Most parents of autistic children are concerned about what they perceive as their child’s “pickiness” about food and negative mealtime behaviors. They describe their child as having a poor appetite, prefer to drink rather than eat, refuse new foods, accept a very limited variety of foods, craves carbohydrates, and has a need for sameness and rituals around eating. For many families, meal-time is a battle ground where their autistic child refuses to eat, gags, throws food, or may have a major tantrum. Parents try everything from forced feeding, bribing, pleading, distracting their child during mealtime with T.V., and following him around the house offering bites of food throughout the day. Usually, none of these techniques work, and parents are left feeling frustrated, overwhelmed, and defeated.
Unfortunately, many healthcare practitioners don’t understand problem feeding and are unable to help parents resolve them, which only add to the frustration. Worse yet, parents are often misinformed and told not to worry because their child will “outgrow his picky eating stage” or “when your child gets hungry enough he will eat”. Both these statements are not true regarding children experiencing feeding problems and most autistic children do have feeding problems as opposed to simply being picky eaters.
PICKY EATERS VS. PROBLEM FEEDERS
In order to help a child overcome issues with food, you first need to determine whether he is a picky eater or a problem feeder.
Characteristics of a Picky Eater
Picky eating is a normal part of childhood development. Approximately 50% of children aged 18 to 23 months are identified as picky eaters.
Picky eaters tend to:
- Eat fewer than 30 foods.
- Eat at least one food from almost every type of food texture.
- Eat the same favorite food every day and will burn-out and discontinue eating the food. Then they will start eating their favorite food again after about a 2-week break.
- Tolerate new foods on their plate and willing to touch or taste the food.
- Eat a new food after they’ve been exposed to it 10 or more times.
Characteristics of Problem Feeders
Problem feeding is not a normal part of childhood development and is much more complicated than a picky eater. Problem feeders tend to eat a very poor diet, may have vitamin and mineral deficiencies, consume inadequate amounts of calories and protein, and may be severe enough to impact his ability to gain normal weight and height.
- Eat fewer than 20 foods.
- Eat fewer foods over time until they accept only 5 – 10 foods.
- Refuse to eat foods from entire categories of textures.
- Will eat the same food every day, but will burn out and stop eating the food; unlike picky eaters, they won’t eat the food again after a 2 week break.
- Won’t tolerate a new food on their plate and are unwilling to even touch or taste the food.
- Cry and or throw a tantrum when offered a new food.
- Have a need for sameness and rituals around mealtime.
- Are very inflexible about particular foods.
- Are unwilling to eat a new food after the typical 10 exposures.
If the child has a feeding problem, he will need long-term, extensive feeding therapy from a multidisciplinary feeding team to help resolve his feeding issues.
FEEDING THERAPY PROGRAMS
If you suspect a child is a problem feeder, it is crucial to build a multidisciplinary feeding team of the appropriate professionals to conduct evaluations, identify factors contributing to the feeding problem, develop a feeding intervention plan, and then start feeding therapy sessions. The feeding team will consist of a Physician, Speech-Language Pathologist, Occupational Therapist, Registered Dietitian, and Behavioral Specialist. A multidisciplinary approach is necessary to work with feeding problems because they require the expertise of various professionals and each team member has a unique role to play. The Physician will be responsible for the medical exam to identify and then treat any medical conditions that may be contributing to the feeding problem. Each of the other therapists; Speech-Language Pathologist, Occupational Therapist, Registered Dietitian, and Behavioral Specialist will each conduct their own evaluation to assess the child’s feeding. Based on the results of each of the evaluations, it may be determined that the child does have feeding problems that warrant ongoing individualized feeding therapy sessions. The feeding team will develop a Feeding Intervention Plan that includes some the following information:
- Factors contributing to the child’s feeding problem
- Strategies to address each of the contributing factors
- Specific feeding treatment approaches
- Frequency of feeding therapy sessions
- Outcome goals for treatment and how to measure progress
- Which therapist will provide the actual feeding therapy
- Mode of communication between feeding team members
There is little research about effective feeding therapy to treat feeding problems among young children with autism and even less information available regarding working with older children. However, there are step-by-step feeding therapy programs that have been quite successful with autistic children. Parents should discuss these treatment approaches with their feeding team. One step-by-step program is called “Food Chaining”. Food chaining is based on the idea that there are specific reasons why the child will eat only certain foods. The child finds these foods acceptable maybe because of the color, texture, flavor, or just visual appearance. Food chaining determines why the child accepts these foods, and then you expand his food repertoire by introducing new foods that have the same features as the foods he currently eats. After the child has expanded his diet from this method, more new foods are introduced that are slightly different. For more information on food chaining, refer to the book; “Food Chaining The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet” by Cheri Fraker, Laura Walbert, Sibyl Cox, and Mark Fishbein.
Another step-by-step program is called the “Sequential Oral Sensory (SOS) Approach to Feeding”. The SOS approach is a multidisciplinary feeding program which is based on 32 steps to eating a new food including tolerate, interact, smell, touch, taste, and eat. It was developed by Dr. Kay Toomey, Ph.D., Pediatric Psychologist located in Denver Colorado who provides advanced courses to train therapist in the SOS Approach.
BUILDING YOUR CHILD’S FEEDING TEAM
Many hospitals, medical facilities, and private clinics in large cities have feeding teams already in place. However, this may not be a viable option for a family because the feeding team is too far away from where they live. Due to the distance, it is not realistic for the parents to drive their child back and forth for weeks and possibly months of ongoing feeding therapy sessions. If the family lives in a smaller town, there may be no feeding team in place even at the local hospital. In reality, most families find that there is not a multidisciplinary feeding team available in their local community that is easily accessible. So, the parents will need to assemble a feeding team themselves. Parents can start by asking their child’s Physician for a referral to various therapists. Parents then start identifying individual providers who are willing to fill the multidisciplinary roles as the Speech-Language Pathologist, Occupational Therapist, Registered Dietitian, and Behavioral Specialist. These providers may be therapist currently providing services to the child or other therapists in their community experienced with feeding problems. At first, parents may think that building a multidisciplinary feeding team for their child is overwhelming, but it is absolutely critical to achieve the goal of resolving the child’s feeding problem and expanding his diet.
AT-HOME STRATEGIES TO IMPROVE YOUR CHILD’S FEEDING PROBLEM
Assembling a multidisciplinary team, obtaining evaluations from each team member, scheduling a medical exam with the physician, developing a feeding intervention plan, and initiating feeding therapy sessions will take an extensive length of time. During this process, I encourage parents to start with the very basic strategies to improve their child’s feeding. Some very basic feeding strategies that parents can do include:
- Positive reinforcement – Verbally reinforce the child when he does something appropriate at mealtime. Also reinforce siblings’ appropriate eating behavior. Keep mealtime positive, pleasant and enjoyable.
- Social modeling – Have the child sit at the dinner table with the rest of the family at mealtime. Parents and siblings should model good eating and social behavior and avoid making negative comments and faces at foods. The child should not be the focus of the mealtime.
- Limit juice – Decrease juice intake to less than one cup per day.
- Do not allow grazing throughout the day – Offer the child three meals plus three small snacks per day. Between meals and snacks the child may have water. Do not allow the child to nibble on small amounts of food throughout the day.
- Structured meals and snacks – Meals and snacks should be approximately 2 ½ – 3 hours apart from each other and offered at consistent times and same place in the home. Children need to learn that there is a daily consistent routine involved with meals and snacks. Meals should be limited to no more than 30 minutes and snacks to 15 minutes.
- Limit distractions during mealtime – Turn off the television during meals and limit excess noises to avoid auditory over stimulation.
- Offer manageable foods – Present foods on the child’s plate in small, easily chewable bites. Limit the number of different foods on his plate to three items. Limit the volume of food on his plate to smaller than normal serving sizes to avoid visual over stimulation.
- Involve child in menu planning, grocery shopping, food prep, set table – Children are more likely to eat a food if he has been involved in some sort of interaction with the food prior to mealtime.
- Use appropriate mealtime language – Do not ask the child a question or make a demand that can be responded with a “no” and lead to a power struggle between the parent and their child. Avoid “can you” questions and “don’t” demands. Instead, speak to child in concrete terms, “you can” and “do”.
Example: “Suzie, can you take a bite of peas for momma?” Replace with, “Suzie eats peas with her spoon.”
Example: “Suzie, please can you drink some milk for daddy?” Replace with, “Suzie sips milk from her cup.”
Example: “Don’t throw your cup!” Replace with, “Cups are for drinking, your cup goes here, until you are ready for a sip.”
Example: “Don’t put so many crackers in your mouth at a time, you’re going to choke!” Replace with, “Johnnie chews one cracker at a time.”
- Avoid food burnout – Eating the same food, the same way, every day will lead to “burn-out” and the child will eventually eliminate the food from his diet. Once an autistic child with a feeding problem eliminates a preferred food, he usually does not accept it again in the future. If this process continues, the child will eventually be left with only a very few foods in his diet. Tips to avoid “burn-out” include:
- Offer a particular food no more than every other day.
- If the child has a very limited variety of foods and the particular food has to be offered daily, change on thing about the color, shape, texture, or taste of the food. The change should be very slight so the child notices a difference but not enough to cause the child to reject the food; but different enough to where the child is less likely to “burn-out” on the food.
Example: Suzie eats a pancake every day, her diet is limited to 3 foods, mom can not eliminate pancakes so she must continue to offer pancakes daily and avoid “burn-out” at the same time.
Monday: Serve pancake as usual.
Tuesday: Change the shape; oblong not perfectly round.
Wednesday: Change the taste; add two eggs in the batter instead of one.
Thursday: Change the texture; add a very small amount of fiber powder to the batter.
Friday: Change the color; add small amount of fruit preserves to the batter.
Saturday: Change the shape of the butter on the pancake.
Sunday: Change the color of the syrup, darker or lighter.
These basic strategies will help to get started in improving the child’s eating behaviors and hopefully prevent them from getting worse while the feeding team is being assembled and more individualized feeding strategies and therapy is initiated.
Please do not take the “wait and see” approach and hope the child’s feeding problem improves on its own. If a feeding problem is not addressed early on, it tends to progress and get worse over time. Feeding problems are very complex and require a multidisciplinary approach from a physician, speech-language pathologist, occupational therapist, behavioral specialist, and registered dietitian. It is important to remember that parents are not feeding therapist and should not be put in the position to assume this role. Children with feeding problems must be referred to a multidisciplinary feeding team for assessment and appropriate individualized feeding therapy sessions. Yes, addressing an autistic child’s feeding problem is challenging, time consuming, and usually takes weeks to months to achieve success. However, when the child’s diet expands and he is eating a variety of healthy foods, it will be well worth all your time, effort, and hard work.