Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

https://doi.org/10.1007/s10882-024-09960-w

ORIGINAL ARTICLE

Long-Term Outcomes after Behavior-Analytic Intervention

for Pediatric Feeding Disorders

Ashley S. Andersen1,2 · Jaime G. Crowley-Zalaket3 · Christopher W. Engler3 ·

Jason R. Zeleny4 · Kathryn M. Peterson3,5 · Aida G. Miles6 · Cathleen C. Piazza7

Accepted: 7 April 2024 / Published online: 18 April 2024

© The Author(s) 2024

Abstract
Many children with autism spectrum disorder experience feeding difficulties that
can lead to increased health risks (e.g., severe nutrition deficiencies, obesity-related
illnesses) if left untreated. Intensive feeding programs that use behavior-analytic
interventions have reported positive outcomes for treating challenging behavior as-
sociated with pediatric feeding disorders at discharge and up to 1 year post dis-
charge. Whether these children achieve and maintain long-term goals is unknown.
The purpose of the current study was to evaluate outcomes of behavior-analytic
intervention for pediatric feeding disorders among children with and without autism
spectrum disorder in an intensive feeding program post discharge. Caregivers of
former patients reported on the positive and negative impact of the program and
their child’s growth and diet variety at follow-up. 85% of caregivers reported the
program had a positive impact. Increases in height-for-age z scores were significant
from admission to discharge from the intensive program, and progress in growth
and diet variety remained the same or improved for most children at follow-up.
Results suggest that behavior-analytic intervention in an intensive feeding program
produced positive short- and long-term outcomes for children and their families.

Keywords Outcomes · Pediatric Feeding Disorders · behavior-analytic

Intervention · Autism Spectrum Disorder · food Selectivity

Pediatric feeding disorders describe the behavior of children who have persistent chal-
lenges meeting nutritional needs, energy needs, hydration needs, or a combination, by
mouth (Goday et al., 2019). Often pediatric feeding disorders have multiple etiologies,
even for children who appear to be “selective eaters” (Manikam & Perman, 2000). Con-
ditions that disrupt oral feeding such as prematurity, or cause eating to be painful (e.g.,
gastroesophageal reflux disease) or difficult (e.g., oral-motor-skill deficits), may contrib-

Extended author information available on the last page of the article

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 1040 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

ute to disordered feeding (Blackman & Nelson, 1985; Bazyk, 1990; Dellert et al., 1993;
Derrickson et al., 1993; Mukkada et al., 2010; Nucci et al., 2002; Piazza et al., 2003;
Vantini et al., 2004). Children with neurological or genetic disorders, such as autism spec-
trum disorder (ASD), are more likely to be diagnosed with a feeding disorder (Anil et al.,
2019). In fact, up to 89% of children with ASD or related diagnoses have feeding difficul-
ties (Bandini et al., 2017). Children with ASD often display change-resistant behavior
during meals, meaning they insist on eating the same few foods and following specific
and rigid routines (Crowley et al., 2020). They may respond with emotional outbursts
or even severe challenging behavior if presented with novel foods or when caregivers
attempt to deviate from usual meal routines (e.g., presentation of higher-textured foods,
restricting access to a bottle). These behaviors may discourage caregivers from attempt-
ing to change the child’s diet or meal routines.
Feeding difficulties for children with and without ASD will likely remain the same
or worsen over time without direct intervention (Peterson et al., 2019). Often, these
difficulties can have a negative and profound impact on child health and the emo-
tional well-being of the family (Auslander et al., 2003; Franklin & Rodger, 2003;
Graves & Ware, 1990; Greer et al., 2008; Milnes et al., 2013). If left untreated, chil-
dren with feeding disorders can experience growth failure, severe nutrition deficien-
cies, and dehydration. Many children require supplemental nutrition in the form of
tube feedings, which involves invasive surgical procedures, long-term maintenance
to avoid infection, additional hospital visits, and increased financial burden (Sharp
et al., 2010).
The health risks associated with change-resistant feeding behavior among some
children with ASD may not be immediately apparent. For example, many children
with ASD and food selectivity will consume sufficient calories for growth but their
diets are lacking in nutrition to a degree that places them at risk for developing obe-
sity-related illnesses, chronic gastrointestinal dysfunction, and metabolic syndrome
(Broder-Fingert et al., 2014). Results of several studies have shown that the preva-
lence of obesity and diabetes among individuals with ASD and the prevalence of
hypertension in males with ASD is higher than that of typically developing peers
(Flygare et al., 2018; Levy et al., 2019), which is alarming given the significant neg-
ative health consequences of obesity, diabetes, and hypertension. Inadequate con-
sumption of fruits, proteins, and vegetables can cause micronutrient deficiencies,
which can have serious and irreversible effects on the brain (Sullivan et al., 2002).
Schreck et al. (2004) determined that the children with ASD from their study ate
about half the dairy items, fruits, proteins, and vegetables compared to the amount
that children without ASD ate. The diets of children with ASD often consist primarily
of processed foods that are low in nutritional content and high in fat, salt, and sugar
(Bandini et al., 2017). Restrictive diets with poor nutritional content can cause further
impairments in cognitive and behavioral functioning (Freedman et al., 1999; Ludwig
et al., 1999; Volkert & Piazza, 2012).
Feeding difficulties for a child with ASD may greatly impact their ability to access
many different types of community-based settings. Clinically, we observe many chil-
dren with feeding disorders and ASD insist on eating only at home or with certain
caregivers and refuse to eat at school, daycare, or other settings. Many are unable
to eat with peers during school lunch and must be pulled away to private locations

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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1041

to have specialized providers facilitate the unique meal routine. Many require spe-
cific mealtime routines that cannot be accommodated or replicated in all settings
(Schreck et al., 2004). For example, one patient from our intensive feeding program
refused to eat any foods other than French fries from a specific McDonald’s, making
travel or attending events with food impossible for the family. Unfortunately, these
types of restrictions can lead to exclusion from the community or social stigmatiza-
tion (Bandini et al., 2010). Because children must eat regularly throughout the day,
the child’s change-resistant feeding behavior can cause more stress on families than
other characteristics of ASD because the consequences of change-resistant feeding
behavior are often more immediate and salient and can disrupt the entire family’s
mealtime or daily routines (Curtin et al., 2015). Caregivers of children with change-
resistant feeding behavior have reported feelings of anger, anxiety, depression, lack
of self-confidence, rejection, and stress (Auslander et al., 2003; Greer et al., 2008).
Caregiver stress interacts with child behavior problems such that higher stress is pre-
dictive of more behavior problems and vice versa (Baker et al., 2003; Blacher &
McIntyre, 2006; McIntyre et al., 2002).
To address these negative nutritional and social impacts of feeding disorders, clinicians
and researchers have evaluated various interventions to determine efficacy. Systematic
reviews of the literature show that interventions for pediatric feeding disorders (for chil-
dren with and without ASD) based on the principles of applied behavior analysis have the
most empirical support (Kerwin, 1999; Sharp et al., 2010; Volkert & Piazza, 2012). Sharp
et al. (2017) reported on the effectiveness of this approach in a meta-analysis of published
intensive-program outcomes. Eight of the 11 studies Sharp et al. analyzed used behavioral
interventions as at least one program component for children with a variety of diagnoses
and histories (Brown et al., 2014; Byars et al., 2003; Clawson et al., 2007; Cornwell et
al., 2010; Greer et al., 2008; Sharp et al., 2016; Silverman et al., 2013; Williams et al.,
2007). Results of these studies showed that feeding behavior and related targets, such as
decreases in tube dependence and increases in oral intake, were improved at discharge
(Brown et al., 2014; Byars et al., 2003; Clawson et al., 2007; Cornwell et al., 2010; Greer
et al., 2008; Sharp et al., 2016; Silverman et al., 2013; Williams et al., 2007).
Intensive feeding programs are often critical for children suffering from feeding dif-
ficulties to jump start their feeding goals and create a new foundation for eating, so they
are eventually able to integrate into community settings for meals with peers and family
members (e.g., restaurants, school cafeteria, social events). However, less is known about
the long-term effects of these programs (i.e., beyond 2 years). Four studies reported fol-
low-up data up to 1 year after discharge (Brown et al., 2014; Byars et al., 2003; Sharp et
al., 2016; Silverman et al., 2013). One study reported follow-up data beyond 1 year (Wil-
liams et al., 2007). Further, little is known about the long-term outcomes of outpatient
step-down programs which often aim to maintain and continue to progress feeding skills,
with the current literature demonstrating outcomes after completion of only the intensive
programs (Patel et al., 2022; Vincent et al., 2024).
Presumably, the goal of intervention for a child with a feeding disorder is to ensure
the child (a) meets appropriate energy and nutritional needs, (b) gains weight and
grows, (c) is less or not dependent on enteral or supplemental feeding and nutrition or
restricted meal routines, and (d) participates in the social aspects of eating similar to
peers (e.g., consuming meals in regular settings and with flexible routines). Another

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 1042 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

critical goal should be to improve the child and family’s quality of life and emotional
well-being. Whether children with feeding disorders treated in intensive programs
achieve and maintain these long-term goals is unknown.
Many social events, celebrations, and activities in life revolve around food (e.g.,
weddings, holidays, birthday parties). It is important that children receive care to
address feeding concerns so they can lead healthy lifestyles, and also so they can inte-
grate with others to access important and meaningful opportunities for social inter-
action. The purpose of the current study was to describe the long-term outcomes of
children who were initially treated in an intensive and then transitioned to an outpa-
tient step-down feeding program with behavior-analytic interventions to target their
feeding difficulties. One goal was to evaluate the psychosocial impact of intervention
on the child and family. A second goal was to assess the program’s long-term effects
on diet variety and growth, given these are crucial goals for children with and without
ASD who have pervasive feeding difficulties. Each time we mention program, we are
referring to the entire admission for the child, which began with an intensive bout of
treatment followed by less-intensive step-down outpatient services.

Method

Participants & Setting

Authors obtained institutional review-board approval to conduct this study. The

authors searched the medical records of children admitted to an intensive pediatric
feeding disorders program at a university-affiliated medical center from 2006 to 2019
to identify participants. Children were included in the study if they completed an
admission in the intensive day-treatment program and were excluded if they chose
to stop the program against medical advice. Authors identified 189 children that met
the inclusion criteria.

Feeding Program Overview

Admission criteria for the intensive day-treatment program included that the child
met the criteria for a pediatric feeding disorder and either had at least 3 months of
previous less-intensive therapy with little to no progress or had an urgent feeding dis-
order, such as recurrent hospitalizations for dehydration. Of the children admitted to
the intensive day-treatment program, approximately 60% were dependent on enteral
feeding (e.g., gastrostomy, jejunostomy) and consumed less than 15% of their energy
needs orally, approximately 30% consumed a limited diet variety in which they ate
few or no foods that were nutritionally appropriate, and 10% were admitted due to
other concerns (e.g., lack of independence with eating).
Mean age of children at admission was 4 years (range, 8 months to 19 years)
with a ratio of six males to four females; 42% of children were diagnosed with a
developmental disorder, such as ASD (23%). The most common medical diagnoses
were gastroesophageal reflux disease (65%) and prematurity (49%). Mean length of
admission was 44 days, during which, children attended the program five days per

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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1043

week for three to five meals per day that were spaced apart by breaks and other activi-
ties (e.g., play time). Children attended the program for approximately 5–8 h per day.
Meals typically ranged from 30 to 45 min in duration, and the breaks between meals
were of equal length. Therapists typically focused on one major skill area per meal
(e.g., solids during meals one, three, and five; liquids during meals two and four) and
each meal was comprised of multiple, time- or trial-based sessions.
The goal of the intensive day-treatment program was to make a substantial change
in the child’s feeding behavior. Common goals across children included increasing
consumption of at least 16 foods, four from the groups of fruit, grain, protein, and
vegetable, and a nutritionally and developmentally appropriate beverage. Increasing
calories consumed by mouth was a goal for children who were not consuming 100%
of their energy needs by mouth.
A dietitian monitored the child’s growth, helped select nutritionally appropriate
foods and liquids, analyzed the child’s intake, and made recommendations for adjust-
ments. A pediatric gastroenterologist provided input on patient care and monitored
medical problems (e.g., vomiting) that arose during the admission. A speech and lan-
guage pathologist was available for consultation if concerns arose about the child’s
oral-motor skills or safety for oral feeding. All children were previously cleared as
safe oral feeders by the child’s previous providers with expertise in pediatric swal-
low safety (e.g., speech language pathologist) and the team followed safety recom-
mendations regarding texture and bolus. If the child did not have a previous provider
who had expertise in swallow safety, our program’s speech language pathologist con-
ducted an evaluation before the admission to confirm whether the child was appro-
priate and safe to participate in the intensive day-treatment program. Our program’s
speech language pathologist periodically observed sessions and monitored child
progress throughout the intensive day-treatment program for children who displayed
oral-motor skill deficits. A licensed psychologist or board certified behavior analyst-
doctoral® level with specialized expertise in pediatric feeding disorders developed
the assessment and intervention protocols and supervised a team of behavior techni-
cians who implemented the protocols with the child (e.g., nonremoval of the spoon,
differential reinforcement; Sharp et al., 2010).
The intensive program was data-based and outcome oriented. The protocols incor-
porated the principles of applied behavior analysis to increase the occurrence of
appropriate feeding behavior, such as accepting and swallowing bites and drinks, and
increasing consumption of a wide variety of foods and liquids. Caregiver training
and generality of intervention effects were critical program components to ensure
that feeding success maintained in community-based settings. Therapists spent the
last week of the admission in other environments (e.g., child’s home, school, day-
care) observing the caregiver(s) (e.g., parents, teachers) implement the intervention.
Transitioning the child to the outpatient step-down program after discharge from
the intensive day-treatment program for less-intensive follow-up services was also
a planned component of the program. The outpatient step-down program focused on
teaching more advanced feeding skills (e.g., chewing, self-feeding) and progressing
the child to age- or developmentally typical eating routines (e.g., portion-based meal
consumption, eating with the family during shared meals, integrating into the school
cafeteria for daily lunch). The dietitian, speech language pathologist, or both were

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 1044 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

consulted as needed during the outpatient step-down program based on the child’s
goals. Typically, sessions were conducted weekly via telehealth or in the clinic set-
ting, and caregivers practiced the intervention or skill-acquisition targets between
sessions. The length of time children participated in the outpatient step-down pro-
gram varied based on when the child met their feeding goals or when the caregiver
felt they could continue working on the child’s goals on their own.

General Study Procedure

We sent a flyer and consent form to each caregiver via surface mail or REDCap,
if an email address was available (Patridge & Bardyn, 2018). The flyer described
the study’s purpose and listed the website URL and QR code to access the RED-
Cap questionnaire. The consent form described that the child and caregiver remained
anonymous if the caregiver completed only the first section of the questionnaire and
completing the second section served as consent for authors to access the child’s
medical records.

Follow-Up Questionnaire

The first section of the follow-up questionnaire included 11 statements with a Lik-
ert scale (1 = strongly disagree to 5 = strongly agree; see Table 1). Eight questions
focused on the potential positive impact of the program (intensive day-treatment and
outpatient step-down) on child and caregiver behavior, six of which were the target
of intervention for all children and caregivers (i.e., overall feeding behavior, fam-
ily meals, calories by mouth, food variety, motivation to eat, caregiver knowledge)
and two of which were the target for only some children and caregivers (i.e., weight
gain and behavior problems). Two questions focused on the potential negative impact
of the child’s feeding disorder (i.e., generality of intervention effects and caregiver
stress) and one question asked whether the family participated in the outpatient step-
down program until the child was an age- or developmentally typical feeder or until
the caregiver thought they could progress the child on their own.
The second section of the questionnaire included seven open-ended questions
about the child’s health and nutrition. The questionnaire asked for the child’s name;
the child’s most recent height and weight; and a list of fruits, grains, proteins, and
vegetables the child regularly consumed. Caregiver responses were analyzed to
determine the child’s status at follow-up. Data from the follow-up questionnaire are
available upon request.

Dependent Variables & Data Analysis

The primary dependent measures were the percentage of caregivers who agreed or
strongly agreed with each question about the positive impact of the program, dis-
agreed or strongly disagreed with each question about the negative impact of the
child’s feeding disorder, and agreed or strongly agreed they participated in the out-
patient step-down program. We divided the number of caregivers who agreed or
strongly agreed for each positive-impact question and the outpatient step-down pro-

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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1045

Table 1 Follow-up questionnaire questions and responses

Question 1 Strongly 2 3 Neutral 4 5
Disagree Disagree Agree Strong-
ly
Agree
1. Overall feeding behavior
My child’s feeding improved as a result of 13% 0% 2% 19% 66%
treatment at the pediatric feeding disorders
program.
2. Family meals
My child always eats what the family is 6% 17% 15% 28% 34%
eating.
3. Calories by mouth
My child meets all their caloric needs orally. 11% 2% 9% 26% 53%
4. Nutrition
My child eats a healthy variety of foods 2% 4% 9% 38% 47%
across food groups (e.g., dairy, fruits, grains,
proteins, vegetables).
5. Motivation to eat
My child requests to eat or gets food on their 6% 9% 4% 32% 49%
own.
6. Caregiver knowledge
If my child began refusing food again, I 11% 4% 13% 34% 38%
feel that I have the knowledge necessary to
handle it on my own because of the training I
received through the feeding program.
7. Weight gain
My child’s weight improved due to the feed- 9% 11% 28% 19% 34%
ing program.
8. Behavior problems
My child’s problem behavior decreased at 15% 0% 21% 19% 45%
meals due to the feeding program.
9. Generality of intervention effects
My child only eats appropriately at home. 17% 45% 9% 19% 11%
10. Caregiver stress
I am stressed by my child’s current eating 21% 53% 9% 13% 4%
habits.
11. Outpatient services
I participated in the outpatient program until 17% 2% 13% 17% 51%
my child met the feeding goals my family set
or until I felt I could progress my child to age-
typical or developmentally appropriate eating
on my own.

gram question or disagreed or strongly disagreed for each negative-impact question

by the number of caregivers who answered the question and converted the ratios to
percentages.
If the caregiver completed the second section of the questionnaire, we obtained
the child’s height; weight; and list of fruits, grains, proteins, and vegetables the child
consumed at admission and discharge from the intensive day-treatment program
from medical records. The program dietitian selected various measures by which

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 1046 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

to determine the child’s growth and nutritional status. More specific, she calculated
each child’s height-for-age and body-mass index-for-age percentiles and z scores at
admission and discharge from the intensive program and at follow-up (CDC, 2000).
The authors used GraphPad QuickCalcs Statistical Software to conduct paired t tests
to compare each child’s z score for height-for-age and body-mass index-for-age from
admission to the intensive day-treatment program to discharge from the intensive
day-treatment program and discharge to the outpatient step-down program.
The dietitian classified each child’s height-for-age and body-mass index-for-age z
scores (Becker et al., 2014; O’Conner et al., 2017; de Onis & Onyango, 2008). The
child’s body-mass index-for-age z score was classified as obese above 1.645, over-
weight from 1.036 to 1.5, within normal limits from − 0.9 to 1.02, mild malnutrition
from − 1 to -1.9, moderate malnutrition from − 2 to -2.9, and severe malnutrition from
− 3 or greater. The child’s height-for-age z score was classified as within normal lim-
its above − 1.9, stunted from − 2 to -2.9, and severely stunted from − 3 or greater. The
dietitian then determined whether the child’s growth status (i.e., body-mass index,
height) stayed the same, improved, or worsened from discharge from the intensive
day-treatment program to the time at which we sent the follow-up questionnaires.
The child’s growth status had not changed if both z scores were within normal limits
or met criteria for the same classification level of body-mass index or height, had
improved if the discharge z score met criterion for obese, overweight, or malnutrition
(stunted or severely stunted) and the follow-up z score met criterion for within normal
limits or less-severe malnutrition or obesity/overweight (less-stunted), had worsened
if the discharge z score met criterion for within normal limits, obese, overweight, or
malnutrition (stunted or severely stunted) and the follow-up z score met criterion for
malnutrition, more-severe malnutrition, or obesity/overweight (more-stunted), and
was not classified if measures were missing.
The dietitian compared the specific foods the child regularly consumed at dis-
charge from the intensive program to follow-up to determine whether the child’s diet
variety increased, decreased, or was unchanged. Diet variety increased if the child
ate more foods from the four groups at follow-up than they had at discharge from
the intensive program, decreased if the child ate fewer foods from the four groups
at follow-up than they had at discharge, or did not change if the child ate the same
number of foods from the four groups at follow-up as they had at discharge.

Results

Forty-seven of 189 caregivers (25%) completed the first anonymous section of the
questionnaire (Table 1). Of the six questions about the positive impact of the intensive
day-treatment and outpatient step-down programs on behavior that was the target of
intervention for all children and caregivers, the percentage of caregivers who agreed
or strongly agreed was 85% for overall improvement in feeding behavior, 62% for
the child eats what the family eats, 79% for the child meeting energy needs by mouth,
85% for the child consuming a healthy variety of foods, 81% for motivation to eat,
and 72% for caregiver knowledge to progress the child’s feeding behavior. Of the two
questions about the positive impact of the program on behavior that was the target of

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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1047

intervention for some children, the percentage of caregivers who agreed or strongly
agreed was 53% for weight gain and 64% for decrease in mealtime problem behav-
ior. Of the two questions that assessed the negative impact of the child’s feeding
disorder, the percentage of caregivers who disagreed or strongly disagreed was 62%
for lack of intervention generality and 74% for caregiver stress. More than two-thirds
of caregivers (68%) participated in the outpatient step-down program until their child
was an age- or developmentally typical feeder or until the caregiver thought they
could progress the child without additional services.
Caregivers of 16 males and 17 females completed the second section of the ques-
tionnaire. Mean age of children was 4.1 years (range, 0.7–11.7 years) at admission to
the intensive program, 4.3 years (range, 0.9–11.9 years) at discharge from the intensive
program, and 10.9 years (range, 3.8–20.1 years) at follow-up. Mean number of years
between discharge from the intensive program and follow-up was 7 (range, 0.4–13).
Mean height-for-age z score was − 1.3 (SD = 1.5) at admission, -0.9 (SD = 1.3)
at discharge, and − 1.0 (SD = 1.2) at follow-up. The difference from admission to
discharge was statistically significant; t(31) = 3.00, p = .0053. The difference from
discharge to follow-up was not statistically significant; t(28) = 0.58; p = .57. At fol-
low-up, height-for-age z score improved for 6%, was unchanged for 66%, decreased
for 19%, and 9% had no data.
Mean body-mass index z score was − 0.4 (SD = 1.4) at admission, -0.5 (SD = 1.3)
at discharge, and − 0.7 (SD = 1.3) at follow-up. The differences were not statistically
significant. At follow-up, body-mass index z score improved for 6%, was unchanged
for 50%, decreased for 9%, and 34% had no data.
Mean number of foods consumed from the groups of fruit, grain, protein, and veg-
etable was 3.3 (range, 0–14) at admission, 16.9 (range, 2–23) at discharge, and 24.8
(range, 1–46) at follow-up. Food variety from discharge to follow-up increased for
75%, was unchanged for 9%, and decreased for 16%.

Discussion

Results of outcome studies suggest that behavior and other targets associated with
pediatric feeding disorders have improved at discharge from intensive feeding pro-
grams that used behavioral interventions (Brown et al., 2014; Byars et al., 2003;
Clawson et al., 2007; Cornwell et al., 2010; Greer et al., 2008; Laud et al., 2009;
Seiverling et al., 2020; Sharp et al., 2016; Silverman et al., 2013; Williams et al.,
2007). One limitation of these studies is that follow-up data mostly described chil-
dren who were dependent on gastrostomy tubes (Brown et al., 2014; Byars et al.,
2003; Cornwell et al., 2010; Silverman et al., 2013; Williams et al., 2007), and only
two studies presented data beyond 1 year (Laud et al., 2009; Williams et al., 2007).
The current study extends the literature by reporting long-term outcomes for children
with heterogeneous presentations of pediatric feeding disorders, including children
with ASD and related disorders, for a mean of 7 years and up to 13 years after dis-
charge. 85% of caregivers reported that treatment in the intensive day-treatment and
outpatient step-down programs improved their child’s feeding behavior.

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 1048 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

Williams et al. (2007) reported that 74% of children who were 100% gastrostomy-
tube dependent at admission were not receiving tube feedings 2 years after treatment
in an intensive program. The current study assessed a slightly different outcome,
whether the child was meeting their energy needs by mouth, for several reasons. First,
eliminating tube feedings is not necessarily equivalent to meeting energy, hydration,
or nutritional needs orally. Some children may not receive tube feedings but also
may not meet all of their needs via oral feeding. For example, the many children
with ASD who engage in change-resistant feeding behavior have significantly limited
diet variety and nutrition, leading to poor health outcomes. Second, unlike Williams
et al., our sample included children with and without a history of tube dependence.
Asking about calories by mouth provided information about the oral intake of the
entire sample, not just those with a history of tube dependence. One limitation is
that we cannot determine whether children who were not consuming 100% of their
energy needs by mouth were those who continued to receive tube feedings or were
exclusive oral feeders with insufficient oral intake. Nevertheless, the 13% of caregiv-
ers who disagreed or strongly disagreed with the question about their child meeting
calorie needs by mouth suggests that some children with feeding disorders continue
to require caloric supplementation even after treatment in an intensive program.
Most caregivers in the current study (85%) reported their child was eating a
healthy variety of fruits, grains, proteins, and vegetables. Mean total foods consumed
at admission was 3.3 (0.7 fruits, 1.3 grains, 1.1 proteins, and 0.2 vegetables). At dis-
charge from the intensive program, mean total foods consumed increased to 16.9 (4.1
fruits, 4.6 grains, 4.4 proteins, and 3.7 vegetables). At follow-up, mean total foods
consumed increased to 24.8 (6.3 fruits, 5.1 grains, 6.8 proteins, and 6.6 vegetables).
This outcome is noteworthy given the documented nutritional deficiencies in the
diets of typically eating children in the United States (Guenther et al., 2006; Krebs-
Smith et al., 2010). This also has important implications for children with ASD who
have limited diets severely lacking in nutrition.
Poor growth can be a concern for some children with pediatric feeding disorders.
Previous outcome studies have reported mixed findings relative to the effect of inter-
vention on growth, including initial weight loss (Byars et al., 2003; Silverman et al.,
2013), weight gain (Greer et al., 2008), and no weight change (Brown et al., 2014;
Cornwell et al., 2010). Comparison between studies is challenging because research-
ers used different measures to report growth and assessed growth at different inter-
vals. Thus, outcomes may be difficult to interpret without information on the child’s
relative growth (Hermanussen, 2015). In this study, the dietitian transformed heights
and BMI’s to z scores. The height and BMI of 72% and 56% of children, respectively,
remained the same or improved from discharge to follow-up, but some children still
had growth concerns. Future research should evaluate why growth remains a chal-
lenge for some children with feeding disorders.
The negative effects of pediatric feeding disorders on the child and family’s psy-
chosocial functioning cannot be underestimated. Caregivers of children with feeding
problems have reported additional stress, depression, and feelings of rejection (Frank-
lin & Rodger, 2003). Much of this stress and anxiety could be due to a lifestyle that
requires frequent contact with medical providers or maintaining unique and complex
feeding routines (e.g., traveling to the same McDonalds every day) to ensure their

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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1049

child meets their nutritional and calorie needs. In the current study, most caregivers
reported that after the intensive feeding program, their child ate what the family ate,
requested to eat or obtained food on their own, and ate appropriately across settings
(i.e., not just in the home); this outcome suggests that the child’s feeding behav-
ior was no longer a barrier to the social aspects of mealtime, likely increasing their
access to other settings. Recall, for many children with ASD and feeding difficulties,
change-resistant feeding behavior serves as a major barrier to them participating fully
in activities that occur in other settings during meals or social events (e.g., birthday
party, holiday gatherings). Therefore, outcomes such as eating appropriately across
settings and eating what the family eats are significant and suggest improvements in
these change-resistant behaviors, which leads to fuller participation in the commu-
nity. Similarly, caregivers in Silverman et al. (2013) reported significantly reduced
aversion to mealtime and significantly improved family mealtime environment. In
Greer et al. (2008) and the current study, 62% and 74% of caregivers, respectively,
did not report stress at follow-up. Future studies should examine the factors that con-
tribute to caregiver pretreatment stress and stress reduction posttreatment.
More than two-thirds of caregivers in this study participated in the outpatient step-
down program until their child was an age- or developmentally typical feeder, or until
the caregiver felt they could progress the child without additional services. Other stud-
ies (a) did not report whether they provided outpatient step-down services (Greer et al.,
2008; Laud et al., 2009; Sharp et al., 2016; Williams et al., 2007), (b) did not describe the
details of outpatient step-down services (Byars et al., 2003; Cornwell et al., 2010), or (c)
referred families to unspecified outpatient providers (Brown et al., 2014). Clawson et al.
(2007) reported that families returned for follow-up at 1, 4, 7, and 12 months following
discharge. The absence of details and lean schedule of outpatient services is surprising
as we find that caregivers need significant support to maintain and progress their child’s
feeding. In addition, outpatient step-down services could be important to ensure success
maintains across community settings, different feeders, expanded food variety, and over
time as the child progresses toward adolescence and adulthood.
Future studies should examine the frequency and intensity of outpatient services
needed to maintain the gains of an intensive program and to progress the child to age-
or developmentally typical feeding. After intensive feeding concerns are addressed,
it may not be necessary to retain long-term support from feeding specialty provid-
ers. Many children with ASD receive ABA treatment for non-feeding related goals
(e.g., communication; Roane et al., 2016). It could be that transitioning a child from
an intensive behavior-analytic feeding program to a less intensive behavior-analytic
general service provider (e.g., in home, school, community) could be one way to
maintain progress and continue to develop skills over time with a similar treatment
philosophy. More research is needed to identify the best methods for children with
feeding difficulties to eventually become age- or developmentally typical feeders.
Although most caregivers in this study reported maintenance or improvement in
their child’s eating over time, some caregivers reported that their child’s feeding behav-
ior relapsed after discharge from the programs (i.e., decrease in growth measure or diet
variety). Questionnaire results did not provide information about why relapse occurred.
Previous researchers evaluating relapse found interfering behavior often increases when
the feeding environment changes (Ibañez et al., 2019). Other researchers have evaluated

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 1050 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

strategies for mitigating relapse during similar contextual changes, but results have been
mixed (Haney et al., 2021; Kelley et al., 2018). Researchers should determine the condi-
tions in which treatment relapse is likely to occur and assess strategies for preventing
relapse. The current survey did not ask caregivers whether they were currently using an
intervention developed during the child’s feeding admission. However, the goal of the
program is to progress children to age-typical eating, meaning that at some point, inter-
ventions should no longer be required. That is, the ultimate goal for children participat-
ing in this type of treatment is for them to eat typically without additional treatment in
place. Future research should assess how long children admitted to an intensive feeding
program require intervention to maintain their progress and how long it takes before they
begin eating age-typically.
The low response rate (25%) is a limitation of the current study. Meta-analyses
have reported a mean response rate of 53% for questionnaires (i.e., return or comple-
tion; Cook et al., 2000). Therefore, we cannot be sure of the long-term outcomes of
the 75% that did not respond to the questionnaire. However, there are a multitude of
factors which can influence response rates (Fan & Yan, 2010). Researchers in other
studies collected follow-up data in person or by phone and had better response rates
(Byars et al., 2003; Laud et al., 2009). Although in-person and telephone follow-up
might increase response rate, it also may increase response bias. By contrast, provid-
ing anonymity may increase respondents’ willingness to respond to questions without
bias (Ong & Weiss, 2000).
Results of the current study suggest that behavior-analytic intervention for children
with feeding disorders produced meaningful and lasting change in feeding behavior,
growth, nutrition, and psychosocial functioning for up to 13 years post treatment.
Important changes included increases in the number and variety of foods the child
consumed and stable or improved growth. The psychosocial functioning of the child
and family appeared to approximate that of families with typically eating children
given the absence of previous challenges (e.g., child ate with family, child indicated
hunger), suggesting these children were better able to access other settings and reduc-
ing stress for caregivers. The changes are noteworthy because these children had not
progressed in traditional outpatient therapy or their feeding disorder was causing sig-
nificant medical problems before admission to the intensive program. Future research
should focus on increasing response rate at follow-up to evaluate whether results are
representative of most children receiving behavior-analytic treatment for pediatric
feeding disorders in an intensive program.

Declarations

Conflict of Interest All authors agree with the content of the manuscript and the order of authorship listed
on the title page; the authors do not have any conflicts of interest (financial or non-financial) to report.

Ethical Approval We received full approval from our University’s Institutional Review Board (IRB) to
conduct this study and as such, obtained informed consent. The study was performed in accordance with
the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or com-
parable ethical standards.

13
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 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1051

Informed Consent The IRB approved the process of sending a flyer and consent form to each caregiver via
surface mail or REDCap, if an email address was available (Patridge & Bardyn, 2018). The flyer described
the study’s purpose and listed the website URL and QR code to access the REDCap questionnaire.
The consent form described that the child and caregiver remained anonymous if the caregiver completed
only the first section of the questionnaire and completing the second section served as consent for authors
to access the child’s medical records. We do not disclose any identifiable protected health information in
the manuscript. Participants were informed that they could withdraw their participation at any time. There
was no funding for this research.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative
Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use
is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/
licenses/by/4.0/.

References
Auslander, G. K., Netzer, D., & Arad, I. (2003). Parental anxiety following discharge from hospital of their very low
birth weight infants. Family Relations, 52(1), 12–21. https://doi.org/10.1111/j.1741-3729.2003.00012.x.
Baker, B. L., McIntyre, L. L., Blacher, J., Crnic, K., Edelbrock, C., & Low, C. (2003). Pre-school children with
and without developmental delay: Behaviour problems and parenting stress over time. Journal of Intel-
lectual Disability Research, 47(4–5), 217–230. https://doi.org/10.1046/j.1365-2788.2003.00484.x
Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., Maslin, M., & Must, A.
(2010). Food selectivity in children with autism spectrum disorders and typically developing children. The
Journal of Pediatrics, 157(2), 259–264. https://doi.org/10.1016/j.jpeds.2010.02.013.
Bandini, L. C., Phillips, S., Anderson, S. E., Maslin, M., & Must, A. (2017). Changes in food selectivity in
children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(2), 439–446.
https://doi.org/10.1007/s10803-016-2963-6.
Bazyk, S. (1990). Factors associated with the transition to oral feeding in infants fed by nasogastric tubes. The
American Journal of Occupational Therapy, 44(12), 1070–1078. https://doi.org/10.5014/ajot.44.12.1070.
Becker, P., Carney, L. N., Corkins, M. R., Monczka, J., Smith, E., Smith, S. E., Spear, B. A., White, J. V., &
American Society for Parenteral and Enteral Nutrition. (2014). Consensus statement of the Academy of
Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators recommended
for the identification and documentation of pediatric malnutrition (undernutrition). Nutrition in Clinical
Practice, 30(1), 147–161. https://doi.org/10.1177/0884533614557642.
Blacher, J., & McIntyre, L. L. (2006). Syndrome specificity and behavioural disorders in young adults with
intellectual disability: Cultural differences in family impact. Journal of Intellectual Disabilities Research,
50(Pt 3), 184–198. https://doi.org/10.1111/j.1365-2788.2005.00768.x
Blackman, J. A., & Nelson, C. L. (1985). Reinstituting oral feedings in children fed by gastronomy tube. Clini-
cal Pediatrics, 24(8), 434–438. https://doi.org/10.1177/000992288502400803.
Broder-Fingert, S., Brazauskas, K., Lindgren, K., Iannuzzi, D., & Van Cleave, J. (2014). Prevalence of over-
weight and obesity in a large clinical sample of children with autism. Academic Pediatrics, 14(4), 408–
414. https://doi.org/10.1016/j.acap.2014.04.004
Brown, J., Kim, C., Lim, A., Brown, S., Desai, H., Volker, L., & Katz, M. (2014). Successful gastrostomy tube
weaning program using an intensive multidisciplinary team approach. Journal of Pediatric Gastroenterol-
ogy and Nutrition, 58(6), 743–749. https://doi.org/10.1097/mpg.0000000000000336.
Byars, K., Burklow, K., Ferguson, K., O’Flaherty, T., Santoro, K., & Kaul, A. (2003). A multicomponent behav-
ioral program for oral aversion in children dependent on gastrostomy feedings. Journal of Pediatric Gas-
troenterology and Nutrition, 37(4), 473–480. https://doi.org/10.1097/00005176-200310000-00014.
Centers for Disease Control and Prevention, National Center for Health Statistics (2000). CDC growth charts:
United States. http://www.cdc.gov/growthcharts/. May 30.

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 1052 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

Clawson, E. P., Kuchinski, K. S., & Bach, R. (2007). Use of behavioral interventions and parent education to
address feeding difficulties in young children with spastic diplegic cerebral palsy. Neurorehabilitation,
22(5), 397–406. https://doi.org/10.3233/nre-2007-22506.
Cook, C., Heath, F., & Thompson, R. L. (2000). A meta-analysis of response rates in web- or inter-
net-based surveys. Educational and Psychological Measurement, 60(6), 821–836. https://doi.
org/10.1177/00131640021970934.
Cornwell, S. L., Kelly, K., & Austin, L. (2010). Pediatric feeding disorders: Effectiveness of multidisciplinary
inpatient treatment of gastrostomy-tube dependent children. Children’s Health Care, 39(3), 214–231.
https://doi.org/10.1080/02739615.2010.493770.
Crowley, J. G., Peterson, K. M., Fisher, W., & Piazza, C. C. (2020). Treating food selectivity as resistance to
change in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 1–22. https://doi.
org/10.1002/jaba.711. Advance online publication.
Curtin, C., Hubbard, K., Anderson, S. E., Mick, E., Must, A., & Bandini, L. G. (2015). Food selectivity, meal-
time behavior problems, spousal stress, and family food choices in children with and without autism
spectrum disorder. Journal of Autism and Developmental Disorders, 45(10), 3308–3315. https://doi.
org/10.1007/s10803-015-2490-x.
de Onis, M., & Onyango, A. W. (2008). WHO child growth standards. The Lancet, 371(9608), 204. https://doi.
org/10.1016/S0140-6736(08)60131-2.
Dellert, S. F., Hyams, J. S., Treem, W. R., & Geertsma, M. A. (1993). Feeding resistance and gastroesopha-
geal reflux in infancy. Journal of Pediatric Gastroenterology and Nutrition, 17(1), 66–71. https://doi.
org/10.1097/00005176-199307000-00009.
Derrickson, J. G., Neef, N. A., & Cataldo, M. F. (1993). Effects of signaling invasive procedures on a hospi-
talized infant’s affective behaviors. Journal of Applied Behavior Analysis, 26(1), 133–134. https://doi.
org/10.1901/jaba.1993.26-133.
Fan, W., & Yan, Z. (2010). Factors affecting response rates of the web survey: A systematic review. Computers
in Human Behavior, 26(2), 132–139. https://doi.org/10.1016/j.chb.2009.10.015.
Flygare, W. E., Ljunggren, G., Carlsson, A. C., Pettersson, D., & Wändell, P. (2018). High prevalence of dia-
betes mellitus, hypertension and obesity among persons with a recorded diagnosis of intellectual disabil-
ity or autism spectrum disorder. Journal of Intellectual Disability Research, 62(4), 269–280. https://doi.
org/10.1111/jir.12462
Franklin, L., & Rodger, S. (2003). Parents’ perspectives on feeding medically compromised children: Implica-
tions for occupational therapy. Australian Occupational Therapy Journal, 50(3), 137–147. https://doi.
org/10.1046/j.1440-1630.2003.00375.x.
Freedman, D. S., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (1999). The relation of overweight to car-
diovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics, 103(6),
1175. https://doi.org/10.1542/peds.103.6.1175
Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S., Delaney, A. L., Feuling, M. B.,
Noel, R. J., Gisel, E., Kenzer, A., Kessler, D. B., de Camargo, K., Browne, O., J., & Phalen, J. A. (2019).
Pediatric feeding disorder: Consensus definition and conceptual framework. Journal of Pediatric Gastro-
enterology and Nutrition, 68(1), 124–129. https://doi.org/10.1097/MPG.0000000000002188.
Graves, J. K., & Ware, M. E. (1990). Parents’ and health professionals’ perceptions concerning parental
stress during a child’s hospitalization. Children’s Health Care, 19(1), 37–42. https://doi.org/10.1207/
s15326888chc1901_5.
Greer, A. J., Gulotta, C. S., Masler, E. A., & Laud, R. B. (2008). Caregiver stress and outcomes of children with
pediatric feeding disorders treated in an intensive interdisciplinary program. Journal of Pediatric Psychol-
ogy, 33(6), 612–620. https://doi.org/10.1093/jpepsy/jsm116.
Guenther, P. M., Dodd, K. W., Reedy, J., & Krebs-Smith, S. M. (2006). Most americans eat much less than
recommended amounts of fruits and vegetables. Journal of the American Dietetic Association, 106(9),
1371–1379. https://doi.org/10.1016/j.jada.2006.06.002.
Haney, S. D., Piazza, C. C., Peterson, K. M., & Greer, B. D. (2021). An evaluation of a renewal-mitigation
procedure for inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 54(3), 903–927.
https://doi.org/10.1002/jaba.815.
Hermanussen, M. (2015). Absolute or relative measures of height and weight? An Editorial. European Journal
of Clinical Nutrition, 69(6), 647–648. https://doi.org/10.1038/ejcn.2015.70.
Ibañez, V. F., Piazza, C. C., & Peterson, K. M. (2019). A translational evaluation of renewal of inappropri-
ate mealtime behavior. Journal of Applied Behavior Analysis, 52(4), 1005–1020. https://doi.org/10.1002/
jaba.647.

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054 1053

Kelley, M. E., Jimenez-Gomez, C., Podlesnik, C. A., & Morgan, A. (2018). Evaluation of renewal mitigation of
negatively reinforced socially significant operant behavior. Learning and Motivation, 63, 133–141. https://
doi.org/10.1016/j.lmot.2018.05.003.
Kerwin, M. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Jour-
nal of Pediatric Psychology, 24(3), 193–214. https://doi.org/10.1093/jpepsy/24.3.193.
Krebs-Smith, S. M., Guenther, P. M., Subar, A. F., Kirkpatrick, S. I., & Dodd, K. W. (2010). Americans do
not meet federal dietary recommendations. The Journal of Nutrition, 140(10), 1832–1838. https://doi.
org/10.3945/jn.110.124826.
Laud, R. B., Girolami, P. A., Boscoe, J. H., & Gulotta, C. S. (2009). Treatment outcomes for severe feeding
problems in children with autism spectrum disorder. Behavior Modification, 33(5), 520–536. https://doi.
org/10.1177/0145445509346729.
Levy, S. E., Pinto-Martin, J. A., & Bradley, C. B. (2019). Relationship of weight Outcomes, co-occurring condi-
tions, and severity of Autism Spectrum Disorder in the study to explore Early Development. Journal of
Pediatrics, 205, 202–209. https://doi.org/10.1016/j.jpeds.2018.09.003
Ludwig, D. S., Majzoub, J. A., Al-Zahrani, A., Dallal, G. E., Blanco, I., & Roberts, S. B. (1999). High glycemic
index foods, overeating, and obesity. Pediatrics, 103(3), E26. 10.1542/peds.103.3.e26
McIntyre, L. L., Blacher, J., & Baker, B. L. (2002). Behaviour/mental health problems in young adults with
intellectual disability: The impact on families. Journal of Intellectual Disability Research, 46(3), 239–249.
https://doi.org/10.1046/j.1365-2788.2002.00371.x
Milnes, S. M., Piazza, C. C., & Carroll, T. (2013). Assessment and treatment of pediatric feeding disorders Ency-
clopedia on Early Childhood Development. Retrieved January 11, 2022, from https://www.child-encyclo-
pedia.com/child-nutrition/according-experts/assessment-and-treatment-pediatric-feeding-disorders.
Mukkada, V. A., Haas, A., Maune, N. C., Capocelli, K. E., Henry, M., Gilman, N., Petersburg, S., Moore,
W., Lovell, M. A., Fleischer, D. M., Furuta, G. T., & Atkins, D. (2010). Feeding dysfunction in chil-
dren with eosinophilic gastrointestinal diseases. Pediatrics, 126(3), 672–677. https://doi.org/10.1542/
peds.2009-2227.
Nucci, A. M., Barksdale, E. M., Yaworski, J. A., Beserock, N., & Reyes, J. (2002). Enteral formula use in
children after small bowel transplant. Nutrition in Clinical Practice, 17(2), 113–117. https://doi.
org/10.1177-0115426502017002113.
O’Connor, E. A., Evans, C. V., Burda, B. U., Walsh, E. S., Eder, M., & Lozano, P. (2017). Screening for obesity
and intervention for weight management in children and adolescents: Evidence report and systematic
review for the US Preventive Services task force. Journal of the American Medical Association, 317(23),
2427–2444. https://doi.org/10.1001/jama.2017.0332.
Ong, A. D., & Weiss, D. J. (2000). The impact of anonymity of responses to sensitive questions. Journal of
Applied Social Psychology, 30(8), 1691–1708. https://doi.org/10.1111/j.1559-1816.2000.tb02462.x.
Patel, M. R., Patel, V. Y., Andersen, A. S., & Miles, A. (2022). Evaluating outcome measure data for an intensive
interdisciplinary home-based pediatric feeding disorders program. Nutrients, 14(21), 4602. https://doi.
org/10.3390/nu14214602.
Patridge, E. F., & Bardyn, T. P. (2018). Research Electronic Data Capture (REDCap). Journal of the Medical
Library Association, 106(1), 142–144. https://doi.org/10.5195/jmla.2018.319.
Peterson, K. M., Piazza, C. C., Ibañez, V. F., & Fisher, W. (2019). Randomized controlled trial of an applied
behavior analytic intervention for food selectivity in children with autism spectrum disorder. Journal of
Applied Behavior Analysis, 52(4), 895–917. https://doi.org/10.1002/jaba.650.
Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. P., Katz, R. M., Sevin, B. M., Gulotta, C. S.,
& Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied
Behavior Analysis, 36(2), 187–204. https://doi.org/10.1901/jaba.2003.36-187.
Roane, H. S., Fisher, W. W., & Carr, J. E. (2016). Applied behavior analysis as treatment for autism spectrum
disorder. The Journal of Pediatrics, 175(1), 27–32. https://doi.org/10.1016/j.jpeds.2016.04.023.
Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children
with and without autism. Journal of Autism and Developmental Disorders, 34(4), 433–438. https://doi.
org/10.1023/B:JADD.0000037419.78531.86.
Seiverling, L., Hendy, H. M., Yusupova, S., Kaczor, A., Panora, J., & Rodriguez, J. (2020). Improve-
ments in children’s feeding behavior after intensive interdisciplinary behavioral treatment: Com-
parisons by developmental and medical status. Behavior Modification, 44(6), 891–908. https://doi.
org/10.1177/0145445519865170.
Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative
synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13(4), 348–365. https://
doi.org/10.1007/s10567-010-0079-7.

13
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
 1054 Journal of Developmental and Physical Disabilities (2024) 36:1039–1054

Sharp, W. G., Stubbs, K. H., Adams, H., Wells, B. M., Lesack, R. S., Criado, K. K., Simon, E. L., McCracken,
C. E., West, L. L., & Scahill, L. D. (2016). Intensive, manual-based intervention for pediatric feeding
disorders: Results from a randomized pilot trial. Journal of Pediatric Gastroenterology & Nutrition, 62(4),
658–663. https://doi.org/10.1097/mpg.0000000000001043.
Sharp, W. G., Volkert, V. M., Scahill, L., McCracken, C. E., & McElhanon, B. (2017). A systematic review and
meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is
the standard of care? The Journal of Pediatrics, 181, 116–124. https://doi.org/10.1016/j.jpeds.2016.10.002.
Silverman, A. H., Kirby, M., Clifford, L., Fischer, E., Berlin, K. S., Rudolph, C. D., & Noel, R. J. (2013). Nutri-
tional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpa-
tient behavioral treatment program. Journal of Pediatric Gastroenterology & Nutrition, 57(5), 668–672.
https://doi.org/10.1097/mpg.0b013e3182a027a3.
Sullivan, P. B., Juszezak, E., Lambert, B. R., Rose, M., Ford-Adams, M. E., & Johnson, A. (2002). Impact of
feeding problems on nutritional intake and growth: Oxford feeding study II. Developmental Medicine &
Child Neurology, 44, 461. https://doi.org/10.1017/s0012162201002365
Vantini, I., Benini, L., Bonfante, F., Talamini, G., Sembenini, C., Chiarioni, G., Maragnolli, O., Benini, F., &
Capra, F. (2004). Survival rate and prognostic factors in patients with intestinal failure. Digestive and Liver
Disease, 36(1), 46–55. https://doi.org/10.1016/j.dld.2003.09.015.
Vincent, L. B., Stone-Heaberlin, M., Kandarpa, K., McIntire, H., Turner, K., & Krebs, K. (2024). Clinical out-
comes from an interdisciplinary outpatient feeding treatment pilot program. Journal of Clinical Psychol-
ogy in Medical Settings, 1–16. https://doi.org/10.1007/s10880-023-09963-3
Volkert, V. M., & Piazza, C. C. (2012). Pediatric feeding disorders. In P. Sturmey, & M. Hersen (Eds.), Hand-
book of evidence-based practice in clinical psychology, vol 1: Child and adolescent disorders (pp. 323–
337). John Wiley & Sons Inc. https://doi.org/10.1002/9781118156391.ebcp001013.
Williams, K. E., Riegel, K., Gibbons, B., & Field, D. G. (2007). Intensive behavioral treatment for severe
feeding problems: A cost-effective alternative to tube feeding? Journal of Developmental and Physical
Disabilities, 19(3), 227–235. https://doi.org/10.1007/s10882-007-9.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

Authors and Affiliations

Ashley S. Andersen1,2 · Jaime G. Crowley-Zalaket3 · Christopher W. Engler3 ·

Jason R. Zeleny4 · Kathryn M. Peterson3,5 · Aida G. Miles6 · Cathleen C. Piazza7

Kathryn M. Peterson
[email protected]

1
Clinic 4 Kidz, Sausalito, CA, USA
2
University of Nebraska Medical Center, Omaha, NE, USA
3
Children’s Specialized Hospital, 888 Easton Ave, Somerset, NJ 08873, USA
4
Department of Pediatrics, Golisano Center for Special Needs, SUNY Upstate Medical
University, Syracuse, NY, USA
5
Rutgers Robert Wood Johnson Medical School, Division of Child Neurology and
Neurodevelopmental Disabilities, New Brunswick, NJ, USA
6
Department of Pediatrics, University of Alabama Birmingham Heersink School of
Medicine, Birmingham, AL, USA
7
Graduate School of Applied and Professional Psychology, Rutgers, New Brunswick, NJ,
USA

13
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