Parent Training for Feeding Problems in Young Children with Autism Spectrum Disorder

Background: Many children with autism spectrum disorder (ASD) have feeding problems including idiosyncratic food selectivity and food refusal, mealtime rituals, and disruptive behaviors at mealtime. Although preliminary evidence suggests that behavioral interventions can reduce these problems, the interventions have not been well tested in randomized clinical trials and are typically delivered in highly specialized settings (inpatient or day treatment centers) by feeding experts with little parental involvement or attention to nutrition. Reports have focused on short-term effects on specific target behaviors such as the number of bites that a child accepts, without systematically measuring nutritional sufficiency or parent perception of behavior. Given the prevalence of ASD, there is a great need for feeding interventions that are more widely available, efficient, cost-effective and capable of producing generalized improvements. Behavioral parent training may be a promising approach because of its success in managing other problem behaviors in children with ASD

Objectives: This three-site project (University of Florida, University of Rochester, University of Pittsburgh) further developed an alpha version of a 9-session, individually delivered manualized behavioral parent training program for feeding problems (PT-F) in children with ASD and conducted an initial test in a 20-week, randomized, waitlist controlled trial. PT-F is innovative in that it is time-limited, takes place in an outpatient setting with ongoing parent engagement, and involves an interdisciplinary collaboration of specialists

Methods: Forty-two young children with ASD were randomized in equal numbers to either PT-F or waitlist control. The sample was predominately male (95%) with a mean age of 5.2 years. The primary outcome measure was the Brief Autism Mealtime Behavior Inventory (BAMBI). Secondary outcomes included a rating by a blinded independent evaluator (Clinical Global Impression – Improvement; CGI-I) and the parent-rated About Your Child’s Eating (AYCE), Irritability subscale of the Aberrant Behavior Checklist (ABC), and Home Situation Questionnaire (HSQ). All outcome measures were administered at baseline and Week 20. Wilcoxon rank-sum tests were calculated for continuous variables (BAMBI, ACYE) and chi-square tests for the categorical variable of responders (participants with CGI-I ratings of much or very much improved) vs. nonresponders (all other participants).

Results: Compared to children in the waitlist control, children whose parents participated in PT-F showed statistically significant reductions on the BAMBI (p = 0.007), AYCE (p = .004) and CGI-I (p =0.000). For the CGI-I, 48% of participants completing PT-F were responders compared to none in waitlist. However, overall disruptive and noncompliant behaviors were not decreased on the ABC-Irritability (p= 0.447) or HSQ (p = 0.179).

Conclusions: Our initial test of efficacy of PT-F in a small RCT yielded promising results on key outcome measures of feeding, eating and mealtime behaviors. Parents reported improvement in their child’s mealtime behaviors and eating habits. In addition, an independent evaluator, masked to treatment group, rated many children in the PT-F group as improved compared to none of the children in the waitlist group. The encouraging outcomes in this small RCT support further investigation in a larger, definitive trial that is powered to explore predictors and moderators.