Date Published: January 23, 2020
Emily S. Kuschner, Ph.D., studies picky eating — also called food selectivity — in children, teenagers, and adults who have autism spectrum disorder (ASD). She developed the BUFFET Program, which stands for Building Up Food Flexibility and Exposure Treatment, to help increase the number of foods that youth with autism will eat. She is a clinical psychologist and scientist at Children’s Hospital of Philadelphia in the Center for Autism Research and the Lurie Family Foundation’s Magnetoencephalography Center. She is also assistant professor of psychology in psychiatry at the University of Pennsylvania Perelman School of Medicine. Some of the answers below were edited for space.
Q: A certain amount of picky eating is common in very young children. How do you define selective or picky eating in people who have autism?
A: It occurs when the level of food selectivity is not consistent with someone’s developmental level and age. When you think about 2- to 5-year-olds in general, they are quite picky. So that alone doesn’t make picky eating concerning to health care providers. For kids on the spectrum, their selective eating may be more intense, more pervasive, and more unusual. It also seems to be longer lasting. In typical development, picky eating tends to end as children get older. That is the case for some children on the spectrum, but for a subgroup, it lasts into later childhood, adolescence, and even adulthood. That is not usually the case in neurotypical development.
Q: Does very picky eating often lead to poor nutrition?
A: It can, but it doesn’t always. We sometimes see nutritional deficiencies when kids aren’t getting enough of the nutrients they need from food. At times, we don’t see those deficiencies until we look at a more in-depth nutritional profile. Of increasing concern is the impact on weight gain and obesity. If you are a selective eater who prefers high-fat or high-sugar foods, but you have a normal appetite, you’re going to be more likely to gain weight even if you’re not overeating. If your appetite is increased and you overeat those high-fat, high-sugar foods, then you have an even further increased risk of obesity.
Q: Research estimates that from 46 to 89 percent of children who have ASD have problem-eating behavior. What does that mean?
A: Problem-eating behavior can span both food selectivity and other types of feeding issues, such as swallowing problems, oral-motor challenges, and, in early childhood, having difficulties going from milk to solid foods.
Q: How common, or prevalent, is food selectivity in teenagers and adults on the spectrum?
A: We don’t have very accurate estimates of picky eating prevalence in teenagers and adults on the spectrum. In our research, we looked at a questionnaire about sensory experiences in autistic adolescents [age 12 and older] and in young adults. One of the questions they were asked was whether they were afraid of eating a new or unfamiliar food, which we might describe as a food selectivity known as food neophobia, or a phobia of eating new foods. About 55% of the adolescents and adults said that they were afraid of eating a new food, compared with about 30% of those who do not have autism.
Q: What do you think causes selective eating in autism?
A: I think there are a lot of aspects of being on the autism spectrum that make someone more likely to become a selective eater, such as having a preference for things being consistent and predictable, and disliking novelty or the unexpected. Food is something that’s really pretty unpredictable. We eat multiple meals a day, and usually people eat different things at every meal. So if you like to eat the same thing every day, three times a day, that’s going to be hard for your family and your daily life. Foods are also really variable. Say you taste one example of cheese, an orange cube of cheddar cheese, and decide that you like cheese. If someone else offers you cheese but it is a slice of Swiss cheese, which is flat and has holes in it, that’s a very different — and unexpected — experience of cheese.
There are also crucial sensory and motor experiences that impact eating. Eating is a total sensory experience, with different textures, flavors, temperatures, and smells. And sometimes foods change consistency as you eat them, leading to all new sensory experiences — for example, a cherry tomato exploding in your mouth once you take a bite. Chewing food certainly demands oral motor skills, but there are also fine motor, or finger and hand, skills that are needed for managing silverware. We have observed that many youth in the pre-adolescent range may make food choices based on not wanting to use silverware.
Of course eating is generally a pretty social activity, done with your family or in a group. So if you’re already struggling with social encounters, it makes it even harder to manage food when also facing social demands.
Finally, we know there are medical conditions that also co-occur in autism that can impact eating, such as food allergies or sensitivities, and gastrointestinal [GI] issues. It goes in both directions. You could have GI issues and so you make food choices accordingly. Or it could be that you have an increased risk for GI issues because of food selectivity. For example, if you’re not eating any fruits and vegetables, you will have decreased fiber intake that makes constipation more likely.
Q: Can you describe the BUFFET Program for children ages 8 and older, which uses group and individual therapy to help children who have autism eat more foods?
A: A lot of the available treatments for eating issues in autism are found in feeding programs, which usually focus on behavioral strategies that help kids with medical issues to eat more foods. These feeding programs manage the child’s appetite so they’re hungry before treatment sessions, and then pair eating with a reward during a structured mealtime. Treatment often starts with a therapist working alone with the child to build new eating skills, and then later integrates the parent back into the mealtime as the child is getting closer to discharge from the program.
With BUFFET, I started thinking about a developmentally appropriate program for pre-adolescents and teenagers who have eating issues that are not at the level of needing an inpatient or day treatment program. This group may be able to communicate about their eating preferences, unlike a 2- or 3-year-old with a language delay.
BUFFET was designed for older youth and teens on the spectrum, particularly those who have cognitive and verbal abilities in the age-appropriate range, because that’s the group that is not being particularly well served by some feeding programs. The program focuses on cognitions, or thoughts, children are having about new or non-preferred foods. It tries to help them shift those thoughts to increase the likelihood of being willing to try and eat the food. Part of the BUFFET program is examining the thoughts you have about a new food, and how that thought might be faulty. Someone may say, ‘That soup looks gross,’ or ‘that food looks like slop.’ But what the food looks like doesn’t impact the way it tastes. So you can change or reframe the way you think about the food to make it more tolerable.
BUFFET is a cognitive behavioral treatment that also tries to capitalize on the social aspects of eating. Some research suggests that if you’re around someone else eating a new food, you’re going to be more likely to eat that new food. If you see someone eat something new and they don’t throw up or make a face of disgust, that might be an exposure that helps you feel comfortable to try it yourself.
We also have parents integrated from the start, so that they see the strategies kids are learning and are able to think about how to shift interactions with their child around eating. Most of these families have been dealing with picky eating since their children were very young, and they have a set pattern of dealing with mealtime. So we’re coming into their system and changing it a bit. Parents learn to think about the balance of supporting their child and keeping them from having a stressful experience with food, while also exposing them to new foods, so they get practice with it.
Q: One aspect of the BUFFET program involves working with parents on their role in the “anxiety cycle” surrounding food. How can parents help their child overcome anxiety around food without inadvertently reinforcing it?
A. One comparison I use is to have people think about something like a fear of snakes. If you know your child is afraid of snakes, you might try to protect and shelter them from experiences involving snakes. Maybe you skip the reptile house at the zoo or fast-forward through something on TV involving a snake. So you’re kindly saving your child from being too stressed from being exposed to a snake. But then you’re also not giving your child practice with how to handle their anxiety when they face a snake. With cognitive behavior therapy, the idea is to gradually increase the amount, or intensity, of exposure to something that makes your child feel nervous or stressed. You want to be sure your child has coping skills for handling that stress or anxiety, but in general, the more exposure your child has to the fear, the better he or she will be at tolerating it.
Looking at food, when parents give a baby a food for the first time and they spit it out and throw it on the ground, it’s natural for parents to decide that the baby doesn’t like that food and then never present it again. A child on the spectrum might have an even bigger reaction or a larger meltdown to that disliked food. But the goal is to keep presenting food in a safe way to keep exposing the child to the new or non-preferred food. Food preferences are allowed, and a child may never like mushrooms or broccoli or soup, but they can get enough practice with the food so that they can tolerate the food being on their plate without having a meltdown, or they can tolerate someone else at the table eating the food in their presence. Or, they can maybe even reach the point of eating the food even if it is not their favorite.
Q: What advice do you have for teenagers and adults on the spectrum who would like to broaden the types of foods they eat?
A: If the teenager or adult is motivated, it makes it a lot easier. We try to find the person’s motivation for broadening their diet. Some of the 10- to 12-year-olds we work with have described wanting certain social experiences to go more smoothly. Maybe they’re going to a party or an activity at school, for example, and they are really rigid about what type of pizza they will eat. They might be motivated to work on being comfortable eating pizza from a variety of restaurants so that those situations would be less stressful for them.
Q: Can people find providers in their communities who offer the BUFFET therapy program?
A: Not yet. I very firmly believe that it’s important that we have treatment manuals available for providers to use. That’s what started me on this program. I was a psychologist in a clinic wanting to treat kids on the spectrum who were older and picky eaters, and I didn’t have a treatment manual to use. A treatment manual has been developed for BUFFET, but we’ve only run one small pilot study. It’s important to have a stronger evidence base before we make the manual available. We want to know that BUFFET works relative to a comparison group — we want to know that it’s better than doing nothing for 14 weeks before we release it for other people to use. Hopefully we will be able to do that soon.
Although BUFFET is not widely available yet, we would encourage therapists and families to read the paper we published about the treatment to learn more.
- Watch a SPARK webinar by Emily Kuschner on “Eating Issues and Food Selectivity in Autism Spectrum Disorder.”
- Kuschner E.S. et al. Clin. Child Fam. Psychol. Rev. 20, 403-421 (2017) PubMed