Taylor, S. A., & Taylor, T. (2021). The distance between empirically-supported treatment and actual practice for paediatric feeding problems: An international clinical perspective. International Journal of Child and Adolescent Health, 14(1).
Review by Sheila Klick, MEd, BCBA and Mary Jane Weiss, PhD, BCBA-D
Melmark
Science in Autism Treatment routinely provides access to research and practice that has direct relevance for people with autism. This article summary is different in that it is not directly focused on autism, but this topic has special relevance to people diagnosed with autism, as they are highly vulnerable to feeding problems. Feeding problems are common among children with autism spectrum disorder (ASD), with some estimates of up to 70% of individuals with ASD having challenges in this area (Seiverling et al., 2010). In addition to the high incidence of these challenges, it has also been found that feeding challenges in individuals with autism are associated with an increased risk of medical problems, nutritional deficiencies, and familial stress (Curtin et al., 2015). While diagnoses can guide treatment recommendations, effective interventions are not always restricted to a specific population. Children with an autism diagnosis experience challenges that transcend autism. This article serves as a reminder that the research to practice gap is not unique to the autism community, and that treatment considerations with other populations can shed light on treatment options for individuals with autism.
Unfortunately, some children diagnosed with developmental disabilities or medical conditions, and some neurotypical children may demonstrate pediatric feeding problems of varying degrees of severity. This is a global issue with potentially dire consequences if not treated early, including nutritional deficiencies, medical complications, as well as negative impacts on learning, development, and family functioning. It is important for children experiencing pediatric feeding problems to access effective treatment. Empirically supported treatments are interventions that are supported by the research literature and shown to be effective. The authors identified concerns that: 1) while pediatric feeding is a global issue, there are few centers, mainly localized to the United States, to provide these services, 2) treatment recommendations identified by Taylor & Taylor (2021) via the internet in Australia and New Zealand may not match empirically supported treatments identified as effective by research.
The study
The researchers’ aim was to identify current recommendations and treatment approaches in Australia and New Zealand, with a focus on separating generic recommendations from research-supported treatment approaches.
First, Taylor & Taylor (2021) searched the internet for treatment recommendations on Australian and New Zealand websites, based on the assumption that parents would likely seek information from the web before seeking medical consultation. Some general recommendations were identified (e.g., routine, modeling healthy eating, and praise), but the majority of recommendations were in contrast to findings of research, as summarized below in Table 1. Some recommendations without contrasting examples included: provide routine and ensure appetite, model healthy eating, and use praise (Taylor & Taylor, 2021).
Table 1. Common recommendations for feeding problems and related research evidence with Contrasting Research Examples (Taylor & Taylor, 2021)
| General Recommendation | Contrasting Research Examples |
| The child needs to be exposed to new foods on a certain number of occasions. | Research evidence for this recommendation is mostly from studies done with children without feeding problems or focuses on sweeter food types (Wardle et. al, 2003). Children with feeding problems typically show no change, or worsening in mealtime behavior where food is merely presented on a repeated schedule (Piazza et al., 2003). |
| The child should control eating. Do not pressure your child. | Multiple studies and media reports highlight the impact on children who continue to restrict eating to specific foods, utensils, or contexts (McKenzie, 2016; Jones, 2012). |
| Let your child play with food/Make food fun. | Research evidence from this recommendation is mostly from studies with children without feeding problems. Another problem with these studies is that the data are limited to a single taste session, and do not focus on consumption (Coulthard & Sealy, 2017). A third problem is that studies focused mainly on consumption of sweet dessert food, and not consumption of other food groups. |
| Children will eat when they are hungry. | Extensive media articles and literature highlight children with weight loss, total refusal to eat, and subsequent hospitalizations when their specific food, utensils, or feeding context are not available (McKenzie, 2016). Treatments involving the rapid reduction of tube feeding report cases where tube feeding was reinstated after insufficient eating and weight loss, and long-term follow-up highlights risk of malnutrition (Marinschek et al., n.d.) |
| Don’t stress/The child will grow out of it. | Literature suggests that feeding problems may not improve over time, particularly for children with developmental disabilities (Suarez et al., 2013; Fisher et al., 2014). Upon admission to treatment, children commonly have had feeding problems for years (Taylor et al., 2021). |
| Preferred foods should not be offered as a reward. | Multiple studies show improvements in the consumption of novel foods when preferred foods are provided as reinforcement (Whelan & Penrod, 2019; Pizzo et al., 2012). |
Second, Taylor & Taylor (2021) determined the most commonly accessed and funded treatment approaches across Australia and New Zealand. They did this by reviewing their clinical intake records and reviewing national health surveys and guidelines. Next, the authors surveyed evidence for the most common treatment approaches by conducting a literature search between the years 2009 and 2020. This information was then coded by research category as controlled (strong experimental control to validate results) or non-controlled (experimental control weaker). The treatments assessed were categorized as: division of responsibility or the trust model (e.g., the parent to decide the “what, where, when” around the meal and the child to decide “if and what” food is eaten (Taylor & Taylor, 2021); sequential oral sensory therapy (SOS) (e.g., foods are introduced via play, with progression from manipulating food to acceptance sequencing smelling, touching, and tasting in between; therapy may also include talking about and/or drawing food as well as sensory preparation routines; with variations termed “systematic desensitization” and sensory integration therapy (SIT; sensory diet) (e.g., SIT: activities targeting oral motor, body part and whole body activities (wheelbarrow walking, blowing bubbles, rolling on a therapy ball, squeezing a stress ball, etc.) and equipment (e.g., weighted vests/blankets and oral instruments), oral-motor therapy approaches (e.g., equipment/ training for oral motor approaches with activities such as chewing on tubes, mouth stretches, brushing the inside of the mouth with a vibrating brush (“desensitization”); hunger provocation approaches (e.g., approach eating as hunger motivated; psychological approaches (e.g., cognitive behavioral therapy, family therapy, and exposure therapy; and medication (e.g., appetite stimulants and psychotropic medication).
Implications for further research on pediatric feeding targeting the autism population
This study on empirically-supported treatment has many implications for research extension specifically to the autism population. The researchers addressed a socially important problem, which affects parents of typically developing children and parents of children with autism. Taylor & Taylor (2021) also employed a pragmatic approach to answering their research question by following the process parents would likely follow (e.g., web-based browsing) to gain information prior to seeking medical guidance to identify any trends. With both good and bad outcomes, parents of children with autism often search for information on the internet, so it is important that parents become savvy consumers of evidence-based treatment options.
The researchers used a specific search process commonly employed for peer-reviewed journals to evaluate the literature base relating to pediatric feeding. In doing so, they provided detail to ensure the process could be followed so others could check their results. They also had another member of their team do this and demonstrated that they agreed on 98% of their identification of research approach and design type, well above the clinically accepted level of 80% agreement.
One limitation surrounds the restriction to the regions of Australia and New Zealand, which may limit generalizability. Although this review focused on identification of ineffective treatment procedures. A future area for review that may be beneficial for parents is to evaluate components of treatment packages proven effective by research.
Overall, Taylor & Taylor (2021) concluded that general recommendations for pediatric feeding lack empirical support by research. Additionally, these general recommendations follow a “one size fits all” model and are not adjusted to meet individual needs. Unfortunately, there are rarely disclaimers provided or information to support determination of when further help should be sought. These general recommendations can be misleading for parents and potentially dangerous for their children.
Additionally, the researchers identified significant time gaps of controlled studies, with many approaches relying on weaker studies such as retrospective reviews or case reports. Outside of behavior analytic interventions, there were few studies that evaluated directly observed changes in feeding. Most studies relied on indirect or subjective measures that did not directly measure observable changes. This is an important consideration for research strength as direct measurement of the behavior of interest is a common index for rating the quality of a study, this helps to determine likelihood of effectiveness when applied to other children’s feeding.
Taylor & Taylor (2021) conclude that it is unacceptable to expose children to a series of treatments without evidence and that there is a literature base for effective treatments. Effective treatments show effects for severe feeding disorders in relatively brief periods of time (e.g., weeks) Additionally, the authors highlight that earlier access to effective treatment based on research both simplifies and decreases the duration of the procedure, which combine to also decrease cost.
For clinicians, these results shed light on how parents obtain information about feeding interventions, and how poorly many common interventions address feeding challenges. This is important to evaluate and to disseminate to parents. Further, analyzing pediatric treatments and their effectiveness may yield meaningful results that may extend to or expand treatment options for individuals with autism. Additional considerations are important for this vulnerable population, some of which are ethical mandates. Functional assessment and selection of behavior interventions should align with the Behavior Analysis Certification Board Code of Ethics (see BACB 2020 code, 2.14 to reference selecting, designing, and implementing behavior change interventions and 2.15 to reference minimizing risk of behavior-change interventions).
References:
Coulthard, H., & Sealy, A. (2017). Play with your food! Sensory play is associated with tasting of fruits and vegetables in preschool children. Appetite, 113, 84-90.
Curtin, C., Hubbard, K., Anderson, S. E., Mick, E., Must, A., & Bandini, L. G. (2015). Food selectivity, mealtime behavior problems, spousal stress, and family food choices in children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(10), 3308–3315.
Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., … & Walsh, T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49-52.
Jones, N. (2012). Marmite crisis: SOS for autistic boy. The New Zealand Herald.
Marinschek, S., Dunitz‐Scheer, M., Pahsini, K., Geher, B., & Scheer, P. (2014). Weaning children off enteral nutrition by netcoaching versus onsite treatment: a comparative study. Journal of Paediatrics and Child Health, 50(11), 902-907.
McKenzie, S. (2016). Dad’s desperate plea prompts lifetime supply of cups for boy with autism. CNN Health.
Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. R., Katz, R. M., Sevin, B. M., Gulotta, C. S., & Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 36(2), 187-204. https://doi.org/10.1901/jaba.2003.36-187
Pizzo, B., Coyle, M., Seiverling, L., & Williams, K. (2012). Plate A–plate B: Use of sequential presentation in the treatment of food selectivity. Behavioral Interventions, 27(4), 175-184.
Seiverling, L., Williams, K., & Sturmey, P. (2010). Assessment of feeding problems in children with autism spectrum disorders. Journal of Developmental and Physical Disabilities, 22(4), 401-413.
Suarez, M. A., Nelson, N. W., & Curtis, A. B. (2014). Longitudinal follow-up of factors associated with food selectivity in children with autism spectrum disorders. Autism, 18(8), 924-932.
Taylor, T., Blampied, N., & Roglić, N. (2021). Controlled case series demonstrates how parents can be trained to treat paediatric feeding disorders at home. Acta Paediatrica, 110(1), 149-157.
Taylor, S. A,. & Taylor, T. (2021). The distance between empirically-supported treatment and actual practice for paediatric feeding problems: An international clinical perspective. International Journal of Child and Adolescent Health, 14(1).
Wardle, J., Herrera, M. L., Cooke, L., & Gibson, E. L. (2003). Modifying children’s food preferences: the effects of exposure and reward on acceptance of an unfamiliar vegetable. European Journal of Clinical Nutrition, 57, 341-348. doi: 10.1038/sj.ejcn.1601541. PMID: 12571670.
Whelan, C. M., & Penrod, B. (2019). An evaluation of sequential meal presentation with picky eaters. Behavior Analysis in Practice, 12(2), 301-309.
Citation for this article:
Klick, S., & Weiss, M. J. (2022). Research review: The distance between empirically supported treatment and actual practice for paediatric feeding problems: An international clinical perspective. Science in Autism Treatment, 19(3).
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