1. Snack Time Training Program for Children with Autism Spectrum Disorder and Their Caregivers
K. Brown, PsyM, A. Foster, L. Stanek, PT, DPT, D. Van Rafelghem, RN, FNP-C, K. Harpster, PhD, OTR/L, K. Burkett, PhD, RN, PPCNP-BC.
Leadership Education in Neurodevelopmental and related Disabilities (LEND) Program
Cincinnati Children's Hospital Medical Center
The University of Cincinnati University Center for Excellence in Developmental Disabilities
Background
Children with autism spectrum disorder (ASD) experience eating difficulties more than children with intellectual disability and neurotypical children.1
Up to 90% of children with ASD have feeding difficulties2 and report unusual eating habits such as
Rigid mealtime behaviors
Limited food repertoire
Food sensitivities and refusal related to food texture, color, smell and temperature.3-4
Eating enjoyment, positive mealtime environment and enthusiastic modeling in both adults and peers have been shown to increase food acceptance and social interaction in children.5-6
Educating caregivers has been shown to be effective in reducing problematic mealtime behaviors and food selectivity.
Parents report that feeding difficulties in children with ASD is one of the most stressful problems they face.7
Procedure:
Phase I: Caregiver education workshop
2 hours training with caregivers
Content includes topics on setting up the environment, managing mealtime behaviors, introducing new foods and 5 additional topics
8 weeks wait time to implement training strategies
Phase: 2: Group-based snack time with caregiver education
Play-based, child-centered snack time training provided in a group for 8 weeks, bi- weekly, 20 minutes per session with sensory play before/after snack time
Small groups of 3-4 children
3-4 foods offered at each session; a combination of familiar and novel foods
Food selection determined by results from FFQ, food allergies and parental preferences
Parents observe child through 2-way mirror
Video taped sessions: Pre/post-videos from home and clinic snack time training
Phase 3: Focus Group
Post Intervention
Caregivers of participants explored concerns and challenges of picky eating behavior in their children with ASD
Method: Data Analysis
Figure 1: Quantitative
Qualitative
Quantitative
Video Data
Intervention
Parent Home
Evidence-based Measures
BAMBI
FFQ - CHAMPS
Parent Mealtime Checklist
Short Sensory Profile (SSP)
Created Questionnaires
Parent Home Program Compliance
Food Sticker Chart
Foods Tried at Home
Demographics
Poisson Regression
Signed Rank Test
Descriptive Statistics
Qualitative Results
Three qualitative themes were identified from the caregiver focus groups regarding what it means to care for a child with ASD who is a picky eater:
Concern for their child’s health and nutrition; fears of not eating enough; anxiousness or hope for change
Feelings of stress and guilt about their own failures; feelings dismissed by others; being with other parents of children with ASD
Quote: “I have guilt feeding him what I feed him because it’s awful food, but that’s all he’s going to eat.”
Facing eating and social challenges by using interventions found in therapy and on their own
Quote: “It’s an hourly decision– am I going to focus on developing you into an amazing person for the next 50 minutes or fold a load of laundry.”
Logistic Regression
Specific Aims
Aim 1: To determine if snack time intervention plus caregiver training shows greater increase in eating behaviors at home than caregiver training alone.
Aim 1a: To determine if snack time intervention has an impact on improving eating behaviors in a group setting.
Aim 2: To determine if snack time intervention plus caregiver training shows greater increase in social communication behaviors at home than caregiver training alone.
Aim 2a: To determine if snack time intervention has an impact on social behaviors in a group setting.
Aim 3: To determine if the caregiver training program results in a change in caregivers’ mealtime behaviors at home.
Aim 3a: To determine if the caregiver training program results in a change in the caregivers’ knowledge regarding mealtime strategies.
Aim 4: To determine if common themes exist amongst individuals providing care for children who have picky eating habits and a diagnosis of ASD
Qualitative Data
Focus Group
Theme Identification
Parent Home Program Compliance
Results
From the Caregiver Mealtime questionnaire by way of a Wilcoxin Signed Rank Test:
There was a trend toward offering more vegetables and grains post-intervention than pre-intervention.
There was a trend toward mealtimes being more structured, dinner time being less stressful for the child, and a decrease in the number of snacks offered per day.
From the BAMBIC by way of a Wilcoxin Signed Rank Test:
33-41% of participants showed improved mealtime behaviors post intervention, including screaming, turning their face/body away from food, and remaining seated until mealtime is over.
From the Food Frequency Questionnaire by way of a Wilcoxin Signed Rank Test:
4 participants showed a significant increase in the variety of miscellaneous foods they tried post-intervention compared to pre-intervention values (p=0.046).
From the Sticker Charts indicating new foods tried and new foods tried at home:
The median for Total New Foods Tried during intervention was (Range 2-18) and 3.00 (Range 0-7) for New Foods Tried at home.
Results, cont.
From the Focus Group Transcripts:
Table 1:
Limitations
Small sample size
Lost/missing data from illness, behavior and procedural error
Non response bias
Lessons Learned
Decrease the number of take home and return questionnaires to be completed by caregivers
Develop a data management plan to decrease missing data and increase participation
Develop a transition plan to include caregiver in intervention toward the end of the study
Method
CCHMC: Cohort design
Participants:
7 boys and 5 girls with ASD (ages 3-6; mean age = 4.08) who are picky eaters and their primary caregiver, recruited from CCHMC
Instrumentation:
Demographics
Food Frequency Questionnaire (FFQ) (pre/post)
Caregiver Mealtime Questionnaire (pre/post)
Brief Assessment of Mealtime Behavior in Children (BAMBIC) (pre/post)
Short Sensory Profile (SSP)
Focus Group with Open Ended Question
Next Steps
Identification of themes from focus group transcripts
Prioritization of data results for manuscript preparation
Journal selection and manuscript preparation
Future Directions
Streamline data
Translation of research findings into clinical practice
Acknowledgements
These projects were funded by The Maternal and Child Health Bureau Grant T73MC00049 and T73MC We would also like to thank the parents, children, and staff at CCHMC and OSU for their participation in this study. For references, please refer to handout.**
References
Available upon request.