Dr Claire Blennerhassett, Dr Michael Richards and Dr Steve Clayton

Food selectivity is considerably more prevalent in children with autism spectrum disorder (ASD) compared to children who are not autistic. Food selectivity is an umbrella term which refers to an insufficient variety of food consumption, characterised by a range of feeding issues including food refusal, limited food repertoire, and a high frequency of single food intake. Factors underlying this include sensitivities to taste, texture, and smell along with gastrointestinal symptoms such as reflux and constipation. The impact of food selectivity depends on the severity of the food restrictions but can include nutrient deficiencies, obesity, and medical complaints associated with poor nutritional status, such as iron deficiency anaemia.

Inappropriate mealtime behaviours are also common in autistic children, causing stress for the child, caregiver, and siblings. Changes to the food served or mealtime routine often heightens challenging behaviours. This can have consequences for the whole family, such as increasing feelings of pressure, worry and stress regarding their child’s nutritional intake as well as difficulties during holidays and family gatherings. It has also been reported that mothers of children with food selectivity, both with and without ASD, can experience more mental health and wellbeing issues, including, but not limited to low self-esteem, anxiety, and social isolation. In the case of mothers of children with ASD, this may reflect the lack of perceived support not only from family members and friends, but also from professionals.

To date, literature reviews have mostly characterised the state of food selectivity, the types of feeding issues and interventions to improve food selectivity. As well as the short-term effectiveness of interventions for improving food intake, eating behaviour, and secondary outcomes such as caregiver stress. Little attention has been paid to evaluating the meaningfulness of reported improvements in these outcome measures for the child or family (e.g., did changes in food intake improve the nutritional status of the child).

On this basis, we decided to critically evaluate the effectiveness of caregiver-led interventions with specific attention to the meaningfulness of any reported improvement. Also, given the current financial limitations in health and social care, the practicality of the intervention. We assessed the meaningfulness of improvements in food, behaviour, and family outcomes, alongside the acceptability of the interventions. Out of the 36 studies reviewed, all 29 case-based studies reported improved food outcomes, and two-thirds of the remaining experimental-design studies resulted in statistically significant improvements. While the statistical significance can be used to determine success, improvements in food outcomes (e.g., adding applesauce, beans and spaghetti to a diet originally consisting of chocolate milk, yoghurt, and rice) may not be sufficient to mitigate potential inadequacies in nutritional status often associated with food selectivity in this population group. This is important, as despite the general acceptability of interventions, the majority were time and resource intensive, for what appear to be marginal gains in food intake. Future research should therefore include health economic outcomes, alongside assessment of nutritional status to better assess the efficacy and viability of such interventions in the current context of diet-related diseases, escalating healthcare costs and long waiting lists.