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Indian Pediatr 2021;58:842-845 |
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Sensory
Processing Dysfunction and Mealtime Behavior
Problems in Children With Autism
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Prahbhjot Malhi, Surya Saini, Bhavneet Bharti,
Savita Attri, Naveen Sankhyan
From Department of Pediatrics, Post Graduate
Institute of Medical Education and Research,
Chandigarh.
Correspondence to: Dr Prahbhjot Malhi, Professor,
Department of Pediatrics, Post Graduate Institute of
Medical Education and Research, Chandigarh 160 012.
Email:
[email protected]
Received: December 27, 2020;
Initial review: January 23, 2021;
Accepted: May 14, 2021.
Published online: May 20, 2021;
PII:S097475591600329
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Objectives: To compare
sensory processing and mealtime problem
behaviors among children with autism spectrum
disorder (ASD) and typically developing
controls, and to examine the relationship
between atypical sensory processing and eating
problems in children with ASD. Methods:
50 children (4-10 years) with a diagnosis of ASD
as per DSM-5 were recruited from the pediatric
psychology clinic of a tertiary care center in
India. The Brief Assessment of Mealtime Behavior
in Children (BAMBIC) and the Short Sensory
Profile (SSP) were administered to measure
feeding and sensory processing problems,
respectively. Parents were interviewed about
their child’s dietary intake using a 3-day
dietary recall. Results: The ASD group
showed greater mealtime behavior problems than
the control group and had significantly higher
total scores on the BAMBIC (P<0.001), and
on two of the three subscales including food
refusal (P<0.001) and disruptive behavior
(P<0.001). The ASD group, relative to the
neurotypical children, showed atypical response
on majority of the subscales of the short
sensory profile including tactile sensitivity (P<0.001),
taste sensitivity (P<0.001), movement
sensitivity (P<0.001), under
responsiveness (P<0.001), auditory
filtering (P<0.001), low weak/energy (P=0.02),
and visual/auditory sensitivity (P<0.001).
Conclusions: The study underscores the
need for detailed evaluation of sensory
processing and feeding problems of children with
ASD so that the interventions can be tailored to
address their unique sensory characteristics.
Keywords: Feeding problems,
Nutritional inadequacies, Sensory dysfunction.
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C
hildren
with autism spectrum disorder (ASD)
have many aberrant behaviors including
limited food preferences, avoidance of certain
foods, non-functional mealtime rituals, pica,
hypersensitivity to food textures or temperatures,
eating only specific brands of foods, and smelling
food items before consuming [1-3]. In a recent
study, Mayes, et al. [4] assessed the aberrant
eating behaviors of 1462 children with ASD. They
found that 70% of children with ASD had feeding
difficulties compared to only 5% of the typically
developing children. The authors argued that early
unusual feeding patterns of behavior in children
might help distinguish autism from other disorders
and should be considered a red flag for autism by
clinicians [4]. Indeed, research indicates that
atypical food preferences may be prevalent as early
as 15 months of age, and this may increase the risk
for nutritional deficiencies and malnutrition among
children with ASD [5-7]. Mealtimes are especially
challenging for parents, and studies show greater
parental stress associated with the feeding of their
autistic children and increased caregiver burden
[7-9].
Research suggests an association
between sensory processing problems, food refusal,
and nutritional adequacy in children with ASD
[7,10,11]. For instance, Nadon, et al. [10] examined
the relationship between sensory processing problems
and the number of eating difficulties reported by
parents in 95 children aged 3-10 years with ASD.
They found that children with tactile, visual or
auditory sensitivities were more likely to have a
more restricted food repertoire than children with
typical sensory processing profile [10]. Thus, there
is a need to understand the complexity of sensory
sensitivity issues leading to a narrower range of
diets, and design specific strategies to decrease
challenging mealtime behaviors. Despite a growing
body of literature on feeding selectivity in
children with ASD, limited research has been done
regarding sensory processing dysfunction and food
selectivity issues in children with ASD,
particularly in developing countries. There is a
need to address some of the factors associated with
challenging mealtime behaviors among children with
ASD to address the nutritional inadequacies found in
these children. This study aims to compare sensory
dysfunction and the number of mealtime behavior
problems among ASD and typically developing
controls, and to examine the relationship between
atypical sensory processing and atypical eating in
children with ASD.
METHODS
Fifty children with ASD
(DSM-5 criteria), aged 4 to 10 years, were
consecutively enrolled from the pediatric psychology
clinic and neurodevelopment clinic of a pediatrics
department in an advanced pediatric center. All
children with any chronic medical condition, on any
exclusion diet, and any medications that could alter
feeding were excluded. A total of 28 age-matched
(within four months) typically developing children
were recruited as controls. The study was approved
by the Institute review board, and informed signed
consent was obtained from the caregivers.
Tools: Brief assessment of
mealtime behavior in children (BAMBIC) consists of
10 items and these assess three domains of mealtime
behaviors including food refusal, limited variety of
food intake, and disruptive mealtime behaviors [12].
The parent has to respond to each item of the scale
using a 5-point scale ranging from always to never.
The responses to each item were summed to yield a
total score. Higher scores indicated more problem
feeding behaviors. Short sensory profile (SSP) is a
38-item questionnaire that assesses seven sensory
domains: tactile, taste/smell, movement,
under-responsive/seeks sensation, auditory
filtering, low energy/weak, and visual/auditory
[13]. Each item is answered on a 5-point scale with
responses ranging from always to never, with higher
scores indicating more typical performance while low
scores indicate heightened sensitivity in that area.
Parents were interviewed about
their child’s dietary intake using a 3-day dietary
recall. Parents were asked to list the food items
and the quantity which their child consumed during
breakfast, lunch, snack, and dinner time. The
three-day recall of macro- and micro-nutrient
consumption was calculated and compared with the
recommended dietary allowances (RDA) as per age
requirements provided by the ICMR 2017 using the
Diet Software. For food selectivity, parents were
asked to report whether their children would eat
commonly consumed foods present in an Indian diet
(vegetables, proteins, fruits, dairy products,
starches) and the responses were recorded as: almost
never/rarely, sometimes and frequently/always. Based
on the caregivers’ responses, the two groups were
compared on food selectivity as defined by the
percentage of children who almost never or rarely
consumed various foods. The height and weight of all
participants was taken, and body mass index (BMI)
was calculated.
Statistical analysis: The two
groups were compared using the t test for
continuous variables and chi-square test for
categorical variables. Multivariate stepwise
regression analysis was performed to identify the
predictors of the total score on the BAMBIC scale
among the ASD children. The predictors used in the
analysis were the seven subscale scores of the SSP.
RESULTS
We enrolled 50 children with ASD
and 28 typically developing children. There were no
significant differ-ences among the groups for
baseline characteristics (Table I). Severe
autism, as assessed by the Childhood Autism Rating
Scale (CARS), was seen in 38 (76.7%) children.
Table I Comparison of Groups on Socioeconomic and Demographic Variables
| Characteristics |
ASD (n=50) |
TD (n=28) |
| Age (y), mean (SD) |
5.3 (1.38) |
5.96 (1.38) |
| Boys, n (%) |
72.0 |
67.9 |
| Urban residence, n (%) |
70.0 |
51.1 |
| Socioeconomic status, n
(%) |
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| Lower |
12.0 |
25.0 |
| Middle |
64.0 |
57.1 |
| Upper |
24.0 |
17.9 |
| Nuclear family, n (%) |
56.0 |
53.6 |
| ASD: autism
spectrum disorder; TD: typically developing
children. All P values >0.05. |
The ASD group showed greater
mealtime behavior problems than the typically
developing group and had significantly higher total
scores on the BAMBIC (P<0.001), and on two of
the three subscales of BAMBIC including food refusal
(P<0.001) and disruptive behavior (P<0.001).
Web Table I presents comparative group
responses on each of the BAMBIC items. Children with
ASD were more likely to scream or cry at mealtimes (P=0.04),
turn their face or body away from food (P=0.03),
close the mouth tightly when food was presented (P=0.04),
and show aggressive behavior (P=0.04) and
disruptive behavior (P=0.006) than typically
developing children.
Comparison of the groups on food
preferences revealed that a significantly higher
proportion of children with ASD refused to eat
commonly consumed fruits like apple (P=0.004),
pomegranate (P<0.001), and guava (P=0.04);
and vegetables like bitter gourd (P=0.004),
ladyfinger (P=0.009), potato (P=0.06),
and cauliflower (P=0.002), and proteins like
red kidney beans (rajma) (P=0.004),
chick peas (chana) (P=0.02), and
snacks like cold drinks (P=0.02) and chips (P=0.003).
Despite limited food diversity, no significant group
differences on the mean daily intake of calories (P=0.9)
and fats were found. However, children with ASD had
lower consumption of proteins (P=0.04),
vitamin D (P=0.04) and folic acid (P<0.001)
when compared to typically developing children.
Among the micronutrients, the mean intake of sodium
was also significantly low (P=0.002). The
intake of vitamin C, copper, zinc, and calcium were
comparable.
Significantly higher proportion
of children with ASD showed atypical response on all
the subscales on the short sensory profile as
compared to typically developing children (Table
II). The mean total score on the SSP score (P<0.001)
and all the subscales of the SSP profile were
significantly lower as compared to control group
suggesting atypical sensory processing in children
with autism. Specifically, ASD children had lower
scores than the control group on the subscales of
tactile sensitivity (P<0.001), taste
sensitivity (P<0.001), movement sensitivity (P<0.001),
under responsiveness (P<0.001), auditory
filtering (P<0.001), low weak/energy (P=0.02),
and visual/auditory sensitivity (P<0.001).
Anthropometric parameters were comparable in terms
of weight (P=0.0.2) and BMI (P=0.55);
however, ASD children had significantly lower height
as compared to the typically developing group (P=0.04).
Table II Performance on Short Sensory Profile (SSP) for Children With Autism Spectrum Disorder and
Typically Developing Children
| Subscales of SSP |
Autism spectrum
|
Typically |
|
disorder, n=50 |
developing
children, n=28 |
| Tactile sensitivity
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23.63.55) |
30.1 (2.99) |
| Taste sensitivity |
11.7 (3.57) |
15.9 (2.78) |
| Movement sensitivity |
9.9 (2.73) |
12.9 (1.72) |
| Under responsive |
21.4 (4.28) |
28.8 (3.92) |
| Auditory filtering |
16.7 (3.93) |
24.4 (4.68) |
|
Low/weak energya |
22.4 (4.75) |
25.0 (4.13) |
| Visual/auditory
sensitivity |
17.3 (3.75) |
21.3 (2.47) |
| Total score |
123.06 (13.83) |
158.32 (15.49) |
|
All values in mean (SD). P<0.001 for all
comparisons except aP=0.02. |
Multivariate stepwise regression
analysis revealed that 31% of the total score
variance on the BAMBIC scale was explained by two of
the SSP subscales, namely the taste sensitivity and
the auditory-visual sensitivity. Parents of ASD
children with more atypical scores on the
taste/smell and auditory/visual subdomains of the
SSP were significantly more likely to report
mealtime behavior difficulties (P=0.01).
DISCUSSION
We examined sensory
sensitivities, mealtime behaviors, and nutritional
insufficiencies of children with ASD and compared it
to a group of typically developing children matched
on age. Parents of children with ASD reported
significantly greater number of problem behaviors
during feeding, food refusal, higher sensory
sensitivities, and nutritional deficiencies as
compared to controls. Indeed, the prevalence of a
restricted variety of foods consumed by children
with autism is 30-84% and these rates are
significantly higher than those reported in
typically developing children [2,4,14-15]. Moreover,
atypical eating behaviors among ASD children are
also related to increased problem behaviors in
children including heightened irritability, anxiety,
emotional lability, and oppositional behavior [3,7].
Previous studies have found a
significant association between oral, visual and
auditory sensitivities and a number of feeding
problems [9-11,16-18]. Evidence indicates that the
ASD children with atypical oral sensory processing
refuse more foods and eat fewer vegetables and it
has been suggested that addressing the oral sensory
processing problems may help in mitigating selective
and picky eating [7,18,19]. Current findings extend
previous research by documenting that the auditory
and visual sensitivities may also be associated with
limited food repertoire in children with ASD.
Possibly, the noise during mealtimes, ongoing
conversations, sound of the spoon against utensils
and the like may cause the hypersensitive ASD
children to overreact, and this may reflect in lower
quality of diet, rejection of nutritious foods, and
disruptive behaviors at mealtimes. Children with
visual sensory dysfunction may also be overly
sensitive to the presentation of meals as this may
be associated with food aversions, unpleasant food
textures, picky eating, and behavioral disturbances.
Previous studies have reported
that feeding problems may not translate into
non-optimal growth in the short run, and caution
should be exercised on anthropometric measures’
reliability as measures of dietary adequacy in
children with ASD [2,14,20]. Our results further
extend these findings that consumption of a limited
food variety may put young children with autism at
higher risk for nutritional insufficiencies and
compromised growth. However, these findings need
further corroboration as they are based on a small
size of ASD children.
The study has a few limitations
including the small sample size, which may have
resulted in decreased power for analyzing
differences between groups. Moreover, obtaining a
reliable three-day dietary record of the child was
often challenging as parents had difficulty in
recalling and estimating quantities of various foods
consumed by the child. Perhaps maintaining a
detailed behavioral mealtime log may help get more
valid information on the child’s food intake. Future
extension of the work needs to incorporate more
objective measures along with parent reported
questionnaires.
Children with ASD have marked
feeding problems along with sensory processing
sensitivities, nutritional inadequacies, and
compromised growth. The study underscores the need
for a detailed evaluation of mealtime behaviors and
sensory processing dysfunction of children with ASD,
so that interventions can be initiated at the
earliest to increase food intake variety and
encourage healthy eating habits. Intervention
strategies need to be personalized to address each
child’s unique sensory characteristics, and a
sensory integration approach may be used to
alleviate mealtime challenging behaviors and
caregiver burden.
Note: Additional material
related to this study is available with the online
version at www.indianpediatrics.net
Ethics clearance: Institute
ethics committee; No.11115/PG-2Trg/2016/7695-96,
dated May 18, 2017.
Contributors: PM, BB, SA, NS:
designed the study; PM,BB: supervised the data
collection, and analyzed and interpreted the data;
SS: collected the data, did the literature search,
helped in analysis and interpretation of the data,
and drafting of the manuscript; PM: wrote the
manuscript with critical inputs from other authors.
All the authors read and approved the final
manuscript.
Funding: None; Competing
interests: None stated.
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WHAT THE STUDY ADDS?
• Feeding problems in children with
autism spectrum disorder are associated with
sensory processing sensitivities.
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