CRITICALLY APPRAISED PAPER (CAP) Sharp, W. G., Burrell, T. L., & Jaquess, D. L. (2014). The Autism MEAL Plan: A parent-training curriculum to manage eating aversions and low intake among children with autism. Autism: The International Journal of Research And Practice, 18(6), 712 722. http://dx.doi.org/10.1177/1362361313489190 CLINICAL BOTTOM LINE: Children with autism spectrum disorders (ASD) have a high prevalence of feeding problems. These feeding problems can manifest in the form of difficulty self-feeding; disruptive mealtime behaviors; and food selectivity based on type, volume, and texture. Pediatric feeding concerns can have significant effects on a child s health, growth, and meaningful participation. Limited evidence exists to guide practitioners on effective feeding interventions to meet the unique needs of children with ASD. Therefore, research is needed to find effective and accessible services for families. The current study examines the effectiveness of the Autism MEAL Plan, a group parent education program for families with children with ASD. Participants received the 8-week, clinic-based program and were compared with a waitlist control group. The Autism MEAL Plan involved weekly parent educational sessions to teach mealtime behavioral strategies. The authors created the Autism MEAL Plan using evidencebased practices, and they cite the relevant research the program is founded on. The intervention had high social validity and decreased parent stress when compared with the waitlist control group. However, the group education sessions did not result in improved child mealtime behaviors or food selectivity. Future research should examine how program modifications could decrease feeding problems in children with ASD and maintain positive parent outcomes. A child s feeding behavior affects family mealtime occupations. Group education programs that train parents on mealtime strategies can support therapists in providing effective interventions. Improved interventions could help therapists reach more families and decrease clinic costs. In addition, parent interventions in the home are integrated into the child s daily routine and natural environment. Feeding interventions that target empowering families can increase meaningful participation and occupational engagement for the entire family. The Autism MEAL Plan did not effectively address child behaviors or food selectivity. However, parent stress outcomes were improved through the group sessions and educational curriculum. Brief content inclusion of each educational session and homework topics are provided in table format for easy access for clinicians. In addition, the article contains a number of resources to support therapists facilitating feeding interventions. Occupational therapists may use the program 1
information to decrease parental stress levels and create a more optimal mealtime environment. RESEARCH OBJECTIVE(S) List study objectives. To examine the effectiveness of an 8-week parent education program designed to improve children s feeding behavior, increase children s food variety, and decrease parental stress in families with children with ASD. DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: randomized controlled trial SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Participants were recruited through flyers, email lists, and email to local early intervention services; parent support groups; and autism groups throughout the state. Participants were further selected by confirmation of their ASD diagnosis through the Social Responsiveness Scale parent form. Researchers received consent from families before enrolling them in the study. All participants were included in baseline measurements and then were randomly assigned through a computer-generated block randomization to an intervention group or a waitlist control group. Inclusion Criteria ASD diagnosis, 3 8 years old, Social Responsiveness Scale total standard score greater than 60 Exclusion Criteria No additional exclusion criteria were listed. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 19 #/ (%) Male 15/(78.9%) #/ (%) Female 4/(21.1%) Ethnicity NR Disease/disability diagnosis ASD INTERVENTION(S) AND CONTROL GROUPS Group 1: Treatment group Brief description of the intervention Eight 1-hr group parent education sessions were implemented by a behavioral psychologist specialized in pediatric feeding disorders and a postdoctoral psychology fellow. The Autism MEAL Plan s 2
How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? eight session subjects were an introduction, information on structuring meals and monitoring behaviors, ways to increase appropriate behavior, effective communication, ways to decrease inappropriate behavior during meals, methods of introducing foods, teaching self-feeding skills, and monitoring and maintaining progress. The intervention s themes across sessions included mealtime structure, behavior management, feeding interventions, self-feeding, and progress maintenance. Homework was given after each session to encourage participants to use the new skills. The homework was reviewed at the following session, and participants were given time to ask questions and receive feedback. 10 NR A behavioral psychologist with a specialty in childhood feeding problems and a psychology fellow facilitated all parent education sessions. The behavioral psychologist also developed the intervention program. Once per week 1 hr each, 8 weeks total Information provided by email related to general behavior management, not feeding interventions 9 By email correspondence A behavioral psychologist with a specialty in childhood feeding problems and a psychology fellow facilitated all parent email communications. NR 8 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: NR X Comment: Contamination is not discussed, but it is possible that parents in the control group communicated with parents in the treatment group about the intervention in the community setting. 3
Co-intervention: NR X Comment: Cointervention is not discussed; however, because participants were recruited from early intervention programs, it is likely that they received other therapy services, which could have contributed to changes in study outcomes. Timing: Site: Comment: Comment: Use of different therapists to provide intervention: Comment: MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of Brief Autism Mealtime Behavior Inventory Parent-reported frequency of mealtime behavior problems; total scores and subscale scores in limited variety, food refusal, and features of ASD YES X YES X When is the Pre- and postintervention Measure 2: Name/type of Food Preference Inventory Parents report of their child s food selectivity 4
When is the Measure 3: Name/type of When is the Measure 4: Name/type of When is the NR X NR X Pre- and postintervention Parenting Stress Index Self-reported parent stress levels YES X YES X Pre- and postintervention Posttreatment satisfaction questionnaire Self-reported program satisfaction, treatment gains, social acceptability NR X NR X Postintervention Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: All outcome measures were self-report or parent report, and parents knew whether they were receiving the intervention or were on the waitlist. Recall or memory bias. Check yes, no, or NR, and if yes, explain. YES X Comment: The measurement tools were self-report and parent report, which required parents to recall their child s behavior, food preferences, and personal stress over the course of the intervention. 5
Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported The Autism MEAL Plan intervention significantly decreased Parenting Stress Index total scores (p =.01, d = 1.1) in the treatment group, compared with the control group. There were no significant differences in feeding behaviors between the two groups in terms of Brief Autism Mealtime Behavior Inventory total score (p =.79) and subscale scores of limited variety (p =.55), food refusal (p =.51), and autism features (p =. 57). There were also no significant changes in food variety from the Food Preference Inventory measurement (p =.21). Both groups were given a posttreatment satisfaction questionnaire after the waitlist control group had received the intervention. The satisfaction questionnaire suggested high social validity and overall caregiver satisfaction with the educational sessions for the treatment and control group. Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: Small sample size and high attrition decreased the statistical power. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES X Comment: Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES X Comment: Was the percent/number of subjects/participants who dropped out of the study reported? YES X Comment: Eleven participants did not complete the study in its entirety but dropped out after baseline assessments and before group randomization and therefore were not included in the sample characteristics above. However, no significant differences were found among variables in the attrition group when compared with the treatment and control groups. 6
Limitations: What are the overall study limitations? A primary limitation of the study is the length of the parent education program. The intervention length might not have given sufficient time to see behavioral changes in the child. In particular, feeding intervention techniques were not introduced until the 6th week of the 8-week education program. Parental stress decreased immediately after the program. However, no further assessments determined whether the effects on parental stress were maintained. The investigation did not involve direct parental observation. This might have resulted in varying effectiveness of the parent-implemented behavioral strategies and child feeding outcomes. The small sample size might have resulted in potential difficulty finding statistical significance and an inability to generalize to a wider population. In addition, the study had high attrition rates as a result of scheduling conflicts and lack of parental motivation to participate. This potentially contributed to outcome bias for the families who completed the study. Furthermore, ASD severity and diagnosis confirmation were determined through a parent report form, not a standardized professional evaluation. CONCLUSIONS State the authors conclusions related to the research objectives. Findings suggest that the Autism MEAL Plan intervention may decrease parenting stress. The group intervention also may decrease the necessary clinical contact time and therefore be a cost-effective intervention delivery method. Caregiver reports demonstrate that parents were satisfied with this intervention method. The study found positive results on parent child relationships and decreased self-reported parental stress. However, the Autism MEAL Plan did not improve feeding outcomes, as measured by mealtime behavior and food selectivity. The authors suggested that further research is needed in the areas of direct observation of parents during mealtimes, differences in program effects on children with varying degrees of feeding problems and intellectual levels, methods to decrease attrition and increase the overall number of families participating in the program, observation of long-term parent education programs on child food selectivity, and manners to expand the Autism MEAL Plan to other settings and clinicians. This work is based on the evidence-based literature review completed by Kate Dorrance, 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. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7