The phrase “picky eating” is often misused when describing the eating habits of children with autism spectrum disorder (ASD). This over generalized term more accurately describes a toddler who has a strong opinion about what they want for dinner; not a child with autism spectrum disorder (ASD) with significant food refusal.
As a parent of a child with ASD, quickly ascribing this title to your child can lead to overlooking the underlying treatable deficits that are in fact causing this food limitation and affecting your child’s health and nutrition.
The first step in a journey towards diet expansion is determining if your child has a feeding problem. “Picky eating” usually indicates children who eat over 30 foods and will eat foods from various food groups.
If these children cut out a food they are tired of, they will eat it again after a few weeks’ break. On the other hand, children on the autism spectrum often have a feeding problem in which their diet consists of less than 20 foods and can exclude entire food groups. If these children cut out a food, it stays eliminated. These problem eaters need to be identified as soon as possible to receive feeding intervention that can work towards improved eating habits and the prevention of further medical issues.
Understanding the root of your child’s limited diet is fundamental to finding him/her the help they need. If your child with ASD has the qualities of a problem eater, underlying deficits in one or more of the following areas is most likely the source.
There are some medical issues that can make eating a negative experience for a child. A child who pairs eating with discomfort or even pain will naturally not be motivated to eat. Possible issues to rule out include respiratory involvement, dysphagia or swallowing disorders, Reflux/GERD, chronic constipation, and other upper and lower GI issues.
Seeking out a pediatrician familiar with ASD and the potential medical deficits associated with feeding difficulty is important. Other professionals such as gastroenterologists, pulmonologists, ENTs, endocrinologists, and nutritionists are also important to have on your team to effectively assess potential medical etiologies.
Children diagnosed with ASD often display sensory processing deficits that can affect their ability to interact with different foods. To a child with an oversensitive sensory system, food may look, sound, smell, feel, or taste offensive. The interaction with certain “offensive” foods can cause a physiological, involuntary response resulting in the child gagging, spitting out, or altogether refusing to interact with it.
When we understand that our children have legitimate sensory processing difficulties working against them at mealtime, we can start moving forward in helping them become more comfortable with a larger variety of food. Occupational therapists (OTs) are trained in treating children with sensory processing difficulties and can evaluate the extent to which this is affecting your child with ASD’s feeding skills.
Eating is a complex process that involves oral motor coordination, or coordination of the lips, tongue, jaw, and facial muscles before the swallow. The process of learning how to eat starts as an infant in breast or bottle feeding and progresses through purees, soft solids, and table foods. When there is a break down in any part of this learning process due to a structural abnormality, an oral motor coordination deficit, or a strength deficit the whole process of eating can fall apart.
Often, food selectivity is an adaptive strategy that children learn in response to an inability to coordinate the necessary motor actions. Children with oral mechanical difficulty gravitate towards a food profile high in starch and soft textures that they are able to successfully handle, often excluding the tougher nutrient rich meats and vegetables that parents want them to eat. Speech language pathologists (SLPs) have extensive training in oral structure, oral motor skill development and swallowing disorders and can evaluate and treat a child’s deficits in this area.
One characteristic of many children with ASD is rigidity, or a resistance to change from a familiar rule or routine. This tendency often compounds the already difficult task of trying an unfamiliar food. Children with ASD may only tolerate a certain brand, type or shape of food, ensuring that they know exactly what their food is going be like every time.
In addition, children with medical, sensory or motor deficits can exhibit a learned avoidance response in which they avoid performing a behavior (eating) that results in an aversive outcome (gagging). Implementation of consistent behavioral strategies and intervention can both address this learned avoidance and assist children with ASD in increasing flexibility related to diet expansion and mealtime routines. Psychologists and Board Certified Behavioral Analysts (BCBAs) are two professions trained in using behavioral strategies to support improved feeding skills during direct treatment.
How parents interact with their child to encourage eating can set the tone for success, or failure. When children experience accusatory or negative language with frequent questions, demands or commands, their confidence and ability to work through eating challenges are affected.
Working to create and maintain a positive environment is important in helping a child with feeding deficits remain hungry and motivated to eat. When children feel safe, encouraged, and engaged in such an environment, mealtime can be transformed into a more successful experience. Psychologists can provide treatment that addresses the family mealtime environment and give strategies for children with anxiety related to food.
Available Treatment Approaches
Feeding deficits are multifaceted, and as a result, a team of professionals is preferable to a single provider. Many feeding programs employ a team of various professionals which can include but is not limited to physicians, dietitians or nutritionists, occupational therapists, speech-language pathologists, physical therapists, psychologists, and behavioral specialists.
Enlisting providers with the expertise to treat each component of your child’s feeding deficits is key. Of course, there may be a crossover between disciplines and specialties, but having a collaborative multi-member feeding team will provide the best chance for successful results.
There are a number of specialists who have spent their professional careers treating children with feeding deficits and starting their own organizations to spread their philosophy and treatment programs. Many feeding therapists gain their expertise by completing continuing education and attaining certifications from these authorities in the field.
Though they may vary in therapeutic delivery, each of the approaches provides holistic treatment, which is vital for successful intervention. Inquiring about the extent of a professional’s training and certifications can guide you in choosing the right feeding team members to treat your child.
The Acceptance, Exposure, Independence, Observation and Understanding (AEIOU) Systematic Approach was founded by Nina Ayd Johanson, M.S., CCC-SLP, CEIM, CHHP. Trained clinicians plan a treatment program for the child that includes both direct therapy services and strategies for families on how to have structured, supportive mealtimes in the home environment.
The CAN-EAT Approach was founded by Krisi Brackett MS SLP-CCC. The first part of the approach stands for “Comfort and Nutrition,” and the second part for “Establish Acceptance, then Therapy.” This approach upholds that medical management of any underlying discomfort or symptoms is vital for children in order to respond well to feeding therapy and improve their food intake.
Created by Cheri Fraker, CCC-SLP, CLC, Food Chaining is designed to determine the reasons a child will not eat and to provide strategies for medical management and sensory, motor, and behavioral difficulties. Therapists trained in Food Chaining ascertain the qualities of foods that a child finds acceptable and uses that information to link and introduce the child to new foods with those same features.
Melanie Potock, MA, CCC-SLP describes using the 3E’s in the treatment of children with feeding deficits: Expose, Explore, and Expand. Her recently published book Adventures in Veggieland is a great resource for children on the autism spectrum that provides numerous ways to have positive experiences with food through fun activities and kid-friendly recipes.
The Sequential Oral Sensory (SOS) Approach to Feeding was founded by Dr. Kay A. Toomey, PhD. Professionals trained in this approach use a hierarchy of steps to break down the sensory component of eating to small attainable parts, use food in their treatment methods to achieve improved oral motor skill, and enlist parents as active participants in feeding therapy.
TalkTools® was founded by Sara Rosenfeld-Johnson MS, CCC-SLP. Therapists trained in this treatment approach address a child’s oral motor skill deficits using TalkTools® brand therapy tools to teach the appropriate muscle movement patterns used in eating. TalkTools® also has information on Tethered Oral Tissues that can often affect feeding and swallowing skills.
Each child with ASD is unique, and as with anything, there is no one path for the remediation of feeding issues. If you feel your child is a problem eater, please contact your pediatrician and seek out the necessary feeding therapists and professionals to add to your child’s team.
This article was featured in Issue 89 – Solutions for Today and Tomorrow with ASD