789396

research-article2018
JEIXXX10.1177/1053815118789396Journal of Early InterventionSeiverling et al

Research Article
Journal of Early Intervention
1­–12
Prevalence of Feeding Problems © 2018 SAGE Publications
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DOI: 10.1177/1053815118789396
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Disorder: A Chart Review Study

Laura Seiverling1, Patricia Towle2, Helen M. Hendy3,

and Joanna Pantelides4

Abstract
Feeding problems are known to be an important clinical issue for children with autism spectrum
disorder (ASD), but the majority of studies on this topic have been carried out on children
preschool age and older. It is important to understand whether these difficulties begin prior
to age 3 years, as well as what parameters are important to study for both assessment and
intervention. The present study used an early intervention chart abstraction method to examine
prevalence of feeding problems in children below 3 years of age with ASD compared with
those evaluated for non-ASD language delays (LD). Prevalence of feeding problems detected
by speech therapists and psychologists was higher for the ASD group than for the comparison
group, with the ASD group showing more food selectivity by texture (23.1% vs. 7.1%), more
food selectivity by type (24.4% vs. 11.8%), more new food refusal (10.3% vs. 0%), and more food
overstuffing (14.1% vs. 3.5%). We also examined the relationship between the total number of
four feeding problems and child characteristics/demographics (ASD or LD diagnosis, gender,
age of first evaluation, neighborhood income). Significantly more feeding problems were seen
for children with ASD. As well, feeding problems were more prevalent for males. Associations
between feeding problems and the other variables, as well as interactions, were not significant.

Keywords
autism, feeding problems, early intervention, chart abstraction

Introduction
Feeding problems are more prevalent for children with autism spectrum disorder (ASD) com-
pared with typically developing children (Bandini et al., 2010; Collins et al 2003; Hubbard,
Anderson, Curtin, Must, & Bandini, 2014; Nadon, Feldman, Dunn, & Gisel, 2011; Olsson,
Carlsson, Westerlund, Gillberg, & Fernell, 2013; Schreck, Williams, & Smith, 2004). Prevalence

1St.Mary’s Hospital for Children, Bayside, NY, USA

2Westchester Institute for Human Development, Valhalla, NY, USA
3Pennsylvania State University, Schuylkill Campus, USA
4Pennsylvania State University, State College, University Park, USA

Corresponding Author:
Laura Seiverling, Department of Special Education, Ball State University, 2000 W. University Ave., Muncie, IN 47306,
USA.
Email: Ljseiverling@bsu.edu
2 Journal of Early Intervention 00(0)

rates of specific feeding problems such as selective eating patterns and food refusal have also
been found to be higher in children with ASD compared with children with other developmental
delays throughout the age range (Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007;
Field, Garland, & Williams, 2003; Williams, Gibbons, & Schreck, 2005). Selective acceptance of
food or refusal to eat many or most foods can be a source of stress in families (Garro, Thurman,
Kerwin, & Ducette, 2005) and can also put children at risk of receiving lower levels of essential
nutrients (Hyman et al., 2012; Sharp et al., 2013). The prevalence estimates of selective accep-
tance of food or refusal to eat many or most foods in children with ASD vary, but researchers
consistently have found that more than 50% of children with ASD exhibit limited food accep-
tance (Ahearn, Castine, Nault, & Green, 2001; Collins et al., 2003; Schreck et al., 2004).
Therefore, feeding issues are important to address from both the vantage points of health and
disruption to family life.
The great majority of studies investigating this issue have been carried out in samples of chil-
dren over the age of 3 years (e.g., Ahearn et al., 2001; Lockner, Crowe, & Skipper, 2008; Schreck
et al., 2004). With such a prevalent and impactful problem, however, it is important to know how
early these difficulties begin, as well as what parameters are important to study for both assess-
ment and intervention.
A few studies have suggested that feeding problems start very early in children with ASD.
Olsson et al. (2013) used a retrospective chart review to examine child health center consulta-
tions (in Sweden) for crying, feeding, and sleeping problems during the first 2 years of life in
children who were diagnosed with ASD by age 3 years. They used an age- and gender-matched
comparison group of children who had been seen at the same child health center or the same
school health care unit areas as the index children. They found that children who were eventually
diagnosed with ASD had significantly more consultations for excessive feeding problems as well
as crying and sleeping problems than the comparison group. In this very general approach, the
feeding issues were not explored in a specific way. There was no detail with respect to the nature
of the feeding problems other than whether the child required treatment for excessive vomiting
within the first 2 years of life or whether the child was reported to feed well as a baby before
developing a feeding problem. A study by Dominick et al. (2007) was also an inquiry into a vari-
ety of problematic behaviors (eating, sleeping, aggression, tantrums) and included certain feed-
ing problems for children diagnosed with ASD who were 4 to 14 years of age at the time of the
study. Dominick and colleagues used a comparison group of children with a history of language
problems. Their approach was also retrospective in that parents were asked to report “age of
onset” for the different sets of behaviors. They also found that feeding problems were often
reported to have begun during the first year of life and almost all were reported to have started
before the age of 3 years.
When comparing eating problems in children with ASD aged 3 to 12 years to their nearest-age
siblings, Nadon et al. (2011) found parents reported their children with ASD had more mealtime
problem behaviors and limited food variety and intake during meals according to the Eating
Profile measure, which was developed for the purpose of their study. Retrospectively, parents
reported that their children with ASD had significantly more eating problems as infants, such as
transitioning from thin purees to textured foods, compared with their siblings. Similar to the
Olsson et al. (2013) and Dominick et al. (2007) studies, limited information was provided with
regard to more elaborated or specific early feeding problems in the ASD sample.
Field et al. (2003) compared feeding problems in children with ASD with two other groups:
children with Down syndrome and children with cerebral palsy. All were referred to a hospi-
tal-based feeding program. While children with ASD were more likely to have food selectiv-
ity than the comparison groups, the participants ranged in age from 1 month to 12 years of age
and analyses for specific age groups were not conducted. Williams et al. (2005) examined
children who were referred for selective eating specifically. They compared children 2 to 12
Seiverling et al 3

years with ASD to those with non-ASD disabilities and those with no disabilities. Similar to
other studies, the reported age of onset was below 18 months.
While these studies have created a useful foundation, they also point toward a variety of
methodological issues that will need to be addressed to further our understanding about the
nature of feeding problems in ASD when they are first beginning. The first is the issue of what
groups to study. If we wish to know the prevalence of feeding problems in young children with
ASD in general, then the participant group should be broader than those who have already been
referred to a feeding clinic. A second consideration is what constitutes an appropriate compari-
son group. Nadon et al. (2011) used the nearest-aged sibling for contrast because they were
interested in the role that the social environment may have in feeding problems. In contrasting
the feeding issues of children with ASD, it will also be important to understand what may dis-
tinguish those with ASD from children with other developmental disabilities who have features
that are likely to be shared that may give rise to feeding challenges (i.e., oral motor and language
delays [LD]). In fact, past research suggests that children with LD are also prone to oral motor
delays (Visscher, Houwen, Scherder, Moolenaar, & Hartman, 2007), which have also been asso-
ciated with feeding problems in children (Field et al., 2003; Rommel, De Meyer, Feenstra, &
Veereman-Wauters, 2003).
The previous studies investigating feeding problems in young children also point to the need
for more detailed information about the nature of early feeding problems that children with ASD
may experience. The existing studies reviewed here tended to focus on age of onset and supplied
few details about the types of eating issues for children below 3 years of age. Field et al. (2003)
did investigate the reported basis of food selectivity in their sample of children with and without
ASD and found that 62% was on the basis of food type and 31% was due to texture. Similar to
other previous studies, however, children of a very wide age range were combined in their analy-
ses. More specific information is available for older children with ASD, whereby it has been
shown that children with ASD are selective by a variety of dimensions such as food texture, taste
or smell, foods mixed together, brands, and food shape (Hubbard et al., 2014) and even with
regard to utensils and dishes used during mealtimes (Williams et al., 2005).
Finally, few studies examining prevalence and onset of feeding problems in children with and
without developmental disabilities have looked at demographic variables or child characteristics
known to be associated with early feeding problems. Past research suggests that low neighbor-
hood income (Janssen, Boyce, Simpson, & Pickett, 2006) as well as male gender and younger
age (Seiverling et al., 2016) may be associated with various eating problems in children.
In summary, there remains a great need for further research on the prevalence of feeding prob-
lems of young children with ASD, using a sample not referred specifically to feeding clinics, and
using a comparison group of other young children at high risk for feeding problems. Therefore,
the first purpose of the present study was to compare the prevalence of four types of feeding
problems for children with ASD below the age of 3 years, with a comparison group of children
with non-ASD LD, who also may be at higher risk for feeding problems associated with oral
motor delays. The second was to explore demographic variables besides ASD diagnosis (i.e.,
gender, age of first evaluation, and neighborhood income as a proxy for socioeconomic status)
for their associations with the total number of reported feeding problems.
In this study, we reviewed the clinical charts of children who were evaluated for early inter-
vention services within their first 3 years by both speech therapists and psychologists—profes-
sional specialties likely to receive referrals for children with ASD and non-ASD LD. Children’s
charts were reviewed for four feeding problems: food selectivity by texture, food selectivity by
type, refusal to eat new foods, and food overstuffing. Based on past research results, we antici-
pated that these specific feeding problems would be diagnosed more often in children meeting
criteria for ASD than for children with non-ASD LD.
4 Journal of Early Intervention 00(0)

Method
Setting
Charts reviewed were those used in a larger, longitudinal study of children living in a large
county in the Hudson Valley, New York (Towle, Vacanti-Shova, Shah, & Higgins-D’alessandro,
2013). The clinical charts were those of families using a University Center for Excellence in
Developmental Disabilities agency for either diagnostic evaluation or Service Coordination
through the public early intervention program for children birth to 3 years of age. Each Early
Intervention chart had a variety of evaluations, service provision records, provider progress
notes, Individualized Family Service Plans, and other documents that together provided rich
detail about child functioning across developmental domains. The evaluations themselves con-
tained information taken both from extensive parent report and clinician strategies including
standardized tests, criterion-referenced tests, and direct observation.

Procedures and Measures

Charts of children seen for services at the agency from the years 1999 to 2005 were reviewed to
select children with ASD and children with non-ASD LD. The chart abstraction process for
determining presence of ASD is described in previous studies (Towle et al., 2013; Towle,
Visintainer, O’Sullivan, Bryant, & Busby, 2009) but is summarized briefly below. Available
charts for review were those that (a) were deemed to have sufficient information and documents
(e.g., not just an audiologic or single discipline evaluation); (b) were for children below the age
of 3 years when evaluated; (c) were not children with primarily health, motor, or global develop-
mental delays; and (d) appeared to be best candidates for the two groups (ASD and LD) to be
sampled. This yielded a pool of 302 charts. After applying the criteria for determining whether
the child chart represented the ASD or non-ASD LD group (see below), there were 128 in the
ASD group and 143 in the LD group.

ASD classification. The Autism Spectrum Disorder-Decision-Making Protocol (ASD-DMP)

(Towle et al., 2013; Towle et al., 2009) was used for determining which children met inclusion
criteria for the sample of children with ASD. This coding system is based on the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric
Association [APA], 2000) criteria, with coding categories as follows: 0—No ASD present (no
evidence or insufficient evidence for ASD); 1—ASD Possible (there is some evidence to sus-
pect the child might have ASD, but the evidence is not quite sufficient either because the chart
was too thin or because of a lack of the details in the behavioral evidence); 2—ASD Highly
Likely (there is sufficient to abundant descriptive, behavioral, and treatment evidence to support
the diagnosis, but no diagnosis per se appears in the chart); 3—ASD Confirmed (a diagnosis is
given by a qualified clinician, and there is sufficient or better evidence from behavioral descrip-
tions to support this). Only charts coded as “2” or “3” were used for the participant pool. “Suf-
ficient evidence” consisted of converging information, pinpointing symptoms from all three
DSM symptom domains, from several sources in the chart—background information from eval-
uation reports; stated concerns of caregivers, teachers, or service providers; the body of evalua-
tion reports; provider progress notes; and Individualized Family Service Plan descriptions and
goals. If a child had an independent diagnosis of ASD, or received one as a result of the early
intervention evaluation, this information would be in these sources. Behavioral descriptions
noted included descriptions of or concerns about eye contact, social relatedness and interaction,
self-stimulatory behaviors, atypical language or LD with significant pragmatic delays, delayed
and/or unusual play patterns, and absence of many descriptions that contraindicated ASD.
Seiverling et al 5

Another source of evidence was the services that the child had been receiving or subsequently
received after the evaluation. Services that are typical of children with ASD are (a) several or
many hours of Applied Behavior Analysis, or other intervention associated with ASD such as
FloorTimeTM, (b) services from many different disciplines combined with above, and (c) atten-
dance in programs that have a high proportion of children with ASD.
Only cases rated Highly Likely (17.3%) and Confirmed (82.7%) were used for the study. As
described in Towle et al. (2009), interrater agreement for the DSM-DMP was good, with a
weighted kappa of .86 (95% confidence interval [.33, .94]).
Non-ASD LD status was determined if (a) the primary referral concern was for delayed lan-
guage, (b) behaviors noted throughout the referral and evaluation process confirmed a LD, and
(c) the child did not show significant difficulties in social (eye contact, lack of social interaction)
or repetitive behaviors.
Narrowing the sample was based on consistency of evaluations available. Across charts, the
number and type of evaluations included for each child varied, but typically fell within the fol-
lowing categories: psychological evaluation, speech/language evaluation, team or multidisci-
plinary evaluation (generally written by a team of clinicians such as a psychologist and speech
language pathologist, and sometimes an additional discipline), occupational therapy, pediat-
rics, and other (e.g., neurology, special education, and physical therapy). For the purposes of
this study, only psychological, speech, and/or multidisciplinary evaluations consisting of only
psychological and speech disciplines were reviewed. Piloting the charts for feasibility of the
study, it was noted that the majority of feeding problems were reported in these two disci-
plines. This way the charts within and across groups were made consistent in terms of the type
of information that was gathered. The final sample then consisted of 78 children with ASD and
85 children with LD.

Child and family demographics.  The child’s gender, age of first evaluation, and the neighborhood
mean income were abstracted from each chart. The ages of children in the sample ranged from 9
to 36 months with 45% of children with ASD and 54% of children with LD below 24 months of
age. Neighborhood income was determined by looking up the median household income for the
reported town of residency according to the U.S. Census Bureau (2010) of each child at first
evaluation.

Selecting and coding feeding problems.  Feeding problems were selected by first piloting the charts
to determine those most consistently reported and described. The selected problems of food
selectivity by texture, food selectivity by food type, and refusal to eat new foods correspond well
to types of problems reported for children with ASD (Ledford & Gast, 2006) and other young
children (Reau, Senturia, Lebailly, & Christoffel, 1996; Wright, Parkinson, Shipton, & Drewett,
2007). We added food overstuffing because this was also mentioned consistently in the reports.
Most often, a description of feeding problems was found in a feeding or oral-peripheral mech-
anism section of a speech language evaluation or in the adaptive skills section of psychological
or team evaluations. Although all children in the sample received evaluations from both psychol-
ogy and speech, for those who did not receive a team evaluation and received individual psycho-
logical and speech evaluations, a minimum of one of the child’s evaluations needed to indicate a
specified feeding problem according to the defining criteria for the feeding problem to be
endorsed. The first author initially used a subset of charts to train an undergraduate student how
to code and classify each feeding variable. Then both these raters independently coded each chart
for presence or absence of each feeding problem using the following operationalizations.

Food selectivity by texture.  Selectivity by texture was determined if an evaluator wrote that the
child was reported to show avoidance or preference toward specific textures of foods. Avoidance
6 Journal of Early Intervention 00(0)

was determined if the evaluators wrote that the child refuses, rejects, disliked, did not care for,
exhibited sensitivity, aversion, restricted acceptance, or had difficulty with certain textures of
foods. Preference was indicated if the evaluator wrote that the child prefers, craves, only eats,
only reliably eats, or tolerates certain textures of foods. The following key words were used
when making determinations whether the child was reported to demonstrate preferences or
avoidance of the following textures of foods: crunchy, mushy, soft, puree, chunky, al dente, easily
chewed, mixed textures, and nontextured foods. Examples from evaluations include the child has
difficulty tolerating mixed textures and foods eaten are primarily puree consistencies. If none of
the evaluators included any of the above statements regarding the child’s eating into their reports
for a child, food selectivity by texture was not endorsed.

Food selectivity by type.  Selectivity by food type was determined if an evaluator wrote that the
child was reported to show preferences or avoidance (using the same criterion as above) toward
specific types or tastes of foods. Selectivity by type was determined if it was noted that the child
preferred or refused entire food categories such as meats, fruits, vegetables, dairies, and starches,
as well as certain tastes (e.g., sweet, salty, sour, high in flavor). Examples from evaluations
include X is a picky eater and generally likes sweeter foods and he prefers eating foods that are
high in flavor. As with selectivity by texture, if none of the evaluators included statements regard-
ing child preference for certain types of food in their reports, the feeding problem was not
endorsed.

Refusal to eat new foods.  Refusal to eat new foods was determined if an evaluator wrote that the
child tended to avoid (according to the avoidance criterion above) eating, consuming, or sam-
pling new foods.The additional key words written by evaluators with regard to the child trying
new foods were used when making determinations if the child was reported to exhibit refusal to
eat new foods: reluctance, hesitation, unwillingness to try, and does not tolerate. Examples from
evaluations include tends to refuse or eat around new food and does not tolerate or cooperate
with trying new foods. If the above descriptions were used to describe a child’s refusal to try
specific types or textures of foods, then selectivity by type or texture was endorsed instead of the
refusal to eat new foods. If child refusal of new foods was not described in any reports, the feed-
ing problem was not endorsed.

Food overstuffing.  Overstuffing was determined if the evaluator indicated that the evaluator,
parent, or guardian was reported to observe the child “shoving” or “stuffing” food in his or
her mouth as well as placing or putting “too much food” in his or her mouth. Additional key
words included overstuffing and overfilling in reference to putting food in the child’s mouth.
If the child was reported to store the food in his or her mouth or if the evaluator wrote that the
child had a tendency to collect a food bolus at the side of the mouth, food overstuffing was
also endorsed. Overstuffing specifically referred to the amount of food in the child’s mouth
while eating and not the total amount of food consumed by the child during mealtimes. If
none of the evaluators included statements regarding food overstuffing using the terms above
regarding a child’s feeding behavior, the feeding problem was not endorsed as a problem for
that child.

Coding reliability. The primary investigator and the trained undergraduate research assistant
reviewed 38 (23%) of the original 163 early intervention charts for interrater reliability pur-
poses. The two raters independently determined whether (0 = no, 1 = yes) the charts recorded
each of the four feeding problems (food texture, food type, new foods, overstuffing). Interrater
reliability was determined by kappa agreement statistics, which showed excellent agreement for
problems of food texture (κ = .78, p = .000), food type (κ = .79, p = .000), new food refusal
(κ = .85, p = .000), and overstuffing (κ = .62, p = .000).
Seiverling et al 7

Table 1.  Descriptive Statistics for Children with Autism Spectrum Disorder (ASD) and Language Delay
(LD).

ASD (n = 78) LD (n = 85)

VARIABLE % % χ2 p
Male gender 79.5 64.7 4.39 .036
  M (SD) (range) M (SD) (range) t df p
Age (months) at first evaluation 26.06 (7.02) (9-36) 23.82 (4.65) (10-34) 2.41 161 .017
Mean neighborhood income $88,918.07 ($40,584.38) $72,859.53 ($33,063.10) 2.71 153 .007
($41,128 - $182,792) ($41,128 - $182,792)

Note. ASD = autism spectrum disorder; LD = language delay.

Data Analysis
The Statistical Package for the Social Sciences (SPSS) was used for data management and analy-
sis. Parametric (analysis of covariance [ANCOVA]) and nonparametric procedures (chi-square
analysis) were used to examine the empirical questions.

Results
Child Characteristics as Abstracted From the Charts
Table 1 shows parameters of child age, gender, and neighborhood income for the sample.
Significant differences between the ASD and LD group were found for each of these demo-
graphic variables. The ASD group had a higher proportion of boys, were slightly older when first
evaluated, and had higher neighborhood incomes.

Feeding Problem Prevalence for Children With ASD and LD

The first goal for data analysis in the present study was to compare the ASD and LD groups on
prevalence of each of the four feeding problems: food selectivity by texture, food selectivity by
type, refusal to eat new foods, and food overstuffing. For each feeding problem, a 2 × 2 chi-
square analysis was conducted to see whether the two groups of children differed in whether or
not a report of the feeding problems was found in the charts (no, yes). When the two groups were
compared on how many children had any (one or more) feeding problems, the ASD group had an
overall prevalence higher than the LD group. The analyses revealed that children with ASD had
significantly higher probability of showing each of the four feeding problems than children with
LD. When the two groups were compared on how many children had any (one or more) feeding
problems, the ASD group had an overall rate higher than the LD group. In addition, the two
groups were compared on mean number of feeding problems using a t test, showing that the ASD
group had a significantly higher average (see Table 2).

Child Characteristics Associated With Total Number of Four Feeding Problems

Because the two groups had been found to differ significantly on child demographics measured
(gender, age of first evaluation, neighborhood income), a second goal for data analysis was to
examine whether the group differences in total number of feeding problems persisted even when
the demographic variables were taken into account. A 2 × 2 ANCOVA was conducted to
8 Journal of Early Intervention 00(0)

Table 2.  Prevalence of Four Feeding Problems for Children with Autism Spectrum Disorder (ASD) and
Language Delay (LD).

ASD (n = 78) LD (n = 85)

FEEDING PROBLEM % % χ2 p
Food selectivity by texture 23.1 7.1 8.31 .004
Food selectivity by type 24.4 11.8 4.41 .036
New food refusal 10.3 0.0 9.17 .002
Food over-stuffing 14.1 3.5 5.79 .016
Presence of one or more problem 43.6 20.0 10.53 .001
  M (SD) (range) M (SD) (range) t df p
Mean # of four feeding problems .72 (.98) (0 - 4) .22 (.47) (0 - 2) 4.16 161 .000

Note. ASD = autism spectrum disorder; LD = language delay.

Table 3.  Analysis of Covariance for Number of Feeding Problems and Diagnosis, Gender, Age, and
Neighborhood Income.

Effect F df p Effect size ( η2p )

Diagnosis (ASD vs. LD) 4.78 (1,149) .030 .031
Gender 7.80 (1,149) .006 .050
Diagnosis × Gender 3.30 (1,149) .071 (ns)  
Age of first evaluation .21 (1,149) .649 (ns)  
Neighborhood income 1.39 (1,149) .240 (ns)  

Note. ASD = autism spectrum disorder; LD = language delay.

compare number of children’s feeding problems across diagnosis groups (ASD, LD), and gender
(male, female), with age of first evaluation and neighborhood income serving as covariates.
Neighborhood income information was missing for eight of the 163 children in the present study,
so only 155 children were included in the ANCOVA because all relevant variables were available
for them.
The results of the analysis supported the significant difference between the two diagnostic
groups (ASD, LD), with children with ASD showing more of the four feeding problems than did
children with LD (ASD: M = .75, SD = 1.00; LD: M = .23, SD = .48). In addition, a significant
main effect for gender was found, with male children showing more feeding problems than did
female children (male: M = .59, SD = .89; female: M = .16, SD = .43). No significant main
effects were found for age of first evaluation or neighborhood income, and no significant
Diagnostic Group × Gender interaction effects appeared (see Table 3).

Discussion
Present results indicate that feeding problems in children with ASD may be identified at a
young age. Specifically, results suggested that children with ASD are at significantly greater
risk than a comparison group with non-ASD LD during their first 3 years of life for each of
four types of feeding problems: problems with food texture, problems with food type, new
food refusal, and food overstuffing. When considering how many children with ASD in the
current sample had any of the four feeding problems, the prevalence rate of 44% of children is
slightly lower than previous estimates that indicated over 50% of children with ASD had
Seiverling et al 9

feeding problems such as food selectivity by type or texture (Ahearn et al., 2001; Collins et al.,
2003; Schreck et al., 2004).
The slightly lower prevalence rates of feeding problems in the ASD population found in this
study may be an underestimate due to the retrospective chart review method because it is possible
that not all feeding problems were identified in the evaluations reviewed. Furthermore, the lower
prevalence rate may be a result of the younger sample examined in this study compared with
most of the previous studies examining prevalence of feeding problems in the ASD population
spanning an older and wider age range of children.
The current results support previous findings that certain feeding problems tend to be greater
in children with ASD compared with various types of comparison groups such as children with
LD without ASD (Dominick et al., 2007), siblings without ASD (Collins et al., 2003), children
with and without other developmental disabilities referred to feeding clinics (Field et al., 2003),
as well as comparison groups of typically developing children (Hubbard et al., 2014; Olsson
et al., 2013; Schreck et al., 2004).
A benefit of the current study is that more detail regarding the prevalence of early feeding
problems seen in the ASD population were gathered compared with previous retrospective chart
reviews during which parents reported mostly whether early feeding problems were present or
absent (Dominick et al., 2007; Olsson et al., 2013). Furthermore, results also suggest that male
children are more likely to have feeding problems than female children—a finding supporting
past research that has found males tend to show more feeding problems than females, separately
and apart from their greater tendency to have ASD (Seiverling et al., 2016). The present study
also gathered information on food overstuffing, a feeding problem that has not been examined in
children with ASD, but which may be especially common in children with motor delays (Field
et al., 2003; Reilly, Skuse, & Poblete, 1996). We were able to do so because this problem tended
to be mentioned by the evaluators seeing this sample of children.

Study Limitations and Directions for Future Research

One of the main limitations of the study was its retrospective method, whereby the researchers
had no control over how much detail regarding feeding problems was provided in each report.
For example, the chart abstractions of the present study could not determine the severity or fre-
quency of each of the four feeding problems, the specific types of foods the child rejected, or
whether the feeding problems were ongoing or only past problems. Furthermore, researchers
could not control how evaluators posed questions regarding child feeding problems to caregivers.
Despite these limitations, we were able to successfully use the chart abstraction method to review
information consistently reported in the charts regarding feeding problems in children under the
age of 3 years.
In addition, the charts did not always include information about the developmental issues of
concern at referral, severity of ASD symptomatology, medical conditions, motor delays, or other
diagnoses for the children, or demographic information such as ethnicity, age, and education of
the parents. Although research has shown that while ASD is a reasonably stable diagnosis over
time, a minority of children initially meeting criteria for ASD will no longer meet criteria during
a follow-up period (Woolfenden, Sarkozy, Ridley, & Williams, 2012). It is also important to note
that the DSM (4th ed.; DSM-IV; APA, 1994) diagnostic criteria for ASD had been used for clas-
sifying children with ASD (Towle et al., 2009), so it remains unknown whether the same children
would have been classified as having ASD if the newer DSM (5th ed.; DSM-5; APA, 2013) crite-
ria had been used.
Finally, since the socioeconomic status of the sample was based on a broad measure of aver-
age town income, influence of socioeconomic differences may be better measured with more
traditional measures of educational and vocational status.
10 Journal of Early Intervention 00(0)

Future research could include investigation of the effects of early intervention for children
identified as having feeding problems using the chart abstraction method used in the present study.
Past research suggests that feeding patterns tend to remain the same across the course of childhood
without intervention (Skinner, Carruth, Bounds, & Ziegler, 2002), but if children are identified as
having feeding problems before the age of 3 years, perhaps their diets can be improved and with
less intensive interventions than those required at a later age. Future research could also use early
intervention charts to investigate the prevalence of other types of behavior problems in children
below the age of 3 years such as restricted, repetitive behaviors typically seen in children with
ASD or adaptive behavior and self-help skills (e.g., dressing oneself, self-feeding) to determine
which types of research questions are best suited for the chart abstraction methodology.
The chart abstraction method may be helpful to researchers examining the prevalence of
feeding problems and other aberrant behaviors in young children; however, with regard to
improving early intervention practice, clinicians working in the field of early intervention and
evaluating young children for feeding difficulties would benefit from using standardized ques-
tionnaires and checklists such as the Brief Assessment of Mealtime Behavior in Children
(BAMBIC; Hendy, Seiverling, Lukens, & Williams, 2013) or Pediatric Eating Assessment
Tool (Pedi-EAT; Thoyre et al., 2014) when conducting evaluations. Using standardized mea-
sures would provide clarity regarding the types and severity of child feeding problems reported
by caregivers of young children.
Future researchers should continue to examine the age of onset of various feeding problems
in children with ASD as well as the role early feeding problems may play in detection of ASD.
While differences in feeding behavior of children with ASD can emerge in infancy (Olsson
et al., 2013), it is unclear whether early feeding problems may be used as a potential marker or
indicator of ASD. Furthermore, the finding that food overstuffing was more commonly seen in
children with ASD compared with the children with LD sparks additional research questions.
Previous researchers have examined interventions for treating two behaviors that may coincide
with food overstuffing, packing behavior (i.e., any food larger than the size of a pea in the
mouth 30 s after acceptance; Buckley & Newchok, 2005; Volkert, Vaz, Piazza, Frese, &
Barnett, 2011), and rapid eating (Anglesea, Hoch, & Taylor, 2008) in children with ASD; how-
ever, researchers have not examined the prevalence of food overstuffing in the ASD popula-
tion. More research examining the early oral motor skills as well as hyper- or hyporeactivity to
sensory input, and self-feeding skills of children with ASD should continue to be examined as
all of these may play a role in the development of food overstuffing behavior.

Authors’ Note
Laura Seiverling is also affiliated to Department of Special Education, Ball State University, Muncie, IN,
USA.

Acknowledgments
The authors thank Lauren Waddell and Carina Baldacci for their assistance with this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: The present study was supported in part by Grant T73MC04320 from Department of
Health and Human Services Health Resources and Services Administration.
Seiverling et al 11

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