The impact of the Schmetterling NBI Program on selective eating behavior: evaluation of creative therapeutic interventions across three families of children with autism spectrum disorder

Children with autism spectrum disorder (ASD) frequently exhibit selective eating behaviors characterized by food refusal and limited dietary variety, which can lead to nutritional deficiencies and impaired family functioning. This study evaluated the effectiveness of the Schmetterling Nutritional Behavior Intervention (NBI) Program, a creative behavioral intervention integrating established behavioral strategies with innovative components, including imitation chaining, shaping, and therapist-guided exoskeleton modeling. Three children (YW, RA, and JK) diagnosed with autism spectrum disorder (ASD) participated in a single-case experimental design. The study employed the Childhood Autism Rating Scale, 2nd Edition (CARS-2) assessing autism symptom severity, while the Child Eating Behavior Questionnaire (CEBQ) measured changes in eating behavior. Substantial increases in food acceptance were observed across all participants, with the highest improvements in food responsiveness, enjoyment of food, and food fussiness. Tau-U analysis revealed large and significant intervention effects for both therapist-implemented and parent-implemented sessions. Although CARS-2 scores remained within the 'severe' classification range, notable percentage reductions suggested clinically relevant improvements in core autism symptoms. These findings support the Schmetterling NBI Program as an individualized, evidence-based approach to enhancing dietary diversity and reducing maladaptive feeding behaviors in children with ASD.