Sensory feeding problems, pica-related behaviors, and sleep habits among children with autism spectrum disorder in palestine: a parent-reported cross-sectional study

Suheir Sabbah, Sana M. Namoura, Hamzeh Yacoub, Zaid Yacoub, Rita Yacoub

Background Autism Spectrum Disorder (ASD) is commonly associated with feeding difficulties and sleep disturbances, yet their co-occurrence remains understudied in Arab and Palestinian contexts. Pica and broader pica-related sensory feeding behaviors are among the most clinically significant feeding problems in children with ASD, carrying serious health risks. This study examined the level of parent-reported sensory feeding problems, pica-related behaviors, and sleep habit disturbances in children with ASD attending care centers in the West Bank, Palestine, and explored their association. Methods A cross-sectional descriptive-correlational survey was conducted. A convenience sample of 105 parents of children with ASD was recruited from care centers in the West Bank during August 2025. Two instruments were used: a 20-item literature-informed Sensory Feeding/Pica-Related Behaviors Scale developed for this study, and a 21-item Sleep Habits Scale adapted from the Arabic scale developed and validated by Al-Merdasi. The feeding scale underwent expert content review and pilot testing, while internal consistency was assessed for both instruments in the present sample. The feeding scale was designed to describe caregiver-reported sensory feeding difficulties and pica-related behaviors rather than to establish a DSM-5-TR or ICD-11 diagnosis of pica. All sleep items were coded so that higher scores indicated greater sleep disturbance; sleep adequacy items were reverse-scored. Data were analyzed using descriptive statistics, independent-samples t-tests, one-way ANOVA with LSD post-hoc tests, and Pearson correlation in SPSS. Effect sizes were reported as Cohen's d for t-tests and partial η ² for ANOVA. Results Sensory feeding problems and Pica-related behaviors scores were at a moderate level overall (M = 1.946, SD = 0.307; relative weight 64.9%). Sleep habit disturbances were also moderate (M = 3.123, SD = 0.551; 62.5%), with sleep anxiety ranking highest (M = 3.507). No significant differences in Sensory feeding and pica-related behavior scores were found by any demographic variable. For sleep habits, significant differences were found by child age (F = 10.038, p = 0.001, η ² = 0.164), with younger children appearing to score higher, though the oldest age group was small (n = 7) and the finding should be interpreted cautiously. Significant differences were also found by child sex (t = 2.195, p = 0.030, d = 0.43), with higher sleep disturbance scores among females. A significant positive moderate correlation was found between pica-related problem scores and sleep disturbance scores (r = 0.463, p < 0.001). Conclusions This parent-reported cross-sectional study found moderate levels of sensory feeding problems, pica-related behaviors, and sleep disturbances among children with ASD in the West Bank, Palestine, and a significant positive association between them. Because the study used convenience sampling and researcher-developed instruments with preliminary validation only, findings should be interpreted as preliminary and should not be taken as estimates of clinically diagnosed pica or sleep disturbances. They highlight the importance of integrating screening for pica-like behaviors and sleep problems within ASD services, and support the need for future longitudinal studies incorporating clinical diagnosis, gastrointestinal assessment, nutritional biomarkers, and validated measures.