Shawn wasn’t your typical four-year-old. Extremely thin and unable to communicate verbally, his entire diet consisted of infant oatmeal cereal with pureed fruit mixed in. For three meals a day, that was it. No meats, no vegetables, no solid food whatsoever. The response of the doctor’s office? “He’ll grow out of it.”
Luckily Shawn’s family was able to find help. During his first visit to a feeding clinic, staffed by an occupational therapist, registered dietitian, and speech language pathologist, Shawn screamed and banged his head on the floor when chicken nuggets were simply brought into the same room. Beyond simple picky eating, this type of response can be common among children on the Autism Spectrum.
April is world autism month. It’s now believed that 1 in every 68 children meets the criteria for Autism Spectrum Disorder (ASD). Common behaviors include problems interpreting social interaction cues, repetitive patterns of behavior, and interests. Gastrointestinal difficulties are common, but the cause and preferred treatment for issues such as constipation, diarrhea and reflux disease hasn’t been fully determined. Problems with communication skills can make it difficult for caregivers to interpret food preferences when attempting to feed, prepare or serve food to their child. Basically, every meal is a battle.
Call it what you will- Food selectivity, sensory integration with food, or problem feeding behaviors, children with ASD are five times more likely to have feeding behavioral issues. In 2013, a new eating disorder diagnosis was added to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) described as Avoidant Restrictive Food Intake Disorder or ARFID to reflect this type of restrictive eating.
A child with these behaviors may refuse to accept certain textures — rejecting those that are more complex than a smooth, purée for instance or completely rejecting anything other than crunchy foods. Smooth vanilla yogurt may be accepted, but offer a pink yogurt with tiny pieces of strawberry and suddenly that yogurt causes a tantrum. Parents would love to offer more healthy foods, but this extreme reaction make it almost impossible.
Children with sensory disorders often will not touch non-preferred foods, especially those which are wet, slimy, sticky etc., and may adamantly refuse to have those types of foods on the same plate as their preferred food. In extreme cases, there may be only five items in a child’s entire food repertoire. New textures and tastes are often rejected, despite multiple attempts at positive reinforcement, encouragement and repeated introduction of the foods.
Preferred foods often lean towards snack foods, starches such as french fries, processed foods which consistently appear the same to the child’s sensitive perception, or easily chewed, processed meats such as chicken nuggets or hot dogs. Children, especially high functioning on the spectrum, may show significant brand specificity choosing only “nuggets from McDonalds” or certain types of crackers.
Despite the fact that there is help for problem feeding behaviors, it’s still common for primary care providers to offer the advice to worried parents such as “They’ll grow out of it,” or “They’ll eat when they get hungry.” Insurance reimbursement for help may be denied, using the same inaccurate justification. Unfortunately, variety is key when it comes to getting enough vitamins and minerals on a daily basis. Children with such limited palates may need key nutrients supplemented to ensure they receive sufficient building blocks for their immune system and growth since sufficient nutrients are lacking in their diets.
Here are a few recommendations you can make if you encounter a family challenged by problem feeding behaviors.
• Start by avoiding forcing or fighting at meals. Expanding a child’s diet relies on careful exposure to new foods in a non-threatening way. Pressuring, bribing, or forcing never fixes the problem.
• Work on establishing a meal time routine by eating at the same location, using the same plates and utensils. Begin by telling the child a week ahead of time that they will start sitting at the table.
• Increase pleasant interaction with non-preferred foods by placing a disliked food on the table, on their tray or even on their plate if they will tolerate it, but avoid prompting them to eat it.
• Seek out help from a registered dietitian nutritionist, qualified occupational therapist or speech language pathologist with experience in treating feeding disorders.
• Enroll in a feeding program which avoids pressure by using an approach similar to that developed by Kay Toomey, PhD known as The Sequential Oral Sensory Approach or SOS. This method uses preferred foods to develop a food chaining approach to expand a child’s repertoire of accepted foods. Based on play, it may help children gradually desensitize their aversions by progressing through steps including touching non-preferred foods, playing with non-preferred foods, and eventually moving non-preferred foods towards their oral cavity.
Feeding problems can be challenging for families and healthcare providers, but there is help!
To learn more about the link between nutrition and autism check out our informative webinar Autism: Nutrition Makes a Difference by autism expert Elizabeth Strickland Sauls MS, RD, LD. Sauls is the author of Eating for Autism and specializes in medical nutrition therapy for autism spectrum disorder and ADHD.