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Exploration of Treatment Response in Parent Training for Children with Autism Spectrum Disorder and Moderate Food Selectivity

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Title: Exploration of Treatment Response in Parent Training for Children with Autism Spectrum Disorder and Moderate Food Selectivity
Language: English
Authors: Burrell, T. Lindsey (ORCID 0000-0003-0682-2614), Scahill, Lawrence, Nuhu, Nadratu, Gillespie, Scott, Sharp, William
Source: Journal of Autism and Developmental Disorders. Jan 2023 53(1):229-235.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 7
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Education Level: Adult Education
Descriptors: Parent Education, Parent Participation, Children, Autism Spectrum Disorders, Food, Parent Background, Mothers, Communication Skills, Outcomes of Treatment, Eating Habits
DOI: 10.1007/s10803-021-05406-w
ISSN: 0162-3257
1573-3432
Abstract: Managing Eating Aversions and Limited Variety (MEAL) Plan is a structured parent-mediated intervention for children with autism spectrum disorder and moderate food selectivity. Our previously reported group-based clinical trial revealed a positive treatment response rate of 47.3%. Although encouraging, this response rate raises questions about factors that may affect treatment outcomes. Here, we examine the impact of child and parent characteristics and feeding behaviors on treatment response. Higher maternal education and higher child communication abilities at baseline were associated with positive treatment response. Improvement in sitting at the table and reductions in disruptive mealtime behavior promoted treatment success. Results also suggest that individually delivered MEAL Plan may offer more flexibility than group-based intervention for some parents.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1364443
Database: ERIC
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  Value: <anid>AN0161607310;aut01jan.23;2023Feb02.05:37;v2.2.500</anid> <title id="AN0161607310-1">Exploration of Treatment Response in Parent Training for Children with Autism Spectrum Disorder and Moderate Food Selectivity </title> <p>Managing Eating Aversions and Limited Variety (MEAL) Plan is a structured parent-mediated intervention for children with autism spectrum disorder and moderate food selectivity. Our previously reported group-based clinical trial revealed a positive treatment response rate of 47.3%. Although encouraging, this response rate raises questions about factors that may affect treatment outcomes. Here, we examine the impact of child and parent characteristics and feeding behaviors on treatment response. Higher maternal education and higher child communication abilities at baseline were associated with positive treatment response. Improvement in sitting at the table and reductions in disruptive mealtime behavior promoted treatment success. Results also suggest that individually delivered MEAL Plan may offer more flexibility than group-based intervention for some parents.</p> <p>Keywords: Autism spectrum disorder; Feeding; Food selectivity; ARFID; Parent-mediated intervention; Parent training</p> <p>Children with autism spectrum disorder (ASD) often have co-occurring developmental delays, behavioral problems, psychiatric disorders, or medical conditions that contribute to overall impairment (Levy, et al., [<reflink idref="bib14" id="ref1">14</reflink>]; Rosen et al., [<reflink idref="bib21" id="ref2">21</reflink>]). In pre-school and young school-age children with ASD, there is an estimated five-fold increased risk of feeding problems compared to the general pediatric population (Sharp et al., [<reflink idref="bib24" id="ref3">24</reflink>]a; Sharp et al., [<reflink idref="bib25" id="ref4">25</reflink>]b). Food selectivity defined by eating a narrow range of food and/or rejecting one or more food groups—is the most common feeding problem in children with ASD (Sharp et al., [<reflink idref="bib24" id="ref5">24</reflink>]a; Sharp et al., [<reflink idref="bib25" id="ref6">25</reflink>]b). Across a wide range from mild to severe, food selectivity affects as many as 95% of children with ASD (Sharp, et al., [<reflink idref="bib24" id="ref7">24</reflink>], [<reflink idref="bib25" id="ref8">25</reflink>]). Mild forms of food selectivity may not require intervention. Moderate to severe food selectivity, however, may meet criteria for a feeding disorder (American Psychiatric Association, [<reflink idref="bib1" id="ref9">1</reflink>]; Goday et al., [<reflink idref="bib6" id="ref10">6</reflink>]; Kovacic et al., [<reflink idref="bib11" id="ref11">11</reflink>]). Dietary restrictions may result in failure to meet nutritional needs, failure to maintain energy needs, and may interfere with psychosocial functioning (American Psychiatric Association, [<reflink idref="bib1" id="ref12">1</reflink>]; Kovacic, et al., [<reflink idref="bib11" id="ref13">11</reflink>]). Children with ASD and severe food selectivity are at high risk for nutritional inadequacies and associated medical sequelae. The current standard of care for this severity of feeding problem is intensive multidisciplinary intervention delivered at day hospital or inpatient settings (Sharp, et al., [<reflink idref="bib28" id="ref14">28</reflink>]). However, this level of intervention may not be necessary for children with ASD and moderate food selectivity, suggesting a need for models of care that are consistent with symptom severity (Smith, Bayless, Mercer, et al. 2013).</p> <p>Behavioral intervention is a well-supported approach for addressing food selectivity in children with ASD (Ledford & Gast, [<reflink idref="bib13" id="ref15">13</reflink>]; Peterson et al., [<reflink idref="bib18" id="ref16">18</reflink>]). A common approach to the treatment of food selectivity involves trained clinicians working directly with the child (Laud et al., [<reflink idref="bib12" id="ref17">12</reflink>]; Sharp et al., [<reflink idref="bib27" id="ref18">27</reflink>]). A growing body of research, however, also suggests that Parent Training (PT) can be applied to reduce feeding problems in children with ASD (Cosbey and Muldoon, [<reflink idref="bib3" id="ref19">3</reflink>]; Johnson et al., [<reflink idref="bib9" id="ref20">9</reflink>]; Sharp et al., [<reflink idref="bib24" id="ref21">24</reflink>]a; Sharp et al., [<reflink idref="bib25" id="ref22">25</reflink>]b). A parent-mediated model of care appears relevant for treating children with ASD and moderate food selectivity. To promote replication of PT, we developed a structured parent-mediated intervention called the Managing Eating Aversions and Limited variety (MEAL) Plan. MEAL Plan was superior to Parent Education, an educational curriculum on ASD, in a 16-week randomized trial (Sharp et al., [<reflink idref="bib26" id="ref23">26</reflink>]). In that study, a blinded independent evaluator rated 47.4% of participants in MEAL Plan as much improved or very much improved on the Clinical Global Impression-Improvement scale compared with 5.3% of participants in parent education. The MEAL Plan model rests on the assumption that decreasing disruptive mealtime behavior (e.g. crying, screaming) and promoting foundational feeding behaviors (e.g. sitting at the table, following mealtime schedule) are prerequisites to expanding dietary variety. Although encouraging, these results raise questions about which children will benefit from MEAL Plan. In line with our treatment model, we examined the impact of child disruptive mealtime behavior (e.g. crying, not sitting at the table) on treatment outcome.</p> <hd id="AN0161607310-2">Methods</hd> <p>This study examines the pre-treatment characteristics of children with ASD and moderate food selectivity randomized to the MEAL Plan treatment arm of our prior study. Analyses compare child and parent characteristics and feeding behavior of participants with a positive treatment response (n = 9) to those with a negative treatment response (n = 10). Therapists delivered treatment in a group format with three to four caregivers per group for the 16-week trial. Participants were invited to return for a 20-week follow-up visit. The Emory University institutional review board approved the study and all parents provided written informed consent prior to the study. A detailed methodology description is provided by Sharp et al. ([<reflink idref="bib26" id="ref24">26</reflink>]).</p> <hd id="AN0161607310-3">Participants</hd> <p>Eligible participants were children between the ages of 3 and 8 with ASD and moderate food selectivity assessed by a dietary recall and 3-day food record. All eligible study participants received a diagnostic evaluation within 6 months of study participation to confirm diagnosis of ASD. The study team defined moderate food selectivity as the child eating: (<reflink idref="bib1" id="ref25">1</reflink>) at least 6 total food items; (<reflink idref="bib2" id="ref26">2</reflink>) at least one fruit or vegetable; (<reflink idref="bib3" id="ref27">3</reflink>) at least one item from other food categories (i.e. protein, grain, & dairy); and (<reflink idref="bib4" id="ref28">4</reflink>) two or fewer food items in one or more food categories (i.e. fruit, vegetable, protein, grain or dairy). Children on medication or receiving community intervention unrelated to feeding were eligible if there were no planned changes during the trial. The study required at least one primary caregiver able to read and speak English and at least one caregiver able to participate in the treatment. Children in need of treatment for severe feeding problems, serious disruptive behavior outside of mealtimes or medical conditions were excluded.</p> <hd id="AN0161607310-4">Treatment</hd> <p>Meal Plan included 10, 90-min group sessions delivered over 12 weeks with a one-month (Week 16) and two-month (Week 20) follow-up session. The manual included therapist scripts, caregiver activities (e.g. role plays, hands-on activities) and informative handouts on session topics (e.g. monitoring mealtime behavior, nutrition planning, modifying mealtime interactions). MEAL Plan incorporated behavioral and nutritional components to promote foundational feeding behaviors (e.g. sitting at the table), reduce disruptive mealtime behavior (e.g. crying and screaming during meals), and improve dietary variety (e.g. diet that included food across all food groups). A psychologist led all sessions; a registered dietitian co-led sessions 2 and 7. All sessions included a didactic teaching component and homework assignments to implement new skills in the home environment. Meal observations with in-vivo coaching involving the parent–child dyad began at session 5 to promote caregiver skill in a feeding situation with the child.</p> <hd id="AN0161607310-5">Measures</hd> <p></p> <hd id="AN0161607310-6">Characterization</hd> <p>Caregivers completed a <emph>demographic form</emph> that included the child's sex, age, ethnicity, school placement, caregiver's age and education, family living arrangement, and income. The diagnosis of ASD was based on clinical assessment supported by the <emph>Social Communication Questionnaire (SCQ)—Lifetime</emph> (Rutter et al., [<reflink idref="bib22" id="ref29">22</reflink>]) and the <emph>Autism Diagnostic Observation Schedule</emph> (ADOS; Lord et al., [<reflink idref="bib15" id="ref30">15</reflink>]). Based on the child's age and verbal abilities, we measured cognitive ability with the <emph>Stanford-Binet Intelligence Scales—Fifth Edition</emph> (SB-5; Roid, [<reflink idref="bib20" id="ref31">20</reflink>]), the <emph>Differential Ability Scales- Second Edition</emph> (DAS-II; Elliott et al., [<reflink idref="bib5" id="ref32">5</reflink>]), or the <emph>Mullen Scales of Early Learning</emph> (Mullen, [<reflink idref="bib17" id="ref33">17</reflink>]). Adaptive functioning was measured by the Parent/Caregiver Form of the Vineland II. The Vineland II is standardized with a population mean of 100 ± 15; higher scores indicate greater adaptive functioning (Sparrow et al., [<reflink idref="bib30" id="ref34">30</reflink>]).</p> <hd id="AN0161607310-7">Outcome Measures</hd> <p>The primary outcome measure was the modified 15-item, parent-reported <emph>Brief Autism Mealtime Behavior Inventory</emph> (BAMBI; Demand et al., [<reflink idref="bib4" id="ref35">4</reflink>]; Lukens & Linscheid, [<reflink idref="bib16" id="ref36">16</reflink>]) collected at Baseline, Weeks 12, 16, and 4 weeks post-treatment (Week 20). The modified BAMBI (Demand et al., [<reflink idref="bib4" id="ref37">4</reflink>]) includes four factors (<emph>Food Selectivity</emph>, 4 items; <emph>Disruptive Mealtime Behaviors</emph>, 5 items; <emph>Food Refusal</emph>, 3 items; and <emph>Mealtime Rigidity</emph>, 3 items). BAMBI items are rated on a 5-point; four items are reverse scored. To compute the total score and subscale totals, these four items were transposed so that higher scores indicate greater severity.</p> <p>The key secondary item was the <emph>Clinical Global Impression—Improvement scale</emph> (CGI-I; Guy, [<reflink idref="bib7" id="ref38">7</reflink>]) rated by an Independent Evaluator (IE), who was blind to treatment assignment. The CGI-I is a 7-point scale ranging from 1 (Very Much Improved) through 4 (Unchanged) to 7 (Very Much Worse). We defined positive response as a CGI-I score of 1 (Very Much Improved) or 2 (Much Improved) at Week 16. Children who did not achieve scores of much or Very Much Improved on the CGI-I at Week 16 and children who dropped out of treatment were classified with negative treatment response.</p> <p>To rate the CGI-I, the IE considered the BAMBI, <emph>Parent Target Problem</emph> narratives, and the <emph>Aberrant Behavior Checklist</emph>. At baseline, the IE asked caregivers to nominate the child's two top problems to develop <emph>Parent Target Problem (PTP)</emph> narratives (Scahill et al, [<reflink idref="bib23" id="ref39">23</reflink>]; Sheridan et al., [<reflink idref="bib29" id="ref40">29</reflink>]). The caregiver and the IE discussed each problem and co-constructed a brief description of the behavior that included the frequency, persistence, and the impact on the family. Common PTPs in this study included limited dietary diversity, disruptive mealtime behavior, inflexibility with mealtime routines. The IE and caregiver reviewed and revised the Baseline PTP narratives at Weeks 12, 16 and 4 weeks post-treatment to inform the CGI-I.</p> <p>The <emph>Aberrant Behavior Checklist</emph> (ABC; Kaat et al., [<reflink idref="bib10" id="ref41">10</reflink>]) is a 58-item, parent-report measure that includes five subscales: <emph>Irritability</emph> (tantrums, aggression, and self-injurious behaviors, 15 items); <emph>Social Withdrawal</emph>, 16 items; <emph>Stereotypy</emph>, 7 items; <emph>Hyperactivity</emph>, 16 items; and <emph>Inappropriate Speech</emph>, 4 items. Items range from 0 to 3 scale with higher scores indicating greater severity.</p> <hd id="AN0161607310-8">Statistical Analyses</hd> <p>We evaluated baseline demographic and clinical characteristics of the 19 children randomly assigned to MEAL Plan using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Statistical tests compared children classified with positive treatment response to those who did not show a positive treatment response using two-sample t-tests and chi-square tests of independence or Fisher's exact tests (when expected frequencies were low, < 5). Normality of continuous variables was evaluated by visual inspections of histograms and quantitative evaluations of summary statistics, including measures of centrality (i.e. mean and median), spread, and skewness. In addition to subgroup contrasts, we calculated Cohen's <emph>d</emph> effect sizes (small = 0.2, moderate = 0.5, and large = 0.8) to show the magnitude of differences.</p> <p>To evaluate the impact of disruptive mealtime behavior on treatment outcomes, we examined the 5 items on the BAMBI Disruptive Behavior subscale. Items include: "My child is disruptive during mealtimes;" "My child is aggressive during mealtimes;" "My child cries or screams during mealtime;" "My child displays self-injurious behavior during mealtimes." These items are scored from 1 to 5 with higher scores indicating greater disruptive behavior. On these items, we set a threshold at Baseline of ≥ 3 to classify children with greater disruptive behavior. The 5<sups>th</sups> item on this subscale: "My child remains seated at the table until the meal is finished" is reverse scored. The scoring on this item was transposed to permit the same ≥ 3 threshold. For consistency in this report, we inserted the words "<emph>does not</emph> remain seated" for this item. The two most common Disruptive Behavior BAMBI items ≥ 3 at Baseline were: "cries or screams during mealtime" and "<emph>does not</emph> remain seated." Using the threshold of ≥ 3 (occasionally or more frequently) on these BAMBI items, we calculated the rate difference: the proportion of children above threshold who showed a positive response on the CGI-I at Week 16 minus the proportion of those who did not show a positive response. Rate differences are presented numerically and plotted visually. Our analysis further included the exact 95% confidence intervals, p-values and effect sizes corresponding to the rate differences. Due to limited sample size, we did not perform longitudinal regression modeling. We calculated results using SAS v.9.4 (Cary, NC), and evaluated statistical significance at the 0.05 level.</p> <hd id="AN0161607310-9">Results</hd> <p></p> <hd id="AN0161607310-10">Baseline and Clinical Characteristics</hd> <p>Table 1 presents the Baseline demographic and clinical characteristics of the 19 children randomized to MEAL Plan. Just over half the sample had an IQ below 70. Participants had mild levels of disruptive behavior (ABC-Irritability subscale < 15) outside of mealtimes as reported on the ABC. By contrast, BAMBI scores reflected high levels of disruptive mealtime behaviors. The blinded IE classified 47.4% (9 of 19) with positive treatment response (i.e. Much Improved or Very Much Improved on the CGI-I) at Week 16. Eight of the 9 participants with positive response at Week 16 maintained positive response status at Week 20.</p> <p>Table 1 Baseline Demographic and Clinical Characteristics for Children Randomly assigned to MEAL Plan and by Treatment Response</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Characteristic</p></th><th align="left"><p>N</p></th><th align="left"><p>MEAL Plan Overall (N = 19)</p></th><th align="left"><p>Positive Response</p><p>(N = 9)</p></th><th align="left"><p>Negative Response (N = 10)</p></th><th align="left"><p>p-value</p></th><th align="left"><p>Effect Size (ES)<sup>1</sup></p></th></tr></thead><tbody><tr><td align="left"><p>Age in Months, Mean (SD)</p></td><td align="left"><p>19</p></td><td align="left"><p>58.3 (14.6)</p></td><td align="left"><p>59.1 (14.3)</p></td><td align="left"><p>57.5 (15.6)</p></td><td align="left"><p>0.817</p></td><td align="left"><p>0.11</p></td></tr><tr><td align="left"><p>Gender, N (%)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Female</p></td><td align="left"><p>19</p></td><td align="left"><p>3 (15.8%)</p></td><td align="left"><p>3 (33.3%)</p></td><td align="left"><p>0 (0%)</p></td><td align="left"><p>0.087</p></td><td align="left"><p><bold>1.00</bold></p></td></tr><tr><td align="left"><p> Male</p></td><td align="left" /><td align="left"><p>16 (84.2%)</p></td><td align="left"><p>6 (66.7%)</p></td><td align="left"><p>10 (100%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Race, N (%)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> White</p></td><td align="left"><p>19</p></td><td align="left"><p>12 (63.2%)</p></td><td align="left"><p>7 (77.8%)</p></td><td align="left"><p>5 (50%)</p></td><td align="left"><p>0.546</p></td><td align="left"><p>0.62</p></td></tr><tr><td align="left"><p> Black</p></td><td align="left" /><td align="left"><p>4 (21%)</p></td><td align="left"><p>1 (11.1%)</p></td><td align="left"><p>3 (30%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Other</p></td><td align="left" /><td align="left"><p>3 (15.8%)</p></td><td align="left"><p>1 (11.1%)</p></td><td align="left"><p>2 (20%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Intelligence Quotient (IQ), N (%)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> < 70</p></td><td align="left"><p>18</p></td><td align="left"><p>10 (55.6%)</p></td><td align="left"><p>4 (44.4%)</p></td><td align="left"><p>6 (66.7%)</p></td><td align="left"><p>0.637</p></td><td align="left"><p>0.46</p></td></tr><tr><td align="left"><p> ≥ 70</p></td><td align="left" /><td align="left"><p>8 (44.4%)</p></td><td align="left"><p>5 (55.6%)</p></td><td align="left"><p>3 (33.3%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Maternal education, N (%)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Advanced degree</p></td><td align="left"><p>19</p></td><td align="left"><p>6 (31.6%)</p></td><td align="left"><p>3 (33.3%)</p></td><td align="left"><p>3 (30%)</p></td><td align="left"><p>0.156</p></td><td align="left"><p><bold>1.45</bold></p></td></tr><tr><td align="left"><p> College degree</p></td><td align="left" /><td align="left"><p>6 (31.6%)</p></td><td align="left"><p>5 (55.6%)</p></td><td align="left"><p>1 (10%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Some college</p></td><td align="left" /><td align="left"><p>5 (26.3%)</p></td><td align="left"><p>1 (11.1%)</p></td><td align="left"><p>4 (40%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> High school graduate</p></td><td align="left" /><td align="left"><p>1 (5.3%)</p></td><td align="left"><p>0 (0%)</p></td><td align="left"><p>1 (10%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Unknown/Not in Household</p></td><td align="left" /><td align="left"><p>1 (5.3%)</p></td><td align="left"><p>0 (0%)</p></td><td align="left"><p>1 (10%)</p></td><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Vineland, Mean (SD)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Daily Living</p></td><td align="left"><p>16</p></td><td align="left"><p>71.3 (15.2)</p></td><td align="left"><p>74.3 (17.6)</p></td><td align="left"><p>68.4 (12.8)</p></td><td align="left"><p>0.460</p></td><td align="left"><p>0.38</p></td></tr><tr><td align="left"><p> Socialization</p></td><td align="left"><p>16</p></td><td align="left"><p>70.3 (15.8)</p></td><td align="left"><p>73.3 (19.3)</p></td><td align="left"><p>67.3 (11.8)</p></td><td align="left"><p>0.468</p></td><td align="left"><p>0.38</p></td></tr><tr><td align="left"><p> Communication</p></td><td align="left"><p>16</p></td><td align="left"><p>74.1 (17.6)</p></td><td align="left"><p>80.8 (12.4)</p></td><td align="left"><p>67.4 (20.3)</p></td><td align="left"><p>0.138</p></td><td align="left"><p><bold>0.80</bold></p></td></tr><tr><td align="left"><p>Aberrant Behavior Checklist, Mean (SD)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Irritability</p></td><td align="left"><p>19</p></td><td align="left"><p>12.2 (8.1)</p></td><td align="left"><p>11.4 (7.9)</p></td><td align="left"><p>12.9 (8.6)</p></td><td align="left"><p>0.705</p></td><td align="left"><p>0.18</p></td></tr><tr><td align="left"><p> Social Withdrawal</p></td><td align="left"><p>19</p></td><td align="left"><p>8.6 (5.3)</p></td><td align="left"><p>7.8 (4.7)</p></td><td align="left"><p>9.3 (5.9)</p></td><td align="left"><p>0.540</p></td><td align="left"><p>0.29</p></td></tr><tr><td align="left"><p> Stereotypic Behavior</p></td><td align="left"><p>19</p></td><td align="left"><p>4.2 (3.5)</p></td><td align="left"><p>3.4 (2.0)</p></td><td align="left"><p>4.9 (4.4)</p></td><td align="left"><p>0.366</p></td><td align="left"><p>0.42</p></td></tr><tr><td align="left"><p> Hyperactivity</p></td><td align="left"><p>19</p></td><td align="left"><p>19.4 (8.6)</p></td><td align="left"><p>18.9 (11.3)</p></td><td align="left"><p>19.9 (5.7)</p></td><td align="left"><p>0.821</p></td><td align="left"><p>0.11</p></td></tr><tr><td align="left"><p> Inappropriate Speech</p></td><td align="left"><p>19</p></td><td align="left"><p>3.4 (3.0)</p></td><td align="left"><p>3.2 (1.7)</p></td><td align="left"><p>3.6 (3.9)</p></td><td align="left"><p>0.785</p></td><td align="left"><p>0.13</p></td></tr><tr><td align="left"><p>BAMBI Measures, Mean (SD)</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p> Total Score</p></td><td align="left"><p>19</p></td><td align="left"><p>45.1 (6.5)</p></td><td align="left"><p>44.7 (5.4)</p></td><td align="left"><p>45.5 (7.6)</p></td><td align="left"><p>0.785</p></td><td align="left"><p>0.13</p></td></tr><tr><td align="left"><p> Food Selectivity</p></td><td align="left"><p>19</p></td><td align="left"><p>15.6 (1.6)</p></td><td align="left"><p>15.2 (1.5)</p></td><td align="left"><p>15.9 (1.7)</p></td><td align="left"><p>0.361</p></td><td align="left"><p>0.43</p></td></tr><tr><td align="left"><p> Food Refusal</p></td><td align="left"><p>19</p></td><td align="left"><p>9.1 (2.5)</p></td><td align="left"><p>8.7 (1.5)</p></td><td align="left"><p>9.4 (3.1)</p></td><td align="left"><p>0.520</p></td><td align="left"><p>0.30</p></td></tr><tr><td align="left"><p> Mealtime Rigidity</p></td><td align="left"><p>19</p></td><td align="left"><p>8.6 (3.0)</p></td><td align="left"><p>8.8 (3.0)</p></td><td align="left"><p>8.5 (3.2)</p></td><td align="left"><p>0.847</p></td><td align="left"><p>0.09</p></td></tr><tr><td align="left"><p> Disruptive Meal Time Behaviors, N (%)</p></td><td align="left"><p>19</p></td><td align="left"><p>11.8 (4.0)</p></td><td align="left"><p>12.0 (4.2)</p></td><td align="left"><p>11.7 (4.0)</p></td><td align="left"><p>0.876</p></td><td align="left"><p>0.07</p></td></tr><tr><td align="left"><p> Disruptive during mealtimes (≥ 3)</p></td><td align="left" /><td align="left"><p>10 (52.6%)</p></td><td align="left"><p>5 (55.6%)</p></td><td align="left"><p>5 (50%)</p></td><td align="left"><p>1.000</p></td><td align="left"><p>0.11</p></td></tr><tr><td align="left"><p> Aggressive during mealtimes (≥ 3)</p></td><td align="left" /><td align="left"><p>5 (26.3%)</p></td><td align="left"><p>3 (33.3%)</p></td><td align="left"><p>2 (20%)</p></td><td align="left"><p>0.629</p></td><td align="left"><p>0.31</p></td></tr><tr><td align="left"><p> Cries or screams during mealtime (≥ 3)</p></td><td align="left" /><td align="left"><p>11 (57.9%)</p></td><td align="left"><p>7 (77.8%)</p></td><td align="left"><p>4 (40%)</p></td><td align="left"><p>0.170</p></td><td align="left"><p><bold>0.83</bold></p></td></tr><tr><td align="left"><p> Self-injurious behavior (≥ 3)</p></td><td align="left" /><td align="left"><p>0 (0%)</p></td><td align="left"><p>0 (0%)</p></td><td align="left"><p>0 (0%)</p></td><td align="left"><p>NA</p></td><td align="left"><p>NA</p></td></tr><tr><td align="left"><p> Does not remain seated (≥ 3)<sup>2</sup></p></td><td align="left" /><td align="left"><p>13 (68.4%)</p></td><td align="left"><p>4 (44.4%)</p></td><td align="left"><p>9 (90%)</p></td><td align="left"><p>0.057</p></td><td align="left"><p><bold>1.11</bold></p></td></tr></tbody></table> </ephtml> </p> <p> <sups>1</sups>ES: small = 0.2, moderate = 0.5, large = 0.8; Bolded text indicates a large ES <sups>2</sups>Original item ranges from Not Seated (<reflink idref="bib1" id="ref42">1</reflink>) to Seated (<reflink idref="bib5" id="ref43">5</reflink>); by convention, the item was reverse scored, ranging from Seated (<reflink idref="bib1" id="ref44">1</reflink>) to Not Seated (<reflink idref="bib5" id="ref45">5</reflink>) <sups>3</sups>Summaries for continuous data are presented as Mean (SD), and p-values are calculated with two-sample t-tests; summaries for categorical data are presented as N (%), and p-values are calculated with chi-square tests of independence or Fisher's exact tests when expected frequencies are low (< 5)</p> <p>There were no statistically significant group Baseline differences by treatment response. However, we observed large effect sizes based on maternal education and pre-treatment scores on the Vineland Communication domain. Eight of nine mothers (88.89%) of children in the positive response group had a college or advanced degree compared to 4 of 10 (40%) mothers of children classified with negative response (ES = 1.45). Children in the positive response group had a 13-point higher pre-treatment mean score on the Vineland Communication than those who did not show a positive response (ES = 0.8). There was a moderate effect by race (ES = 0.62). Just over half of white participants (7/12, 58.3%) were classified with positive treatment response compared to one in four (25%) for black participants. The three black participants who did not show a positive response dropped out of the study and were not evaluated at Week 16. By convention, these participants were classified with negative treatment response. These three participants also received a lower dose of treatment having missed two to three treatment sessions due to scheduling conflicts and child and parent illness prior to dropping out of treatment.</p> <hd id="AN0161607310-11">Mealtime Behavior</hd> <p>As noted, the most common BAMBI Disruptive Behavior subscales that met or exceeded our threshold of 3 or greater at Baseline included: "My child cries or screams during mealtimes" and "My child <emph>does not</emph> remain seated at the table until the meal is finished." At Baseline, 7 of 9 (77.8%) of children in the positive response group were rated ≥ 3 on "cries or screams during mealtimes" compared to 40% of children who did not show a positive treatment response (ES = 0.83, Rate Difference = 37.8%, see Table 1 and Fig. 1). By Week 16, the rate of scoring ≥ 3 on "cries or screams during mealtimes" in the positive treatment group dropped to 11.1% (1 of 9) compared to 3 of 7 (42.9%, i.e. no change) in children in the negative treatment response group (ES = 0.77, Rate Difference = − 31.8%, see Fig. 1).</p> <p>Graph: Fig. 1 Proportions and Rate differences for "My child cries or screams during mealtime" by Week 16 MEAL Plan Response Status and Study Follow-up Time. The left figure axis shows the percentage of participants rating the BAMBI item "cries or screams during mealtime" a 3 or greater. The right axis shows the difference between participants who had a positive and negative treatment response. The line in the figure demonstrates the rate difference between the positive and negative response group at each time point</p> <p>On the "does not remain seated" item, participants in both groups demonstrated improvement. At Baseline, 44.4% (n = 4 of 9) children in the positive response group met or exceeded threshold on this item compared to 90% of children who did not show a positive response (ES = 1.11, Rate Difference = − 45.6%, see Table 1; Fig. 2). By Week 16, the rate of "does not remain seated" declined by 50% in both groups from 44.4% to 22% in the positive response group and 90% to 43% in children who did not show a positive treatment response (ES = 0.45, Rate Difference = − 20.6%, see Table 1, Fig. 2).</p> <p>Graph: Fig. 2 Proportions and Rate differences for "My child does not remain seated at the table until the meal is finished" by Week 16 MEAL Plan Response Status and Study Follow-up Time. The left figure axis shows the percentage of participants rating the BAMBI item "my child does not remain seated at the table until the meal is finished" a 3 or greater. The right axis shows the difference between participants who had a positive and negative treatment response. The line in the figure demonstrates the rate difference between the positive and negative response group at each time point</p> <hd id="AN0161607310-12">Discussion</hd> <p>The Autism MEAL Plan is a structured, parent-mediated intervention designed to expand dietary variety in children with disruptive mealtime behavior and moderate food selectivity (Sharp, et al., [<reflink idref="bib26" id="ref46">26</reflink>]). We built MEAL plan on a firm foundation of PT in children with ASD and disruptive behavior (Bearss et al., [<reflink idref="bib2" id="ref47">2</reflink>]). Our model posits that establishing foundational feeding behaviors and reducing disruptive mealtime behavior are prerequisites to treatment success. The program also incorporates instruction on nutrition to promote health through dietary expansion. In a previous report, we showed that MEAL Plan was superior to parent education in reducing disruptive mealtime behavior and expanding dietary variety. The report also noted that 9 of the 19 children (47.4%) in MEAL Plan were rated Much Improved or Very Much Improved by a blinded IE at Week 16. Although these results are similar to other parent-mediated interventions for children with ASD and feeding problems (see Johnson, et al., [<reflink idref="bib8" id="ref48">8</reflink>]), it raises questions about factors affecting treatment outcome.</p> <p>In this study, we examined baseline characteristics of children randomized to MEAL Plan who showed a positive response to those who did not show a positive response. Variables with at least a moderate effect size included maternal education, race, and adaptive communication skills. The effect size for positive treatment response was larger for children of mothers with higher maternal educational achievement. This observation suggests that caregivers with higher education may have greater family resources, potentially more time to implement treatment strategies in the home or both. We note that just over 50% of the sample had IQ < 70. Children in the positive response group had a 13-point higher pre-treatment score on the Vineland Communication domain. This finding supports, but does not prove, that greater functional communication may improve the child's understanding of verbal instruction on mealtime expectations (e.g. food selection, bite size).</p> <p>The level of pre-treatment disruptive mealtime behavior may also have affected treatment outcome. On the BAMBI at Baseline, the two most endorsed items ≥ 3 (i.e. occasionally, or more frequently) were "cries or screams during mealtimes" and "<emph>does not</emph> remain seated." Caregivers of children in the positive treatment group indicated high rates of crying and screaming during mealtimes at Baseline followed by a dramatic decline over the 16-weeks of MEAL Plan. Although the children who did not show a positive treatment response had a lower rate of crying and screaming at Baseline, there was no change in this behavior during the trial.</p> <p>Caregivers rated 5 of 9 (55.5%) children in the positive response group at or above threshold on the "<emph>does not</emph> remain seated at the table" item at Baseline. This rate declined to 22% by Week 16. By contrast, 9 of 10 children in the negative response group met or exceeded threshold on the "<emph>does not</emph> remain seated" item at Baseline. In this group, the rate declined to 43%, which was roughly equal to pretreatment rate in the positive treatment group. Thus, although all children in MEAL plan demonstrated improvement in sitting at mealtime, roughly 80% of children in the positive response group were below threshold on this pivotal item at Week 16 (Fig. 2). Improved "sitting at the table" and decreased crying and screaming at mealtimes fit with our model and may set the stage for dietary expansion. These findings are consistent with findings from a previous randomized trial of parent training in children with ASD and disruptive behavior more broadly where reduction in disruptive behavior set the stage for improvement in adaptive behavior (Scahill et al., [<reflink idref="bib23" id="ref49">23</reflink>]).</p> <p>One of four Black children in the study showed a positive response. The three of four Black children who did not show a positive treatment response received a lower treatment dose (attending 7–8 of the 10 sessions) due to child illness, parent illness and scheduling problems. These intervening events may have contributed to attrition in these participants.</p> <hd id="AN0161607310-13">Limitations</hd> <p>This was an exploratory examination of baseline variables that influence positive treatment outcome in the Autism MEAL Plan. The relatively small sample precluded more formal moderator analyses. Thus, we examined effect sizes to evaluate observed group differences in pre-treatment measures (e.g. maternal education, disruptive mealtime behavior). These results are of interest but should be accepted with caution. In this study, MEAL Plan was delivered in a group format and treatment sessions continued despite participant absences. MEAL Plan delivered individually could offer greater scheduling flexibility and prior studies have demonstrated high retention rates when PT is delivered individually (Johnson, et al., [<reflink idref="bib8" id="ref50">8</reflink>]).</p> <hd id="AN0161607310-14">Conclusion</hd> <p>The findings in this study complement the results of our previous report on the efficacy of MEAL Plan and fit with the larger body of evidence on the efficacy of PT for disruptive behavior in children with ASD (Postorino et al., [<reflink idref="bib19" id="ref51">19</reflink>]). These convergent findings suggest that MEAL Plan is an efficacious intervention for moderate food selectivity in children with ASD. In this study, we found that children who entered the trial sitting at the table or acquired this skill early in MEAL Plan and demonstrated a reduction in crying and screaming during mealtime had a positive treatment response. This suggests that these two behaviors, sitting at the table and low disruptive behavior, are important prerequisites to a positive treatment outcome.</p> <hd id="AN0161607310-15">Author Contributions</hd> <p>TLB carried out the project, developed research questions and hypotheses, interpreted results and was the primary manuscript author. LS provided project guidance and mentorship of TLB and assisted in interpretation of results and manuscript writing. NN assisted in developing research questions and hypotheses, data collection and analysis, and manuscript writing. SG assisted in project development, data analysis, interpretation of results, and manuscript writing. WS was the principal investigator on the project, provided project guidance, interpretation of results, and manuscript writing.</p> <hd id="AN0161607310-16">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0161607310-17"> <title> References </title> <blist> <bibl id="bib1" idref="ref9" type="bt">1</bibl> <bibtext> American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 20135; American Psychiatric Association. 10.1176/appi.books.9780890425596</bibtext> </blist> <blist> <bibl id="bib2" idref="ref26" type="bt">2</bibl> <bibtext> Bearss K, Johnson C, Smith T, Lecavalier L, Swiezy N, Aman M, Scahill L. Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: A randomized clinical trial. 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  Data: <searchLink fieldCode="EL" term="%22Adult+Education%22">Adult Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Parent+Education%22">Parent Education</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Participation%22">Parent Participation</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Food%22">Food</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Background%22">Parent Background</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Communication+Skills%22">Communication Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Eating+Habits%22">Eating Habits</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10803-021-05406-w
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0162-3257<br />1573-3432
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Managing Eating Aversions and Limited Variety (MEAL) Plan is a structured parent-mediated intervention for children with autism spectrum disorder and moderate food selectivity. Our previously reported group-based clinical trial revealed a positive treatment response rate of 47.3%. Although encouraging, this response rate raises questions about factors that may affect treatment outcomes. Here, we examine the impact of child and parent characteristics and feeding behaviors on treatment response. Higher maternal education and higher child communication abilities at baseline were associated with positive treatment response. Improvement in sitting at the table and reductions in disruptive mealtime behavior promoted treatment success. Results also suggest that individually delivered MEAL Plan may offer more flexibility than group-based intervention for some parents.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2023
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1364443
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1364443
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1007/s10803-021-05406-w
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 7
        StartPage: 229
    Subjects:
      – SubjectFull: Parent Education
        Type: general
      – SubjectFull: Parent Participation
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Autism Spectrum Disorders
        Type: general
      – SubjectFull: Food
        Type: general
      – SubjectFull: Parent Background
        Type: general
      – SubjectFull: Mothers
        Type: general
      – SubjectFull: Communication Skills
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
      – SubjectFull: Eating Habits
        Type: general
    Titles:
      – TitleFull: Exploration of Treatment Response in Parent Training for Children with Autism Spectrum Disorder and Moderate Food Selectivity
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Burrell, T. Lindsey
      – PersonEntity:
          Name:
            NameFull: Scahill, Lawrence
      – PersonEntity:
          Name:
            NameFull: Nuhu, Nadratu
      – PersonEntity:
          Name:
            NameFull: Gillespie, Scott
      – PersonEntity:
          Name:
            NameFull: Sharp, William
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2023
          Identifiers:
            – Type: issn-print
              Value: 0162-3257
            – Type: issn-electronic
              Value: 1573-3432
          Numbering:
            – Type: volume
              Value: 53
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Journal of Autism and Developmental Disorders
              Type: main
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