Advances in Neurodevelopmental Disorders

https://doi.org/10.1007/s41252-023-00338-1

ORIGINAL PAPER

Oral Sensory Issues with Feeding and Communication Skills in Autistic

Children
Nivedya Maria Raj1 · Kadiyali Damodar Veena1 · Bellur Rajashekhar1 · Ashitha C. A. Sreelakshmi1

Accepted: 20 May 2023

© The Author(s) 2023, corrected publication 2023

Abstract
Objectives Oral sensory, communication, and feeding issues are frequently observed to co-occur in autistic children. The
study attempted to explore the association between oral sensory deficits, feeding, and communication deficits in autistic
children.
Methods Behavioral Pediatric Feeding Assessment Scale (BPFAS), Child Sensory Profile 2 (SP-2), and Communication and
Symbolic Behavior Scales Developmental Profile Infant/Toddler Checklist (CSBS-DP) were administered to forty autistic
children in the age range of 2.5-7 years. The correlation among the three domains was determined using Spearman’s rank
correlation coefficient.
Results A low negative correlation was found between SP-2 scores and CSBS-DP (r = −0.24, p = 0.13), indicating that the
higher the oral sensory scores, the poorer the communication skills. SP-2 and BPFAS scores had a moderate positive cor-
relation (r = 0.47, p = 0.002) i.e., higher scores in SP-2 were associated with higher scores in feeding, indicating that oral
sensory issues were directly related to the feeding issues.
Conclusions The overall findings indicated that the presence of oral sensory issues is associated with feeding and commu-
nication deficits in autistic children.
Study Registration Clinical Trial Registry of India CTRI/2020/07/02681

Keywords Autism spectrum disorder · Oral sensory issues · Communication · Feeding

Autism Spectrum Disorder (ASD) is “a heterogeneous group vestibular (balance and spatial orientation), and propriocep-
of neurodevelopmental disorders characterized by impair- tion (the awareness of one’s limbs in space).
ment in social interaction, communication, and stereotyped/ Around 70% of autistic children have SPD (Baker et al.,
limited behaviors” (American Psychiatric Association, 2013, 2008; Ben-Sasson et al., 2007; Kientz & Dunn, 1997; Tom-
p. 50). It is estimated that one in 100 children globally have chek & Dunn, 2007). In India, around 98% of autistic chil-
ASD (Zeidan et al., 2022). Based on DSM-5, hypersensi- dren exhibit SPD (Shah et al., 2015). Baker et al. (2008)
tivity or hyposensitivity towards sensory information or reported the presence of different sensory processing pat-
stimuli is a diagnostic criterion of ASD. A neurological terns including difficulties in auditory filtering, seeking sen-
disorder called Sensory Processing Disorder (SPD) causes sation, under responsiveness in movement and vestibular
difficulties in absorbing, processing, and reacting to sen- input, and typical and varied responsiveness in visual, audi-
sory information from the environment and within one’s own tory, movement, taste, and smell. It needs to be noted that
body (Ayers, 1963). Some of the senses that are affected are SPD is not identified as a critical indicator for the diagnosis
visual, auditory, olfaction (smell), tactile, gustatory (taste), of ASD (Miller et al., 2007; Suarez, 2012). Research is cur-
rently focused on figuring out how autistic children vary
from other children. As autistic children exhibit an early
beginning of sensory processing problems, a child’s cogni-
* Kadiyali Damodar Veena
[email protected] tive and speech development could be impacted at an early
age (Ben-Sasson et al., 2007; Talay-Ongan & Wood, 2000).
1
Department of Speech and Hearing, Manipal College Early sensory features have been shown to predict different
of Health Professions (MCHP), Manipal Academy of Higher adaptive behaviors (Williams et al., 2018).
Education (MAHE), Manipal, Karnataka, India

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An oral sensation is a form of tactile sensation that is (Baghdadli et al., 2012; Lord et al., 2004; Sigman & McGov-
specifically located in the mouth. Oral hypersensitivity and ern, 2005) and this often develops after the age of 5 (Pickett
hyposensitivity are the two groups of oral sensitivity disor- et al., 2009). It has been found from the literature that non-
ders in autistic children. Oral sensory development is a nor- verbal children have substantially worse outcomes than ver-
mal aspect of childhood development that must be considered bal autistic children. In autistic children, acquiring functional
when assessing infants. They are the elements that make up verbal communication and/or development of speech before
the motor-sensory patterns learned during the formation of age 5 predicted educational success, work, independence, and
both basic and complex skills such as eating and speaking. social interactions (Kobayashi et al., 1992; Venter et al., 1992).
Autistic children struggle to register and modulate sensory Patten et al. (2013) hypothesized atypical sensory behaviors
inputs in one or more sensory systems to varying degrees as a factor constraining verbal communication development
(Yack et al., 2015). This makes it difficult to initiate and exe- in autistic children. They indicated that hypo-responsiveness
cute movements or create a feedback system. Evidence from and behaviors related to sensory seeking were associated with
clinical practice has revealed that hyposensitivity and hyper- the verbal communication of the child; that is, those children
sensitivity symptoms coexisted, potentially leading to feeding who belonged to the non-verbal ASD category were exhibit-
issues and poor speech intelligibility (Aswathy et al., 2016). ing higher sensory-seeking behaviors and hypo-responsive-
Almost 90% of autistic children are reported to have feed- ness to the sensory stimuli. However, hyper-responsiveness
ing problems (Kodak & Piazza, 2008). Feeding problems did not vary evidently in both verbal and non-verbal children.
exhibited in autistic children could be attributed to maternal Observational evidence has suggested that preschool autistic
anxiety and maladaptive feeding strategies (Zlomke et al., children had hypo-responsiveness to stimuli including social
2020). Allen et al. (2015) reported that feeding issues and stimuli, which correlated with impaired communication. Liss
ASD symptoms reported by the parents were positively cor- et al. (2006) used cluster analysis and identified elevated levels
related with behavioral problems, parental stress, and sleep of hypo-responsiveness and sensory-seeking behaviors, which
problems in 2-5-year-old autistic children. However, no sig- were associated with poor communication in autistic children.
nificant correlation was found among the severity of ASD, Hilton et al. (2007) suggested that the severity of the social-
a child’s cognitive ability, age, and vocabulary. Autistic communicative symptoms was linked to the three sensory
children exhibited more problems in feeding and presented response trends such as hypo-responsiveness and/or hyper-
atypical oral sensory sensitivity of either hyposensitivity or responsiveness, and sensory seeking. Watson et al. (2011)
hypersensitivity. They ate a limited variety of foods, and reported that hypo-responsiveness had a positive correlation
consumed fewer fruits and vegetables, proteins, starches, with social communication, whereas language and adaptive
and dairy products when compared to normal. Furthermore, skills were negatively correlated.
autistic children with atypical oral sensitivity also rejected While several studies have revealed that oral sensory, feed-
food, exhibited a more limited food repertoire, consumed a ing, and communication deficits co-occur in autistic children,
limited variety of foods, needed special utensils, struggled they have mostly concentrated on measuring the oral sensory
with the texture of food, and were picky eaters (Bandini abnormalities in autistic children and their relationship to
et al., 2010; Chistol et al., 2017; Schreck & Williams, 2006). feeding concerns. Food selectivity in autistic children may be
Furthermore, it has been reported that food selectivity is related to poor sensory processing, particularly oral sensory
linked to sensory processing impairment, especially oral sensitivity, according to current research (Suarez, 2012; Zobel-
sensory, in children diagnosed with ASD (Cermak et al., Lachiusa et al., 2015). Furthermore, children with abnormal
2010; Suarez et al., 2014; Zobel-Lachiusa et al., 2015). Fear oral sensitivity among those with ASD refused food more fre-
of unfamiliarity, sensory impairment, social compliance def- quently and ate less. Very few studies have hypothesized oral
icits, and biological food aversion are the causes of feeding sensory deficits as a reason or a component that restricted the
problems in ASD (Cumine et al., 2000), whereas limited occurrence of functional verbal communication in autistic chil-
food repertoire could be linked to inadequate nutrient intake dren. One of the most frequently mentioned causes of delayed
(Herndon et al., 2009). verbal communication development in autistic children is sen-
One of the factors that inhibit and influence verbal com- sory abnormalities in the detection of external cues. However,
munication development in autistic children could be the this explanation has received less attention than others. There-
abnormality in the perception of external sensory stimuli fore, in the present study, the aim was to assess the correlation
(Patten et al., 2013). Roughly, 25-50% of autistic children between oral sensory issues with feeding and communication
are not able to communicate verbally to meet their desires in autistic children.

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Method The parents/caregivers were either native speakers of

Malayalam or Kannada or were fluent in English. For the
Participants SP-2 administration, the clinician interviewed the par-
ents in their native language and recorded their responses
Participants were recruited from different tertiary care hospi- regarding the child’s performance in response to the stimuli.
tals and private centers based on the inclusion and exclusion To acquire the results, the raw scores were analyzed and
criteria. Forty participants either already diagnosed with appraised. English-speaking parents/caregivers were given
ASD, of any severity, based on DSM-5 criteria and Child- the CSBS-DP and BPFAS checklists and instructed to record
hood Autism Rating Scale (CARS; Schopler et al., 1988), the responses themselves. An interview was conducted for
attending therapy, or with a new diagnosis of ASD in the parents who had trouble responding to the questions in writ-
age range of 2.5-7 years (mean age = 4.18; SD = 1.06) were ing or reading. Total scores for each of the test materials
selected for the study. Participants were excluded if they pre- were summed up and compared with the normative to iden-
sented other neurodevelopmental disorders such as attention- tify the issues and deficits. All the details were documented
deficit/hyperactivity disorder (ADHD), intellectual disability in the data collection sheet and Excel sheet.
(ID), or specific language impairment (SLI). Details of the
participants along with the severity are provided in Table 1. Measures

Procedure Child Sensory Profile 2, one of the variations of Sensory

Profile-2, was used to measure oral sensory difficulties (SP-
Approval and informed consent were obtained from the par- 2; Dunn, 2014). It contains several sensory sections such
ents of the participants. After receiving the approval, general as visual, auditory, touch, movement, body position, oral
background information was collected from the parents/car- sensory, and social emotional responses. Only 10 items from
egivers of participants. This included birth history, family the oral sensory section were used as the study objective
history, and developmental milestones in terms of motor, was to investigate oral sensory issues and their association
speech and language, social skills, and behavioral skills. with feeding and communication deficits in autistic children.
After collecting the background information, an informal The Behavioral Pediatric Feeding Assessment Scale
evaluation was done of the participants. Results revealed (BPFAS; Crist & Napier-Phillips, 2001) is a validated
poor verbal and non-verbal communication and feeding 35-item parental report questionnaire with 70 items designed
skills. Following this SP-2, CSBS-DP and BPFAS question- to examine children’s feeding behaviors and difficulties. This
naires were administered to identify the relationship among test was used as it measures the mealtime behavioral issues,
these three domains in autistic children. Though these such as parental stress and anxiety during feeding time, and
test materials were not developed in India, they are being the need for forceful feeding on refusal to eat in addition to
widely used in India to assess sensory skills, communication the participants’ feeding abilities.
aspects, and feeding behaviors, respectively. Communication and Symbolic Behavior Scales Devel-
opmental Profile Infant/Toddler Checklist (CSBS-DP;
Wetherby & Prizant, 2002) measures communication skills
using seven communication predictors including emotional
Table 1  Participant characteristics of children diagnosed with ASD expression and eye gaze, communication, gestures, sound
Total Mean SD production, word production, word comprehension, and
object use. Total scores were calculated for the oral sensory
Age (in years) 4.18 ± 1.06
section of SP-2, BPFAS, and CSBS-DP.
Less than 3 years 3 2.5 ±0
Equal to/more than 3 years 37 4.34 ± 0.98
Data Analyses
Gender
Male 30 4.14 ± 1.08
Oral Sensory Section of SP‑2 The child’s frequency of each
Female 10 4.39 ± 1.007
item behavior was measured on a Likert scale that ranged
CARS score - 38.86 ± 6.82
from 1 (almost never = 10% or less) to 5 (almost always =
Severity
90% or more). Out of a possible 50 points, the total score
Mild–moderate 22 - -
for the oral sensory section was calculated and was then
Severe 18 - -
classified as, “less than others” (score less than 7), “just like
Therapy intervention period 5.72 ±7.37
many others” (score between 8 and 24), “more than others”
Less than 12 months 31 2.35 ±3.20
(score 25-32), and “much more than others” (score between
Equal to/more than 12 months 9 17.33 ±5.56
33 and 50).

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Behavioral Pediatric Feeding Assessment Scale (BPFAS) The Table 2  Mean and SD of oral sensory processing section of SP-2 for
first 25 Likert-style items are about the child’s feeding various classifications
behaviors (which are added together to get the child fre- Classification N Mean SD
quency score (CFS), and the next 10 are about parental
Just like majority of others 10 17.40 ±3.43835
mealtime strategies and feelings (totaled to get the parent
More than others 23 28.52 ±2.33296
frequency score (PFS)). Total frequency score (TFS) was
Much more than others 7 39.14 ±4.59814
calculated by adding the CFS and PFS. “Is this a problem
Total 40 27.60 ±7.755
for you?” poses a yes/no question after each of the Likert-
style objects. The child problem score (CPS) was calculated
using questions that can be answered either as “yes” or “no”
for the first 25 Likert-style items, whereas the parent prob-
lem score (PPS) was calculated using the last 10 questions. Table 3  Mean CSBS-DP Infant-Toddler Checklist Standard Scores
The total problem score was calculated by adding the CPS CSBS-DP measure ASD (n = 40)
and PPS (TPS). All 35 Likert scale items ranged from 1 to
Mean SD Range
5, with 1 being “never” and 5 being “always.” When the
questionnaire was graded, favorable scores were converted Communication composite 11.3 ± 4.50 4-23
because questions were given as either positive or negative. Expressive speech composite 6.55 ± 3.30 1-13
The resulting TFS was graded on a scale of 175 points. The Symbolic composite 8.05 ± 3.33 4-15
TPS was scored out of a maximum of 35 points, with one Total score 25.65 ± 8.99 14-49
point awarded for each “yes” response. As a result, higher
CSBS-DP Communication and Symbolic Behavior Scales Develop-
TPS and TFS scores were suggestive problematic feeding
mental Profile Infant/Toddler Checklist
behaviors and parental difficulties in dealing with them,
respectively.

Communication and Symbolic Behavior Scales Develop‑ Results

mental Profile Infant/Toddler Checklist (CSBS‑DP) The test
had 24 questions with points ranging from 0 to 4 in seven The present study looked at the SP-2 ratings for any varia-
language predictors. Items marked “Not Yet” received a tions in oral sensory sensitivity processing subscales. The
score of 0, “Sometimes” received one point, and “Often” mean and standard deviation for different classifications
received two points. “None” received 0 points, and ques- is given in Table 2. On average, autistic children scored
tions with numbered choices received 1 to 4 points. The higher, indicating more atypical oral sensory processing.
sum of the points in each cluster yielded seven distinct Among 40 autistic children, 23 (57%) revealed oral sen-
cluster scores, namely “emotion and use of eye gaze,” “use sory scores between 25 and 32, classified as “more than
of communication,” “use of gestures,” “use of sounds,” others” (mean = 28.52; SD = 2.3), and 10 (25%) scored
“use of words,” “understanding of words,” and “use of between 8 and 24, classified as “just like the majority of
objects”. The cluster scores were added up to create three others” (mean = 17.40, SD = 3.43) and 7 (18%) between
composite scores including “communication composite,” 33 and 50, classified as “much more than others” (mean
“expressive speech composite,” and “symbolic composite”. = 39.14, SD = 4.59). The mean age of the oral sensory
These scores when added together provided the final score subgroups was not notably different, and gender was not
that was then compared to the normative score. The lesser significantly related to any of these factors.
the score, the more at risk for developing communication Table 3 shows the mean, standard deviation, and range
impairment. for the expression, expressive speech, symbolic compos-
After scoring, the results were subjected to statistical ites, and overall score. On average, autistic children had
analysis. Spearman’s rank correlation was used to investi- poorer cut-offs for all the composites and total scores indi-
gate the relationship between oral sensory difficulties and cating their falling in the range of concern, i.e., they were
each of the independent variables, CSBS-DP and BPFAS. not communicating their needs as expected for their age.
The strength of association and relationship between the Furthermore, the overall mean of the expressive speech
variables was also examined. In addition to establishing the composite was less compared to the communication and
correlation, this step also helped to check the linearity in symbolic composite scores.
the relationship between the SP-2 scores and each of the Table 4 shows the mean, standard deviation, and range
independent variables. SPSS Statistics version 21 was used for the total frequency score (TFS) and total problem
for all analyses. score (TPS). On average, autistic children had prob-
lematic behaviors exhibited during feeding time and

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Table 4  Mean and standard deviations of BPFAS scores Correlation Between Oral Sensory and Feeding
Variables Mean SD Range
Spearman’s rank correlation was performed as data violated
TFS 96.92 ±13.10 74-124 the normality assumption. A moderate positive correlation
TPS 16.37 ±4.60 10-26 existed between oral sensory score with TFS and TPS with
BPFAS Behavioral Pediatric Feeding Assessment Scale, TFS total statistical significance. Spearman’s rank correlation coef-
frequency score, TPS total problem score ficient 0.43 p-value = 0.006 for oral sensory and TFS (Fig-
ure 2) and 0.005 for oral sensory and TPS (Figure 3).

parental difficulties in dealing with them. Investigators

also noted that mealtime induced stress in families of Discussion
autistic children.
The present study investigated oral sensory issues and their
association with feeding and communication deficits in
Correlation Between Oral Sensory autistic children and attempted to find out the correlation
and Communication among the three variables. The primary objective was to
explore the oral sensory issues found among autistic chil-
Spearman’s rank correlation was performed as the data dren. In the present study, on average, autistic children
violated the normality assumption and was found to be a scored higher in the oral sensory processing section of SP-2,
correlation coefficient of −0.29 (p-value = 0.075). A weak indicating increased atypical oral sensory processing. The
negative correlation existed between these two variables majority of the children had selective eating habits espe-
which was not statistically significant. Figure 1 shows the cially concerning food textures, compared to other oral sen-
scatter diagram of the analysis. sory issues. In addition, they exhibited a craving for food,
taste and smell, ate only certain tastes, and were limited to

Figure 1  Correlation between

oral sensory and communica-
tion

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Figure 2  Correlation between

oral sensory and TFS

certain food textures. Previous studies have also reported autistic children reported mealtime behavioral issues, such
that autistic children have greater oral sensory problems as parental stress and anxiety during feeding time, and the
(Ermer & Dunn, 1998; Hazen et al., 2014; Leekam et al., need for forceful feeding on refusal to eat. This suggests
2007; Nadon et al., 2011; Rogers et al., 2003; Tomchek & that children who exhibit oral sensory issues may have food
Dunn, 2007). However, in the present study, no considerable selectivity and restrictive eating behaviors. This is consistent
differences in oral sensory processing in terms of age and with earlier research in the literature that claimed autistic
gender were observed. children may have particular food preferences due to sensory
Previous research has confirmed that autistic children dysfunction, specifically oral sensory issues (Cermak et al.,
possess greater feeding challenges and food preferences than 2010; Suarez, 2012; Zobel-Lachiusa et al., 2015). Children
children who are typically developing (Bandini et al., 2010; who have oral sensory sensitivity can restrict their diet to
Ledford & Gast, 2006; Schreck & Williams, 2006; Sharp foods that they prefer, find manageable, or tolerate (Cermak
et al., 2013; Williams et al., 2005; Zimmer et al., 2012). The et al., 2010). In the present study, mealtime was a cause
present study evaluated how abnormal oral sensory process- of stress in families of autistic children, a finding congru-
ing may be associated with feeding problems and food selec- ent with previous qualitative studies (Ausderau & Juarez,
tion. It was observed that the majority of the children scored 2013; Marquenie et al., 2011; Suarez, 2012; Zobel-Lachiusa
“more than others” on SP-2 of the oral sensory processing et al., 2015). However, parents’ preferences for food were
section, suggesting higher oral sensory processing deficits not collected for the current study analysis and hence, it
in autistic children. Furthermore, the findings of this study is not clear if the food options and preferences of parents
revealed that children with unusual oral sensory sensitivity had influenced the food selectivity/food habits of autistic
also had feeding issues. They chewed food poorly, ate less children. Furthermore, it was noted that parents’ choices of
variety of fruits and vegetables, ate strained/soft food, got food were restricted to a lesser variety of meals, leading to a
up from the table during mealtime, spat food, and exhibited limited number of children’s food repertoires (Chistol et al.,
tantrums during feeding time. They also took more than 2018). Besides, only the food that was offered was rejected
20 min to finish their meal. A great number of parents of by the autistic children, as reported by the parents.

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Figure 3  Correlation between

oral sensory and TPS

Even though this study has not assessed oral sensory sen- not exhaustive) through the “expressive speech composite”
sitivity, it could provide information regarding food selec- score. Among the 3 composite scores (communication,
tivity behaviors in autistic children to delineate variations expressive speech, and symbolic), the expressive speech
between over and under-sensitivity towards stimuli. For composite score was found to be the lowest for participants.
instance, oral over-sensitivity can make textures challenging This indicates that autistic children have reduced expressive
and make it difficult to eat, whereas oral under-sensitivity vocabulary and poor oral production. With respect to other
in which children may not seem to interpret sensation suf- communication deficits, the children showed poor name
ficiently can lead to a child eating significant quantities of call response, not paying attention to speech, or pointing to
a certain food or stuffing food in the mouth (Cermak et al., objects, requesting for objects, asking for help, and overall
2010). In several studies, neurobiological processes were poor communication skills. This finding is in congruence
suggested to understand how oral sensitiveness could lead with the previous studies reporting autistic children having
to food-selective behavior. Food selectivity in children diag- deficiencies in social communication at all ages and levels
nosed with ASD is influenced by medical, genetic, cultural, (Tager-Flusberg et al., 2001).
maternal, and developmental influences (Sharp et al., 2013; Results of the current study suggest a low negative
Takasaki & Baron-Cohen, 2012), restricted preferences and/ correlation between the oral sensory processing score of
or behavior rigidity (Johnson et al., 2014; Schreck et al., SP-2 and CSBS-DP (r = −0.24, p = 0.13), indicating that
2004; Suarez et al., 2014), and differing perceptions of smell the higher the oral sensory scores, the higher the oral
and taste sensations (Bennetto et al., 2007). sensory dysfunction, and the poorer communication skills
The next objective of this study was to find out the cor- including poor oral production. It was also observed that
relation between oral sensory and communication issues. On those children who fell in the category of “just like the
scoring CSBS-DP to check for communicative competence, majority of others” in the oral sensory processing sec-
autistic children had poorer cut-offs for all the composite tion of SP-2 also exhibited communication impairment.
and total scores of CSBS-DP indicating that they came in Similar findings are reported in the literature suggesting
the range of concern i.e., they were not communicating their that oral sensory issues and communication difficulties
needs as expected of their age. The test also provided insight are common in autistic children (Baranek et al., 2013;
into the oral production capacity of the participants (though Watson et al., 2011). In addition, it is reported in the

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literature that both sensory hypo-responsiveness and address problems related to oral sensory, feeding, and oral
sensory-seeking behaviors are negatively correlated with communication. Furthermore, with the limited sample, the
language skills indicating that sensory processing skills relationship or extent to which behavior aligns with feed-
play an important role in the rate of language acquisition ing and oral communication requires further investigation.
and communication skills (Watson et al., 2011). Further- Autistic children have variable over-sensitivity and under-
more, oral sensory problems may not be considered the sensitivity issues. However, only limited studies on over
only issue limiting the growth of communication devel- and under-sensitivity of taste/smell stimuli have been pub-
opment in autistic children. Unusual sensory responses lished. This calls for future studies focusing on the same.
can lead to some of the signs of communication associ- The current study has indicated that sensory influences
ated with ASD, not exclusively addressed in the current could be manifested in autistic children as food selectiv-
study. Therefore, it cannot be emphatically stated that oral ity. Further studies are necessary to clarify the extent of
sensory deficits can cause communication issues. It was the relationship among feeding issues, food selectivity,
interesting to note that even with therapeutic intervention, and oral sensory processing factors. In-depth studies on
children were exhibiting atypical oral sensory processing, the relationship between oral production and oral sensory
feeding issues, and communication deficits. issues or sensory issues and communication skills will be
The current study provides insight into autistic chil- a fruitful area of research in the future. The present study
dren having feeding and communication problems due is based on a cross-sectional design which limits the con-
to oral sensory issues. Although the impact of sensory clusions that can be drawn from the data. By the use of a
processing problems on verbal communication has been cross-sectional design, no causal relationship regarding
hypothesized, no studies in the literature have specifically the investigated variables can be drawn as what is seen
addressed the potential for sensory response patterns to be are only correlations that speak of associations and not
a factor constraining the development of verbal commu- predictions of causality.
nication (i.e., by grouping participants based on the pres-
Acknowledgements We would like to acknowledge the participants
ence or absence of verbal communication) in autistic chil- and the head of the departments of the private centers who allowed us
dren. Hence, the present study is a preliminary attempt to interact and collect data from their patient population.
aimed at highlighting the importance of addressing the
oral sensory issues. In summary, a clear link between oral Author Contributions Conceptualization: Nivedya Maria Raj, Kadiyali
Damodar Veena; data curation: Nivedya Maria Raj; formal analysis:
sensory and feeding issues has been established. Feeding Nivedya Maria Raj, Kadiyali Damodar Veena; Investigation: Nivedya
issues exhibited included ritualized eating, food rejection, Maria Raj; methodology: Nivedya Maria Raj, Kadiyali Damodar
and mealtime refusal. Besides, a relationship between oral Veena; project administration: Nivedya Maria Raj, Kadiyali Damodar
sensory issues and communication deficits has been iden- Veena; resources: Nivedya Maria Raj, Kadiyali Damodar Veena; vali-
dation: Nivedya Maria Raj, Kadiyali Damodar Veena; visualization:
tified, particularly with oral production. This hints at the Nivedya Maria Raj, Kadiyali Damodar Veena; writing—original draft:
necessity to examine the oral sensory processing deficits Nivedya Maria Raj, Kadiyali Damodar Veena; writing—review and
in autistic children as it could lead to other problematic editing: Bellur Rajashekhar, Ashitha Sreelakshmi C. A.
behaviors such as communication and feeding deficits.
Funding Open access funding provided by Manipal Academy of
It is always advisable for a team of medical specialists Higher Education, Manipal
including speech-language pathologists, clinical psy-
chologists, occupational therapists, nutritionists, dieti- Declarations
cians, and others to work together to identify and man-
age autistic children. Working with a multidisciplinary Ethics Approval Ethical approval for the study was obtained from Insti-
tutional Research Committee (IRC) of Manipal College of Health Pro-
team will be helpful for autistic children who experience fessions, MAHE, Manipal and Kasturba Medical College and Kasturba
extraordinary oral sensory sensitivity, feeding issues, and Hospital—Institutional Ethics Committee (IEC approval 206/2020) of
communication difficulties. MAHE, Manipal.

Consent to Participate Informed consent was obtained from the parents

Limitations and Future Research of children included in the study.

The present study did not relate the results to the sever- Conflict of Interest The authors declare no competing interests.
ity of the disorder or quantify the type and nature of
therapeutic intervention received. Since the study used Open Access This article is licensed under a Creative Commons Attri-
different self-reported measurement tools to assess the bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
sensory, feeding, and communication skills, common test as you give appropriate credit to the original author(s) and the source,
administration bias could have affected the test results. provide a link to the Creative Commons licence, and indicate if changes
More research is warranted in the future to recognize and were made. The images or other third party material in this article are

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Advances in Neurodevelopmental Disorders

included in the article's Creative Commons licence, unless indicated disorders. Journal of the American Dietetic Association, 110(2),
otherwise in a credit line to the material. If material is not included in 238–246. https://​doi.​org/​10.​1016/j.​jada.​2009.​10.​032
the article's Creative Commons licence and your intended use is not Chistol, L. T., Bandini, L. G., Must, A., Phillips, S., Cermak, S. A.,
permitted by statutory regulation or exceeds the permitted use, you will & Curtin, C. (2017). Sensory sensitivity and food selectivity in
need to obtain permission directly from the copyright holder. To view a children with autism spectrum disorder. Journal of Autism and
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. Developmental Disorders, 48(2), 583–591. https://​doi.​org/​10.​
1007/​s10803-​017-​3340-9
Chistol, L. T., Bandini, L. G., Must, A., Phillips, S., Cermak, S. A.,
& Curtin, C. (2018). Sensory sensitivity and food selectivity in
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