Methods
Registration
Eligibility Criteria
Information Sources and Search Strategy
1 | ASD OR special need* OR autis* OR Asperger OR Autistic-Disorder OR Asperger-Syndrome OR developmental disability OR intellectual disability OR ID OR autism spectrum disorder* OR mental* OR handi* OR retard* OR learning disab* OR cognitive impair* OR developmental delay OR DD OR global dev* OR GDD OR pervasive develop* OR PDD OR ADHD OR attention deficit hyperactivity disorder OR attention deficit disorder OR ADD |
2 | Fussy eat* OR Picky eat* OR food neophobia OR food fuss* OR selective eat* OR food select* OR eating habit* OR Food phobia OR Food refusal OR ARFID OR avoidant-restrictive food intake disorder OR Avoidant restrictive food intake disorder OR feeding disorder OR Pediatric feeding disorder OR feeding problem OR feeding difficult* OR Paediatric feeding disorder OR unhealthy diet OR diet quality OR inappropriate mealtime behav* OR problematic mealtime behav* OR feeding difficult* OR mealtime or tantrum* OR faddy eat* OR food fad* OR food sensitive* OR food defensive OR food aversion OR eating problem OR food restrictive OR food type OR CEBQ OR CFQ OR SFQ OR EBQ OR ORI-CEBI OR CPEBQ |
3 | Healthy eating OR vegetable OR novel food OR experiential learning OR sensory learning OR experience OR applied behaviour analysis OR exposure OR ABA OR applied behavior analysis OR Behavioral intervention OR behavioural intervention OR Behavioral treatment OR behavioural treatment OR Intervention OR parent training OR nonremoval OR non-removal OR reinforcement OR reward OR punish* OR systematic desensitisation OR systematic desensitization OR SD OR escape extinction OR representation OR shaping OR fading OR teach* OR learn* |
4 | Willingness to try OR report OR recall OR food diar* OR weight OR weigh OR amount eaten OR food choice OR novel food OR food refus* OR eating behaviour OR eating behaviour OR diet OR health OR sensory sensitive* OR sensitivity OR defensive OR compliance OR eating OR bite* OR number of bite* |
5 | 1 AND 2 AND 3 AND 4 |
Study Selection
Data Collection Process
Data Items
Risk of Bias
Summary Measures
Synthesis of Results
Results
Study Selection
Study Characteristics
Study ID (First author, year published, country) | Study characteristics | Participants (N, age, gender and diagnoses) | Setting | Interventions used | Duration of intervention | Measures used | Outcomes | Follow-up | |||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
% Bite acceptance | Number of foods eaten | Number of bites | Behavioural demands | Weighed intake | Self-report | ||||||||
Ahearn (2003), USA | Case study, multiple baseline | N: 1 Age: 14 Gender: M Diagnoses: autism (profound) | Clinical | Adding condiments (simultaneous presentation) to 3 disliked vegetables) | 38 Sessions | ✓ | Increased from 0 to 20% (baseline) to 100% (intervention)a | 2-Week diet history 1-year after intervention | |||||
Allison et al. (2012), USA | Case study, multiple baseline | N: 1 Age: 3 Gender: M Diagnoses: Autism | Clinical | DRA + EE versus NCR + EE. | 38 Sessions | ✓ | Increased 0% (baseline) to 100% (intervention)a | N | |||||
Barahona et al. (2013), USA | Case study, two baselines and two interventions | N: 1 Age: 18 Gender: F Diagnoses: Autistic disorder and moderate ID | SEN School | Demand fading, verbal positive reinforcement, sticker reinforcement | 49 Sessions | ✓ | Increased acceptance of 5 novel food items. Regular home packed meals fully replaced with novel foods at end of interventiona | N | |||||
Binnendyk and Lucyshyn (2009), USA | Case study with family. | N: 1 Age: 6 Gender: M Diagnoses: autism | Clinical/home | PBS with family and intervention including: stimulus fading, shaping procedures, NCR and EE | 22 therapist sessions and 12 probe sessions with parents | ✓ | ✓ | Acceptance with therapist increased from 0% (baseline) to 100% (post-intervention) with 5 foods. % of food consumption with family increased from 0% (baseline) to average 64% (post-intervention)a | 5 follow up sessions up to 2-years post intervention | ||||
Brown (2002), UK | Case study, multiple baseline | N: 1 Age: 7 Gender: M Diagnoses: moderate Learning disabilities | Clinical | Using new foods that are similar to those previously accepted, portion fading, NCR and verbal reinforcement | Daily intervention lasting 3-months | ✓ | Amount of a new foods eaten increased from 0 chips eaten to 10 chips at 3 month FU, 0 to 1 bread roll at FU and 1 to 4 different flavoured yoghurts eaten at FUa | 3-Months | |||||
Cassey et al. (2016), USA | Case series, baseline, modified baseline and intervention | N: 4 Ages: 14, 15, 16 and 19 Gender: All M Diagnoses: PDD; ASD and ID; ASD and ADHD; ASD (respectively) | After school programme | Visual and verbal positive reinforcement using a game | 15 sessions | ✓ | Number of bites of FV eaten increased. Baseline M = 0 bites, Modified Baseline M = 6.2 bites (no SD reported), range = 0-15.6 bites Intervention M = 13.8 (range = 8–31.3 bites)a | N | |||||
Cosbey and Muldoon (2017), USA | Case series, baseline and intervention | N: 3 Ages: 6, 7 and 8 Gender: All M Diagnoses: All ASD | Home | Environmental intervention tasks with the family | Not reported | ✓ | ✓ | Mean % food acceptance increased. Food frequency Average = + 14 foods. + 6, + 16 and + 20 new foods eaten by each participanta | FU maintenance probes until 6-months | ||||
Ewry and Fryling (2016), USA | Case study, multiple baseline, intervention and parent implementation | N: 1 Age: 15 Gender: M Diagnoses: ASD | Home | High probability sequence to 2 non-preferred foods | 19 Sessions | ✓ | Increased % acceptance of low-p foods. Baseline M = 0%, intervention M = 96%. Return to baseline M = 16%, return to intervention M = 94%. Parental implementation M = 96%.a | Two sessions at 7-months | |||||
Fernand et al. (2016), USA | Case series | N: 2 Ages: 6 and 7 Gender: F and M (respectively) Diagnoses: both ASD | Not reported | Choice of 2 of 4 non-preferred foods presented + NRS (if did not self-feed). versus NRS alone without a choice of foods | 47–51 sessions | ✓ | ✓ | Choice intervention increased the number and frequency of accepted non-preferred bites consumed for one participant. This did not work for the other participant and frequency only increased when NRS was useda | N | ||||
Fu et al. (2015), USA | Case series, Non-concurrent multiple baseline | N: 2 Ages: 9 and 10 Gender: Both M Diagnoses: both autism | Clinical | Modelling, DRA and NRS | 33 Sessions | ✓ | Participant 1: modelling + DRA increased percentage of bites consumed from 0% (modelling alone) to around 70%. Modelling + DRA + NRS increased this to 100%. participant 2: Modelling + DR made no difference from baseline. Modelling + DR + NRS increased intake to 100%a | Two sessions at 8 and 4-weeks (each participant) | |||||
Hodges et al. (2017), USA | Case series, Baseline, intervention and maintenance phase | N: 2 Ages: 7 and 8 Gender: M and F (respectively) Diagnoses: ASD; and ASD, epilepsy, ADHD, ID (respectively) | Clinical | Single food reinforcement contingency, DRA. | 92–113 trials | ✓ | ✓ | Intervention gradually increased level of acceptance from total refusal at baseline through touching food to lips, putting food in the mouth and eventually swallowing the food. Number of new foods eaten increased from 0 to 4 for both participantsa | N | ||||
Hubbard et al. (2015), USA | Quasi-experimental, pre–post design | N: 43 Age: 11–22 years Gender: 51% female Diagnoses: All ID or developmental disorder | Residential School for Intellectual Disabilities | Environment change to school lunchroom informed by behavioural economics | 3-months | ✓ | Mean gram weight of foods consumed did not change over the study | N | |||||
Kadey et al. (2013), USA | Case series, Multiple baseline and interventions | N: 2 Ages: 3 and 9 Gender: M and F (respectively) Diagnoses: ASD; ASD and severe-profound ID (respectively) | Clinical | NRS + NCR and Physical guidance using Nuk brush to facilitate child opening mouth. Graded fading, verbal prompts, fade prompts, hand over hand guidance and Nuk prompts were also used | Various session lengths depending on participant and intervention | ✓ | Participant 1 0% acceptance at baseline, increased following NRS and NRS + NCR phases to 80-100% using NRS + NCR + physical guidance. Participant 2 increased acceptance for a rejected food after non-removal, fading and Nuk procedure intervention, as Nuk procedure alone did not increase acceptancea | 107-days after intervention for one participant | |||||
Kim et al. (2018), South Korea | Pre-post experimental design. Intervention with control group | N: 27 (13 intervention group versus 12 control group) Age: 2–5 years Gender: 23 M and 3 F (11 M in intervention and 2 F) Diagnoses: intervention group all diagnosed ASD | Laboratory | Visual + tactile guided vegetable exposure through play | One activity a day, for 4 days a week (5–10 min). Total 6-months | ✓ | Increased from Pre intervention (M = 5.73, SD = 13.55) to Post (M = 19.46, SD = 23.84). The control group did not differ, Pre (M = 1.75, SD = 3.82) Post (M = .46, SD = 1.10)a | N | |||||
Koegel et al. (2012), USA | Case series, Baseline, Intervention and follow-up | N: 3 Age: 6-8 years Gender: all M Diagnoses: all autism | Not reported | Individualized reinforcers, high probability sequence, and NCR | Until 15 new foods accepted or 22-weeks | ✓ | Number of new foods accepted increased from 0 (baseline) to 9, 8 and 5 (for each participant) after intervention. At generalization, 15, 16 and 6 new foods accepteda | FU after intervention to measure generalisation | |||||
Levin and Carr (2001), USA | Case series, baseline and multiple interventions | N: 4 Ages: 5, 6, 6 and 7 Gender: 3 M and 1 F Diagnoses: all autistic disorder | Classroom | Access to preferred food pre-intervention and positive reinforcement | 30-45 sessions (depending on participant) | ✓ | Only 3 participants took part in intervention phases. Only the no access to preferred food prior to intervention and positive reinforcement condition resulted in intake of non-preferred fooda | N | |||||
Parallel-group randomized clinical trial | N: 78 (68 in intervention) Age: 2–6 years Gender: 50 M and 18 F Diagnoses: all ASD | Clinical | Operant conditioning (faded verbal and visual prompts with social reinforcement) versus systematic desensitisation (modelling and play based, with social reinforcement) | Ten sessions, either weekly (10-weeks) or intensive (10 sessions in 1 week) | ✓ | Total food count, FV count, carbohydrate count and protein counts increased in both OC and SysD intervention groups. There were no significant differences between weekly and intensive intervention modelsa | 3-months | ||||||
Miyajima et al. (2017), Japan | Before and after self-control study | N: 23 Age: 3–6 years Gender: 18 M and 5 F Diagnoses: 19 ASD, 4 other developmental disorders | Not reported | Psychoeducation during parental training | Two 40-min sessions and two discussions for the parents of children with ASD | ✓ | The number of food items consumed (out of 47 foods) increased from 20.52 to 25.17 items (p = .004) after intervention. The number of unaccepted food items decreased from 14.52 to 11.79 items after intervention (p < .001a | N | |||||
Muldoon and Cosbey (2018), USA | Case series. Pre-post design | N: 3 Ages: 3, 4 and 5 Gender: all M Diagnoses: all ASD | Clinical | Mealtime plans, parental training and behavioural strategies based on the EAT-UP model | 6 months | ✓ | ✓ | Food frequency questionnaire (results not reported) and 24 h Recall reported that all participants increased the variety of foods eaten in a 24-h period and diets included previously non-preferred foodsa | The study is a FU | ||||
Najdowski et al. (2003), USA | Case study, multiple baseline | N: 1 Age: 5 Gender: M Diagnoses: ASD | Home and Restaurant | Demand fading, DRA and DRA + EE + demand fading | 79 meals | ✓ | ✓ | During baseline and DRA, participant never accepted or swallowed non-preferred foods. During DRA + EE + demand fading, participant accepted (but expelled) one bite of non-preferred food and began swallowing bites during the fifth meal. At home, the participant eventually swallowed 62 bites of five different non-preferred foods (Baseline = 0–5 bites)a | 2, 4, 6 and 12 weeks after intervention | ||||
Najdowski et al. (2010), USA | Case series. Multiple baseline, intervention and generalisation | N: 3 (only 2 with a-typical development) Ages: 2 and 4 Gender: F and M (respectively) Diagnoses: Both Autism | Home | Home-based Parental training. Mothers implemented DRA + EE at baseline and DRA + NRS + Demand Fading at intervention | Up to 49 sessions | ✓ | All participants increased percentage of swallowed non-preferred target foods after intervention phasea | 2, 4, 6 and 12 weeks after intervention | |||||
Patel et al. (2007), USA | Case study, multiple baseline | N: 1 Age: 4 Gender: M Diagnoses: PDD | Clinical | High-probability instructional sequence | 28 sessions including 3-month follow-up | ✓ | Compliance to low-probability (low-p) requests was zero when low-p (spoon with food) instructions were presented in isolation. This increased to 100% when the high-p sequence (empty spoon) preceded low-p instructionsa | 3-months | |||||
Paul et al. (2007), USA | Case series, baseline and intervention | N: 2 Ages: 3 and 5 Gender: M and F (respectively) Diagnoses: both autism | Clinical | Repeated taste exposure, EE and portion fading | 13–15 days and 3-month FU | ✓ | ✓ | Number of foods eaten increased from two foods at baseline to 65 foods after intervention and 53 foods (reported by parents) at FU. The other participant increased from 0 foods at baseline to 49 foods after intervention and 47 foods (reported by parents) at FUa | 3-months | ||||
Penrod et al. (2010), USA | Case series. baseline and multi-element design | N: 3 Ages: 4, 4 and 5 Gender: all M Diagnoses: sensory, visual-motor and oral-motor delays; ASD; and ASD (respectively) | Clinical and Home | High-probablility sequence, simultaneous presentation of high and low probability foods and prompts NRS and bite fading procedures were added to the intervention | Not reported | ✓ | All participants showed an increased percentage of bites consumed for most previously Non-preferred foodsa | N | |||||
Penrod et al. (2010), USA | Case series. Multiple-baseline, and phased intervention | N: 3 Ages: 3, 4 and 4 Gender: All M Diagnoses: autism; autism; and PDD (respectively) | Home | Parent delivered intervention: Phase 1: DRA + Escape + bite fading. Phase 2: DRA + Escape + bite fading + reinforcer manipulation. Phase 3: DRA + bite fading + reinforcer manipulation + EE | Up to 129 sessions | ✓ | Participants 1 and 2 never accepted or swallowed any food until phase 3. Participant 3 accepted a small number of bites at phase 1 and consistently accepted and swallowed non-preferred foods at phase 2a | 12-weeks | |||||
Pizzo et al. (2012), USA | Case study, baseline and intervention | N: 1 Age: 16 Gender: M Diagnoses: ASD | Clinical | Sequential presentation (plate A–plate B) | Up to 55 meals | ✓ | ✓ | Participant met mastery criterion for 14 new foods; six starches, two dairy, two fruit, one vegetable, and three proteins. Percentage of successful bites increased from 0% (baseline) to an average of 74% during interventiona | N | ||||
Seiverling et al. (2018), USA | Case series, alternating treatments design. | N: 2 Ages: 5 and 6 Gender: both M Diagnoses: both ASD | Clinical | Behavioural feeding interventions with and without Sensory Integration Therapy condition NRS was used if non-compliant | 24-30 daily sessions | ✓ | Percentage of bites was less than 40% (baseline) and increased to above 90% during sensory integration therapy and control conditions. Both participants increased total amount consumed across both treatment conditionsa | 2-months (only for one participant) | |||||
Seiverling et al. (2012a), USA | Case study, baseline and intervention | N: 1 Age: 3 Gender: M Diagnoses: ASD | Clinical | NCR (plate A–plate B) and DRA, EE and demand fading (size of bites) | Five days from approximately 8:30 AM to 4:30 PM as part of an intensive day treatment program. 35 sessions | ✓ | ✓ | Percentage of accepted bites increased from 0% (baseline) to 100% when using EE. Number of foods eaten increased from 17 to 39 (+ 22 foods)a | 1 and 3-months | ||||
Seiverling et al. (2012b), USA | Case series, multiple baseline | N: 3 Ages: 4, 5 and 8 Gender: all M Diagnoses: all ASD | Home | Behavioural skills parent training and treatment package including taste exposure, EE and fading | 11 treatment days and 3–4 weeks follow-up | ✓ | During baseline taste sessions, all children consistently refused bites. During post training, each child showed an increase in bites accepteda | Weekly FU for 3-weeks | |||||
Sharp et al. (2011), USA | Retrospective chart review | N: 13 Age: 2–8 years Gender: 11 M and 2 F Diagnoses: All ASD | Clinical | EE, NCR, DRA, and stimulus fading procedures | 8-weeks, for an average total of 39 treatment days (range 29–46 days) | ✓ | At baseline, low rates of acceptance (M = 7%; range 0–48%) and swallowing (M = 7%; range 0–65%) were observed. There was a significant main effect for mouth cleans after treatment, F(1,15) = 114, p < 0.001, partial eta squared = 0.92. The increase in intake was seen in fruits, vegetables, proteins and six starches. Wilcoxon signed rank (Z = − 2.972; p < 0.003)a | N | |||||
Silbaugh and Falcomata (2017), USA | Case study, reversal design | N: 1 Age: 4 Gender: M Diagnoses: ASD | Home | Lag schedule of positive reinforcement and NCR | 30 sessions | ✓ | ✓ | A decreasing trend in consumption (M = 52.5%; range 20–90%) and variety (M = 2.5; range 2–4) was observed across sessions during lag 0. Lag 1 increased consumption relative to lag 0 but with variability (M = 53.3%; range 20–90%); variety of foods consumed also increased (M = 3.06; range 2–4)a | N | ||||
Silbaugh et al. (2017), USA | Case study, baseline and multiple graded interventions | N: 1 Age: 3 Gender: F Diagnoses: ASD | Home | Lag schedule of positive reinforcement and Response blocking of invariant consumption, least-to-most prompting and EE | 36 sessions | ✓ | ✓ | No independent consumption was observed during baseline or Lag1/toys conditions. Lag 1/toys/least-to-most prompting/response blocking increased percentage consumption (M = 43%). Lag 1/Response blocking increased variety of foods consumed (M = 2.3). During Lag 2/RB, the variety of food consumed increased from a mean of 2 foods to a mean of 3.3 foodsa | N | ||||
Tanner and Andreone (2015), Canada | Case study, baseline and intervention | N: 1 Age: 3 Gender: M Diagnoses: ASD | Clinical | Graduated Exposure and DRA. | 6-months/100 sessions | ✓ | Increased food acceptance from four foods to over 50 foods, with 27 of those foods generalizing to additional settings and peoplea | N | |||||
VanDalen and Penrod (2010), USA | Case series, multiple baseline combined with multi-element intervention | N: 2 Ages: 4 and 5 Gender: both M Diagnoses: both ASD | Clinical | Simultaneous presentation of a non-preferred food with a high-preference food and sequential presentation. NRS with a schedule of reinforcement was also used | Between 55 and 64 sessions | ✓ | At baseline neither participant consumed non-preferred foods. During simultaneous and sequential presentation, minimal bites were accepted or consumed. When NRS was adopted, 80–100% of bites were consumeda | 1-year | |||||
Wallen et al. (2013), Sweden | Cross-sectional, intervention versus control | N: 89 (27 in intervention group) Age: 16–21 years Gender: Intervention group = 15 F and 12 M, Control group = 29 F and 33 M Diagnoses: all moderate/mild ID, 12 with Down’s syndrome and 3–6 with ASD (ASD rates not well reported) | School | School environmental intervention using modified plates and psychoeducation | Minimum 6-months | ✓ | ✓ | No significant differences observed between groups based on food choice, plate waste or intake, including FV intake | N | ||||
Wood et al. (2009), USA | Case study, multiple probe design | N: 1 Age: 5 Gender: M Diagnoses: Autistic disorder | Home | Combined task direction, NCR, physical prompts (hand over hand), and demand fading | 39 sessions | ✓ | At baseline, only already accepted foods were eaten. During intervention, bites of non-preferred foods increased to 100%, until bites presented increased from three to six per session. Foods never eaten at baseline increased to 50% bites consumeda | N |
Methods
Participants
Intervention
Method/intervention | Description | Number of studies |
---|---|---|
Based on operant conditioning | ||
Escape extinction (EE) | This technique describes various procedures that prevent escape from the feeding situation (including non-removal of the spoon: NRS and physical guidance; Piazza et al. 2003) | 18 |
Non-removal of the spoon (NRS) | A type of EE that holds a spoon close to the mouth until the food is accepted | 7 |
Physical guidance | Guiding the mouth open or applying small pressure to the jaw to assist with accepting food into the mouth | 2 |
Differential reinforcement of alternative behaviour (DRA) | Positive reinforcement of ‘target’ or ‘good’ behaviours (e.g. reinforced with food, toys, stickers and verbal praise) on a variable schedule (Piazza et al. 1996) | 14 |
Non-contingent reinforcement (NCR) | Reinforcement that is not dependent on completing a ‘target’ behaviour (e.g. swallowing a non-preferred food item) | 9 |
Lag schedules | A schedule of reinforcement in which a single response, or a sequence of responses, is reinforced if it varies from previous responses or sequences of responses (Page and Neuringer 1985) | 2 |
Based on exposure | ||
Systematic desensitisation (SysD) | A method designed to reduce avoidance behaviour towards an adverse stimulus by gradually increasing exposure to it (Davison 1968) | 15 |
Stimulus/texture, Portion and Demand fading | Three methods of SysD Stimulus/texture fading: Gradually changing the texture of a food (e.g. runny mashed potato can be made increasingly thicker) Portion fading: Gradually increasing a portion of a new food (e.g. from a pea size to a recommended serving) Demand fading: Gradually increasing behaviours that are required by the participant (e.g. increasing the demand from one bite to three bites) | 3, 2 and 7 respectively |
Simultaneous presentation | A type of flavour–flavour conditioning that pairs a non-preferred food with a preferred food or liked condiment | 3 |
Using new foods similar to those previously accepted | Using similar foods to those already accepted (e.g. matching by food group, brand, colour, texture etc.) | 1 |
Modelling | Watching others eat the non-preferred food (e.g. parents, siblings, friends) | 2 |
High probability sequences | This requires asking the participant to complete a high-probability task (e.g. put spoonful of preferred food in the mouth) before asking them to perform a low-probability task (e.g. put a spoonful of non-preferred food in the mouth) (Ewry and Fryling 2016) | 4 |
Choice of foods | Allowing the person a choice between different non-preferred foods (Fernand et al. 2016) | 1 |
Access to preferred food | The preferred food is offered before the non-preferred food is presented | 4 |
Family and environmental methods | ||
Psychoeducation | Psychoeducation involves providing education and information to family members about selective eating in the DD population | 2 |
Parental training | Most of the techniques described are implemented by clinicians or researchers. Parental training is designed so that parents can implement some strategies themselves | 6 |
Mealtime plans | Mealtime plans are implemented by the family and focus on areas such as communication, food, social and physical environment during mealtimes (Muldoon and Cosbey 2018) | 1 |
Positive behavioural support (PBS) | A multi-component intervention that aims to support an individual with DD. This includes a functional assessment of possible relationships between environment and behaviour, which can inform support for eating using appropriate methods (methods in this table) for the individual (Binnendyk and Lucyshyn 2009) | 2 |
Environmental interventions | Environmental interventions used by studies in the current review included changing the layout and placement of healthy foods in lunchrooms, using special plates that show how much of the plate should be filled with portions from each food type and using team games to encourage snack FV intake | 4 |
Setting
Outcomes
Risk of Bias Within Studies
