Parent Strategies to Support Mealtime Participation for Children with Autism Spectrum Disorders: Integration of Behavior and Narrative Data

Background:  Mealtime is significantly affected in families with children with autism spectrum disorders (ASD) as they report significant mealtime behaviors, increased focus on the child with ASD, disrupted eating patterns, and an overall increased level of stress. Families use a number of strategies to support their child with ASD’s engagement in mealtime, but these strategies have not yet been clearly identified within natural mealtime contexts.

Objectives:  The purpose of this study was to identify and triangulate parent reported and observed strategies used to support their child’s mealtime participation.

Methods: Twelve families with a child between the ages of 2 and 7 years with ASD were recruited to participate in 1 to 2 videotaped mealtime observations and 1 to 3 semi-structured interviews. Videos were reviewed to identify strategies families used during mealtimes to facilitate participation. The strategies were identified, defined, and arranged into categories using qualitative conventional content analysis. The categories were used to develop coding schemes with detailed definitions that were used to code family mealtime videos with each video being coded independently by two research team members. Agreement measures of inter-rater reliability were calculated. Thematic analysis was used on the transcribed parent interviews to identify strategies parents reported using during child eating experiences and family mealtimes. Categories of observed behavioral strategies were compared to the themes of reported parent strategies.

Results:  Six categories of observed parental strategies were identified through the mealtime video data: 1) Parent Intervening and Ignoring, 2) Meal Preparation and Adaptability, 3) Positive Reinforcements, 4) Play and Imagination, 5) Distractions, and 6) Modeling. In contrast, only four primary themes of parent reported strategies were identified through the parent interview data: 1) Setting the Mealtime Stage, 2) Essential Food Modifications, 3) Social Strategies, and 4) Letting Go. When describing mealtime strategies, parents consistently discussed the importance of the environmental and child context in determining when and what strategies they may use to support their child. Families were observed to and reported using multiple strategies within and across mealtimes with variable success, highlighting the individualistic nature of feeding challenges in children with ASD. However, the observed and reported family strategies were not necessarily the same.

Conclusions:  Similarities and differences were found when comparing the observed and parent-reported mealtime strategies to support their child with ASD. For example, parents described the strategies they used to prepare and create an environment to promote food acceptance during mealtime (Setting the Mealtime Stage), which was clearly confirmed through their behaviors during the observed mealtimes (Mealtime Preparation/Adaptability). However, multiple direct strategies were observed during mealtime (i.e., Parent Intervening/Ignoring and Distractions) that were absent in the parent interviews. Identifying the relationship between parent-reported and observed mealtime strategies will allow for a richer understanding of the context and motivation leading to parent behaviors during family mealtimes that will support the development of family-centered interventions to promote mealtime participation for children with ASD.