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When Dinnertime is a Struggle: Very Picky Eating in Children with Autism
Marina Sarris
Date Published: June 10, 2024
It’s dinnertime, and you don’t have time to get the only thing your son will eat: chicken nuggets from a particular fast-food restaurant. You feel tense as you await the tantrum to come. What if he won’t eat at all tonight?
Picky eating is fairly common among young children, but it can be more intense for those on the autism spectrum. Children with autism are five times more likely to have picky eating and a fear of new foods than typically developing youngsters.1
Some autistic children are so picky that they may refuse to eat entire food groups, such as vegetables, fruit, or meat. Some would rather go hungry than eat a different brand of their favorite food. Although picky eating often lessens with age,2 some older children, teens, and adults on the spectrum still struggle with it.
No one knows exactly why picky eating occurs more often and lasts longer in autistic children. Autism traits may play a role. Many are very sensitive to texture, taste, and smell, all of which are triggered in eating. Some also dislike change and unpredictability. “Food is something that’s really pretty unpredictable,” explains autism researcher Emily S. Kuschner, Ph.D., in a Q&A article.
Sixteen percent of the more than 113,000 children in the SPARK autism study have a feeding disorder, according to their parents.3 A different study of autistic participants in SPARK found that one in five were at high risk for having a form of picky eating called avoidant/restrictive food intake disorder.4 Genetics may be a cause, according to those researchers.
Certainly, dinnertime can become stressful if the child’s favorite food – often chicken nuggets, fries, or macaroni – is not served. But parents often have other worries: Are their children getting the nutrition they need? Is a limited diet causing their children’s constipation or stomach aches, which are more common in autistic people. Or are gastrointestinal issues triggering their eating problems?
The First Step in Addressing Picky Eating in Autism
Many parents bring their concerns to their child’s pediatrician. Doctors can check for nutritional and medical problems that could affect eating and appetite. They can also refer the child to a feeding disorder program or therapist.
Common therapies used for autistic children include sensory and oral motor therapies, led by occupational and speech-language therapists. These therapies are often used for youngsters who are having trouble transitioning to solid foods. Behavior therapies are also common, particularly for older children and teens.
But sometimes, parents say, their concerns are brushed off at the doctor’s office. Picky eating is common, and some doctors may not be worried if the child is growing properly, says Dena E. Kelly, a board certified behavior analyst and counselor who provides feeding therapy through her company, Focused Approach.
“When the doctor gets their height and weight, and they see that the child is growing and growing well, oftentimes they will brush it aside and say to the parent, ‘Don’t worry about it. It’s a phase. They will grow out of it,'” Kelly says.
Even if children are not malnourished, Kelly says, their picky eating can hold them back socially and affect family life. Parties, summer camps, school lunches, vacations, and restaurants may be out of the question if their preferred foods will not be there. “For most of us, eating is such a social activity,” she says.
Also, children who are not eating properly may feel hungry more often, which can affect their mood and behavior, she says.
When working with children, Kelly says, she looks at “eating the same way that we as parents look at other types of nonnegotiable behavior in the child’s day.” Although children can make choices and have preferences, she says, they need to eat an appropriate amount and variety of food, just like they need to hold hands with an adult while crossing the street.
Kelly works with families weekly for months to gradually introduce the child to new foods. She starts with foods that are similar to what they already eat. For example, a child who likes macaroni and cheese may be given a bite of a buttery noodle one week, along with his regular food. The next week, the child may be offered a bite of macaroni with tomato sauce. A cheese quesadilla may be offered another week because it’s similar in taste and texture to mac and cheese.
If the child completes the food goal of the day, they may earn something that they want, such as screen time, a trip to the park, or a toy.
Kelly provides individualized feeding plans for babies up to teenagers. Teens may be motivated to expand their diet so they can have pizza with friends. A 12-year-old boy once told her that his pickiness came from fear. “He said, ‘I was so scared to try new food, and I don’t know why, but after trying it I realized it wasn’t so bad,'” Kelly recalls.
What Can Families Do to Help Their Picky Eater?
What can you do to discourage picky eating from developing or address it once it starts?
Eating in the car or at different times at home, while common for many busy families, does not help a picky eater, Kelly says. She recommends setting up routines around eating and mealtime. For example:
- Establish set times for breakfast, lunch, dinner, and snacks. Do not allow children to snack so often that they are not hungry at mealtime.
- Offer them different brands and flavors of their favorite foods so that they become comfortable with some variety.
- Don’t use food during playtime, such as using pudding to draw or pretending a broccoli is a tree. Although parents may be encouraged to use food for sensory play activities, Kelly prefers that food only be presented for meals and snacks.
- Introduce a new food one day a week and encourage the child to take a bite. Do not serve new foods the other days of that week.
When Picky Eating Is More Severe
Sometimes picky eating, also called selective eating, falls outside what families can address by themselves.
A severe form, called avoidant/restrictive food intake disorder, or ARFID, appears to be more common among autistic people and their families, according to a study of almost 10,000 participants in SPARK.4
ARFID involves very picky eating, fear of new foods, and avoiding foods for sensory reasons. Unlike certain eating disorders, people with ARFID do not have a distorted body image. However, children with it may fail to gain weight and adults may lose weight. They also may have significant nutritional deficiencies, according to the American psychiatric diagnostic manual.
A study of 5,100 autistic people in SPARK, and 5,000 of their parents, found that 21 percent of the children, and up to 17 percent of the parents, are at high risk for having ARFID. However, only 1 percent had a medical diagnosis of ARFID.4
The diagnostic manual notes that autistic people often have rigid eating patterns and sensory sensitivities. ARFID should only be diagnosed when the autistic person has the symptoms and the eating problem requires specific treatment, the manual says.
The research findings from SPARK participants suggests that ARFID may be underdiagnosed. “A lot of people, and probably a lot of clinicians, don’t have ARFID on their radar as something that needs attention. But over the long term, the poor nutrition it causes will have a cumulative effect on a person’s health, and that might not be fully apparent until adulthood,” one of the researchers, Jacob J. Michaelson, Ph.D., associate psychiatry professor at University of Iowa, has said.
To learn more about feeding problems and tips for better mealtime behaviors, watch a SPARK webinar by Dena Kelly.
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