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J Autism Dev Disord (2017) 47:564–578 DOI 10.1007/s10803-016-2977-0

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ORIGINAL PAPER

EAT-UP™ Family-Centered Feeding Intervention to Promote Food Acceptance and Decrease Challenging Behaviors: A Single- Case Experimental Design Replicated Across Three Families of Children with Autism Spectrum Disorder

Joanna Cosbey1  · Deirdre Muldoon2,3 

Published online: 30 November 2016 © Springer Science+Business Media New York 2016

Introduction

Feeding and eating difficulties among children with autism spectrum disorder (ASD) are increasingly being recognized as an integral part of the disorder (e.g., Cermak et al. 2010; Edmond et al. 2010). The growing body of research in this area has provided information to establish evidence-based practices (EBPs) to support mealtimes, particularly through the use of therapists or other professionals as the interven- tionists. There is limited information regarding the efficacy of multicomponent interventions that are implemented by parents using these established EBPs.

Parent implemented intervention (PII), in which a par- ent learns to provide intervention in their home or commu- nity through a guided training program, is an EBP for use with young children to make the behavior change sustain- able across time and outcome areas (Moes and Frea 2002; Wong et al. 2013). Studies such as one conducted by John- son et  al. (2015) examined the use of parents as interven- tionists through strategies such as clinic-based behavioral training programs. However, the majority of studies related to promoting mealtime behaviors involve an interventionist working directly with the child and may or may not have a family training component. In fact, a comprehensive syn- thesis of treatment outcomes in feeding interventions by Sharp et  al. (2010) indicated that only 58.3% of the inter- ventions documented caregiver training and over 80% of the studies had trained professionals, rather than parents, providing the intervention. Additional research is needed to determine appropriate methods for integrating PII and feed- ing interventions to make lasting changes for children and their families.

The current research has examined the efficacy of spe- cific strategies and intervention approaches, such as behav- ioral strategies, sensory strategies, and communication

Abstract This study evaluated the effectiveness of a fam- ily-centered feeding intervention, Easing Anxiety Together with Understanding and Perseverance (EAT-UP™), for promoting food acceptance of children with autism spec- trum disorder at home. A concurrent multiple-baseline design was used with systematic replication across three families. Baseline was followed by an ‘Intervention-Coach- ing’ phase and then an ‘Intervention-Independent’ phase. Using direct observation and pre- and post-intervention questionnaires, data on acceptance of less preferred foods and challenging mealtime behaviors were collected. Proce- dural fidelity was monitored throughout all study phases. Data were analyzed using visual analysis and measures of effect size. All children demonstrated increases in food acceptance (effect size >0.90) and dietary diversity and decreased challenging behaviors. Implications for practice and research are discussed.

Keywords Autism spectrum disorder · Parent implemented intervention · Mealtime behaviors · Food refusal · Evidence based practices

* Joanna Cosbey [email protected]

1 Division of Occupational Therapy, Department of Pediatrics, University of New Mexico, HSSB Room 140, MSC09 5240, 1 University of New Mexico, Albuquerque, NM 87131, USA

2 Center for Development and Disability, Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA

3 Present Address: Department of Communication Sciences and Disorders, The College of Saint Rose, Albany, NY, USA

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interventions. The majority of the research in the area of feeding and eating difficulties in ASD is focused on spe- cific behavioral strategies to ameliorate difficult behaviors at mealtimes (for a review see Volkert and Piazza 2012). These evidence based practices (EBPs) include strategies such as: functional assessment (e.g., Gale et  al. 2011); positive, differential, or non-contingent reinforcement (e.g., Allison et  al. 2012); and escape extinction (e.g., Galensky et  al. 2001). Several researchers have addressed the possi- ble behavioral functions of food avoidance and challenging mealtime behaviors (e.g., Gale et al. 2011). Although iden- tifying the clear functions of these behaviors is extremely important within research and clinical contexts, in natural contexts it may not always be appropriate or feasible for parents to fully evaluate the function of a particular behav- ior. While many of the current feeding interventions are behavioral and include assessment of function, it is often difficult to decide which interventions are most appropri- ate to address challenging mealtime behaviors and thus, require multi-disciplinary assessment and treatment (Sharp et al. 2013; Tanner et al. 2015).

A number of authors have described the impact of a child’s sensory processing characteristics on food selectiv- ity and subsequent mealtime behaviors (see Cermak et  al. 2010 for a review). Sensory factors, such as the taste, tex- ture, or appearance of foods, can influence an individual’s behavioral response to foods, leading to food refusal, gag- ging, vomiting, etc. Researchers in this area have focused on manipulating food (Ahearn 2003) or using sensory- based interventions to support the child (Adison et  al. 2012). Other interventions that have been found to be effec- tive in supporting the mealtimes of children with ASD address both behavioral and sensory components of feed- ing, such food chaining (Fishbein et al. 2006) and changing bite size and/or number of bites (e.g., Sharp et al. 2010), as well as changes to the physical environment, such as seating and type of plate (e.g., Gale et al. 2011; Gentry and Luiselli 2007). Communicative strategies such as functional assess- ment and functional communication training with children with ASD and their families has been found to be effective in reducing the occurrences of challenging behavior (Moes and Frea 2002; Wong et al. 2013), but have not been explic- itly investigated during mealtimes. Additionally, visual sup- port strategies to support a child’s receptive understanding and promote appropriate behavior during meals have been used as part of intervention packages (e.g., Binnendyk and Lucyshyn 2008). However, these communication strategies have not been explicitly investigated during mealtimes and have not been used to address the complex, dynamic com- munication interactions that occur between the parent and the child.

Most of these studies and other research conducted in the area of promoting mealtime behaviors has focused

on identifying specific variables that are responsible for behavior change. For example, studies have evaluated the efficacy of one specific strategy or of one strategy in comparison to another (e.g., Ahearn 2003; Peterson et al. 2016). These studies have contributed to the knowledge base regarding EBPs, but typically do not focus on the complex, dynamic nature of naturally occurring family mealtimes. So although they are able to demonstrate effi- cacy from a research perspective under controlled condi- tions, the success of the intervention in a more natural context is not as clear. Additionally, as discussed, most of the interventions addressed in published research approach feeding difficulties as residing in the child, with either behavioral or sensory explanations for the challenges. More recent research (e.g., Chao and Chang 2016; Estrem et al. 2016) recognizes that feeding difficul- ties impact both child and parents and supports a more comprehensive approach to addressing mealtime behav- iors. In other words, although it can be important to sys- tematically control for all variables in the early stages of research examining EBPs, after a practice has been established to be effective in controlled settings, it is also important to evaluate its efficacy in more natural settings, which often includes the use of multiple interventions simultaneously to promote progress.

In order to address the dynamic nature of eating, feed- ing and mealtimes, the components outlined above are the focus of the current study. For clarity when talking to the parents, the components were organized as (a) social environment (use of behavioral interventions, such as reinforcement, prompting strategies, etc.), (b) physical environment (positioning, etc.), (c) food characteristics (primarily sensory manipulations, such as the types of food provided at meals/snacks); and (d) dyadic commu- nication supports (both receptive and expressive for both the parent and the child). These components provided a framework for the menu of intervention options for par- ents when individualizing their intervention and directly addressed the unique dynamics of each family in the study. As outlined above, a number of researchers have evaluated these components in isolation or by grouping one or two components together. However, interventions looking holistically at the mealtime environment related to all of those areas have not been explored, particularly in the context of family-as-interventionist.

The purpose of this preliminary study was to expand on the research outlined above and to determine the efficacy and perceived intervention acceptance (social validity) of EAT-UP™, a parent-implemented multicom- ponent intervention package designed to improve the mealtime performance of children. This study specifically examined the efficacy of EAT-UP™ with children with ASD.

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Method

Participants

Three boys from diverse backgrounds who were diagnosed with ASD (Blake, Craig, and Dominic) and their families participated in this study. Each of the boys had received a diagnosis of ASD prior to his third birthday by interdisci- plinary teams, meeting criteria for autism according to the World Health Organization, ICD-10, (1992).

The children were recruited from a statewide interdis- ciplinary feeding clinic. Families were provided informa- tion about the study by the second author and completed a screening to determine eligibility for participation. To be included in the study, the family had to live within 30 miles of the clinic and have at least one parent who was profi- cient in English. The child had to have a multidisciplinary diagnosis of ASD, be between the ages of 2 and 9  years old, have no medical contraindications for oral feeding, and have significant behavioral difficulties around meal- times. Significant behavior difficulties were assessed using the Brief Autism Mealtime Behavior Inventory (BAMBI) (Lukens 2005) and were defined as a total score >45, which corresponds to a score that is >+2 SD from the mean for children who are typically developing (Lukens 2005). Upon completion of the screening, if they met the inclusion crite- ria for the study, families were provided with more detailed information about the study and the opportunity to pro- vide informed consent to participate. Informed consent was obtained from all individual participants included in the study. Because of their age and language abilities, the children were not asked to provide assent for participation. This study was approved by the University of New Mexico Human Research Protection Office.

Blake was a 6-year-old White, Hispanic boy who lived with his married parents and several siblings. He had two older siblings and two younger siblings when the project began, with a baby born towards the middle of the project. His father worked full-time out of the home and his mother worked part-time, mostly from home. His family typically ate together at a dinner table, with the expectation that everyone eat the same meal. Blake would stay at the table for very short periods of time and often would not eat any of the dinner. He would eat granola bars and other “snack foods” during non-meal times. His parents’ primary goals were (1) increase his participation in family mealtimes, (2) incorporate vegetables into his diet, and (3) decrease chal- lenging behaviors (leaving the table and banging his head with his hand to communicate refusal). Both of his parents were targeted as interventionists and they worked together to support Blake and the other children during meals.

Craig was an 8-year-old White boy who lived with his married parents. His father typically traveled 1–2 weeks out

of every month for work, so it was often just Craig and his mother at home for meals. Craig was an only child and his mother did not work outside the home. Craig typically ate his meals alone at a desk in their living room or while rid- ing in the car to/from therapy sessions. His mother reported that they had him eat alone because he frequently chewed food without swallowing it, then spit the masticated food into his palm, shaped it into a ball, and put it back in his mouth to chew again. He commonly repeated this routine multiple times before ultimately swallowing the food. He primarily ate highly processed and/or fast-food and was very particular about the brand of food. He did not eat any fruits, vegetables, or meats, and was significantly over- weight at the time of his initial evaluation at the feeding clinic. His mother was the interventionist and her primary goals were (1) increase his acceptance of healthier foods, (2) decrease his manipulation of masticated foods so that he could eat with his parents, and (3) decrease other chal- lenging behaviors (verbal refusals, licking preferred foods repeatedly, hitting others, and throwing objects).

Dominic was a 7-year-old African-American boy who lived with his mother, grandmother, and grandfather. He was an only child and his mother was a single mother. His mother worked full-time outside the home, typically eve- nings and weekends, so his mother and grandmother shared caregiving responsibilities relatively equally. Both of his grandparents also worked outside the home. Dominic’s diet consisted of crunchy and sweet food, as well as a nutritional supplement drink and large quantities of milk. He would not eat any fruit or vegetable and he disliked food that was wet (e.g., apple slices). Everyone in the family ate meals at different times and was on a different specialty diet (e.g., gluten-free), so meals did not have a social component at his house. Dominic most often ate dry cereal, cookies, and chips in front of the television. Dominic’s mother and grandmother were both the interventionists and their pri- mary goals were (1) increase the number of foods he would eat and (2) decrease challenging behaviors (verbal refusals, overstuffing of his mouth, and hiding under pillows/blan- kets). Most often only his mother or his grandmother was home during an intervention session, but if they were both home, they would identify the primary parent for that par- ticular meal or snack.

Setting

All of the sessions were conducted in the family home using the foods and utensils that were typically used by the family during mealtimes. Based on family preference, intervention sessions occurred during mealtimes for Blake and snack times for Craig and Dominic.

Blake’s interventions were at the family dinner table, typically with both parents and all of his siblings present.

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On rare occasions, his father wasn’t present for the meal. Craig’s interventions were initially at a small table in the living room, but within the first month of intervention, his mother began expecting him to eat at the family dinner table at least during intervention sessions. Dominic’s inter- ventions, like his meals and snacks, took place in a variety of places within his house, including in front of the tele- vision, on the living room floor, in his bedroom, and in a hallway. Over the course of the intervention, an increasing number of sessions occurred at a small corner of the dining room table that had been cleared specifically for the ses- sions with the researchers.

Experimental Design

A mixed-methods quantitative design was used to examine changes in mealtime behaviors of the child and his parents (i.e., Craig’s mother, Blake’s mother and father, and Domi- nic’s mother and grandmother). This study used both sin- gle-case experimental design (i.e., single subject research design) and pre-/post- measures to document changes in child and parent behavior over time. The use of the two types of data collection methods allowed for triangulation of our findings, providing support for the conclusions both through parent report and through direct observation.

Single subject data collection for this project was devel- oped following the recommended practices for single-case experimental research (e.g., Wolery 2013). A concurrent multiple-baseline design with replication across partici- pants was used to document changes in the children’s food acceptance by direct observation. In this study, reversals of the target behaviors were unlikely, so the multiple base- line design was used to demonstrate causality. The baseline phase was limited to 5–6 sessions per participant because this number of sessions provided adequate documentation of the stability of the children’s behaviors (Gast and Led- ford 2010) without unnecessarily prolonging the delay in implementing intervention and risking further behavioral and/or nutritional difficulties. Following baseline, Phase 1 was an Intervention-Coaching phase during which the par- ent was trained to implement the interventions with coach- ing and post-session feedback. When the parent indepen- dently implemented 90% of the intervention strategies each session over three consecutive data sessions, they would begin Phase 2, which was an Intervention-Independent phase. During this phase, the coaching was eliminated but the post-session feedback continued. Phase 2 was termi- nated after the child met a level of food acceptance score greater than 85% based on their individualized food accept- ance hierarchy across three consecutive data days or after 5  months of intervention, whichever came first. Neither randomization nor blinding strategies were used in this study. The decision was made to start the intervention at

the same time for all families rather than randomly assign- ing them to staggered baseline and intervention phases because of the families’ expressed urgency for intervention.

Procedural fidelity data were collected on the parents’ implementation of the intervention during every session. Using a variety of questionnaires, quantitative data were collected prior to the initiation of the intervention and upon completion of the intervention period to document the children’s food acceptance and their parents’ perceptions of mealtime behaviors, as well as the parents’ perceived acceptance of the intervention.

Interobserver Agreement

Interobserver agreement (IOA) between the authors was established prior to the interventions using video tape of evaluations conducted at the feeding clinic. IOA was estab- lished across three variables: ‘less preferred opportunities,’ ‘less preferred points on hierarchy,’ and ‘parent behavior.’ IOA was considered adequate when agreement reached 90%. Through direct observation of sessions, IOA was col- lected for an average of 34.1% of the total sessions per par- ticipant (range 31.0–38.5%), with IOA sessions distributed relatively evenly across study phases.

Data Collection

Data to assess the effectiveness of the intervention were collected at various points throughout the study. Prior to the onset of intervention and again after the completion of the intervention phase, each child’s mother completed questionnaires related to his mealtime behaviors, food acceptance/dietary diversity, and family quality of life. The children’s mealtime behaviors were assessed using two questionnaires: the BAMBI (Lukens 2005) and the Behav- ioural Pediatrics Feeding Assessment Scale (BPFAS) (Crist and Napier-Phillips 2001). Both measures use anchored Likert-scales, are quick to administer, and have been used in other studies to assess the parent’s perception of meal- time behaviors. The children’s food acceptance and dietary diversity were assessed through the use of a Food Fre- quency Questionnaire (adapted from Harvard School of Public Health 2012) and a 24-h food recall (adapted from Lukens 2005). The Food Frequency Questionnaire (FFQ) provides parents with a list of approximately 150 foods, asking them to indicate if each food had been presented to the child in the previous 6  months and, if so, if the child rejected it or how often they ate it. In addition, they were asked to document everything that their child ate in one 24-h period (Lukens 2005).

In addition to these data, data on the child’s food accept- ance and the parent’s behaviors were collected during every session throughout the study. The researchers developed

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coding sheets to document the food available to the child and the child’s interaction with the food based on a food acceptance hierarchy. Data were collected throughout the course of a meal or snack, as defined by the parent, so the number of opportunities per session varied greatly. A bite opportunity was defined as beginning when either the par- ent or the child initiated interaction with the food and end- ing when both the parent and the child ceased interaction with the food. At the end of every session, the researcher completed a feedback sheet for the parent that documented the parents’ implementation of the intervention strategies. These feedback sheets were shared with the parent during the Intervention and Maintenance phases.

To assess the acceptability of the intervention strategy by the child’s parent, a goodness-of-fit survey that used an anchored Likert-scale (adapted from Albin et  al. 1996) was distributed to the parent before the intervention began and after the intervention period ended, as well as a Family Quality of Life Scale (Hoffman et  al. 2006) that evaluates multiple aspects of quality of life for families that include an individual with a disability. All three mothers responded to these surveys.

Procedures

Individualization of Intervention Targets and Strategy

The authors facilitated the intervention for all three fami- lies. Prior to baseline, the researchers met with each fam- ily to identify the primary intervention goals for their child. Additionally, at this stage in the study, data were collected regarding the child’s food consumption (using the 24-h food recall and FFQ), as well as mealtime behaviors (using BPFAS). During baseline, data were collected on the inter- vention targets identified and on a wide variety of potential

intervention strategies that the parent could use. At this time, a food acceptance hierarchy was also individualized for each child based on his individual patterns of accepting new foods (see Table 1).

Following baseline, the researchers met with each child’s parent to finalize the goals and to develop an individualized intervention plan that would collectively address the child’s needs, fit within the family routines, and utilize strategies that addressed the family’s strengths (see Table  2). As discussed previously, the same two general goals related to increasing dietary diversity (the total number of foods accepted) and decreasing challenging behaviors were iden- tified by all three families. The specific foods introduced and the challenging behaviors to target were individual- ized for each family. All three of the family’s intervention plans included interventions in four areas: food character- istics, dyadic communication supports, physical environ- ment, and social environment. See Table  2 for a complete accounting of the interventions that were selected by each family. Food characteristics included strategies to increase the variety of foods presented, recognize the sensory char- acteristics of the foods being presented, and increase the consistency of presentation of less preferred foods. Dyadic communication supports included strategies to promote communication between the parent and child, including giving the child a voice in the process and ensuring that the parent was communicating appropriately and effectively. Physical environment strategies were designed to ensure appropriate positioning and use the physical environment to promote attention, compliance, and reciprocal interac- tions. Finally, social environment strategies were intended to support positive parent–child interactions around meals and food, including avoiding power struggles and ensuring clear communication. There were several intervention strat- egies that were consistent across all three families, but each

Table 1 Individualized food acceptance hierarchies and associated point scores

Point Scores Blake Craig Dominic

0 Anything lower than “touches with tool”

Anything lower than “toler- ates on table/plate”

Anything lower than “touches with tool”

1 Touches with tool Tolerates on table/plate Tolerates on table/plate 2 Touches with hand Touches with tool Touches with tool 3 Touches to face Touches with hand Touches with hand 4 Touches to lip(s) Touches to face Touches to face 5 Touches to teeth Touches to lip(s) Touches to lip(s) 6 Touches with tongue Touches to teeth Touches to teeth 7 Food hovers in mouth Touches with tongue Touches with tongue 8 Spits bite out Spits bite out Spits out small bite 9 Spits bite out after delay Swallows small bite Swallows small bite 10 Chews once, spits it out Swallows typical bite Spits out typical bite 11 Chews >1×, spits it out – Swallows typical bite 12 Swallows bite – –

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family also had strategies specific to their situation (see Table 2).

Baseline

During baseline sessions, the parent was asked to provide a meal or snack to the child under usual circumstances. The researcher(s) observed the meal/snack to collect data on parent and child behavior, but no instruction on mealtime interventions was provided to the children or their parents. Blake and Craig each had five baseline sessions and Domi- nic had six.

Intervention‑Coaching

During the first part of the intervention phase of the study, one researcher coached the parent through the meal/snack to increase the child’s food acceptance. Coaching continued until the parent demonstrated the ability to independently

implement at least 90% of the intervention strategies each session across three consecutive data sessions. This phase of the intervention lasted for 9–21 sessions, depending on the needs of the family (Craig = 9, Blake = 11, Domi- nic = 21). Strategies such as demonstration, verbal instruc- tions, and visual supports were used to teach the parents to implement various strategies. Significant efforts were made to maintain the interaction between the child and the par- ent, so most of the coaching was conducted verbally while the parent was implementing the strategy. Occasionally it was necessary for the researcher to teach a technique out- side of the meal or snack. Parents were asked to implement the intervention throughout the week, but were not required to document the use of the interventions outside of the data collection sessions. The researchers emphasized that the parents had ownership of the intervention and were free to decide how often to implement it throughout the week, with the understanding that more frequent implementa- tion would likely lead to faster progress. At the end of each

Table 2 Components of individualized intervention plans for each family

Intervention strategy Child

Blake Craig Dominic

Food characteristics  Offer foods from three food groups X X X  Select foods he is likely to learn to eat (texture, color, shape, etc.) X X X  Present both preferred and less-preferred foods at each snack/meal X X X

Dyadic communication  Use picture menu or verbal choices for child to select foods to eat X X  Promote communication during meals X X X  Use visual supports for “first/then” X X X  Follow through with use of “first/then” X X X  Use more commands/statements than requests for less preferred foods X X X  Use visual food acceptance hierarchy X X X  Help child appropriately …