Friday, August 13, 2021

Food selectivity is associated with more severe autism symptoms in toddlers with autism spectrum disorder

Stolar O, Zachor DA, Itzchak EB. Food selectivity is associated with more severe autism symptoms in toddlers with autism spectrum disorder. Acta Pediatrica|August 13, 2021 

Background: Studies of children with autism spectrum disorder (ASD) report a high prevalence of eating abnormalities (46-92%) compared to typically developed (TD) toddlers (25-50%), and food selectivity is considered the most frequent eating problem in ASD. Notwithstanding, there is no consensus regarding the meaning of the term "food selectivity". Children with ASD and food selectivity are at a greater risk for having inadequate intake of various minerals and vitamins that might affect development. Previous research reported that food selectivity was positively related to parent-reported autism symptoms but unrelated to autism severity or linguistic and cognitive abilities as measured by professionals. Two possible mechanisms may underlie co-morbid food selectivity in ASD: sensory over-responsivity and inflexible adherence to routines or rituals that are part of the restricted and repetitive behaviors (RRB) criterion for ASD. In addition, as meals often have social facets, food selectivity might also be related to deficits in the social-communication domain. The current study investigates these possibilities with two major aims: 1. To examine the association between significant food selectivity and autism severity in toddlers, as assessed by parents and intervention staff; and 2. To compare autism severity in toddlers as assessed by parents and intervention staff.  

Method: The study was approved by the Helsinki committee of the Assaf Harofeh Medical Center and included 180 toddlers (147 boys; 33 girls), aged 16-39 months (M = 28.88; SD = 4.73), diagnosed with ASD based on DSM IV or DSM 5 criteria, according to the date of the diagnostic evaluation. Two assessment instruments were utilized. The Social Communication Questionnaire (SCQ), based on the original Autism Diagnostic Interview (ADI), consists of 40 yes/no questions to be completed by a parent/caregiver. It yields scores for: 1. reciprocal social interaction (RSI); 2. language/communication; 3. restricted, repetitive, and stereotyped behaviors (RRBS) and interests. Higher scores reflect more severe ASD symptoms.  Eating habit evaluation was based on two sources of information. Parents filled out a detailed questionnaire on the foods the participant would eat, eating behaviors (i.e., licking food, spitting food out, or stuffing food), type of textures, and a detailed dietary intake (vegetables, meat, carbohydrates, and dairy). If food selectivity was reported, parents were requested to complete a three-day dietary intake. Additionally, the Early Intervention Day Care Centers (EIDCC) staff recorded the toddlers' eating habits during mealtimes. We defined 'moderate-severe food selectivity' as eating fewer than 16 different food items and a lack of diversity in food groups, meaning eating fewer than three different foods from each food group and only when supported by reports of both parents and staff. 

Procedure: This study was conducted in 11 different government funded EIDCCs for toddlers with ASD. During the first two months in the EIDCC, autism severity was assessed using the SCQ, which was completed separately by the parents and the behavioral analyst or psychologist in each intervention center. Of the study population (N = 180), fifty-eight participants (32.2%) were excluded from the study due to having other eating problems (only baby formula or puree food fed (n=6) and mild food selectivity (n=31) and abnormal eating such as, spitting, stuffing and licking food (n=21). Of the remaining participants, two subgroups were defined: one with 'moderate -severe food selectivity' (n = 49, 27.2%) and the second without food selectivity (n =73, 40.6%). The two groups did not differ significantly in sex ratio 2 = 2.59, p > .05), age, maternal age, or maternal education (p > .05) 

Results: The prevalence of food selectivity (27.2%) in the current study was significantly higher than the reported prevalence in TD toddlers (9.5%)5 using a chi goodness of fit analysis 2 = 133.43, p < .001). A 2X2 (with/without food selectivity; parent/intervention staff evaluation) MANOVA with repeated measures for the rater, for the SCQ-RSI, and for the communication and RRSB subdomain scores, yielded a food selectivity main effect [F (3,80) = 4.58, p < .01, µ2 = .147). As presented in Table 1, the univariate ANOVAs revealed significant differences between the groups for the SCQ RSI and communication subscale scores. The group with food selectivity had higher scores in these measures, reflecting more severe ASD symptoms for this group. In addition, the analysis yielded a significant rater main effect [F (3,80) = 32.24, p < .001, µ2 = .547). The intervention staff rated participants significantly higher on the RSI and communication subscales than the parents did (Table 1). Interestingly, for the RRSB subscale, parents gave higher scores than the intervention staff did (a trend toward statistical significance). No significant interaction between the two variables - food selectivity and rater - was noted [F (3,80) = 0.35, p > .05, µ2 = .013). 

Discussion: We found food selectivity is common in toddlers with ASD in comparison to TD toddlers. In addition, having significant food selectivity in toddlers with ASD is associated with more severe social-communication symptoms as reported by parents and early intervention staff. This finding suggests that social-communication deficits in toddlers with ASD might interrupt the social aspects of mealtime and result in food selectivity behaviors. These communication deficits may result in reduced ability of parents to encourage and convince their child to experience a variety of foods. This study did not support the contribution of RRB to food selectivity, as proposed by previous studies.6 This is the first study conducted in toddlers to demonstrate the association between food selectivity and the severity of ASD symptoms. Interestingly, the intervention staff reported more severe impairments in reciprocal social interaction and communication, while the parents reported more severe RRB symptoms. It is possible that the intervention staff is experienced in recognizing social-communication deficits typical to ASD at this early stage, and that in the intervention program, children have fewer opportunities to exhibit stereotypical behaviors because they are participating in one-on-one therapy throughout the day. In addition, the intervention staff applies behavioral methods to reduce the intensity of the RRBs. To our best knowledge, this is the first report of differences in the perception of ASD symptoms between parents and intervention staff in toddlers. Important clinical implications from this study include the need to consider the child's variety of food as part of diagnostic procedures and intervention programs, since it is related to the severity of ASD symptoms.  

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