for a prior snack), (4) slowness in eating,
(5) fussiness (being highly selective about the range
of foods that are accepted), (6) emotional overeat-
ing (eating more food during negative emotional
states), (7) emotional undereating (eating less food
during negative emotional states), and (8) desire
for drinks (Wardle, Guthrie, Sanderson, & Rapo-
port, 2001). Caregivers were asked to indicate their
responses on a 5-point Likert scale ranging from
‘never’ to ‘always.’ The questionnaire has shown
good internal consistency, test-retest reliability, and
stability over time (Ashcroft, Semmler, Carnell, van
Jaarsveld, & Wardle, 2008; Carnell & Wardle,
2007; Wardle et al., 2001).
Assessment of caregiver feeding prac-
tices. Caregivers completed the Child Feeding
Questionnaire (CFQ), which is a 31-item instrument
that assesses (1) parents’ perceptions of their
responsibility for child feeding; (2) parents’ percep-
tions of their own weight status history; (3) par-
ents’ perceptions of their child’s weight status
history; (4) parents’ concerns about the child’s risk
of being overweight; (5) extent to which parents
oversee their child’s eating (monitoring); (6) extent
to which parents restrict their child’s access to food
(restriction); and (7) parents’ tendency to pressure
their children to eat more food (Birch et al., 2001).
For each item, caregivers were asked to indicate
their response on a 5-point Likert Scale, with each
point on the scale represented by a specific word
anchor. The questionnaire showed adequate inter-
nal consistency with Cronbach’s alpha coefficients
for the various subscales ranging from 0.70 to 0.92
(Birch et al., 2001).
Caregivers also completed the Parental Feeding
Style Questionnaire (PFSQ), which is a 27-item
caregiver-report questionnaire that assesses (1)
maternal emotional feeding, (2) instrumental feed-
ing (using food as reward), (3) prompting/encour-
agement to eat, and (4) control over child eating
(Wardle et al., 2002). Response options for each
item range from “I never do” to “I always do” on a
5-point Likert Scale. Internal reliability coefficients
(Cronbach’s a) ranged from 0.65 to 0.85 and test-
retest reliability coefficients ranged from 0.76 to
0.83 for the four subscales.
Assessment of child sensory processing.
Caregivers were asked to complete the 125-item
Sensory Profile Caregiver Questionnaire (Dunn,
1999), which measures children’s sensory process-
ing abilities across the following nine factors: (1)
sensory seeking, (2) emotionally reactive, (3) low
endurance/tone, (4) oral sensory sensitivity, (5)
inattention/distractibility, (6) poor registration, (7)
sensory sensitivity, (8) sedentary, and (9) fine
motor/perceptual. For this study, we limited the
analysis to the oral sensory sensitivity factor only,
which is comprised of the following items: “Avoids
certain tastes or food smells that are typically part
of children’s diets,” “Will only eat certain tastes,”
“Limits self to particular food textures/tempera-
tures,” “Picky eater, especially regarding food tex-
tures,” “Routinely smells nonfood objects,” “Shows
strong preference for certain smells,” “Shows strong
preference for certain tastes,” “Craves certain
foods,” and “Seeks out certain tastes or smells.”
Caregivers were asked to indicate, on a 5-point
scale ranging from ‘always’ (1) to ‘never’ (5), the
frequency with which their child responds to these
sensory experiences. Lower scores correspond to
more frequent child behavioral responses. Children
were categorized into “Typical Performance,” “Prob-
able Difference,” or “Definite Difference” in oral
sensory sensitivity based on the classifications spec-
ified by Dunn (Dunn, 1999).
 Kral et al.: Eating Behaviors of Children with Autism 5

‘typical oral sensory sensitivity’) and a “Definite Dif-

Analytic strategy
Data were analyzed using the SAS System for Win-
dows (Version 9.3; SAS Institute, Cary, NC, USA)
and SPSS (Version 20; SPSS Inc., Chicago, IL,
USA). We used the Shapiro-Wilk test in conjunction
with distribution plots and summary statistics to
examine the normality of the distribution of contin-
uous variables. For Aims 1 and 2, we used indepen-
dent samples t tests for normally distributed
continuous variables, nonparametric tests for non-
normally distributed variables, and Chi-Square and
Fisher’s Exact tests for categorical variables to com-
pare children with ASD and TDC in caregiver-
reported eating behaviors, feeding practices, and
weight-related measures. In a subgroup analysis, we
examined child eating behaviors and caregiver feed-
ing practices by children’s oral sensory sensitivity
status. In an effort to reduce the number of statisti-
cal comparisons, we limited this subgroup analysis
to (1) only children with ASD and (2) children with
“Typical Performance” (hereinafter referred to as
ference” (hereinafter referred to as ‘atypical oral
sensory sensitivity’). Descriptive statistics are
reported as means (SDs) for continuous variables
or as percentages for categorical variables unless
otherwise indicated. Reported p values are 2-sided
and p < .05 was considered significant for all tests.
Results
Child characteristics
Table 1 depicts demographic, anthropometric, and
sensory sensitivity characteristics of children. Among
children with ASD, the majority of children (72%)
were male, Caucasian (60%), and non-Hispanic
(84%). Among TDC, approximately half of the chil-
dren were male (47%) and the majority of them were
African American (83%) and non-Hispanic (97%).
Children with ASD, when compared to TDC,
showed a significantly higher waist circumference
(56.2  7.5 cm vs. 51.9  4.0 cm; p = .01), and

TABLE 1. Characteristics (Mean  SD) of Children with Autism Spectrum Disorders (ASD; n = 25) and Typically Develop-
ing Children (TDC; n = 30)

Child characteristic ASD TDC P-value

Age (years) 5.0  0.9 5.2  0.7 .39
Sex (male/female) 18 (72%)/7 (28%) 14 (47%)/16 (53%) .06
Race (%)
Asian 3 (12) 0 (0) <.0001
Black or African American 6 (24) 25 (83)
White 15 (60) 2 (7)
More than one race 1 (4) 3 (10)
Ethnicity (%)
Hispanic 4 (16) 1 (3) .17
Not Hispanic 21 (84) 29 (97)
Height (cm) 109.4  6.5 112.6  7.2 .10
Weight (kg) 19.9  3.7 20.1  3.6 .79
BMI (kg/m2) 17.0  2.9 15.8  1.5 .11
BMI z-score 0.75  1.39 0.17  1.07 .09
BMI-for-age percentile 66.1  29.9 55.6  30.2 .20
Weight status (%)
Underweight/normal-weight 14 (56) 24 (80) .055
Overweight/obese 11 (44) 6 (20)
Waist circumference (cm) 56.2  7.5 51.9  4.0 .01
Waist-to-height ratio 0.51  0.06 0.46  0.03 <.001
SCQ total score 17.4  5.6 5.9  3.3 <.001
Oral sensory sensitivity 29.4  10.4 39.5  8.5 <.001
Oral sensory sensitivity classification (%)
Typical performance (typical) 10 (40) 25 (83) <.001
Probable difference 4 (16) 3 (10)
Definite difference (atypical) 11 (44) 2 (7)
6 Public Health Nursing

waist-to-height ratio (0.51  0.06 vs. 0.46  0.03; caregivers of children with ASD and typical oral
p < .001). Differences in children’s BMI z-scores sensory sensitivity (N = 10), engaged in signifi-
(ASD: 0.75  1.39 vs. TDC: 0.17  1.07; p = .09) cantly greater emotional feeding (2.3  0.3 vs.
and percentages of overweight/obesity (ASD: 44% 1.4  0.2; p = .02). None of the remaining care-
vs. TDC: 20%; p = .055) were not significant. Chil- giver feeding practices significantly differed by child
dren with ASD showed significant differences in oral sensory sensitivity status (p > .24).
their total score on the SCQ (17.4  5.6 vs.
5.9  3.3; p < .001) and the oral sensory sensitivity Discussion
factor (29.4  10.4 vs. 39.5  8.5; p < .001; lower
scores indicating more frequently endorsed behav- In this study, children with ASD showed signifi-
iors related to oral sensory sensitivity). cantly greater waist circumferences and waist-to-
height ratios when compared to TDC. Children with
Child eating behaviors ASD also showed significantly greater food avoid-
Table 2 depicts caregiver-reported eating behaviors ance behaviors, especially those with atypical oral
for children. Children with ASD showed signifi- sensory sensitivity. Caregivers of children with ASD
cantly greater food fussiness (p < .001) when com- appear to address these nutritional challenges by
pared to TDC. Children with ASD and atypical oral using feeding practices that differ in several
sensory sensitivity (N = 11), when compared to chil- domains from caregivers of TDC.
dren with ASD with typical oral sensory sensitivity In this study, 44% of children with ASD and
(N = 10), showed significantly greater food avoid- 20% of TDC were considered overweight or obese
ance behaviors, such as food neophobia (2.9  0.1 and of those 24% of children with ASD and 13% of
vs. 2.4  0.1; p = .004) and food fussiness TDC were considered obese (data not shown). The
(4.2  0.2 vs. 3.3  0.3, p = .03), and greater prevalence of obesity (24%) among the children
emotional undereating (3.2  0.2 vs. 2.3  0.3; with ASD in this study is slightly lower than the
p = .02), respectively (Figure 1). prevalence rate (30%) reported in a study by Curtin
et al. (2010), which was based on data collected in
Caregiver feeding practices the 2003–2004 National Survey of Children’s
Caregivers of children with ASD differed in several Health. In that study, determination of children’s
feeding practices from caregivers of TDC (Table 3). obesity status was based on caregiver-reported
Caregivers of children with ASD reported to engage rather than measured heights and weights and chil-
in significantly higher levels of prompting and dren’s ages ranged from 3 to 17 years. Differences
encouragement to eat (p = .002), when compared in methods used to determine children’s height and
to caregivers of TDC. weight (i.e., caregiver-reported vs. measured) and
Caregivers of children with ASD and atypical differences in children’s age range may account for
oral sensory sensitivity (N = 11), when compared to differences in obesity prevalence rates between the
two studies. National prevalence rates for over-
TABLE 2. Caregiver-Reported Eating Behaviors weight and obesity among U.S. children differ
(Mean  SEM) of Children with Autism Spectrum Disor- based on their race/ethnicity. In 2009–2010, the
ders (ASD; n = 25) and Typically Developing Children prevalence of overweight and obesity among chil-
(TDC; n = 30) dren ages 2–5 years and 6–11 years was estimated
to be 23.8% and 27.6% for non-Hispanic White
Eating trait ASD TDC P-value
children and 28.9% and 42.7% for non-Hispanic
Food neophobia 2.6  0.1 2.6  0.1 .90
Responsiveness to food 2.5  0.2 2.3  0.1 .39
Black children, respectively (Ogden, Carroll, Kit, &
Enjoyment of food 3.4  0.1 3.8  0.1 .06 Flegal, 2012). In this study, the majority of children
Satiety responsiveness 3.0  0.1 2.9  0.1 .60 with ASD were White (60%), while the majority of
Slowness in eating 3.0  0.2 2.7  0.1 .07 TDC were African American (83%). Despite the
Food fussiness 3.7  0.2 2.6  0.2 <.001 demographic differences between groups and the
Emotional overeating 2.0  0.2 1.7  0.1 .19
increased odds of obesity among African American
Emotional undereating 2.7  0.2 2.5  0.1 .25
Desire to drink 3.3  0.3 3.3  0.2 .90 children (Ogden et al., 2012), children with ASD
showed higher levels of overweight/obesity and sig-
 Kral et al.: Eating Behaviors of Children with Autism 7

Food Neophobia Food Fussiness

4 5
*
3
P = 0.004 * 4 P = 0.03

Score

Score
2
2
1
1

0 0
Typical Oral Atypical Oral Typical Oral Atypical Oral
Sensory Sensitivity Sensory Sensitivity Sensory Sensitivity Sensory Sensitivity

Emotional Overeating Emotional Undereating

5 5

P = 0.02
4
P = 0.07
4
*
3 3
Score

Score
2 2

1 1

0 0
Typical Oral Atypical Oral Typical Oral Atypical Oral
Sensory Sensitivity Sensory Sensitivity Sensory Sensitivity Sensory Sensitivity

Figure 1. Caregiver-Reported Eating Behaviors (Mean  SEM) of Children with Autism Spectrum
Disorders (ASD; n = 25) by Oral Sensory Sensitivity Status

TABLE 3. Caregiver Feeding Practices (Mean  SEM) for value for identifying cumulative cardiovascular risk
Children with Autism Spectrum Disorders (ASD; n = 25) factors in preschool children (Campagnolo, Hoff-
and Typically Developing Children (TDC; n = 30)
man, & Vitolo, 2011). Together, these findings sug-
Caregiver feeding practice ASD TDC P-value gest that children with ASD are at an increased risk
Control over eating 3.8  0.1 4.0  0.1 .10 for excess weight gain at an early age, which can
Prompting and 4.1  0.1 3.4  0.2 .002 have both immediate and long-term adverse effects
encouragement on children’s health including, but not limited to,
to eat an increased risk for developing cardiovascular dis-
Instrumental feeding 2.2  0.2 1.8  0.1 .08
ease, type 2 diabetes, stroke, several types of can-
Emotional feeding 1.9  0.2 1.5  0.1 .15
Perceived responsibility for 4.5  0.1 4.6  0.1 .73 cer, and bone and joint problems (e.g.,
child feeding Anandacoomarasamy, Caterson, Sambrook, Fran-
Concern about child weight 2.2  0.3 2.2  0.3 .77 sen, & March, 2008; Calle & Kaaks, 2004; Reaven,
Restriction 3.8  0.2 3.3  0.2 .07 Abbasi, & McLaughlin, 2004).
Pressure for child to eat 3.0  0.2 3.1  0.2 .62 This study further aimed to compare children
more food
Monitoring 4.4  0.1 4.2  0.1 .22
with ASD and TDC in caregiver-reported child eat-
ing behaviors. While our findings showed signifi-
cantly greater food fussiness among children with
nificantly greater abdominal waist circumferences ASD, overall there were relatively few differences in
and waist-to-height ratios when compared to TDC. caregiver-reported child eating behaviors between
The waist-to-height ratio has been recommended as children with ASD and TDC. Children with ASD
an anthropometric tool predicting cardiovascular and TDC did, however, significantly differ in oral
risk in preschool and older children (e.g., Freedman sensory sensitivity, which corroborates findings
et al., 2007; Kahn, Imperatore, & Cheng, 2005; from prior research (Cermak et al., 2010; Watling,
Maffeis, Banzato, & Talamini, 2008). In our study, Deitz, & White, 2001). Interestingly, when compar-
children with ASD averaged a waist-to-height ratio ing children with ASD by their oral sensitivity sta-
that exceeded the 0.5 waist-to-height ratio cutoff tus, our data indicate that ASD children with
8 Public Health Nursing
atypical oral sensory sensitivity showed significantly
greater food neophobia (e.g., reluctance to eat and/
or avoidance of novel foods), greater food fussiness,
and increased undereating due to negative emo-
tions. Together, these increased food avoidance
behaviors can put children with ASD and atypical
oral sensory sensitivity at an increased risk for
potential nutrient deficiencies, which in turn can
adversely affect their growth and development.
Future research needs to determine the extent to
which these food avoidance behaviors in children
may be food-specific (i.e., apply only to certain
types of foods or food groups) and if they can be
modified through targeted behavioral interventions.
A second aim of this study was to assess if
caregivers of children with ASD use child feeding
practices that differ from those used by caregivers
of TDC. Our data showed that caregivers of chil-
dren with ASD reported to significantly more often
prompt and encourage their children to eat com-
pared to caregivers of TDC. Future research using
larger samples of children will need to determine if
caregivers use specific types of foods to try to regu-
late their child’s eating. When comparing children
with ASD by their oral sensitivity status, our data
indicate that caregivers of children with atypical
oral sensory sensitivity showed significantly greater
emotional feeding than caregivers of children with
typical oral sensory sensitivity. This finding,
together with the finding that children with ASD
and atypical oral sensory sensitivity show greater
levels of under- and overeating due to negative
emotions, suggests that food plays an important
role in regulating child feeding in response to nega-
tive emotional states among families of children
with ASD. Future research is needed to evaluate
the efficacy of behavioral interventions to substitute
child eating and caregiver feeding to regulate nega-
tive emotional states in children with other com-
forting behaviors that do not involve food and
eating.
The strengths of this study include the concur-
rent assessment of caregiver-reported child eating
behaviors and measured child height, weight, and
waist circumference in a unique cohort of children.
To our knowledge, this also is the first study to
comprehensively assess feeding practices in caregiv-
ers of children with ASD. The study also had sev-
eral limitations. First, the skewed distribution of
children’s race between groups may have intro-
duced a recruitment bias and attenuated the
between-group differences in weight-related out-
comes due to the higher prevalence of overweight
and obesity among African American children. It is
also possible that the racial/ethnic differences may
have affected caregiver reporting on some question-
naires due to cultural differences surrounding fam-
ily mealtimes and eating (Skala et al., 2012).
Second, the relatively small sample size may have
precluded us from finding significant differences in
child and caregiver related outcomes, as evident by
findings of several nonstatistically significant
trends. Therefore, before any practice changes can
be implemented, it will be important for future
research to study larger samples of children and to
statistically control for between-group differences
in subject characteristics and adjust for multiple
comparisons. Moreover, caregiver-reported rather
than observed child eating behaviors may be sub-
ject to caregiver bias. The completion of numerous
questionnaires likely placed considerable burden on
caregivers and some items may have overlapped
between questionnaires (e.g., Food Neophobia Scale
and Sensory Profile). Future studies that build on
these preliminary findings should therefore be more
selective in the number of questionnaires that are
being administered to families and/or may use
interview-based assessment techniques to reduce
subject burden. Lastly, due to the communication
deficits in children with ASD, it is possible that
some children may have had undiagnosed medical
conditions, which may have impacted their eating
behaviors or experience of sensory sensitivity.
The findings of this study have important
implications for public health nurses. First, the high
prevalence of feeding difficulties in children with
ASD warrants a comprehensive gastrointestinal and
feeding history be completed by the nurse/provider
at routine health checks. Second, nurses/providers
should complete a thorough physical exam includ-
ing abdominal assessment and measurement of
children’s heights, weights, and waist circumfer-
ences, and determine their BMI-for-age percentiles
and waist-to-height ratios. The results of the assess-
ment and corresponding weight and cardiovascular
health status should be shared with the caregivers
or individuals with ASD. When necessary nurses
should refer families to a specialty feeding clinic
where an interdisciplinary team of behavioral psy-
chologists, advanced practice nurses, and registered
 Kral et al.: Eating Behaviors of Children with Autism
dieticians can address complex child feeding behav-
iors. Lastly, for individuals at risk for overweight/
obesity, in particular, nurses can be trained to play
a critical role in modeling for parents/caregivers
behaviors that reward healthy food choices and eat-
ing behaviors and managing negative child emo-
tions with behavioral strategies and nonfood
alternatives.
In sum, the data from this pilot study suggest
that young children with ASD show increased
abdominal waist circumferences and waist-to-
height ratios, differences in oral sensory sensitivity,
and, for children with atypical oral sensory sensitiv-
ity, in particular, greater feeding challenges than
TDC. Caregivers of children with ASD address these
nutritional challenges by using feeding practices
that differ in several domains from caregivers of
TDC. Public health nurses can take the lead and
build awareness that all individuals with ASD
should be assessed for their eating behaviors and
nutritional status. Moreover, caregivers will need
ongoing support to prevent maladaptive feeding
behaviors, address sensory sensitivities and pro-
mote healthy dietary practices for their family.
Acknowledgments
Financial support: This research was supported by
a pilot grant from the Biobehavioral Research Cen-
ter at the University of Pennsylvania School of
Nursing. We also acknowledge funding support
from the Hillman Scholars Program in Nursing
Innovation.
Conflict of interest: The authors declare that
they have no conflict of interest.
References
Ahearn, W. H., Castine, T., Nault, K., & Green, G. (2001). An
assessment of food acceptance in children with autism or
pervasive developmental disorder-not otherwise specified.
Journal of Autism and Developmental Disorders, 31(5),
505–511.
Anandacoomarasamy, A., Caterson, I., Sambrook, P., Fransen, M.,
& March, L. (2008). The impact of obesity on the musculo-
skeletal system. International Journal of Obesity (London),
32(2), 211–222.
Ashcroft, J., Semmler, C., Carnell, S., van Jaarsveld, C. H., & War-
dle, J. (2008). Continuity and stability of eating behaviour
traits in children. European Journal of Clinical Nutrition,
62(8), 985–990.
Ashwell, M., Gunn, P., & Gibson, S. (2012). Waist-to-height ratio is
a better screening tool than waist circumference and BMI
for adult cardiometabolic risk factors: Systematic review
and meta-analysis. Obesity Reviews, 13(3), 275–286.
9
Autism and Developmental Disabilities Monitoring Network. (2014).
Prevalence of autism spectrum disorder among children
aged 8 years, 11 sites, United States, 2010. MMWR Surveil-
lance Summaries, 63(2), 1–21.
Birch, L. L., & Davison, K. K. (2001). Family environmental factors
influencing the developing behavioral controls of food
intake and body weight. Pediatric Clinics of North Amer-
ica, 48(4), 893–907.
Birch, L. L., & Fisher, J. O. (2000). Mothers’ child-feeding practices
influence daughters’ eating and weight. American Journal
of Clinical Nutrition, 71(5), 1054–1061.
Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Saw-
yer, R., & Johnson, S. L. (2001). Confirmatory factor analy-
sis of the Child Feeding Questionnaire: A measure of
parental attitudes, beliefs and practices about child feeding
and obesity proneness. Appetite, 36(3), 201–210.
Calle, E. E., & Kaaks, R. (2004). Overweight, obesity and cancer:
Epidemiological evidence and proposed mechanisms. Nat-
ure Reviews Cancer, 4(8), 579–591.
Campagnolo, P. D., Hoffman, D. J., & Vitolo, M. R. (2011). Waist-
to-height ratio as a screening tool for children with risk fac-
tors for cardiovascular disease. Annals of Human Biology,
38(3), 265–270.
Carnell, S., & Wardle, J. (2007). Measuring behavioural susceptibil-
ity to obesity: Validation of the child eating behaviour ques-
tionnaire. Appetite, 48(1), 104–113.
Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity
and sensory sensitivity in children with autism spectrum
disorders. Journal of the American Dietetic Association,
110(2), 238–246.
Coulthard, H., & Blissett, J. (2009). Fruit and vegetable consump-
tion in children and their mothers. Moderating effects of
child sensory sensitivity. Appetite, 52(2), 410–415.
Curtin, C., Anderson, S. E., Must, A., & Bandini, L. (2010). The preva-
lence of obesity in children with autism: A secondary data
analysis using nationally representative data from the
National Survey of Children’s Health. BMC Pediatrics, 10, 11.
DeMeyer, M. K. (1979). Parents and children in autism. New York:
Wiley.
Dunn, W. (1999). The sensory profile: Examiner’s manual. San
Antonio, TX: The Psychological Corporation.
Fisher, J. O., & Birch, L. L. (2000). Parents’ restrictive feeding
practices are associated with young girls’ negative self-eval-
uation of eating. Journal of the American Dietetic Associa-
tion, 100(11), 1341–1346.
Freedman, D. S., Kahn, H. S., Mei, Z., Grummer-Strawn, L. M., Di-
etz, W. H., Srinivasan, S. R., et al. (2007). Relation of body
mass index and waist-to-height ratio to cardiovascular dis-
ease risk factors in children and adolescents: The Bogalusa
Heart Study. American Journal of Clinical Nutrition, 86(1),
33–40.
Galloway, A. T., Fiorito, L., Lee, Y., & Birch, L. L. (2005). Parental
pressure, dietary patterns, and weight status among girls
who are “picky eaters”. Journal of the American Dietetic
Association, 105(4), 541–548.
Kahn, H. S., Imperatore, G., & Cheng, Y. J. (2005). A population-
based comparison of BMI percentiles and waist-to-height
ratio for identifying cardiovascular risk in youth. Journal of
Pediatrics, 146(4), 482–488.
Klein, U., & Nowak, A. J. (1999). Characteristics of patients with
autistic disorder (AD) presenting for dental treatment: A
survey and chart review. Special Care in Dentistry, 19(5),
200–207.
Kral, T. V., Eriksen, W. T., Souders, M. C., & Pinto-Martin, J. A.
(2013). Eating behaviors, diet quality, and gastrointestinal
symptoms in children with autism spectrum disorders: A
brief review. Journal of Pediatric Nursing, 28(6), 548–556.
Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L.
M., Flegal, K. M., Mei, Z., et al. (2002). 2000 CDC Growth
Charts for the United States: Methods and development.
Vital Health Statistics, 11(246), 1–190.
10 Public Health Nursing
Lohman, T., Roche, A., & Martorell, R. (1988). Anthropometric
standardization reference manual. Champaign, IL: Human
Kinetics.
Maffeis, C., Banzato, C., & Talamini, G. (2008). Waist-to-height
ratio, a useful index to identify high metabolic risk in over-
weight children. Journal of Pediatrics, 152(2), 207–213.
Mennella, J. A. (2014). Ontogeny of taste preferences: Basic biology
and implications for health. American Journal of Clinical
Nutrition, 99(3), 704S–711S.
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prev-
alence of obesity and trends in body mass index among US
children and adolescents, 1999-2010. Journal of the Ameri-
can Medical Association, 307(5), 483–490.
Ogden, C. L., Kuczmarski, R. J., Flegal, K. M., Mei, Z., Guo, S., Wei,
R., et al. (2002). Centers for Disease Control and Preven-
tion 2000 growth charts for the United States: Improve-
ments to the 1977 National Center for Health Statistics
version. Pediatrics, 109(1), 45–60.
Pliner, P. (1994). Development of measures of food neophobia in
children. Appetite, 23(2), 147–163.
Raiten, D. J., & Massaro, T. (1986). Perspectives on the nutritional
ecology of autistic children. Journal of Autism and Devel-
opmental Disorders, 16(2), 133–143.
Reaven, G., Abbasi, F., & McLaughlin, T. (2004). Obesity, insulin
resistance, and cardiovascular disease. Recent Progress in
Hormone Research, 59, 207–223.
Rutter, M., Bailey, A., & Lord, C. (2003). Manual for the Social
Communication Questionnaire. Los Angeles, CA: Western
Psychological Services.
Schoen, S. A., Miller, L. J., Brett-Green, B. A., & Nielsen, D. M.
(2009). Physiological and behavioral differences in sensory
processing: A comparison of children with autism spectrum
disorder and sensory modulation disorder. Frontiers in
Integrative Neuroscience, 3, 29.
Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E.,
Saulnier, C. A., et al. (2013). Feeding problems and nutri-
ent intake in children with autism spectrum disorders: A
meta-analysis and comprehensive review of the literature.
Journal of Autism and Developmental Disorders, 43(9),
2159–2173.
Skala, K., Chuang, R. J., Evans, A., Hedberg, A. M., Dave, J., &
Sharma, S. (2012). Ethnic differences in the home food
environment and parental food practices among families of
low-income Hispanic and African-American preschoolers.
Journal of Immigrant and Minority Health, 14(6), 1014–
1022.
Smith, A. M., Roux, S., Naidoo, N. T., & Venter, D. J. (2005).
Food choice of tactile defensive children. Nutrition, 21(1),
14–19.
Wardle, J., & Carnell, S. (2007). Parental feeding practices and
children’s weight. Acta Paediatrica Supplement, 96(454),
5–11.
Wardle, J., Carnell, S., & Cooke, L. (2005). Parental control over
feeding and children’s fruit and vegetable intake: How are
they related? Journal of the American Dietetic Association,
105(2), 227–232.
Wardle, J., Guthrie, C. A., Sanderson, S., & Rapoport, L. (2001).
Development of the children’s eating behaviour question-
naire. Journal of Child Psychology and Psychiatry, 42(7),
963–970.
Wardle, J., Sanderson, S., Guthrie, C. A., Rapoport, L., & Plomin,
R. (2002). Parental feeding style and the inter-generational
transmission of obesity risk. Obesity Research, 10(6), 453–
462.
Watling, R. L., Deitz, J., & White, O. (2001). Comparison of Sensory
Profile scores of young children with and without autism
spectrum disorders. American Journal of Occupational
Therapy, 55(4), 416–423.
Williams, P. G., Dalrymple, N., & Neal, J. (2000). Eating habits of
children with autism. Pediatric Nursing, 26(3), 259–264.