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The treatment of food selectivity and other feeding problems in children with autism spectrum disorders
Research in Autism Spectrum Disorders 3 (2009) 455–461
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Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
The treatment of food selectivity and other feeding problems in children with autism spectrum disorders Johnny L. Matson *, Jill C. Fodstad Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 September 2008 Accepted 29 September 2008
Food selectivity and other feeding problems are endemic in children with autism spectrum disorders (ASD). Additionally, many of the challenging behaviors which fall into this category are idiosyncratic to ASD. A technology is beginning to emerge regarding methods to lessen and effectively treat these issues which, if unchecked, can result in poor nutrition and difficulties in feeding. Specificity in foods consumed, choking, and aggression associated with food refusal can put the child and caregiver at risk. This paper provides a critical review of the current status of evidence-based clinical practices for this highly important set of challenging behaviors of ASD children. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Treatment Feeding problems Food selectivity Children Autism spectrum disorders
Autism spectrum disorders (ASD) are a set of neurodevelopmental conditions characterized by social and communication deficits and repetitive and restrictive behaviors (Matson, 2007a, 2007b; Matson & Boisjoli, 2007; Matson, Nebel-Schwalm, & Matson, 2007). All of these characteristics are considered to be inherited, although a good deal of genetic variability is evident (Ronald et al., 2006; Ronald, Happe´, & Plomin, 2005). Among the hallmark symptoms that these persons display are signs of inflexibility, preoccupation with sensory stimuli such as visual stimulation or routines, and a preoccupation with particular smells and textures (Cuccaro et al., 2003; Matson & Boisjoli, 2008a, 2008b; Matson & Wilkins, 2008; Szatmari et al., 2006). These unusual behaviors can be persistent and can markedly affect social skills and interactions in general (Matson, Carlisle, & Bamburg, 1998; Matson, Leblanc, & Weinheimer, 1999b; Matson & Wilkins, 2007). Attempts to redirect or stop these behaviors can lead to a variety of challenging behaviors (Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Matson, Dixon, & Matson, 2005; Matson & Logan, 1997; Matson & Nebel-Schwalm,
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2008.09.005
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2007; Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001; Rojahn, Matson, Naglieri, & Mayville, 2004; Singh, Matson, Cooper, Dixon, & Sturmey, 2005). Another set of problem behaviors related to these particular issues are restricted food intake and ritualized eating (Ahearn, Castine, Nault, & Green, 2001; Schreck, Williams, & Smith, 2004). While they constitute core symptoms of ASD (Matson et al., 2007), environmental functions may also be present (Applegate, Matson, & Cherry, 1999; Matson, Bamburg, Cherry, & Paclawskyj, 1999a; Matson, Mayville, et al., 2005; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2000). However, regardless of the cause and the potential interactions of biological and environmental factors, all of these issues require systematic evaluation if effective interventions are to be implemented. Given recent data suggesting that ASD is one of the highest incident and most debilitating of the childhood disorders, investigation into the current state of research and analysis of additional research on the topic of feeding problems in these children would appear to be warranted. The purpose of this review is to analyze the current state of the field with respect to these issues. 1. Nosology An important setting event for the discussion of feeding problems in children with ASD is to define the problem adequately. Twachtman-Reilly, Amaral, and Zebrowski (2008) stress the unique qualities of feeding problems in these children and the modification to assessment and treatment that are required to tailor these methods to the child, thus resulting in the most effective intervention. With this point in mind, it should be noted that feeding problems are much more frequent than what is observed with other children with disabilities that have some similarities to ASD such as language impairments (Dominick et al., 2007). In fact, these atypical eating styles are so common that at one time they were considered symptomatic of ASD (Ritvo & Freeman, 1978). Rituals are very common (Schreck et al., 2004), but the difficulties that appear most frequently are in the area of food selectivity, particularly with respect to the texture of the food or type of food consumed (Field, Garland, & Williams, 2003; Williams, Dalrymple, & Neal, 2000). These data are supported by Schreck et al. (2004) who compared the eating habits of autistic and normally developing children. They found that the children with autism had significantly greater feeding problems and ate a much narrower range of foods when compared to typically developing peers. Schmitt, Heiss, and Campbell (2008) examined the 3-day food record of 20 autistic and 18 typically developing boys aged 7–10 years. These authors found that this restrictive approach to types of foods consumed was based primarily on texture, but did not affect nutritional intake. The findings of Johnson, Handen, Mayer-Costa, and Sacco (2008) further bolster the results of Schmitt et al. (2008). They reported no differences in nutritional intake between 19 young autistic children and 15 regularly developing same age matched peers. However, they did note more mealtime behavior differences in the autistic group. These results are contradicted by Keen (2008), although the latter was a review versus a direct empirical test. The author asserts that early onset feeding problems, abnormally slow growth (presumable due to poor nutrition), and ASD are linked. Thus, some disagreement regarding the role of feeding problems for these persons and their nutrition and physical development exists. What does not seem to be at issue is the potential for lifelong feeding difficulties. 2. Etiology The causes of eating problems and food selectivity are complex and often interrelated. Because of this, a considerable amount of research will be required to tease out these variables. At present, such efforts have only just begun. Having noted this, we would point out that three broad domains have been identified: comorbid psychopathology, biological variables, and environmental factors. Some tentative conclusions based on the available data are possible and will be reviewed next. 2.1. Comorbid psychopathology Zucker and colleagues have been the principles looking at this issue. These researchers are eating disorders experts (e.g., anorexia nervosa-AN), and, thus, have approached the problem from the
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standpoint that ASD is comorbid to AN (Zucker & Losh, 2008). The authors note that, in fact, overlap in symptoms between the two conditions are considerable, particularly with respect to cognitive obsessions, behavioral rituals, and impaired social functioning (Zucker et al., 2007). Supporting these observations are data from Berkman, Lohr, and Bulik (2007), who assert that Asperger’s syndrome and autism occur at higher rates for persons with AN relative to the general population. 2.2. Medical conditions Physiological variables may also contribute markedly to feeding problems in persons with ASD. Jyonouchi, Geng, Ruby, Reddy, and Zimmerman-Brier (2005) evaluated the association between gastrointestinal problems in autism and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). Seventy-five children ranging from 1 to 10 years of age were evaluated. They were divided into one of two groups: those with and those without gastrointestinal (GI) problems. GI symptoms were defined as vomiting, diarrhea, chronic loose stools, colon and GI cramping, and constipation. The authors note that GI symptoms are frequently observed in children with ASD. They conclude that cellular immune response may play a role in these gut-related difficulties. Obviously, adverse physical reactions to various food items or compounds in food could markedly affect the child’s willingness to eat specific types of foods. Much is yet to be learned with respect to this topic. The research on comorbid disorders and feeding difficulties in ASD is extremely limited. However, these preliminary data underscore the necessity of looking more carefully at the overlap of ASD and other disorders which could increase risk, effect prognosis, and determine specific symptom patterns and severity as related to eating problems. 2.3. Biological and environmental effects There have not been many studies on the effects of these factors on eating problems of children with ASD and what has appeared is not particularly systematic. Regarding biological factors, Lindsay et al. (2006) studied the eating patterns of nine children who were being treated with risperidone for challenging behaviors versus eight controls. The authors conclude that risperidone did not significantly affect nutrition. Thus, the purpose of the study appears to be more focused on justifying the use of the drug versus studying the etiology of eating problems in children with ASD. In a second study looking at environmental factors, Levin and Carr (2001) did a functional assessment of excessive food selectivity in children with ASD. Specifically, they attempted to establish maintaining variables that co-occurred with food selectivity. Positive reinforcement was provided for two conditions: presentation of preferred and nonpreferred foods. Significantly more challenging behaviors occurred during the latter condition. The authors conclude that the challenging behaviors were maintained by negative reinforcement (e.g., escape from consuming nonpreferred foods). Suggested interventions were based on this hypothesis and included stimulus fading and escape extinction. Environmental factors have received very limited attention as well. Schreck and Williams (2006), for example, found that families with more restricted eating had ASD children with more restricted eating patterns. They contrast this finding to those families who ate a broader range of foods. In this latter case, the children ate a broader range of foods as well. Thus, these authors found that parental behavior can markedly effect, either positively or negatively the eating patterns of children with ASD. To note that a good deal more attention to this topic is needed is to state the obvious. 3. Assessment One reason so little has been done with respect to the etiology of feeding problems in ASD is related to the lack of adequate methods to assess these problems. One of the best studies to date on the topic was by Ahearn et al. (2001). They evaluated 30 children between 3 and 14 years of age who were diagnosed with autism or PDD-NOS. Children were exposed to 12 food items across six assessment sessions. Food acceptance, food expulsion, and challenging behaviors were recorded for each trial.
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About half of the children were sensitive to food texture or category, while the remainder of the children were indifferent to these factors. A second approach to evaluating food problems is described by Lukens and Linscheid (2008). They describe the Brief Autism Mealtime Behavior Inventory (BAMBI), which they note to be the first standardized measure of mealtime behavior for children with autism. Caregivers of 40 typically developing children and 68 children with autism completed the BAMBI and also the Behavior Pediatric Feeding Assessment Scale. The authors concluded that the BAMBI had good internal consistency, test– retest reliability, and good construct and criterion-related reliability. Because only one study has been conducted on the measure, further research is warranted. However, this instrument appears to be promising and more focus on the assessment of feeding problems with ASD children appears to be needed as well. 4. Treatment A variety of food-related problems have been treated in ASD children such as eating compliance, rapid eating, inadequate food consumption, and food packing. However, food selectivity has been the most frequently studied feeding problem. Furthermore, applied behavior analysis has been the treatment model of choice in most instances. Patel et al. (2007) used a behavioral momentum procedure to increase eating compliance of a young boy. Treatment consisted of three trials of a high probability compliance task, putting an empty spoon in his mouth. This sequence of trials was followed by a low probability event, presenting a spoon with food. The child increased eating when trials of the presentation of the empty spoon were interspersed with the presentation of a spoon, versus presenting trials only with a spoon filled with food. As noted, rapid eating has also been reported and treated, in this case with three autistic teenagers. Anglesea, Hoch, and Taylor (2008) trained the participants to take a bite only when a pager they were carrying vibrated. This intervention proved to be effective for a serious problem that can compromise good digestion and can greatly increase the risk of choking. Some children with autism also suffer from insufficient food consumption. Buckley, Strunck, and Newchok (2005) compared two variations of response cost for a 5-year-old autistic boy. The target behavior was the child swallowing all his food. Response cost was paired with either noncontingent reinforcement or with differential reinforcement of alternative behavior (DRA) where the DRA consisted of returning preferred items taken from the child for food refusal or expulsion. Noncontingent reinforcement plus response cost was used for increasing food swallowing. An unusual eating problem in ASD is described by Buckley and Newchok (2005). They described a 9-year-old autistic girl who engaged in food packing. This child, ‘‘Maria,’’ consumed most food, but when presented with bites of new or nonpreferred foods, she would pack the bites in her mouth for long periods of time. Packing was defined as any food in her mouth larger than a grain of rice. Using methods similar to Buckley et al. (2005), they employed differential reinforcement plus response cost. Maria could watch a preferred video while eating, but it was removed following packing. The video was returned and verbal praise was given once she had swallowed all the food in her mouth. This procedure was presented with and without what the authors labeled as simultaneous presentation. With this procedure, one of Maria’s most preferred foods, a small piece of chocolate cookie, was placed on the spoon behind the target food. Simultaneous presentation plus differential reinforcement and response cost proved to be the most effective intervention. Luiselli, Ricciardi, and Gilligan (2005) describe another innovative treatment. In this case, the child who was treated was a 4-year-old autistic girl with food selectivity. Treatment consisted of gradually increasing the percentage of milk in a preferred beverage she would always consume. In another treatment study on food selectivity for autistic children, Levin and Carr (2001) limited access to preferred foods and gave positive reinforcement for consumption of nonpreferred items. Najdowski, Wallace, Doney, and Ghezzi (2003) treated a 5-year-old boy with ASD for food refusal of nonpreferred items. The effective intervention was based on a functional analysis showing escape from demands as the maintaining function. Treatment consisted of presenting nonpreferred foods one at a time by his mother who asked him to take a bite of broccoli, grapes, cheese, chicken, or hot dogs.
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Sessions were terminated when ‘‘Jack’’ accepted a bite of food or after 30 min. Accepting a bite of the nonpreferred food resulted in his receiving an entire plate of preferred foods such as chicken nuggets, french fries, Cheetos, and gummy bears. Bites expelled or vomited resulted in a new bite of nonpreferred food being presented. Gradually the number of bites of nonpreferred food was increased, and the amount of preferred food provided was simultaneously decreased. The authors described their intervention as differential reinforcement of alternative behavior, plus escape extinction, plus demand fading. Ahearn (2003) also used bites as the target behavior in his treatment of food refusal of a 14-yearold boy with autism and profound intellectual disability (ID). In a treatment component similar to Buckley and Newchok (2005), Ahearn combined a preferred food item in the same bite with a nonpreferred food. Ahearn, however, used condiments such as barbecue sauce, mustard, and ketchup as the preferred items. This food addition and multiple presentations of food bites per trial were sufficient to promote greater food acceptance. Piazza et al. (2002) also used simultaneous food presentation in their case with three children: Alex a 10-year-old boy with autism, Vonda an 11year-old girl with pervasive developmental disorder and profound ID, and Brad an 8-year-old boy with pervasive developmental disabilities and severe ID. Nonpreferred foods were imbedded in preferred foods. For example, broccoli was placed inside an apple slice. Additionally, manual guidance was required when simultaneous presentation alone was not effective. When a child failed to take a bite within 30 s, the therapist applied pressure to the jaw and the food was placed in the child’s mouth. Simultaneous presentation is also described by Ogata, Trahms, Lucas, and Schwartz (1999). In their package program, they also stress increased exposure to various foods and social interactions during mealtimes for the four, 4–5 year old children with autism or PDD-NOS they treated. Paul, Williams, Riegel, and Gibbons (2007) also stress taste exposure as an important aspect of intervention for food selectivity. They treated a 3.5-year-old autistic boy whose eating was restricted almost exclusively to milk, hot dogs, and grilled cheese sandwiches. A second participant, Kim, who was a 5-year-old girl with autism, had completely stopped eating for 6 months prior to initiation of the study and she was on a gastronomy tube. Parents selected food from a list of 139 items which they commonly consumed at home. These were the food items used in the current study. Pea-sized bites on a spoon (i.e., low volume bites) were used at first since they were less likely to be refused, according to the authors. Children were offered small drinks of milk, juice, or water. If the bite was expelled, a second bite of the same food was presented. Five minutes was given between sessions at which time the child played with toys or books or went outside with their parents. Successfully eating the same item for three of four sessions resulted in increasing the portion on the spoon. Once the child would eat a full spoon of a given food, it was only presented periodically in probe sessions thereafter. 5. Conclusions Feeding problems of children with ASD are frequent and can have serious consequences. As a result, better understanding the nature of the problem and establishing sound assessment and intervention strategies are warranted. Initial attempts, particularly with respect to behaviorally based interventions have been promising. However, little is known at this time about the complex biological and environmental factors which are likely to cause the condition. Additionally, it is surprising and a bit disheartening that so little emphasis has been placed on the topic, given early success. The potentially serious consequences associate with the presence of these feeding problems further underscore the importance of this issue. Feeding problems should be, but are rarely screened for in children with ASD. Such efforts are encouraged but await more development of instruments and methods to achieve the task. This approach should be multimethod. Normed, standardized assessment instruments, such as the BAMBI, need further development. Furthermore, existing measures such as the Screening Tool of fEeding Problems (STEP), which have been developed for persons with intellectual disability, could be easily adapted to the ASD population (Kuhn & Matson, 2002; Matson & Kuhn, 2001). Functional assessment and direct observational methods should also be included in comprehensive assessment (Fodstad & Matson, 2008; Matson & Nebel-Schwalm, 2007; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2001).
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From an intervention perspective, all studies have been single-case. There is nothing wrong with this set of methodological procedures. However, the treatment area may be reaching a point where group outcome studies are also warranted as a means of further enhancing the generalizability of treatment effects. Furthermore, group methodologies lend themselves better to the comparison of various treatments. As with the other topics covered in our review, more research on treatment is urgently needed.
References Ahearn, W. H. (2003). Using simultaneous presentation to increase vegetable consumption in a mildly selective child with autism. Journal of Applied Behavior Analysis, 36, 361–365. Ahearn, W. H., Castine, T., Nault, K., & Green, G. (2001). An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified. Journal of Autism and Developmental Disorders, 31, 505–511. Anglesea, M. M., Hoch, H., & Taylor, B. A. (2008). Reducing rapid eating in teenagers with autism: Use of a pager prompt. Journal of Applied Behavior Analysis, 41, 107–111. Applegate, H., Matson, J. L., & Cherry, K. E. (1999). An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions About Behavioral Function Scale (QABF). Research in Developmental Disabilities, 20, 229–238. Berkman, N. D., Lohr, K. N., & Bulik, C. M. (2007). Outcomes of eating disorders: A systematic review of the literature. International Journal of Eating Disorders, 40, 293–309. Buckley, S. D., & Newchok, D. K. (2005). An evaluation of simultaneous presentation and differential reinforcement with response cost to reduce packing. Journal of Applied Behavior Analysis, 38, 405–409. Buckley, S. D., Strunck, P. G., & Newchok, D. K. (2005). A comparison of two multicomponent procedures to increase food consumption. Behavioral Interventions, 20, 139–146. Cuccaro, M. L., Shao, Y., Grubber, J., Slifer, M., Wolpert, C. M., Donnelly, S. L., et al. (2003). Factor analysis of restricted and repetitive behaviors in autism using the Autism Diagnostic Interview-R. Child Psychiatry and Human Development, 34, 3–17. Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilties, 28, 145–162. Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Pediatrics and Child Health, 39, 299–304. Fodstad, J. C., & Matson, J. L. (2008). A comparison of feeding and mealtime problems in adults with intellectual disabilities with and without autism. Journal of Developmental and Physical Disabilities 10.1007/SI0882-008.9116-6. Johnson, C. R., Handen, B. L., Mayer-Costa, M., & Sacco, K. (2008). Eating habits and dietary status in young children with autism. Journal of Developmental and Physical Disabilities, 20, 437–448. Jyonouchi, H., Geng, L., Ruby, A., Reddy, C., & Zimmerman-Brier, B. (2005). Evaluation of an association between gastrointestinal symptoms and cytokine production against common dietary proteins in children with autism spectrum disorders. The Journal of Pediatrics, 146, 605–610. Keen, D. V. (2008). Childhood autism, feeding problems, and failure to thrive in early infancy: Seven case studies. European Child and Adolescent Psychiatry, 17, 2089–2216. Kuhn, D. E., & Matson, J. L. (2002). A validity study of the Screening Tool of fEeding Problems (STEP). Journal of Intellectual and Developmental Disabilities, 27, 161–167. Levin, L., & Carr, E. G. (2001). Food selectivity and problem behavior in children with developmental disabilities. Behavior Modification, 25, 443–470. Lindsay, R. L., Eugene, A. L., Aman, M. G., Vitiello, B., Posey, D. J., McDougle, C. J., et al. (2006). Dietary status and impact of risperidone on nutritional balance in children with autism: A pilot study. Journal of Intellectual and Developmental Disabilities, 31, 204–209. Luiselli, J. K., Ricciardi, J. N., & Gilligan, D. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20, 155–163. Lukens, C. T., & Linscheid, T. R. (2008). Development and validation of an inventory to assess mealtime behavior problems in children with autism. Journal of Autism and Developmental Disorders, 38, 342–352. Matson, J. L. (2007a). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disabilities, 28, 109–118. Matson, J. L. (2007b). Determining treatment outcome in early intervention programs for autism spectrum disorders: A critical analysis of measurement issues in learning based interventions. Research in Developmental Disabilities, 28, 218–297. Matson, J. L., Bamburg, J. W., Cherry, K. E., & Paclawskyj, T. R. (1999a). A validity study on the Questions About Behavior Function (QABF) scale: Predicting treatment success for self-injury, aggression, and stereotypies. Research in Developmental Disabilities, 20, 163–176. Matson, J. L., & Boisjoli, J. A. (2007). Differential diagnosis of PDD-NOS in children. Research in Autism Spectrum Disorders, 1, 75–84. Matson, J. L., & Boisjoli, J. A. (2008a). Cutoff scores for the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER) for adults with intellectual disabilities. Behavior Modification, 32, 109–120. Matson, J. L., & Boisjoli, J. A. (2008b). Strategies for assessing Asperger’s Syndrome: A critical review of data based methods. Research in Autism Spectrum Disorders, 2, 237–248. Matson, J. L., Carlisle, C. B., & Bamburg, J. W. (1998). The convergent validity of the Matson Evaluation of Social Skills in Individuals with Severe Retardation (MESSIER). Research in Developmental Disabilities, 19, 493–500. Matson, J. L., Dixon, D. R., & Matson, M. L. (2005a). Assessing and treating aggression in children and adolescents with developmental disabilities: A 20-year review. Educational Psychology, 26, 41–45. Matson, J. L., & Kuhn, D. E. (2001). Identifying feeding problems in mentally retarded persons: Development and reliability of the Screening Tool of fEeding Problems (STEP). Research in Developmental Disabilities, 22, 165–172.
J.L. Matson, J.C. Fodstad / Research in Autism Spectrum Disorders 3 (2009) 455–461
461
Matson, J. L., Leblanc, L. A., & Weinherimer, B. (1999b). Reliability of the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER). Behavior Modification, 23, 647–661. Matson, J. L., & Logan, J. R. (1997). A review of destructive behavior in developmental disabilities: Diagnosis and treatment. Contemporary Psychology, 42, 545–546. Matson, J. L., Mayville, S. B., Kuhn, D. E., Sturmey, P., Laud, R. B., & Cooper, C. (2005b). The behavioral function of feeding problems as assessed by the Questions About Behavior Function (QABF). Research in Developmental Disabilities, 26, 399–408. Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children with autism spectrum disorder: A review. Research in Developmental Disabilities, 28, 567–579. Matson, J. L., Nebel-Schwalm, M. S., & Matson, M. L. (2007). A review of methodological issues in the differential diagnosis of autism spectrum disorders in children. Research in Autism Spectrum Disorders, 1, 38–54. Matson, J. L., & Wilkins, J. (2007). A critical review of assessment targets and methods for social skills excesses and deficits for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 1, 28–37. Matson, J. L., & Wilkins, J. (2008). Nosology and diagnosis of Asperger’s syndrome. Research in Autism Spectrum Disorders, 2, 288–300. Najdowski, A. C., Wallace, M. D., Doney, J. K., & Ghezzi, P. M. (2003). Parental assessment and treatment of food selectivity in natural settings. Journal of Applied Behavior Analysis, 36, 383–386. Ogata, B., Trahms, C., Lucas, B., & Schwartz, I. (1999). A behavior-based approach to food refusal in children with autism and pervasive developmental disorder. Journal of the American Dietetic Association, 99, A104. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2000). Questions About Behavioral Function (QABF): A behavioral checklist for functional assessment of aberrant behavior. Research in Developmental Disabilities, 21, 223–229. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2001). Assessment of the convergent validity of the Questions About Behavioral Function (QABF) with analog functional assessment and the Motivation Assessment Scale (MAS). Journal of Intellectual Disability Research, 45, 484–494. Patel, M., Reed, G. K., Piazza, C. C., Mueller, M., Bachmeyer, M. H., & Layer, S. A. (2007). Use of high-probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction. Behavioral Interventions, 22, 305–310. Paul, C., Williams, K. E., Riegel, K., & Gibbons, B. (2007). Combining repeated taste exposure and escape prevention: An intervention for the treatment of extreme food selectivity. Appetite, 49, 708–711. Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D., & Lancaster, B. M. (2002). An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35, 259–270. Ritvo, E. R., & Freeman, B. J. (1978). Current research on the syndrome of autism: Introduction. The national society for autistic children’s definition of the syndrome of autism. Journal of the American Academy of Child and Adolescent Psychiatry, 17, 565–575. Rojahn, J., Aman, M. G., Matson, J. L., & Mayville, E. A. (2003). The aberrant behavior checklist and the behavior problems inventory: Convergent and divergent validity. Research in Developmental Disabilities, 24, 391–404. Rojahn, J., Matson, J. L., Lott, D., Esbensen, A., & Smalls, Y. (2001). The Behavior Problems Inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Journal of Autism and Developmental Disorders, 31, 577–588. Rojahn, J., Matson, J. L., Naglieri, J. A., & Mayville, E. A. (2004). Relationships between psychiatric conditions and behavior problems among adults with mental retardation. American Journal on Mental Retardation, 109, 21–33. Ronald, A., Happe´, F., Bolton, P., Butcher, L. M., Price, T. S., Wheelwright, S., et al. (2006). Genetic heterogeneity between the three components of the autism spectrum: A twin study. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 691–699. Ronald, A., Happe´, F., & Plomin, R. (2005). The genetic relationship between individual differences in social and nonsocial behaviours characteristic of autism. Developmental Science, 8, 444–458. Schmitt, L., Heiss, C. J., & Campbell, E. E. (2008). A comparison of nutrient intake and eating behaviors of boys with and without autism. Topics in Clinical Nutrition, 23, 23–31. Schreck, K. A., & Williams, K. (2006). Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities, 27, 353–363. Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34, 433–438. Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203–218. Szatmari, P., Georgiades, S., Bryson, S., Zwaigenbaum, L., Roberts, W., Mahoney, W., et al. (2006). Investigating the structure of the restricted, repetitive behaviours and interests domain of autism. Journal of Child Psychology and Psychiatry, 47, 582–590. Twachtman-Reilly, J., Amaral, S. C., & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autism spectrum in school-based settings: Physiological and behavioral issues.. Language, Speech, and Hearing Services in Schools, 39, 261–272. Williams, P. G., Dalrymple, N., & Neal, J. (2000). Eating habits of children with autism. Pediatric Nursing, 26, 259–264. Zucker, N. L., & Losh, M. (2008). Repetitive behaviours in anorexia nervosa, autism, and obsessive-compulsive personality disorder. Psychiatry, 7, 183–187. Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven, J., & Pelphrey, K. A. (2007). Anorexia nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes. Psychological Bulletin, 133, 976–1006.
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
The treatment of food selectivity and other feeding problems in children with autism spectrum disorders Johnny L. Matson *, Jill C. Fodstad Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 September 2008 Accepted 29 September 2008
Food selectivity and other feeding problems are endemic in children with autism spectrum disorders (ASD). Additionally, many of the challenging behaviors which fall into this category are idiosyncratic to ASD. A technology is beginning to emerge regarding methods to lessen and effectively treat these issues which, if unchecked, can result in poor nutrition and difficulties in feeding. Specificity in foods consumed, choking, and aggression associated with food refusal can put the child and caregiver at risk. This paper provides a critical review of the current status of evidence-based clinical practices for this highly important set of challenging behaviors of ASD children. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Treatment Feeding problems Food selectivity Children Autism spectrum disorders
Autism spectrum disorders (ASD) are a set of neurodevelopmental conditions characterized by social and communication deficits and repetitive and restrictive behaviors (Matson, 2007a, 2007b; Matson & Boisjoli, 2007; Matson, Nebel-Schwalm, & Matson, 2007). All of these characteristics are considered to be inherited, although a good deal of genetic variability is evident (Ronald et al., 2006; Ronald, Happe´, & Plomin, 2005). Among the hallmark symptoms that these persons display are signs of inflexibility, preoccupation with sensory stimuli such as visual stimulation or routines, and a preoccupation with particular smells and textures (Cuccaro et al., 2003; Matson & Boisjoli, 2008a, 2008b; Matson & Wilkins, 2008; Szatmari et al., 2006). These unusual behaviors can be persistent and can markedly affect social skills and interactions in general (Matson, Carlisle, & Bamburg, 1998; Matson, Leblanc, & Weinheimer, 1999b; Matson & Wilkins, 2007). Attempts to redirect or stop these behaviors can lead to a variety of challenging behaviors (Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Matson, Dixon, & Matson, 2005; Matson & Logan, 1997; Matson & Nebel-Schwalm,
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2008.09.005
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2007; Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001; Rojahn, Matson, Naglieri, & Mayville, 2004; Singh, Matson, Cooper, Dixon, & Sturmey, 2005). Another set of problem behaviors related to these particular issues are restricted food intake and ritualized eating (Ahearn, Castine, Nault, & Green, 2001; Schreck, Williams, & Smith, 2004). While they constitute core symptoms of ASD (Matson et al., 2007), environmental functions may also be present (Applegate, Matson, & Cherry, 1999; Matson, Bamburg, Cherry, & Paclawskyj, 1999a; Matson, Mayville, et al., 2005; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2000). However, regardless of the cause and the potential interactions of biological and environmental factors, all of these issues require systematic evaluation if effective interventions are to be implemented. Given recent data suggesting that ASD is one of the highest incident and most debilitating of the childhood disorders, investigation into the current state of research and analysis of additional research on the topic of feeding problems in these children would appear to be warranted. The purpose of this review is to analyze the current state of the field with respect to these issues. 1. Nosology An important setting event for the discussion of feeding problems in children with ASD is to define the problem adequately. Twachtman-Reilly, Amaral, and Zebrowski (2008) stress the unique qualities of feeding problems in these children and the modification to assessment and treatment that are required to tailor these methods to the child, thus resulting in the most effective intervention. With this point in mind, it should be noted that feeding problems are much more frequent than what is observed with other children with disabilities that have some similarities to ASD such as language impairments (Dominick et al., 2007). In fact, these atypical eating styles are so common that at one time they were considered symptomatic of ASD (Ritvo & Freeman, 1978). Rituals are very common (Schreck et al., 2004), but the difficulties that appear most frequently are in the area of food selectivity, particularly with respect to the texture of the food or type of food consumed (Field, Garland, & Williams, 2003; Williams, Dalrymple, & Neal, 2000). These data are supported by Schreck et al. (2004) who compared the eating habits of autistic and normally developing children. They found that the children with autism had significantly greater feeding problems and ate a much narrower range of foods when compared to typically developing peers. Schmitt, Heiss, and Campbell (2008) examined the 3-day food record of 20 autistic and 18 typically developing boys aged 7–10 years. These authors found that this restrictive approach to types of foods consumed was based primarily on texture, but did not affect nutritional intake. The findings of Johnson, Handen, Mayer-Costa, and Sacco (2008) further bolster the results of Schmitt et al. (2008). They reported no differences in nutritional intake between 19 young autistic children and 15 regularly developing same age matched peers. However, they did note more mealtime behavior differences in the autistic group. These results are contradicted by Keen (2008), although the latter was a review versus a direct empirical test. The author asserts that early onset feeding problems, abnormally slow growth (presumable due to poor nutrition), and ASD are linked. Thus, some disagreement regarding the role of feeding problems for these persons and their nutrition and physical development exists. What does not seem to be at issue is the potential for lifelong feeding difficulties. 2. Etiology The causes of eating problems and food selectivity are complex and often interrelated. Because of this, a considerable amount of research will be required to tease out these variables. At present, such efforts have only just begun. Having noted this, we would point out that three broad domains have been identified: comorbid psychopathology, biological variables, and environmental factors. Some tentative conclusions based on the available data are possible and will be reviewed next. 2.1. Comorbid psychopathology Zucker and colleagues have been the principles looking at this issue. These researchers are eating disorders experts (e.g., anorexia nervosa-AN), and, thus, have approached the problem from the
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standpoint that ASD is comorbid to AN (Zucker & Losh, 2008). The authors note that, in fact, overlap in symptoms between the two conditions are considerable, particularly with respect to cognitive obsessions, behavioral rituals, and impaired social functioning (Zucker et al., 2007). Supporting these observations are data from Berkman, Lohr, and Bulik (2007), who assert that Asperger’s syndrome and autism occur at higher rates for persons with AN relative to the general population. 2.2. Medical conditions Physiological variables may also contribute markedly to feeding problems in persons with ASD. Jyonouchi, Geng, Ruby, Reddy, and Zimmerman-Brier (2005) evaluated the association between gastrointestinal problems in autism and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). Seventy-five children ranging from 1 to 10 years of age were evaluated. They were divided into one of two groups: those with and those without gastrointestinal (GI) problems. GI symptoms were defined as vomiting, diarrhea, chronic loose stools, colon and GI cramping, and constipation. The authors note that GI symptoms are frequently observed in children with ASD. They conclude that cellular immune response may play a role in these gut-related difficulties. Obviously, adverse physical reactions to various food items or compounds in food could markedly affect the child’s willingness to eat specific types of foods. Much is yet to be learned with respect to this topic. The research on comorbid disorders and feeding difficulties in ASD is extremely limited. However, these preliminary data underscore the necessity of looking more carefully at the overlap of ASD and other disorders which could increase risk, effect prognosis, and determine specific symptom patterns and severity as related to eating problems. 2.3. Biological and environmental effects There have not been many studies on the effects of these factors on eating problems of children with ASD and what has appeared is not particularly systematic. Regarding biological factors, Lindsay et al. (2006) studied the eating patterns of nine children who were being treated with risperidone for challenging behaviors versus eight controls. The authors conclude that risperidone did not significantly affect nutrition. Thus, the purpose of the study appears to be more focused on justifying the use of the drug versus studying the etiology of eating problems in children with ASD. In a second study looking at environmental factors, Levin and Carr (2001) did a functional assessment of excessive food selectivity in children with ASD. Specifically, they attempted to establish maintaining variables that co-occurred with food selectivity. Positive reinforcement was provided for two conditions: presentation of preferred and nonpreferred foods. Significantly more challenging behaviors occurred during the latter condition. The authors conclude that the challenging behaviors were maintained by negative reinforcement (e.g., escape from consuming nonpreferred foods). Suggested interventions were based on this hypothesis and included stimulus fading and escape extinction. Environmental factors have received very limited attention as well. Schreck and Williams (2006), for example, found that families with more restricted eating had ASD children with more restricted eating patterns. They contrast this finding to those families who ate a broader range of foods. In this latter case, the children ate a broader range of foods as well. Thus, these authors found that parental behavior can markedly effect, either positively or negatively the eating patterns of children with ASD. To note that a good deal more attention to this topic is needed is to state the obvious. 3. Assessment One reason so little has been done with respect to the etiology of feeding problems in ASD is related to the lack of adequate methods to assess these problems. One of the best studies to date on the topic was by Ahearn et al. (2001). They evaluated 30 children between 3 and 14 years of age who were diagnosed with autism or PDD-NOS. Children were exposed to 12 food items across six assessment sessions. Food acceptance, food expulsion, and challenging behaviors were recorded for each trial.
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About half of the children were sensitive to food texture or category, while the remainder of the children were indifferent to these factors. A second approach to evaluating food problems is described by Lukens and Linscheid (2008). They describe the Brief Autism Mealtime Behavior Inventory (BAMBI), which they note to be the first standardized measure of mealtime behavior for children with autism. Caregivers of 40 typically developing children and 68 children with autism completed the BAMBI and also the Behavior Pediatric Feeding Assessment Scale. The authors concluded that the BAMBI had good internal consistency, test– retest reliability, and good construct and criterion-related reliability. Because only one study has been conducted on the measure, further research is warranted. However, this instrument appears to be promising and more focus on the assessment of feeding problems with ASD children appears to be needed as well. 4. Treatment A variety of food-related problems have been treated in ASD children such as eating compliance, rapid eating, inadequate food consumption, and food packing. However, food selectivity has been the most frequently studied feeding problem. Furthermore, applied behavior analysis has been the treatment model of choice in most instances. Patel et al. (2007) used a behavioral momentum procedure to increase eating compliance of a young boy. Treatment consisted of three trials of a high probability compliance task, putting an empty spoon in his mouth. This sequence of trials was followed by a low probability event, presenting a spoon with food. The child increased eating when trials of the presentation of the empty spoon were interspersed with the presentation of a spoon, versus presenting trials only with a spoon filled with food. As noted, rapid eating has also been reported and treated, in this case with three autistic teenagers. Anglesea, Hoch, and Taylor (2008) trained the participants to take a bite only when a pager they were carrying vibrated. This intervention proved to be effective for a serious problem that can compromise good digestion and can greatly increase the risk of choking. Some children with autism also suffer from insufficient food consumption. Buckley, Strunck, and Newchok (2005) compared two variations of response cost for a 5-year-old autistic boy. The target behavior was the child swallowing all his food. Response cost was paired with either noncontingent reinforcement or with differential reinforcement of alternative behavior (DRA) where the DRA consisted of returning preferred items taken from the child for food refusal or expulsion. Noncontingent reinforcement plus response cost was used for increasing food swallowing. An unusual eating problem in ASD is described by Buckley and Newchok (2005). They described a 9-year-old autistic girl who engaged in food packing. This child, ‘‘Maria,’’ consumed most food, but when presented with bites of new or nonpreferred foods, she would pack the bites in her mouth for long periods of time. Packing was defined as any food in her mouth larger than a grain of rice. Using methods similar to Buckley et al. (2005), they employed differential reinforcement plus response cost. Maria could watch a preferred video while eating, but it was removed following packing. The video was returned and verbal praise was given once she had swallowed all the food in her mouth. This procedure was presented with and without what the authors labeled as simultaneous presentation. With this procedure, one of Maria’s most preferred foods, a small piece of chocolate cookie, was placed on the spoon behind the target food. Simultaneous presentation plus differential reinforcement and response cost proved to be the most effective intervention. Luiselli, Ricciardi, and Gilligan (2005) describe another innovative treatment. In this case, the child who was treated was a 4-year-old autistic girl with food selectivity. Treatment consisted of gradually increasing the percentage of milk in a preferred beverage she would always consume. In another treatment study on food selectivity for autistic children, Levin and Carr (2001) limited access to preferred foods and gave positive reinforcement for consumption of nonpreferred items. Najdowski, Wallace, Doney, and Ghezzi (2003) treated a 5-year-old boy with ASD for food refusal of nonpreferred items. The effective intervention was based on a functional analysis showing escape from demands as the maintaining function. Treatment consisted of presenting nonpreferred foods one at a time by his mother who asked him to take a bite of broccoli, grapes, cheese, chicken, or hot dogs.
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Sessions were terminated when ‘‘Jack’’ accepted a bite of food or after 30 min. Accepting a bite of the nonpreferred food resulted in his receiving an entire plate of preferred foods such as chicken nuggets, french fries, Cheetos, and gummy bears. Bites expelled or vomited resulted in a new bite of nonpreferred food being presented. Gradually the number of bites of nonpreferred food was increased, and the amount of preferred food provided was simultaneously decreased. The authors described their intervention as differential reinforcement of alternative behavior, plus escape extinction, plus demand fading. Ahearn (2003) also used bites as the target behavior in his treatment of food refusal of a 14-yearold boy with autism and profound intellectual disability (ID). In a treatment component similar to Buckley and Newchok (2005), Ahearn combined a preferred food item in the same bite with a nonpreferred food. Ahearn, however, used condiments such as barbecue sauce, mustard, and ketchup as the preferred items. This food addition and multiple presentations of food bites per trial were sufficient to promote greater food acceptance. Piazza et al. (2002) also used simultaneous food presentation in their case with three children: Alex a 10-year-old boy with autism, Vonda an 11year-old girl with pervasive developmental disorder and profound ID, and Brad an 8-year-old boy with pervasive developmental disabilities and severe ID. Nonpreferred foods were imbedded in preferred foods. For example, broccoli was placed inside an apple slice. Additionally, manual guidance was required when simultaneous presentation alone was not effective. When a child failed to take a bite within 30 s, the therapist applied pressure to the jaw and the food was placed in the child’s mouth. Simultaneous presentation is also described by Ogata, Trahms, Lucas, and Schwartz (1999). In their package program, they also stress increased exposure to various foods and social interactions during mealtimes for the four, 4–5 year old children with autism or PDD-NOS they treated. Paul, Williams, Riegel, and Gibbons (2007) also stress taste exposure as an important aspect of intervention for food selectivity. They treated a 3.5-year-old autistic boy whose eating was restricted almost exclusively to milk, hot dogs, and grilled cheese sandwiches. A second participant, Kim, who was a 5-year-old girl with autism, had completely stopped eating for 6 months prior to initiation of the study and she was on a gastronomy tube. Parents selected food from a list of 139 items which they commonly consumed at home. These were the food items used in the current study. Pea-sized bites on a spoon (i.e., low volume bites) were used at first since they were less likely to be refused, according to the authors. Children were offered small drinks of milk, juice, or water. If the bite was expelled, a second bite of the same food was presented. Five minutes was given between sessions at which time the child played with toys or books or went outside with their parents. Successfully eating the same item for three of four sessions resulted in increasing the portion on the spoon. Once the child would eat a full spoon of a given food, it was only presented periodically in probe sessions thereafter. 5. Conclusions Feeding problems of children with ASD are frequent and can have serious consequences. As a result, better understanding the nature of the problem and establishing sound assessment and intervention strategies are warranted. Initial attempts, particularly with respect to behaviorally based interventions have been promising. However, little is known at this time about the complex biological and environmental factors which are likely to cause the condition. Additionally, it is surprising and a bit disheartening that so little emphasis has been placed on the topic, given early success. The potentially serious consequences associate with the presence of these feeding problems further underscore the importance of this issue. Feeding problems should be, but are rarely screened for in children with ASD. Such efforts are encouraged but await more development of instruments and methods to achieve the task. This approach should be multimethod. Normed, standardized assessment instruments, such as the BAMBI, need further development. Furthermore, existing measures such as the Screening Tool of fEeding Problems (STEP), which have been developed for persons with intellectual disability, could be easily adapted to the ASD population (Kuhn & Matson, 2002; Matson & Kuhn, 2001). Functional assessment and direct observational methods should also be included in comprehensive assessment (Fodstad & Matson, 2008; Matson & Nebel-Schwalm, 2007; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2001).
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From an intervention perspective, all studies have been single-case. There is nothing wrong with this set of methodological procedures. However, the treatment area may be reaching a point where group outcome studies are also warranted as a means of further enhancing the generalizability of treatment effects. Furthermore, group methodologies lend themselves better to the comparison of various treatments. As with the other topics covered in our review, more research on treatment is urgently needed.
References Ahearn, W. H. (2003). Using simultaneous presentation to increase vegetable consumption in a mildly selective child with autism. Journal of Applied Behavior Analysis, 36, 361–365. Ahearn, W. H., Castine, T., Nault, K., & Green, G. (2001). An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified. Journal of Autism and Developmental Disorders, 31, 505–511. Anglesea, M. M., Hoch, H., & Taylor, B. A. (2008). Reducing rapid eating in teenagers with autism: Use of a pager prompt. Journal of Applied Behavior Analysis, 41, 107–111. Applegate, H., Matson, J. L., & Cherry, K. E. (1999). An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions About Behavioral Function Scale (QABF). Research in Developmental Disabilities, 20, 229–238. Berkman, N. D., Lohr, K. N., & Bulik, C. M. (2007). Outcomes of eating disorders: A systematic review of the literature. International Journal of Eating Disorders, 40, 293–309. Buckley, S. D., & Newchok, D. K. (2005). An evaluation of simultaneous presentation and differential reinforcement with response cost to reduce packing. Journal of Applied Behavior Analysis, 38, 405–409. Buckley, S. D., Strunck, P. G., & Newchok, D. K. (2005). A comparison of two multicomponent procedures to increase food consumption. Behavioral Interventions, 20, 139–146. Cuccaro, M. L., Shao, Y., Grubber, J., Slifer, M., Wolpert, C. M., Donnelly, S. L., et al. (2003). Factor analysis of restricted and repetitive behaviors in autism using the Autism Diagnostic Interview-R. Child Psychiatry and Human Development, 34, 3–17. Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilties, 28, 145–162. Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Pediatrics and Child Health, 39, 299–304. Fodstad, J. C., & Matson, J. L. (2008). A comparison of feeding and mealtime problems in adults with intellectual disabilities with and without autism. Journal of Developmental and Physical Disabilities 10.1007/SI0882-008.9116-6. Johnson, C. R., Handen, B. L., Mayer-Costa, M., & Sacco, K. (2008). Eating habits and dietary status in young children with autism. Journal of Developmental and Physical Disabilities, 20, 437–448. Jyonouchi, H., Geng, L., Ruby, A., Reddy, C., & Zimmerman-Brier, B. (2005). Evaluation of an association between gastrointestinal symptoms and cytokine production against common dietary proteins in children with autism spectrum disorders. The Journal of Pediatrics, 146, 605–610. Keen, D. V. (2008). Childhood autism, feeding problems, and failure to thrive in early infancy: Seven case studies. European Child and Adolescent Psychiatry, 17, 2089–2216. Kuhn, D. E., & Matson, J. L. (2002). A validity study of the Screening Tool of fEeding Problems (STEP). Journal of Intellectual and Developmental Disabilities, 27, 161–167. Levin, L., & Carr, E. G. (2001). Food selectivity and problem behavior in children with developmental disabilities. Behavior Modification, 25, 443–470. Lindsay, R. L., Eugene, A. L., Aman, M. G., Vitiello, B., Posey, D. J., McDougle, C. J., et al. (2006). Dietary status and impact of risperidone on nutritional balance in children with autism: A pilot study. Journal of Intellectual and Developmental Disabilities, 31, 204–209. Luiselli, J. K., Ricciardi, J. N., & Gilligan, D. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20, 155–163. Lukens, C. T., & Linscheid, T. R. (2008). Development and validation of an inventory to assess mealtime behavior problems in children with autism. Journal of Autism and Developmental Disorders, 38, 342–352. Matson, J. L. (2007a). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disabilities, 28, 109–118. Matson, J. L. (2007b). Determining treatment outcome in early intervention programs for autism spectrum disorders: A critical analysis of measurement issues in learning based interventions. Research in Developmental Disabilities, 28, 218–297. Matson, J. L., Bamburg, J. W., Cherry, K. E., & Paclawskyj, T. R. (1999a). A validity study on the Questions About Behavior Function (QABF) scale: Predicting treatment success for self-injury, aggression, and stereotypies. Research in Developmental Disabilities, 20, 163–176. Matson, J. L., & Boisjoli, J. A. (2007). Differential diagnosis of PDD-NOS in children. Research in Autism Spectrum Disorders, 1, 75–84. Matson, J. L., & Boisjoli, J. A. (2008a). Cutoff scores for the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER) for adults with intellectual disabilities. Behavior Modification, 32, 109–120. Matson, J. L., & Boisjoli, J. A. (2008b). Strategies for assessing Asperger’s Syndrome: A critical review of data based methods. Research in Autism Spectrum Disorders, 2, 237–248. Matson, J. L., Carlisle, C. B., & Bamburg, J. W. (1998). The convergent validity of the Matson Evaluation of Social Skills in Individuals with Severe Retardation (MESSIER). Research in Developmental Disabilities, 19, 493–500. Matson, J. L., Dixon, D. R., & Matson, M. L. (2005a). Assessing and treating aggression in children and adolescents with developmental disabilities: A 20-year review. Educational Psychology, 26, 41–45. Matson, J. L., & Kuhn, D. E. (2001). Identifying feeding problems in mentally retarded persons: Development and reliability of the Screening Tool of fEeding Problems (STEP). Research in Developmental Disabilities, 22, 165–172.
J.L. Matson, J.C. Fodstad / Research in Autism Spectrum Disorders 3 (2009) 455–461
461
Matson, J. L., Leblanc, L. A., & Weinherimer, B. (1999b). Reliability of the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER). Behavior Modification, 23, 647–661. Matson, J. L., & Logan, J. R. (1997). A review of destructive behavior in developmental disabilities: Diagnosis and treatment. Contemporary Psychology, 42, 545–546. Matson, J. L., Mayville, S. B., Kuhn, D. E., Sturmey, P., Laud, R. B., & Cooper, C. (2005b). The behavioral function of feeding problems as assessed by the Questions About Behavior Function (QABF). Research in Developmental Disabilities, 26, 399–408. Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children with autism spectrum disorder: A review. Research in Developmental Disabilities, 28, 567–579. Matson, J. L., Nebel-Schwalm, M. S., & Matson, M. L. (2007). A review of methodological issues in the differential diagnosis of autism spectrum disorders in children. Research in Autism Spectrum Disorders, 1, 38–54. Matson, J. L., & Wilkins, J. (2007). A critical review of assessment targets and methods for social skills excesses and deficits for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 1, 28–37. Matson, J. L., & Wilkins, J. (2008). Nosology and diagnosis of Asperger’s syndrome. Research in Autism Spectrum Disorders, 2, 288–300. Najdowski, A. C., Wallace, M. D., Doney, J. K., & Ghezzi, P. M. (2003). Parental assessment and treatment of food selectivity in natural settings. Journal of Applied Behavior Analysis, 36, 383–386. Ogata, B., Trahms, C., Lucas, B., & Schwartz, I. (1999). A behavior-based approach to food refusal in children with autism and pervasive developmental disorder. Journal of the American Dietetic Association, 99, A104. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2000). Questions About Behavioral Function (QABF): A behavioral checklist for functional assessment of aberrant behavior. Research in Developmental Disabilities, 21, 223–229. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2001). Assessment of the convergent validity of the Questions About Behavioral Function (QABF) with analog functional assessment and the Motivation Assessment Scale (MAS). Journal of Intellectual Disability Research, 45, 484–494. Patel, M., Reed, G. K., Piazza, C. C., Mueller, M., Bachmeyer, M. H., & Layer, S. A. (2007). Use of high-probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction. Behavioral Interventions, 22, 305–310. Paul, C., Williams, K. E., Riegel, K., & Gibbons, B. (2007). Combining repeated taste exposure and escape prevention: An intervention for the treatment of extreme food selectivity. Appetite, 49, 708–711. Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D., & Lancaster, B. M. (2002). An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35, 259–270. Ritvo, E. R., & Freeman, B. J. (1978). Current research on the syndrome of autism: Introduction. The national society for autistic children’s definition of the syndrome of autism. Journal of the American Academy of Child and Adolescent Psychiatry, 17, 565–575. Rojahn, J., Aman, M. G., Matson, J. L., & Mayville, E. A. (2003). The aberrant behavior checklist and the behavior problems inventory: Convergent and divergent validity. Research in Developmental Disabilities, 24, 391–404. Rojahn, J., Matson, J. L., Lott, D., Esbensen, A., & Smalls, Y. (2001). The Behavior Problems Inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Journal of Autism and Developmental Disorders, 31, 577–588. Rojahn, J., Matson, J. L., Naglieri, J. A., & Mayville, E. A. (2004). Relationships between psychiatric conditions and behavior problems among adults with mental retardation. American Journal on Mental Retardation, 109, 21–33. Ronald, A., Happe´, F., Bolton, P., Butcher, L. M., Price, T. S., Wheelwright, S., et al. (2006). Genetic heterogeneity between the three components of the autism spectrum: A twin study. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 691–699. Ronald, A., Happe´, F., & Plomin, R. (2005). The genetic relationship between individual differences in social and nonsocial behaviours characteristic of autism. Developmental Science, 8, 444–458. Schmitt, L., Heiss, C. J., & Campbell, E. E. (2008). A comparison of nutrient intake and eating behaviors of boys with and without autism. Topics in Clinical Nutrition, 23, 23–31. Schreck, K. A., & Williams, K. (2006). Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities, 27, 353–363. Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34, 433–438. Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203–218. Szatmari, P., Georgiades, S., Bryson, S., Zwaigenbaum, L., Roberts, W., Mahoney, W., et al. (2006). Investigating the structure of the restricted, repetitive behaviours and interests domain of autism. Journal of Child Psychology and Psychiatry, 47, 582–590. Twachtman-Reilly, J., Amaral, S. C., & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autism spectrum in school-based settings: Physiological and behavioral issues.. Language, Speech, and Hearing Services in Schools, 39, 261–272. Williams, P. G., Dalrymple, N., & Neal, J. (2000). Eating habits of children with autism. Pediatric Nursing, 26, 259–264. Zucker, N. L., & Losh, M. (2008). Repetitive behaviours in anorexia nervosa, autism, and obsessive-compulsive personality disorder. Psychiatry, 7, 183–187. Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven, J., & Pelphrey, K. A. (2007). Anorexia nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes. Psychological Bulletin, 133, 976–1006.