Exploring behavioral pediatric feeding problems and parental perceptions among children with developmental disabilities

INTRODUCTION

Development is the process by which a person changes physically, cognitively, and psychosocially throughout his/ her life. Developmental disabilities are prevalent worldwide, with conditions such as autism spectrum disorder (ASD), Attention-deficit hyperactivity disorder (ADHD), intellectual disability (ID), specific language disability (SLD), and other developmental delays being common examples. Globally, nearly 240 million children live with disabilities, with SubSaharan Africa and South Asia representing more than half of this population.^[1,2] The actual burden of neurodevelopmental disorders may be higher due to limitations in the studies. In India, approximately one in eight children between the ages of 2 and 9 suffer from at least one of the nine developmental disorders.^[3]

Feeding is an essential activity that facilitates interaction between parent and child and plays a critical role in influencing the child’s health. “Feeding behavior refers to the patterns of behavior at and around mealtimes, parental strategies, foods accepted and refused, refusal patterns such as whining and delaying, and behavior related to difficulty handling certain foods such as gagging.”^[4] The most common feeding behavior problems present in childhood include refusing to eat, eating too little, being selective about food, and acting inappropriately during mealtime. The prevalence of feeding difficulties is approximately 30–90% among children with special needs, resulting in chronic malnutrition, decreased quality of life, and early death in children.^[5] Food intake difficulties, self-feeding issues, oromotor skill deficits, or behavioral problems can cause these difficulties.^[6] These problems are seen in 25–40% of healthy children, but the prevalence can rise to as much as 80% in children with neurodevelopmental disorders.^[7] Research in India has also indicated that children with special needs who experience feeding challenges face a higher risk of malnutrition compared to typically developing children.^[6] In children with neurodevelopmental challenges, disruptions in the typical progression of feeding skill development can lead to both temporary and lasting effects on behavior, sensory processing, psychological well-being, and nutritional health. A tactile oversensitivity, for instance, has been shown to influence children with and without atypical development in terms of their eating habits and food selection.^[8] Consequently, there is a strain on the parent-child relationship during feeding, more coercive feeding strategies are used, the child’s autonomy in feeding tasks is reduced, and the child’s maladaptive feeding behavior persists.^[9] A variety of environmental factors can also influence feeding skills, including family interactions during meals, particular feeding practices by the parents, and their level of knowledge regarding feeding.^[10] Investigating feeding problems in clinical populations by examining how various factors interact and contribute to these challenges can offer valuable insights into the underlying mechanisms affecting feeding behaviors in children with developmental disabilities.

MATERIALS AND METHODS

After obtaining the administrative approval and ethical clearance from Rajkumari Amrit Kaur College of Nursing and the Ethical Review Board of Safdarjung Hospital, this cross-sectional study performed at the Child Development Center of Safdarjung Hospital, New Delhi, a specialized facility that focuses on assessing, diagnosing, and offering a variety of intervention services to children with developmental delays and disabilities that have been referred to it. Children between the age group of 6 years and 11 years were diagnosed with ASD, ADHD, ID, cerebral palsy, SLD, and Down syndrome attending the Child Development Center selected through purposive sampling technique. First, self-introduction and establishment of rapport with the subjects were done. All samples were selected using the purposive sampling method. Written consent was taken from the parents of each sample, who are willing to participate and confidentiality of the respondent was assured and maintained. Parents of children who do not understand Hindi and English were excluded.

We will begin by calculating the sample size for an infinite population and then adjust it to fit the desired population size. Given: Z = 1.960, P = 0.1 (prevalence of children with developmental disabilities in India = 10% by RBSK), M = 0.05.

Using Cochrane’s sample size formula, S = Z2 × P × (1−P)/M ×M S= (1.960)2 × 0.1 × (1−0.1)/0.05 ×0.05 = 3.8416 × 0.25/0.0025 S = 138.

The sample size for the population is 138 by the Cochran formula; hence, 150 subjects were taken for the final study.

RESULTS

DISCUSSION

The quality of life and emotional state of parents of children with neurodevelopmental disorders are recognized to be lower than those of parents whose children are developing normally and who require assistance to improve.^[11] Other authors also described in their study that children with neurodevelopmental disorders need parental support for feeding and daily care.^[3,11,12] In addition, these children show disrupted feeding patterns, which may have short- or long-term effects on behavioral, sensory, psychological, and nutritional domains. Parent-child interactions during feeding tend to be problematic, leading to more coercive feeding, limited autonomy in feeding, and maladaptive feeding-related behaviors.^[7,^11,12]

The present study found that almost all children with ASD, ADHD, ID, SLD, cerebral palsy, and Down syndrome were having behavioral feeding problems and problematic parental strategies and feelings. This supports the study done among children diagnosed with ASD, cerebral palsy, ID, ADHD, and SLD.^[7,11,13-^16]

Children with ASD frequently experience food refusal and limited food variety, with studies showing significant differences in mealtime behavior compared to typically developing peers.^[17] Feeding difficulties often include picky eating, delayed self-feeding skills, and a reliance on specific food types among children with ASD.^[18] Feeding difficulties in children with ASD can lead to malnutrition and childhood obesity. Parents report feeding difficulties and poor nutrition among children diagnosed with ASD.^[19,^20] According to previous studies, children with eating problems had a significantly higher prevalence of ADHD and/or ASD, suggesting an overlap.^[21]

While specific studies on ADHD and ID were less prevalent, children with these conditions also demonstrated increased feeding problems, often exacerbated by behavioral issues and parenting stress. Disruptive behaviors in children with ADHD can lead to maladaptive feeding strategies, further complicating their nutritional intake.^[22] Other studies also suggested that hyperactive children and children with psychiatric problems were susceptible to feeding problems.^[23]

Previous similar studies indicate that children having feeding and eating disorders are at more risk for developing ADHD, ASD, and ID, suggesting a potential link between these neurodevelopmental disorders and behavioral feeding problems.^[24] Feeding behavior problems are common in children diagnosed with SLD and found that 39.5% of children had feeding problems, which were associated with lower dietary protein intake and negative correlations with anthropometric measurements.^[15] The BPFAS effectively captures the nuances of parental feelings and strategies, which are critical in understanding feeding behaviors in children with various diagnoses.^[25] Similarly, another study showed a significant relationship between intellectual and developmental disabilities levels and feeding problems along with nutritional status in young adults with intellectual disabilities.^[26]

The conclusions of this review are that children with ASD and their parents found significant challenges and need support and coping strategies to manage their child’s care and their own well-being.^[27] Feeding is strongly correlated with nutritional status and health status in children with CP, and multiple diagnosed health issues can also make feeding difficult.^[28,^29] Feeding issues reported by parents of children with Down syndrome include fussiness, satiety responsiveness, and a slower eating pace.^[30] The most common behavioral feeding problems among developmentally disabled children according to rank order and the findings reveal that with regard to behavioral pediatric feeding assessment score, leaving the table during meals (95.3%), prolonged meal durations exceeding 20 min (83.3%), and tantrums occurring at mealtimes (82%) were found to be the three most concerned behavioral feeding problems present in children with varying developmental challenges. This is supported by the study in which the feeding behavior during mealtime such as delaying eating by talking and getting up from the table during meals were the main characteristics of food refusal among children.^[4]

The study concluded that there is a relationship between parental feeding behavior and child weight status based on the child’s diagnosis, family income, and gender.^[31,^32] Another literature on feeding interventions conducted among children with disabilities also identifies a lack of economic resources, insufficient training among medical staff and caregivers, and the need for sustainable interventions in resource-limited settings.^[5] A systematic review study concluded that occupational therapists along with other health team members are best positioned to address different feeding behaviors through behavioral and parent-mediated interventions.

CONCLUSION

Children with ASD, ADHD, and ID exhibit higher behavioral feeding problems, with parental pediatric feeding strategies and feelings being more problematic. Leaving the table during meals (95.3%), prolonged meal durations exceeding 20 min (83.3%), and tantrums occurring at mealtimes (82%) were found to be the three most concerning behavioral problems of feeding present among children with learning and developmental differences. The study found an association between behavioral feeding issues, maternal occupation, child’s nutritional status, and diagnosis and also found a link between parental pediatric feeding strategies and feelings as well as problems, delivery mode, and family socioeconomic status. The finding of the study also has several implications so that nursing services are to be based on individualized periodic assessment and dietary intervention for behavioral feeding problems among children. Parental counseling and training can be done for adopting better feeding strategies to deal with feeding problems among children with developmental disabilities in the hospital as well as in the community settings. The nurse administrator should take the initiative to make protocols and policies of regular screening for nutritional and feeding problems related to the behavior among these neurodiverse children. Future studies should involve a larger sample size to improve robustness and generalizability and adopt a multicentric approach, incorporating data from various regions of India and international settings.