Comorbid Feeding and Gastrointestinal Symptoms, Challenging Behavior, Sensory Issues, Adaptive Functioning and Quality of Life in Children and Adolescents with Autism Spectrum Disorder

An investigation of sleep problems, gastrointestinal symptoms, comorbid psychopathology and challenging behavior in children and adolescents with Down Syndrome

BACKGROUND

Down syndrome (DS) is one of the most common chromosomal abnormalities, and children with DS have increased risks of receiving diagnoses of specific comorbidities.

AIMS

This study aimed to assess the frequencies and relationships between sleep problems, gastrointestinal (GI) symptoms, comorbid psychopathology, and challenging behavior.

METHODS AND PROCEDURES

The Children's Sleep Habits Questionnaire, Gastrointestinal Symptom Inventory, Autism Spectrum Disorder-Comorbid for Children, and Behavior Problems Inventory-Short Form were completed by 123 parents of children and adolescents with DS.

OUTCOMES AND RESULTS

The frequency of GI symptoms was 74.8 %, with high frequencies also found for: sleep problems (100 %), challenging behavior (100 %), and moderate to severe levels of comorbid psychopathology (tantrum=80 %; repetitive behavior=63 %; avoidant behavior=82 %; worry/depressed=61 %; conduct behavior=100 %; over-eating=100 %; under-eating=100 %). A significant moderate correlation was found between total GI symptoms and self-injurious behavior frequency. Children who presented with abdominal pain engaged in self-injurious behavior more frequently than those with no abdominal pain.

CONCLUSIONS AND IMPLICATIONS

Findings indicated a high frequency of sleep problems, comorbid psychopathology, GI symptoms, and challenging behavior and demonstrated a relationship between GI symptoms and self-injurious behavior in children and adolescents with DS. This research illustrated the importance of investigating comorbid conditions in individuals with DS. WHAT THIS PAPER ADDS?: Down Syndrome (DS) is a genetic condition characterized by trisomy 21 and is a leading cause of intellectual disability worldwide. The prevalence of DS is commonly associated with advanced maternal age and is associated with multiple comorbid conditions. The current study aimed to investigate the frequency of and relationship between sleep problems, gastrointestinal symptoms, comorbid psychopathology, and challenging behavior in children and adolescents with DS. High-frequency levels were found for sleep problems (100 %), challenging behavior (100 %), gastrointestinal symptoms (74.8 %), and moderate to severe levels of the different comorbid psychopathologies (tantrum=80 %; repetitive behavior=63 %; avoidant behavior=82 %; worry/depressed=61 %; conduct behavior=100 %; over-eating=100 %; under-eating=100 %). Results indicated a significant difference in self-injurious behavior frequency between individuals who presented with abdominal pain and those who did not. This study is the first to investigate the relationship of multiple comorbid conditions in a sample of children with DS. This paper adds to the literature by demonstrating the frequency of a number of comorbid conditions in children and adolescents with DS. The paper also adds novel findings to the literature by investigating the relationships between comorbid conditions in this population. The findings of this paper highlighted the frequency and comorbidities that exist between gastrointestinal symptoms, sleep problems, comorbid psychopathology, and challenging behavior. Analyses indicated that those who presented with abdominal pain, engaged in self-injurious behavior more frequently. Sleep problems, gastrointestinal symptoms, comorbid psychopathology, and challenging behavior in children and adolescents with Down Syndrome.

Forwarding the Science of Sensory Features in Autism and Related Conditions

This editorial accompanies the JADD Special Issue on Sensory Features in Autism and Related Conditions: Developmental Approaches, Mechanisms and Targeted Interventions. The editorial is a commentary on the state of the science in sensory features in autism and related conditions and provides a synopsis of the information contained in the special issue including provocative thoughts about moving the field forward in this area.

Treating Pediatric Feeding Disorders and Dysphagia: Evidence-Based Interventions for School-Based Clinicians

PURPOSE

Children with pediatric feeding disorder (PFD) and dysphagia are increasingly prevalent in school-based caseloads. This tutorial discusses the current best practices for treating children with PFD and dysphagia as well as considerations for service delivery in educational settings.

METHOD

The rationale for treating PFD and dysphagia in an educational setting is discussed. A review of various interventions for PFD and dysphagia and a discussion of the available evidence are provided. The principles of experience-dependent neuroplasticity and theory-driven practice are discussed in light of the need for additional empirical research. Practical considerations to enhance evidence-based practice for PFD and dysphagia in educational settings are explored.

RESULTS

The reader will be able to identify evidence-based interventions for students with PFD and dysphagia and plan for the implementation of these approaches in the school setting.

CONCLUSIONS

Students with PFD and dysphagia require skilled interventions to support their participation in educationally relevant activities and to promote continued development of feeding and swallowing skills while at school. A discussion of the current evidence for various interventions is provided to promote the utilization of evidence-based interventions in school-based settings.

Dietary intake and gastrointestinal symptoms are altered in children with Autism Spectrum Disorder: the relative contribution of autism-linked traits

BACKGROUND

Dietary and gastrointestinal (GI) problems have been frequently reported in autism spectrum disorder (ASD). However, the relative contributions of autism-linked traits to dietary and GI problems in children with ASD are poorly understood. This study firstly compared the dietary intake and GI symptoms between children with ASD and typically developing children (TDC), and then quantified the relative contributions of autism-linked traits to dietary intake, and relative contributions of autism-linked traits and dietary intake to GI symptoms within the ASD group.

METHODS

A sample of 121 children with ASD and 121 age-matched TDC were eligible for this study. The dietary intake indicators included food groups intakes, food variety, and diet quality. The autism-linked traits included ASD symptom severity, restricted repetitive behaviors (RRBs), sensory profiles, mealtime behaviors, and their subtypes. Linear mixed-effects models and mixed-effects logistic regression models were used to estimate the relative contributions.

RESULTS

Children with ASD had poorer diets with fewer vegetables/fruits, less variety of food, a higher degree of inadequate/unbalanced dietary intake, and more severe constipation/total GI symptoms than age-matched TDC. Within the ASD group, compulsive behavior (a subtype of RRBs) and taste/smell sensitivity were the only traits associated with lower vegetables and fruit consumption, respectively. Self-injurious behavior (a subtype of RRBs) was the only contributing trait to less variety of food. Limited variety (a subtype of mealtime behavior problems) and ASD symptom severity were the primary and secondary contributors to inadequate dietary intake, respectively. ASD symptom severity and limited variety were the primary and secondary contributors to unbalanced dietary intake, respectively. Notably, unbalanced dietary intake was a significant independent factor associated with constipation/total GI symptoms, and autism-linked traits manifested no contributions.

CONCLUSIONS

ASD symptom severity and unbalanced diets were the most important contributors to unbalanced dietary intake and GI symptoms, respectively. Our findings highlight that ASD symptom severity and unbalanced diets could provide the largest benefits for the dietary and GI problems of ASD if they were targeted for early detection and optimal treatment.

A Scoping Review of the Complementary Feeding Practices and Early Eating Experiences of Children With Down Syndrome

OBJECTIVE

Children with Down syndrome may experience more challenges in their early feeding and may be introduced to complementary foods comparatively later than typically developing (TD) children. This scoping review aimed to identify and synthesize the existing literature that describes feeding problems and early eating experiences relating to the period of complementary feeding for children with Down syndrome.

METHODS

Scopus, PubMed, Medline, Web of Science, and PsycInfo were searched. Journal articles published between January 1991 and June 2022 that reported on the complementary feeding period with children with Down syndrome were included.

RESULTS

Eighteen journal articles met the inclusion criteria. Children with Down syndrome were introduced to complementary foods later than TD children and progressed to more challenging food textures at a slower rate. Gross and fine motor skill delays and sensory difficulties contributed to secondary feeding problems such as difficulties chewing, biting, and reduced awareness of food on lips and tongue. Parents of children with Down syndrome reported exercising more caution and employing more controlling feeding practices compared to TD and had higher levels of concern regarding their child's weight.

CONCLUSIONS

Guidelines and early feeding support specific to children with Down syndrome should be available before the first complementary foods are introduced and throughout this period. Feeding support should aim to address parental concerns and provide assistance when feeding problems occur, to minimize delays and encourage the optimum development of eating abilities. Future research should address the development of feeding problems during this period and explore possible interventions.

Gastrointestinal and Sleep Issues in Toddlers With Autism Versus Other Neurodevelopmental Disorders

Neurodevelopmental disorders (NDDs) are frequently associated with gastrointestinal symptoms (GIS) and sleep issues, but there are insufficient data on the occurrence of these symptoms in young children with autism spectrum disorder (ASD) compared with other NDDs. We abstracted data on 500 children aged 18 to 36 months with ASD and 146 children aged 18 to 47 months with non-ASD NDDs to compare the frequency of these symptoms. In the overall sample, there was a high rate of GIS (46.0%) and sleep difficulties (22.6%). In age-adjusted analyses, children with non-ASD NDDs were more likely to have GIS (61.0% vs 41.6%; adjusted odds ratio [OR] = 2.35; 95% confidence interval = 1.56-3.56) and sleep difficulties (34.9% vs 19.0%; adjusted OR = 2.08; 95% confidence interval = 1.33-3.26) compared with those with ASD. These findings demonstrate the need to assess these symptoms in all young children with developmental concerns to provide appropriate guidance to their families.

Role of gastrointestinal health in managing children with autism spectrum disorder

Children with autism spectrum disorders (ASD) or autism are more prone to gastrointestinal (GI) disorders than the general population. These disorders can significantly affect their health, learning, and development due to various factors such as genetics, environment, and behavior. The causes of GI disorders in children with ASD can include gut dysbiosis, immune dysfunction, food sensitivities, digestive enzyme deficiencies, and sensory processing differences. Many studies suggest that numerous children with ASD experience GI problems, and effective management is crucial. Diagnosing autism is typically done through genetic, neurological, functional, and behavioral assessments and observations, while GI tests are not consistently reliable. Some GI tests may increase the risk of developing ASD or exacerbating symptoms. Addressing GI issues in individuals with ASD can improve their overall well-being, leading to better behavior, cognitive function, and educational abilities. Proper management can improve digestion, nutrient absorption, and appetite by relieving physical discomfort and pain. Alleviating GI symptoms can improve sleep patterns, increase energy levels, and contribute to a general sense of well-being, ultimately leading to a better quality of life for the individual and improved family dynamics. The primary goal of GI interventions is to improve nutritional status, reduce symptom severity, promote a balanced mood, and increase patient independence.

Relationship Between Gastrointestinal Symptoms in Autism Spectrum Disorder and Parent Stress, Anxiety, Depression, Quality of Life and Social Support

Gastrointestinal (GI) symptoms are a common comorbidity in children and adolescents with autism spectrum disorder (ASD). Little is known about the impact that GI symptoms have on parental well-being. Parents of 409 children and adolescents with ASD completed the GI Symptoms Inventory, Parenting Stress Index-Short Form, World Health Organization Quality of Life Abbreviated Version, Hospital Anxiety and Depression Scale, and the Multidimensional Scale of Perceived Social Support. High levels of stress were demonstrated by parents with 40.1% receiving clinically significant scores. A relationship was found between parental stress and GI symptoms. Parental anxiety and depression were found at high levels but were not more common in parents of individuals with GI symptoms than those without. Lower levels of quality of life were found in parents of individuals with GI symptoms compared to parents of individuals without GI symptoms. Parents of children with GI symptoms were less satisfied with their personal and social relationships with others. Parents of children with GI symptoms had lower scores on a measure of perceived social support than parents of children and adolescents without GI symptoms. GI symptoms are stressful for parents and future research is needed to determine how to alleviate this stress and to improve the quality of life of parents of individuals with ASD.

Autism diagnosis in females by eating disorder professionals

IMPORTANCE

Autism and eating disorders cooccur at high rates, with autism impacting the efficacy of eating disorder treatments and outcomes. Females are underdiagnosed with autism and diagnosed later in life than their male counterparts.

OBJECTIVE

The purpose of this study was to define the incidence of eating disorder professionals identifying autism in female adolescents and young adults engaged in treatment for an eating disorder.

DESIGN

The research design is a cross-sectional retrospective records review. The charts reviewed were from the medical records of forty assigned-at-birth females between the ages of 13-25 who received treatment for an eating disorder at the partial hospitalization program (PHP) level of care between 2020 and 2022.

MAIN OUTCOMES

Upon entering PHP for an eating disorder, 10% of the study participants had a pre-existing diagnosis of autism. A total of 27.5% of participants had clinical suspicion of autism. The number of autism traits that an individual possessed directly correlated with the number of calendar days in treatment.

CONCLUSION

Eating disorder professionals in this study identified autism in 17.5% of adolescent and young adult females who entered PHP treatment for an eating disorder who had not previously been diagnosed with autism. Eating disorder professionals can anticipate that individuals with autism may be in treatment for a longer duration. Further studies should explore effective treatment measures for those with autism in treatment for an eating disorder.

Gastrointestinal Disorders and Food Selectivity: Relationship with Sleep and Challenging Behavior in Children with Autism Spectrum Disorder

The aim of this study was to evaluate the interaction between gastrointestinal (GI) disorders, sleep problems, and challenging behaviors in children with a diagnosis of Autism Spectrum Disorder (ASD) and their effect on parental stress. The secondary objective was to assess the frequency and type of GI and feeding disorders in a sample of children with ASD through a multidisciplinary assessment and, finally, to investigate families' perceptions and satisfaction with the proposed multidisciplinary approach. All children underwent a comprehensive gastroenterological and neuropsychiatric evaluation supported by standardized questionnaires. Pediatric gastroenterologists, specifically trained in Applied Behavior Analysis (ABA), provided advice for parent-delivered behavioral intervention for food selectivity. Thirty-six children with an autism diagnosis (29 males, age 4.5 +/-2.2 years, mean +/- SD) were enrolled. A positive correlation between sleep problems and aggressive behavior was found, and this association was stronger in children experiencing more problematic mealtime behaviors (b = 0.788, p = 0.014). Sleep difficulties were associated with stereotyped behaviors and parent-perceived stress. Parents interviewed about the gastroenterology visit perceived this multidisciplinary approach as helpful in addressing food selectivity. This study shows that sleep and mealtime issues can have a synergistic negative impact on ASD symptoms. A multidisciplinary approach and an integrated assessment of GI, feeding problems, and sleep disorders could be helpful in diagnosing comorbidities and to provide targeted advice to parents.

Clinical Spectrum and Science Behind the Hamartomatous Polyposis Syndromes

The hamartomatous polyposis syndromes are a set of clinically distinct disorders characterized by the occurrence of hamartomatous polyps in the gastrointestinal tract. These syndromes include juvenile polyposis syndrome, Peutz-Jeghers syndrome, and PTEN hamartoma tumor syndrome. Although each of the syndromes has distinct phenotypes, the hamartomatous polyps can be challenging to differentiate histologically. Additionally, each of these syndromes is associated with increased lifetime risks of gene-specific and organ-specific cancers, including those outside of the gastrointestinal tract. Germline pathogenic variants can be identified in a subset of individuals with these syndromes, which facilitates molecular diagnosis and subsequent gene-enabled management in the setting of genetic counseling. Although the malignant potential of hamartomatous polyps remains elusive, timely recognition of these syndromes is important and enables presymptomatic cancer surveillance and management before symptom exacerbation. Presently, there are no standard agents to prevent the development of polyps and cancers in the hamartomatous polyposis syndromes.

Treating Obesity in Children and Adolescents with Special Healthcare Needs

PURPOSE OF REVIEW

This paper aims to summarize the literature regarding treatment of obesity in children with special healthcare needs and provide examples of implementation based on the available scientific evidence and the clinical experience of the authors.

RECENT FINDINGS

Due to the complexity of providing treatment for children with obesity and special healthcare needs, multidisciplinary teams are recommended to adapt care to meet the children's unique needs and ensure coordination of care across settings/caregivers. Medication management is often required to assist with the side effects of psychotropic medications. Children with special healthcare needs (SHCN) such as intellectual and developmental disabilities (IDD) should be considered for metabolic and bariatric surgery as they have similar outcomes to children without SHCN. Children with special healthcare needs can be successful in weight management treatment when they have access to comprehensive care including dietary, behavioral, pharmacological, and surgical interventions. Each child requires a tailored approach to ensure their special healthcare needs are addressed within the treatment plan.

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.

Bibliometric analysis of research themes and trends in childhood autism spectrum disorders from 2012 to 2021

Background

Autism spectrum disorders (ASD) are heterogeneous neurodevelopmental conditions that affect people worldwide. Early diagnosis and clinical support help achieve good outcomes. However, medical system structure and restricted resource availability create challenges that increase the risk of poor outcomes. Understanding the research progress of childhood ASD in recent years, based on clinical literature reports, can give relevant researchers and rehabilitation therapists more resonable research guides.

Objective

This bibliometric study aimed to summarize themes and trends in research on childhood ASD and to suggest directions for future enquiry.

Methods

Citations were downloaded from the Web of Science Core Collection database on childhood ASD published from 1 January 2012, to 31 December 2021. The retrieved information was analyzed using CiteSpace.5.8. R3, and VOS viewer.

Results

A total of 7,611 papers were published across 103 areas. The United States was the leading source of publications. The clusters that have continued into 2020 include coronavirus disease 2019, gut microbiota, and physical activity, which represent key research topics. Keywords with frequency spikes during 2018-2021 were "disabilities monitoring network," "United States," and "caregiver."

Conclusions

The Autism and Developmental Disabilities Monitoring Network in the United States can be used as a reference for relevant workers worldwide. An intelligent medical assistant system is being developed. Further studies are required to elucidate challenges associated with caring for a child 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.

Gastrointestinal Symptoms in Autism Spectrum Disorder: A Systematic Review

This systematic review aims to offer an updated understanding of the relationship between gastrointestinal symptoms (GIS) and autism spectrum disorder (ASD) in children and adolescents. The databases PsycINFO, Medline, Cinahl, and ERIC were searched using keywords, and relevant literature was hand-searched. Papers (n = 3319) were systematically screened and deemed eligible if they were empirical studies published in English since 2014 and measured the GIS of individuals with ASD who were under 18 years old. Thirty studies were included in the final review. The study findings were synthesized under eight themes, including the prevalence and nature of GIS and their relationship with developmental regression, language and communication, ASD severity, challenging behavior, comorbid psychopathology, sleep problems, and sensory issues. The review found that GIS were common and that there was contradictory evidence concerning their relationship with co-occurring conditions. It also identified evidence of some causal relationships that support the existence of the gut–immune–brain pathways. Future research needs to use large prospective designs and objective and standardized GIS measurements to provide a nuanced understanding of GIS in the context of ASD.

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.

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.

Attention Deficit/Hyperactivity Disorder Symptoms Impair Adaptive and Social Function in Children With Autism Spectrum Disorder

Background: Autism spectrum disorder (ASD) often co-exists with attention deficit/hyperactivity disorder (ADHD), which may aggravate functional impairment. However, it is unclear how comorbid ADHD symptoms influence the adaptive behavior and social interaction deficits of children with ASD. Methods: The study enrolled 340 children (ranging from 2 to 14 years) with ASD, with comorbid ASD and ADHD, or with typical development (TD). A psychological evaluation involving adaptive behavior and social function was conducted using the Vineland Adaptive Behavior Scale, Second Edition (VABS-II) and the Social Responsiveness Scale (SRS). Results: There was a high prevalence of ADHD symptoms (46.6%) in children with ASD, and children with ASD + ADHD presented the worse profile of ASD symptoms. The ASD + ADHD group had higher scores on VABS and lower scores on SRS in comparison with the ASD alone group and TD group. The regression analysis revealed that ASD symptoms and ADHD symptoms were significantly associated with greater impairments in adaptive behavior and social function. The ADHD symptoms were responsible for an additional 0.8% of the variance in adaptive behavior, and 9.5% of the variance in social function. Conclusions: More severe ASD symptoms and greater impairment in adaptive function and social ability were found in children with ASD and comorbid ADHD, highlighting the need to identify ADHD comorbidities early on in children with ASD and to reduce their negative impact on functioning.