Limited and picking eating is a common occurrence for children with autism. Feeding challenges include food selectivity, food refusal, behavioral rigidity during meals, and limited dietary variety (Sharp et al., 2013). Upwards of 89% of autistic individuals have feeding difficulties (Cermak et al., 2010; Ledford & Gast, 2006;) while recent meta-analyses suggest that 12% have feeding challenges severe enough to meet the clinical threshold for Avoidant and Restrictive Food Intake Disorder (Sader et al., 2024).
Although picky eating is common in early childhood, the feeding concerns observed in children with autism differ significantly from their nonautistic peers (Sharp et al., 2013; Sharp et al., 2018). Most nonautistic children with an early history of restrictive eating will show more typical eating patterns as they enter their later childhood years (Cermak et al., 2010). In contrast, children with autism who present with “picky eating” in early childhood often develop more restrictive eating patterns throughout childhood. These patterns tend to persist in adolescence and even adulthood, posing health risks due to poor nutritional intake (Bandini et al., 2010; Sharp et al., 2018). Autistic children with food selectivity get less nutrients in specific areas (e.g., protein, calcium) and may have limited intake or complete omission of important food groups such as fruits and vegetables (Sharp et al., 2018).
Despite well-documented contrasts in nutritional intake, there are no clear differences in patterns of height, weight, and/or BMI between children with and without autism (Sharp et al., 2013). While height and weight are commonly used as indicators of growth and nutrition, they can be overly influenced by calorie consumption and, in turn, may mask underlying nutritional deficits in children with poor diets who otherwise appear to be growing typically for their age. As such, parents of children with autism may not recognize feeding challenges as an important area to integrate into their comprehensive intervention program (Sharp et al., 2013). As a result, feeding concerns are often not targeted until later years of life, when problematic eating patterns have become more prominent and difficult to change.
Given that autism is becoming increasingly recognized in our society today—currently estimated at 1 in 36 children (CDC, 2024)—it is crucial to develop better identification and intervention tools to address feeding concerns early and, therefore, improve nutrition in this population.
Feeding Interventions
Best practices from the basis of scientific literature indicate that behavioral interventions employed by a multidisciplinary team are the most effective evidence-based treatment option for food selectivity among the autism population (Ledford & Gast, 2006; Sharp et al., 2010, 2017, 2024). These programs can be provided on an inpatient, intensive outpatient (e.g., daily for multiple hours), and standard outpatient (e.g., weekly) basis and generally involve collaboration between behavior analysts, speech-language pathologists, occupational therapists, physicians, psychologists, and/or dieticians (Sharp et al., 2024). Inpatient and intensive outpatient programs are often necessary for children with moderate to severe food selectivity, whereas weekly outpatient approaches can be helpful for autistic children with mild to moderate feeding challenges (Sharp et al., 2014, 2019). Although programs for children with moderate to severe feeding challenges are effective (Sharp et al., 2024), they can be difficult for families to access due to lengthy waitlists and limited availability in many geographical areas (Sharp et al., 2014). Given that restrictive feeding tends to worsen over time, it is best to intervene early on when feeding challenges are less severe.
The approach to treating autistic children with less severe feeding challenges, though, has fewer established guidelines. Commonly, feeding interventions provided in community-based, outpatient settings are led by behavior therapists, psychologists, speech and language pathologists, or occupational therapists. Approaches may utilize applied behavioral analysis (ABA) or sequential oral sensory (SOS) methodology. Research on the outcomes is mixed, and in general, sample sizes are too small to make strong conclusions, but it’s suggested that behavioral interventions have some advantages over sensory methods when looking at increased consumption of new foods (Peterson, Piazza, & Volkert, 2016). At the same time, behavioral approaches must be implemented with careful consideration and sensitivity to the ethical implications of feeding interventions (Tereshko, Weiss, & Olive, 2021). Individuals participating in feeding interventions, whether behavioral or otherwise, should provide informed consent, have personalized goals aimed at expanding their dietary variety and intake, and retain the freedom to disengage from the intervention at any time.
The Managing Eating Aversions and Limited Variety (MEAL PlanR), formerly The Autism MEAL Plan, was developed with a strong foundation in both ethics and science. It shows promise as an approach that can be integrated into a child’s existing intervention program to address picky eating early before it worsens. Randomized controlled trials show the program to be feasible and efficacious (Sharp et al., 2014, 2019), with improvements observed across mealtime behaviors, variety of food consumed, and reductions in caregiver stress (Sharp et al., 2019).
MEAL PlanR as a Feeding Intervention
MEAL PlanR is an evidence-based, parent-mediated program designed to improve mealtimes through a positive, child-led behavioral approach. It aims to make mealtimes more positive for the child while increasing the variety of acceptable foods the child will eat (Sharp et al., 2014; Sharp et al., 2019). MEAL PlanR was created from fifteen years of research and clinical applications, with outcomes indicating improvements in meal hygiene and food variety among children in early-to-middle childhood who present with (up to) moderate food selectivity. Food selectivity is defined as “consuming a restricted diet (i.e., two or fewer food items in one or more food categories) but also with some degree of variety (i.e., multiple foods from at least two food groups)” (MEAL PlanR Therapist Manual, n.d.).
MEAL PlanR can be used as an individual or group intervention (MEAL PlanR Therapist Manual, n.d.). The recommended profile for MEAL PlanR is children in early-to-middle childhood (i.e., ages 4 to 12) who consume solid food, demonstrate some independence during mealtimes (i.e., can self-feed), and whom a parent-directed intervention is still developmentally appropriate. Additionally, it is recommended that children have some degree of independent communication to make choices between items and/or indicate preferences. MEAL PlanR is not intended for children who present with complex medical concerns (e.g., feeding tube dependence, signs of malnutrition, swallow safety concerns) or are dependent on oral supplementation.
The three pillars that compose the treatment approach include behavioral intervention, caregiver involvement, and nutritional integration. The MEAL PlanR intervention utilizes a variety of behavior-based strategies to support the introduction of novel foods, promote oral intake of foods, and expand dietary diversity (MEAL PlanR Therapist Manual, n.d.). Caregiver involvement is crucial for the delivery of intervention and for the generalization of skills into the home setting, and nutrition education is integrated throughout the curriculum to promote health and wellness and to develop sustainable healthy habits.
The MEAL PlanR curriculum is broken down into three phases of treatment: establishing meal hygiene practices, food exposures with behavioral intervention, and demonstrating generalization to the home setting (MEAL PlanR Therapist Manual, n.d.). Sessions are divided into twelve topics across the three phases. As caregiver-child pairs demonstrate mastery of each skill area, the clinician will introduce the next skill. During each session, the clinician provides the didactic portion of the lesson to the caregiver, followed by a meal observation. This allows the clinician an opportunity to model any skills for the caregiver and for the caregiver to practice while receiving feedback from the clinician. Homework is assigned on a weekly basis to ensure skills are maintained across sessions.
Throughout the intervention, caregivers are taught a variety of behavior-based strategies and how to apply these strategies to best support their children. Additionally, caregivers learn about the importance of nutrition and how to select foods to introduce into their child’s diet. Overall, MEAL PlanR affords parents the opportunity to learn the skills necessary to increase their child’s overall health and nutritional intake. By utilizing a parent-mediated model of intervention, the likelihood of maintenance and generalization of skills across settings is significantly increased (Sharp et al., 2013; Sharp et al., 2019).
Intervention at the Child Mind Institute
At the Child Mind Institute’s Autism Center, we provide a comprehensive range of services for individuals with autism or related disorders and their families. Our team of developmental specialists, including psychologists, speech-language pathologists, and Board Certified Behavior Analysts (BCBAs), create personalized intervention plans for each individual and collaborate closely with home and school-based providers. For autistic individuals with feeding challenges, we collaborate closely with them and their families to develop a personalized feeding plan that aligns with their goals and needs. Meal PlanR is one program, among others, that we offer as part of our clinical services. For more information, please visit childmind.org or email us at autismprograms@childmind.org.
E. Emilie Weiner, MA, BCBA, is Board Certified Behavior Analyst, Alexis Bancroft, PhD, is Licensed Psychologist, and Cynthia Martin, PsyD, is Clinical Psychologist and Senior Director of the Autism Center at Child Mind Institute.
References
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Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238-246.
Centers for Disease Control and Prevention. (2024). Data and statistics on autism spectrum disorder. Centers for Disease Control and Prevention. https://www.cdc.gov/autism/data-research/index.html
Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders: A review. Focus on autism and other developmental disabilities, 21(3), 153-166.
MEAL PlanR Therapist Manual [Unpublished manuscript].
Peterson, K. M., Piazza, C. C., & Volkert, V. M. (2016). A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 49(3), 485–511.
Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Pediatric feeding disorders: a quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology, 13(4), 348-365.
Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., Klin, A., Jones, W., & Jaquess, D. L. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: a meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43(9), 2159–2173.
Sharp, W.G., Burrell, L., & Jaquess, D.L. (2014). The Autism MEAL Plan: A parent training curriculum to manage eating aversions and low intake among children with autism. Autism, 18(6), 712-722.
Sharp, W. G., Volkert, V. M., Scahill, L., McCracken, C. E., & McElhanon, B. (2017). A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: how standard is the standard of care? The Journal of Pediatrics, 181, 116-124.
Sharp, W. G., Postorino, V., McCracken, C. E., Berry, R. C., Criado, K. K., Burrell, T. L., & Scahill, L. (2018). Dietary intake, nutrient status, and growth parameters in children with autism spectrum disorder and severe food selectivity: an electronic medical record review. Journal of the Academy of Nutrition and Dietetics, 118(10), 1943–1950.
Sharp, W.G., Burrell, T.L., Berry, R.C., Stubbs, K.H., McCracken, C.E., Gillespie, S.E., Scahill, L. (2019). The Autism MEAL plan vs. Parent Education: A Randomized Clinical Trial. The Journal of Pediatrics, 21: 185-192.
Sharp, W. G., Malugen, E., Pederson, J., Martin-Halpine, L., Dempster, R., Baranwal, N., Hodges, A., Raol, N., & Volkert, V. M. (2024). Intensive multidisciplinary feeding day programs in the United States: a report regarding the treatment landscape. The Journal of Pediatrics, 272, 114126.
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