Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-021-04978-x

ORIGINAL PAPER

Eating Challenges in Children with Autism Spectrum Disorder:

Development and Validation of the “Aut‑Eat” Questionnaire (AEQ)
Eynat Gal1 · Rotem Gal‑Mishael1 · Roni Enten Vissoker1 · Darren Hedley2 · Simon M. Bury2 · Orit Stolar3

Accepted: 10 March 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
The Aut-Eat Questionnaire (AEQ) provides a novel and comprehensive assessment of eating problems and patterns in chil-
dren with ASD. To establish the internal consistency and discriminant validity of the AEQ, parents of children with ASD (n
= 105, Mage = 40.85, SD = 15.67 months) or typical development (TD; n = 98, Mage = 50.33, SD = 16.50 months) completed
the AEQ. Questionnaire construction, content validity, factor analysis, internal consistency and discriminant validity are
reported. The AEQ was reliable with high internal consistency in most domains. Significant differences were found between
groups in all domains. The AEQ is a reliable and valid tool and may help to characterize eating difficulties in this population.

Keywords Autism spectrum disorder (ASD) · Eating problems · Autism eating assessment

Introduction Common problematic or atypical eating behaviors exhib-

ited by children with ASD include food selectivity, food
Pediatric feeding disorders affect around 25% of all children avoidance, chewing and swallowing problems, problems
and up to 80% of children with developmental disabilities associated with repetitiveness, rituals, and restricted behav-
(Manikam & Perman, 2000). In children with Autism Spec- iors and interests, overeating, problem behaviors during
trum Disorder (ASD) (American Psychiatric Association, mealtime and pica. Food selectivity is the most common
2013), feeding difficulties occur more frequently and with eating problem and includes refusal of entire food groups
greater diversity than in children who are typically develop- (e.g., of fruits, vegetables, and proteins), restricted food
ing and those with other developmental disabilities (Schreck repertoires (e.g., starches, snack or processed foods), and
et al., 2004; Dominick et al., 2007). Up to 90% of children excessive or selective intake (Ledford & Gast, 2006; Ban-
with ASD present with some feeding difficulties (Kodak & dini et al., 2010; Cermak et al., 2010; Sharp et al., 2013).
Piazza, 2008), with food selectivity (up to 70%) being the Food avoidance, or the inability or refusal to eat all or most
most common (Twachtman-Reilly et al., 2008). Although developmentally appropriate foods presented is more severe
not all infant or childhood feeding issues are severe, even or extreme, and can result in the failure to meet caloric needs
minor feeding problems can cause distress for both child and or dependency on a supplemental formula (Williams et al.,
parent (Latzer, & Stein, 2013; Keel & Forney, 2013), and 2000). Chewing and swallowing issues are also prevalent
severe feeding issues can lead to serious medical complica- and can increase the risk of choking, respiratory infection,
tions (Kerwin, 1999). aspiration, malnutrition, and the need for medical procedures
(Kerwin, 1999; Field et al., 2003; Nicholls & Bryant-Waugh,
2009). Rumination or the non-purposeful regurgitation of
* Eynat Gal recently ingested food from the stomach to the mouth follow-
[email protected] ing consumption, where it is either expelled or re-swallowed,
and pocketing or packing of food, characterized by holding
1
Department of Occupational Therapy, University of Haifa, food in the oral cavity or in the cheeks without swallow-
Mount Carmel, 31905 Haifa, Israel
ing for extended periods, are also serious feeding problems
2
Olga Tennison Autism Research Centre, La Trobe University, that pose significant health risks (e.g., malnutrition, weight
Melbourne, Australia
loss, dehydration, tooth decay, choking and gastrointestinal
3
Shamir Medical Center, Department of Pediatrics, Autism bleeding, aspiration risk, decreased caloric intake) (Nicholls
Center, Zerifin, Israel

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 Journal of Autism and Developmental Disorders

& Bryant-Waugh, 2009; Seiverling et al., 2010; Lang et al., The Brief Autism Mealtime Behavior Inventory (BAMBI;
2011; Levin et al., 2014). Children with ASD can also insist Lukens & Linscheid, 2008) and the revised Brief Assess-
on specific methods of food preparation, food types, and ment of Mealtime Behavior in Children (BAMBIC; Hendy
mealtime rituals (e.g., insisting on same color plate, present- et al., 2013) were designed for the clinical assessment of eat-
ing food in a specific order) (Raiten & Massaro, 1986; Wil- ing behavior in children with ASD. These instruments assess
liams et al., 2000; Twachtman-Reilly et al., 2008); behaviors the frequency of behavioral problems expressed during
characteristic of higher order repetitive behaviors (Ahearn mealtime. The BAMBIC includes ten items which produce
et al., 2001; Schreck et al., 2004; Williams et al., 2005). three subscales including Limited Variety, Food Refusal,
Sensory issues in and around the mouth, for example, a and Disruptive Behavior. However, as a brief instrument,
desire for strong tasting foods (Broder-Fingert et al., 2014), the BAMBIC was not designed to be a thorough and com-
or compulsive behaviors (Hackler, 1986), can lead to binge prehensive assessment and does not include all of the eating
and overeating, or eating too quickly. Pica, the repetitive problems that characterize children with ASD, nor does it
ingestion of non-food items without nutritional value (Bee- provide the eating patterns of the child in the context of the
croft et al., 1998), is more commonly seen in individuals family environment. For example, it does not thoroughly
with co-occurring intellectual disability but, when present, assess sameness rituals and compulsive eating behavior. In
can have potentially serious health effects (Matson et al., addition, it does not address excessive eating, which also
2011; Matson et al., 2013). Behavior problems including occurs in the ASD population.
aggression and tantrums can also be prevalent at mealtime The Behavioral Pediatrics Feeding Assessment Scale
(Provost et al., 2010), limiting families from eating out or (BPFAS) is a 35-item, parent-report measure of mealtime
participating in extended family meals, and increasing meal- and feeding behavior (Crist & Napier-Phillips, 2001). The
time stress. first 25 items address child behavior and the last 10 provide
Given the risks associated with feeding and eating prob- information about parental feelings regarding, and strategies
lems in children, it is of major importance to thoroughly for, addressing mealtime and feeding problems. Parents are
assess and understand the nature of the eating problems in asked to rate the frequency of the behavior on a scale from
this population, which includes being able to accurately 1 (never) to 5 (always) with greater overall scores indicating
identify, describe, and diagnose feeding and eating patterns higher levels of problematic mealtime and feeding behavior
and problems. Although questionnaires completed by par- (positively phrased items are reverse-scored). Research on
ents or caregivers are routinely used in the assessment of the BPFAS suggests that the first 25 items provide a reli-
feeding problems, few instruments have been developed spe- able and valid estimate of behavior-based feeding problems
cifically for the oftentimes unique feeding challenges present across a range of non-ASD pediatric populations and there-
in children with ASD, or have demonstrated psychometric fore do not include the full range of eating problems seen in
validity and reliability for use in children with ASD. ASD populations.
Several instruments have been developed that could be In addition, the Mealtime Behavior Questionnaire
potentially suitable for use in children with ASD, or that (MBQ), a 33-item and four subscale tool created by psy-
have been designed for use in this population. However, chologists and members of a multidisciplinary feeding team,
upon closer inspection, all are either lacking in scope, not uses a 5-point frequency scale to rate mealtime behaviors.
suitable for use in young children, or have not been vali- As with the BPFAS, the MBQ is not an ASD-specific tool
dated in ASD. The Swedish Eating Assessment for ASD and its focus is on behavior-based problems during meals
(SWEAA; Karlsson et al., 2013) is a self-report question- rather than the broader scope of eating related concerns,
naire that was designed for young adults with ASD (15–25 which include chewing problems, over-eating and more
years) and is therefore not suitable for use in young children. (Berlin et al., 2010).
The Screening Tool of Feeding Problems (STEP; Matson Due to the limitations of the aforementioned instruments,
& Kuhn, 2001) was designed to assess feeding problems we aimed to develop a new instrument which would provide
in children and youth with intellectual and developmental an in-depth picture of the autistic child eating concerns and
disabilities but was not specifically designed for use in the to assess feeding problems in young children with ASD, the
ASD population. The Children’s Eating Behavior Inventory Autism Eating (“Aut-Eat”) Questionnaire (AEQ). The Aut-
(CEBI) (Archer et al., 1991), is a caregiver report for evalu- Eat was designed and intended for use as a comprehensive
ating mealtime and eating behaviors. It measures the fre- practical descriptive assessment; an indirect tool that effec-
quency of 19 different eating behaviors and asks caregivers tively describes a parent’s perspective on their child’s eating
to evaluate whether each of the behaviors presents a prob- behaviors and provides the clinician with detailed informa-
lem for the family. The tool is clinically used with children tion about various child eating concerns.
with ASD, but it was not constructed specifically for this The current study describes the development and psycho-
population. metric validation of this instrument. Unlike its counterparts,

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Journal of Autism and Developmental Disorders

the AEQ considers the child’s eating patterns within the cul- and swallowing problems, (b) eating avoidance, (c) eating
tural and familial context. The questionnaire was developed selectivity, (d) eating sameness and rituals (e) over-eating,
in Hebrew, with translations currently available in Arabic, and (f) problem behavior during mealtime; and (3) a food
English, and Spanish. The aim of the present study was to list eaten by the child, that is subdivided into specific food
examine the construction and validation (discriminative categories. The questionnaire takes approximately about 30
validity, internal consistency reliability) of the original min to complete.
Hebrew version of the Aut-Eat questionnaire in a large sam- The first section includes various open questions which
ple of children from Israel. address demographic information and various eating related
history and behaviors (e.g., does your child perform the fol-
lowing independently: does your child drink from a baby
Method bottle, from a cup, use a spoon, use a fork, use a knife, need
support instruments for feeding?; does your child sit at a
Participants table during meals? And does your child eat meals at regular
times?).
The study sample consisted of 203 children aged 3 to 7.9 The second section comprises 44 questions which are
years (Mage = 45.42, SD = 16.72 months); 105 with an ASD rated on a six-point Likert scale ranging from (0) “behavior
diagnosis (82.9% male; Mage = 40.85, SD = 15.67 months) does not occur/irrelevant” to (5) “behavior occurs very fre-
and 98 typically developing children (TD; 82.7% male; Mage quently.” The third section provides a food table with 137
= 50.33, SD = 16.50 months). There were no significant dif- items. For each item, the parent is required to identify in the
ferences in gender, χ2(1) = 0.001, p = 0.969; however, there previous month, whether the item is regularly eaten by the
was a significant difference in age (mean difference = 9.48 child, and whether the item is regularly consumed by the rest
months), t(201) = 4.20, p < 0.001, 95% CI 5.03, 13.93, d = of the family. The child’s behavior is then rated against the
0.59. Recruitment of participants was by convenience sam- items based on how frequently the behavior occurs using a
pling; parents of children with ASD were contacted directly six-point Likert scale, ranging from never (0) to very fre-
and requests for enrolment were also posted in online forums quently (5). The following guide is provided to indicate how
for parents of children with ASD. Diagnoses of ASD were often each of the behaviors occur: 0 < 10%, 1 = 10%, 2 =
based on DSM-5 diagnostic criteria (American Psychiat- 25%, 3 = 50%, 4 = 75%, 5 = 90% of the time.
ric Association, 2013) and were conducted at various child
development centres by an interdisciplinary team including Instrument Development
a pediatric neurologist and psychologist. In addition, all chil-
dren with ASD were recognized by the Israel National Insur- The Aut-Eat was developed to assess the eating problems
ance Institute as meeting health department criteria for the and habits of children with ASD with the aim of forming
condition. For the current study, all children with ASD were a basis for clinical intervention. Questionnaire items were
required to score above the recommended cut-off for ASD initially selected based on ASD symptom presentation and
(> 15) on the Social Communication Questionnaire (SCQ; the prevailing literature concerning the types of eating prob-
Rutter et al., 2003). Children who had a psychiatric diagno- lems of children with ASD. Structured interviews and focus
sis, comorbid neuro-developmental disorders such as cer- groups were then conducted with experts (three special edu-
ebral palsy, and uncorrected sensory disorders (e.g., blind- cation teachers, one physician, two occupational therapists,
ness), and children who are tube-fed, were excluded from and two behavior therapists, each with over 5 years of expe-
this study. Children with TD had no known developmental rience working with children with ASD) to refine the item
disabilities (as reported by their parents) and attended typi- list. The experts were asked to rate each item and to identify
cal day cares or schools. Children with known serious ill- any additional items they felt should be included. The result-
nesses, injuries, or physical disabilities were excluded from ing list consisted of 54 items encompassing the main eating
both study and control groups. problems and 133 food items as part of the food table. The
revised list was then examined by a second group of experts
Design of the AEQ (two special education teachers, one research dietitian, two
occupational therapists, one behavior therapist, each with
The AEQ was designed as a parent-report questionnaire that over five years of experience working with children with
aims to assess the breadth of the unique eating problems ASD) to assess face validity. Two more items were added,
and feeding profile of children with ASD aged 3 to 8 years. resulting in 56 items, and a “behavior does not occur/irrel-
The questionnaire includes three sections: (1) demograph- evant” option was added to the original five-point Likert
ics and developmental information regarding the child with scale. Four foods were added to the food chart resulting in
ASD; (2) six categories of eating problems: (a) chewing 137 food items. This section was also changed from a list

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 Journal of Autism and Developmental Disorders

to a table and included a five-point Likert type response developing child (9% missing). Following their removal, the
scale ranging from (1) “avoids food” to (5) “frequently eats.” pattern of missing values appeared random; overall missing
The original two major domains were also changed to six values for the Aut-Eat was 0.18%, and no individual level
domains (described above). In order to ensure that questions of missing data greater than 4.6%. In order to retain as large
were formulated in a clear and understandable manner and a sample size as possible, rather than trimming the data, the
that the language was not overly technical or jargonistic; remaining missing values were imputed by the mean score
three parents of children with ASD aged 3 to 5 years pro- of five multiple imputations (Tabachnick & Fidel, 2007).
vided feedback regarding the clarity of the items. As participant responses across the individual items
A third group of experts (two occupational therapists, one were not normatively distributed, principal axis factoring
of whom was also a behavior therapist, one physician, and exploratory factor analysis (PAF-EFA) with direct oblimin
two special educators) completed a specification table which rotation was used to determine factor structure (Fabrigar
included all items and associated domains. The experts were et al., 1999; Costello & Osborne, 2005). Cronbach’s alpha
asked to assess the fit between the items and domains. Cor- coefficient was used to measure the internal consistency
rections were made and a fourth group of experts (two occu- reliability of the domain scales. To test whether differences
pational therapists and two special educators) completed existed between children with ASD and typically developed
a second specification table. At this stage, items which children, Multiple Analysis of Variance (MANOVA) was
achieved 75% agreement were included in the questionnaire. conducted, followed by independent t-tests with 1000 boot-
Eight items did not achieve at least 75% agreement. Of these, strapped samples across all factors established via PAF-EFA.
four were changed to a new domain and four were removed
from the questionnaire, leaving 52-items in the main sec-
tion. Following preliminary data analysis, eight further items Results
were subsequently removed, resulting in the 44-item ques-
tionnaire reported here. Factor Analysis
The third part of the questionnaire was developed sepa-
rately. It included an original list of 133 items created by PAF-EFA was conducted on the 44 items of the Aut-Eat
the tool authors. A focus group of one physician, one occu- within the ASD sample.1 The Kaiser-Meyer Olkin measure
pational therapist and two dietitians then stated the need to verified good sampling adequacy for the analysis (Field,
add foods that are unique to specific cultural groups, and 2018), KMO = 0.79, with the Bartlett test of sphericity
suggested the addition of 11 more items, resulting in the 149 showing sufficiently large correlations for EFA (χ946 =
items in the food list. The dietitians of this focus group also 3492.10, p = < 0.001). A 10-factor solution was obtained
recommended to divide the food list into food categories using the Kaiser criterion, however, parallel analysis using
(e.g. vegetables, fruits, dairy products etc.) the O’Connor (2000) SPSS syntax suggested a seven factor
A table of specification was then completed by three die- solution was more appropriate. Analysis forcing seven com-
titians to confirm the division of the foods to food groups. ponents showed that Items c10 (“Eats foods only when are
Foods that did not receive 100% agreement, were then dis- at a certain temperature”) and a5 (“Doesn’t close lips while
cussed by the dietitians and the authors until full agreement chewing”) did not load sufficiently on any factor (< 0.3) and
was achieved. were removed. Results showed six strong factors and one
The completed third part of the questionnaire provides uninterpretable factor, consequently PAF-EFA was re-run
information regarding the diet of the child (i.e., how many with six factors, which improved interpretability. Removal of
foods he/she eats, how often, and his family- how many item c8 (“prefers only sweet, salty or sour foods”) improved
foods are presented at home). However, unlike the second reliability and interpretability, with a final six-item model
part that was developed based on factor analysis, and is vali- (Table 1) explaining 61.38% of the variance (KMO = 0.82,
dated and “closed,” the third part was designed to be flexible χ741 = 3057.55, p = < 0.001).
in order to meet cultural needs. That is, it for allows the addi- With the exception of Factor 1, which has combined
tion of foods by therapists and parents according to culture items measuring both ‘eating sameness and inflexibility’
and family habits. and ‘eating rituals,’ the factors largely reflect the designed
factors; Factor 2—overeating; Factor 3—chewing and
Data Cleaning and Analysis Plan swallowing problems, Factor 4—eating/food selectivity;

Participant responses with >5% missing data from the Aut-

Eat were removed from the analyses. This resulted in the 1
Given that the tool is designed to be used on an ASD sample, only
removal of data from six children with ASD (34%, 27%, the ASD responses were used in the PAF-EFA analysis. Analysis on
16%, 14%, 7%, 7% missing, respectively) and one typically the full sample produced similar loadings (Appendix A).

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Journal of Autism and Developmental Disorders

Table 1  Summary of principal axis factoring exploratory factor analysis for the AEQ on ASD sample (n = 99; Items a5, c8 & c10 removed)
Factor
1 2 3 4 5 6

e2. Insists that items related to meal will be organized in a certain manner 0.786 −0.136 0.109 0.088 0.027 −0.239
e3. Prefers foods be served in a certain way 0.747 0.199 0.145 0.134 0.205 −0.248
d5. Prefers foods that were prepared in a certain way (ex: sandwich with peanut but- 0.735 0.178 0.208 0.014 0.224 0.084
ter and jelly spread on in a certain order)
e7. Shows signs of frustration when the meal doesn’t go the way s/he’s accustomed 0.681 0.089 −0.008 − 0.028 − 0.138 0.025
d3. Selective about shape of food (i.e. will only eat a certain shape of pasta) 0.675 − 0.158 0.033 0.114 − 0.120 0.123
d4. Makes sure foods don’t touch one another 0.664 0.018 − 0.006 0.142 − 0.009 − 0.016
e5. Eats only with certain utensils and dishes (specific plate/cup/spoon) 0.629 0.085 0.071 0.040 0.071 0.072
d2. Selective about color of food 0.625 − 0.005 0.086 0.086 − 0.100 0.117
e4. Is inflexible regarding mealtime 0.575 0.071 − 0.022 − 0.166 − 0.088 0.370
e6. There are foods he/she will only eat in a certain environment (ex: apple only at 0.513 0.028 − 0.110 0.166 − 0.314 − 0.213
school)
e1. Eats/drinks in a certain order at mealtime 0.492 0.050 − 0.135 0.104 − 0.209 0.031
d1. Only eats foods from certain origins (i.e. a certain brand of ketchup even if 0.344 0.120 − 0.078 0.083 − 0.188 0.208
packaging is unseen –based upon taste alone)
f5. Eats large portions of foods in an uncontrolled manner, without relation to − 0.015 0.915 0.159 0.062 0.158 0.050
hunger
f4. Keeps eating as long as there is food available 0.017 0.900 0.045 0.012 0.049 0.067
f1. Eats a lot of food in a short amount of time 0.124 0.795 − 0.138 0.079 0.026 − 0.090
f3. Shoves a lot of food into mouth − 0.009 0.769 − 0.115 0.025 − 0.164 0.046
f2. Swallows food without effective chewing 0.029 0.623 0.234 − 0.034 − 0.263 − 0.279
f7. Steals or tries to steal food from others during mealtime 0.014 0.602 − 0.200 0.063 − 0.038 0.014
f6. Chokes or gags while swallowing − 0.022 0.485 0.255 − 0.051 − 0.158 0.179
a2. Refuses to eat hard to chew foods 0.027 − 0.046 0.771 0.043 − 0.127 − 0.127
a4. Has difficulty biting 0.066 0.061 0.715 − 0.075 − 0.175 − 0.100
a7. Eats only soft or mashed foods (i.e. rice, pudding) − 0.050 − 0.197 0.656 0.217 − 0.081 0.085
a3. Sucks on food instead of chewing (with or without swallowing) 0.212 0.058 0.633 − 0.019 − 0.124 0.129
a8. Eats only liquid foods 0.072 − 0.027 0.575 0.189 0.094 0.148
a1. Keeps food in mouth or chews for a long time 0.108 0.118 0.377 0.043 − 0.025 0.223
a6. Drools during mealtime 0.186 0.282 0.332 − 0.175 − 0.147 0.233
c7. Eats a narrow selection of foods 0.041 0.046 − 0.129 0.836 0.056 0.210
c4. Refuses to taste new foods − 0.028 0.083 − 0.003 0.834 0.019 0.044
c3. Prefers the same foods at every meal 0.043 0.091 − 0.054 0.800 − 0.034 − 0.005
c1. Eats/drinks only certain things at meals 0.080 − 0.097 0.120 0.787 − 0.077 − 0.079
c5. Is given different foods from those prepared for rest of family 0.015 0.077 0.079 0.767 − 0.094 − 0.138
c2. Eats only one food during meals 0.195 − 0.135 0.053 0.693 − 0.103 0.090
c6. Eats certain textures (soft or hard) 0.076 0.044 0.248 0.592 0.094 0.115
c9. Avoids foods with strong smells 0.257 0.208 0.011 0.346 − 0.069 − 0.068
g3. Cries or yells during meals 0.019 − 0.028 0.183 0.077 − 0.755 0.164
g1. Aggressive during meals 0.030 0.244 0.176 0.025 − 0.683 − 0.020
g4. Inflicts injury upon self during meals (ex: bites own hand) 0.249 − 0.014 0.052 − 0.018 − 0.670 0.032
g2. Disturbs others during mealtime − 0.126 0.125 0.178 0.191 − 0.602 0.063
b1. Closes mouth when people try to come near her/him with food − 0.005 − 0.027 0.096 0.159 − 0.179 0.539
b2. Turns her/his face or body away from food − 0.007 0.036 0.023 0.293 − 0.023 0.467
b3. Spits out food before it is swallowed 0.026 0.147 0.333 − 0.052 − 0.252 0.401
Eigenvalues 13.77 3.64 3.08 2.10 1.30 1.08
% of variance 33.57 8.87 7.51 5.12 3.16 2.63
α 0.92 0.91 0.86 0.93 0.89 0.74

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 Journal of Autism and Developmental Disorders

Table 2  Correlations between Factor 1 2 3 4 5

factors with 1000 bootstrap
samples (ASD sample; n =99) 1. Eating sameness and rituals
2. Overeating 0.45***
3. Chewing and swallowing problems 0.48*** 0.30**
40. Food selectivity 0.60*** 0.30*** 0.42***
5. Problem behaviors during mealtime 0.50*** 0.44*** 0.60*** 0.43***
6. Food avoidance 36*** 0.29** 0.49*** 0.40*** 0.51***
*
p < 0.05
**
p < 0.01
***
p < 0.001

Table 3  Internal consistency reliability of questionnaire domains Discriminant Validity

ASD TD Combined
A multivariate analysis of variance (MANOVA) was used
1. Eating sameness and rituals 0.92 0.88 0.91 to compare responses among children with ASD to those of
2. Overeating 0.91 0.77 0.90 TD children across the six identified factors. Using Pillai’s
3. Chewing and swallowing problems 0.86 0.69 0.85 trace, there was a significant difference between groups, with
4. Food selectivity 0.93 0.90 0.93 children with ASD showing significantly higher scores on the
5. Problem behaviors during mealtime 0.89 0.73 0.87 AEQ than TD children, V = 0.32, F(6, 189) = 14.48, p <
6. Food avoidance 0.74 0.92 0.82 0.001, ηp2 = 0.32.
Means and standard deviations (Table 4) showed that the
children with ASD were rated higher than TD children across all
Factor 5—problems behaviors during mealtime; Factor factors. However, overall responses on the six factors was gener-
6—food avoidance. ally quite low, with all means below the mid-point of the scale
Correlation analysis with 1000 bootstrap samples for both ASD and TD groups. Independent t test with 1000 boot-
showed significant relationships between all factors, strapped samples were then run on the six factors, with results
suggesting the factors are related, but distinct variables showing that the ASD group reported significantly higher scores
(Table 2). on all of the AEQ factors. The children with ASD reported more
chewing and swallowing problems, more selective eating, insist-
ence on sameness and on rituals during meals, were rated more
Internal Consistency and Reliability prone to either excessive eating or to food avoidance, and to
problematic behaviors during meal-time, than the TD children.
Internal consistency and reliability of the established fac-
tors in the autism sample range from high to very high, with
a Cronbach’s alpha of 0.86 to 0.93, with the exception of Discussion
Factor 6 (food avoidance) which was acceptable, α = 0.74.
This was higher than the internal consistency of the sample The eating and feeding problems seen in children with
of typically developed children (ranging from 0.73 to 92) ASD are multi-factorial and likely to include behavioral,
(see Table 3). physiological, emotional, and cognitive origins (Turner,

Table 4  Between groups means Factor ASD (n = 99) TD (n = 97) t(df) p BCa ­CI95% d
and standard deviations and
independent t tests with 1000 M SD M SD
bootstrapped samples
1. 0.71 0.94 0.45 0.62 2.32 (170.67) 0.022 0.05; 0.49 0.33
2. 1.08 1.22 0.45 0.50 4.75 (130.67) 0.001 0.37; 0.88 0.68
3. 0.81 0.98 0.32 0.41 4.56 (132.41) 0.001 0.28; 0.71 0.65
4. 2.20 1.52 1.04 1.00 6.36 (170.24) 0.001 0.82; 1.49 0.90
5. 0.74 1.04 0.29 0.49 3.95 (139.92) 0.002 0.24; 0.68 0.55
6 1.57 1.37 0.37 0.83 7.39 (161.72) 0.001 0.89; 1.50 1.06

CI Bias corrected and accelerated 95% Confidence Intervals

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Journal of Autism and Developmental Disorders

1999; Vissoker et al., 2015). Given these problems are Chewing and Swallowing Problems
frequent and diverse in this population (Schreck et al.,
2004; Dominick et al., 2007), the availability of psycho- The chewing and swallowing factor was found to be dis-
metrically valid and reliable instruments that can be used tinct from others in that it mainly includes items associated
to assess eating behaviors is essential to both clinical with motor deficiencies. In the literature, these items are
management and the development of appropriate interven- most commonly associated with physical and developmental
tions. Although instruments such as the BAMBI/BAMBIC disabilities such as cerebral palsy (Speyer et al., 2019) and
(Lukens & Linscheid, 2008; Hendy et al., 2013) have been intellectual disabilities; one study involving 91 children aged
critical in advancing the assessment of eating problems four to nine years with mild, moderate or severe IDD found
among children with ASD, newer instruments specific to that certain problems (i.e., skills and aspiration risk) are
ASD are required that expand upon the scope of behav- more prevalent among the group with more severe/profound
iors assessed and address limitations of these existing intellectual disability (Gal et al., 2011). Indeed, in our sam-
measures. ple, chewing and swallowing problems were not as prevalent
The aim of the current research was to develop and as other factors in the questionnaire, which include items
report the psychometric properties of a new, comprehen- that more directly relate to ASD diagnostic criteria. Further
sive eating questionnaire intended for use in children with research should examine this factor in ASD in relation to
ASD. The Aut-Eat was designed to be a comprehensive intellectual abilities and to the severity of ASD symptoms.
practical descriptive assessment (rather than a prescriptive
assessment), that reliably assesses eating problems and Food Selectivity
patterns in children with ASD and describes the parental
perspective on their child’s eating behaviors. It provides Food selectivity/restricted food intake is defined as eating
clinicians with an in-depth picture of the child’s eating only a narrow variety of foods, and is often used to refer
history, current eating concerns, and unique dietary habits. to a range of different eating problems, such as selectivity
The instrument was intended to be used by multi- by texture and type, eating a limited repertoire of accepted
disciplinary professionals including, but not limited to, foods, and high-frequency single food intake (Matson &
occupational therapists, nurses, paediatricians, dieticians/ Fodstad, 2009; Bandini et al., 2010; Cermak et al., 2010;
nutritionists, speech pathologists, applied behavior ana- Marı-Bauset, 2013). Food selectivity in the Aut-Eat includes
lysts, and psychologists. It has the potential to be used as items such as “eats/drinks only certain things at meals,”
part of an assessment to identify specific behaviors that “eats only one item at mealtime,” “prefers the same foods
would be observed and analysed in following assessment at each meal,” “refuses to try new foods,” and “has differ-
during a clinic visit, and serve as the basis for clinical ent foods prepared for him/her compared to the rest of the
intervention and re-administration as needed, during the family.” Some studies have suggested that food selectivity in
course of treatment. In this paper, we reported the (a) steps ASD is, at least in part, a manifestation of restricted interests
taken to develop the questionnaire and (b) establishment and activities (Ahearn et al., 2001) and others related the
of content validity (internal consistency and reliability, food selectivity of children with ASD to their sensory pro-
discriminant validity). cessing disorders, specifically to sensory hyper sensitivity
Factor analysis, following the removal of three ques- (Cermak et al., 2010 )
tionnaire items, revealed the following six stable factors:
overeating, chewing and swallowing problems, food selec- Food Avoidance
tivity, problem behaviors during mealtime, food avoidance
and eating sameness and rituals. Cronbach’s alpha indi- Food avoidance is defined as the inability or refusal to eat
cated good to excellent internal consistency. The discri- certain foods/developmentally appropriate foods/eat all or
minant validity of the Aut-Eat was supported as evidenced most foods presented, resulting in the failure to meet caloric
by significant differences for all factors between children needs or in dependency on a supplemental formula (Wil-
with ASD and the typically developing control sample, liams et al., 2000). This eating/feeding problem is consid-
who were expected to report fewer eating difficulties. As ered to be one of the more severe and may also manifest as
a result of the factor analysis and test for internal consist- decreased appetite, turning of the head, mouth closure upon
ency, pica, which was not included in any of the factors presentation of foods, spitting out, gagging, and vomiting
and decreased the questionnaire’s internal consistency, of food (Kral et al, 2014). Food avoidance in the Aut-Eat
was removed from the main section of the questionnaire includes items such as “closes mouth when presented with
and instead is presented in the first section which includes food,” “turns head or body away from food,” and “spits out
general information. In the following section, we elaborate food before swallowing.”
upon each of the identified factors/questionnaire domains.

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 Journal of Autism and Developmental Disorders

Eating Sameness and Rituals food selectivity (with a preference for carbohydrates), sleep
problems, motor clumsiness and limited physical exercise,
Insistence on sameness (IS) refers to complex patterns of and poor family functioning (Curtin et al, 2014). Overeat-
rigid, routinized, and ritualistic behaviours that form a class ing has also been linked to sensory processing issues in the
of restrictive and repetitive behaviours and interests (RRBI) mouth and taste buds, which can lead to overeating or bing-
which are a diagnostic criterion for ASD (American Psy- ing and a desire for foods with strong tastes (Broder-Fingert
chiatric Association, 2013). Provost et al. (2010) reported et al., 2014). In addition, compulsive behaviors in ASD may
on the presence of eating routines or rituals in many young manifest as overeating and binging (Hackler, 1986), that is,
children with ASD. In their study, at least one-third of the they may relate to eating as they relate to other actions, in a
children were considered ritualistic eaters (8 children, 33%), repetitive way, and therefore they eat more than is required
and even more ate the same food in a repetitive manner (10 to satisfy hunger.
children, 42%), or had routines or rituals with food or eat- The Aut-Eat items which fell under the overeating domain
ing (9 children, 37%). In addition, up to 50% of the chil- include: “eats large amount of food,” “swallows without
dren with ASD required food prepared in a special way or chewing,” “shoves a large quantity of food into mouth,”
became upset if a mealtime routine was broken. This factor “continues to eat as long as food is available,” “eats a large
of the Aut-Eat included items related to visual aspects such amount without relation to hunger,” “gags while eating,” and
as color, shape, brand and packaging of food. Items in this “tries to grab food from others during mealtimes.” A number
factor include behavioral items related to serving order and of these items also appear in the diagnostic criteria for binge
lack of mealtime flexibility such as “prefers foods that were eating disorder diagnostic criteria (defined as recurrent epi-
prepared in a certain way (e.g., sandwich with peanut butter sodes of binge eating characterized by both consuming an
and jelly spread on in a certain order),” and “makes sure abnormally large amount of food in a short period of time
foods don’t touch one another.” compared with what others might eat in the same amount
These items relate to behaviors that share similarities of time, under the same or similar circumstances, and expe-
with those behaviors seen in obsessive compulsive disorder riencing a loss of control over eating during the episode;
(OCD). Indeed, the possibility of trans-diagnostic mecha- American Psychiatric Association, 2013). Such episodes
nisms underpinning obsessive compulsive behavior across also feature at least three of the following: consuming food
clinical diagnoses is supported by research that suggests the faster than normal; consuming food until uncomfortably
presence of symptoms among subgroups of individuals diag- full; consuming large amounts of food when not hungry;
nosed with OCD (Arildskov et al., 2016). Further explora- consuming food alone due to embarrassment; and feeling
tion of potentially shared mechanisms between these two disgusted, depressed, or guilty after eating a large amount
conditions is warranted. of food. Although these behaviors are more prevalent in the
ASD population than in the general individuals, they are
Overeating less prevalent than food selectivity. The presence of both in
this population highlights the sensory origins of overeating,
Just as under-eating is a serious problem among children specifically hypo-sensory processing issues in the mouth and
with ASD, overeating, defined as eating to excess, or binge taste buds which can lead to binge eating and a desire for
eating, an eating disorder characterized by the frequent con- foods with strong tastes (Broder-Fingert et al., 2014) and
sumption of unusually large amounts of food and feeling may also have implications for nutritional status.
unable to stop eating, is also prominent among the ASD
population. Studies suggests that children with ASD have Problem Behaviors During Mealtime
a prevalence of obesity at least as high as that seen in typi-
cally developing (TD) children (Curtin et al., 2014). Many The factor analysis clearly identified problem behaviors dur-
of the risk factors for children with ASD are likely the same ing mealtime as an individual and separate factor. Problem
as for TD children, especially within the context of today’s behaviors are common in ASD in general and specifically
obesogenic environment. However, the unique needs and during mealtime. In Aut-Eat, mealtime behaviour problems
challenges that this population faces may also render them items include “aggressive during meals,” “disturbs oth-
more susceptible to the adverse effects of typical risk factors, ers during mealtime,” and “inflicts injury upon self during
and they may also be vulnerable to additional risk factors not meals (e.g., “bites own hand”).” The literature indicates a
shared by children in the general population (Curtin et al., range of potential causes for such behaviors including pain
2014). Such risks factors include medication side effects caused by gastrointestinal dysfunction, such as abdominal
(such as, anti-psychotic, risperidone and aripiprazole), pain and gastro-oesophageal reflux, which often manifests

13
Journal of Autism and Developmental Disorders

as vomiting (Buie et al., 2010) and amplified pain resulting setting, there was no potential to assess interrater or test-
from sensory sensitivity (Clarke, 2015). Problem behaviors retest reliability, the nature of these psychometric properties
often co-occur with other eating problems, such as food should be explored in future research.
selectivity and food refusal (Sharp et al., 2013).
The findings of the current study also establish the dis-
criminant validity of all domains of the Aut-Eat between Conclusion
TD children and children with ASD. Significant differences
between the groups were found among all the questionnaire The goal of this study was to report on the psychometric
domains. These differences were characterized by a greater reliability and validity of a newly developed and compre-
frequency of eating problems among the ASD group. These hensive instrument for the assessment of the specific eating
findings support those of previous literature, which identi- and feeding problems and patterns in children with ASD,
fied increased eating problems among children with ASD for use in multi-disciplinary clinical settings. Following the
and a decreased total number of foods eaten, with a greater exclusion of three items, the factor analysis identified six
tendency towards food refusal as well as selection of foods stable domains of eating and feeding problems among 44
based on texture (Raiten & Massaro, 1986; Schreck et al., items in the questionnaire. In the future, we aim to digitize
2004; Martins et al., 2008). the questionnaire to facilitate accessibility. The instrument
is currently available in four languages, with the intention of
increasing the number of translated versions to increase use
Limitations and Future Research of the instrument more broadly. Future research is required
to further explore the underlying mechanisms contributing
It is important to mention several limitations in the develop- to each of the six domains, and to differentiate between the
ment of the Aut-Eat questionnaire. First, there was a signifi- sensory, motor and behavioral basis of eating and feeding
cant difference in mean age for the ASD group which was problems in children with ASD. In addition, the instrument
younger than the TD group. It is thus possible that some of may be useful as an outcome measure for eating interven-
the eating difficulties reported in the ASD group may have tion studies. Lastly, the tool in its current format is suitable
been influenced by their younger age. Although there was to children. In order to use it with adults, it is recommended
a multi-disciplinary team involved in the focus groups and to adapt it to their unique characteristics, and to create a
in the questionnaire development, nurses were not included self-report version.
in the team. In addition, the questionnaire does not include
questions pertaining to parent demographics, such as educa-
tion and employment background. The questionnaire does
not address severity of eating problems nor does it include Appendix A
measures over time which could identify patterns of eating
behaviors and this should be considered in future versions of See Table 5.
the Aut-Eat. As the current study was conducted in a clinical

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 Journal of Autism and Developmental Disorders

Table 5  Summary of principal axis factoring exploratory factor analysis for the AEQ on the combined sample (N = 196; Items a6 & c10
removed)
Factor
1 2 3 4 5 6
e3. Prefers foods be served in a certain way 0.845 0.148 − 0.093 − 0.022 0.213 − 0.131
e2. Insists that items related to meal will be organized in a certain manner 0.811 − 0.058 − 0.103 0.039 0.171 0.076
d4. Makes sure foods don’t touch one another 0.717 − 0.026 0.038 − 0.081 0.011 − 0.011
d5. Prefers foods that were prepared in a certain way (ex: sandwich with peanut but- 0.673 0.088 − 0.109 − 0.066 − 0.004 − 0.156
ter and jelly spread on in a certain order)
e7. Shows signs of frustration when the meal doesn’t go the way s/he’s accustomed 0.573 0.136 − 0.050 − 0.015 − 0.149 0.057
e5. Eats only with certain utensils and dishes (specific plate/cup/spoon) 0.533 0.030 − 0.033 − 0.021 − 0.034 0.042
d3. Selective about shape of food (i.e. will only eat a certain shape of pasta) 0.496 − 0.087 − 0.052 − 0.173 − 0.186 0.147
e1. Eats/drinks in a certain order at mealtime 0.492 0.078 0.108 0.005 − 0.164 0.228
e4. Is inflexible regarding mealtime 0.467 0.031 0.035 0.061 − 0.297 0.156
e6. There are foods he/she will only eat in a certain environment (ex: apple only at 0.451 − 0.003 0.094 − 0.220 − 0.216 − 0.051
school)
d2. Selective about color of food 0.440 0.007 − 0.074 − 0.216 − 0.236 0.009
f5. Eats large portions of foods in an uncontrolled manner, without relation to 0.037 0.875 − 0.103 − 0.009 0.140 0.009
hunger
f4. Keeps eating as long as there is food available 0.066 0.857 − 0.035 0.068 0.061 0.030
f1. Eats a lot of food in a short amount of time 0.051 0.791 0.132 − 0.112 0.028 − 0.035
f3. Shoves a lot of food into mouth − 0.018 0.749 0.100 − 0.056 − 0.090 0.122
f2. Swallows food without effective chewing 0.069 0.625 − 0.225 0.047 − 0.055 0.022
f7. Steals or tries to steal food from others during mealtime − 0.023 0.603 0.133 − 0.123 − 0.035 0.038
f6. Chokes or gags while swallowing 0.012 0.432 − 0.245 0.130 − 0.189 0.105
a4. Has difficulty biting 0.068 0.105 − 0.710 0.032 − 0.068 0.032
a2. Refuses to eat hard to chew foods 0.120 − 0.014 − 0.693 − 0.029 0.045 0.099
a7. Eats only soft or mashed foods (i.e. rice, pudding) − 0.033 − 0.194 − 0.666 − 0.178 − 0.008 0.152
a3. Sucks on food instead of chewing (with or without swallowing) 0.156 0.064 − 0.615 − 0.007 − 0.178 0.004
a8. Eats only liquid foods 0.031 − 0.028 − 0.585 − 0.178 0.051 0.049
a5. Doesn’t close lips while chewing − 0.058 0.259 − 0.372 − 0.104 − 0.243 − 0.138
a1. Keeps food in mouth or chews for a long time 0.092 0.085 − 0.357 − 0.088 − 0.126 − 0.005
c7. Eats a narrow selection of foods 0.008 0.013 0.069 − 0.851 0.004 0.081
c4. Refuses to taste new foods − 0.016 0.073 − 0.046 − 0.814 0.083 0.040
c3. Prefers the same foods at every meal − 0.015 0.082 − 0.031 − 0.808 − 0.023 − 0.030
c5. Is given different foods from those prepared for rest of family 0.045 0.068 − 0.123 − 0.740 0.033 0.008
c1. Eats/drinks only certain things at meals 0.114 − 0.060 − 0.149 − 0.734 0.022 0.038
c2. Eats only one food during meals 0.099 − 0.090 − 0.078 − 0.721 − 0.074 0.133
c6. Eats certain textures (soft or hard) 0.066 0.050 − 0.233 − 0.526 0.095 0.177
c8. Prefers only sweet, salty or sour foods 0.038 0.081 0.098 − 0.468 − 0.287 0.047
c9. Avoids foods with strong smells 0.296 0.114 0.013 − 0.380 − 0.098 − 0.020
g4. Inflicts injury upon self during meals (ex: bites own hand) 0.120 0.034 − 0.192 0.001 − 0.596 0.055
g3. Cries or yells during meals 0.000 0.013 − 0.285 − 0.056 − 0.594 0.240
g1. Aggressive during meals 0.050 0.235 − 0.258 − 0.005 − 0.505 0.115
d1. Only eats foods from certain origins (i.e. a certain brand of ketchup even if 0.194 0.063 0.053 − 0.273 − 0.427 − 0.106
packaging is unseen -based upon taste alone)
g2. Disturbs others during mealtime − 0.032 0.099 − 0.212 − 0.135 − 0.393 0.140
b2. Turns her/his face or body away from food 0.025 0.129 0.016 − 0.197 0.148 0.802
b1. Closes mouth when people try to come near her/him with food − 0.009 0.037 − 0.063 − 0.091 − 0.065 0.752
b3. Spits out food before it is swallowed 0.033 0.165 − 0.290 0.090 − 0.190 0.416
Eigenvalues 15.10 2.91 2.47 1.91 1.10 0.97
% of variance 35.95 6.93 5.89 4.54 2.62 2.30
α 0.90 0.90 0.84 0.93 0.85 0.82

13
Journal of Autism and Developmental Disorders

Author Contributions EG Instructed the research, Created original of Developmental and Behavioral Pediatrics, 22(5), 279–286.
AutEat questionnaire, Contributed to writing and editing of manu- https://​doi.​org/​10.​1097/​00004​703-​20011​0000-​00001
script; RG Co-creator of original version AutEat with Eynat Gal and Curtin, C., Jojic, M., & Bandini, L. G. (2014). Obesity in children with
original study; DH Contributed to the writing, editing and review of the autism spectrum disorder. Harvard review of psychiatry, 22(2),
manuscript, and to the statistical analyses; SB Conducted the statistical 93–103.
analyses and contributed to the editing and review of the manuscript; Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., &
REV Contributed to writing and editing of manuscript; OS Contributed Folstein, S. (2007). Atypical behaviors in children with autism
to the improvement of the most recent revised version of AutEat and and children with a history of language impairment. Research in
review of manuscript. Developmental Disabilities, 28(2), 145–162. https://​doi.​org/​10.​
1016/j.​ridd.​2006.​02.​003
Fabrigar, L. R., Wegener, D. T., MacCallum, R. C., & Strahan, E.
J. (1999). Evaluating the use of exploratory factor analysis in
psychological research. Psychological Methods, 4(3), 272–299.
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