Train-the-Trainers: A Parent-Coaching Model for Increasing Food Acceptance in Children With Autism Spectrum Disorder Open Access

HYPOTHESIS: We hypothesized that private clinic-based occupational therapists (OTs) can be trained to effectively implement a parent-coaching program that will increase food acceptance of their children with autism spectrum disorder (ASD).

BACKGROUND: Children with ASD frequently exhibit challenging mealtime behaviors, including food refusal. A number of behavioral interventions have been found to be effective in improving these behaviors, but there is currently very limited research related to the ability of OTs to learn to implement parent-coaching interventions in a clinical setting and the efficacy of these interventions.

DESIGN: This pilot study used a mixed-methods design to collect pre and post data regarding food acceptance and mealtime behaviors over the course of a 4-mo intervention.

PARTICIPANTS: We recruited 4 parent–child dyads from two outpatient pediatric OT clinics. The children were 5–9 yr old, and all had an ASD diagnosis.

METHOD: The Brief Autism Mealtime Behavior Inventory (BAMBI) is an 18-item Likert-scale (1 = never/rarely to 5 = at almost every meal) that asks parents to rate the frequency of child mealtime behaviors and whether those behaviors are problematic. The Behavioral Pediatric Feeding Assessment Scale (BPFAS) follows a similar format (1 = never to 5 = always), with 25 questions on child behaviors and 10 questions on parent behaviors.

Additional information included responses to a Food Frequency Questionnaire that asks for information regarding the foods presented to the child over the previous 6 mo and semistructured parent interviews, as well as procedural fidelity data related to both the parents’ and the therapists’ implementation of their roles in the intervention. During weekly sessions over 4 mo, the therapists provided coaching, with the researcher’s guidance, to train the parents to implement the intervention. Both pre- and postintervention data were collected from the parents regarding their perceptions of the child’s behavior at home. Weekly data were collected by the therapist, parent, and researcher regarding the fidelity of implementation of the intervention during the clinic sessions.

ANALYSIS: For this pilot study, pre- and post intervention data were compared to identify meaningful changes in behavior for each child (e.g., z score changes from >3.0 to <1.5). For the BAMBI and BPFAS, z scores were compared. For the Food Frequency Questionnaire, percentages of food categories (e.g., dairy, snacks) and absolute food values (e.g., number of different foods) were compared. Procedural fidelity data were analyzed both for trends across the duration of the study and changes in level from the onset to the conclusion of intervention.

RESULTS: Data indicate that all of the parents and therapists were able to implement the intervention with high levels of fidelity. Both groups were able to learn target strategies and implement them. All 4 children demonstrated fewer challenging mealtime behaviors and increased acceptance of a variety of foods.

DISCUSSION: Private clinic-based OTs demonstrated the ability to learn to implement a parent-coaching intervention to teach parents to improve the mealtime behaviors and food acceptance of children with ASD. The parent-led intervention was effective in improving the mealtime behaviors and food acceptance of these children. This study furthers our understanding of how to support children with ASD and their parents related to food acceptance and mealtime behaviors.

IMPACT: These findings provide support for the use of parent-coaching interventions in clinical settings. It also provides a framework for OTs to effectively improve food acceptance and mealtime behaviors of children with ASD working with parents as interventionists.