CRITICALLY APPRAISED PAPER (CAP) Sharp, W. G., Jaquess, D. L., Morton, J. F., & Miles, A. G. (2011). A retrospective chart review of dietary diversity and feeding behavior of children with autism spectrum disorder before and after admission to a day-treatment program. Focus on Autism and Other Developmental Disabilities, 26(1), 37 48. http://dx.doi.org/10.1177/1088357609349245 CLINICAL BOTTOM LINE: Intensive Day-Treatment Program With an increasing number of children being diagnosed with autism spectrum disorder (ASD), related eating difficulties have also been increasing, given that feeding challenges are one of the most common associated characteristics. Mealtimes are an essential daily activity for families, and rigid mealtime habits can have a negative effect on family mealtime occupations. This study examines the effectiveness of escape extinction (EE), reinforcement, and stimulus fading (SF) during an 8-week day-treatment program for a group of children with ASD. The intervention treatment package occurred in a pediatric clinical setting and was administered by a trained therapist, with the goal of increasing the child s consumption of target foods identified by the child s family. Using a retrospective chart review, the researchers found that the intervention increased food variety and improved mealtime behaviors and participation. Implications for Occupational Therapy On the basis of the evidence from this study, occupational therapists could use the protocols studied as a framework for interventions that address outcomes related to food selectivity and mealtime behaviors for children with ASD in a relatively short time period. In particular, the methods described in this study EE, reinforcement, and SF when implemented by a trained therapist and continued by the parents, were shown to have a significant effect on consumption of food and the related behaviors. The intervention included multiple treatment protocols, so it is unknown whether all or part of the treatment was effective. However, the combination of these techniques was shown to increase food variety and could be supported for use in occupational therapy practice targeting mealtimes for children with ASD. Further research is needed to assess the intervention with a randomized control group as well as to report a detailed follow-up to determine long-term outcomes of the treatment. RESEARCH OBJECTIVE(S) List study objectives. To evaluate effectiveness of an intensive day-treatment program on the dietary diversity and 1
mealtime performance of children with ASD DESIGN TYPE AND LEVEL OF EVIDENCE: Level III: One group, nonrandomized before after SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Participants were referred to the intensive treatment program if they had severe food selectivity and were recommended for treatment by professionals, such as pediatricians and speech therapists, who were not affiliated with the program (n = 11) or by parents who referred their child to the program after learning about it through word of mouth (n = 2). Inclusion Criteria Children with ASD, pervasive developmental disorder not otherwise specified, or Asperger syndrome who ranged in age from 2 years and 11 months to 7 years and 8 months and who participated in an intensive day-treatment program Exclusion Criteria No additional exclusion criteria were reported. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 13 #/ (%) Male 11/(84.6%) #/ (%) Female 2/(15.4%) Ethnicity Not reported Disease/disability diagnosis ASD INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1: Intervention group Brief description of the intervention Each participant received a treatment package that involved a combination of EE, noncontingent access (NCA), differential reinforcement (DRA), and SF. EE involves not allowing a child to escape food presentations by spoon removal or expulsion. NCA allows unlimited access to social attention or objects, regardless of mealtime performance, and DRA occurs when the participant receives the reinforcer immediately after completing the desired behavior. SF is gradually changing conditions to move toward more appropriate mealtime behaviors. The treatment packages most commonly included EE and either NCA or DRA. 2
How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? 13 Pediatric disorders day-treatment program Trained therapists from a multidisciplinary team or caregiver after completing a training Four times per day (excluding weekends), 30- to 45-min feeding sessions 8 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: NO Comment: There was no control group in this study. Co-intervention: Comment: Participants received interventions from all parts of the interdisciplinary team during the treatment, but it was not reported whether any participants received services outside the day-treatment program. Timing: Site: NO Comment: Children selected for the day-treatment program had a long history of food selectivity and difficult mealtime behaviors, so it is unlikely that maturation was a factor over an 8-week period. Comment: All participants received the intervention at the same location, the clinic setting. Use of different therapists to provide intervention: Comment: Although multidisciplinary therapists were reported as conducting the intervention, the exact discipline of the therapist was not reported, and it is unclear whether they remained consistent throughout the intervention or among participants. At the end of the treatment, parents were also trained about the intervention, so the participants could have had a different intervention experience at discharge and in the follow-up period. MEASURES AND OUTCOMES 3
Complete for each measure relevant to occupational therapy: Measure 1: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Acceptance: child opens mouth and allows food to be deposited within 5 s; collected on a computer with an event recorder program Percentage of bites with acceptance YES Baseline, therapist intervention, and immediately before discharge Measure 2: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Measure 3: Name/type of measure used: What outcome was measured? reliable? valid? When is the measure used? Mouth clean: swallow all food within 30 s; collected on a computer with an event recorder program Percentage of bites with mouth clean YES Baseline, therapist intervention, and immediately before discharge Combined inappropriate behaviors, such as head turns or disruptions, collected on a computer with an event recorder program Combined inappropriate behaviors per minute YES YES Baseline, therapist intervention, and immediately before discharge Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: 4
Recall or memory bias. Check yes, no, or NR, and if yes, explain. NO Others (list and explain): Comment: Retrospective chart reviews were conducted, but the intervention was assessed with clearly defined measures. RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported Improvements were seen for mealtime measures before and after the day-treatment intervention program. Acceptance showed significant improvements between baseline and treatment (p <.001, partial η 2 =.99). Mouth clean data also showed significant improvement between baseline and treatment (p <.001, partial η 2 =.92). The rate per minute of combined inappropriate behaviors showed a significant decrease between baseline and treatment (p <.05, partial η 2 =.45). There was no significant decline (p >.05) with any of the variables between the treatment phase with therapists and before discharge with the caregivers as therapists, which suggests stability of the treatment. The number of foods consumed before treatment was a median of 3 and increased to a median of 19 for those who completed the treatment. The increase in the total number of foods consumed from before until after treatment was determined to be statistically significant (p <.003). Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: The authors did not address the power of the study; however, this study had a small sample size, including only 13 children admitted to an intensive day-treatment program. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Comment: Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Comment: Was the percent/number of subjects/participants who dropped out of the study reported? YES NO 5
Limitations: What are the overall study limitations? This study had no control group and a relatively small sample size. The data for this study were collected from a retrospective chart review; this might have caused inaccurate understanding of the charts and overall negatively affected the quality of the conclusion. The researchers did not control for the other aspects of the day-treatment program (e.g., occupational therapy) that could have contributed to improvements in feeding. The authors did not clearly define severe food selectivity for the inclusion of participants in the study. The event recorder computer program used for data collection in the study also was not clearly described. In addition, the intervention included multiple interventions that were not consistent across participants, and it was not determined whether all or part of the intervention package increased food intake. The researchers did not understand the reasons for 1 participant not responding to the treatment and therefore deciding to leave the program early. Finally, this treatment involved an 8-week process with a trained therapist before a parent trained as a therapist began to deliver the treatment, which might have limited an individual s access to the intervention. Future research should have a more detailed follow-up to determine long-term outcomes and generalization of the intervention to other settings. CONCLUSIONS State the authors conclusions related to the research objectives. The intensive day-treatment program showed an improvement in mealtime performance for the group of children with ASD and food selectivity. Significant improvement was shown in before-and-after comparisons for all measured areas. In addition, the group maintained the results in the follow-up after discharge for food variety and mealtime behaviors. Further research was suggested to determine exact patterns for feeding behaviors in children with ASD and to strengthen the results by including a control group. This work is based on the evidence-based literature review completed by Molly Hamre, OTS, and Karla Ausderau, PhD, faculty advisor, University of Wisconsin Madison. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. 6