CRITICALLY APPRAISED PAPER (CAP) Johnson, C. R., Foldes, E., DeMand, A., & Brooks, M. M. (2015). Behavioral parent training to address feeding problems in children with autism spectrum disorder: A pilot trial. Journal of Developmental and Physical Disabilities, 27(5), 591 607. https://doi.org/10.1007/s10882-015-9437-1 CLINICAL BOTTOM LINE Children with autism spectrum disorders (ASD) have a higher prevalence of feeding challenges compared with same-age, typically developing peers. Feeding problems present differently for every child and can include food selectivity, challenging mealtime behaviors, and self-feeding difficulties. Feeding concerns among children with ASD significantly influence the child s health, development, and participation in daily activities. In addition, feeding difficulties affect the whole family s well-being and occupational engagement. Behavioral Parent-Training Program The authors investigated the feasibility, fidelity, and initial efficacy of a nine-session, manualized behavioral parent-training program (PT-F) in the current pilot study. The authors completed the study over 16 weeks, with a focus on feeding and mealtime behaviors with 14 children (M = 4 years) with ASD. Direct instruction, modeling, and discussion were facilitated by a trained professional in each 60 90-minute session. PT-F was developed on the basis of the RUPP Autism Network Parent Training program and the primary author s sleep-problem parent-training program. The results support the PT-F sessions feasibility and parent satisfaction. The program s treatment fidelity was supported by high treatment integrity, parent adherence, and interrater reliability for both integrity and adherence components. The program s efficacy was supported by significant improvement in Brief Autism Mealtime Behavior Inventory total scores, Aberrant Behavior Checklist subscale scores, and Parenting Stress Index total scores. The authors found no significant nutritional change as a result of the treatment. The results are limited by the lack of a control group and the small sample size. Future research should increase the sample size and compare the results with a control group to improve the strength of the authors findings for translation to practice. 1
Implications for Occupational Therapy Parent-training programs may be a more cost-effective method than traditional specialized pediatric feeding interventions, with increased opportunity to generalize the behaviors to the home environment. The PT-F session outline and topics addressed are provided to ease transition to practice. Occupational therapists should use caution when interpreting the data, however, given the study s lack of rigorous methods. Clinicians should also consider suggestions for session changes made by the authors and other related literature in implementation to practice. Occupational therapists may use the study in combination with other parent-training intervention studies as support for implementing parent-training feeding interventions to decrease challenging child mealtime behaviors and parent stress. RESEARCH OBJECTIVE(S) Examine the feasibility and initial efficacy of a nine-session, manualized behavioral parenttraining program for parents of children with ASD and feeding problems, to decrease parent stress and improve child mealtime behaviors and nutritional status DESIGN TYPE AND LEVEL OF EVIDENCE Level III: Pretest posttest PARTICIPANT SELECTION How were participants recruited and selected to participate? No information on recruitment was provided. Participants were selected through verification of their ASD diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria and Autism Diagnostic Observation Schedule. All participants gave consent prior to participation. Inclusion criteria: Child needed to be between 2 and 7 years old; have an ASD diagnosis; and have at least one feeding problem, as determined by initial interview questions. Exclusion criteria: Child was taking prescribed medication or supplements to target appetite, was receiving enteral feeding, and/or had significant oral motor concerns PARTICIPANT CHARACTERISTICS N= 14 #/ % Male: 11/79% #/ % Female: 3/21% Ethnicity: 87% Caucasian, 14% multiethnic 2
Disease/disability diagnosis: ASD INTERVENTION AND CONTROL GROUPS Group 1: PT-F 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? The intervention consisted of nine sessions (60 90 minutes each, over 16 weeks) of an individually implemented parent-training program with a focus on feeding and mealtime problems. The program started with an in-home and in-clinic observation of a parent child mealtime. The nine PT-F session topics were basic behavioral principles and nutrition, prevention techniques and mealtime routines, Consequences I, Consequences II, noncompliance, stimulus shaping and fading, response shaping and prompting, higher level feeding skills, and booster and maintenance. Order of the session topics was individualized for each participant. Participants engaged in direct instruction, modeling, role-playing, strategy videos, and discussion. Participants created a home feeding and mealtime plan throughout the program. 14 Clinic setting Therapists: doctoral or master s trained, applied behavioral analysis trained, and experienced with children with ASD NR 60 90 minutes each, over 16 weeks INTERVENTION BIASES Contamination: YES NO There was no control group present; all participants received the intervention. Co-intervention: Children and parents were not receiving other therapy specific to feeding, and children were not taking medications or supplements that targeted appetite. Children or parents might have been receiving other related therapies that affected outcome measures of parent stress and child mealtime behaviors, however. 3
Timing of intervention: Site of intervention: YES NO The short treatment duration might not have allowed sufficient time for the intervention or assessment of nutrition. Intervention site consistent among all participants Use of different therapists to provide intervention: Baseline equality: YES No control group NR MEASURES AND OUTCOMES Although the treatment program was manualized, different therapists implemented the treatment, which might have created varied treatment experiences. Measure 1: Parent Satisfaction Questionnaire reliable (as reported in the article)? ( article)? Parent Satisfaction Questionnaire Parent satisfaction rating of quality of sessions, including session number, length, and topic and helpfulness of teaching tools, worksheets, and homework Week 16 Measure 2: Treatment Fidelity Checklist Treatment Fidelity Checklist Treatment integrity and parents adherence to treatment Not Reported 4
in the Week 16 Measure 3: Brief Autism Mealtime Behavior Inventory in the Brief Autism Mealtime Behavior Inventory Mealtime behaviors common to children with ASD Not Reported Baseline, Week 8, and Week 16 Measure 4: Aberrant Behavior Checklist in the Aberrant Behavior Checklist Measure 5: Parenting Stress Index Disruptive and noncompliant behaviors Baseline, Week 8, and Week 16 Parenting Stress Index Short Form Parent stress and parent child relationship 5
in the Measure 6: 3-Day Food Records in the Baseline, Week 8, and Week 16 3-Day Food Records Recent dietary intake: all food, beverages, supplements, and medications consumed within a 3-day period Baseline and Week 16 MEASUREMENT BIASES Were the evaluators blind to treatment status? YES NO Was there recall or memory bias? Evaluators were aware of the intervention and not blinded. All outcome measures were parent-report tools that required parents to remember their child s food intake, behavior, food preferences, and personal stress levels over time. Other measurement biases: (List and explain) NA RESULTS List key findings based on study objectives: The PT-F intervention significantly decreased Brief Autism Mealtime Behavior Inventory total scores (p <.001, d = 1.50). The treatment also had significantly decreased Aberrant Behavior Checklist Irritability (p < 6
.05, d = 0.62) and Hyperactivity subscale scores (p <.05, d= 0.75). Efficacy outcomes also demonstrated a significant effect on Parenting Stress Index total score (p <.05, d = 0.45). Participants (parent child dyad) attended 96.8% of sessions. The mean parent satisfaction was 81.96%. Treatment integrity had a mean of 98.4%, and parent adherence of had a mean of 94.1%. Three-Day Food Records did not have significant changes in total fat intake from daily calories, fiber deficiency, and other nutrients. Was this study adequately powered (large enough to show a difference)? Sample size was large enough to show an effect of the intervention. Were the analysis methods appropriate? (Check yes or no, and include a brief explanation) The appropriate analysis was used, on the basis of the purpose of the study and the number of outcome variables. All nonparametric equivalent use and degrees of freedom corrections were explained. Were statistics appropriately reported (in written or table format)? Statistics were appropriately represented for all outcome measures in table and written format. Was participant dropout less than 20% in total sample and balanced between groups? YES NO The 18% dropout rate was due to participants not meeting diagnostic eligibility, not returning for baseline visit, and encountering scheduling conflicts. What are the overall study limitations? The lack of a control group limits the rigor of the study s findings, because the researchers were unable to determine whether the results were due to the intervention. Maintenance of outcomes over time is unknown, given the absence of follow-up tests. In addition, the outcome measures used were all parent report, which can lead to numerous measurement biases. The PT-F sessions were provided in the clinic setting, which might decrease generalizability to natural environments, such as home and school. The children in the study were majority Caucasian and male, which also contributes to the lack of generalizability of the study s findings. The study cannot be generalized to children outside of the 2 7-year-old age range. The study s results also cannot be applied to children with more serious feeding concerns, because participants did not have severe feeding characteristics, including oral motor challenges, swallowing difficulties, and tube feeding. 7
CONCLUSIONS State the authors conclusions related to the research objectives. The PT-F program for children with ASD and co-occurring feeding challenges was determined to be feasible by the low dropout rate and parent satisfaction ratings. Treatment integrity and parent adherence were both high. The authors found the PT-F program to be initially effective in decreasing negative child mealtime behaviors, parent stress levels, and noncompliant and disruptive behaviors. The program did not have a significant effect on child nutritional status, however. The authors should revise the PT-F program to change the last session, on the basis of parent satisfaction ratings, and to include one session focused on nutritional counseling. Overall, the authors found the PT-F program to be a plausible treatment for pediatric feeding problems. This work is based on the evidence-based literature review completed by Kate Dorrance, OTS, and Karla Ausderau, PhD, OTR/L, 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, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8