A recent study in the Journal of Family Medicine (Aug 2018) found that the incidence of feeding issues in children with autism was 82.4%. Other studies (JABA 2010) have placed the incidence closer to 90%. If you are reading this and you have a child with autism, you know exactly what I’m talking about. Restricted variety of food, refusal to try new foods, choosy about color, smell or packaging, ritualistic behaviors and separate meals for your child are all part of your daily life.
We typically have 3 – 6 eating opportunities per day, which includes both meals and snacks. If you are battling the above list of issues at every one of these 3 – 6 opportunities, it is no wonder that many parents give up and let their child eat the limited food variety. You cannot even go to a restaurant or family celebration without packing a special meal.
Many of the parents of the clients I treat tell me that the feeding issues aren’t even at the top of the list when it comes to autism issues. Communication, self-care, educational concerns, behavior, potty training, and community safety are all higher on the list. As long as their child is eating something, they can be content.
But what if you could impact this issue in a positive way without major turmoil?
First, let’s understand why these kiddos are experiencing extreme feeding issues.
What is the cause of all of these difficulties?
- Sensory sensitivity: Many kids on the autism spectrum also have sensory issues. They may be sensory seeking or sensory avoiding – and both will absolutely cause problem feeding. A seeker will over-stuff his or her mouth, crave only certain flavors and textures, like very spicy or extremely sweet or everything crunchy. This child may be on the move all the time, and dislike sitting at the table for a meal. If the mealtime experience does not meet a sensory seeker’s expectations, you can be sure that the meal will last only moments until he eats what he wants, then takes off for more adventure. Conversely, an avoider will be afraid of anything new, reject color, smell or packaging that looks different that what he or she is used to, and reject new or non-preferred texture. Even a busy environment could impact an avoider’s willingness to eat. Mealtimes may be met with resistance and tears, which could escalate into full on meltdowns.
- Rigid thinking: This is another hallmark of ASD. It will show up in feeding problems as a child needing to use the same plate/cup/utensils every time, unable to sit still without the iPad or a video to during a meal or snack, and insisting on a certain brand/flavor/packaging or that food be prepared exactly the same every time. These behaviors wear a parent down – and in my experience, are often placed in the “not worth the battle” category, meaning the parents give in to their child’s demands to avoid constant battles.
- Maladaptive responses: Children on the autism spectrum typically have difficulty with self-regulation, meaning some part of their system frequently feels “off” and maladaptive behaviors are formed. Maladaptive responses are different from the ritualistic/ rigid thinking described above. These may include having big meltdowns when seeing a new food or even brand of food, frequently leaving the table or refusing to come to the table for food, throwing food, eating non-food items such as play-doh, and gagging or vomiting when new or non-preferred food is presented. I have had clients who could trigger their gag or vomit reflex in a heartbeat, with the most miniscule piece of non-preferred food. It presents as a habit, and it is definitely a maladaptive response!
- Oral-motor weakness: if chewing and textured foods have been avoided for some time, a child with ASD may actually have weak oral-motor structures. Having a varied diet requires the lips, tongue and teeth to work together to prepare different foods for swallowing. This work begins before the age of one, and progresses through the toddler and preschool years until a child is able to handle all manner of textures. A soft diet consisting of chicken nuggets and French fries and a squeezable yogurt doesn’t allow for many biting and hard chewing opportunities. Think of biting and chewing apples and carrots, crackers, raisins, nuts and seeds as “exercise” for the mouth muscles. (If oral-motor weakness is an issue, I recommend a mesh fresh food feeder. I also frequently use these chewy tubes to be able to work on this skill safely).
- Oral-motor “know-how” or praxis: Praxis is the ability to motor plan for a specific activity, such as getting dressed in the correct sequence. An individual who puts clothes on out of order, or perhaps cannot even initiate this task, would be described as “apraxic”. Oral-motor apraxia may occur with problems chewing or being able to drink from an open cup. This can be a common cause of feeding issues in children with autism, though it’s not often recognized! I also see apraxia showing up in not knowing how to suck through a straw, blow (such as on a bubble wand) or spit (toothpaste or icky food). Apraxia of speech, quite common in ASD, may also affect oral-motor know how.
What can I do to help?
Many children with autism have no doubt had years of therapy, from the time of diagnosis. Occupational, speech, and physical therapy, feeding therapy with either an OT or SLP, possibly behavioral therapy. There are a lot of different methods out there and if you dare to search “feeding therapy for autism” you will be overwhelmed!
Up until now, I have written this blog as an informative piece to help families understand the causes to the problems they may be facing when their child on the autism spectrum has major feeding difficulties. So now that you know the why, I would like to offer my own 2 cents regarding the what to do portion of this equation.
It’s not always the most popular opinion, but it’s mine and I stand behind it!
I feel strongly that eating is not a behavior and should not be treated in a behavioral analysis type of way. In other words, rewarding positive feeding behaviors and punishing negative feeding behaviors is counterproductive. You may see some results with this method, but your child loses in the end. Behavioral terms like escape extinction and non-contingent positive reinforcement do not belong at what is supposed to be a social, relaxed, pleasant experience – family mealtime. You can save those ABA goals for other things. For feeding issues, there is a better way! Allow me to explain.
In my 10+ years of doing feeding therapy with kids on the autism spectrum, I have figured out what works and what does not. One of the main reasons I started my own practice and developed my Intensive Feeding Therapy program was because I knew I had a better way than 1x weekly, high-pressure, contrived, therapist-led feeding therapy! I have been seeing the results of my new program!
Here, I share with you my 10 biggest tips for improving eating with kids with autism.
10 low pressure, stress-free steps toward better eating
- Re-define your family roles. A book that I love and recommend to all, Ellyn Satter’s Child of Mine, Feeding with Love and Good Sense, defines the following roles for parent and child: The parent decides what to serve, where and when. The child decides whether they will eat, and how much. This simple shift gives the child control of their body, but not over the entire family. For our extremely picky eater, we will always offer something they will accept, but it is not the center of the meal.
- Figure out food preferences, and similarities to other foods. Just like adults, children do have true food preferences. We want to honor their individuality, but continue to offer varied items without forcing them. Start by making a list with 3 columns: Always eats, Sometimes eats, Never eats. Once you have honed in on preferences, you can look for similarities in texture, flavor, color, and begin to choose complementary foods in the Always eats category to “bridge” or “chain” toward something that is not so similar. This method is called food chaining and when done correctly, it works wonders!
- No pressure exposure. This is another key component of Satter’s book. No pressure means no excessive praise, no begging or bargaining, no “try it” bites, no punishment, and no nutritional admonitions. Food is offered as a matter-of-fact thing that we do to nourish our bodies and enjoy as a family. Repeated exposure without pressure takes the anxiety out of the equation.
- Develop solid routines. Provide eating opportunities every 2 – 3 hours, depending on size of previous meal and hunger level. “Close the kitchen” in between. Providing opportunities at predictable intervals does a few things to help this process: your child will understand that if she chose not to eat anything at the last meal, another opportunity for something will be forthcoming in a few hours; it will eliminate the battle for grazing and snacking all day; it decreases parent worry, as your child should be hungry enough at the next time to eat what is offered; it establishes increased trust between the child and his or her parents.
- Involve the whole family. I cannot even begin to tell you how many of my clients would eat alone before I started working with them. They would sit at a small table in a playroom, or the family meal table, with an iPad, with their separate meal, alone. I get that it is unavoidable at times, but if you have an established routine, try to stick to it. Even feeding all the siblings earlier, then having them stay at the table with mom and dad for a few minutes is better than all alone. Being the odd one out, food-wise, can be hard enough.
- Remove distractions. Once everyone is seated together, there will be no need for videos or games at the table. The no-electronics rule should apply to parents, as well!
- Get friends and extended family involved. Sharing meals in large groups can be fun. Up until now, I can already picture your child eating quietly in another room, or by himself before attending a gathering. He may have been worried that there would be nothing available for him to eat. Simply sitting at the table with others with no pressure to eat will provide sensory and social exposure.
- Have fun outside of mealtime. Look at the food in the grocery store, including the deli and bakery area. Watch cooking shows and competitions together. Engage in sensory play with food (pasta, rice, beans, pudding) and non-food (shaving cream, paints, sand). Create art, blow bubbles, read books, make up stories, engage in pretend play… the possibilities are endless!
- Model good habits. Be matter of fact about liking or disliking a food. We don’t want to gush over something really good, or “yuck” something you don’t like. Acknowledge and respect that each of us are different. You can point out that Mommy likes pickles and Daddy doesn’t – and that’s okay. Remember, too, to eat mindfully and not while scrolling Facebook or watching TV. The more frequently your child sees you modeling desired behavior and good habits, the more likely she is to do the same.
- Praise mindfully. When you provide praise, use specific phrasing, such as “I like how you tried the sweet potato tonight!” When your child begins to expand the variety of foods he is eating, do acknowledge and praise, but without major exuberance (we don’t want to have to throw a party every time a piece of broccoli is consumed!) You can also ask questions, like “What did you like about the carrots?” then “Yes! I think they are sweeter when they are cooked, as well!”
If any of what I’ve said resonates with you, you may be ready to try this super low pressure, yet proven, program!
Find out if your child is a good fit for this program by filling out my Intensive Feeding Program Questionnaire. You must be in California or Arizona at this time.