The relationship between sensory sensitivity, food fussiness and food preferences in children with neurodevelopmental disorders

Testing maternal effects of vitamin-D and omega-3 levels on offspring neurodevelopmental traits in the Norwegian Mother, Father and Child Cohort Study

BACKGROUND

Maternal vitamin-D and omega-3 fatty acid (DHA) deficiencies during pregnancy have previously been associated with offspring neurodevelopmental traits. However, observational study designs cannot distinguish causal effects from confounding.

METHODS

First, we conducted Mendelian randomisation (MR) using genetic instruments for vitamin-D and DHA identified in independent genome-wide association studies (GWAS). Outcomes were (1) GWAS for traits related to autism and ADHD, generated in the Norwegian mother, father, and child cohort study (MoBa) from 3 to 8 years, (2) autism and ADHD diagnoses. Second, we used mother-father-child trio-MR in MoBa (1) to test causal effects through maternal nutrient levels, (2) to test effects of child nutrient levels, and (3) as a paternal negative control.

RESULTS

Associations between higher maternal vitamin-D levels on lower ADHD related traits at age 5 did not remain after controlling for familial genetic predisposition using trio-MR. Furthermore, we did not find evidence for causal maternal effects of vitamin-D/DHA levels on other offspring traits or diagnoses. In the reverse direction, there was evidence for a causal effect of autism genetic predisposition on lower vitamin-D levels and of ADHD genetic predisposition on lower DHA levels.

CONCLUSIONS

Triangulating across study designs, we did not find evidence for maternal effects. We add to a growing body of evidence that suggests that previous observational associations are likely biased by genetic confounding. Consequently, maternal supplementation is unlikely to influence these offspring neurodevelopmental traits. Notably, genetic predisposition to ADHD and autism was associated with lower DHA and vitamin-D levels respectively, suggesting previous associations might have been due to reverse causation.

The characterization of feeding challenges in autistic children

LAY ABSTRACT

Feeding challenges are common for autistic children. Currently, research and intervention for feeding challenges focuses on single factors (e.g. behavior or sensory). Research is needed to understand the complexity of feeding challenges. This study provides a comprehensive description of feeding challenges. Furthermore, this study identifies what factors predict the severity and type of feeding challenges experienced by autistic children. Using the Survey for Characterization of Feeding Challenges in Autistic Children-United States, 427 caregivers of autistic children provided information about their child's feeding challenges. Children were between the ages of 2 and 12 with an average age of 8.42 years. Children in the study had a wide variety of feeding difficulties including challenges in early childhood, sensory challenges, difficulty with family mealtime, and variable self-help skills. On average children's feeding challenges were present prior to their autism diagnosis. We found that children who had early feeding challenges had more severe feeding challenges in later childhood. Also, specific early feeding challenges predicted the types of feeding challenges children would have later in childhood. For example, children who had difficulty transitioning to table foods and who continued to restrict their diet over time were more likely to have sensory-based feeding challenges. Results from this study show how feeding challenges present in a wide variety of ways for autistic children. The findings also highlight the importance of screening for feeding challenges in early childhood and collaborating with families to understand individualized feeding challenge experiences. These results could be used to inform evaluation and intervention for feeding.

Avoidant restrictive food intake disorder: recent advances in neurobiology and treatment

Avoidant restrictive food intake disorder (ARFID) is an eating disorder characterized by persistent insufficient nutritional and/or energy intake. ARFID, before referred to as "selective eating disorder", was introduced recently in the DSM-5 as a replacement for and expansion of the previous diagnosis. Individuals with ARFID may limit food variety and intake due to avoidance based on the sensory characteristics of the food or related to any adverse consequences of eating without the intention of losing weight and concerns of body image. The limited understanding of avoidant and restrictive eating poses challenges to effective treatment and management, impacting directly on the growth and development of children and adolescents. The ARFID neurobiological concept has not yet been clearly defined to clinical practice for nutritionists, thereby hindering screening and impeding the development of treatment recommendations. This narrative review provide useful practical information to consult the pathophysiology, the neurobiology, the clinical features, the assessment and the treatment for healthcare professionals seeking to enhance their clinical knowledge and management of this disorder.

Neurodevelopmental and psychiatric conditions in 600 Swedish Children with the ARFID phenotype

Objective

Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder characterized by extremely restricted dietary variety and/or quantity resulting in serious consequences for physical health and psychosocial functioning. ARFID often co-occurs with neurodevelopmental conditions (NDCs) and psychiatric conditions, but previous data are mostly limited to small clinical samples examining a narrow range of conditions. Here, we examined NDCs and psychiatric conditions in a large, population-based group of children with ARFID.

Method

In a sample of 30,795 children born 1992-2008 in Sweden, ARFID was assessed using parent reports and clinical diagnoses from national health registers. Parents further reported symptoms of NDCs and psychiatric conditions at child age 9 or 12 years. We conducted regressions for symptom scores and screening diagnoses (identified using validated cut offs) on ARFID and examined interactions with sex.

Results

Children with ARFID had significantly increased odds of all 17 screening diagnoses with odds ratios ranging from 3.3 for visual hallucinations to 13.7 for autism (all p<.0001). The most common NDCs were oppositional defiant disorder (19.4%), ADHD (16.9%), tic disorders (14.8%), and autism (12.1%). Among psychiatric conditions, separation anxiety disorder (29.0%) and sleep problems (20.0%) had the highest prevalence. We did not find any sex-specific differences in co-occurring conditions.

Conclusion

This study highlights the co-occurrence of a broad range of NDCs and psychiatric conditions with ARFID in a large, non-clinical cohort. Our findings underscore that children with ARFID face significant burden from multiple co-existing conditions which should be considered during assessment and treatment.

Olfactory bulb anomalies in KBG syndrome mouse model and patients

ANKRD11 (ankyrin repeat domain 11) is a chromatin regulator and the only gene associated with KBG syndrome, a rare neurodevelopmental disorder. We have previously shown that Ankrd11 regulates murine embryonic cortical neurogenesis. Here, we show a novel olfactory bulb phenotype in a KBG syndrome mouse model and two diagnosed patients. Conditional knockout of Ankrd11 in murine embryonic neural stem cells leads to aberrant postnatal olfactory bulb development and reduced size due to reduction of the olfactory bulb granule cell layer. We further show that the rostral migratory stream has incomplete migration of neuroblasts, reduced cell proliferation as well as aberrant differentiation of neurons. This leads to reduced neuroblasts and neurons in the olfactory bulb granule cell layer. In vitro, Ankrd11-deficient neural stem cells from the postnatal subventricular zone display reduced migration, proliferation, and neurogenesis. Finally, we describe two clinically and molecularly confirmed KBG syndrome patients with anosmia and olfactory bulb and groove hypo-dysgenesis/agenesis. Our report provides evidence that Ankrd11 is a novel regulator of olfactory bulb development and neuroblast migration. Moreover, our study highlights a novel clinical sign of KBG syndrome linked to ANKRD11 perturbations in mice and humans.

Parents' perceptions of the impact of the novel coronavirus (COVID-19) on the eating behaviors and routines of children with autism spectrum disorders (ASD)

Background

Restricted interests and repetitive behavior are characteristics of autism spectrum disorder (ASD). The likelihood that persons with ASD will respond adversely to unfamiliar situations is great. The novel coronavirus outbreak has resulted in disruptions to all aspects of routine and behavior. Hence, this study proposed to investigate the impact of the outbreak on the eating behavior and routines of children with ASD in Saudi Arabia through the perceptions of their parents.

Method

A cross-sectional study with a quantitative approach was utilized to obtain data from 150 parents of children with ASD aged ≤18 years in Saudi Arabia. The data collected included demographic data of the parents, the ASD status of the family, impact of COVID-19 to the family, eating behavior of the children with ASD, and daily routines of the children with ASD. Moreover, parents were able to provide comments regarding their children's eating behavior or daily routines.

Results

The study found that changes in the eating behavior of children with ASD were found to differ significantly (p<0.05) based on the number of children with ASD, the age of the children with ASD, the gender of the children with ASD, and the severity of their ASD symptoms. Moreover, changes to dinner-time routines were found to differ significantly (p<0.05) based on the age of the children with ASD. Also, changes to morning routines were found to differ significantly (p<0.05) based on the age of the children with ASD, their gender, and the severity of their ASD symptoms. Additionally, impact of COVID-19 to the family had a significant impact to eating behavior and daily routines of the children with ASD.

Conclusion

This study found that the eating behavior and daily routines of children with ASD in Saudi Arabia have been considerably worsened and changed. The study recommends the collaboration of multidisciplinary teams and parents to modify or design interventions that help to change their eating behavior and routine can be implemented in the home. It also recommends the provision of virtual helplines to aid parents of children with ASD in such cases.

New understandings meet old treatments: putting a contemporary face on established protocols

In the twenty years since the publication of the most widely used treatment manuals describing evidence-based therapies for eating disorders, there have been some substantial advances in the field. New methods of delivering treatments have been trialled and our perception of mental health has advanced; significant cultural changes have led to shifts in our societal landscape; and new technologies have allowed for more in-depth research to be conducted. As a result, our understanding of eating disorders and their treatment has broadened considerably. However, these new insights have not necessarily been translated into improved clinical practice. This paper highlights the changes we consider to have had the greatest impact on our work as experienced clinical psychologists in the field and suggests a list of new learnings that might be incorporated into clinical practice and research design.

Investigating the impact of autistic children's feeding difficulties on caregivers

AIM

The aim of this study was to investigate the influence of children's autism characteristics, sensory profiles and feeding difficulties on caregiver-reported impact at mealtimes.

BACKGROUND

Caregivers of children (5-12 years) with a diagnosis of Autism Spectrum Disorder completed an online survey examining (a) demographic characteristics, (b) children's autism characteristics (Social Communication Questionnaire), (c) sensory profiles (Sensory Profile 2-short form), (d) feeding difficulties (Behavioural Paediatrics Feeding Assessment Scale, BPFAS) and (c) caregiver-reported impact of feeding difficulties (Feeding-Swallowing Impact Survey, FS-IS).

RESULTS

Seventy-eight caregivers completed surveys for 80 children. Children with clinically significant feeding difficulties on the BPFAS (n = 55, 68.8%) had higher levels of caregiver-reported impact on daily activities, worry and feeding difficulties compared to children without clinically significant feeding difficulties (FS-IS; U = 257.000, z = -4.471, p < 0.01). Spearman's rank correlation showed a statistically significant, moderate correlation between BPFAS total frequency score and FS-IS Daily activities score, rs (98) = 0.56, p < 0.01, indicating that as the frequency of feeding difficulties increased, the impact of these feeding difficulties on caregivers also increased. Using multiple regression, a model comprising of the three factors was statistically significant (F[1, 78] = 87.75, p < 0.001, adj. R2  = 0.52), with children's frequency of feeding difficulties the strongest predictor of caregiver-reported impact with a moderate effect size (r = 0.49).

CONCLUSION

Autistic children's feeding difficulties had a greater impact on caregivers than autism or sensory profiles, with the frequency of feeding difficulties and the caregiver impact of these feeding difficulties positively correlated. The findings demonstrate that efforts to understand and address feeding difficulties in autistic children must extend beyond the children to include their families.

Changes in Anxiety following Taste Education Intervention: Fussy Eating Children with and without Neurodevelopmental Disorders

Despite the surge in studies on fussy eating in recent years, anxiety as an associated factor is generally not considered, even though children with fussy eating and those with neurodevelopmental disorders, including Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder (ADHD) often have higher levels of anxiety than typically developing children. The current study investigated changes in anxiety scores during a Taste Education intervention, a seven-week school-based intervention for 71 children with fussy eating. Comparisons were made based on neurodevelopmental status (between children with (n = 30) and without (n = 41) neurodevelopmental disorders). Participants were paired based on age, sex, and neurodevelopmental disorder. The Multidimensional Anxiety Scale for Children (MASC) was administered at delayed intervention (for those waiting 7 weeks before starting the intervention), pre-intervention, post-intervention, and at six-month follow-up. Results did not indicate elevated anxiety based on mean MASC T-scores. MASC Total T-scores ranged from slightly elevated to average, decreasing significantly between pre-intervention and post-intervention, plateauing at six-month follow-up. Significant reductions between measurement points were seen for the physical symptoms, social anxiety, and separation anxiety subscales, but not for harm avoidance. Repeated measures analysis of variance with neurodevelopmental disorders as between-subjects factors did not reveal a significant interaction effect between neurodevelopmental disorders and changes in MASC Total score or subscales. The results indicated that our food-based intervention did not elevate MASC scores in fussy eating children, with or without neurodevelopmental disorders.

Eating and Sensory Features of Children With Autism Spectrum Disorder and Their Typically Developing Peers

IMPORTANCE

Impaired sensory processing is associated with eating problems. There seem to be no previous studies that compare those who have autism spectrum disorder (ASD) with eating problems (ASD-W) and those with ASD without eating problems (ASD-WO) with typically developing (TD) groups. Comparisons are expected to provide further knowledge to guide the intervention programs.

OBJECTIVE

To investigate differences among ASD-W, ASD-WO, and TD groups in eating and sensory features; to detect associations between sensory and eating behaviors and any most involved sensory dimensions; and to search for age-related differences in sensory and eating features in ASD.

DESIGN

Nonrandomized comparison study.

SETTING

Questionnaires administered as parent interviews.

PARTICIPANTS

A total of 165 children were recruited: 117 with ASD and 48 TD children.

OUTCOMES AND MEASURES

Standardized questionnaires: the Brief Autism Mealtime Behaviors Inventory for eating problems; the Short Sensory Profile and the Sensory Experience Questionnaire for sensory problems.

RESULTS

The ASD-W group showed generalized, impaired eating behaviors and turned out to be the most impaired with regard to sensory responsiveness. No differences in feeding behaviors were found between the ASD-WO and TD groups. All children with ASD showed sensory hyper- or hyporesponsiveness. Four main sensory dimensions were found to be associated with eating behaviors in ASD. No age differences were found in the eating and sensory behaviors of children with ASD.

CONCLUSIONS AND RELEVANCE

Differing eating and sensory profiles were found between the ASD and TD groups, especially in children with ASD-W. Early eating interventions using sensory stimulations are strongly recommended. What This Article Adds: This study reports novel information derived from the comparisons of children with ASD with eating problems and those with ASD without eating problems with typically developing groups of children.

Weight Suppression and Risk for Childhood Psychiatric Disorders

Weight suppression, defined as the discrepancy between an individual's highest historical weight and their current weight, has been implicated in the development and maintenance of eating disorders. Although weight suppression has also been found to impact mood, anxiety and suicidal behavior in patients with and without disordered eating, it has not been examined as a transdiagnostic risk factor for general psychopathology. The current study examined growth records of 281 children and adolescents (ages 7 to 17) newly diagnosed with psychiatric disorders to determine whether these children were more likely to be weight suppressed as compared to an age- and gender-matched control group. Findings suggest that weight suppression is related to an increased risk for anxiety disorders and externalizing disorders for males. These results underscore the need for psychiatric and behavioral health providers to review pediatric growth charts as a routine part of psychiatric evaluation. As weight restoration is a necessary precondition for eating disorder recovery, more research is necessary to determine if weight restoration can enhance treatments for psychiatric symptoms occurring in the context of weight suppression.

Nutritional Status and Feeding Problems in Pediatric Specific Learning Disability

This cross-sectional study aims to determine the feeding problems and nutritional status of children diagnosed with specific learning disability (SLD), which is one of the neurodevelopmental disorders. Sociodemographic information, anthropometric measurements, and food consumption records of 76 children (38 boys and 38 girls) diagnosed with SLD were obtained by applying a questionnaire. The Behavioral Pediatrics Feeding Assessment Scale was used to determine the feeding problems of children. About 31.6% of children with SLD are overweight and obese. Feeding behavioral problems were found in 39.5% of the children with SLD. Binary logistic regression analysis showed a significantly higher frequency of feeding behavior problems in children with SLD: (1) lower body mass index (adjusted odds ratio [AOR]: 0.841, 95% confidence interval [CI]: 0.722-0.979), (2) lower tri-ponderal mass index (AOR: 0.738, 95% CI: 0.585-0.933), (3) lower upper middle arm circumference (AOR: 0.772, 95% CI: 0.649-0.918),and (4) lower triceps skinfold thickness (TSFT) (AOR: 0.890, 95% CI: 0.808-0.980). In this study, feeding behavior problems are common in children diagnosed with SLD. Therefore, identifying feeding behavior problems in children diagnosed with SLD and developing solutions specific to the problem are important for gaining healthy eating habits throughout life.

Change in preference for vegetables and their perceptual attributes as a function of age and pickiness

Preference for vegetables is influenced by various factors, including demographic, psychological, socio-environmental, and genetic factors. This study confirmed that age, pickiness, and perceptual attributes were predictors of preference for vegetables and examined how preference for vegetables and their perceptual attributes varies with age and pickiness. Children (8-14 years, n = 420), youth (15-34 years, n = 569), middle-aged adults (35-64 years, n = 726), and older adults (65-85 years, n = 270) were asked which vegetables they liked (or disliked) and which perceptual attributes of each vegetable they liked (or disliked). On the basis of their responses, an overall preference score and a preference sub-score for each perceptual attribute were calculated. Participants in each age group were classified into four statuses (non-, mild, moderate, and severe) according to their pickiness scores. Multiple regression analysis revealed that age and preference sub-scores for eight perceptual attributes (sweetness, sourness, bitterness, umami, pungency, orthonasal aroma, texture, and appearance) were positive predictors of overall preference score and that pickiness score and four perceptual attributes (saltiness, astringency, retronasal aroma, and aftertaste) were negative predictors. In addition, overall preference score and preference sub-scores for perceptual attributes other than saltiness increased with increasing age group and decreasing picker status; however, preference sub-scores for at least one of the six perceptual attributes (bitterness, astringency, pungency, orthonasal aroma, retronasal aroma, and aftertaste) exhibited negative values in children, youth, and pickers (mild, moderate, and severe). The increase in preference for these perceptual attributes might be an indicator of the adultization of food perception and the expansion of food acceptance.

Body Composition in Fussy-Eating Children, with and without Neurodevelopmental Disorders, and Their Parents, Following a Taste Education Intervention

Fussy eaters may have an increased risk of becoming overweight or obese as adolescents, with fussy eating and weight status also correlating with neurodevelopmental disorders (NDs) such as autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD). Further, maternal and children's weight status relationships are well-established. In this study, we analyzed the body composition of parent-child dyads using bioelectrical impedance analysis (BIA). Fifty-one children aged 8-12 years, with an ND (n = 18) and without (n = 33), and their parents, participated in a 7-week food-based Taste Education intervention with 6-month follow-up. The paired t-test was used to compare differences in body composition based on children's ND status. In logistic regression analysis, odds of children being in the overweight/obese or overfat/obese categories increased by a factor of 9.1 and 10.6, respectively, when having NDs, adjusting for parents' BMI (body mass index) or fat percentage (FAT%). Children with NDs and their parents had significantly higher mean BMI-SDS (BMI standard deviation score) and FAT% at pre-intervention than children without NDs and their parents. Mean BMI-SDS and FAT% lowered significantly between time points for children with NDs and their parents but not for children without NDs or their parents. The findings underline the need for additional exploration into the relationships between children's and parents' body composition based on children's ND status.

Nutrient intake and adequacy in children with autism spectrum disorder: EPINED epidemiological study

LAY ABSTRACT

Children with autism spectrum disorder (ASD) have a fivefold elevated risk of developing eating problems, which predisposes them to nutritional deficiencies. This study assesses nutritional intake and adequacy in children with ASD, subdiagnostic autistic symptoms and typically developing (TD) children. Preschool children with ASD and subdiagnostic symptoms had slightly lower intake of monounsaturated fatty acids (MUFA), vitamin D and vitamin B12. Primary school children with ASD and subdiagnostic symptoms had slightly higher intake of protein, cholesterol, thiamine and niacin, and a higher percentage of obesity than children with TD. All children had a high intake in sugars, fats and saturated fatty acids; a very highly inadequate intake of vitamins (vitamins D and E), fibre, b-carotene, calcium and magnesium; and a moderately inadequate intake of vitamin C, folate and iron. However, although all children need nutrition advice, children with ASD and subdiagnostic autistic symptoms had a poorer quality diet than those with TD.

Experience-dependent plasticity of gustatory insular cortex circuits and taste preferences

Early experience with food influences taste preference in adulthood. How gustatory experience influences development of taste preferences and refinement of cortical circuits has not been investigated. Here, we exposed weanling mice to an array of taste solutions and determined the effects on the preference for sweet in adulthood. We demonstrate an experience-dependent shift in sucrose preference persisting several weeks following the termination of exposure. A shift in sucrose palatability, altered neural responsiveness to sucrose, and inhibitory synaptic plasticity in the gustatory portion of the insular cortex (GC) were also induced. The modulation of sweet preference occurred within a restricted developmental window, but restoration of the capacity for inhibitory plasticity in adult GC reactivated the sensitivity of sucrose preference to taste experience. Our results establish a fundamental link between gustatory experience, sweet preference, inhibitory plasticity, and cortical circuit function and highlight the importance of early life nutrition in setting taste preferences.

Systematic Review of the Relation Between Feeding Problems and Sensory Processing in Children With Autism Spectrum Disorder

PURPOSE

Many studies have linked sensory sensitivities to feeding problems in children with autism spectrum disorder (ASD). Despite the importance of sensory processing for a variety of mealtime and eating skills, the specific sensory processes that may impact feeding problems in children with ASD have not been comprehensively reviewed. Thus, the goal of this systematic review was to understand the associations between sensory processing and feeding difficulties in children with ASD.

METHOD

This systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PubMed, CINAHL Plus with Full Text (EBSCOhost), Scopus (Elsevier), and Embase (Elsevier) databases were searched from their dates of inception through the final search date of April 19, 2022, for English language studies that examined both sensory processing and feeding among children with ASD. Studies were assessed for quality using the Joanna Briggs Institute critical appraisal tools.

RESULTS

A total of 27 studies were included. Findings supported the existence of a relationship between sensory processing and feeding problems in children with ASD. Specifically, studies reported that overall scores on sensory processing measures as well as measures of oral sensory processing were frequently associated with feeding problems.

CONCLUSIONS

This review supports the development of future feeding interventions focusing on sensory processing given the relationship between sensory processing and feeding problems among children with ASD. Future research should focus on utilizing consistent feeding assessments specific to children with ASD and collect information on medical diagnoses that can impact feeding in order to report on feeding more holistically in this population.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21453909.

Changes in Eating Behaviors Following Taste Education Intervention: Focusing on Children with and without Neurodevelopmental Disorders and Their Families: A Randomized Controlled Trial

Fussy-eating children often display problematic behaviors around mealtimes, such as irritation, opposition, or may even throw tantrums. This may lead to reduced food variety and poor nutritional profiles, which may increase parents' worries about their children's diet, particularly when the children also have neurodevelopmental disorders (ND) such as Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactive Disorder (ADHD). To investigate the effect of Taste Education on problematic mealtime behaviors, 81 children aged 8-12 years, with ND (n = 33) and without (n = 48), and their parents, participated in a 7-week Taste Education intervention. Children were matched on age, sex, and ND, and allocated at random into Immediate-intervention and Delayed-intervention groups. Parents completed the Meals in Our Household Questionnaire (MiOH). To examine changes in MiOH-scores, repeated-measures analysis-of-variance with time-points were used, with condition as factors (Immediate intervention and Delayed intervention). Baseline measures were adjusted for, and a robust linear mixed-model was fitted. Results showed superior outcomes for Intervention compared to waiting on all measures of MiOH, with stable effects through six-month follow-up. Differences were non-significant between children with and without ND. The Taste Education program suggests a promising, simple, and non-intrusive way to reduce children's problematic mealtime behaviors in the long term.

Eating Patterns in Children with Autism Spectrum Disorder

The purpose of this research was to analyze the eating patterns of preschool- and school-aged children with ASD, as provided by their families, in the La Araucanía Region of Chile. It involved a cross-sectional study with 72 families with children diagnosed with ASD aged between 2 and 12 years old. Food selectivity, appetite, body mass index (BMI) and frequency of food consumption were studied. The research determined that 97.67% present food selectivity, corresponding to alterations in the frequency of consumption of specific food groups. Moreover, 93.06%, 90.28%, 80.56% and 62.50% of children in the study do not meet the daily recommendations for fruit, fish, water and vegetable consumption, respectively. Therefore, it is important for these findings to be considered when designing and carrying out educational interventions regarding food in families with children with ASD for greater assertiveness and effectiveness in improving health.

Meals, Microbiota and Mental Health in Children and Adolescents (MMM-Study): A protocol for an observational longitudinal case-control study

Recent studies indicate that the interplay between diet, intestinal microbiota composition, and intestinal permeability can impact mental health. More than 10% of children and adolescents in Iceland suffer from mental disorders, and rates of psychotropics use are very high. The aim of this novel observational longitudinal case-control study, "Meals, Microbiota and Mental Health in Children and Adolescents (MMM-Study)" is to contribute to the promotion of treatment options for children and adolescents diagnosed with mental disorders through identification of patterns that may affect the symptoms. All children and adolescents, 5-15 years referred to the outpatient clinic of the Child and Adolescent Psychiatry Department at The National University Hospital in Reykjavik, Iceland, for one year (n≈150) will be invited to participate. There are two control groups, i.e., sex-matched children from the same postal area (n≈150) and same parent siblings (full siblings) in the same household close in age +/- 3 years (n<150). A three-day food diary, rating scales for mental health, and multiple questionnaires will be completed. Biosamples (fecal-, urine-, saliva-, blood samples, and buccal swab) will be collected and used for 16S rRNA gene amplicon sequencing of the oral and gut microbiome, measurements of serum factors, quantification of urine metabolites and host genotype, respectively. For longitudinal follow-up, data collection will be repeated after three years in the same groups. Integrative analysis of diet, gut microbiota, intestinal permeability, serum metabolites, and mental health will be conducted applying bioinformatics and systems biology approaches. Extensive population-based data of this quality has not been collected before, with collection repeated in three years' time, contributing to the high scientific value. The MMM-study follows the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) guidelines. Approval has been obtained from the Icelandic National Bioethics Committee, and the study is registered with Clinicaltrials.gov. The study will contribute to an improved understanding of the links between diet, gut microbiota and mental health in children through good quality study design by collecting information on multiple components, and a longitudinal approach. Furthermore, the study creates knowledge on possibilities for targeted and more personalized dietary and lifestyle interventions in subgroups. Trial registration numbers: VSN-19-225 & NCT04330703.

Food Selectivity and Its Implications Associated with Gastrointestinal Disorders in Children with Autism Spectrum Disorders

Food selectivity (FS) in children with autism spectrum disorders (ASD) is common, and its impact on a nutritional level is known. However, the etiology of gastrointestinal disorders (GID) related to alterations in the intestinal microbiota in children with ASD remains unclear. This article provides a narrative review of the literature on FS from the last 15 years, and its relationship with GID in children with ASD. Sensory aversion in ASD leads to food elimination, based on consistencies, preferences, and other sensory issues. The restriction of food groups that modulate the gut microbiota, such as fruits and vegetables, as well as the fibers of some cereals, triggers an intestinal dysbiosis with increased abundance in Enterobacteriaceae, Salmonella Escherichia/Shigella, and Clostridium XIVa, which, together with an aberrant immune response and a leaky gut, may trigger GID. It is observed that FS can be the product of previous GID. GID could provide information to generate a hypothesis of the bidirectional relationship between FS and GID. Emphasis is placed on the need for more studies with methodological rigor in selecting children with ASD, the need for homogeneous criteria in the evaluation of GID, and the adequate classification of FS in children with ASD.

Sensory processing and eating behaviours in autism: A systematic review

OBJECTIVES

The aim of this study was to assess the relationship between sensory processing and a broad range of eating behaviours across the lifespan.

METHODS

Five electronic databases of published and unpublished quantitative studies were systematically searched, evaluated for risk of bias and synthesised according to identified eating outcomes.

RESULTS

Across 25 studies, there was consistent evidence of a relationship between sensory processing and a range of eating behaviours. There was early evidence for the particular role of taste/smell sensitivities, as well as hypersensitivities, although future research is needed looking at different sensory patterns and modalities. There was also tentative evidence to suggest this relationship extends across development.

DISCUSSION

Study findings are discussed in relation to implications for sensory-based eating and feeding interventions and the development of eating disorders. Methodological and conceptual limitations are discussed and suggestions for future research are made to address these limitations. A broader investigation of multi-sensory issues and clearly defined eating behaviours, including disordered eating in clinically diagnosed samples, will allow for a more comprehensive and robust understanding of the relationship between sensory processing and eating behaviours in autism.

Can EEG Correlates Predict Treatment Efficacy in Children with Overlapping ASD and SLI Symptoms: A Case Report

Evaluation of the rehabilitation efficacy may be an essential indicator of its further implementation and planning. The research aim is to examine whether the estimation of EEG correlates of auditory-verbal processing in a child with overlapping autism spectrum disorder (ASD) and specific language impairment (SLI) symptoms may be a predictor of the treatment efficacy in conditions when behavioral tests do not show improvement during the time course. The prospective case report reports follow-up results in a child aged 36 to 66 months. During continuous integrative therapy, autism risk index, cognitive, speech-language, sensory, and EEG correlates of auditory-verbal information processing are recorded in six test periods, and their mutual interrelation was analyzed. The obtained results show a high statistically significant correlation of all observed functions with EEG correlates related to the difference between the average mean values of theta rhythm in the left (F1, F3, F7) and right (F2, F4, F8) frontal region. The temporal dynamics of the examined processes point to the consistency of the evaluated functions increasing with time flow. These findings indicate that EEG correlates of auditory-verbal processing may be used to diagnose treatment efficacy in children with overlapping ASD and SLI.

How genetic analysis may contribute to the understanding of avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) was introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Unlike anorexia nervosa, ARFID is characterised by avoidant or restricted food intake that is not driven by weight or body shape-related concerns. As with other eating disorders, it is expected that ARFID will have a significant genetic risk component; however, sufficiently large-scale genetic investigations are yet to be performed in this group of patients. This narrative review considers the current literature on the diagnosis, presentation, and course of ARFID, including evidence for different presentations, and identifies fundamental questions about how ARFID might fit into the fluid landscape of other eating and mental disorders. In the absence of large ARFID GWAS, we consider genetic research on related conditions to point to possible features or mechanisms relevant to future ARFID investigations, and discuss the theoretical and clinical implications an ARFID GWAS. An argument for a collaborative approach to recruit ARFID participants for genome-wide association study is presented, as understanding the underlying genomic architecture of ARFID will be a key step in clarifying the biological mechanisms involved, and the development of interventions and treatments for this serious, and often debilitating disorder.

Odds of fussy eating are greater among children with obesity and anxiety

BACKGROUND

Fussy eating has been associated with autism spectrum disorder (ASD), attention-deficit/hyperactive disorder (ADHD), anxiety, and depression. Despite these disorders being prevalent in obesity treatment, no studies have been published on the association of fussy eating in children with obesity and these disorders. Understanding fussy eating in children with obesity and comorbid disorders is important as acceptance of healthy foods tends to be low, especially in children with sensory sensitivities.

OBJECTIVES

Investigate the prevalence of fussy eating in a cross-sectional sample of children with obesity and ASD, ADHD, anxiety, and depression; and whether they were more likely to be fussy eaters, comparing those with and without these disorders.

METHODS

One hundred and four children referred to family-based obesity treatment in Iceland 2011-2016, mean age 12.0 (SD = 3.0), mean body mass index standard deviation score 3.5 (SD = 0.9). Binary logistic regression was used to estimate the relationship between fussy eating and disorders, adjusting for medication use.

RESULTS

A large minority (41.6%) were fussy eaters and 48.9% had at least one comorbid disorder. Over a third of children rejected bitter and sour tastes, and 1.9% and 7.9% rejected sweet and salty tastes, respectively. Compared with those without disorders, the odds of being a fussy eater were increased by a factor of 4.11 when having anxiety (95% confidence intervals) (1.02-16.58, p = 00.046), adjusting for medication use. The odds of being a fussy eater were not increased for other disorders; ASD, ADHD, or depression.

CONCLUSIONS

In children attending obesity treatment, fussy eating was common. Clinical care models in pediatric obesity treatment should address fussy eating, especially in children with anxiety.

Sensory Processing Phenotypes in Phelan-McDermid Syndrome and SYNGAP1-Related Intellectual Disability

Sensory processing differences are an established feature of both syndromic and non-syndromic Autism Spectrum Disorders (ASDs). Significant work has been carried out to characterize and classify specific sensory profiles in non-syndromic autism. However, it is not known if syndromic autism disorders, such as Phelan-McDermid Syndrome (PMD) or SYNGAP1-related Intellectual Disability (SYNGAP1-ID), have unique sensory phenotypes. Understanding the sensory features of these disorders is important for providing appropriate care and for understanding their underlying mechanisms. Our objective in this work was to determine the sensory processing abnormalities present in two syndromic ASDs: Phelan-McDermid Syndrome and SYNGAP1-related Intellectual Disability. Using a standardized instrument, the Short Sensory Profile-2, we characterized sensory features in 41 patients with PMD and 24 patients with SYNGAP1-ID, and sub-scores were then calculated for seeking, avoiding, sensitivity and registration, as well as overall sensory and behavior scores. We found both patient groups exhibited atypical sensory features, including high scores in the areas of avoiding and seeking. Thus, we discovered significant sensory processing abnormalities are common in these syndromic ASDs. Measurements of sensory processing could serve as useful clinical endpoints for trials of novel therapeutics for these populations.

An exploration of eating behaviours and caregiver mealtime actions of children with Tourette syndrome

Food avoidant behaviours are common concerns amongst individuals with Tourette syndrome, with high levels of food selectivity reported in children and food neophobia and avoidant restrictive eating behaviours in adults. However, less is known about food approach behaviours. The current study aimed to explore differences in food approach and food avoidant eating behaviours in children with Tourette syndrome (TS) and their relationship to caregiver mealtime actions. Thirty-seven caregivers of children with Tourette syndrome were compared with children with Autism Spectrum Disorders, children with Attention-Deficit/Hyperactivity Disorder and a control group. Caregivers completed the Child Eating Behaviour Questionnaire and Parent Mealtime Action Scale-Revised. Caregiver-reported findings revealed that children with Tourette syndrome exhibited more food approach behaviours, specifically greater food responsiveness, emotional overeating and desire to drink, compared to controls. Children from the three neurodiverse groups had similar levels of emotional overeating and food selectivity, which were all significantly higher than the control group. Positive persuasion was uniquely identified as a mealtime strategy adopted by caregivers of children with Tourette syndrome. The results suggest that children with Tourette syndrome are at more risk of showing a broader array of food difficulties than previously reported, including food avoidant and approach behaviours. It is encouraged that clinicians monitor eating behaviour in appointments with children with Tourette syndrome.

Mothers' accounts of mealtime and feeding challenges for children with Tourette syndrome or persistent tic disorders

Parenting a young person with a tic disorder can present daily challenges to families struggling to manage their child's tics and establish routines. Research recognises that tics can be problematic to everyday activities, however no attention has been given to mealtimes, arguably an important family activity closely related to quality of life of the family. The current qualitative study aimed to investigate the mealtime experiences of families with a child with a tic disorder from the perspective of mothers, looking at mealtime challenges, their impact and how these challenges are navigated. Seventeen mothers with children diagnosed with Tourette Syndrome (TS) or a Persistent Tic Disorder (PTD) (aged 3-14) took part in semi-structured interviews. Interpretative phenomenological analysis of 17 semi-structured interviews resulted in seven subthemes which were grouped under two superordinate themes: (1) tics as a barrier to positive mealtime experiences and (2) eating behaviours and other mealtime challenges. The findings highlight tics to create functional mealtime challenges, affecting a young person's ability to eat, drink and be seated, with mothers noting the family dynamic was often intensified and compounded by additional challenges related to their child's tics and comorbidities. Tics also have the power to disrupt the conviviality of mealtimes. For example, eating out-of-home can be especially challenging, with restaurants being high-pressure environments for young people with tics and their families. The cumulative effect of dissatisfaction, stress and additional foodwork can have a diminishing effect on maternal and familial resilience and wellbeing. Mealtime-related interventions need to be considered to help increase confidence and skills in managing mealtimes.

Functional links between thermoregulation and sleep in children with neurodevelopmental and chronic health conditions

The bi-directional relationship between sleep and wake is recognized as important for all children. It is particularly consequential for children who have neurodevelopmental disorders (NDDs) or health conditions which challenge their sleep and biological rhythms, and their ability to maintain rhythms of participation in everyday activities. There are many studies which report the diverse reasons for disruption to sleep in these populations. Predominantly, there is focus on respiratory, pharmaceutical, and behavioral approaches to management. There is, however, little exploration and explanation of the important effects of body thermoregulation on children's sleep-wake patterns, and associated behaviors. Circadian patterns of sleep-wake are dependent on patterns of body temperature change, large enough to induce sleep preparedness but remaining within a range to avoid sleep disturbances when active thermoregulatory responses against heat or cold are elicited (to maintain thermoneutrality). Additionally, the subjective notion of thermal comfort (which coincides with the objective concept of thermoneutrality) is of interest as part of general comfort and associated behavioral responses for sleep onset and maintenance. Children's thermoregulation and thermal comfort are affected by diverse biological functions, as well as their participation in everyday activities, within their everyday environments. Hence, the aforementioned populations are additionally vulnerable to disruption of their thermoregulatory system and their capacity for balance of sleep and wakefulness. The purpose of this paper is to present hitherto overlooked information, for consideration by researchers and clinicians toward determining assessment and intervention approaches to support children's thermoregulation functions and promote their subjective thermal comfort, for improved regulation of their sleep and wake functions.

The ESSENCE-Questionnaire in Medical Records Screening for Neurodevelopmental Symptoms/Problems: Utility and Clinical Validity

PURPOSE

Determine the prevalence of symptoms of neurodevelopmental problems (NDPs) with a semi-structured review of fourth grade students' medical records, its interrater agreement and validity as compared with clinical assessment.

METHODS

A school-based sample of 11-year-old children provided child health care (CHC) records and school health care (SHC) records. A pediatric neurologist, child psychiatrist and an adult psychiatrist scored the records, with the "Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations-Questionnaire" (ESSENCE-Q, 12 items scored 0-2, summary score range 0-24). Agreement was measured with model-based kappa and intraclass correlation coefficient (ICC). Ratings were validated against a multidisciplinary assessment involving a physician, psychologist, teacher- and parental behavioral rating scales rendering a clinical global impression severity rating (CGI-S, range 1-7) of NDPs.

RESULTS

Out of 223 participants, medical charts were available from 201, of whom 169 were rated by all three raters. Kappa agreement was moderate/strong (~0.8) for 7 of the 12 questionnaire items. Measured with the ICC, concordance in the summary score was good for agreement (~0.8) and excellent (~0.9) for consistency. Test-retest reliability was excellent (ICC = ~0.9). Area under the curve for the ESSENCE-Q in predicting clinical-level problems (CGI ≥4) was ~80% for all three raters, albeit with differing optimal cutoffs.

CONCLUSION

Using the ESSENCE-Q as a template, NDPs appear to be common in medical records, are identified reliably, and predict clinical-level concern. Medical records screening may facilitate a structured review of medical records in work-ups or be applied in conjunction with other screening measures for neurodevelopmental disorders. However, differences in calibration currently preclude defining a universal cutoff for using the ESSENCE-Q for medical records screening.

A comparison of food avoidant behaviours and sensory sensitivity in adults with and without Tourette syndrome

Food selectivity has been shown to be more persistent and severe in children with Tourette syndrome (TS) compared to their typically developing peers. The current study aimed to examine differences in food selectivity, food neophobia and Avoidant Restrictive Food Intake Disorder (ARFID)-associated behaviours, between adults with and without TS. Fifty-three adults diagnosed with TS were compared to 53 neurotypical adults and completed the following measures online: Adult Eating Behaviour Questionnaire (AEBQ), Nine-Item Avoidant/Restrictive Food Intake disorder screen (NIAS), Food Neophobia Scale (FNS) and the Sensory Perception Quotient (SPQ). Higher levels of food avoidant behaviours, in terms of food fussiness, food neophobia and ARFID-associated behaviours, were identified in adults with TS compared to adults without TS. While heightened sensory sensitivity failed to predict food fussiness, greater sensitivity to taste was found to be predictive of food neophobia in TS. These are the first findings to suggest that food avoidant behaviours are more prevalent for adults with TS and signal a need to address health implications.

Development of a parent-reported screening tool for avoidant/restrictive food intake disorder (ARFID): Initial validation and prevalence in 4-7-year-old Japanese children

The prevalence of avoidant/restrictive food intake disorder (ARFID) in the general child population is still largely unknown and validated screening instruments are lacking. The aims of this study were (1) to investigate the prevalence of children screening positive for ARFID in a Japanese birth cohort using a newly developed parent-reported screening tool, (2) to estimate the prevalence of children with ARFID experiencing physical versus psychosocial consequences of their eating pattern, and (3) to provide preliminary evidence for the validity of the new screening tool. Data were collected from 3728 4-7-year-old children born between 2011 and 2014 in Kochi prefecture, Japan (response rate was 56.5%); a sub-sample of the Japan Environment and Children's Study (JECS). Parents completed a questionnaire including the ARFID screener and several other measures to assess convergent validity. The point prevalence of children screening positive for ARFID was 1.3%; half of them met criteria for ARFID based on psychosocial impairment alone, while the other half met diagnostic criteria relating to physical impairment (and additional psychosocial impairment in many cases). Sensory sensitivity to food characteristics (63%) and/or lack of interest in eating (51%) were the most prevalent drivers of food avoidance. Children screening positive for ARFID were lighter in weight and shorter in height, they showed more problem behaviors related to mealtimes and nutritional intake, and they were more often selective eaters and more responsive to satiety, which together provides preliminary support for the validity of the new screening tool. This is the largest screening study to date of ARFID in children up to 7 years. Future studies should examine the diagnostic validity of the new ARFID screener using clinically ascertained cases. Further research on ARFID prevalence in the general population is needed.

Picky Eating in Children: A Scoping Review to Examine Its Intrinsic and Extrinsic Features and How They Relate to Identification

The health benefits and importance of family mealtimes have been extensively documented. Picky eating can impact this complex activity and has numerous extrinsic (or external) and intrinsic (or internal) features. Occupational therapists work with children and their families by looking at both intrinsic and extrinsic influences and are therefore well-placed to work within this context. This scoping review comprises a comprehensive search of key health industry databases using pre-determined search terms. A robust screening process took place using the authors pre-agreed inclusion and exclusion criteria. There were 80 studies that met the inclusion criteria, which were then mapped using content analysis. The most common assessments used to identify picky eating relied on parental reports and recall. Often additional assessments were included in studies to identify both the intrinsic and extrinsic features and presentation. The most common reported intrinsic features of the child who is a picky eater included increased sensitivity particularly to taste and smell and the child's personality. Extrinsic features which appear to increase the likelihood of picky eating are authoritarian parenting, rewards for eating, and pressuring the child to eat. Most commonly reported extrinsic features that decrease the likelihood of picky eating are family meals, responsive parents, and involving the child in the preparation of food. In conclusion, there is a lack of published papers addressing the role of occupational therapists in the assessment and identification of picky eating in children. There appears to be a complex interplay between intrinsic and extrinsic features which impact caregiver responses and therefore on the picky eater.

Fussy Eating among Children and Their Parents: Associations in Parent-Child Dyads, in a Sample of Children with and without Neurodevelopmental Disorders

Parents are important agents in shaping children's eating habits. However, the associations between children's and parents' eating behaviors are complex and may be convoluted for various reasons, such as parenting feeding styles, stressful mealtimes, and children's neurodevelopmental disorders (ND), such as Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD). The purpose of this study was to analyze associations between parents and their children's fussy eating, in a cross-sectional sample of children, with and without ND. Ninety-seven parents answered screening questionnaires prior to an intervention study. Associations were investigated using two-way ANOVAs and chi-square analyses. Overall, children with ND accepted fewer food items and consumed unhealthier foods more frequently than children without ND. Fussy eating parents had children who accepted fewer food items and consumed unhealthier foods more frequently than children whose parents were not fussy eaters. Interaction effects were not significant. A higher proportion of fussy eating parents, than non-fussy eating parents, had children who had difficulties with combined foods and hidden ingredients. The findings highlight the need for further investigation into the relationships between parents' influence on their children's eating behavior and food consumption, as well as possible reciprocal impacts.

Utilising an integrated approach to developing liking for and consumption of vegetables in children

Children eat too few vegetables and this is attributed to disliked flavours and texture as well as low energy density. Vegetables confer selective health benefits over other foods and so children are encouraged to eat them. Parents and caregivers face a challenge in incorporating vegetables into their child's habitual diet. However, liking and intake may be increased through different forms of learning. Children learn about vegetables across development from exposure to some vegetable flavours in utero, through breastmilk, complementary feeding and transitioning to family diets. Infants aged between 5 and 7 m are most amenable to accepting vegetables. However, a range of biological, social, environmental and individual factors may act independently and in tandem to reduce the appeal of eating vegetables. By applying aspects of learning theory, including social learning, liking and intake of vegetables can be increased. We propose taking an integrated and individualised approach to child feeding in order to achieve optimal learning in the early years. Simple techniques such as repeated exposure, modelling, social praise and creating social norms for eating vegetables can contribute to positive feeding experiences which in turn, contributes to increased acceptance of vegetables. However, there is a mismatch between experimental studies and the ways that children eat vegetables in real world settings. Therefore, current knowledge of the best strategies to increase vegetable liking and intake gained from experimental studies must be adapted and integrated for application to home and care settings, while responding to individual differences.

Do Children with Autism Spectrum Disorders Eat Differently and Less Adequately than Those with Subclinical ASD and Typical Development? EPINED Epidemiological Study

Food consumption in children with ASD, subclinical ASD and with typical development (TD), and their adequacy to dietary recommendations was studied. A school population sample of 77 children with ASD, 40 with subclinical ASD, and 333 with TD participated. Compared to children with TD, pre-schoolers with ASD consumed fewer raw vegetables and less fish and eggs, while primary school children consumed fewer legumes, raw vegetables, citrus fruits, cheese/yogurt and olive oil, and more meat. All groups consumed an excess of sugar but those with ASD consumed even a greater amount than their peers. The higher prevalence of obesity found in primary school children with ASD may be the consequence of a less healthy eating pattern sustained over time.

Correlates of Feeding Difficulties Among Children with Autism Spectrum Disorder: A Systematic Review

Feeding difficulties related to selective intake, or eating a limited variety of foods, are very common in children with autism spectrum disorder (ASD). A systematic search of PubMed, Embase, PsycInfo, and CINAHL identified 29 studies that evaluated eight correlates: age, ASD symptoms and severity, cognitive and adaptive skills, sensory processing and perception, challenging behavior, weight status, gastrointestinal symptoms, and parenting stress. Feeding difficulties related to selective intake are consistently correlated with impaired sensory processing and perception and tend to be positively associated with rigidity and challenging behavior. These feeding difficulties tend to persist with advancing age. Other correlates demonstrated inconsistent findings. A significant limitation of research reviewed is variability in terminology, definitions, and measurement of feeding difficulties.

Sensory Profiles of Children with Autism Spectrum Disorder with and without Feeding Problems: A Comparative Study in Sicilian Subjects

The aim of this study is to better understand the relationship between sensory and feeding problems in Autism Spectrum Disorder (ASD) by comparing sensory responsiveness of ASD children with (ASD-W) and without (ASD-WO) feeding problems. The feeding and sensory characteristics of 111 children with ASD (37 ASD-W and 74 ASD-WO) were assessed by using two questionnaires tapping on feeding problems and two on sensory problems. A comparative study was carried out with between-group as well as intra-group comparisons design; a correlation analysis was also added. A statistically significant correlation was found between sensory and feeding problems. ASD-W children showed more severe and extensively impaired sensory responses than ASD-WO, with lower sensory adaptation and more generalized and severe deficits in all subdomains. Taste/Smell sensitivity was strongly impaired only in ASD-W, whereas in ASD-WO it was found to be a point of strength. Both groups showed a Hyporesponsive profile, though it was more marked in ASD-W. Both groups showed strengths in Visual/Auditory sensitivity, Low-Energy/Weak, and Movement sensitivity, again more marked in ASD-WO. These results might prove to be particularly useful for sensory training and psychoeducational treatment.