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The Buffet Program: A Cognitive Behavior Therapy Approach to Food Selectivity in School Age Children with ASD
Behavioral treatments for food selectivity can be effective in children with ASD; however, evidence-supported treatment does not exist for cognitively higher functioning, school age children with ASD. Research indicates that higher-level cortical processes may drive food selectivity in children and adolescents with ASD rather than low-level taste detection impairments, suggesting that food selectivity could be malleable to cognitive behavior therapy (CBT).
Objectives:
The goal of this novel, proof-of-concept study was to create the Building Up Food Flexibility and Exposure Treatment (BUFFET) Program, a parent-supported, group-based CBT to increase food flexibility and food repertoire. The program integrates components of behavioral principles for food exposure with elements from two evidence-based CBTs for anxiety (Facing Your Fears) and flexibility (Unstuck and On Target!) in children with ASD.
Methods:
A preliminary feasibility and efficacy study was conducted with 11 food selective males with ASD (mean age=9.9 yrs, range 8.5-11.9; mean FSIQ=109, range 91-132) and their parent(s). The BUFFET Program was administered across 14 weekly, 90-minute sessions; children were assigned to one of three groups. The program provides seven weeks of skill building (e.g., coping strategy identification, cognitive restructuring of “Food Foe Thoughts” into “Food Friend Thoughts”, food dimensionality psychoeducation), followed by seven weeks of exposure practice (termed “BUFFET Building”).
Results:
Preliminary data from the first completed treatment group (n=4) suggest promising acceptability and satisfaction (Client Satisfaction Questionnaire ratings range 3.5-4.0 on a 4-pt scale; 83-100% attendance rate). Child “willingness to eat” ratings improved from baseline to outcome assessments; relative to baseline, children indicated at outcome that they would refuse fewer foods if asked to eat them (mean change=16%; range 4-30%), and that they were willing to eat more foods (mean change=8%; range 3-31%). (Note: accepted and refused foods were not necessarily the same.) In addition, on average children spontaeously tried and ate at least a bite of 19/29 foods presented during weekly BUFFET snack time. During the seven weeks of BUFFET Building (i.e., exposure) practice, children averaged 17 BUFFET Building sessions (completing ~2-3 group or home practice sessions per week), completed hierarchies for an average of 9 food goals (range 3-16), and moved at least 2 foods from the “NO” or “MAYBE” category into the “YES” category. Parents also reported generalization of the skills learned during BUFFET; children spontaneously ate new foods in the “YES” category in their daily lives within the final weeks of group. Outcome data are not yet available for the remaining two groups (n=7) as they are currently ongoing. Acceptability remains high, as evidenced by no dropouts and continued regular attendance by all group members.
Conclusions:
Preliminary data suggest feasibility and acceptability of the BUFFET Program intervention. Initial efficacy analyses, within a multiple baseline design model, will be completed when the remaining two pilot groups complete their treatment course in November/December 2014. A pilot randomized clinical trial will be the next step to evaluating efficacy of the program in the context of a waitlist control or comparison treatment design.