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Although clinicians typically assume that feeding problems co-exist with a diagnosis of aut-
ism, no previous research has compared the eating behavior of children with autism to typi-
cally developing children. This study compared caregiver report of eating problems of
children with and without autism on a standardized questionnaire. The questionnaire
included items pertaining to food refusal and acceptance patterns as well as food presenta-
tion requirements. Caregivers were also asked to complete a food inventory that indicated
the number of foods eaten within each food group for both the child and the family.
Results indicated children with autism have significantly more feeding problems and eat a
significantly narrower range of foods than children without autism.
1995; Teplin, 1999). The majority of the studies parents of all children in classrooms within the tar-
have reported only individual cases of feeding prob- get age group received a packet containing identical
lems for children with autism. Only a pair of studies materials as the autism group. To ensure confidenti-
has examined groups of children with autism and ality, all names and addresses were kept secured by
found strong preferences and idiosyncratic feeding the principal co-investigators after mailing labels
behavior among them (Ahearn et al., 2001; Archer were typed by a research assistant. No identifying
& Szatmari, 1991; Nagai, 1983). Ahearn et al. information was required on the returned responses
(2001) have conducted one of the first systematic for either the autism group or the control group.
attempts at discovering the amounts of foods within Caregiver report of an autism diagnosis and
each food group children with autism have typically the Gilliam Autism Rating Scale (GARS) (Gilliam,
consumed. Unfortunately, the study was of limited 1995) were used to assist with group assignment (a
generalizability due to the small sample size. All of description of this instrument is included below).
the studies examining types of feeding problems in Two initial groups were developed from this infor-
children with autism have been limited by several mation:
factors including small sample size, lack of knowl-
1. Control (n ¼ 298): Children were assigned to this
edge of co-morbid medical conditions that could
group if their GARS scores were less than 80
affect eating, lack of comparison to the feeding
(indicating below average to very low probability
behaviors of children without autism, and inade-
of autism) and their parents reported no previous
quate information on the foods typically available
or current diagnosis of autism or pervasive devel-
within the family environment.
opmental disorder. Questionnaire return rate for
The goal of this study was to corroborate and
this group was approximately 25%.
expand on the information provided by previous
2. Autism (n ¼ 138): This group was composed of
case studies and clinical reports by answering the
children who had been diagnosed with autism
following research questions: (a) do children with
or pervasive developmental disorder by a profes-
autism have different eating habits from typical chil-
sional and had a GARS score P80. Although
dren? if so (b) what types of foods do children with
the cut-off score falls within the GARS range
autism typically eat or refuse? and (c) do families of
of below average probability of autism, the
children with autism eat a narrower range of foods
GARS manual indicates that 90% of children
than families of children without autism?
with autism fall within scores of 80 and above
(Gilliam, 1995). Consequently, this range was
chosen to include the maximum amount of chil-
METHOD dren with autistic behavior. Questionnaire return
rate for this group was approximately 29%.
Participants However, precise return rates for this group
would be difficult to obtain because autism soci-
Caregivers of children between the ages of 5
eties and schools were given permission to make
and 12 years (n ¼ 472; actual range ¼ 7–9.5 years)
copies of the packets and distribute to addi-
were recruited to complete questionnaires pertaining
tional parents.
to their family’s and child’s eating habits. This age
range was chosen to avoid the infant and toddler Children whose caregivers reported a profes-
years when children transition from formula to solid sional diagnosis of autism or pervasive developmen-
foods and adolescents when children engage in tal disorder, but had GARS scores O80ðn ¼ 31Þ
activities outside of the home (making it harder for and children whose caregivers did not report a pro-
caregivers to accurately report their child’s food fessional diagnosis of autism, but whose GARS
preferences). scores P80ðn ¼ 5Þ, were excluded from analysis.
Caregivers of the children with autism were Demographic information was collected for all
recruited through membership lists for local, state, participants and included: date of birth, height,
and national autism societies, schools for children weight, gender, presence of developmental disabili-
with autism, and from local doctors. A control ties, and presence of medical problems. Statistical
group was recruited from local school districts. A t-tests were conducted to determine if the control
local school district in central Pennsylvania agreed group and autism group differed on age, height,
to participate in this study. For a control group, weight, or gender. Significant differences were only
Comparison of Eating Behaviors between Children with and without Autism 435
Table I. Child Characteristics by Group Assignment the only measure of eating and mealtime behaviors
in children, and has been used previously with chil-
Characteristic Control (n = 298) Autism (n = 138)
dren with autism (Archer & Szatmari, 1991).
Sexa
Female 47 10
Male 53 88 Food Preference Inventory
Heightb 52 51
The Food Preference Inventory is a listing of
Weightc 71 66
Aged 108 99 foods from each of the five food groups (fruits,
vegetables, dairy, proteins, and starches). Caregivers
a
Reported by percentages of group. indicate whether the child will eat an age-appropri-
b
Average height reported in inches. ate portion of a particular food and whether the
c
Average weight reported in pounds.
d food is typically offered at meals and eaten by the
Average age reported in months.
family. Scores for the five food groups are obtained
by summing the foods accepted by children within
each food group (e.g., total number of starches typi-
found for gender t(397.32) ¼ )9.32, p ¼ .001 (see
cally eaten). Scores are also obtained for what types
Table I for basic demographic information by
of foods are typically eaten by the parents (e.g.,
group).
total number of starches eaten).
Although certain medical problems could influ-
ence eating and mealtime behavior, no specific med-
ical diagnoses were excluded. Instead, data on Gilliam Autism Rating Scale
medical diagnoses that could possibly influence
The GARS (Gilliam, 1995) is a professional
feeding was collected. Children with autism were
and parent report scale for evaluating autism, con-
found to have significantly higher rates than
structed from criteria in the Diagnostic and Statisti-
expected of medical problems; however, the number
cal Manual of Mental Disorders: Fourth Edition
of children with these problems within the autism
(DSM-IV) (American Psychiatric Association, 1994)
group (n ¼ 138) was small: seizure disorder (n ¼ 7),
and from the Autism Society of America’s (1994)
current lactose intolerance (n ¼ 8), obsessive com-
definition of autism. Gilliam reported the scale’s
pulsive disorder (n ¼ 21), anxiety (n ¼ 14), pulmo-
uses as providing supplemental information for
nary problems (n ¼ 3), current gastroesophageal
identification of autism, identifying serious behavior
reflux (n ¼ 5), previous gastroesophageal reflux
problems, evaluating progress for educational goals,
(n ¼ 9), constipation (n ¼ 11), diarrhea (n ¼ 6), and
identifying target goals, and as providing a research
current g-tube feedings (n ¼ 2). Since children with
measurement for autism (Gilliam, 1995). The four
medical problems constituted such a small propor-
domains (stereotyped behavior, communication,
tion of the children with autism and the causal links
social interaction, and developmental disturbances)
between these medical problems and eating is not
together yield an Autism Quotient (AQ) to deter-
clear, the responses for these children were not elim-
mine probability and severity of autism (with a
inated from the study.
mean of 100 and a SD of 15). The AQ was normed
on a sample of children (n ¼ 1,092) with autism.
Materials The manual reports that of children with diagnosed
autism, 90% obtain AQ scores P80. The test man-
Children’s Eating Behavior Inventory
ual (Gilliam, 1995) reported adequate validity and
The Children’s Eating Behavior Inventory reliability for test domains and for the AQ.
(CEBI) (Archer, Rosenbaum, & Streiner, 1991),
caregiver report for evaluating mealtime behaviors
Personal History Form
and eating behaviors, measures the frequency of 19
different eating behaviors through the use of a 5- The personal history form was used to gather
point rating scale. It also asks caregivers to evaluate demographic information (date of birth, weight,
whether or not each behavior presents a problem height, and gender). The form also listed a number of
for the family. Reliability for the total eating medical diagnoses for the caregivers to indicate if
problem score is in the acceptable range (r ¼ .87), their child was currently or previously diagnosed with
as is construct validity. This instrument is currently any of the listed medical diagnoses. All of the medical
436 Schreck et al.
diagnoses were chosen because they have been associ- dren with autism on the CEBI total problem score.
ated with feeding or eating problems in the literature. The Levene’s Test for Equality of Variances was
A list of developmental disabilities was also provided significant indicating unequal variances. Conse-
and the caregivers were asked to indicate if their child quently, the t-test for unequal variances is reported
was currently or previously diagnosed with any of the t(226.22) ¼ 7.35, p ¼ .001. The autism group (M ¼
listed developmental disabilities. 47.00; SD ¼ 7.01) scored higher than children in the
control group (M ¼ 41.97; SD ¼ 5.76). Although
these differences indicated that children with autism
Procedures
experienced more general feeding problems com-
Initial approval for the project was obtained pared to children with fewer autism symptoms, it
from the Penn State Office of Regulatory Compli- did not indicate what types of feeding problems
ance and the Penn State College of Medicine. Per- were being exhibited.
mission to conduct the research was also obtained
from the autism societies, the pediatricians’ offices,
Types of Feeding Problems
and the school district administrations. Once verbal
permission was granted, the packets were distributed Further analyses were conducted on the types
to the autism societies and schools by mail, by hand of feeding problems children with autism exhibited.
delivery from one of the co-investigators, or by fax. Parent reports of refusing most foods, requiring
The autism societies and school districts then distrib- specific utensils, requiring particular food presenta-
uted the packets (with return postage included) to tion, accepting only pureed or low textured foods,
the parents. Patients of participating doctors and eating a narrow variety of foods were com-
received a packet sent directly to them through the pared between the control group and the children
mail. All participants were asked to complete the with autism.
questionnaires and return them via the mail An analysis of expected and observed
(returned postage was included in all packets). Chi-square scores for food refusal for each group
indicated that children with autism had a tendency
to refuse more foods than children in the control
RESULTS groups, v2 ð1; n ¼ 436Þ ¼ 101:13; p < :000. To accept
foods, children with autism more likely required
All analyses were computed using the Statisti- specific utensils ½v2 ð1; n ¼ 436Þ ¼ 35:29; p < :000
cal Package for the Social Sciences (SPSS) (2000). and particular food presentations ½v2 ð1; n ¼ 436Þ ¼
As previously stated, for purposes of general com- 80:75; p < :000 than children in the control group.
parisons of children with autism characteristics, Additionally, children with autism were more likely
these results were obtained by comparing the eating to only accept foods of low texture, such as puréed
behavior of the control group (n ¼ 298) and the foods, v2 ð1; n ¼ 436Þ ¼ 8:75; p < :01:
autism group (n ¼ 138). Parents also reported that children of autism,
regardless of texture, ate only a narrow variety of
presented foods, v2 ð1; n ¼ 436Þ ¼ 105:06; p < :000.
General Eating Habits
In fact, 72% of the children with autism were
Since no significant difference in age between reported to eat a narrow variety of foods. Clarifica-
the groups was found and previous research has tion of the types of foods eaten by children with
indicated no age difference interactions with use of autism was then conducted by comparing parent
the CEBI (Archer et al., 1991), age was not used as responses on the Food Preference Inventory’s (FPI)
a separate variable in the analyses. five food group domains (fruits, vegetables, dairy,
General differences in the children’s eating hab- protein, and starch) for the two groups.
its were compared using the CEBI’s total problem
score domain (Archer et al., 1991). The hypothesis
Types of Foods Eaten
that caregivers of children with autism report their
children have significantly more feeding problems Statistical t-tests were conducted to determine
than caregivers of children without autism was when the children with autism differed from the con-
confirmed. A t-test was conducted to determine if trol group on numbers of fruits, vegetables, dairy,
the children without autism differed from the chil- proteins, and starches eaten. When Levene’s Test for
Comparison of Eating Behaviors between Children with and without Autism 437
Equality of Variances was significant indicating (Archer & Szatmari, 1991). This study also presents
unequal variances, the t-test for unequal variances a new and much needed (Ahearn et al., 2001) aspect
was reported. Because multiple comparisons were to the study of feeding problems for children with
performed, a more conservative alpha was set at .01, autism—a comparison to typically developing chil-
due to the exploratory nature of this investigation. dren.
Significant differences in the numbers of each type In this study, parents reported their children
of foods eaten were reported for all of the food with autism exhibited more general feeding prob-
groups: fruits: tð308:48Þ ¼ 10:79, p ¼ :001; dairy: lems including refusing foods, requiring specific pre-
tð434Þ ¼ 10:63, p ¼ :001; vegetables: tð318:5Þ ¼ sentations of foods and specific utensils, eating only
7:76, p ¼ :001; proteins: tð324:79Þ ¼ 9:65, p ¼ low texture foods, and eating a narrow variety of
:001; starches: tð337:88Þ ¼ 8:28, p ¼ :001. The aut- foods than children without autism. Results from
ism group reportedly ate significantly fewer foods the analysis of the numbers of specific foods eaten
within each category (Table II contains the means within each food group supported that children
and SD of the number of foods eaten by food group with autism eat fewer foods within each food group
for each group of children). than typically developing children. However, the
Although the children with autism ate signifi- families of children with and without autism eat
cantly fewer foods from each of the food groups similar numbers of foods within the food groups.
than children without autism, this finding did not Consequently, the differences in foods eaten did not
extend to the families, with no significant differences appear to be a direct result of fewer opportunities
in number of foods eaten from each food group for different foods within the families of children
between families of the children with autism and with autism.
families of children without autism. Although this study supplements the available
information concerning feeding problems and chil-
dren with autism, some methodological problems
DISCUSSION could have partially influenced the results. For
example, the selection process for the families of
The hypothesis that children with autism exhi- children with autism could have provided skewed
bit more eating and meal-time problems than typi- results. The number of children with autism
cally developing children advanced by previous case within the sample (n ¼ 138) constituted approxi-
reports and studies (Ahearn et al., 2001; Archer & mately 32% of the total sample. This was higher
Szatmari, 1991; DeMyer et al., 1968; Kanner, 1943; than the estimated occurrence of autism within
Kinnell, 1983; Lopreiato & Wulfsberg, 1992; Min- the population (American Psychiatric Association,
shew & Payton, 1988; Raiten & Massaro, 1986; 1994) and also could have indicated a selection
Stone et al., 1995; Teplin, 1999) was supported. bias for children with autism with feeding prob-
Specifically, the results of this study supported pre- lems. However, because this study contained
vious research that children with autism’s eating greater numbers of participants with autism than
behavior is restricted by food category (Ahearn previous studies, it has provided far greater sup-
et al., 2001), by texture (Ahearn et al., 2001; Archer port to the occurrence of feeding problems within
& Szatmari, 1991), and that these children refuse this population.
foods more often than typically developing children Because the sample of children could also have
been restricted due to the chosen target age group,
Table II. Numbers of Foods Eaten by Children for Each Food
the results of this study are also limited to the feed-
Group ing problems of older children with autism. Conse-
quently, the chosen target age restrictions can be
Food types Autism group Control group viewed as a partial limitation to this study.
Although feeding problems can be observed in
M SD M SD
younger children with autism than our chosen tar-
Fruits 8.09 6.52 15.75 7.62 get age, the results of this study can nonetheless be
Dairy 4.32 3.30 8.07 3.48 used to evaluate enduring feeding problems for
Vegetables 4.00 5.00 8.23 6.06 these children.
Proteins 7.82 5.98 14.24 7.40
Starches 15.82 8.80 24.08 11.38
Additionally, the use of parental report of
foods eaten by children may have also created less
438 Schreck et al.