Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development
Introduction
Atypical eating behaviors have been recognized as common in autism since autism was first conceptualized as a diagnosis by Kanner (1943). Limited food preferences (also referred to as selective eating, food selectivity, restricted variety, or reduced food repertoire) is the most frequent feeding problem in children with autism (Beighley, Matson, Rieske, & Adams, 2013; Bicer & Alsaffar, 2013; Postorino et al., 2015). Many children with autism demonstrate atypical eating behaviors during infancy (Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007) and have narrower diets than typical peers by 15 months of age (Emond, Emmett, Steer, & Golding, 2010).
A systematic literature review summarized in Table 1 revealed six studies of children with autism (1–18 years) that included the prevalence of limited food preferences, yielding a median prevalence of 62%. The prevalence estimates for autism are far higher than the 6%–50% range for picky eating in preschool typical children in a review by Cardona Cano, Hoek, and Bryant-Waugh, (2015) and medians of 27% for preschool children and 28% for children and adolescents in a review by Taylor, Wernimont, Northstone, and Emmett, (2015).
In fifteen studies, limited food preferences in children with autism were compared to children in contrast groups, with autism sample sizes ranging from 19 to 269 (median 53). Children and adolescents with autism had significantly more limited food preferences compared to (1) typical children (Bandini et al., 2017; Beighley et al., 2013; Castro et al., 2016; Curtin et al., 2015; Emond et al., 2010; Kuschner et al., 2015; Lockner, Crowe, & Skipper, 2008; Martins, Young, & Robson, 2008; Matson, Fodstad, & Dempsey, 2009; Schreck, Williams, & Smith, 2004; Valicenti-McDermott et al., 2006; Zimmer et al., 2012), (2) their parents and siblings (Aponte & Romanczyk, 2016; Schreck & Williams, 2006), and (3) children with developmental disabilities other than autism (Beighley et al., 2013; Dominick et al., 2007; Matson et al., 2009; Valicenti-McDermott et al., 2006).
Studies analyzing other atypical eating behaviors reported that children with autism rejected foods based on texture more so than controls (Dominick et al., 2007; Field, Garland, & Williams, 2003; Kuschner et al., 2015; Lockner et al., 2008; Matson et al., 2009; Schreck et al., 2004; Valicenti-McDermott et al., 2006). Other atypical eating behaviors documented in autism include pica (Matson et al., 2009) pocketing food without swallowing (Levin, Volkert, & Piazza, 2014; Mayes, 2012), eating only specific brands of a food (Mayes, 2012), not mixing foods and smelling foods before eating (Valicenti-McDermott et al., 2006), and mealtime rituals, such as using only a certain plate or cup or eating food only if presented a certain way (Mayes, 2012; Williams, Dalrymple, & Neal, 2000; Williams, Gibbons, & Schreck, 2005).
Postorino et al. (2015) reported that parents of children with autism who had limited food preferences experienced greater stress than parents of children with autism who did not have restricted diets. Limited food preferences in autism were associated with child behavior problems in some small studies (Curtin et al., 2015; Dominick et al., 2007; Postorino et al., 2015; Williams et al., 2000), but a large study of children with autism found that oppositional behavior, conduct problems, ADHD, irritability, emotional overreactivity, anxiety, depression, and social problems were not significant correlates (Zickgraf & Mayes, 2018). Deficient nutrition and growth are not reported in most studies of children with autism, despite food selectivity (Cardona Cano et al., 2015; Kral, Eriksen, Souders, & Pinto-Martin, 2013; Mari-Bauset, Zazpe, Mari-Sanchis, Llopis-Gonzalez, & Suarez-Varela, 2015; Postorino et al., 2015; Zickgraf & Mayes, 2018). Findings on the relationship between limited food preferences and gastrointestinal problems in autism are inconsistent (Gorrindo et al., 2012; Postorino et al., 2015; Suarez & Nelson, 2012; Valicenti-McDermott et al., 2006; Zickgraf & Mayes, 2018). A study investigating atypical eating behaviors in 1112 children with autism (who were participants in the present study) showed that young age, increasing autism severity, poor appetite, and constipation were significant correlates of atypical eating behaviors, whereas IQ, sex, race, psychotropic medication use, maternal behavior rating scale scores, weight, and health problems other than constipation were not (Zickgraf & Mayes, 2018).
The study purpose was to compare the prevalence of limited food preferences and other atypical eating behaviors in children and adolescents with autism versus other disorders (including ADHD, which has not yet been studied) and typical development in a sample of children with autism far larger than previous studies covering a broad age range (1–18 years).
Section snippets
Material and methods
The study was approved by the Institutional Review Board, which waived informed consent because analyses were conducted retrospectively on existing clinical data.
Prevalence of atypical eating behaviors
In the Child Diagnostic Clinic sample (Table 2), atypical eating behaviors were 4.2 times more common in autism (70.4%) than in ADHD (16.6%), χ2 = 224.9, p < .0001. Atypical eating behavior percentages did not differ significantly between children and adolescents with and without intellectual disability (ID) in the autism group (χ2 = 0.8, p = .37) and in the ADHD group (χ2 = 3.5, p = .08).
In the CASD Standardization sample (Table 2), atypical eating behaviors were 7.0 times more common in
Discussion
Combining results for the 2102 children from the child diagnostic clinic and CASD standardization samples, atypical eating behaviors were five times more common in autism (70%) than in children with other disorders (13%) and were 15 times more common in autism than in typical children (5%). Percentages were similar for the two independent autism samples (child diagnostic clinic 70% and CASD standardization 68%) with CASDs administered by different clinicians, supporting the reliability of the
Conflicts of interest
None.
Acknowledgements
No funding.
References (60)
- et al.
Assessment of feeding problems in children with autism spectrum disorder
Research in Autism Spectrum Disorders
(2016) - et al.
Food selectivity in children with and without an autism spectrum disorder: Investigation of diagnosis and age
Research in Developmental Disabilities
(2013) - et al.
Body mass index, dietary intake and feeding problems of Turkish children with autism spectrum disorder (ASD)
Research in Developmental Disabilities
(2013) - et al.
Feeding behavior and dietary intake of male children and adolescents with autism spectrum disorder: A case-control study
International Journal of Developmental Neuroscience
(2016) - et al.
Subtreshold autism spectrum disorder in patients with eating disorders
Comprehensive Psychiatry
(2018) - et al.
Atypical behaviors in children with autism and children with history of language impairment
Research in Developmental Disabilities
(2007) - et al.
Age at intervention and treatment outcome for autistic children in a comprehensive intervention program
Analysis and Intervention in Developmental Disabilities
(1985) - et al.
A comparison of intensive behavior analytic and eclectic treatments for young children with autism
Research in Developmental Disabilities
(2005) - et al.
The SWedish Eating Assessment for Autism spectrum disorders (SWEAA)-Validation of a self-report questionnaire targeting eating disturbances within the autism spectrum
Research in Developmental Disabilities
(2013) - et al.
Early concerns of mothers of children later diagnosed with autism: Implications for early identification
Research in Autism Spectrum Disorders
(2011)