A version of this article first appeared in iancommunity.org.
Children with autism spectrum disorder (ASD) may have restrictive and ritualistic behaviors that affect their eating habits. Some of them limit what they eat, in some instances so severely that it results in nutritional deficiencies1 that lead to weight loss, malnutrition and inadequate growth, says Melissa Olive, a psychologist who treats children with ASD with feeding disorders at her practice in New Haven, Connecticut.
Research differs on how prevalent picky eating is in children with autism, but it does make clear that children with autism are much more likely than typically developing children to be selective about food.1,2
PICKY EATING OR FEEDING DISORDER?
Eric Levey, medical director of the Pediatric Feeding Disorders Continuum at the Kennedy Krieger Institute in Baltimore, says that feeding problems in children with ASD can range from mild to severe. He says that most feeding problems are mild at the onset but may become severe because parents have difficulty managing their child’s challenging behavior and end up enabling the child.
Some children with severe feeding problems are so selective with their food that it qualifies as a disorder.
Peter Girolami, clinical director of Pediatric Feeding Disorders at Kennedy Krieger, explains that typically developing children may also have preferences, refuse some foods now and then, and throw an occasional tantrum — but at other times, they try different foods. “Children with autism, however, take selective eating to another level,” he says. “For example, a child may want this particular brand of french fry. If the parents don’t give that to him, he may respond with a burst of tantrums.”
Olive says children with autism who have feeding problems fear new foods. “We often see that they develop inappropriate behaviors to avoid them—for example, they don’t want to use a certain utensil or sit at the table. And the parents naturally let the kids have their way because they just want to get them to eat,” she says.
Isaiah Stevens, a nonverbal child with autism, struggled with a severely restrictive diet until he was five. His mother, Audrey Stevens, says he preferred crunchy yellow foods like Goldfish crackers, waffles and toast. However, Isaiah was allergic to gluten (a protein found in wheat) and casein (a milk protein). Since the foods he preferred contained these allergens, Isaiah often had wheezing, asthma and constipation when he ate them.
“I eventually found an organic waffle recipe that was basically rice flour, honey and almond oil. I would make 30 of these a day, and Isaiah would eat this throughout the day,” Audrey Stevens says. “He would also eat crunchy, salty bacon and drink almond milk — but nothing else besides these foods.”
Olive says children with autism who are extremely picky eaters may limit themselves to five foods or fewer. “Typical children get fussy, but they never restrict themselves to so few foods,” she says.
Like Isaiah, some children with autism may be selective with the color of the food, eating only yellow or white foods such as rice, potatoes and pasta. Others may prefer a particular texture—some may like smooth foods while others may eat only crunchy foods3.
“A lot of children with autism tend to prefer foods that are high in carbs, high in calories and low in fiber. This interferes with their gut function and leads to constipation,” Levey says.
Girolami and Olive say that children with autism tend to go days without eating when they do not get the foods that they want.
Audrey Stevens reports that several health care professionals initially suggested she not feed Isaiah the foods he ate, and change his diet to include whole foods, with different drinks like coconut water and rice milk, for three days.
“They told me, ‘He will starve, but after three days, he’ll have no choice but to eat,’“ she says. “Well, that just landed him in the ER [emergency room], dehydrated and so pale. His mouth was sticky. Even then, when I offered him some coconut milk in the hospital, he would move his head and have a meltdown.” Audrey Stevens says after that plan to improve Isaiah’s feeding habits failed, she and Isaiah’s medical team felt that there was no option but to put him in an intensive feeding clinic.
INTERVENTIONS FOR PROBLEM BEHAVIORS IN AUTISM
Health care professionals say that interventions that eliminate problem behaviors and reteach feeding can help children with autism to eat a healthy, balanced diet.3 Girolami says that while some children with autism may be selective with their diets because of compulsive behaviors, others may face motor and sensory challenges that restrict their ability to eat a variety of foods. A child with motor deficits may have trouble chewing and swallowing, which is why he or she may develop a preference for smooth foods that do not require much of either.
“Imagine if you had difficulty with the physical ability to put food into your mouth and move it around,” Girolami explains. “Food is no longer fun to eat when you put it in your mouth and, all of a sudden, you’re gagging and you can’t swallow it. You would naturally gravitate toward foods that would be easy for you to eat.”
Some children may have a sensory intolerance to foods that make a loud noise, such as the sound of biting into a crunchy apple.3 These children may acquire a preference for soft foods.
GASTROINTESTINAL PROBLEMS IN ASD
Olive says that some children with ASD also learn to avoid certain foods because they exacerbate gastrointestinal (GI) problems such as reflux and abdominal pain. “These children associate eating with pain,” she explains.
Children with autism who are verbal and those who can otherwise communicate their abdominal discomfort may let their parents know about it. Research shows that some children, particularly those who are nonverbal like Isaiah, engage in repetitive behaviors suggestive of pain.
Other children may engage in problem behaviors such as self-injury, aggression or having a meltdown when their caregivers give them foods that are uncomfortable for them to eat. “I treated a little three-year-old boy who was Hispanic. He cried every time he ate, and he hit himself in the head many times every day. During meals, the father had to restrain him in a chair while the mom force-fed him,” Olive says. “I asked the family to complete a GI screening. The doctor found an ulcer in the child’s esophagus the size of a softball! He needed to be on an antiacid diet, but his family was feeding him garlic, peppers and tomatoes. So imagine the pain that little guy was in.”
Olive says that she now begins every intervention for challenging feeding behaviors in a child with autism with a screening for underlying GI problems and oral or motor issues that the child may have. Health care professionals need to rule out medical conditions, she adds, before they can be certain that the reasons for the child’s feeding problems are behavioral.
However, Levey says, most health care facilities do not perform a GI evaluation before starting treatment for feeding problems.
INTERVENTIONS FOR FEEDING PROBLEMS IN AUTISM
Levey says most children with mild feeding issues can benefit from outpatient treatment with an occupational or behavioral therapist or a speech and language pathologist.
Health care professionals treat feeding disorders caused by motor problems or sensory preferences by evaluating a child’s diet, Girolami says, and the evaluation also gives them clues about possible causes for the selective eating. Levey says that speech and occupational therapy can treat obvious motor deficits: speech pathologists may work with the child to strengthen jaw muscles and the muscles they use to move their tongues, bite, chew, swallow and perform other functions involved in eating food. Occupational therapists may teach the child to use utensils, good posture and other supports she or he may need to eat a meal. They may use aids such as chewy tubes to help with motor functions involved in getting food from the child’s plate into the mouth and swallowed.
CAUSE OF FEEDING PROBLEMS IN AUTISM MAY BE UNCLEAR
However, Girolami says, the cause of the feeding problems are sometimes unclear. “For example, if the child is eating only fries, they’re chewing and you can rule out motor issues. Then the resistance to other foods may just be a preference,” he explains. “But if you have a child who is only eating smooth food, we don’t know if he/she has an oral/motor issue or if it’s just a preference.”
In such a case, Girolami says, health care professionals present the child with different foods and observe the reaction. If a child who eats only smooth food seems averse to other textures, health care providers will probably judge the child to have motor deficits, such as jaw weakness that may prevent the child from chewing food. But if the child seems open to trying other types of food, eating smooth food may be a preference.
“If we don’t get a reaction to some of the foods, we can assume that the child is not averse to trying it,” Girolami explains. “We can say, ‘Hey, he didn’t seem too put off by the carrot or he picked up that pear and sniffed it,’ This can be helpful for us to get going with some kind of treatment.”
Treatments can help children overcome sensory problems by repeatedly exposing them to a food item they may be refusing until they eat it. The repeated exposures reduce their defensiveness to unfavorable sensory input such as sound, light or color.5 “We keep presenting the child with a certain type of food item they may have an aversion to, and as they get practice, their averse response diminishes over time. So it’s not always clear if we’ve cured a sensory issue or a behavioral problem,” Levey says.
Girolami says that often health care professionals introduce foods by gradually slipping in food types that the child does not usually eat.3 He explains that in the case of an 11-year-old boy with autism who always had a gray-colored smooth drink with every meal, professionals on one occasion added a pureed peach to the smooth drink, and then an orange and then a green food item. Over time, they gradually increased the amount of the food item that was different from the original gray drink.
“After a while, the child knew that the food was drastically different from what he was used to. But by then, he had already had stuff in the gray food that was orange and green that he didn’t mind anymore,” Girolami explains.
Olive uses a different technique that teaches children with autism to overcome their fear of new foods. “The first step is to have them touch the food to their lips,” she explains. “It teaches the kid to overcome the fear of the food in general. Pair that with reinforcement, praise or an incentive, such as time on the iPad or whatever, and over time, conditioning them to think that this food is associated with good things. When they get comfortable with new food, they start taking small bites. Then we increase the expectations, with the bites of food getting bigger and bigger.”
Olive used this technique with Isaiah Stevens. “He went from tolerating the look of his food to putting it in his mouth to chewing it and eating it,” Audrey Stevens says. “By day three, he was successfully eating different foods. His biggest incentive was getting to play with Thomas the Train on the tracks. He also wanted the iPad. For every minute worth of therapy, he would get a minute worth of play time.”
PARENTS CAN REINFORCE GOOD FEEDING HABITS
There are many ways parents can reinforce good feeding habits in their child with autism.5
They can have their child try at least one mouthful of a food item they do not like at every meal, perhaps making it more palatable by adding condiments that the child does like, such as ketchup or honey. They can also change the texture of the food by chopping it into small pieces or pureeing it, according to the child’s preference.5
Another technique involves an adult physically guiding a spoon to the child’s mouth by putting her or his hands over the child’s hands, and giving positive reinforcement when the child accepts the food. In other instances, the caregiver may remove the food item that the child refuses to eat but not allow the child to escape from eating other foods on the plate. Research has found that this technique allows parents to successfully expose their children to new foods.5
A method called differential reinforcement involves using positive reinforcement when the child behaves in a desirable way and withholding the reinforcement for undesirable behaviors. For example, if children refuse food to get attention, adults will attend to them when they eat but not do so if they are throwing tantrums.5
Most parents unwittingly use an intervention popularly called “Grandma’s Law.” They motivate their children to eat foods they do not like by offering a reward for eating them. For example, “If you eat your vegetables, you get to have dessert.”5 Girolami says that it is important for parents and caregivers to scale back the reward once they notice the child eating a wider variety of foods.
“We give reinforcement until the point when the child relearns that broccoli is a good thing — or ‘Oh, look! Beans are actually yummy!’” Olive explains. “At that point, the food itself becomes reinforcing, mealtimes are no longer stressful and everybody is happy at the table.”
Girolami says that children with autism often thrive after their feeding problems are treated. He adds, “Children with autism are the most rewarding to work with because once you introduce them to different varieties of food, they really get going and flourish by enjoying a lot more types of food.”
Isaiah is now a healthy 7-year-old who enjoys different types of foods. “Isaiah is so much happier. He’s gained some weight; his digestive system is working better,” Audrey Stevens says. “He has enough energy to run or participate in gymnastics. The color in his face is bright. He used to be thin and frail and now he’s a lean, strong boy.”