Eating behaviour, behavioural problems and sensory profiles of children with avoidant/restrictive food intake disorder (ARFID), autistic spectrum disorders or picky eating: Same or different?

Does food selectivity drive differences in dietary resemblance between children with intellectual disabilities and typical development?

Although children's dietary intake often resembles that of their parents', dietary resemblance has not been examined among children with intellectual disabilities (ID), where food selectivity is a common parental concern. We compared dietary resemblance in children with typical development (TD), ID, and ID and co-occurring autism (ID + A) in parent-child dyads, and examined whether child food selectivity mediated between-group differences. Dietary data from parents and their children (3-8 years, male = 61.8%, TD = 52.9%, ID = 18.6%, ID + A = 28.4%) were analyzed as mother-child (n = 100) and father-child (n = 70) dyads. Dietary resemblance was operationalized as the proportion of foods that were reported as eaten/not eaten by both parent and child in parent-completed Food Frequency Questionnaires. Food refusal rate was used to capture food selectivity (total foods children would not eat/total foods offered). Among mother-child dyads, dietary resemblance did not differ between children with ID compared to TD (P = 0.243). Among father-child dyads, dietary resemblance was 10% lower in children with ID than TD (66.4% vs. 74.1%, P = 0.032), and the difference was partially explained (mediated) by food refusal. Among mother-child dyads, dietary resemblance was 19% lower among children with ID + A than TD (61.5% vs. 75.6%, P = 0.001), and the difference was completely explained by food refusal. Among father-child dyads, dietary resemblance was 22% lower among children with ID + A than TD (57.9% vs. 74.1%, P < 0.001), and the difference was completely explained by food refusal. Subanalyses by food groups produced similar results. Compared to TD children, dietary resemblance was lower in children with ID + A, but not children with ID, and differences were explained by food selectivity. Our findings suggest parents of children with ID + A may have less influence over their child's dietary intake than parents of children with ID or TD.

GABA (gamma-aminobutyric acid) levels in dorsal anterior cingulate cortex are negatively associated with food motivation in a pediatric sample

Food motivation varies between individuals, affecting body weight and risk for eating disorders. Prior neuroimaging studies in youth and adults have revealed functional and structural alterations in the anterior cingulate cortex [ACC] in those with obesity and disordered eating but have not investigated their neurochemical underpinnings. In a sample of 37 children aged 4 to 13 years old, we used Magnetic Resonance Spectroscopy [MRS] to assess levels of γ-aminobutyric acid [GABA] - the major inhibitory neurotransmitter in the human brain - quantified relative to creatine in a 27-ml voxel including the dorsal ACC. We used the CEBQ to assess trait food motivation. In analyses adjusting for age, lower GABA+/Cr levels in the dorsal ACC were associated with higher trait enjoyment of food. Higher enjoyment of food scores were in turn associated with higher energy intake during an ad libitum test meal and during a postprandial task assessing intake in the absence of hunger, and higher body weight. Our results indicate a role for GABA function in the dorsal ACC in determining individual variation in food motivation in children.

Development of a toolkit to help parents/caregivers manage feeding problems in autistic children: A protocol for a realist synthesis and toolkit co-design

Many autistic children have feeding problems, typically eating a limited range of foods. Feeding problems affect quality of life, health, and development. Research suggests that parents are often unsure when to or whether to seek help. When they do, local provision of help across the UK is often lacking. A toolkit could offer a tailored, accessible, and scalable early intervention to support parents. We aim to develop the blueprint of a toolkit to help parents/caregivers manage feeding problems in their autistic children. Medical Research Council guidance on developing complex interventions informs three successive work packages: Realist review: a literature search and analysis using realist theory of logic to construct programme theory(s) in line with RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidance.Realist evaluation: interviews of three groups: autistic children, young people and adults (experts), parents/caregivers of autistic children (parents), and professionals who help parents manage feeding problems (professionals) across the UK. Analysis of verbatim interview transcripts using realist theory of logic to refine programme theory(s).Co-design of the toolkit blueprint: behaviour change theory applied to the programme theory(s) will generate candidate components for the online tool. A blueprint (a detailed textual outline) will be co-designed. A participatory research team of experts, parents, and professionals will be involved in each work package. Where consensus is needed it will be reached by asynchronous nominal group technique. A PPI (public and patient involvement) advisory group of experts and parents will ensure the project is relevant, respectful, and accessible. Findings of each step will be disseminated via journal publications, conferences, social media, as well as PPI-co-produced webinars and a dissemination event. On completion, this project will provide the foundation for the subsequent development and refinement of the prototype toolkit.

Association of the retinol to all-trans retinoic acid pathway with autism spectrum disorder

BACKGROUND

Autism spectrum disorder (ASD) is a complex group of neurodevelopmental disorders. Research has highlighted a close association between the retinoic acid (RA) signaling pathway and ASD. This study investigates alterations in the vitamin A (VA, retinol) to RA metabolic pathway in children with ASD and speculates on the underlying reasons for these changes. We propose a subtype characterized by downregulated RA signaling in ASD, laying the groundwork for precise diagnosis and treatment research.

METHODS

We included 489 children with ASD and 280 typically developing (TD) children. Those with ASD underwent evaluations of core symptoms and neuro-developmental levels, which were conducted by professional developmental behavior physicians using assessment scales. Serum VA and all-trans RA (atRA) levels were determined by high-performance liquid chromatography and ultra-high-performance liquid chromatography-tandem mass spectrometry. The expression levels and concentrations of enzyme molecules such as retinol dehydrogenase 10 were assessed using quantitative polymerase chain reaction and enzyme-linked immunosorbent assay.

RESULTS

Children with ASD exhibited reduced serum atRA, accompanied by a downregulation of atRA synthesis enzymes. The reduction in serum atRA levels was linked not only to VA levels but also to the aberrant expression of metabolic enzymes responsible for atRA. Furthermore, the serum atRA levels in children with ASD were more strongly correlated with core symptoms and neurodevelopmental levels than VA levels.

CONCLUSION

Children with ASD exhibited a dual regulation of reduced serum atRA levels, influenced by both VA levels and abnormal expression of atRA metabolic enzymes.

Conceptualizing avoidant/restrictive food intake disorder via an executive functioning lens

Avoidant/restrictive food intake disorder (ARFID) is a heterogeneous disorder wherein restrictive eating is primarily attributed to non-shape/weight-based reasons (e.g., sensory sensitivity) that empirical research continues to explore. Mounting evidence suggests that ARFID often presents alongside neurodevelopmental diagnoses (NDs) or divergent neurodevelopment broadly. Executive functioning (EF) differences often characterize divergent neurodevelopmental trajectories. Additionally, restrictive eating in anorexia nervosa has been conceptualized as related to EF factors (e.g., set shifting). Given the neurodevelopmental phenotype that may be associated with ARFID and the role of EF in anorexia nervosa, this paper proposes EF as a potentially important, yet understudied factor in ARFID pathology. We posit that various observed ARFID behavioral/cognitive tendencies can be conceptualized in relation to EF differences. We contextualize commonly observed ARFID presentations within "core" EF components (i.e., cognitive flexibility, working memory, inhibitory control), leading to hypotheses about EF in ARFID. Finally, we offer additional considerations/directions for future research on EF in ARFID. Increased research on EF in ARFID is needed to consider this potential common factor in the etiology and maintenance of this heterogeneous disorder. We aim to promote further consideration of EF in ARFID etiology, maintenance, and treatment-outcome research. PUBLIC SIGNIFICANCE: This article proposes that aspects of executive functioning (EF) may play a role in the onset and maintenance of avoidant/restrictive food intake disorder (ARFID), although this notion is largely untested by existing research. Further research on the role of EF in ARFID may assist with refining models and treatments for this heterogeneous disorder.

Physical health complications in children and young people with avoidant restrictive food intake disorder (ARFID): a systematic review and meta-analysis

BACKGROUND

Avoidant restrictive food intake disorder (ARFID) is a feeding and eating disorder with known acute and longstanding physical health complications in children and young people (CYP) and commonly presents to paediatricians.

OBJECTIVE

To systematically review the published literature on physical health complications in CYP with ARFID using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

A systematic search of PubMed, Embase, Web of Science, PsycINFO and Cochrane Library was performed on 14 February 2024. Studies reporting physical health complications in CYP ≤25 years with ARFID were included. We pooled studies for meta-analysis comparing ARFID with healthy controls or anorexia nervosa (AN).

RESULTS

Of 9058 studies found in searches, we included 132 studies. We found evidence for low weight, nutritional deficiencies and low bone mineral density. CYP with ARFID can present across the weight spectrum; however, the majority of CYP with ARFID were within the healthy weight to underweight range. Most studies reported normal range heart rates and blood pressures in ARFID, but some CYP with ARFID do experience bradycardia and hypotension. CYP with ARFID had higher heart rates than AN (weighted mean difference: 12.93 bpm; 95% CI: 8.65 to 17.21; n=685); heterogeneity was high (I2: 81.33%).

CONCLUSION

There is a broad range of physical health complications associated with ARFID requiring clinical consideration. Many CYP with ARFID are not underweight yet still have complications. Less cardiovascular complications found in ARFID compared with AN may be related to chronicity.

PROSPERO REGISTRATION NUMBER

CRD42022376866.

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.

Perceptual Dysfunction in Eating Disorders

Eating disorders (EDs) are characterized by abnormal responses to food and weight-related stimuli and are associated with significant distress, impairment, and poor outcomes. Because many of the cardinal symptoms of EDs involve disturbances in perception of one's body or abnormal affective or cognitive reactions to food intake and how that affects one's size, there has been longstanding interest in characterizing alterations in sensory perception among differing ED diagnostic groups. Within the current review, we aimed to critically assess the existing research on exteroceptive and interoceptive perception and how sensory perception may influence ED behavior. Overall, existing research is most consistent regarding alterations in taste, visual, tactile, and gastric-specific interoceptive processing in EDs, with emerging work indicating elevated respiratory and cardiovascular sensitivity. However, this work is far from conclusive, with most studies unable to speak to the precise etiology of observed perceptual differences in these domains and disentangle these effects from affective and cognitive processes observed within EDs. Further, existing knowledge regarding perceptual disturbances in EDs is limited by heterogeneity in methodology, lack of multimodal assessment protocols, and inconsistent attention to different ED diagnoses. We propose several new avenues for improving neurobiology-informed research on sensory processing to generate actionable knowledge that can inform the development of innovative interventions for these serious disorders.

Analysis of feeding and eating disorders in 191 children according to psychiatric or gastroenterological recruitment: The PEDIAFED cohort study

OBJECTIVE

The DSM-5 classification introduced new Feeding and Eating Disorders (FED) diagnostic categories, notably Avoidant and Restrictive Food Intake Disorder (ARFID), which, like other FED, can present psychiatric and gastrointestinal symptoms. However, paediatric clinical research that focuses on children below the age of 12 years remains scarce. The aim of this study was first to investigate the clinical features of FED in a cohort of children, second to compare them according to their recruitment (gastroenterology or psychiatry unit).

METHOD

This non-interventional retrospective cohort study analysed 191 patients in a French paediatric tertiary care centre (gastroenterology n = 100, psychiatry n = 91). The main outcome variables were clinical data (type of FED, BMI, nutritional support, chronic diseases, psychiatric comorbidities, sensory, sleep, language disorders, gastrointestinal complaints, adverse life events, family history). The outcome was defined by a Clinical Global Impression of Change-score.

RESULTS

FED diagnoses were ARFID (n = 100), Unspecified FED (UFED, n = 57), anorexia nervosa (AN, n = 33) and one pica/rumination. Mean follow-up was 3.28 years (SD 1.91). ARFID was associated with selective and sensory disorders (p < 0.001); they had more anxiety disorders than patients with UFED (p < 0.001). Patients with UFED had more chewing difficulties, language disorder (p < 0.001), and more FED related to chronic disease (p < 0.05) than patients with ARFID and AN. Patients with AN were female, underweight, referred exclusively to the psychiatrist, and had more depression than patients with ARFID and UFED (p < 0.001). The gastroenterology cohort included more UFED, while the psychiatry cohort included more psychiatric comorbidities (p < 0.001). A worse clinical outcome was associated with ARFID, a younger age at onset (p < 0.001), selective/sensory disorders and nutritional support (p < 0.05).

CONCLUSION

ARFID and UFED children were diagnosed either by gastroenterologists or psychiatrists. Due to frequently associated somatic and psychiatric comorbidities, children with FED should benefit from a multidisciplinary assessment and care.

Assessing the Body Composition of "Picky Eaters" Using Body Impedance Analysis: An Experience From a Tertiary Care Center

BACKGROUND

Picky eating might be associated with a higher risk of being underweight and poor growth. This study aimed to investigate if picky eaters aged between three and 12 years showed differences in height, weight, and body composition compared to their non-picky peers using a body impedance analysis (BIA).

METHODS

This cross-sectional study was conducted between March 1, 2022, and July 31, 2022, on children aged three to 12 years who presented to the outpatient pediatric clinics at Al Habib Ar Rayyan in Riyadh, Saudi Arabia. Body composition was measured using BIA after manually inserting the height, gender, and age into the machine, where body mass index (BMI), fat mass, and skeletal muscle mass were recorded. Participants were classified as under/normal/over for each body composition measurement.

RESULTS

A total of 2234 children were entered into the final data analysis. Our analysis showed that 1917 (85.8%) were Saudis and 1117 (50%) were males. The mean age of participants was 6.08±2.01 years and 1151 (51.5%) were in the pre-school age. The reported prevalence of picky eaters was 1684 (75.4%), of whom, 606 (27.0%) were selective eaters, 365 (16.2%) were low appetite eaters, and 723 (32.2%) were both selective and low appetite eaters. Being underweight was significantly more common among the picky eaters 487 (28.9%) compared to those non-picky eaters 55 (10.0%) (p<0.001). Significantly, 1280 (76%) picky eaters had below-average skeletal muscle mass compared to 151 non-picky eaters (27.5%) (p<0.001). The low appetite picky eater group had more under skeletal muscle mass children 277 (75.9%) compared to the selective picky eater group 412 (68.0%) (p=0.009). Additionally, the low appetite group possessed lower muscle ratios (p=0.012) and were more underweight than the selective group (p<0.001). Furthermore, the low appetite group showed a higher percentage of children below the 3rd percentile in the height for age category (p=0.003) compared to the selective group.

CONCLUSION

This study is the first of its kind in Saudi and globally to evaluate body composition using BIA among children. The study showed that picky eating is more associated with underweight children and low muscular mass. Despite the normal BMI, height, and weight of a picky eater, their skeletal muscle mass might be less than average, which could be associated with an increased risk of morbidity.

Clinical Feeding and Swallowing Evaluation for the School-Based Speech-Language Pathologist

PURPOSE

From preschool through high school, eating is part of the school day. Children with feeding and/or swallowing issues are now in our neighborhood schools, our responsibility in our care, and require adequate nutrition and hydration to participate in school and access the curriculum. The whole child is in school, including all of their medical, behavioral, social, and educational needs. This clinical focus article describes a holistic process of evaluating swallowing and feeding in the school setting for the school speech-language pathologist (SLP) leading the team supporting the child.

METHOD

This clinical focus article explores the evaluation process in the educational setting for the school SLP in identification of pediatric feeding disorders (PFDs), which can involve dysphagia. Detailed descriptions of the related U.S. educational law, PFD, assessment processes for the multiple systems relating to eating, and collaboration with an interdisciplinary team are highlighted. Using the four overlapping domains of PFD (medical, psychosocial, feeding skill-based systems and associated nutritional aspects), medical and background history gathering; integration with instrumental results; and the need to consider the complex interaction of developmental, physical, cognitive, social, behavioral, family, and cultural aspects in the evaluation are detailed.

CONCLUSIONS

School-age children require safe and adequate nutrition and hydration for learning and social participation. The SLP has a lead role in the school team in evaluating swallowing and feeding, and developing a plan for team implementation. A holistic school-based SLP clinical evaluation process is described.

Sensory sensitivity and intelligence are correlated with nutrient deficiency in children with autism spectrum disorder and intellectual disability

BACKGROUND/OBJECTIVES

Relationship between dietary intake and sensory sensitivity and intelligence in autism spectrum disorder (ASD) is not well described. This study aims to investigate nutrition status in children with ASD and ID and its association with sensory sensitivity and intelligence.

SUBJECTS/METHODS

84 students (34 ASD and 48 ID) in a special education school were recruited. Dietary intakes were evaluated with 3-day food dairy. Sensory sensitivity was measured using short sensory profile (SSP). Wechsler IQ test were performed.

RESULTS

Two out of twenty-four investigated nutrients had an adequate intake rate of over 50%. Four out of ten investigated vitamins had an inadequate intake rate of over 90% and another two over 80%. 75.6% of participants had inadequate energy intake. After adjusting for age, ASD participants had a higher intake of all surveyed nutrients but only the intake of vitamin E and folate were statistically different (p < 0.05) along with a smaller number of inadequate nutrients (p < 0.001). Taste/smell sensitivity, movement sensitivity, underresponsive/seeks sensation, and total sensory sensitivity symptoms severity were slightly higher in ASD group than in ID group (all p < 0.05). After adjusting for IQ and sensory sensitivity score, difference of number of inadequate nutrients between ASD and ID group were not statistically significant (p = 0.193).

CONCLUSIONS

Individuals with ASD had better dietary intake but worse sensory sensitivity compared to those with ID. Sensory sensitivity and intelligence are correlated with nutritional status in individuals with neurodevelopmental disorder.

Systematic review of pharmacological treatments that reduce conditioned taste aversions in rodents: A potential animal model of pediatric feeding disorder and avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is diagnosed when food avoidance leads to clinically significant nutritional, weight/growth, or psychosocial impairment. As many as 81.5% of children and adolescents diagnosed with ARFID have a history of a medical condition associated with pain, fatigue, or malaise. ARFID is diagnosed and treatment begins after the medical condition is resolved but food avoidance remains. Effective treatment involves repeated exposure to eating food and related stimuli aimed at creating inhibitory learning to counteract learned fears and aversions. Treatment usually involves positive reinforcement of food approach behavior and escape extinction/response prevention to eliminate food avoidant behavior. To shed light on the neural mechanisms that may maintain ARFID and to identify candidate pharmacological treatments for adjuncts to behavioral interventions, this paper systematically reviews research on drug treatments that successfully reduce conditioned taste aversions (CTA) in animal models by disrupting reconsolidation or promoting extinction. The mechanism of action of these treatments, brain areas involved, and whether these CTA findings have been used to understand human eating behavior are assessed. Collectively, the results provide insight into possible neural mechanisms associated with resuming oral intake following CTA akin to the therapeutic goals of ARFID treatment and suggest that CTA animal models hold promise to facilitate the development of interventions to prevent feeding problems. The findings also reveal the need to investigate CTA reduction in juvenile and female animals and show that CTA is rarely studied to understand disordered human feeding even though CTA has been observed in humans and parallels many of the characteristics of rodent CTA.

The Sensory Profiles, Eating Behaviors, and Quality of Life of Children with Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder

Eating disorders frequently accompany autism spectrum disorder (ASD). One such novel eating disorder is avoidant/restrictive food intake disorder (ARFID). This study compares the eating attitudes, quality of life, and sensory processing of typically developing children (TDC), autistic children, and autistic children with ARFID. A total of 111 children aged 4-10 with a diagnosis of ASD and ARFID (n = 37), ASD without ARFID (n = 37), and typical development (n = 37) were recruited. After an interview in which Childhood Autism Rating Scale (CARS) was administered, Child Eating Behavior Questionnaire (CEBQ), Pediatric Quality of Life Inventory (PedsQL), Social Responsiveness Scale (SRS) and Sensory Profile (SP) were completed by caregivers. Autistic children with ARFID had higher scores in CEBQ subscales relating to low appetite and lower scores on the subscales associated with weight gain. Both groups of autistic children scored lower than TDC on all PedsQL subscales and autistic children with ARFID had lower social QL scores than both groups. SRS scores were highest in autistic children with ARFID, followed by autistic and typically developing children. CARS scores were similar in both groups of autistic children, but higher than TDC. Auditory, vision, touch, multi-sensory, oral processing scores; as well as all quadrant scores, were significantly lower in autistic children with ARFID. Oral sensory processing scores were found to be the most significant predictor of ARFID comorbidity in ASD and reliably predicted ARFID in autistic children in the clinical setting. Autistic children with ARFID demonstrate differences in social functioning, sensory processing, eating attitudes, and quality of life compared to autistic and TD children.

Nutritional blindness from avoidant-restrictive food intake disorder - recommendations for the early diagnosis and multidisciplinary management of children at risk from restrictive eating

Avoidant-restrictive food intake disorder (ARFID) is an eating disorder characterised by limited consumption or the avoidance of certain foods, leading to the persistent failure to meet the individual's nutritional and/or energy needs. The disordered eating is not explained by the lack of available food or cultural beliefs. ARFID is often associated with a heightened sensitivity to the sensory features of different types of food and may be more prevalent among children with autism spectrum disorder (ASD) for this reason. Sight loss from malnutrition is one of the most devastating and life-changing complications of ARFID, but difficult to diagnose in young children and those with ASD who have more difficulty with communicating their visual problems to carers and clinicians, leading to delayed treatment and greater probability of irreversible vision loss. In this article, we highlight the importance of diet and nutrition to vision and the diagnostic and therapeutic challenges that clinicians and families may face in looking after children with ARFID who are at risk of sight loss. We recommend a scaled multidisciplinary approach to the early identification, investigation, referral and management of children at risk of nutritional blindness from ARFID.

Validation of the adult eating behavior questionnaire in a Norwegian sample of adolescents

Eating behaviors are related to health and well-being. To examine stability and change in eating behaviors throughout life, developmentally appropriate measures capturing the same eating behavior dimensions are needed. The newly developed Adult Eating Behavior Questionnaire (AEBQ) builds on the well-established parent-reported Children's Eating Behavior Questionnaire (CEBQ), and together with the corresponding Baby Eating Behavior Questionnaire (BEBQ), these questionnaires cover all ages. However, validation studies on adolescents are relatively sparse and have yielded somewhat conflicting results. The present study adds to existing research by testing the psychometric properties of the AEBQ in a sample of 14-year-olds and examining its construct validity by means of the parent-reported CEBQ. The current study uses age 14 data (analysis sample: n = 636) from the ongoing Trondheim Early Secure Study, a longitudinal study of a representative birth cohort of Norwegian children (baseline: n = 1007). Confirmatory factor analysis (CFA) was conducted to test the factorial validity of AEBQ. Construct validity was examined by bivariate correlations between AEBQ subscales and CEBQ subscales. CFAs revealed that a 7-factor solution of the AEBQ, with the Hunger scale removed, was a better-fitting model than the original 8-factor structure. The 7-factor model was respecified based on theory and model fit indices, resulting in overall adequate model fit (χ2 = 896.86; CFI = 0.924; TLI = 0.912; RMSEA = 0.05 (90% CI: 0.043, 0.051); SRMR = 0.06). Furthermore, small-to-moderate correlations were found between corresponding AEBQ and CEBQ scales. This study supports a 7-factor solution of the AEBQ without the Hunger scale and provide evidence of its construct validity in adolescents. Several of the CEBQ subscales were significantly associated with weight status, whereas this was the case for only one of the AEBQ scales.

A qualitative inquiry of parents of extremely picky eaters: Experiences, strategies and future directions

BACKGROUND/AIM

Picky eating is a common childhood phenomenon in younger children, impacting family relationships and mealtimes. Limited qualitative studies have explored parents' experiences of parenting an extremely picky eater. This study aimed to address this gap.

METHODS

This exploratory qualitative research design included participants who were Australian-based parents (n = 10) of children aged 2-6 years with a minimum picky eating score of 3.33, indicating extreme picky eating, on the Food Fussiness subscale of the Child Eating Behavior Questionnaire (CEBQ). Parents were interviewed online via Zoom using semi-structured interviews focused on their experiences of having a child who is a picky eater. Reflexive thematic analysis was used to analyze the data.

RESULTS

Five themes were identified: 1: The picky eating journey for parents. 2: Picky eating impacts families and mealtimes. 3: Parents have attempted multiple strategies to manage picky eating. 4: Emotions associated with parenting an extremely picky eater. 5: Parents of extremely picky eaters have a positive outlook for the future.

CONCLUSION

This qualitative study demonstrates that parents' experiences of parenting an extremely picky eater are varied. Parents desire health professionals who listen to their concerns and provide evidence-based knowledge around parent feeding practices to positively impact picky eating.

Child characteristic correlates of food rejection in preschool children: A narrative review

Dietary habits formed in early childhood are key for establishing a healthy diet later in life. Picky eating and food neophobia - the two main forms of food rejection in young children - form an important barricade to establishing such healthy habits. Understanding these types of food rejection is thus essential for promoting healthy eating behaviour in both children and adults. To this end, the present narrative review aims to provide an overview of food rejection research in preschool-aged children, focusing on recent advances in the cognitive literature. Specifically, we evaluate the link between children's cognitive development, chemosensory perception and affective evaluation of food, food knowledge, decision-making strategies, anxiety and disgust sensitivity, and food rejection behaviour. Longitudinal and experimental studies are necessary to establish how the relationships between food rejection and cognitive processes develop over time and to determine their causal directions.

Childhood hyperactivity, eating behaviours, and executive functions: Their association with the development of eating-disorder symptoms in adolescence

BACKGROUND

Cross-sectional studies have shown that hyperactivity and impaired executive functioning are associated with symptoms of eating disorders in adolescence and adulthood. Whether hyperactivity and executive functions in early life can prospectively predict the emergence of eating disorder symptoms in adolescence remains unknown. The present study relies on a longitudinal design to investigate how hyperactivity at age 3, eating behaviours at age 3.5 and cognition at ages 3-6 were associated with the development of eating-disorder symptoms from 12 to 20 years old.

METHODS

Using archival data collected since 1997 from the Quebec Longitudinal Study of Child Development cohort (N = 2, 223), we used Latent Curve Models to analyse predictors of youth's trajectories of eating-disorder symptoms at four timepoints.

RESULTS

A quadratic (curvilinear) trajectory of eating-disorder symptoms was found to be most representative of the data. Higher hyperactivity at age 3 was associated with higher levels of eating-disorder symptoms at age 12, and this association was partially mediated by higher levels of overeating and cognitive inflexibility in childhood. Cognitive inflexibility in childhood also mediated the association between hyperactivity at age 3 and increases in eating-disorder symptoms during adolescence. Furthermore, working memory was indirectly related to eating-disorder symptoms via the mediational role of cognitive flexibility.

CONCLUSIONS

Hyperactivity, overeating, cognitive inflexibility, and working memory early in life might precede the onset of eating-disorder symptoms in adolescence. Early behavioural and cognitive screening may help to identify children who are most at risk for eating disorders. This, in turn, could guide preventive interventions.

Gap between the concerns of healthcare professionals and parents' perceptions regarding dietary habits for 18-month- and 3-year-old children in Japan

BACKGROUND

A gap has been reported between healthcare professionals' (hereafter "professionals") recognition of preschool children's diets and parents' perception of concern. This study investigated the gap between the concerns reported by professionals and parents' perceptions regarding health and dietary habits by age (18 months and 3 years) and gender in Japan.

METHODS

The study design consisted of a cross-sectional, multilevel survey. The request letters were sent to all households with target children with the cooperation of local governments. After obtaining written informed consent from parents, questionnaires were distributed to them. The survey included 30 items on children's concerns about health and dietary habits. At the health checkup, parents indicated whether they were concerned in response to each item, and responded child's height and weight and birth height and weight. Next, the professionals provided counseling to the parents at a health checkup. After that, the professionals noted their concerns in response to the same 30 items as those given to parents. The participation rates were 82.9% (18 months) and 82.8% (3 years). Data of 239 persons for 18 months and 223 persons for 3 years old were analyzed. In the statistical analysis, the items that were judged as concerning by professionals but not by parents were identified; likewise, the items that were of concern to parents but not to professionals were identified. Sensitivity, false negative rate, specificity, false positive rate, and Youden index were calculated to analyze the discordance rate for each item.

RESULTS

Many parents in this study were concerned about the issues that professionals did not consider to be concerning. Moreover, the parents worried about more issues for 3-year-olds than for 18-month-olds. The items for which ≥ 10 professionals indicated concerns and with higher discordance between the professionals and parents for both boys and girls were "picky eating" for 18-month-olds and "inconsistent amount of food" for 3-year-olds.

CONCLUSIONS

The concerns that professionals have with respect to children's diets and the things that parents worry about show gaps. It might be necessary to provide professional counseling for parents to develop a correct understanding of their children's dietary habits.

Prevalence and Characterization of Avoidant Restrictive Food Intake Disorder in a Pediatric Population

Objective

Avoidant/restrictive food intake disorder (ARFID) is a relatively new feeding and eating disorder category in DSM-5 characterized by extreme food avoidance/restriction. Much is unknown about ARFID, with limited understanding of its prevalence and comorbidities in general pediatric populations. This study aimed to classify ARFID prevalence and characteristics in children within the Generation R Study, a population-based Dutch cohort (N = 2,862).

Method

ARFID was assessed via an Index that comprised parent-reported questionnaires and researcher-assessed measures of picky eating, energy intake, diet quality, growth, and psychosocial impact, all in the absence of body/weight dissatisfaction to align with DSM-5 criteria. Parents also reported on child appetitive traits and emotional/behavioral problems (eg, anxiety, depression, attention problems).

Results

Using DSM-5-based categorization, 183 (6.4%) of 2,862 children were classified as presenting with ARFID symptoms. Compared with children not exhibiting symptoms, children classified with ARFID symptomatology expressed other avoidant eating behavior, including decreased enjoyment of food (d = -1.06, false discovery rate-corrected p [p FDR] < .001), increased satiety responsiveness (d = 1.06, p FDR < .001), and emotional undereating (d = 0.21, p FDR < .01), as well as more emotional problems, including withdrawn/depressed (d = 0.38, p FDR < .001), social problems (d = 0.34, p FDR < 0.001), attention problems (d = 0.38, p FDR < .001), anxiety (d = 0.30, p FDR < .001), obsessive/compulsive problems (d = 0.15, p FDR < .05), and autistic traits (d = 0.22; p FDR < .05). Associations did not differ by sex.

Conclusion

This is the first large-scale community-based study to characterize ARFID and to demonstrate that ARFID symptom classification is common in children aged ≤10 years. Findings suggest that appetitive, emotional, and behavioral comorbidities may underlie or reinforce the presentation of ARFID.

Diversity & Inclusion Statement

We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. Diverse cell lines and/or genomic datasets were not available. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. We actively worked to promote sex and gender balance in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

The clinical presentation of avoidant restrictive food intake disorder in children and adolescents is largely independent of sex, autism spectrum disorder and anxiety traits

Background

Avoidant restrictive food intake disorder (ARFID) is a new eating disorder with a heterogeneous clinical presentation. It is unclear which patient characteristics contribute to its heterogeneity.

Methods

To identify these patient characteristics, we performed symptom-level correlation and driver-level regression analyses in our cross-sectional study in up to 261 ARFID patients (51% female; median age = 12.7 years) who were assessed at the Maudsley Centre for Child and Adolescent Eating Disorders, London between November 2019 and July 2022.

Findings

Symptoms across the three drivers 1) avoidance based on sensory characteristics of food; 2) apparent lack of interest in eating; and 3) concern about aversive consequences positively correlated with each other. Patients' anxiety traits showed the greatest positive correlations with symptoms of concern about aversive consequences of eating. Patient sex was not significantly associated with any of the three ARFID drivers. Patients with comorbid autism spectrum disorder (ASD; 28%) showed more food-related sensory sensitivities (RR = 1.26) and greater lack of interest in eating (RR = 1.18) than those of patients without ASD (49%).

Interpretation

In our clinical sample, the ARFID drivers occurred together and did not show clinically meaningful differences between the sexes. ASD may accentuate food-related sensory sensitivities and lack of interest, but may not drive a completely different symptom presentation. ARFID is multi-faceted and heterogenous, requiring a comprehensive multidisciplinary assessment to sufficiently understand the drivers of the restrictive eating behaviour. Results need replication in larger samples with more statistical power.

Funding

None.

Systematic Review of the Incidence and/or Prevalence of Eating Disorders in Individuals With Food Allergies

BACKGROUND

Chronic diseases involving strict dietary adherence have been associated with an increased risk of eating disorders (EDs). This is the first systematic review investigating the rate of EDs among individuals with food allergies (FAs).

OBJECTIVE

To report the incidence, prevalence, and types of EDs in individuals with FAs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched 4 databases for studies published to January 2022 that reported the prevalence or incidence of EDs in samples with immunoglobulin E (IgE) or non-IgE-mediated allergy. Risk of bias was assessed and evidence qualitatively synthesized.

RESULTS

From 1,180 papers identified, 9 met inclusion criteria. There were 4,161 adult and pediatric participants with IgE-mediated FAs or eosinophilic esophagitis. Avoidant/Restrictive Food Intake Disorder (ARFID) or anorexia nervosa/bulimia nervosa were the main EDs identified. The prevalence of EDs in samples with FA ranged from 0.8% to 62.9%. Among studies investigating IgE-mediated FA (n = 6), the prevalence of anorexia nervosa and/or bulimia nervosa ranged from 17.6 to 61%, ARFID was 62.9%, and unspecified EDs was 0.8% to 6%. Among samples with eosinophilic esophagitis (n = 3), ARFID prevalence ranged from 4.5% to 51%. Most studies were limited by small sample size, possible selection bias, and lack of diagnostic EDs tools validated for food allergic populations.

CONCLUSIONS

Eating disorders appear prevalent in individuals with FA; however, prevalence estimates varied widely. Large studies with healthy control groups and validated measures to identify EDs in individuals with FA are needed to accurately determine the prevalence of EDs.

Risk Factors Related to Eating Disorders in a Romanian Children Population

(1) Background: The complex known as avoidant/restrictive food intake disorder (ARFID) is one of the eating disorders that cannot be explained by chronic disease. The aim of this study was to determine the characteristics of patients who were identified as being at risk of developing ARFID and referred to paediatricians, according to their age and duration of symptoms. (2) Methods: Children aged 2-10 years (Group 1) presenting with eating disorders were initially recruited in the "Dr. Victor Gomoiu" Clinical Children Hospital in Bucharest. Group 2 included patients presenting for routine paediatric visits as controls. The study population was given the PARDI questionnaire as well as questions related to demographics, screening growth and development, physical and mental background, and current feeding and eating patterns. Items were scored on a 7-point scale ranging from 0 to 6. (3) Results: A total of 98 individuals were divided equally into the two study groups. There was no difference in terms of sex, living area, mothers' education level or living standards between the two groups. ARFID children were more likely to be underweight, were unsuccessful at weaning or have irregular feeding habits and a history of allergies. The mean age of onset for chronic symptoms was significantly lower than the onset of acute food refusal-4.24 ± 2.29 vs. 6.25 ± 3.65, p = 0.005. (4) Conclusions: feeding disorders are an important issue among paediatricians, and a proper awareness of them when treating these patients should be included in daily practice.

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.

Avoidant/Restrictive Food Disorder (ARFID), Food Neophobia, Other Eating-Related Behaviours and Feeding Practices among Children with Autism Spectrum Disorder and in Non-Clinical Sample: A Preliminary Study

Previous research shows that children with autism spectrum disorder (ASD) may experience several difficulties-including those related to eating-and this area of research needs to be explored further. This study had two main objectives: (1) comparison of the clinical (autism spectrum disorder) and non-clinical sample of children in terms of avoidant/restrictive food disorder, food neophobia, other eating-related behaviours and feeding practices; (2) assessment of selected predictors of food neophobia. The final sample included 54 children and parents from the clinical sample (ASD) and 51 from the non-clinical sample. Parents completed: the autism spectrum rating scales (ASRS), the eating disorders in youth questionnaire (EDY-Q), the children food neophobia scale (CFNS), the child eating behaviour questionnaire (CEBQ), the child feeding questionnaire (CFQ), and a socio-demographic survey. Our analysis allowed us to partially confirm the first hypothesis since the clinical sample (vs. the non-clinical group) had significantly higher scores in such variables as (a) avoidant/restrictive food disorder (ARFID), (b) food neophobia, (c) other eating-related behaviours: emotional under-eating, desire to drink, food fussiness, (d) feeding practices: pressure to eat. Moreover, our analysis of predictors of food neophobia in the clinical and non-clinical samples also allowed us to partially confirm the second hypothesis because it turned out that only in the clinical sample (vs. the non-clinical sample) were the predictors significantly associated with food neophobia, but only two of them (food fussiness and selective eating). In conclusion, our study showed that children with ASD (compared to children without this diagnosis) experience increased difficulties in eating behaviours, and their parents present a stronger intensity of the feeding practice based on pressure to eat. This study showed that feeding problems for children in the ASD sample are a significant problem, and it is still worth exploring this area in research.

Targeting Shank3 deficiency and paresthesia in autism spectrum disorder: A brief review

Autism spectrum disorder (ASD) includes a group of multifactorial neurodevelopmental disorders characterized by impaired social communication, social interaction, and repetitive behaviors. Several studies have shown an association between cases of ASD and mutations in the genes of SH3 and multiple ankyrin repeat domain protein 3 (SHANK3). These genes encode many cell adhesion molecules, scaffold proteins, and proteins involved in synaptic transcription, protein synthesis, and degradation. They have a profound impact on all aspects of synaptic transmission and plasticity, including synapse formation and degeneration, suggesting that the pathogenesis of ASD may be partially attributable to synaptic dysfunction. In this review, we summarize the mechanism of synapses related to Shank3 in ASD. We also discuss the molecular, cellular, and functional studies of experimental models of ASD and current autism treatment methods targeting related proteins.

How multiple threats to safety affects quality of life for picky eating adults: A new explanatory model

Picky eating describes a pattern of eating characterised by a narrow dietary range with rejection of both novel and familiar foods. Research has suggested that picky eating in adulthood is associated with several negative psychosocial outcomes including impaired quality of life. This research aimed to build and test a model explaining the relationship between picky eating and quality of life. 230 participants were recruited via online support forums for picky eating, and an undergraduate research participation scheme. Participants completed self-report measures of picky eating, sensory sensitivity, disgust, anxiety, fear of negative evaluation and eating related quality of life. Regression analysis indicated that picky eating, disgust sensitivity, anxiety, and fear of negative evaluation were all associated with impaired eating-related quality of life. A theoretical model was then devised which aimed to explain the interactions between these factors, and Path Analysis indicated that this model was a good fit for the data. This Safety in Picky Eating and Quality of life (SPEQ) model suggests that threat perception and the drive for safety underlies the relationship between picky eating and impaired quality of life. The SPEQ model provides a preliminary basis for understanding how picky eating impacts quality of life in adulthood.

Symptoms of Avoidant/Restrictive Food Intake Disorder (ARFID) in the Orthodox and Secular Jewish Communities in Israel

Symptoms related to avoidant/restrictive food intake disorder (ARFID) are not well defined in the general population. The aim of this study was to determine whether differences exist in the presentation of ARFID-related eating disturbances between healthy, religious and secular Jewish children in Israel. Sixty-four families participated in this study. Parents completed standardized questionnaires to assess ARFID behaviors of children, parental feeding problems and overall functioning, anxiety and sensory-aversion. No significant between-group differences were found for almost all assessments. However, sensory-related pleasure and sensory-seeking behavior was greater in secular children. Overall, religious and non-religious Israeli children do not differ in parental-reported ARFID-related feeding and eating behaviors.

Food selectivity and neophobia in children with autism spectrum disorder and neurotypical development: a systematic review

CONTEXT

Individuals with autism spectrum disorder (ASD) have common eating problems, including food refusal, dietary restrictions, and behavioral problems during eating.

OBJECTIVE

The aim of this systematic review was to find more clear evidence on the relationship between food selectivity or food neophobia (FN) and ASD in children up to age 14 years. The PECO-based question was: Are food selectivity and FN behaviors more prevalent in children with ASD than in children with neurotypical development (NTD)?, in which the P is children, E is ASD, C is children with NTD, and O is food selectivity and FN.

DATA SOURCES

Clinical studies in the databases PubMed, Embase and Web of Science, comparing children with ASD and those with NTD, were reviewed from October 1966 to October 2021.

STUDY SELECTION AND DATA EXTRACTION

A total of 122 studies were analyzed for summary reading, and only 17 of these were included in the descriptive qualitative analysis. In 9 studies, the analysis of food selectivity was performed via a questionnaire.

RESULTS

The results showed that children with ASD are more selective than those with NTD. Four studies evaluated FN through scales; however, only 2 found higher levels of FN in the ASD group than in children with NTD. The sensory profile was measured using questionnaires in 9 studies, and we found that altered sensory processing is more common in children with ASD.

CONCLUSION

Children with ASD present greater food selectivity than children with NTD. However, the occurrence of FN was higher in only 50% in which FN was investigated, which points to a need for studies that compare FN between siblings with ASD and those with NTD in the same family nucleus. In addition, atypical oral sensitivity seems to be a sensory characteristic most related to eating disorders.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021247880.

Symptoms of Avoidant/Restrictive Food Intake Disorder among 2-10-Year-Old Children: The Significance of Maternal Feeding Style and Maternal Eating Disorders

The aim of the present study was to investigate whether the feeding style and core behavioral features of eating disorders of mothers are related to the symptoms of Avoidant/Restrictive Food Intake Disorder (ARFID) among their children. This study involved 207 mothers of children aged 2 to 10 years (Mage = 5.82 ± 2.59 years), of which 19.32% were children with neurodevelopmental disorders and 22.71% were children with chronic diseases (e.g., allergy, asthma, diabetes). The mothers were asked to complete the ARFID Parents Questionnaire-Parents Report (ARFID-Q-PR), the Parental Feeding Style Questionnaire (PFSQ) and the Eating Disorder Examination Questionnaire (EDE-Q). Our findings revealed that both the maternal feeding style and core behavioral features of eating disorders were associated with ARFID symptoms among their 2-10-year-old children. While biological factors increase the risk of feeding/nutrition difficulties, the maternal attitude towards feeding and eating behavior may play a relevant role in children's eating behavior.

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.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Classification of Children and Adolescents With Avoidant/Restrictive Food Intake Disorder

BACKGROUND AND OBJECTIVES

Evidence suggests that children and adolescents with avoidant/restrictive food intake disorder (ARFID) have heterogeneous clinical presentations. To use latent class analysis (LCA) and determine the frequency of various classes in pediatric patients with ARFID drawn from a 2-year surveillance study.

METHODS

Cases were ascertained using the Canadian Pediatric Surveillance Program methodology from January 1, 2016, to December 31, 2017. An exploratory LCA was undertaken with latent class models ranging from 1 to 5 classes.

RESULTS

Based on fit statistics and class interpretability, a 3-class model had the best fit: Acute Medical (AM), Lack of Appetite (LOA), and Sensory (S). The probability of being classified as AM, LOA, and S was 52%, 40.7%, and 6.9%, respectively. The AM class was distinct for increased likelihood of weight loss (92%), a shorter length of illness (<12 months) (66%), medical hospitalization (56%), and heart rate <60 beats per minute (31%). The LOA class was distinct for failure to gain weight (97%) and faltering growth (68%). The S class was distinct for avoiding certain foods (100%) and refusing to eat because of sensory characteristics of the food (100%). Using posterior probability assignments, a mixed group AM/LOA (n = 30; 14.5%) had characteristics of both AM and LOA classes.

CONCLUSIONS

This LCA suggests that ARFID is a heterogeneous diagnosis with 3 distinct classes corresponding to the 3 subtypes described in the literature: AM, LOA, and S. The AM/LOA group had a mixed clinical presentation. Clinicians need to be aware of these different ARFID presentations because clinical and treatment needs will vary.

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.

ARFID—Strategies for Dietary Management in Children

Avoidant/Restrictive Food Intake Disorder (ARFID) is a relatively new disease entity in DSM-5 and ICD-11. This disorder continues to pose a diagnostic and therapeutic challenge for many professionals. This disorder can affect people of all ages. The most characteristic pattern is considered to be a lack of interest in eating or avoidance of food intake, which may result in nutritional deficiencies, weight loss or lack of expected weight gain, dependence on enteral feeding or dietary supplements, and impaired psychosocial functioning. This disorder cannot be explained by a current medical condition or co-occurring other psychiatric disorders, but if ARFID co-occurs with another disorder or illness, it necessarily requires extended diagnosis. Its treatment depends on the severity of the nutritional problem and may include hospitalization with multispecialty care (pediatrician, nutritionist, psychologist, psychiatrist, neurologist). The nutritional management strategy may include, inter alia, the use of Food Chaining, and should in the initial stage of therapy be based on products considered “safe” in the patient’s assessment. The role of the dietitian in the management of a patient with ARFID is to monitor weight and height and nutritional status and analyze the foods that should be introduced into the food chain first.

Feeding problems, age of introduction of complementary food and autism symptom in children with autism spectrum disorder

In this cross-sectional study, 84 children with autism spectrum disorder (ASD) and 77 healthy subjects showing typical development (TD) were reviewed. Parents reviewed the age of introduction of complementary foods (CFs), completed a demographic, diet behavior questionnaire and the Autism Behavior Checklist (ABC). The results showed that the age of introduction of CFs was later in children with ASD than their TD counterparts. The age of introduction of CFs in ASD group was positively correlated with feeding problem. While the correlation was not observed in TD group. Children in the ASD group had higher total scores of the diet behavior questionnaire and all four subdomains (poor eating ability, mealtime eating behavior, food selectivity, and parental feeding behavior). ASD symptoms were clearly associated with feeding problems. The sensory subdomain score in ABC was positively correlated with poor eating ability, mealtime behavior and total score of the diet behavior questionnaire. The social self-care subdomain score was positively correlated with food selectivity. The interaction subdomain score was negative correlated with parental feeding behavior and total score of the diet behavior questionnaire. Further studies are required to establish the utility of delayed CFs introduction and/or early feeding problems as potential indicators of ASD.

Feeding/Eating Problems in Children Who Refrained From Treatment in the Past: Who Did (Not) Recover?

BACKGROUND

Young children with disordered feeding may be at increased risk for problematic eating in the future. This retrospective study attempts to identify predictors of later feeding problems.

OBJECTIVES

Children (N = 236) with disordered feeding, who refrained from behavioral treatment after consultation at a tertiary treatment center for feeding and eating problems were followed-up after, on average, 6 years and 3 months (timepoint 2).

METHOD

Logistic regressions were carried out with characteristics taken at intake (timepoint 1)-sex, pre/dysmaturity, gastro-intestinal disease, history of age-adequate feeding, syndrome/developmental impairment, autism spectrum disorder, comorbidity, age, and several variables of a restrictive- and selective food intake-and duration between timepoint 1 and 2, as predictor variables, and age-appropriate food intake at t2 as the dependent variable.

RESULTS

Despite improvement over time, 63% did not reach an age-adequate food intake at t2. Predictors of age-inadequate food intake were: (a) older age; (b) sex (male), (c) longer duration between timepoint 1 and timepoint 2; (d) autism spectrum disorder; (e) selective texture choices and (f) lack of varied nutritional intake.

CONCLUSION

This study shows that most untreated young children's feeding problems do not improve over years. Besides the advice to seek help at an early age, it seems especially recommended to treat (male) children with autism spectrum disorder and selective feeding patterns.

Feeding Problems Including Avoidant Restrictive Food Intake Disorder in Young Children With Autism Spectrum Disorder in a Multiethnic Population

We examined feeding problems, including Avoidant Restrictive Food Intake Disorder (ARFID), in preschool children with Autism Spectrum Disorder (ASD). Data were collected from a prospective longitudinal study of 46 children with ASD in a multiethnic, low resource area in Gothenburg, Sweden. Feeding problems were found in 76% of the children with ASD, and in 28%, the criteria for ARFID were met. The study highlights early onset age, the heterogeneity of feeding problems, and the need for multidisciplinary assessments in ASD as well as in feeding problems, and also the need for further elaboration of feeding disorder classifications in children.

Child Autistic Traits, Food Selectivity, and Diet Quality: A Population-Based Study

BACKGROUND

Children with Autism Spectrum Disorders (ASDs) tend to be selective in their food intake, which may compromise their diet quality. While ASD diagnoses capture severe levels of impairment, autistic traits vary on a continuum throughout the population. Yet, little is known about how autistic traits relate to diet quality at the population level.

OBJECTIVES

This study examines the association between autistic traits in early childhood and diet quality in mid-childhood and explores the mediating role of food selectivity.

METHODS

Participants were children (n = 4092) from the population-based Generation R Study. Parents reported their child's autistic traits at 1.5, 3, and 6 years; food selectivity at 4 years; and food intake at 8 years, from which a diet quality score was derived. Associations of autistic traits and the autistic trait trajectory (identified using Latent Class Growth Modelling) with diet quality were examined using multiple linear regression models. The indirect effect of food selectivity in the association between autistic traits at 1.5 years and diet quality was examined using mediation analysis.

RESULTS

Autistic traits were associated with diet quality (e.g., 1.5 years: β = -0.09; 95% CI: -0.13 to -0.06). Two classes captured the autistic trait trajectories from 1.5 to 6 years: children with "low and stable" (95%) and "high and increasing" (5%) mean scores. Children in the high and increasing group had poorer diet quality than those in the low and stable group (β = -0.28; 95% CI: -0.44 to -0.11). Food selectivity mediated the association between autistic traits at 1.5 years and diet quality at 8 years (βindirect = -0.03; 95% CI: -0.03 to -0.02).

CONCLUSIONS

Autistic traits in early childhood are associated with poorer diet quality in mid-childhood, and food selectivity appears to mediate this association. Interventions intended to optimize nutrition in children with elevated autistic traits may integrate behavioral strategies to support parents' responding to their child's food selectivity.

Prospective associations between childhood social communication processes and adolescent eating disorder symptoms in an epidemiological sample

Deficits in social cognition and communication, the processes associated with human social behavior and interaction, have been described in individuals with eating disorder psychopathology. The current study examined whether social communication characteristics present in middle childhood (ages 8-14) were associated with eating disorder behaviors, cognitions, and diagnoses across adolescence (ages 14-18) in a large, population-based sample. Participants (N = 4864) were children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based, prospective study of women and their children. Regression methods tested prospective associations between social functioning using a facial emotion recognition task and parentally reported social communication symptoms (or difficulties), measured by the Social Communication Disorder Checklist (SCDC), with eating disorder symptoms and diagnoses. Misattribution of faces as sad or angry at age 8.5 was associated with purging and anorexia nervosa diagnosis at age 14, respectively, among girls. Furthermore, autistic-like social communication difficulties during middle childhood were associated with bulimia nervosa symptoms during adolescence among both girls and boys. Results did not support global associations between measured social communication deficits and eating disorder risk in this sample, but specific difficulties with facial emotion recognition and social communication may enhance the risk for disordered eating behaviors.

Food selectivity, nutritional inadequacies, and mealtime behavioral problems in children with autism spectrum disorder compared to neurotypical children

OBJECTIVE

To evaluate body composition, nutritional status through food selectivity and degree of inadequate intake, and mealtime behavior in children with autism spectrum disorder (ASD) compared to neurotypical children.

METHOD

A cross-sectional case-control study was carried out in 144 children (N = 55 with ASD; N = 91 with neurotypical children) between 6 and 18 years of age. Body composition, nutritional intake, food consumption frequency (FFQ), and mealtime behavior were evaluated.

RESULTS

Results showed a greater presence of children with a low weight (18.4% ASD vs. 3.20% comparison group) and obesity (16.3% ASD vs. 8.6% comparison group) in the ASD group for body mass index (BMI) categories (p = .003; number needed to take [NNT] = 8.07). The presence of obesity in ASD children compared to the comparison group was even higher when considering the fat component (47.5% ASD vs. 19.4% comparison group, p = .002; NNT = 10.3). ASD children had greater intake inadequacy (50% ASD vs. 22% comparison group, p = .014; NNT = 3.58), high food selectivity by FFQ (60.6% ASD vs. 37.9% comparison group, p < .037; NNT = 4.41), and more eating problems (food rejection, limited variety, disruptive behavior), compared to neurotypical children (p = .001).

CONCLUSION

Children with ASD showed an unbalanced body composition toward both underweight and obesity, a greater degree of inadequate intake, high food selectivity as indicated by their consumption frequency, and more disturbed eating behavior than children with neurotypical development. We suggest monitoring nutritional inadequacies and implementing nutritional strategies to expand the variety of foods children with ASD consume.

Eater profile and associated factors in pediatric patients of the PEDIANUT cohort

Appetite traits have multifactorial origins. In association with environmental and genetic factors, they could become problematic and lead to Feeding or Eating Disorders (FED). As the DSM-5 classification is not suitable for pediatric FED, another way to describe eating behavior is to distinguish the clinical profiles of "small eater" and "big eater". The aim of this study was to identify socio-demographic and medical factors associated with these profiles, and to compare problematic and non-problematic profiles. From the Pedianut study, we analyzed socio-demographic, medical and family history data among 401 children according to 4 age groups (<1 year n = 101, 1-6 years n = 99, 6-12 years n = 100, 12-18 years n = 101). The information collected on eating behavior made it possible to define small eater profile (SEP) and big eater profile (BEP) using predefined grids. BEP was more frequent in adolescents (35.6%), and SEP was more frequent in children aged 1-6 years (34.3%). BEP was associated with having separated parents, being male and the oldest sibling (p < 0.05). Problematic BEP was associated with eating while watching television, being a girl, and having sensory disorders (p < 0.05). SEP was associated, whatever age, with non-breastfeeding, chronic illness, psychological history, sensory disorders, language delays (in the 1-6 year age group), and family history of FED (in the adolescent group) (p < 0.05). This analysis of factors associated with eater profile opens new perspectives for research on risk factors associated with eating traits, which warrants further study in larger populations to delineate transition from healthy to problematic eating.

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.

Delayed diagnosis of avoidant/restrictive food intake disorder and autism spectrum disorder in a 14-year-old boy

Psychiatric comorbidities are common among individuals with ARFID and may contribute to a failure to establish an accurate diagnosis, delayed diagnosis, and poor long-term prognosis, especially among children and adolescents.

The Effect of Learning Module Program on Mothers’ Ability to Adapt to New Foods, Feeding Styles, and Self-efficacy to Their Children with Avoidant Restrictive Food Intake Disorder

BACKGROUND: The education to improve a mother’s knowledge is deemed to be important because it may improve children’s nutritional status. AIM: The aim of this study was to examine the effects of learning module program on the mothers’ ability to adapt to new foods, feeding styles, and self-efficacy to their children with avoidant restrictive food intake disorder (ARFID). METHODS: Quasi-experimental design was used to evaluate the effectiveness of learning module program. Fifteen mothers of experimental group were given four meetings within 4 weeks. Each meeting ran about 50 min. Fifteen mothers of control group were conducted home visit and received twice education about the health principals of feeding children. Both experimental group and control group had pre-test and post-test. The data were analyzed using Chi-square test, Fisher’s exact test, and Mann–Whitney U-test. RESULTS: The participants of the experimental group have shown bigger surge of new foods adaptation (t = –2.973, p < 0.003), feeding style (t = –4.646, p < 0.001), self-efficacy (t = –3.652, p = 0.001) than the control group has. CONCLUSION: The findings indicated that the learning module program was deemed to be effective to improve mothers’ ability to adapt to new foods, feeding styles, and self-efficacy to their children with ARFID.