Feeding problems in children with ASD may include selective eating or “picky eaters,” rapid eating (child takes numerous bites within a short period of time), inappropriate mealtime behaviors (e.g., tantrums), and inadequate intake/food consumption. These behaviors can lead to numerous health (e.g., aspiration, choking), developmental, and social concerns for children. Feeding problems occur more frequently in children with ASD than in typically developing children (Burklow, Phelps, Schultz, McConnell, & Rudolph, 1998). Studies have shown that 72% of children with ASD eat a “narrow” variety of foods, 31% display sensitivity to various food textures, and 53% of children with ASD have some type of nutrient deficiency related to feeding patterns (Schreck, Williams, & Smith, 2004; Field, Garland, & Williams, 2003; Cornish, 1998). Additionally, feeding issues can be extremely stressful for both the child and the family. Therefore, the successful treatment of feeding problems can have significant impacts such as improved health, improved quality of life for both children and families, decreased mental health problems in families, and reduced risk of long-term eating problems (Piazza & Carroll-Hernandez, 2004).
Michelle Myers, BA, BCaBA and Brandon Nichols, MSEd, BCBA, LBA at the Tom Golisano Center for Autism at Springbrook
Feeding behaviors in children with ASD may occur for numerous reasons and are specific to each individual. These include medical, sensory, and behavioral causes. If a child is having medical problems such as constipation, stomach aches, or toothaches then this may result in a child refusing to eat. Similarly, many children with ASD have difficulties with sensory processing and this can make eating certain foods a challenge (Baxter, Bellando, Pulliam, Watson, Powell, Srivorakiat, & Bing, 2014). This can include but is not limited to certain textures and colors (e.g. child only eats beige food or refuses to eat any green foods; a child may not eat crunchy or soft foods). Numerous researchers have reported that the inadvertent reinforcement of inappropriate mealtime behaviors frequently contributes to the onset and maintenance of feeding problems (Piazza et al., 2003). For example, if a caregiver removes non-preferred food items when a child refuses to eat or consume the correct amount of food, the child may be more likely to display inappropriate behaviors during meals to avoid eating less preferred food (Bachmeyer, 2009). Similarly, if a caregiver provides access to preferred food items when a child refuses to eat less desirable food items, the child may be more likely to refuse in the future in order to gain access to the preferred foods.
Knowing the signs and symptoms of feeding issues for children with ASD can be challenging. Many caregivers are unfamiliar with common symptoms and struggle with knowing when to get help. Some of the most common signs and symptoms of feeding problems include:
- If there are weight changes (loss or gain)
- If a child only eats a limited number of food items or only certain textured food (e.g., only soft foods)
- If mealtime behaviors are causing stress
- If a child complains or shows signs of pain (e.g., constipation, tooth pain, food allergy/rash)
Even when a caregiver observes these signs or symptoms, identifying what to do next can be difficult. Many parents and caregivers are left with the question of “What do I do now?” It is recommended that caregivers begin seeking assistance with primary care providers (Baxter et al., 2014). Primary care providers generally have the skills to help evaluate and decide the first course of treatment. The primary care provider is able to manage the problems in many situations. However, if additional assistance or expertise is needed then the primary care provider is able to make referrals to the correct specialists. These specialists may include allergists, gastroenterologists, psychologists, speech language pathologists, occupational therapists, registered dieticians, and/or behavior analysts. If extra assistance is needed then the caregivers, primary care provider, and additional specialists are able to work together to address the problem.
Not all feeding issues require expert assistance and there are situations where caregivers are able to intervene using simple strategies to correct the problem such as:
Create a schedule and routine: This may include having your child eat at the same time and place. By creating a schedule the child will learn what is expected during meals.
Avoid eating all day: Having food and drink available all day decreases your child’s appetite and may limit how much they want to eat during mealtimes. If you’re full, you’re not going to want to eat anymore!
Limit the amount of distractions during mealtimes: Distractions take the focus off the food and may lead to the child being more focused on the activities rather than eating. Common distractions include television, video games, toys, books, phones, computers, and an excessive number of people.
Model healthy eating behaviors: Children learn many new things by watching and imitating the behaviors of others. So make sure that you model the feeding behaviors you want to see.
Reward behaviors that you want to continue seeing: If the child exhibits a behavior you want to see such as trying new foods or eating all of his/her dinner, reward them for doing this. Rewards may include social attention such as praise or high five’s, getting access to preferred food items, or favorite toys/activities.
Ignore challenging behavior: When possible, do not provide extra attention to a child who is doing things that you do not want them to display. Common challenging feeding behaviors may include spitting, throwing food, or screaming. Limiting the amount of attention may reduce the enjoyment or any “fun” the child may be having by displaying these behaviors. At times, it may not be possible to ignore the behavior due to safety concerns and you may need to consult with an expert for additional advice concerning how to best manage your child’s challenging meal-time behaviors.
Follow the rule of 3: When presenting food to your child it is important to present a combination of preferred and non-preferred food items. The rule of thumb is to offer 3 foods at a time and at least 1-2 of these foods should be items your child already likes. The other food should be an item your child does not like. This will expose your child to non-preferred food items and get used to having those food items near him. Initially, encourage your child to try a small bit and gradually try to get them to eat a little more. Eventually, the goal is for the child to eat a good size portion of the new food.
Presentation of food items: Altering the way you present new foods may increase your child’s willingness to try them. Present new foods in small bites or in fun, familiar ways that make it more likely your child will eat them.
It is important to note that each child is different and these strategies may not be effective for every child. Caregivers should have ongoing dialogue and support from the child’s primary care provider while implementing these basic strategies (Baxter et al., 2014). By using these “caregiver friendly” strategies, caregivers may be able to prevent the need for more specialized interventions (Bachmeyer, 2009).
While there are some simple strategies that families can implement without consultation from a specialist, there are also interventions that have been effective in reducing feeding problems but require a specialist. If your child continues to struggle with mealtimes using some of the simple strategies above, you will want to share these struggles with the primary care provider and perhaps contact a Board-Certified Behavior Analyst (BCBA) with experience treating feeding challenges. It is important to highlight that these more complicated interventions should not be done without support and guidance from the appropriate specialist(s).
In summary, it is important to emphasize how challenging and stressful feeding problems can be for parents/caregivers of children with ASD. Feeding problems are often complicated with each child’s problems being unique. In many cases, even with professional guidance, the strategies listed above may result in slow progress marked by small, subtle gains (Baxter et al., 2014) or may be entirely ineffective. Feelings of frustration, sadness, or hopelessness may be overwhelming to caregivers. Thus, it is recommended that caregivers reach out for support and individualized coping techniques from family, friends, professionals, or support groups. By ensuring their own mental health, they may be better able to successfully implement feeding interventions like those above, in collaboration with a physician. Finally, it is recommended that caregivers keep the treatment team informed of the child’s progress and remember to celebrate even the smallest improvements.
Brandon Nichols, MSEd, BCBA, LBA, is Clinical Coordinator and Michelle Myers, BA, BCaBA, is Assistant Clinical Coordinator at The Tom Golisano Center for Autism at Springbrook. For more information please contact Brandon at nicholsb@springbrookny.org or visit the Springbrook website at www.springbrookny.org.
References
Backmeyer, M.H. (2009). Treatment of selective and inadequate food intake in children: a review and practical guide. Behavior Analysis in Practice, 2(1), 43 – 50.
Baxter, B., Bellando, J., Pulliam, Watson, J., Powell, P., Srivorakiat, L., & Bing, N. (2014). Exploring Feeding Behavior in Autism: A Parent’s Guide. Autism Speaks.
Burklow, K.A., Phelps, A.N., Schultz, J.R., McConnell, K., & Rudolph, C. (1998). Classifying complex feeding disorders. Journal of Pediatric Gastroenterology and Nutrition, 27, 143 – 147.
Cornish, E. (1998). A balanced approach towards healthy eating in autism. Journal of Human Nutrition and Dietetics, 11, 501 – 509.
Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Pediatrics and Child Health, 39, 299 – 304.
Piazza, C.C., & Carroll-Hernandez, T.A. Assessment and treatment of pediatric feeding disorders. In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal Quebec: Centre of Excellence for Early Childhood Development; 2004: 1-7. Available at: http://www.enfant-encyclopedie.com/Pages/PDF/Piazza-Carroll-HernandezANGxp.pdf. Accessed February 27, 2015.
Piazza, C.C., Fisher, W.W., Brown, K.A., Shore, B.A., Patel, M.R., Katz, R.M. et al. (2003). Functional Analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 36, 309 – 324.
Schreck, K.A., Williams, K., & Smith, A.F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34, 433 – 438.
