Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-023-06013-7

BRIEF REPORT

A Survey of Community Providers on Feeding Problems in Autism

Spectrum Disorder
Teresa Lindsey Burrell1,2,3 · William G. Sharp1,2,3 · Scott Gillespie1 · Katherine Pickard1,2 · Susan Brasher4 ·
Derianne Buckley2,3 · Lawrence Scahill1,2

Accepted: 27 June 2023

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023, Corrected Publication 2023

Abstract
Purpose Feeding problems, ranging from mild to severe, are common in children with autism spectrum disorder. We con-
ducted a 15-item online survey of community providers to gather information on service demand and current treatment
approaches for this clinical population.
Methods Respondents, speech-language pathologists, occupational therapists, registered dietitians, and Board-Certified
Behavior Analysts, were recruited via e-mail listservs, professional conferences, continuing education programs, social
media and electronic newsletters. The survey included questions about professional discipline, years in practice, patient
population served, feeding problem types, therapeutic approaches, and level of interest in parent-mediated interventions.
Results A total of 541 community practitioners responded to the survey; 419 provided usable data. Across all providers,
97% (n = 406) reported seeing children with ASD and feeding problems. Of these, 90% (n = 367) offered treatment. Provid-
ers (n = 23) who did not treat feeding problems cited “insufficient training.” Most common presenting problems included
limited dietary variety, texture sensitivity, and disruptive mealtime behavior. Although treatment approaches varied across
disciplines, 89.3% indicated openness to parent-mediated treatment.
Conclusions These results indicate a high demand for treatment of children with ASD and feeding problems across disci-
plines. Food selectivity was the most common problem. Treatment approaches varied across disciplines. Dissemination and
implementation of evidence-based, parent-mediated intervention is warranted.

Keywords Autism Spectrum Disorder · Pediatric Feeding Disorder · ARFID · Community Involvement · Parent
Training · Evidence-Based Treatment

The estimated prevalence of autism spectrum disorder in
school-age children has increased over the past two decades
from 2 to 1000 to 18.5 per 1000 (Yeargin-Asllopp et al., 2003;
Maenner et al., 2021). This trend reflects the broadening of
The Original article is revised to update the first author.
Lawrence Scahill
lawrence.scahill@emory.edu
1
Emory University School of Medicine, 201 Dowman Dr,
Atlanta, GA, USA
2
Marcus Autism Center, 1920 Briarcliff Rd NE, Atlanta, GA,
USA
3
Children?s Healthcare of Atlanta, Atlanta, GA, USA
4
Nell Hodgson Woodruff School of Nursing, Emory
University, 1520 Clifton Road, NE, Atlanta, GA, USA
the diagnostic criteria, improved assessment methods and
increased awareness. Over this same period, there has also
been an increase in evidence-based interventions for treat-
ing core features of ASD and commonly occurring behav-
ioral problems in this population (Lord & Charman et al.,
2022). There has also been an increase in demand for these
services (Landa, 2018). The adoption of empirically sup-
ported interventions into routine practice, however, has not
kept pace with the growing body of evidence and increased
demand (Boyd et al., 2021). Although not unique to ASD,
the gap between accumulated research evidence and clinical
practice is recognized in many fields of medicine (Morris
et al., 2011; Lyon et al., 2020). Barriers to the adoption of
new evidenced-based treatments by community providers
for children with ASD may include questions about the fit of
the intervention in community settings, staff turnover, and
limited access to training on the intervention in community

13

settings perhaps due to, insufficient administrative support
for training (Boyd et al., 2021).
In children with ASD, findings from many studies sup-
port the effectiveness of parent-mediated interventions for
skill development and reduction of behavioral problems in
children with ASD (Bearss et al., 2015). Parent-mediated
interventions that teach parents to implement therapeu-
tic strategies have demonstrated efficacy in improving
social communication and joint attention skills (Ingersoll
& Wainer, 2013; Kasari et al., 2015), disruptive behavior
(Postorino et al., 2017; Tarver et al., 2019), as well as sleep
and feeding problems (Johnson et al., 2013, 2019; Sharp et
al., 2019). Collectively, this body of work illustrates that
parent-mediated interventions for children with ASD pro-
vide caregivers information and techniques that specifically
target the child’s behavioral problem or skill deficit. By
contrast, parent education provides caregivers with useful
– but more general information about autism (Bearss et al.,
2015). The transfer and integration of parent training into
community practice, however, is limited, with only a hand-
ful of studies examining the implementation of parent train-
ing programs within community systems (Chlebowski et al.,
2018; Rieth et al., 2022; Stahmer et al., 2017). However,
gathering information from community providers about the
service demand for the clinical problem (e.g., feeding prob-
lems) and interest in parent-mediated intervention may offer
guidance on the translation of evidence-based interventions
into community settings.
Over the past decade, there has been increased interest
in the clinical management of feeding problems in children
with ASD (Sharp et al., 2011, 2014a, 2017; Johnson et al.,
2019). Feeding problems ranging from mild to severe are
common in autistic children. Severe feeding problems often
require intensive treatment in specialty clinics (Sharp et al.,
2017). Children with mild feeding problems may not need
treatment beyond parent education. Moderate feeding prob-
lems, often characterized by food selectivity and disruptive
mealtime behavior may adversely affect the child’s health
(Mayes & Zickgraf, 2019; Sharp et al., 2013; Sharp & Post-
orino, 2017) and the quality of family life (Postorino et al.,
2015; Suarez et al., 2014). Therefore, treatment for or autis-
tic children with moderate feeding problems is warranted.
Recently, our group conducted a randomized clinical
trial of a structured parent-mediated intervention: Manag-
ing Eating Aversions and Limited Variety (MEAL) Plan
compared to a structured Parent Education program. In that
study of children with ASD and moderate food selectivity,
MEAL Plan was found acceptable to caregivers. Moreover,
it was superior to Parent Education in decreasing disruptive
mealtime behavior and increasing dietary variety (Sharp et
al., 2019). These results on the efficacy of parent-mediated
intervention for children with ASD and food selectivity are
13
Journal of Autism and Developmental Disorders
consistent with other reports (Johnson et al., 2019). Current
treatment demand for feeding problems in autistic children
in community settings and approaches to treatment, how-
ever, are uncertain. In addition, the level of interest in a
structured parent-mediated intervention for food selectivity
in community providers is unknown.
In the community, feeding problems in children with
ASD may be treated by Speech-language pathologists
(SLPs), occupational therapists (OTs), registered dietitians
(RDs), or Board-Certified Behavior Analysts (BCBAs)
(Marshall et al., 2013; Taylor & Taylor, 2021; Sharp et al.,
2013). Intervention strategies may vary by provider disci-
pline. We surveyed SLPs, OTs, BCBAs and RDs in commu-
nity practice to collect information on demand for treating
feeding problems in children with ASD, on the current
treatment approaches used in community practice and on
the level of interest in parent-mediated intervention for this
clinical population. The report presents the key findings of
the survey.
Methods
Survey Design and Distribution
To gather information on the demand and community treat-
ments of feeding problems in autistic children, we devel-
oped a 15-item online survey (available from corresponding
author upon request). The initial draft was revised following
review and feedback from experts in the multidisciplinary
feeding program at Marcus Autism Center at Emory Univer-
sity School of Medicine . The final version included ques-
tions about professional discipline, practice setting, years in
practice, patient population served, feeding problem types,
therapeutic approaches, and level of interest in structured,
parent-mediated interventions. Five items required “yes”
or “no” responses; four multiple-choice items requested a
single selection; four items invited respondents to check all
that apply. Two additional items, adapted from the Ottawa
Acceptability Survey, inquired about provider openness to
new treatment approaches and attitudes on using a manual-
driven treatment (O’Connor & Cranney, 1996). These two
items were scored on a 5-point Likert scale ranging from
strongly disagree to strongly agree.
Between November 2019 and November 2020, we
invited BCBAs, SLPs, OTs, RDs and other interested pro-
viders to complete the survey. We used various methods to
recruit local (greater Atlanta metropolitan area), regional
(Southeast United States), and national (United States)
participants. These efforts included announcements on
e-mail listservs, professional conferences, continuing edu-
cation programs, social media webpages of professional
Journal of Autism and Developmental Disorders
organization and electronic newsletters (see Table 1). Sur-
vey respondents who answered “no” to the question: “Do
you see children with ASD and feeding problems?“ were
excluded from analysis. Individuals who checked “other”
on the professional discipline item were reclassified into
an aligned group if possible (e.g., registered behavior tech-
nicians were classified with BCBAs, SLP assistants were
classified with SLPs). Respondents who checked “other”
but could not be reclassified due to incomplete information
were dropped from the analyses.
The survey was approved by the Emory University
School of Medicine Institutional Review Board. The elec-
tronic consent document indicated that participation was
voluntary and that survey responses were anonymous.
However, respondents were invited to provide contact infor-
mation if interested in “learning more about assessment and
treatment of feeding problems in children with ASD.“ Sur-
vey data were collected and managed using Research Elec-
tronic Data Capture (REDCap) hosted by Emory University.
Analytic Plan
Data analyses were performed in SAS v.9.4 (Cary, NC);
statistical significance was set at the 0.05 threshold. Survey
responses were summarized overall and by professional cat-
egories using means and standard deviations for continuous
variables and frequencies and percentages for categorical
data. Differences in responses between professional catego-
ries were assessed using unequal variances one-way analy-
sis of variance (ANOVA) tests for continuous data. Post hoc
pairwise tests were calculated when omnibus tests were sig-
nificant. For categorical comparisons, we used Chi-square
tests of independence or Fisher’s exact tests. Statistically
significant differences are labeled in Tables by superscripts.
Table 1 Recruitment Strategy by Discipline
Discipline Recruitment Strategy Location
Type
BCBA 51 ABA practices Regional
Georgia Applied Behavior Analysis Face- Regional
book Page
Behavior Analyst Certification Board National
(BACB) Listserv
SLP/OT Affiliated pediatric hospital OTs and SLPs Local
34 Rehabilitative practices Regional
Presentation at Georgia Association for Regional
Speech and Hearing Sciences (GSHA)
Conference
Presentation at the Association for Speech National
and Hearing Sciences (ASHA) Conference
Pediatric feeding newsletter National
Dietitians Presentation at Georgia Atlanta Dietetic Regional
Association (GADA) Conference
Pediatric Nutrition Practice Group Listserv National
In this exploratory and descriptive study, we did not adjust
the p-value for multiple comparisons.
Results
A total of 541 survey respondents began the survey; 446
participants completed all survey questions. Of those, 6 par-
ticipants “did not see children” and 21 selected “other” pro-
fession and could not be re-classified. The characteristics of
the final sample N = 419 are shown by professional category
in Fig. 1.
Provider demographic and practice characteristics are
presented in Table 2. There were significant differences by
profession on years in practice, number of children seen
per week, and number of children with ASD (all p < .001).
On “years in professional experience” OTs had the high-
est percentage of late-career providers (> 15 years); BCBAs
had the highest percentage of early career providers (0 to
5 years) and lowest percentage of late-career providers. As
shown in Table 2, SLPs and OTs reported higher weekly
volumes for patients with and without ASD. As a percent-
age, SLPs and OTs reported that > 10 children with ASD
per week equaled 30% of their caseloads. This was slightly
higher than BCBAs and considerably higher than RDs.
Patient Characteristics and Treatment Approaches
Of the 419 respondents included in the analyses, 406
(96.7%) reported seeing autistic children; 367 (87.5%)
endorsed providing treatment for feeding problems. The
39 of 406 (9.6%) providers who did not treat children with
feeding problems cited “insufficient training” (23/39; 59%)
and “outside scope of practice” (21/39; 53.9%) as the most
common reasons. All 39 providers who did not offer treat-
ment for feeding problems for autistic children, however,
reported current demand and professional interest in treat-
ing this population.
Figure 2 presents the survey responses for the 367 provid-
ers (87.6% of the sample) who indicated that they treat feed-
ing problems in autistic children. Across all disciplines, the
most reported treatment targets were limited variety, texture
sensitivity and disruptive mealtime behavior. Differences
across providers are shown in Table 3. BCBAs reported the
highest percentage of treating disruptive mealtime behavior.
By contrast, OTs and SLPs reported higher percentages of
treating texture sensitivity.
Practice differences emerged in treatment approach by
provider type (Fig. 3; Table 3). Details on these differences
are presented in Table 3. OTs and SLPs reported using
the highest number treatment of approaches compared to
BCBAs or RDs. There was a significant difference in the
13

Fig. 1 Flow Chart of Survey Respondents
use of sensory and oral-motor approaches. OTs and SLPs
reported significantly higher rates of these approaches. By
contrast, BCBAs or RDs did not often report using sen-
sory and oral-motor approaches. BCBAs used behavioral
approaches in nearly all cases compared to just over half
of cases for RDs. RDs reported a significantly higher per-
centage of applying nutritional intervention compared to
BCBAs.
Provider Acceptance of Structured Parent-Mediated
Treatment
The survey did not include queries on the details of paren-
tal involvement; however, over 90% of respondents across
all disciplines reported including parents in treatment. Most
providers indicated openness to “an approach that differs
from current practice” and willingness to use a treatment
manual (90% and 89.3% respectively).
13
Journal of Autism and Developmental Disorders
Discussion
This study surveyed SLPs, OTs, BCBAs and RDs to obtain
information on service demand and practice patterns for
children with ASD and feeding problems. Survey responses
provide new information on the landscape of community-
based practice for this clinical population. Across all four
disciplines, over 90% of providers reported seeing autistic
children with feeding problems, suggesting high demand
for feeding services in this clinical population. There
were differences in volume across disciplines. SLPs and
OTs reported the highest volume of assessing and treating
patients with ASD and feeding problems. RDs reported the
lowest volume. Despite demand, approximately 10% of
respondents indicated that they do not treat children with
ASD and feeding problems. Insufficient training was given
as the most common reason for this decision.
Survey respondents reported limited dietary variety, tex-
ture sensitivity, and disruptive mealtime behavior as the
most common feeding problems in autistic children. The
high rate of food selectivity is consistent with studies based
on parent reports in this population (Beighley et al., 2013;
Postorino et al., 2015). Our findings are also consistent with
an online survey of BCBAs who treat children with ASD
Journal of Autism and Developmental Disorders

Table 2 Demographic and clinical characteristics by provider type

Survey Questions N All SLP OT BCBA RD P-Value
Participants N = 109 N = 63 N = 195 N = 52
N = 419 (26%) (15.1%) (46.5%) (12.4%)
Practice years
0–5 419 141 (33.6%) 29 (26.6%)a 13 (20.6%)b 82 (42%)c 17 < 0.001
(32.7%)a,b
6–15 147 (35.1%) 37 (33.9%) 13 (20.6%) 85 (43.6%) 12 (23.1%)
>15 131 (31.3%) 43 (39.5%) 37 (58.7%) 28 (14.4%) 23 (44.2%)
Child cases per week
0–5 419 75 (17.9%) 4 (3.7%)a 3 (4.8%)a 58 (29.7%)b 10 (19.2%)c < 0.001
6–10 112 (26.7%) 11 (10.1%) 8 (12.7%) 78 (40%) 15 (28.9%)
>10 232 (55.4%) 94 (86.2%) 52 (82.5%) 59 (30.3%) 27 (51.9%)
ASD cases per week
0–5 419 178 (42.5%) 42 (38.5%)a 28 (44.4%)a 62 (31.8%)a 46 (88.4%)b < 0.001
6–10 135 (32.2%) 34 (31.2%) 16 (25.4%) 82 (42.1%) 3 (5.8%)
>10 106 (25.3%) 33 (30.3%) 19 (30.2%) 51 (26.1%) 3 (5.8%)
Ages of children served
Only young children (≤ 10 years) 419 175 (41.8%) 53 (48.6%)a 22 86 (44.1%)a 14 (26.9%)b 0.038
(34.9%)a,b
Young and children > 10 years) 244 (58.2%) 56 (51.4%) 41 (65.1%) 109 (55.9%) 38 (73.1%)
See children with ASD + feeding problems? 419 406 (96.9%) 105 (96.3%) 63 (100%) 188 (96.4%) 50 (96.2%) 0.537
Treat children with ASD + feeding problems?1 406 367 (90.4%) 102 59 165 41 (82%)b 0.009
(97.1%)a (93.6%)a,b (87.8%)b
Treatment for feeding problems involve parents?2 367 360 (98.1%) 102 (100%) 59 (100%) 159 (96.4%) 40 (97.6%) 0.115
1
Denominator is providers that see patients with ASD + feeding problems (N = 406); 2Denominator is providers that see autistic patients and
feeding problems, and do provide treatment (N = 367); *Omnibus tests are unequal variances one-way ANOVA for continuous variables, sum-
marized by Mean (SD), and Chi-square or Fisher’s Exact tests for discrete variables, summarized by N (%); †Pairwise p-values were calculated
when omnibus tests were significant–non-overlap of superscripts indicates significant pairwise comparisons (e.g., a vs. b is significant; a vs. a
is insignificant)

Fig. 2 Types of presenting problems treated by all respondents

13
 Journal of Autism and Developmental Disorders

Table 3 Respondents who report treating autistic children with feeding problems
Survey Questions All Respon- SLP OT BCBA RD P-Value
dents N = 367 N = 102 N = 59 N = 165 N = 41
Types of feeding problems treated1
Number of types, Mean (SD) 6.0 (2.2) 6.7 (2.0)a 7.8 (1.8)b 5.1 (1.8)c 5.4 (2.1)c,d < 0.001
a,b a a,b
Limited variety 356 (97%) 100 (98%) 59 (100%) 160 (97%) 37 (90.2%)b 0.030
Texture sensitivity 322 (87.7%) 96 (94.1%)a 58 (98.3%)a 135 (81.8%)b,c 33 (80.5%)c 0.001
Disruptive mealtime behavior 302 (82.3%) 81 (79.4%)a,b 48 (81.4%)a,b 146 (88.5%)a 27 (65.8%)b 0.006
Self-feeding 265 (72.2%) 60 (58.8%)a 56 (94.9%)b 130 (78.8%)c 19 (46.3%)a < 0.001
Chewing difficulty 210 (57.2%) 90 (88.2%)a 53 (89.8%)a 47 (28.5%)b 20 (48.8%)c < 0.001
a a b,c
Pocketing 198 (53.9%) 78 (76.5%) 50 (84.8%) 60 (36.4%) 10 (24.4%)c < 0.001
Messy eating 192 (52.3%) 46 (45.1%)a 46 (78%)b 93 (56.4%)a 7 (17.1%)c < 0.001
Feeding tube/formula dependence 178 (48.5%) 66 (64.7%)a 43 (72.9%)a 42 (25.5%)b 27 (65.8%)a < 0.001
Weight loss 161 (43.9%) 57 (55.9%)a 39 (66.1%)a 29 (17.6%)b 36 (87.8%)c < 0.001
Other 27 (7.4%) 8 (7.8%) 8 (13.6%) 7 (4.2%) 4 (9.8%) 0.110
Types of approaches used for feeding problems1
Number of types, Mean (SD) 2.1 (1.1) 2.9 (1.0)a 3.0 (1.1)a 1.4 (0.8)b 1.9 (0.7)c < 0.001
a a b
Behavioral 324 (88.3%) 90 (88.2%) 46 (78%) 164 (99.4%) 24 (58.5%)c < 0.001
Sequential Oral Sensory (SOS) 164 (44.7%) 84 (82.3%)a 49 (83.1%)a 22 (13.3%)b,c 9 (21.9%)c < 0.001
Nutritional intervention 128 (34.9%) 43 (42.2%)a 25 (42.4%)a 23 (13.9%)b 37 (90.2%)c < 0.001
Oral motor 110 (30%) 53 (52%)a 40 (67.8%)a 16 (9.7%)b,c 1 (2.4%)c < 0.001
Other 52 (14.2%) 21 (20.6%)a 18 (30.5%)a 6 (3.6%)b 7 (17.1%)a < 0.001
1
Denominator is providers that see autistic patients and feeding problems, and do provide treatment (N = 367); *Omnibus tests are unequal
variances one-way ANOVA for continuous variables, summarized by Mean (SD), and Chi-square or Fisher’s Exact tests for discrete variables,
summarized by N (%); †Pairwise p-values were calculated when omnibus tests were significant–non-overlap of superscripts indicates signifi-
cant pairwise comparisons (e.g., a vs. b is significant; a vs. a is insignificant)

and feeding problems (Clark, Wilder & Lesser, 2023). The
common co-occurrence of limited dietary variety, texture
sensitivity, and disruptive mealtime behavior suggests that
sensory sensitivities and behavioral elements may be linked.
Studies in neophobia (reluctance to try new foods) and dis-
gust (rejection of food considered unsafe) support this asso-
ciation and may play a role in the underlying mechanism
of feeding problems in autistic children (Al-Shawaf et al.,
2015).
Survey respondents reported using a variety of treat-
ment approaches including behavioral, sensory, oral motor,
and nutritional interventions for feeding problems in chil-
dren with ASD. However, practice differences did emerge.
SLPs and OTs reported using the widest range of treatment
approaches but relied primarily on behavioral interventions
and the Sequential Oral Sensory (SOS) approach. BCBAs
reported the use of behavioral interventions and rarely used
other approaches. By contrast, dietitians reported nearly
exclusive use of nutritional guidance as their intervention of
choice. These practice differences presumably reflect differ-
ences in professional background and training across disci-
plines resulting in separate referral pathways. For example,
children with feeding problems and moderate or greater
disruptive behavior may be more likely to be referred to a
BCBA rather than a RD. By contrast, a multidisciplinary
approach is recommended for children with severe feeding
problems due to the individualized roles and expertise of
these unique disciplines. The assessment and treatment of
children with ASD and moderate feeding problems such as
food selectivity, however, may also benefit from a multidis-
ciplinary approach.
Survey results indicate that a large majority of respon-
dents would consider an intervention that differs from their
current approach including willingness to use parent-medi-
ated intervention. These findings are consistent with survey
results of community providers in Australia (Marshall et al.,
2013).
Nearly all respondents in our survey reported involving
parents in treating children with ASD and feeding prob-
lems. The survey did not inquire about the nature or extent
of parental involvement. Available evidence supports the
efficacy of structured, parent-mediated interventions for
children with ASD and moderate food selectivity (Sharp et
al., 2019; Johnson et al., 2019). As noted above, children
with severe feeding disorders require intensive treatment in
day or inpatient treatment programs. The findings from the
studies by Sharp et al. and Johnson et al. suggest that parent-
mediated intervention is fitting for children with ASD and
moderate food selectivity.
These interventions provide parents with practical tools
to manage disruptive mealtime behavior and expand dietary
variety. These tools may reduce the stress reported by par-
ents of children with ASD and food selectivity (Postorino et
al., 2015; Silverman et al., 2021). Integration of parents as

13
Journal of Autism and Developmental Disorders
Fig. 3 Survey responses by discipline on treatment approach and treatment strategy at p < .001
change agents may also reduce commonly reported parental
discouragement due to unsuccessful efforts to expand the
child’s diet (Suarez et al., 2014).
Limitations
Because survey participation was anonymous, we do not
have information on respondents’ geographic location to
evaluate regional differences. The study sample may reflect
providers with high interest in autistic children with feeding
problems. Although we did not exclude psychologists, the
survey did not gather responses from psychologists. There-
fore, our results may not be representative of all commu-
nity providers. The brief survey did not include details on
the nature of parental involvement in treatment, questions
about severity of feeding problems or items about nutri-
tional assessment. The inclusion of broad, undefined terms
(e.g., behavioral, nutritional, oral motor) that were used to
describe interventions and items that allowed respondents
to “check all that apply” reduced the precision analyses and
interpretation of the findings.
Conclusions
This study provides information about current community
practice for children with ASD and feeding problems. The
survey results indicate a high demand for treatment of chil-
dren with ASD and feeding problems such as limited vari-
ety, texture sensitivity, and disruptive mealtime behaviors.
Although most respondents reported treating children with
ASD and feeding problems, treatment approaches varied
across disciplines. Most respondents indicated willing-
ness to use parent-mediated intervention to address feeding
problems in this population. This study presents opportuni-
ties to disseminate empirically supported parent-mediated
approaches across disciplines. To be successful, a struc-
tured, parent-mediated intervention will face the challenge
of integrating differences and contributions of providers
13

across disciplines. Noting that nearly all respondents indi-
cated parental involvement in treatment suggests that par-
ent-mediated intervention may be a good fit for community
practitioners. Further study on how to translate empirically
supported, structured, parent-mediated intervention into
community settings is warranted.
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