Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by repetitive behaviors, severely constrained interests, and difficulties in verbal and nonverbal communication [1, 2].

One of the most significant issues related to ASD in children is the behavior during meals. Feeding issues are present in 46–89% of children with ASD and often fall into one of three categories: type and texture-based food selection, food rejection, and disruptive mealtime behaviors [3, 4]. Food selection is one of the most prevalent issues for autistic children [5]. Although it is not a specific symptom for the ASD population, children with ASD were found to have slightly worse self-feeding skills. Also, they were more likely to avoid foods and exhibit food-neophobic behaviors [6]. One of the diagnostic criteria for avoidant and restrictive food intake disorder is limiting food intake [7].

Lukens and Linscheid [8] created the Brief Autism Mealtime Behavior Inventory (BAMBI) scale. The BAMBI can distinguish between the eating issues that people with ASD have and those that children with regular development present. The BAMBI concentrates on eating-related behaviors while ignoring the gastrointestinal and sensory problems typically observed in ASD and can affect a person’s eating behavior [9].

The BAMBI is an observation made by someone other than the patient or a health professional. It showed a significant concept and criterion-related validity in evaluating mealtime behavior issues in autistic children. It also showed good internal consistency, high test–retest reliability, a clear factor structure, and qualities [8].

The BAMBI has 18 items based on three criteria: limited variety, food rejection, and autism-related characteristics. Eight items comprise the limited variety factor, which measures the child’s openness to trying new foods and categorizes them according to preparation, texture, and type. Five elements comprise the eating refusal factor, which describes the problematic behaviors seen when a kid refuses to eat. The features of the autism factor contain questions that indicate the behavioral traits of ASD, including self-harming behavior, inattention, and repetitive behaviors during mealtimes [8].

Insufficient research investigates whether child ASD symptom severity is associated with observed child mealtime behaviors. To our best knowledge, there are lacking data discussing the psychometric qualities of the BAMBI among autistic children. In Egypt, no scale has been created or modified to assess the mealtime and feeding issues faced by people with autism or intellectual disabilities. The current study was conducted among Egyptian children with ASD to evaluate their feeding behavioral problems and their correlation with ASD severity using the Arabic version of the Brief Autism Mealtime Behaviors Inventory and the Childhood Autism Rating Scale.

Methods

Ethical considerations

This study was approved by our Ethics Committee. After an explanation of the purpose and procedures of the study, written informed consents were obtained from the participants’ parents or guardians. We secured the confidentiality of the participants’ data.

Study design, setting, and duration

This cross-sectional study evaluated the outpatients’ children suspected to have or diagnosed previously with ASD who attended the Otolaryngology Clinic of Tanta Faculty of Medicine, Egypt with their parents or caregivers between November 2022 and April 2023.

Participants

The study included Egyptian children between 2 and 11 years old, diagnosed with ASD based on the diagnostic and statistical manual of mental disorder-V criteria [2]. Children with other neurodevelopmental disorders and genetic syndromes were excluded. This study used the Arabic version of BAMBI as it is the native language of the participants.

Demographic characteristics of the child and their parents were collected. In addition, the birth and medical history of the child were obtained. The child’s body weight and height were measured and plotted against the reference growth charts.

Study tools

This study was performed by interviewing the children’s parents or caregivers. The investigators examined the child and used the following tools:

  • Childhood Autism Rating Scale (CARS)

We used the CARS to measure the severity of autism [10]. Clinicians evaluated 15 questions on a 4-point Likert scale to assess the behaviors of children. Relating to people, communication, responsiveness, and activity level were among the domains evaluated. All participants, including those who might have had more excellent functioning and were older than advised, were given the CARS standard form. Since our goal was to assess the severity of autism, we utilized the same format for all participants to have comparable scales across all participants.

  • Brief Autism Mealtime Behavior Inventory (BAMBI)

The BAMBI is a standardized, reliable tool for investigating food problems and mealtime behaviors in children with ASD [8]. It has been used in several countries, with different populations, and in many languages. It has been found to have adequate psychometric properties [11,12,13]. We used the Arabic version of the questionnaire that was previously translated and validated by a group of Arabic researchers [14]. It consists of 18 items entailing food refusal, limited variety, and features of autism. The responses are graded on a 5-point Likert scale, from 1, denoting “never/very rarely,” to 5, indicating almost/at every meal. The higher scores indicate greater problems with mealtime behavior.

Sample size

An average of 8–10 children each month were among those who visited the clinic. Since there was little comparable literature, we assumed that the percentage of disordered mealtime behavior among autistic children was 50%. The study sample was calculated using the EPI-Info software program. The credentials were a 0.5 margin of error, 95% confidence level, and 80% study power. Therefore, a sample size of 50 participants was estimated. Every third child who visited the clinic was selected using a convenience sampling approach.

Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences software (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.). The quantitative variables were presented as mean, standard deviation (SD), and range. Frequency and percentages were used to show qualitative characteristics. The independent t-test and one-way analysis of variance (ANOVA) with post hoc analysis were used. A linear regression analysis identified the independent variables connected to disruptive eating behavior and autism degree. A Pearson correlation coefficient test was used for the association between the BAMBI and the CARS scales. A value of p < 0.05 was considered significant.

Results

This study enrolled 52 autistic children with a mean age of 6.1 ± 2.6 years, a mean weight of 27.2 ± 12.17 kg, and a mean height of 104.8 ± 33.7 cm. Males from urban areas were the most frequent. Most children’s parents reported that their income was just enough to cover the basic needs. Over one-third of children’s fathers had professional jobs, and half of their mothers were housewives. The mean CARS was 39.9 ± 9.8, indicating moderate autism severity (Table 1).

Table 1 Bio-demographic characteristics of the studied children (n = 52)
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Limited variety factors including the preference for crunchy foods (57.7%) and the preference for only sweet food (52%) were the most prevalent BAMBI. Most (46.1%) parents reported that their child remained seated at the table until finishing the meal, which belonged to the autism feature factor (Table 2).

Table 2 The frequency distribution of BAMBI items according to its three functional factors (n = 52)
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Table 3 demonstrates that the mean BAMBI score was 48.11 ± 12.2, and the most significant mean (24.15 ± 5.7) was for the limited food variety factor.

Table 3 Brief Autism Mealtime Behaviors Inventory (BAMBI) scale and its three functional factors
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A significant moderate correlation was observed between the mealtime behavior and CARS scales (r = 0.4 and p = 0.02, shown in Fig. 1).

Fig. 1
figure 1

Correlation between the Brief Autism Mealtime Behaviors Inventory (BAMBI) and the Childhood Autism Rating Scale (CARS)

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We observed a significant correlation between disruptive mealtime behavior with participants from rural residences and limited income levels (p = 0.04). Furthermore, autistic children whose mothers attained elementary education and whose fathers were unemployed had higher disruptive behavior scores incomparable to their counterparts (61.5 ± 14, 66 ± 5.29; p = 0.01, 0.02; respectively). Also, smoking was significantly correlated with disruptive behavior (p = 0.02). Children who were low birth weighted and admitted to the neonatal care unit had a substantial relation with high BAMBI (57.3 ± 6.6, and 52.33 ± 12.39; p = 0.04 and 0.02; Table 4).

Table 4 The relationship between BAMBI score and bio-demographic characteristics of the studied children (n = 52)
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Table 5 reveals a statistically significance correlation between children with different levels of ASD and the BAMBI scale. Severe ASD children had the highest BAMBI scale (51.8 ± 12.2, p = 0.02). The limited variety factor was significantly observed among children with severe ASD (26.5 ± 5.3, p = 0.006).

Table 5 Relationship between ASD level and BAMBI mealtime behavior scale and three functional factors
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Discussion

Feeding issues and inappropriate behavior during meals are frequently reported among children with ASD [15]. This study investigated the psychometric qualities of the BAMBI on autistic children in Egypt. Our main findings revealed that limited food selectivity features, such as preferring crunchy food or only sweet foods, were significant problems. Moreover, a significantly positive correlation was observed between eating behaviors using the BAMBI and the CARS scales.

Several studies have shown that children with ASD preferred particular foods, comparable foods, or foods prepared in particular ways [15,16,17,18]. The BAMBI scale was used as a valid, reliable scale to determine the mealtime behavior of Turkish [19], Vietnamese [16], Italian [20], and Chinese American [12] children with autism.

A limited variety of foods, only selecting specific food items, or only preferring certain food items characterized by their textures, consistency, or tastes were other behavioral disorders at mealtimes among children with ASD [15]. Our findings agreed with earlier studies [16, 20,21,22,23] reporting that the scores of the “limited variety” group were higher than those associated with the other behaviors. A limited variety of food might be connected to ASD-related clinical symptoms, such as narrow interests and behavior [7]. Nadon et al. [24] attributed that to the connection between issues with the four senses of touch, smell, sight, and hearing in autistic children and the eating difficulties they experienced because of their limited food selectivity characterized by their textures, colors, and tastes. Moreover, sensory processing problems could cause the limited food preferences seen in eating disorders in ASD kids. These food behaviors may be related or attributed to the limited or restricted interests feature of ASD.

Food rejection and the limited range of food eaten frequently go hand in hand [11]. Ahearn et al. [25] found that autistic kids struggled more with flexibility in mealtime routines, were less able to stay seated until the meal was done, and were more hostile at mealtimes. Bandini et al. [5] discovered that children with autism exhibited greater food refusal and had a more constrained food variability than typical healthy growing children. Also, Ha et al. [16] showed that mealtime aggressiveness, self-injury, rigid eating habits, and refusal to consume foods that require a lot of chewing were all present in autistic children. All these behaviors demonstrate ASD behavioral traits [26].

In the United Arab Emirates, Attlee et al. [27] noticed that a lack of diversity, food refusal, and selective eaters were common problems. Protein was the food group rejected at a higher rate than carbohydrate, which was the most accepted and frequently consumed food item. Consequently, a lack of diversity in food and an increase in food refusal can make it difficult to maintain a balanced diet. These factors raise the risk of medical problems and deficiencies, and poor bone growth can negatively impact these children’s growth and development [28].

Moreover, a positive association was noticed between limited food variety and ASD severity by CARS, suggesting that the children with more severe ASD symptoms had restrictive food preferences. Patton et al. [29] reported that children with more severe ASD may eat less and behave more disruptively during eating. Additionally, they suggested that the BAMBI might be a sensitive indicator of behaviors related to eating, such as flexibility and refusal. However, Patton et al. [29] did not discover any correlations between the severity of a child’s ASD and the parent’s reports of problematic mealtime behaviors. These could be because the parents of children with more severe ASD symptoms have grown accustomed to their child’s troublesome behaviors. Thus, they do not see their child’s behavior at meals as problematic, so they endorse so few BAMBI products [30,31,32].

Our study was the first to examine the mealtime behaviors of children with ASD in Egypt. It emphasized the necessity to address diet and feeding issues in children with ASD. Understanding the relationship between ASD symptom severity and mealtime behaviors could have important clinical implications, such as developing targeted interventions to address feeding difficulties in children with more severe ASD symptoms.

This study relied on parents’ self-reports of their children with ASD’s eating habits; however, eating disorders may be overstated or understated, which is the drawback of most research based on parent or self-reported data. To lessen this issue, parents received comprehensive information regarding the study, its significance, and the confidentiality assurance process used in this study. Future research utilizing direct observations and a higher number of participants would help understand eating issues in children with ASD fully.

Conclusion

Using the BAMBI scale, children with more severe ASD have limited food selectivity. The BAMBI scale was significantly correlated with the CARS scale indicating that the BAMBI may be a measure of severity of autistic symptoms in children with ASD.