Feactures of mastication and feeding behavior in children with autism spectrum disorder

INTRODUCTION. Children with autism spectrum disorder (ASD) often exhibit altered oral sensory processing, atypical feeding patterns, and non-standard responses to dental stimuli, complicating endodontic care.

AIM. To profile feeding behavior, mastication, and swallowing in ASD and to identify endodontically relevant risks: verification of odontogenic pain, effectiveness of local infiltration anesthesia, and tolerance to rubberdam isolation.

MATERIALS AND METHODS. Observational controlled study of 178 children aged 3–9 years (ASD n = 124, controls n = 54). Caregiver questionnaires and clinician-rated protocols assessed meal frequency/duration, oral sensory responses, mastication, and swallowing. Dental visits were evaluated for pain verification, infiltration-anesthesia performance, and isolation tolerance. Between-group differences were tested at α = 0.005, significant effects were observed for all p ≤ 0.003.

RESULTS. ASD was associated with more frequent but smaller meals, prolonged mealtimes, heightened oral sensory reactivity, and higher rates of mastication/swallowing difficulties. In the dental setting, ASD patients more often demonstrated hard-to-verify odontogenic pain, variable infiltration-anesthesia efficacy, and poor tolerance to rubber-dam isolation.

CONCLUSIONS. The ASD feeding / sensory profile differs from neurotypical peers and predicts challenges in pain verification and treatment tolerance. Routine pre-visit preparation and sensory-aware communication improve cooperation. Stepwise behavior guidance and flexible isolation strategies reduce aversive responses. When infiltration shows inconsistent effect, clinicians should reassess pain source, adapt anesthetic technique, and allow sufficient latency/graded dosing within safety limits. Integrating caregiver-reported feeding / sensory cues into chairside decisions increases anesthesia success and overall endodontic feasibility.  

1. Seiverling L., Hendy H.M., Williams K. The Screening Tool of Feeding Problems applied to children (STEP-CHILD): psychometric characteristics and associations with child and parent variables. Res Dev Disabil. 2011;32(3):1122–1129. https://doi.org/10.1016/j.ridd.2011.01.012

2. Matson J.L., Kuhn D.E. Identifying feeding problems in mentally retarded persons: development and reliability of the screening tool of feeding problems (STEP). Res Dev Disabil. 2001;22(2):165–172. https://doi.org/10.1016/s0891-4222(01)00065-8

3. Kuhn D.E., Matson J.L. A validity study of the Screening Tool of Feeding Problems (STEP). J Intellect Dev Disabil. 2002;27(3):161–167. https://doi.org/10.1080/1366825021000008594

4. DeMand A., Johnson C., Foldes E. Psychometric properties of the brief autism mealtime behaviors inventory. J Autism Dev Disord. 2015;45(9):2667–2673. https://doi.org/10.1007/s10803-015-2435-4

5. Lamboglia A., Romano R., Valente D., Berardi A., Cavalli G., Giovannone F. et al. Brief Autism Mealtime Behavior Inventory (BAMBI): Italian translation and validation. Children. 2023;10(7):1201. https://doi.org/10.3390/children10071201

6. Hendy H.M., Seiverling L., Lukens C.T., Williams K.E. Brief assessment of mealtime behavior in children: Psychometrics and association with child characteristics and parent responses. Children’s Health Care. 2013;42(1):1–14. https://doi.org/10.1080/02739615.2013.753799

7. Williams K.E., Hendy H.M., Seiverling L.J., Can S.H. Validation of the parent mealtime action scale (PMAS) when applied to children referred to a hospital-based feeding clinic. Appetite. 2011;56(3):553–557. https://doi.org/10.1016/j.appet.2011.01.021

8. Bandini L.G., Anderson S.E., Curtin C., Cermak S., Evans E.W., Scampini R. et al. Food selectivity in children with autism spectrum disorders and typically developing children. J Pediatr. 2010;157(2):259–264. https://doi.org/10.1016/j.jpeds.2010.02.013

9. Bowers L. An audit of referrals of children with autistic spectrum disorder to the dietetic service. J Hum Nutr Diet. 2002;15(2):141–144. https://doi.org/10.1046/j.1365-277x.2002.00345.x

10. Field D., Garland M., Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003;39(4):299–304. https://doi.org/10.1046/j.1440-1754.2003.00151.x

11. Fodstad J.C., Matson J.L. A comparison of feeding and mealtime problems in adults with intellectual disabilities with and without autism. J Dev Phys Disabil. 2008;20(6):541–550. https://doi.org/10.1007/s10882-008-9116-6

12. Kodak T., Piazza C.C. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2008;17(4):887–905. https://doi.org/10.1016/j.chc.2008.06.005

13. Kerwin M.E., Eicher P.S., Gelsinger J. Parental report of eating problems and gastrointestinal symptoms in children with pervasive developmental disorders. Children’s Health Care. 2005;34(3):217–234. https://doi.org/10.1207/s15326888chc3403_4

14. Mayville S.B., Matson J.L., Laud R.B., Cooper C., Kuhn D.E. The relationship between depression and feeding disorder symptoms among persons with severe and profound mental retardation. J Dev Phys Disabil. 2005;17(3):213–224. https://doi.org/10.1007/s10882-005-4378-8

15. Ledford J.R., Gast D.L. Feeding problems in children with autism spectrum disorders: A review. Focus Autism Other Dev Disabl. 2006;21(3):153–166. https://doi.org/10.1177/10883576060210030401

16. MacCallum R.C., Browne M.W., Sugawara H.M. Power analysis and determination of sample size for covariance structure modeling. Psychol Methods. 1996;1(2):130–149. https://doi.org/10.1037/1082-989X.1.2.130

17. McGrew S., Malow B.A., Henderson L., Song Y., Stone W.L. Developmental and behavioral questionnaire for autism spectrum disorders. Pediat Neurol. 2007;37(2):108–116. https://doi.org/10.1016/j.pediatrneurol.2007.04.013

18. Marsh H.W., Balla J.R., McDonald R.P. Goodness-of-fit indexes in confirmatory factor analysis: The effect of sample size. Psychological Bulletin. 1988;103(3):391–410. https://doi.org/10.1037/0033-2909.103.3.391

19. Matson J.L., Cooper C.L., Mayville S.B., González M.L. The relationship between food refusal and social skills in persons with intellectual disabilities. J Intellect Dev Disabil. 2006;31(1):47–52. https://doi.org/10.1080/13668250600561937

20. Matson J.L., Fodstad J.C., Boisjoli J.A. Cutoff scores, norms and patterns of feeding problems for the Screening Tool of fEeding Problems (STEP) for adults with intellectual disabilities. Res Dev Disabil. 2008;29(4):363–372. https://doi.org/10.1016/j.ridd.2007.06.001

21. Matson J.L., Mayville S.B., Kuhn D.E., Sturmey P., Laud R., Cooper C. The behavioral function of feeding problems as assessed by the questions about behavioral function (QABF). Res Dev Disabil. 2005;26(4):399–408. https://doi.org/10.1016/j.ridd.2004.11.008

22. Raiten D.J., Massaro T. Perspectives on the nutritional ecology of autistic children. J Autism Dev Disord. 1986;16(2):133–143. https://doi.org/10.1007/BF01531725

23. Ritvo E.R., Freeman B.J. Current research on the syndrome of autism: introduction. The National Society for Autistic Children’s definition of the syndrome of autism. J Am Acad Child Psychiatry. 1978;17(4):565–575. https://doi.org/10.1016/s0002-7138(09)61011-6

24. Schermelleh-Engel K., Moosbrugger H., Müller H. Evaluating the fit of structural equation models: Tests of significance and descriptive goodness-of-fit measures. Methods of Psychological Research. 2003;8(2):23–74. https://doi.org/10.23668/psycharchives.12784

25. Schreck K.A., Williams K., Smith A.F. A comparison of eating behaviors between children with and without autism. J Autism Dev Disord. 2004;34(4):433–438. https://doi.org/10.1023/b:jadd.0000037419.78531.86

26. Twachtman-Reilly J., Amaral S.C., Zebrowski P.P. Addressing feeding disorders in children on the autism spectrum in school-based settings: physiological and behavioral issues. Lang Speech Hear Serv Sch. 2008;39(2):261–272. https://doi.org/10.1044/0161-1461(2008/025)

27. Williams K.E., Riegel K., Kerwin M.L. Feeding disorder of infancy or early childhood: How often is it seen in feeding programs? Children’s Health Care. 2009;38(2):123–136. https://doi.org/10.1080/02739610902813302

28. Lukens C.T., Linscheid T.R. Development and validation of an inventory to assess mealtime behavior problems in children with autism. J Autism Dev Disord. 2008;38(2):342–352. https://doi.org/10.1007/s10803-007-0401-5

29. Hendy H.M., Williams K.E., Camise T.S., Eckman N., Hedemann A. The Parent Mealtime Action Scale (PMAS). Development and association with children’s diet and weight. Appetite. 2009;52(2):328–339. https://doi.org/10.1016/j.appet.2008.11.003

30. Hendy H.M., Williams K.E., Riegel K., Paul C. Parent mealtime actions that mediate associations between children’s fussy-eating and their weight and diet. Appetite. 2010;54(1):191–195. https://doi.org/10.1016/j.appet.2009.10.006

31. Bakke M., Bergendal B., McAllister A., Sjögreen L., Asten P. Development and evaluation of a comprehensive screening for orofacial dysfunction. Swed Dent J. 2007;31(2):75–84.

32. McAllister A., Hammarström I.L. Oral sensorimotor functions in typically developing children 3 to 8 years old, assessed by the Nordic orofacial test, NOT-S. J Med Speech Lang Pathol. 2014;21(1):51–59. Available at: https://www.mun-h-center.se/siteassets/munhcenter/3-information-och-utbildning/4--not-s/mcallister_jmslp_2013.pdf (accessed: 27.10.2025).

33. Bergendal B., Bakke M., McAllister A., Sjögreen L., Åsten P. Profiles of orofacial dysfunction in different diagnostic groups using the Nordic Orofacial Test (NOT-S) – a review. Acta Odontol Scand. 2014;72(8):578–584. https://doi.org/10.3109/00016357.2014.942874

34. Szuflak K., Gerreth K., Jankowski M., Malak R., Samborski W., Karlik M. Nordic orofacial test-screening protocol as a tool for assessment of orofacial dysfunction in pediatric and adult patients. Diagnostics. 2025;15(13):1656. https://doi.org/10.3390/diagnostics15131656

35. Thoyre S.M., Pados B.F., Park J., Estrem H., Hodges E.A., McComish C. et al. Development and content validation of the Pediatric Eating Assessment Tool (Pedi-EAT). Am J Speech Lang Pathol. 2014;23(1):46–59. https://doi.org/10.1044/1058-0360(2013/12-0069)

36. Thoyre S.M., Pados B.F., Park J., Estrem H., McComish C., Hodges E.A. The pediatric eating assessment tool: Factor structure and psychometric properties. J Pediatr Gastroenterol Nutr. 2018;66(2):299–305. https://doi.org/10.1097/MPG.0000000000001765

37. Schreck K.A., Williams K. Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Res Dev Disabil. 2006;27(4):353–363. https://doi.org/10.1016/j.ridd.2005.03.005

38. Schott T.C., Göz G. Young patients’ attitudes toward removable appliance wear times, wear-time instructions and electronic wear-time measurements--results of a questionnaire study. J Orofac Orthop. 2010;71(2):108–116. https://doi.org/10.1007/s00056-010-9925-y

39. Destriatania S., Februhartanty J., Nurwidya F., Sekartini R. Feeding Problems assessment tools in children: A scoping review. Children. 2024;12(1):37. https://doi.org/10.3390/children12010037

40. Ahearn W.H., Castine T., Nault K., Green G. An assessment of food acceptance in children with autism or pervasive developmental disorder-not otherwise specified. J Autism Dev Disord. 2001;31(5):505–511. https://doi.org/10.1023/a:1012221026124

41. Chow C.Y., Skouw S., Bech A.C., Olsen A., Bredie W.L.P. A review on children’s oral texture perception and preferences in foods. Crit Rev Food Sci Nutr. 2024;64(12):3861–3879. https://doi.org/10.1080/10408398.2022.2136619