Eating difficulties among toddlers on the autism spectrum in relation to sensory processing and repetitive-stereotyped behaviors (Hebrew)

Background: Eating difficulties are highly prevalent among toddlers and children on the autism spectrum and may emerge as early as the first year of life. Manifestations include selective eating, food refusal, ritualistic mealtime behaviors, and atypical responses to textures, smells, and tastes. Prior studies link such difficulties to autism core characteristics: Restricted and repetitive behaviors (RRBs) and atypical sensory processing (SP), as well as to autism severity and early breastfeeding experiences. Yet, most studies have examined these associations in broad age ranges or among children older than three years. The present study focuses specifically on autistic toddlers under the age of three and a half, aiming to deepen understanding of these associations and at an early developmental stage.
Objectives: This study examined the associations between eating difficulties and RRBs, sensory processing (SP), autism severity, and breastfeeding history among autistic toddlers. It further aimed to characterize early eating difficulties during toddlerhood and to assess the predictive contribution of individual characteristics (age, RRBs, SP, autism severity) to eating-related challenges.
We hypothesized that greater eating difficulties would be associated with higher levels of RRBs (especially rigidity), more pronounced SP challenges (particularly oral sensitivity), and higher autism severity. We also expected early breastfeeding difficulties and shorter breastfeeding duration to predict later greater eating difficulties, particularly food selectivity.
Method: Participants were parents of 29 autistic toddlers under the age of three years and two months (19–38 months; M = 30.0, SD = 4.5; 24 boys, 5 girls), recruited through ALUT rehabilitative early intervention daycare centers for toddlers diagnosed with autism spectrum disorders. Parents completed self-report questionnaires, including the AUT-EAT autism-specific eating difficulties questionnaire, and breastfeeding history (Gal et al., 2022), the Repetitive Behavior Scale–Revised (R-RBS; Bodfish et al., 2000), the Toddler Sensory Profile 2 (Dunn, 2014), and the Social Communication Questionnaire
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(SCQ; Rutter, Bailey, & Lord, 2003) to assess autism severity. Data were analyzed using analyses of variance to examine eating characteristics, Pearson correlations to assess associations, and multivariate regression models to test predictive relationships between variables.
Results: Selective eating emerged as the most prominent difficulty, with vegetables most frequently avoided food group. Restricted behaviors were the most prominent RRBs, followed by stereotyped behaviors, though overall mean scores remained low (< 1 on a 0–3 scale). Over half of the toddlers scored outside the normative range on SP, and more than 80% showed atypical auditory processing. Breastfeeding patterns paralleled prior findings: 56% of parents reported breastfeeding difficulties;
45% breastfed up to 2 months, 40% up to 6 months, and 48% did not breastfeed.
Eating difficulties correlated positively with both RRBs and sensory challenges. Selective and ritualistic eating were most strongly related to rigidity and sensory atypicality. Autism severity correlated positively with selective eating but not with other domains. Shorter breastfeeding duration predicted greater selectivity, and early breastfeeding difficulties were associated with later rigidity, overeating, and ritualistic behaviors. Regression analyses revealed that selective eating was predicted by age, RRBs, and autism severity; ritualistic eating by RRBs; and mealtime behavioral problems were negatively predicted by age and severity. High sensory sensitivity (low thresholds) predicted chewing, swallowing, and food-avoidance difficulties, whereas low sensory registration did not.
Conclusions: Findings highlight strong interrelation between eating difficulties and core autism characteristics, particularly RRBs and SP. The links between breastfeeding history and later eating difficulties, shorter duration predicting greater selectivity and early breastfeeding challenges predicting rigidity and overeating, underscore the value of early identification and intervention. Integrating sensory and behavioral strategies while considering breastfeeding history may enhance eating compliance and dietary
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habits. Identifying these associations during toddlerhood emphasizes the critical importance of intervention immediately following diagnosis to support healthy eating and adaptive development in autistic children.