Journal of Autism and Developmental Disorders, Vol. 34, No.

4, August 2004 (Ó 2004)

A Comparison of Eating Behaviors between Children with and

without Autism

Kimberly A. Schreck,1,4 Keith Williams,2 and Angela F. Smith3

Although clinicians typically assume that feeding problems co-exist with a diagnosis of aut-
ism, no previous research has compared the eating behavior of children with autism to typi-
cally developing children. This study compared caregiver report of eating problems of
children with and without autism on a standardized questionnaire. The questionnaire
included items pertaining to food refusal and acceptance patterns as well as food presenta-
tion requirements. Caregivers were also asked to complete a food inventory that indicated
the number of foods eaten within each food group for both the child and the family.
Results indicated children with autism have significantly more feeding problems and eat a
significantly narrower range of foods than children without autism.

KEY WORDS: Autism; food refusal; food selectivity; pediatric feeding.

INTRODUCTION Among these children with developmental disabili-

For new parents some of the most important
information related to relatives consists of the
weight and height of their new baby. At each well
child visit, the child’s progress on the growth charts
is recorded. It is no wonder that caregivers have
viewed feeding as one of their most important
responsibilities. For the majority of parents, feeding
their children has presented only transient chal-
lenges. However, the prevalence of feeding problems
among children with developmental disabilities has
ranged from 13% to as high as 80% (Coffey &
Crawford, 1971; Jones, 1982; Palmer & Horn, 1978;
Perske, Clifton, McClean, & Stein, 1977).
Within our clinical practice, the overwhelming
number of children who present with feeding
problems also have developmental disabilities.
1
Penn State Harrisburg.
2
Hershey Medical Center.
3
Melmark Inc.
4
Correspondence should be addressed to Kimberly A. Schreck,
Ph.D., 777 W. Harrisburg Pike, W157 Olmsted Building, Middle-
town, PA 17047-4898; Tel.: +717-948-6048; Fax: +717-948-
6519; e-mail: kas24@psu.edu
433
ties are a number of children with autism spectrum
disorders. Anecdotal stories have included children
who only eat the ‘‘yellow’’ (i.e., McDonald’s French
fries, chicken nuggets, etc.) or ‘‘baby food’’ diets, or
who will only eat when food has been presented in
a particular manner (e.g., on a Thomas the tank
engine plate with no foods touching and only sitting
at his picnic table). Unfortunately, although parents
have reported these behaviors and even diagnostic
sources have assumed that eating problems have
been more serious for children with autism than for
typically developing children (American Psychiatric
Association, 1994), very little research has described
these feeding issues related to the diagnosis of aut-
ism spectrum disorders.
The few technical reports on eating problems
that have been conducted with children with autism
have reported selective eating based on food presen-
tation (e.g., only drinking from bottles) and on food
types (Ahearn, Castine, Nault, & Green, 2001;
Archer & Szatmari, 1991; DeMyer, Ward, & Lintze-
nich, 1968; Kanner, 1943; Kinnell, 1983; Lopreiato
& Wulfsberg, 1992; Minshew & Payton, 1988; Rai-
ten & Massaro, 1986; Stone, MacLean, & Hogan,
0162-3257/04/0800-0433/0 Ó 2004 Plenum Publishing Corporation
434
1995; Teplin, 1999). The majority of the studies
have reported only individual cases of feeding prob-
lems for children with autism. Only a pair of studies
has examined groups of children with autism and
found strong preferences and idiosyncratic feeding
behavior among them (Ahearn et al., 2001; Archer
& Szatmari, 1991; Nagai, 1983). Ahearn et al.
(2001) have conducted one of the first systematic
attempts at discovering the amounts of foods within
each food group children with autism have typically
consumed. Unfortunately, the study was of limited
generalizability due to the small sample size. All of
the studies examining types of feeding problems in
children with autism have been limited by several
factors including small sample size, lack of knowl-
edge of co-morbid medical conditions that could
affect eating, lack of comparison to the feeding
behaviors of children without autism, and inade-
quate information on the foods typically available
within the family environment.
The goal of this study was to corroborate and
expand on the information provided by previous
case studies and clinical reports by answering the
following research questions: (a) do children with
autism have different eating habits from typical chil-
dren? if so (b) what types of foods do children with
autism typically eat or refuse? and (c) do families of
children with autism eat a narrower range of foods
than families of children without autism?
METHOD
Participants
Caregivers of children between the ages of 5
and 12 years (n ¼ 472; actual range ¼ 7–9.5 years)
were recruited to complete questionnaires pertaining
to their family’s and child’s eating habits. This age
range was chosen to avoid the infant and toddler
years when children transition from formula to solid
foods and adolescents when children engage in
activities outside of the home (making it harder for
caregivers to accurately report their child’s food
preferences).
Caregivers of the children with autism were
recruited through membership lists for local, state,
and national autism societies, schools for children
with autism, and from local doctors. A control
group was recruited from local school districts. A
local school district in central Pennsylvania agreed
to participate in this study. For a control group,
Schreck et al.
parents of all children in classrooms within the tar-
get age group received a packet containing identical
materials as the autism group. To ensure confidenti-
ality, all names and addresses were kept secured by
the principal co-investigators after mailing labels
were typed by a research assistant. No identifying
information was required on the returned responses
for either the autism group or the control group.
Caregiver report of an autism diagnosis and
the Gilliam Autism Rating Scale (GARS) (Gilliam,
1995) were used to assist with group assignment (a
description of this instrument is included below).
Two initial groups were developed from this infor-
mation:
1. Control (n ¼ 298): Children were assigned to this
group if their GARS scores were less than 80
(indicating below average to very low probability
of autism) and their parents reported no previous
or current diagnosis of autism or pervasive devel-
opmental disorder. Questionnaire return rate for
this group was approximately 25%.
2. Autism (n ¼ 138): This group was composed of
children who had been diagnosed with autism
or pervasive developmental disorder by a profes-
sional and had a GARS score P80. Although
the cut-off score falls within the GARS range
of below average probability of autism, the
GARS manual indicates that 90% of children
with autism fall within scores of 80 and above
(Gilliam, 1995). Consequently, this range was
chosen to include the maximum amount of chil-
dren with autistic behavior. Questionnaire return
rate for this group was approximately 29%.
However, precise return rates for this group
would be difficult to obtain because autism soci-
eties and schools were given permission to make
copies of the packets and distribute to addi-
tional parents.
Children whose caregivers reported a profes-
sional diagnosis of autism or pervasive developmen-
tal disorder, but had GARS scores O80ðn ¼ 31Þ
and children whose caregivers did not report a pro-
fessional diagnosis of autism, but whose GARS
scores P80ðn ¼ 5Þ, were excluded from analysis.
Demographic information was collected for all
participants and included: date of birth, height,
weight, gender, presence of developmental disabili-
ties, and presence of medical problems. Statistical
t-tests were conducted to determine if the control
group and autism group differed on age, height,
weight, or gender. Significant differences were only
Comparison of Eating Behaviors between Children with and without Autism 435

Table I. Child Characteristics by Group Assignment the only measure of eating and mealtime behaviors
in children, and has been used previously with chil-
Characteristic Control (n = 298) Autism (n = 138)
dren with autism (Archer & Szatmari, 1991).
Sexa
Female 47 10
Male 53 88 Food Preference Inventory
Heightb 52 51
The Food Preference Inventory is a listing of
Weightc 71 66
Aged 108 99 foods from each of the five food groups (fruits,
vegetables, dairy, proteins, and starches). Caregivers
a
Reported by percentages of group. indicate whether the child will eat an age-appropri-
b
Average height reported in inches. ate portion of a particular food and whether the
c
Average weight reported in pounds.
d food is typically offered at meals and eaten by the
Average age reported in months.
family. Scores for the five food groups are obtained
by summing the foods accepted by children within
each food group (e.g., total number of starches typi-
found for gender t(397.32) ¼ )9.32, p ¼ .001 (see
cally eaten). Scores are also obtained for what types
Table I for basic demographic information by
of foods are typically eaten by the parents (e.g.,
group).
total number of starches eaten).
Although certain medical problems could influ-
ence eating and mealtime behavior, no specific med-
ical diagnoses were excluded. Instead, data on Gilliam Autism Rating Scale
medical diagnoses that could possibly influence
The GARS (Gilliam, 1995) is a professional
feeding was collected. Children with autism were
and parent report scale for evaluating autism, con-
found to have significantly higher rates than
structed from criteria in the Diagnostic and Statisti-
expected of medical problems; however, the number
cal Manual of Mental Disorders: Fourth Edition
of children with these problems within the autism
(DSM-IV) (American Psychiatric Association, 1994)
group (n ¼ 138) was small: seizure disorder (n ¼ 7),
and from the Autism Society of America’s (1994)
current lactose intolerance (n ¼ 8), obsessive com-
definition of autism. Gilliam reported the scale’s
pulsive disorder (n ¼ 21), anxiety (n ¼ 14), pulmo-
uses as providing supplemental information for
nary problems (n ¼ 3), current gastroesophageal
identification of autism, identifying serious behavior
reflux (n ¼ 5), previous gastroesophageal reflux
problems, evaluating progress for educational goals,
(n ¼ 9), constipation (n ¼ 11), diarrhea (n ¼ 6), and
identifying target goals, and as providing a research
current g-tube feedings (n ¼ 2). Since children with
measurement for autism (Gilliam, 1995). The four
medical problems constituted such a small propor-
domains (stereotyped behavior, communication,
tion of the children with autism and the causal links
social interaction, and developmental disturbances)
between these medical problems and eating is not
together yield an Autism Quotient (AQ) to deter-
clear, the responses for these children were not elim-
mine probability and severity of autism (with a
inated from the study.
mean of 100 and a SD of 15). The AQ was normed
on a sample of children (n ¼ 1,092) with autism.
Materials The manual reports that of children with diagnosed
autism, 90% obtain AQ scores P80. The test man-
Children’s Eating Behavior Inventory
ual (Gilliam, 1995) reported adequate validity and
The Children’s Eating Behavior Inventory reliability for test domains and for the AQ.
(CEBI) (Archer, Rosenbaum, & Streiner, 1991),
caregiver report for evaluating mealtime behaviors
Personal History Form
and eating behaviors, measures the frequency of 19
different eating behaviors through the use of a 5- The personal history form was used to gather
point rating scale. It also asks caregivers to evaluate demographic information (date of birth, weight,
whether or not each behavior presents a problem height, and gender). The form also listed a number of
for the family. Reliability for the total eating medical diagnoses for the caregivers to indicate if
problem score is in the acceptable range (r ¼ .87), their child was currently or previously diagnosed with
as is construct validity. This instrument is currently any of the listed medical diagnoses. All of the medical
436
diagnoses were chosen because they have been associ-
ated with feeding or eating problems in the literature.
A list of developmental disabilities was also provided
and the caregivers were asked to indicate if their child
was currently or previously diagnosed with any of the
listed developmental disabilities.
Procedures
Initial approval for the project was obtained
from the Penn State Office of Regulatory Compli-
ance and the Penn State College of Medicine. Per-
mission to conduct the research was also obtained
from the autism societies, the pediatricians’ offices,
and the school district administrations. Once verbal
permission was granted, the packets were distributed
to the autism societies and schools by mail, by hand
delivery from one of the co-investigators, or by fax.
The autism societies and school districts then distrib-
uted the packets (with return postage included) to
the parents. Patients of participating doctors
received a packet sent directly to them through the
mail. All participants were asked to complete the
questionnaires and return them via the mail
(returned postage was included in all packets).
RESULTS
All analyses were computed using the Statisti-
cal Package for the Social Sciences (SPSS) (2000).
As previously stated, for purposes of general com-
parisons of children with autism characteristics,
these results were obtained by comparing the eating
behavior of the control group (n ¼ 298) and the
autism group (n ¼ 138).
General Eating Habits
Since no significant difference in age between
the groups was found and previous research has
indicated no age difference interactions with use of
the CEBI (Archer et al., 1991), age was not used as
a separate variable in the analyses.
General differences in the children’s eating hab-
its were compared using the CEBI’s total problem
score domain (Archer et al., 1991). The hypothesis
that caregivers of children with autism report their
children have significantly more feeding problems
than caregivers of children without autism was
confirmed. A t-test was conducted to determine if
the children without autism differed from the chil-
Schreck et al.
dren with autism on the CEBI total problem score.
The Levene’s Test for Equality of Variances was
significant indicating unequal variances. Conse-
quently, the t-test for unequal variances is reported
t(226.22) ¼ 7.35, p ¼ .001. The autism group (M ¼
47.00; SD ¼ 7.01) scored higher than children in the
control group (M ¼ 41.97; SD ¼ 5.76). Although
these differences indicated that children with autism
experienced more general feeding problems com-
pared to children with fewer autism symptoms, it
did not indicate what types of feeding problems
were being exhibited.
Types of Feeding Problems
Further analyses were conducted on the types
of feeding problems children with autism exhibited.
Parent reports of refusing most foods, requiring
specific utensils, requiring particular food presenta-
tion, accepting only pureed or low textured foods,
and eating a narrow variety of foods were com-
pared between the control group and the children
with autism.
An analysis of expected and observed
Chi-square scores for food refusal for each group
indicated that children with autism had a tendency
to refuse more foods than children in the control
groups, v2 ð1; n ¼ 436Þ ¼ 101:13; p < :000. To accept
foods, children with autism more likely required
specific utensils ½v2 ð1; n ¼ 436Þ ¼ 35:29; p < :000

and particular food presentations ½v2 ð1; n ¼ 436Þ ¼
80:75; p < :000
than children in the control group.
Additionally, children with autism were more likely
to only accept foods of low texture, such as puréed
foods, v2 ð1; n ¼ 436Þ ¼ 8:75; p < :01:
Parents also reported that children of autism,
regardless of texture, ate only a narrow variety of
presented foods, v2 ð1; n ¼ 436Þ ¼ 105:06; p < :000.
In fact, 72% of the children with autism were
reported to eat a narrow variety of foods. Clarifica-
tion of the types of foods eaten by children with
autism was then conducted by comparing parent
responses on the Food Preference Inventory’s (FPI)
five food group domains (fruits, vegetables, dairy,
protein, and starch) for the two groups.
Types of Foods Eaten
Statistical t-tests were conducted to determine
when the children with autism differed from the con-
trol group on numbers of fruits, vegetables, dairy,
proteins, and starches eaten. When Levene’s Test for
Comparison of Eating Behaviors between Children with and without Autism
Equality of Variances was significant indicating
unequal variances, the t-test for unequal variances
was reported. Because multiple comparisons were
performed, a more conservative alpha was set at .01,
due to the exploratory nature of this investigation.
Significant differences in the numbers of each type
of foods eaten were reported for all of the food
groups: fruits: tð308:48Þ ¼ 10:79, p ¼ :001; dairy:
tð434Þ ¼ 10:63, p ¼ :001; vegetables: tð318:5Þ ¼
7:76, p ¼ :001; proteins: tð324:79Þ ¼ 9:65, p ¼
:001; starches: tð337:88Þ ¼ 8:28, p ¼ :001. The aut-
ism group reportedly ate significantly fewer foods
within each category (Table II contains the means
and SD of the number of foods eaten by food group
for each group of children).
Although the children with autism ate signifi-
cantly fewer foods from each of the food groups
than children without autism, this finding did not
extend to the families, with no significant differences
in number of foods eaten from each food group
between families of the children with autism and
families of children without autism.
DISCUSSION
The hypothesis that children with autism exhi-
bit more eating and meal-time problems than typi-
cally developing children advanced by previous case
reports and studies (Ahearn et al., 2001; Archer &
Szatmari, 1991; DeMyer et al., 1968; Kanner, 1943;
Kinnell, 1983; Lopreiato & Wulfsberg, 1992; Min-
shew & Payton, 1988; Raiten & Massaro, 1986;
Stone et al., 1995; Teplin, 1999) was supported.
Specifically, the results of this study supported pre-
vious research that children with autism’s eating
behavior is restricted by food category (Ahearn
et al., 2001), by texture (Ahearn et al., 2001; Archer
& Szatmari, 1991), and that these children refuse
foods more often than typically developing children
Table II. Numbers of Foods Eaten by Children for Each Food
Group
Food types Autism group Control group
M SD M SD
Fruits 8.09 6.52 15.75 7.62
Dairy 4.32 3.30 8.07 3.48
Vegetables 4.00 5.00 8.23 6.06
Proteins 7.82 5.98 14.24 7.40
Starches 15.82 8.80 24.08 11.38
437
(Archer & Szatmari, 1991). This study also presents
a new and much needed (Ahearn et al., 2001) aspect
to the study of feeding problems for children with
autism—a comparison to typically developing chil-
dren.
In this study, parents reported their children
with autism exhibited more general feeding prob-
lems including refusing foods, requiring specific pre-
sentations of foods and specific utensils, eating only
low texture foods, and eating a narrow variety of
foods than children without autism. Results from
the analysis of the numbers of specific foods eaten
within each food group supported that children
with autism eat fewer foods within each food group
than typically developing children. However, the
families of children with and without autism eat
similar numbers of foods within the food groups.
Consequently, the differences in foods eaten did not
appear to be a direct result of fewer opportunities
for different foods within the families of children
with autism.
Although this study supplements the available
information concerning feeding problems and chil-
dren with autism, some methodological problems
could have partially influenced the results. For
example, the selection process for the families of
children with autism could have provided skewed
results. The number of children with autism
within the sample (n ¼ 138) constituted approxi-
mately 32% of the total sample. This was higher
than the estimated occurrence of autism within
the population (American Psychiatric Association,
1994) and also could have indicated a selection
bias for children with autism with feeding prob-
lems. However, because this study contained
greater numbers of participants with autism than
previous studies, it has provided far greater sup-
port to the occurrence of feeding problems within
this population.
Because the sample of children could also have
been restricted due to the chosen target age group,
the results of this study are also limited to the feed-
ing problems of older children with autism. Conse-
quently, the chosen target age restrictions can be
viewed as a partial limitation to this study.
Although feeding problems can be observed in
younger children with autism than our chosen tar-
get age, the results of this study can nonetheless be
used to evaluate enduring feeding problems for
these children.
Additionally, the use of parental report of
foods eaten by children may have also created less
438
accurate results than method of actual presentation
of foods (see Ahearn et al., 2001). For example,
parents may limit exposure (not supported by this
study), present foods to the child that he will read-
ily accept, or inaccurately report what the child
eats. However, as noted in Ahearn et al. (2001)
artificial eating environments may also create prob-
lems with feeding for children with autism due to
difficulties in accepting differences in their environ-
ments. Consequently, the use of multiple parental
report measures of eating behavior, including a
standardized eating problem questionnaire (CEBI:
Archer et al., 1991), affords more confidence in the
results of this study and may provide a more nor-
malized view of children with autism’s typical eat-
ing patterns.
Although significantly more research should
be conducted to determine the feeding problems
associated with autism, this study provides one of
the most comprehensive preliminary investigations
into the differences between parental reports of
feeding problems for children with and without
autism. The results in this study indicate that the
problems parents of children with autism face dur-
ing feeding situations continue to be a problem,
long after well child visits stop concentrating on
the growth charts.
Because feeding issues do not appear to be as
transient for children with autism as children with-
out autism, clinicians should continue to address
feeding issues in children with autism after the well
child visits. In fact, one study has shown that if the
selective feeding issues of children with autism are
not addressed, these children are at higher risk for
nutritionally related medical problems, such as rick-
ets (Clark, Rhoden, & Turner, 1993). While the
long-term effects of feeding problems are not clear,
it is certainly possible they could lead to nutritional
deficits and significant medical issues.
ACKNOWLEDGMENTS
This project was partially funded from a grant
to K.A. Schreck & K. Williams from the Pennsylva-
nia State University Research Council. Thanks are
given to the many families, support groups, and
schools that participated in our study. Special thanks
are given to the Eden school and the South Eastern
school district for their cooperation with distributing
questionnaires to the families of their students.
Schreck et al.
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