The Autism Managing Eating Aversions and Limited Variety Plan vs parent education

Article Reviews
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Read Full Text: The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial (Not free yet, but should be free within a year because it received NIH funding)
Journal: The Journal of Pediatrics (Impact Factor 3.890)
Year Published: 2019
Thank you to Katie Caspero, MS, OTR/L for helping me find and review this article!

This is the first time since we began the Club that we have specifically sought out research around a suggested topic—and this topic is pediatric feeding.

Articles on pediatric feeding interventions didn’t naturally fall into our current list of the most influential OT related articles, but we know that this is a common referral for many of you.

This study seeks to analyze the feasibility and efficacy of a protocol that caters to children who have both ASD and moderate food selectivity. To be more specific, the study examines how well a behavior-based parent-education model called Managing Eating Aversions and Limited Variety (MEAL) worked with such children.

Unfortunately, the MEAL protocol is not currently on the market (we’re hoping it will be released more widely)—but, in the meantime, this research can help us start to form general principles around feeding interventions for ASD. And this information can also help us consider how occupational therapy will factor into these types of interventions in the future.

What OTs need to know about this article

Food selectivity impacts as many as 95% of children with autism. The stress can be immense for parents, who try to provide nutritional diets for their children—but face an uphill battle of children refusing non-preferred foods.

This 16-week randomized clinical trial (RCT) compared the MEAL Plan protocol to a control group (which consisted of parent education alone).

The interventions were delivered at a multidisciplinary feeding program, which you can read about here.

The MEAL Plan is a group-based program with a structured lesson plan of modules on nutrition education, meal structure, and increased variety in the child’s diet. The remainder of the session included real-time coaching with the child and parent during feeding intervention, along with time when group members watched and learned from each other. In addition, the families completed weekly individualized home instruction.

The group was lead by a psychologist, and co-led with a nutritionist, with the goal of improving mealtime behaviors and increasing dietary variety in children with ASD and moderate food selectivity.

Diagnoses of children in the study included:

38 children between the ages of three and eight were randomly divided into two groups. All children in the groups were diagnosed with ASD and moderate food selectivity, which was defined in the following way:

Children with ASD with moderate food selectivity that ate:

  • Greater than or equal to six items
  • Greater than or equal to ne fruit or vegetable
  • Greater than or equal to one item from another food category
  • Two or fewer items in > One food category
  • Persistent refusal behaviors with non-preferred foods

Interventions

The MEAL Plan Intervention

The primary intervention took place over ten 90-minute group sessions, over the course of 12 weeks, with three booster sessions at weeks 14 and 16. These sessions were offered via phone or in person, and were led by a behavioral psychologist and assisted by a psychology graduate student. Sessions two and seven were co-led by a dietician.

Here’s the general flow of what took place:

Initial sessions included scripts for the following subjects:

  • Introduction to feeding difficulties in ASD
  • Monitoring mealtime behavior
  • Nutrition planning
  • Structuring meals

Sessions four through seven consisted of:

  • Methods for promoting appropriate mealtime behavior
  • Introducing foods
  • Modifying mealtime interactions
  • Implementing feeding intervention incorporating new foods in the future

Final sessions consisted of:

  • Generalization of treatment gains
  • When to introduce new foods
  • Program review
  • Summary of key elements

Each session from the fifth one on included:

  1. 30 minutes of parent-child meal demonstrations so participants could practice the application of treatment element. This included in-vivo coaching from therapist (in room or with ear bud) and immediate feedback on the treatment implementation for others to learn from each other
  2. Each pair took turns while others watched behind a one-way mirror

Materials needed were a parent workbook with summaries of each session and homework to help with implementation. Role plays were included in the book, using visuals and hands-on activities for parents to practice what they learned during the sessions.

The Control Group: Parent Education Program (PEP)

For the control group a psychologist led the parents through a structured education curriculum about ASD. The program was also ten 90 minute session (just like the MEAL program) and thus served as control for whether just general parent education was a difference maker as opposed to specific MEAL protocol.

10 sessions (90 minutes each)

  • Group format
  • Delivered to parents only
  • Parents are given a script for each session, containing:
    • General information on young children with ASD
    • Developmental expectations
    • Education planning
    • Advocacy
    • Current treatment options

Assessments utilized during this study

What they found

The study found that the MEAL Plan appears to be a feasible program, and preliminary data suggests that it may improve maladaptive mealtime behaviors and improve dietary expansion in children with ASD and moderate food selectivity. MEAL Plan has possible sustainable long-term effects.

Specific improvements identified after completing MEAL Prep included:

All parents who participated in the MEAL Plan group stated they would continue to use the behavioral techniques from the program after it was completed, as they were highly satisfied.

And, 94% of parents indicated that the treatment improved their own child’s mealtime behaviors.

Based on the CG-I, 47.4% participants of the MEAL Plan Group: rated “improved” or “very much improved” at 16 weeks. This is significant, especially compared to participants of the Parent Education Program (PEP), in which only 5.3% rated “much improved” or “very much improved.”

Children in MEAL Plan showed a significantly lower BAMBI total score (which is a good thing), too.

Grams consumed during the meal observation increased at both time points in the MEAL Plan Group, whereas grams consumed decreased at each time point in PEP.

Limitations

There were a few limitations of this study, including:

  • Reliance on parents who were not “blinded.” This means parents were aware of whether their child or other children were in the treatment group versus control group
  • Small sample size
  • No standardized measure of diet variety

Key Takeaways for OT Practitioners

  1. It seems that, for kids with autism, it may be possible that food sensitivities can improved through a structured therapy program.
  2. A blend of parent education and coaching strategies with feeding intervention seems to be more helpful than parent education alone.
  3. OTs may have some advocacy to do to be included as providers of the MEAL Plan protocol, but it seems like a natural fit.
  4. Feeding interventions that are currently implemented in the clinic require more rigorous studies like this one to prove the efficacy—and to provide support from the greater health care community
  5. This study mentioned the group-based format was logistically difficult, and that future studies would benefit from examining individualized sessions using the MEAL Plan format.

Listen to my takeaways in podcast form

Find other platforms for listening to the [OT Potential Podcast here.](https://otpotential.com/ot-potential-podcast)

Full APA Citation

Sharp, W. G., Burrell, T. L., Berry, R. C., Stubbs, K. H., Mccracken, C. E., Gillespie, S. E., & Scahill, L. (2019). The Autism Managing Eating Aversions and Limited Variety Plan vs Parent Education: A Randomized Clinical Trial. The Journal of Pediatrics , 211 . doi: 10.1016/j.jpeds.2019.03.046

What questions/thoughts does this article raise for you?

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Sarah, I appreciate the diversity of topics the club is covering. Feeding and mealtime are significant issues for parents with children who have autism. Mealtime should be a time for a family to connect and spend quality time together, but mealtime is a time of battles, stress, and anxiety for both the parent and the child with autism.

Another summary I found helpful was here CTG Labs - NCBI.

This site broke the study into short comparisons of two interventions: Autism MEAL plan and Parent education. I also appreciated the listing of outcomes measures. What is missing from this link if the actual outcomes listed in the article?

The article made me curious as to methods other known ‘Feeding Program’ advertise or state that they use. Kennedy Krieger Institute is one I was familiar with from a former client and family. They use a full team, as noted in the article, but an approach with a name or method is not stated.

They offer assessment and three levels of programs: outpatient program, day program, and inpatient programs based on child needs. Outpatient for children whose mealtime behavior is problematic, but their nutritional state is not severely impaired. Day treatment for children who do not need round the clock supervision but need a stronger intensity of therapy provided daily. Finally, the inpatient program for children who have severe feeding difficulties requiring 24-hour nursing /medical supervision.

Duke University’s occupational therapy and speech therapy work as a team to address feeding disorders, and again, an actual model of practice is not outlined.

I appreciate this article for as you indicated, providing a foundation for the need to look at feeding disorders and create evidence-based approaches, which have been researched.

I find the combination of parent education and child therapy a robust approach to feeding disorders, which have many contributing factors to their causes. Hands-on child-specific feeding interventions with parent report and home data logs focusing on the application of skills makes sense from a behavioral model approach.

To those in the group who focus on feeding, what are your thoughts on your approach vs. that outlined in the Autism MEAL plan? How about parent education is done as a group vs. one-on-one?

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Wow, @sherry that breakdown from clinicaltrials.gov was really helpful!! Thanks for sharing that. I’ve been really impressed with the steps that the NIH is taking to make research more accessible—honestly, this seachange is honestly what makes this journal club possible!

I’m glad you mentioned inpatient programs for children with severe feeding difficulties. The article mentioned that inpatient programs for these children is “well-supported” be research and the articles they cite would be interesting to dig into.

I agree that I’m excited to hear from therapists who deliver feeding treatments!

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Thanks Sarah! My understanding of autism and selective eating is quite limited, but I have 3 thoughts regarding this subject.
1–my son, never diagnosed but appears ASD-Asperger’s, stated at age 3 that he wanted to be a vegetarian because when he chewed meat, it was too loud in his ears (again with the suspected cranial nerve involvement.)
2—Lack of oral-motor skills and lateralization. I have known children who consistently eat from the “white group” as these refined flour foods can be mashed with saliva to form the sweet bolus, and are much easier to swallow.
3–I have not studied nor know about metabolism differences in ASD. I suspect there may be differences in their energy requirements, based on the repetitive / stereotypic behaviors, etc. Quick energy demands a different eating style.

Just more thinking, but I hope someone can provide guidance on these subjects!

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Still being in my first few years of practice this is a population that I am striving to better serve, so I appreciate the inclusion of this article! I am currently working in an outpatient clinic of Children’s Hospital of Richmond at VCU and (like Kennedy Krieger and Duke) they have their own in-house feeding program that isn’t a named method or approach.

Children’s Hospital of Richmond Feeding Clinic

Before working for CHoR I had been attempting to implement SOS Feeding Program (Star Institute Feeding Therapy) methods as that was what I had exposure to in my course work and during fieldwork, but now I am being encouraged to follow our in-house protocols instead for consistency’s sake. Presently I don’t have any children on my caseload with feeding goals in their plan of care, so I haven’t had as much opportunity lately to put what I’m learning into practice, but I look forward to future opportunities. Also, I may get the chance to shadow some OT’s at the Brook Road campus where the main feeding clinic is because I find that the art of feeding therapy is better learned in person. There’s so much nuance, especially when it comes to reconditioning behavioral responses and knowing when and how to introduce new foods.

One of my favorite resources to share with parents who are frustrated by how long the process of introducing new foods is taking is Kay Toomey’s Steps to Eating which gives them a very clear visual. I also LOVE interactives during feeding including board game place mats, sorting/matching place mats, spinning wheel or dice for which food to interact with (smell,touch, lick etc) and building with food (celery stick log cabin, noodle hair etc.).

I look forward to any other posts along with @sherry’s because the more ideas around this complex topic the better!

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Wow! @maggie, I love that Steps to Eating visual. I’ve never seen an activity analysis presented in that way. I wish we had something like that for every ADL to help explain our work to patients.

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Very interesting topic and great discussion around it. I only see babies in the NICU and sometimes do feeding along with the SLP. I wonder if some of these issues start very early and are there any symptoms to be watched in a preemie? There are many babies who cannot go home due to not taking a bottle prior to dc. Most of the times, it has to do with coordination with breathing but maybe some of these issues surface early?. Parent education regarding looking out for these problems may be a good start in the NICU.
Maggie, the “Steps to Eating” ladder is interesting and could serve as a guide for parents.
Sherry, thanks for the added resources.
I am sure there are many feeding assessments in OT. Interestingly, recently I was asked to review a new assessment being developed by an OT and one of our students to assess feeding in children. I was amazed to see the number of detailed areas included in it. I was happy to see such a daunting task been undertaken by OTs.

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The Steps to Eating visual is so helpful in our clinic to show progress to parents that may be frustrated and don’t understand why they won’t just eat something. For older kids a clinician made a laminated step chart with each of these steps listed so they could literally jump or step forward and have some control over the next progression.

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I also love the resource Maggie on Steps to Eating, which provides a great visual for the successful road to eating. Who knew that playing with food would be appropriate for some kids while we all know that playing with food is a method of development and learning so it makes perfect sense!

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I love the Steps to Eating Visual - Thank you Maggie! I am sending it to a family today. Thank you to Sherry for the helpful link and information. Meal time and limited diets are such a source of stress for many of the families I work with so I really appreciate this topic.

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Hey @maggie, I’ve been wondering about the copyright status of the Steps to Feeding visual? Did it come from a packet in the course work? I’m seeing some free downloads from the website, but I can’t find that one: https://www.spdstar.org/basic/feeding-therapy##f6

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To my knowledge it’s from out of print materials. The copy I have is from a packet of resources that my field work educator gave me and the copy I posted is an image I found online though I could have scanned my copy if I had time. Thank you for bringing that up!

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All, I have been thinking more about the study this week and a few more things jumped out at me that all of us can consider in our practice settings.

  1. In the MEAL plan, Education was offered generally the first three sessions, but the next seven sessions were individualized based on parent – report and home data collection. While the education provided in the Active Comparator was general education for ten weeks and did not include education related to feeding problems (interesting), so are we comparing apples and oranges?

My take away here is that the group made application of patient education research, which suggests the need to understand the literacy of clients, involve clients and have clients teach-back education or in this case give homework to apply what they have learned, offer visuals to support learning, and use technology. https://patientengagementhit.com/news/4-patient-education-strategies-that-drive-patient-activation

  1. The sessions provided by the MEAL study were client centered as the last seven sessions were based on the parent and child, so they were individualized, and the other group appeared just to select topics they felt the parents needed to know about regarding autism.

‘Take away’ OT practitioners are aware of the need to individualize client care based on needs.

  1. My last thought is regarding current practice and the great debate about protocols that are established. Several members stated facilities desire therapists to follow protocols. One thinks these are created by research, but do facilities make the research available to practitioners and clients to confirm the use of research in establishing protocols?
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Wow ! Great Topic Sarah.
On one hand my practice area was mostly Ortho, Hands, Neuro-mainly with adults and seniors. Did some pediatric work-mostly those little adorable hands.
On the other hand I have a son with ASD (diagnosed a little later in life)who came into my life at the age of 9 (after his mother passed away)
And then it was a big long roller coaster ride for both of us. I read and studied and took him to psychologists, nutritionists etc-the whole gamut. For more reasons than one.
I tried my best to manage his ‘eating aversions’ with a keen clinical eye and also a heart full of compassion and understanding. To be honest he was very clear about what he liked and disliked. Body language was also very clear re the same.
So, I managed as best as I could given the situation of his ‘eating aversions’, possible medication side effects ( cos he was Dx as ADHD ) and perhaps some cultural situations too. I cooked and served based on my knowledge of nutrition at that time, his preferences, in a happy comfortable with minimal or nil criticism.
Now he is a 33 years young adult. Graduated and close to completing his post graduation (has a paper left to complete and he is not one bit interested in completing it). Overall healthier in body and mind. Conscious and comfortable in his body despite some weight issues. Eats outside a lot and has been educated to pick quality over price.
I think the article is very good-especially cos it stimulated the discussion. Maybe I have not contributed much in a hard core clinical sense. But wanted to share my personal struggles anyway to fellow OTs.
The comments that followed were even better. Thanks to Sherry, Kelli, Maggie,Sanchala, Katie, Tee :clap:

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I love so many things about your #1 point! I agree that the choice of comparing the MEAL protocol to general autism education gave me pause as well. I find myself wishing in every study like this that there was a no-treatment group, a conventional intervention, then the experimental intervention.

Your takeaway from #1 totally opened my eyes to the concept of “patient activation.” I’ve always been interested in patient engagement, but honestly didn’t realize the helpful framework and language that is out there for thinking about it.

Finally, the article you posted led me to this group, which is a proponent for sharing notes with patients. https://www.opennotes.org/

I have long thought that this is the direction OTs need to head, as I believe we need to have patients FULLY involved and bought in in the OT process, if we hope to make a lasting impact.

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Hi @sridevi, as I was spending time with this article, I definitely suspected that the topic would hit close to home for some of our readers, so I’m so glad that you jumped in with your personal struggles.

It is especially good to hear from someone who has a son who has transitioned into adulthood and now has reached the point of being comfortable in their body and is directing their own meal choices.

I never anticipated this, but I’m so thankful to be an OT if only for how much it has impacted my parenting. And, I’m so glad you were able to apply your OT critical thinking to helping your own son.

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Hi all! Tardy the party but I thought I’d weigh in since I’m fortunate to e part of a unique feeding therapy team. We have found that on a whole that feeding therapy programs to which utilize ABA-based tenets don’t do much to quell the students’ fear or lack of desire to interact with foods…therefore not tapping into their intrinsic motivation, which is the only true path to success in building healthy relationship with food. Eating is the most sensory experience we take part in, so the best course we have found to truly help students is to take it slowly, let them explore without pressure to eat. This might mean doing food art, building with food, or smelling/touching new foods. It takes encouragement but is never forced.

Our feeding therapy program has evolved from and is informed by various methodologies (including those already mentioned in the comments) in combination with child-centered strategies such as use of positive mealtime language, modeling, and use of visuals such as a social story, matching, games & visual art templates.

We treat outpatient students with parents present, as well as students in a day program and those who are residential. Our students really shine within the residential program, bc we have trained dietitians and chefs on site who are familiar with the program and along w residential staff work collaboratively with the child’s feeding therapist to optimize results.

We find that the biggest hurdles include elimination of the “first, then” concept related to meantime… also the fact that many children w autism may compartmentalize their habits, meaning they will eat something in one environment such as a tx session but not necessarily other environments (such as classroom or home).

Our team is working towards developing a parent training curriculum including various topics and trainings. I love the idea of ongoing 1:1 support, and think something like this could really enhance the parent education outreach program & promote higher levels of success and carryover at home.

Has anyone taken part in a successful parent training program? If so do you have any other recommendations?

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Wow! Betsy, it is so amazing to hear from someone with your experience!!!

So much of what you said backs up the research that we are seeing, from the fact that folks within the residential program are really shining to just the general trend that the successes that we see in the therapy environment sometimes don’t translate to the home without proper bridging.

I was wondering if you had an example of positive meal-time language? The concept makes a lot of sense to me, but I haven’t read anything about that!

@bryden or @katie, do you know of any successful parent training programs?

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