Abstract
Food consumption in children with ASD, subclinical ASD and with typical development (TD), and their adequacy to dietary recommendations was studied. A school population sample of 77 children with ASD, 40 with subclinical ASD, and 333 with TD participated. Compared to children with TD, pre-schoolers with ASD consumed fewer raw vegetables and less fish and eggs, while primary school children consumed fewer legumes, raw vegetables, citrus fruits, cheese/yogurt and olive oil, and more meat. All groups consumed an excess of sugar but those with ASD consumed even a greater amount than their peers. The higher prevalence of obesity found in primary school children with ASD may be the consequence of a less healthy eating pattern sustained over time.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Agència de Salut Pública de Catalunya. (2005). La alimentación saludable en la etapa escolar. Barcelona: Agència de Salut Pública de Catalunya. Generalitat de Catalunya. Retrieved April 4, 2020 from https://es.calameo.com/read/000784569c7c9f5e80645.
Al-Farsi, Y. M., Waly, M. I., Deth, R. C., Al-Sharbati, M. M., Al-Shafaee, M., Al-Farsi, O., et al. (2013). Impact of nutrition on serum levels of docosahexaenoic acid among Omani children with autism. Nutrition, 29(9), 1142–1146. https://doi.org/10.1016/j.nut.2013.03.009
Al-Thbiany, A., Farghal, S., Al-Harbi, G., Abduallah, M., Al-Rehaly, R., Al-Johani, G., et al. (2017). Assessment of some nutritional risk factors that predispose to autism among preschool & school Saudi children living in AL-Madinah Al-Monawarah city. Journal of Studies and Searches of Specific Education, 3(1), 133–145.
Aparicio, E., Canals, J., Pérez, S., & Arija, V. (2015). Dietary intake and nutritional risk in Mediterranean adolescents in relation to the severity of the eating disorder. Public Health Nutrition, 18(8), 1461–1473. https://doi.org/10.1017/S1368980014002043
Araujo, A., Almeida, P., Alves, L., Carvalho, W., Zagmignan, A., Rodrigues de Oliveira, B., et al. (2018). Consumption of ultra-processed foods and nutritional status of children with autism spectrum disorder. Revista Brasileira em Promoção da Saúde. Retrieved from https://core.ac.uk/download/pdf/235419963.pdf.
Arija, V., Salas Salvadó, J., Fernández-Ballart, J., Cucó, G., & Martí-Henneberg, C. (1996a). Consumption, dietary habits and nutritional status of the Reus (IX) population. Evolution of food consumption, energy and nutrient intake and relationship with the socioeconomic and cultural level, 1983–1993. Medicina Clinica, 106(5), 174–179.
Arija, V., Salas Salvadó, J., Fernández-Ballart, J., Cucó, G., & Martí-Henneberg, C. (1996b). Food consumption, habits, and nutritional status of the population of Reus (VIII). Evolution of energy and nutrient intake from 1983 to 1993. Medicina Clínica (Barcelona), 106(2), 45–50.
Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., et al. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. The Journal of Pediatrics, 157(2), 259–264. https://doi.org/10.1016/j.jpeds.2010.02.013
Bandini, L. G., Curtin, C., Phillips, S., Anderson, S. E., Maslin, M., & Must, A. (2017). Changes in food selectivity in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(2), 439–446. https://doi.org/10.1007/s10803-016-2963-6
Barnhill, K., Gutierrez, A., Ghossainy, M., Marediya, Z., Marti, C. N., & Hewitson, L. (2017). Growth status of children with autism spectrum disorder: A case-control study. Journal of Human Nutrition and Dietetics, 30(1), 59–65. https://doi.org/10.1111/jhn.12396
Berding, K., & Donovan, S. M. (2018). Diet can impact microbiota composition in children with autism spectrum disorder. Frontiers in Neuroscience, 12, 515. https://doi.org/10.3389/fnins.2018.00515
Castro, K., Faccioli, L. S., Baronio, D., Gottfried, C., Perry, I. S., & Riesgo, R. (2016). Feeding behavior and dietary intake of male children and adolescents with autism spectrum disorder: A case-control study. International Journal of Developmental Neuroscience: the Official Journal of the International Society for Developmental Neuroscience, 53, 68–74. https://doi.org/10.1016/j.ijdevneu.2016.07.003
Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238–246. https://doi.org/10.1016/j.jada.2009.10.032
Chistol, L. T., Bandini, L. G., Must, A., Phillips, S., Cermak, S. A., & Curtin, C. (2018). Sensory sensitivity and food selectivity in children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 48(2), 583–591. https://doi.org/10.1007/s10803-017-3340-9
Chung, L., Law, Q., & Fong, S. (2020). Using physical food transformation to enhance the sensory approval of children with autism spectrum disorders for consuming fruits and vegetables. Journal of Alternative and Complementary Medicine, 26(11), 1074–1079. https://doi.org/10.1089/acm.2020.0215
Clark, M. J., & Slavin, J. L. (2013). The effect of fiber on satiety and food intake: A systematic review. Journal of the American College of Nutrition. https://doi.org/10.1080/07315724.2013.791194
Curtin, C., Hubbard, K., Anderson, S. E., Mick, E., Must, A., & Bandini, L. G. (2015). Food selectivity, mealtime behavior problems, spousal stress, and family food choices in children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(10), 3308–3315. https://doi.org/10.1007/s10803-015-2490-x.
de Onis, M., Onyango, A. W., Borghi, E., Siyam, A., Nishida, C., & Siekmann, J. (2007). Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization, 85(9), 660–667. https://doi.org/10.2471/blt.07.043497
Dickerson Mayes, S., & Zickgraf, H. (2019). Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development. Research in Autism Spectrum Disorders, 64, 76–83. https://doi.org/10.1016/j.rasd.2019.04.002
Diolordi, L., del Balzo, V., Bernabei, P., Vitiello, V., & Donini, L. M. (2014). Eating habits and dietary patterns in children with autism. Eating and Weight Disorders, 19(3), 295–301. https://doi.org/10.1007/s40519-014-0137-0
Emond, A., Emmett, P., Steer, C., & Golding, J. (2010). Feeding symptoms, dietary patterns, and growth in young children with autism spectrum disorders. Pediatrics, 126(2), e337–e342. https://doi.org/10.1542/peds.2009-2391
Esteban-Figuerola, P., Canals, J., Fernández-Cao, J. C., & Arija Val, V. (2019). Differences in food consumption and nutritional intake between children with autism spectrum disorders and typically developing children: A meta-analysis. Autism, 23(5), 1079–1095. https://doi.org/10.1177/1362361318794179
Esteban-Figuerola, P., Jardí, C., Canals, J., & Arija Val, V. (2020). Validación de un cuestionario corto de frecuencia de consumo alimentario en niños pequeños. Nutrición Hospitalaria, 37(1), 101–113. https://doi.org/10.20960/nh.02670
Evans, E. W., Must, A., Anderson, S. E., Curtin, C., Scampini, R., Maslin, M., & Bandini, L. (2012). Dietary patterns and body mass index in children with autism and typically developing children. Research in Autism Spectrum Disorders, 6(1), 399–405. https://doi.org/10.1016/j.rasd.2011.06.014
Gotham, K., Pickles, A., & Lord, C. (2009). Standardizing ADOS scores for a measure of severity in autism spectrum disorders. Journal of Autism and Developmental Disorders, 39(5), 693–705. https://doi.org/10.1007/s10803-008-0674-3
Graf-Myles, J., Farmer, C., Thurm, A., Royster, C., Kahn, P., Soskey, L., Rothschild, L., & Swedo, S. (2013). Dietary adequacy of children with autism compared with controls and the impact of restricted diet. Journal of Developmental and Behavioral Paediatrics, 34(7), 449–459. https://doi.org/10.1097/DBP.0b013e3182a00d17
Herndon, A. C., DiGuiseppi, C., Johnson, S. L., Leiferman, J., & Reynolds, A. (2009). Does nutritional intake differ between children with autism spectrum disorders and children with typical development? Journal of Autism and Developmental Disorders, 39(2), 212–222. https://doi.org/10.1007/s10803-008-0606-2
Hertz-Picciotto, I., Green, P. G., Delwiche, L., Hansen, R., Walker, C., & Pessah, I. N. (2010). Blood mercury concentrations in CHARGE Study children with and without autism. Environmental Health Perspectives, 118(1), 161–166. https://doi.org/10.1289/ehp.0900736
Hollingshead, A. B. (2011). Four factor index of social status. Yale Journal of Sociology, 8, 21–52.
Hubbard, K. L., Anderson, S. E., Curtin, C., Must, A., & Bandini, L. G. (2014). A comparison of food refusal related to characteristics of food in children with autism spectrum disorder and typically developing children. Journal of the Academy of Nutrition and Dietetics, 114(12), 1981–1987. https://doi.org/10.1016/j.jand.2014.04.017
Huxham, L. (2012). Feeding problems and current dietary practices in children with autism spectrum disorder in England [Doctoral Thesis, University of Stellenbosch]. Retrieved from http://scholar.sun.ac.za/handle/10019.1/20190.
Jardí, C., Aranda, N., Bedmar, C., & Arija, V. (2019a). Excess nutritional risk in infants and toddlers in a Spanish city. International Journal for Vitamin and Nutrition Research, 89(3–4), 210–220. https://doi.org/10.1024/0300-9831/a000530
Jardí, C., Aranda, N., Bedmar, C., Ribot, B., Elias, I., Aparicio, E., et al. (2019b). Consumption of free sugars and excess weight in infants. A longitudinal study. Anales de Pediatría, 90(3), 165–172. https://doi.org/10.1016/j.anpedi.2018.03.018
Johnson, C. R., Turner, K., Stewart, P. A., Schmidt, B., Shui, A., Macklin, E., et al. (2014). Relationships between feeding problems, behavioral characteristics and nutritional quality in children with ASD. Journal of Autism and Development Disorders, 44, 2175–2184. https://doi.org/10.1007/s10803-014-2095-9.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., et al. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988. https://doi.org/10.1097/00004583-199707000-00021
Leader, G., Tuohy, E., Chen, J. L., Mannion, A., & Gilroy, S. P. (2020). Feeding problems, gastrointestinal symptoms, challenging behavior and sensory issues in children and adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(4), 1401–1410. https://doi.org/10.1007/s10803-019-04357-7
Liu, X., Liu, J., Xiong, X., Yang, T., Hou, N., Liang, X., et al. (2016). Correlation between nutrition and symptoms: Nutritional survey of children with autism spectrum disorder in Chongqing, China. Nutrients, 8(5), 294. https://doi.org/10.3390/nu8050294
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule (ADOS) (2nd ed.). Beaverton: Western Psychological Corporation.
Ludwig, D. S., Hu, F. B., Tappy, L., & Brand-Miller, J. (2018). Dietary carbohydrates: Role of quality and quantity in chronic disease. British Medical Journal, 361, 2340. https://doi.org/10.1136/bmj.k2340
Maenner, M. J., Shaw, K. A., Baio, J., Washington, A., Patrick, M., DiRienzo, M., et al. (2020). Prevalence of autism spectrum disorder among children aged 8 years—Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016. Morbidity and Mortality Weekly Report. Survellance Summaries, 69(4), 1–12.
Makarem, N., Bandera, E. V., Nicholson, J. M., & Parekh, N. (2018). Consumption of sugars, sugary foods, and sugary beverages in relation to cancer risk: A systematic review of longitudinal studies. Annual Review of Nutrition, 38(1), 17–39. https://doi.org/10.1146/annurev-nutr-082117-051805
Malhi, P., Venkatesh, L., Bharti, B., & Singhi, P. (2017). Feeding problems and nutrient intake in children with and without autism: A comparative study. The Indian Journal of Pediatrics, 84(4), 283–288. https://doi.org/10.1007/s12098-016-2285-x
Mannion, A., Leader, G., & Healy, O. (2013). Comorbidity in autism spectrum disorder: A literature review. Research in Autism Spectrum Disorders, 7(12), 1595–1616. https://doi.org/10.1016/j.rasd.2013.09.006
Marí-Bauset, S., Llopis-González, A., Zazpe, I., Marí-Sanchis, A., & Suárez-Varela, M. (2017). Comparison of nutritional status between children with autism spectrum disorder and typically developing children in the Mediterranean Region (Valencia, Spain). Autism, 21(3), 310–322. https://doi.org/10.1177/1362361316636976
Marí-Bauset, S., Zazpe, I., Mari-Sanchis, A., Llopis-González, A., & Suárez-Varela, M. (2014). Evidence of the gluten-free and casein-free diet in autism spectrum disorders: A systematic review. Journal of Child Neurology, 29(12), 1718–1727. https://doi.org/10.1177/0883073814531330
Martínez Leo, E. E., & Segura Campos, M. R. (2020). Effect of ultra-processed diet on gut microbiota and thus its role in neurodegenerative diseases. Nutrition, 71, 110609. https://doi.org/10.1016/j.nut.2019.110609
Matheson, B. E., & Douglas, J. M. (2017). Overweight and obesity in children with Autism Spectrum Disorder (ASD): A critical review investigating the development, and maintenance of this relationship. Review Journal of Autism and Developmental Disorders, 4, 4142–4156. https://doi.org/10.1007/s40489-017-0103-7
McElhanon, B. O., McCracken, C., Karpen, S., & Sharp, W. G. (2014). Gastrointestinal symptoms in autism spectrum disorder: A meta-analysis. Pediatrics, 133(5), 872–883. https://doi.org/10.1542/peds.2013-3995
Morales-Hidalgo, P., Hernández-Martínez, C., Voltas, N., & Canals, J. (2017). EDUTEA: A DSM-5 teacher screening questionnaire for autism spectrum disorder and social pragmatic communication disorder. International Journal of Clinical and Health Psychology, 17(3), 269–281. https://doi.org/10.1016/j.ijchp.2017.05.002
Nadon, G., Feldman, D. E., Dunn, W., & Gisel, E. (2011a). Association of sensory processing and eating problems in children with autism spectrum disorders. Autism Research and Treatment. https://doi.org/10.1155/2011/541926
Nadon, G., Feldman, D. E., Dunn, W., & Gisel, E. (2011b). Mealtime problems in children with autism spectrum disorder and their typically developing siblings: A comparison study. Autism, 15(1), 98–113. https://doi.org/10.1177/1362361309348943
Neumeyer, A. M., Cano Sokoloff, N., McDonnell, E. I., Macklin, E. A., McDougle, C. J., Holmes, T. M., et al. (2018). Nutrition and bone density in boys with autism spectrum disorder. Journal of the Academy of Nutrition and Dietetics, 118(5), 865–877. https://doi.org/10.1016/j.jand.2017.11.006
Norte Navarro, A. I., & Ortiz Moncada, R. (2011). Calidad de la dieta española según el índice de alimentación saludable. [Spanish diet quality according to the healthy eating index]. Nutrición Hospitalaria, 26(2), 330–336. https://doi.org/10.1590/S0212-16112011000200014
Ranjan, S., & Nasser, J. A. (2015). Nutritional status of individuals with autism spectrum disorders: Do we know enough? Advances in nutrition (Bethesda, Md.), 6(4), 397–407. https://doi.org/10.3945/an.114.007914
Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism diagnostic interview revised (ADI-R). Beaverton: Western Psychological Services.
Salazar, F., Baird, G., Chandler, S., Tseng, E., O’sullivan, T., Howlin, P., et al. (2015). Co-occurring psychiatric disorders in preschool and elementary school-aged children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8), 2283–2294. https://doi.org/10.1007/s10803-015-2361-5
Santocchi, E., Guiducci, L., Fulceri, F., Billeci, L., Buzzigoli, E., Apicella, F., et al. (2016). Gut to brain interaction in Autism Spectrum Disorders: A randomized controlled trial on the role of probiotics on clinical, biochemical and neurophysiological parameters. BMC Psychiatry, 16, 183. https://doi.org/10.1186/s12888-016-0887-5
Schreck, K. A., & Williams, K. (2006). Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities, 27(4), 353–363. https://doi.org/10.1016/j.ridd.2005.03.005
Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34(4), 433–438. https://doi.org/10.1023/b:jadd.0000037419.78531.86
Scott, F. J., Baron-Cohen, S., Bolton, P., & Brayne, C. (2002). The CAST (Childhood Asperger Syndrome Test): Preliminary development of a UK screen for mainstream primary-school-age children. Autism, 6(1), 9–31. https://doi.org/10.1177/1362361302006001003
Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., et al. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: A meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43(9), 2159–2173. https://doi.org/10.1007/s10803-013-1771-5
Smith, B., Rogers, S. L., Blissett, J., & Ludlow, A. K. (2020). The relationship between sensory sensitivity, food fussiness and food preferences in children with neurodevelopmental disorders. Appetite, 150, 104643. https://doi.org/10.1016/j.appet.2020.104643
Sociedad Española de Nutrición Comunitaria. (2018). Guía de Alimentación Saludable para Atención Primaria y colectivos ciudadanos. La alimentación saludable en la etapa escolar. Planeta. Retrieved April 4, 2020 from https://www.nutricioncomunitaria.org/es/noticia/guia-alimentacion-saludable-ap.
Trinidad Rodríguez, I., Fernández Ballart, J., Cucó Pastor, G., Biarnés Jordà, E., & Arija Val, V. (2008). Validación de un cuestionario de frecuencia de consumo alimentario corto: reproducibilidad y validez. Nutrición Hospitalaria, 23(3), 242–252. Retrieved January 19, 2021 from http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0212-16112008000300011&lng=es&tlng=es.
Tsujiguchi, H., Miyagi, S., Nguyen, T., Hara, A., Ono, Y., Kambayashi, Y., et al. (2020). Relationship between autistic traits and nutrient intake among Japanese children and adolescents. Nutrients, 12(8), 2258. https://doi.org/10.3390/nu12082258
Venn, B., Thies, F., & O’Neil, C. (2012). Whole grains, legumes, and health. Journal of Nutrition and Metabolism, 2012, 903767. https://doi.org/10.1155/2012/903767
Vermeirsch, J., Verhaeghe, L., Casaer, A., Faes, F., Oostra, A., & Roeyers, H. (2020). Diagnosing autism spectrum disorder in toddlers born very preterm: Estimated prevalence and usefulness of screeners and the autism diagnostic observation schedule (ADOS). Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-020-04573-6
Vissoker, R. E., Berger, D., Latzer, Y., & Gal, E. (2018). Food selectivity, gastrointestinal symptoms and urine organic acids in autism spectrum disorder: A pilot study. Current Nutrition & Food Science, 14, 171–179. https://doi.org/10.2174/1573401313666170525133604.
Vissoker, R. E., Latzer, Y., Stolar, O., Rabenbach, A., & Gal, E. (2019). Eating problems and patterns among toddlers and young boys with and without autism spectrum disorders. Research in Autism Spectrum Disorders, 59, 1–9. https://doi.org/10.1016/j.rasd.2018.12.001
Wallace, G. L., Richard, E., Wolff, A., Nadeau, M., & Zucker, N. (2020). Increased emotional eating behaviors in children with autism: Sex differences and links with dietary variety. Autism. https://doi.org/10.1177/1362361320942087
Webber, A., Sinha, S., Robinson, C., & Gray, H. L. (2018). Associations among diet variety, mealtime behaviors, and diet quality in children with autism spectrum disorder. Journal of Nutrition Education and Behavior, 50(7), S27. https://doi.org/10.1016/j.jneb.2018.04.071
Wechsler, D. (2003). Wechsler intelligence scale for children—Fourth Edition (WISC-IV). San Antonio, TX: The Psychological Corporation.
Wechsler, D. (2012). Wechsler preschool and primary scale of intelligence—Fourth Edition (WPPSI-IV). San Antonio, TX: The Psychological Corporation.
Williams, K. E., Gibbons, B. G., & Schreck, K. A. (2005). Comparing selective eaters with and without developmental disabilities. Journal of Developmental and Physical Disabilities, 17(3), 299–309. https://doi.org/10.1007/s10882-005-4387-7
World Health Organization. (2007c). WHO Growth Standards: Head Circumference-for-Age, Arm Circumference-for-Age, Triceps Skinfold-for-Age and Subscapular Skinfold-for-Age: Methods and Development. Geneva: World Health Organization. Retrieved January 2, 2020 from https://www.who.int/childgrowth/standards/second_set/technical_report_2.pdf?ua=1.
World Health Organization. (2015). Guideline: sugars intake for adults and children. Geneva, World Health Organization. Retrieved June 10, 2020 from https://www.who.int/publications/i/item/9789241549028.
Zhu, J., Guo, M., Yang, T., Lai, X., Tang, T., Chen, J., et al. (2020). Nutritional status and symptoms in preschool children with autism spectrum disorder: A two-center comparative study in Chongqing and Hainan province, China. Frontiers in Pediatrics, 8, 469. https://doi.org/10.3389/fped.2020.00469
Zimmer, M. H., Hart, L. C., Manning-Courtney, P., Murray, D. S., Bing, N. M., & Summer, S. (2012). Food variety as a predictor of nutritional status among children with autism. Journal of Autism and Developmental Disorders, 42(4), 549–556. https://doi.org/10.1007/s10803-011-1268-z
Acknowledgments
The authors are grateful to the URV English Service for the review of the manuscript
Funding
This study was supported by Spain’s Ministry of Economy and Competitiveness and the European Regional Development Fund (ERDF) [Grant PSI2015-64837-P]; by the Catalan Government’s Department of Universities, Research and Information Society and the European Social Fund (FSE), [Grant 2019FI_B2_00148]; and by Spain’s Ministry of Science, Innovation and Universities and the European Regional Development Fund (ERDF) [Project RTI2018-097124-B-I00].
Author information
Authors and Affiliations
Contributions
Study concept and design: JC-S. Material preparation, data collection and analysis were performed by JC-S, PE-F and PM-H. The first draft of the manuscript was written by JC-S, PE-F and VA All authors reviewed the manuscript for important intellectual content and approved the final version to be published. JC-S is the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Corresponding author
Ethics declarations
Conflict of interest
We declare no conflict of interest to disclose.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Canals-Sans, J., Esteban-Figuerola, P., Morales-Hidalgo, P. et al. Do Children with Autism Spectrum Disorders Eat Differently and Less Adequately than Those with Subclinical ASD and Typical Development? EPINED Epidemiological Study. J Autism Dev Disord 52, 361–375 (2022). https://doi.org/10.1007/s10803-021-04928-7
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10803-021-04928-7