The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial

doi:10.1016/j.jpeds.2019.03.046

The Journal of Pediatrics

Volume 211, August 2019, Pages 185-192.e1

https://doi.org/10.1016/j.jpeds.2019.03.046 Get rights and content

Objective

To assess the feasibility and initial efficacy of a structured parent training program for children with autism spectrum disorder and moderate food selectivity.

Study design

This 16-week randomized trial compared the Managing Eating Aversions and Limited variety (MEAL) Plan with parent education. MEAL Plan (10 core and 3 booster sessions) provided parents with nutrition education and strategies to structure meals and expand the child's diet. Parent education (10 sessions) provided information about autism without guidance on nutrition, meal structure, or diet. In addition to feasibility outcomes, primary efficacy outcomes included the Clinical Global Impression - Improvement scale and the Brief Autism Mealtime Behaviors Inventory. Grams consumed during a meal observation served as a secondary outcome.

Results

There were 38 eligible children (19 per group, 32 males). For MEAL Plan, attrition was <10% and attendance >80%. Therapists achieved >90% fidelity. At week 16, positive response rates on the Clinical Global Impression - Improvement scale were 47.4% for the MEAL Plan and 5.3% for parent education (P < .05). The adjusted mean difference (SE) on Brief Autism Mealtime Behaviors Inventory at week 16 was 7.04 (2.71) points (P = .01) in favor of MEAL Plan. For grams consumed, the adjusted standard mean difference (SE) was 30.76 (6.75), also in favor of MEAL Plan (P = .001).

Conclusions

The MEAL Plan seems to be feasible, and preliminary efficacy results are encouraging. If further study replicates these results, the MEAL Plan could expand treatment options for children with autism spectrum disorder and moderate food selectivity.

Trial registration

Clinicaltrials.gov: NCT02712281.

Section snippets

Methods

Children were randomly assigned in a 1:1 ratio to the Managing Eating Aversions and Limited variety (MEAL) Plan or the structured parent education program (PEP)¹⁷ for 16 weeks. At week 16, parents of children randomly assigned to PEP were invited to participate in the MEAL Plan. Parents of children randomly assigned to MEAL Plan were asked to return at week 20 for a post-treatment follow-up. The study treatments were delivered in a group format. To ensure consistent baseline measurements across

Results

Enrollment began in January 2017 and ended in October 2017. Of the 111 children screened, 50 were ineligible; parents of 23 presumably eligible children declined participation (Figure 1; available at www.jpeds.com); 38 children were randomly assigned to 16 weeks of MEAL Plan or PEP. Participants (32 boys, 6 girls) ranged in age from 38 to 88 months (mean, 58.7 ± 13.8 months). The study groups appeared similar at baseline except for body mass index weight category status (Table II).

Discussion

This study tested the feasibility and preliminary efficacy of the Autism MEAL Plan vs parent education (an active comparator) in 38 children with ASD and moderate food selectivity. Feasibility metrics indicated the MEAL Plan curriculum was acceptable to parents. Nearly two thirds of apparently eligible participants actually enrolled in the group-based randomized trial. Attrition was <20%. We successfully collected 88% of study data. Parents in the MEAL Plan group expressed high satisfaction

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The participants were parents/caregivers of children aged 3–6 years. The ASD-MBQ and a demographic data sheet were mailed to parents/caregivers who consented to participate in this study. Descriptive statistics were used to characterize ASD and non-autistic groups. Group differences were calculated using the Mann-Whitney U test. Receiver operating characteristic (ROC) analysis was performed to determine the sensitivity, specificity, and area under the curve (AUC).
The sample comprised 128 children with ASD and 128 non-autistic children (3–6 years). The mean total and all subdomain scores of the ASD-MBQ obtained from children with ASD were significantly higher than the scores of those non-autistic children (P < 0.001). The total mean score of the ASD-MBQ differentiated children with ASD from non-autistic children with an excellent ROC-AUC of 0.885 (95% CI 0.845–0.942). A total mean score of 2.04, calculated using the Youden score showed the best sensitivity (0.648) and specificity (0.953).
These results indicate that the ASD-MBQ is a promising tool for identifying problematic mealtime behavior in 3–6 year old children with ASD, in Japan.
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Feeding clinics are available for children who are clinically diagnosed with feeding disorders (e.g., avoidant/restrictive food intake disorder, ARFID) or severe food selectivity. However, there is a lack of available programs that address mealtime behaviors and healthy eating for children with ASD who have mild to moderate food selectivity or nutritional issues [12,13]. One of the few interventions is the Autism MEAL Plan, which is a parent training program for caregivers with a three- to eight-year-old child with ASD and moderate food selectivity and showed promising results in improving mealtime behaviors and quantity of food consumed by participants [11,12].
Autism spectrum disorder (ASD) is a developmental disorder that affects communication and social behaviors. Children with ASD often experience mealtime behavior challenges and selective eating behaviors. They also tend to consume fewer fruits and vegetables and more high-energy dense foods, compared to neurotypical peers. A nutrition intervention was designed to prevent the development of feeding disorders and the long-term negative health impacts associated with poor dietary intake. This randomized controlled trial will evaluate the feasibility and preliminary efficacy of the nutrition education intervention for children with ASD and their parents through the Early Intervention (EI) services. We will recruit EI providers and parent-child dyads (n = 48) from EI programs, and randomly assign them into Autism Eats intervention (n = 24) or enhance usual care (EUC) comparison group (n = 24). The Autism Eats is 10 weekly sessions delivered individually as part of EI, while the EUC group will receive only 1 nutrition education session and then weekly parent handouts. The Autism Eats integrates ASD-specific feeding strategies and behaviorally-focused intervention strategies such as goal setting. Feasibility indicators include reach/participation, attrition, completion, fidelity, compatibility, and qualitative participant feedback. Outcome measures include dietary intakes and mealtime behaviors of children with ASD using 3-day food records and a validated questionnaire, the Brief Autism Mealtime Behavior Inventory (BAMBI). We will examine whether there are differences in children's food intakes, variety, diet quality, and mealtime behaviors between Autism Eats and EUC groups at post-intervention and 5-month follow-up assessment. This study will provide critical data to inform a full-scale randomized controlled trial.
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Antegrade therapies (Malone Appendicostomy, Chait tube, MiniACE®, etc.) have often been utilized as the final step in the treatment algorithm given the need for surgical intervention and possible increased morbidity [7,8]. However, it has been observed that many children with neurodiverse disorders have food biases, resistance to medical therapy, and may be anally defensive [8–10]. These behaviors create notable challenges to providers when attempting laxative and/or retrograde enema therapy.
Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas.
Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's.
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A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children.
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: Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development by grants to Emory University (MH081148; principal investigator: W.S.; Marcus Foundation and Children Health Care Trust). The authors declare no conflicts of interest.

View full text

Original ArticleThe Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial

Objective

Study design

Results

Conclusions

Trial registration

Section snippets

Methods

Results

Discussion

J Pediatr

J Acad Nutr Diet

Res Autism Spect Disord

Res Dev Disabil

J Clin Epidemiol

Feeding problems and nutrient intake in children with autism spectrum disorders: a meta-analysis and comprehensive review of the literature

J Autism Dev Disord

Feeding problems in children with autism spectrum disorders: a review

Focus Autism Other Dev Disabl

Reduced bone cortical thickness in boys with autism or autism spectrum disorder

J Autism Dev Disord

Overweight and obese status in children with autism spectrum disorder and disruptive behavior

Autism

The health status of adults on the autism spectrum

Autism

Food selectivity, mealtime behavior problems, spousal stress, and family food choices in children with and without autism spectrum disorder

J Autism Dev Disord

Mealtime problems in children with autism spectrum disorder and their typically developing siblings: a comparison study

Autism

Development and validation of an inventory to assess mealtime behavior problems in children with autism

J Autism Dev Disord

A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care?

J Pediatr

A retrospective chart review of dietary diversity and feeding behavior of children with autism spectrum disorder before and after admission to a day treatment program

Focus Autism Other Dev Disabl

Original Article
The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial