The BUFFET Program: Development of a Cognitive Behavioral Treatment for Selective Eating in Youth with Autism Spectrum Disorder
Selective eating (often referred to as “picky” eating) is common in individuals with autism spectrum disorder (ASD) across the lifespan. Behavioral interventions are widely used to treat selective eating; however, most of these programs are time intensive, have not been evaluated for use in outpatient settings, and do not typically include youth beyond early childhood. Despite the functional impact and risk for negative outcomes associated with selective eating, there are no empirically supported treatments available for older children, adolescents, or adults, either with or without ASD. To address this treatment gap, we developed BUFFET: the Building Up Food Flexibility and Exposure Treatment program. BUFFET is a 14-week, multi-family group cognitive behavioral treatment for selective eating in children (8–12 years) with ASD. In this paper, we will (1) discuss the theoretical conceptualization of BUFFET, (2) describe the treatment content and structure, (3) present feasibility data from the initial pilot trial, and (4) consider next steps in treatment development.
KeywordsAutism spectrum disorder Feeding Picky eating Cognitive behavior therapy Intervention Sensory
This study was supported by a grant from Autism Speaks (8130; PI: Kuschner). The authors gratefully acknowledge the families who participated in this study. We thank the BUFFET Stakeholder Advisory Board and Dr. Julie Worley for guidance during treatment development. We also thank Ligia Antezana, Dana Kamerling, Rebecca Murray, Jeremy Rudoler, and Kelsey Spielman for their help with facilitating treatment groups. Finally, we thank Dr. Colleen Lukens for review of a draft of the manuscript.
This study was funded by Autism Speaks (#8130; PI: E. Kuschner).
Compliance with Ethical Standards
Conflict of interest
Dr. Kuschner, Dr. Maddox and Ms. Morton declare no conflicts of interest. Dr. de Marchena reports that her work on this project was (in part) supported by the National Institute of Neurological Disorders and Stroke (#T32NS007413). Dr. Anthony receives royalties from the Unstuck and On Target program, currently published by Paul Brookes Publishing (Cannon et al. 2011; Kenworthy et al. 2014). Dr. Reaven receives royalties from the Facing Your Fears program, currently published by Paul Brookes Publishing (Reaven et al. 2011).
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 declaration of Helsinki and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
- Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W. I., Scampini, R., et al. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. The Journal of Pediatrics, 157(2), 259–264. doi: 10.1016/j.jpeds.2010.02.013.PubMedPubMedCentralCrossRefGoogle Scholar
- Barron-Linnankoski, S., Reinvall, O., Lahervuori, A., Voutilainen, A., Lahti-Nuuttila, P., & Korkman, M. (2014). Neurocognitive performance of children with higher functioning Autism Spectrum disorders on the NEPSY-II. Child Neuropsychology, 21(1), 55–77. doi: 10.1080/09297049.2013.873781.PubMedCrossRefGoogle Scholar
- Cannon, L., Kenworthy, L., Alexander, K. C., Werner, M. A., & Anthony, L. G. (2011). Unstuck and On Target. Baltimore, MD: Brookes Publishing.Google Scholar
- Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50(3), 217–226. doi: 10.1097/MLR.0b013e3182408812.PubMedPubMedCentralCrossRefGoogle Scholar
- Curtin, C., Hubbard, K., Anderson, S. E., Mick, E., Must, A., & Bandini, L. G. (2015). Food selectivity, mealtime behavior problems, spousal stress, and family food choices in children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 45, 3308–3315.PubMedPubMedCentralCrossRefGoogle Scholar
- Dowell, L. R., Mahone, E. M., & Mostofsky, S. H. (2009). Associations of postural knowledge and basic motor skill with dyspraxia in autism: Implication for abnormalities in distributed connectivity and motor learning. Neuropsychology, 23(5), 563–570. doi: 10.1037/a0015640.PubMedPubMedCentralCrossRefGoogle Scholar
- Dziuk, M. A., Larson, J. C. G., Apostu, A., Mahone, E. M., Denckla, M. B., & Mostofsky, S. H. (2007). Dyspraxia in autism: association with motor, social, and communicative deficits. Developmental Medicine and Child Neurology, 49(10), 734–739. doi: 10.1111/j.1469-8749.2007.00734.x.PubMedCrossRefGoogle Scholar
- Elliott, C. D. (2007). Differential Ability Scales-II (DAS-II). San Antonio, TX: Pearson Assessments.Google Scholar
- Johnson, C. R., Turner, K. S., Foldes, E., Brooks, M. M., Kronk, R., & Wiggs, L. (2013). Behavioral parent training to address sleep disturbances in young children with autism spectrum disorder: A pilot trial. Sleep Medicine, 14(10), 995–1004. doi: 10.1016/j.sleep.2013.05.013.PubMedPubMedCentralCrossRefGoogle Scholar
- Kedesdy, J. H., & Budd, K. S. (1998). Childhood feeding disorders: Biobehavioral assessment and intervention. Baltimore, MD: Paul H. Brookes Publishing Co., Inc.Google Scholar
- Kendall, P. C., & Hedtke, K. A. (2006). Coping Cat workbook (Vol. 2). Atlanta: Ardmore.Google Scholar
- Kenworthy, L., Anthony, L. G., Naiman, D. Q., Cannon, L., Wills, M. C., Luong-Tran, C., et al. (2014). Randomized controlled effectiveness trial of executive function intervention for children on the autism spectrum. Journal of Child Psychology and Psychiatry and Allied Disciplines, 55(4), 374–383. doi: 10.1111/jcpp.12161.CrossRefGoogle Scholar
- Kuschner, E. S., Eisenberg, I. W., Orionzi, B., Simmons, W. K., Kenworthy, L., Martin, A., et al. (2015). A preliminary study of self-reported food selectivity in adolescents and young adults with autism spectrum disorder. Research in Autism Spectrum Disorders, 15–16, 53–59. doi: 10.1016/j.rasd.2015.04.005.PubMedPubMedCentralCrossRefGoogle Scholar
- Laugeson, E. A., Frankel, F., Gantman, A., Dillon, A. R., & Mogil, C. (2012). Evidence-based social skills training for adolescents with autism spectrum disorders: the UCLA PEERS program. Journal of Autism and Developmental Disorders, 42(6), 1025–1036. doi: 10.1007/s10803-011-1339-1.PubMedCrossRefGoogle Scholar
- Linstone, H. A., & Turoff, M. (1975). The Delphi method: Techniques and applications. Boston, MA: Addison-Wesley.Google Scholar
- Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2013). Autism diagnostic observation schedule (2nd ed.). Torrance: Western Psychological Services.Google Scholar
- Maes, J. H. R., Eling, P. A. T. M., Wezenberg, E., Vissers, C. T. W. M., & Kan, C. C. (2010). Attentional set shifting in autism spectrum disorder: Differentiating between the role of perseveration, learned irrelevance, and novelty processing. Journal of Clinical and Experimental Neuropsychology, 33(2), 210–217. doi: 10.1080/13803395.2010.501327.PubMedCrossRefGoogle Scholar
- Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., et al. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy In Mental Health, 38(2), 65–76. doi: 10.1007/s10488-010-0319-7.PubMedCrossRefGoogle Scholar
- Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53(4), 410–419. doi: 10.1111/j.1469-7610.2011.02486.x.PubMedPubMedCentralCrossRefGoogle Scholar
- Reaven, J., Blakeley-Smith, A., Nichols, S., & Hepburn, S. (2011). Facing your fears: Group therapy for managing anxiety in children with high-functioning autism spectrum disorders. Baltimore, MD: Brookes Publishing Company.Google Scholar
- Reaven, J., & Hepburn, S. (2006). The parent’s role in the treatment of anxiety symptoms in children with high-functioning autism spectrum disorders. Mental Health Aspects of Developmental Disabilities, 9(3), 73–80.Google Scholar
- Rutter, M., Bailey, A., & Lord, C. (2003). The Social Communication Questionnaire. Torrance, CA: Western Psychological Services.Google Scholar
- Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., et al. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: A meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-013-1771-5.Google Scholar
- Sharp, W. G., Volkert, V. M., Scahill, L., McCracken, C. E., & McElhanon, B. (2016). 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. doi: 10.1016/j.jpeds.2016.10.002.PubMedGoogle Scholar
- Storch, E. A., Arnold, E. B., Lewin, A. B., Nadeau, J. M., Jones, A. M., De Nadai, A. S., et al. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 52(2), 132–142.e2. doi: 10.1016/j.jaac.2012.11.007.PubMedCrossRefGoogle Scholar
- Storch, E. A., Lewin, A. B., Collier, A. B., Arnold, E., De Nadai, A. S., Dane, B. F., et al. (2015). A randomized controlled trial of cognitive-behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depression and Anxiety, 32(3), 174–181. doi: 10.1002/da.22332.PubMedCrossRefGoogle Scholar
- Tager-Flusberg, H., Edelson, L., & Luyster, R. (2011). Language and communication in autism spectrum disorders. In D. G. Amaral, G. Dawson, & D. Geschwind (Eds.), autism spectrum disorders (pp. 172–185). United Kingdom: Oxford.Google Scholar
- Twachtman-Reilly, J., Amaral, S. C., & Zebrowski, P. P. (2008). Addressing feeding disorders in children on the autism spectrum in school-based settings: Physiological and behavioral issues. Language, Speech, and Hearing Services in Schools, 39(2), 261. doi: 10.1044/0161-1461(2008/025).PubMedCrossRefGoogle Scholar
- Ung, D., Selles, R., Small, B. J., & Storch, E. A. (2015). A systematic review and meta-analysis of cognitive-behavioral therapy for anxiety in youth with high-functioning autism spectrum disorders. Child Psychiatry and Human Development, 46(4), 533–547. doi: 10.1007/s10578-014-0494-y.PubMedCrossRefGoogle Scholar
- White, S. W., Ollendick, T., Albano, A. M., Oswald, D., Johnson, C., Southam-Gerow, M. A., et al. (2013). Randomized controlled trial: Multimodal anxiety and social skill intervention for adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(2), 382–394. doi: 10.1007/s10803-012-1577-x.PubMedPubMedCentralCrossRefGoogle Scholar
- Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., & Langer, D. A. (2009a). Cognitive behavioral therapy for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of Child Psychology and Psychiatry, 50(3), 224–234. doi: 10.1111/j.1469-7610.2008.01948.x.PubMedPubMedCentralCrossRefGoogle Scholar
- Wood, J. J., Drahota, A., Sze, K., Van Dyke, M., Decker, K., Fujii, C., et al. (2009b). Brief Report: Effects of cognitive behavioral therapy on parent-reported autism symptoms in school-age children with high-functioning autism. Journal of Autism and Developmental Disorders, 39(11), 1608–1612. doi: 10.1007/s10803-009-0791-7.PubMedPubMedCentralCrossRefGoogle Scholar
- Yerys, B. E., Wallace, G. L., Harrison, B., Celano, M. J., Giedd, J. N., & Kenworthy, L. E. (2009). Set-shifting in children with autism spectrum disorders: Reversal shifting deficits on the Intradimensional/Extradimensional Shift Test correlate with repetitive behaviors. Autism, 13(5), 523–538. doi: 10.1177/1362361309335716.PubMedPubMedCentralCrossRefGoogle Scholar