Food Challenges and Children with Autism

Feeding a young child can be a very exciting and highly gratifying time in a caregiver’s life. As a mother of two, some of my favorite memories are the quiet moments of breastfeeding my babies and later watching them grow into little adult eaters! I’m sure we can all recall the first time we offered a bite of solid food to our little ones. What excitement and thrill we experienced watching them succeed at this important milestone. My time helping families and children with feeding difficulties tells a much different story.  When the process goes awry and children begin to refuse to eat or drink, it can create some of the most stressful experiences at home.  Eating is such a basic biologic need for all of us, and when this need presents differently in our little ones, it can be quite scary.

When do food challenges become a Pediatric Feeding Disorder?

As a parent of a toddler, it is not uncommon to hear these words at the dinner table, “Um I don’t like that…” accompanied by the not-so-graceful scooting of grilled asparagus onto the placemat. I am sure many of you are nodding your heads in agreement. In fact, toddlers are famous for decreasing their willingness to try new foods beginning around 18 months. Around this time, they also begin to show stronger preferences for flavors and texture and amounts of food they want to eat. Developmentally speaking, children naturally demonstrate some unwillingness to try new things, as they are beginning to assert their independence. As parents, we try to encourage our child’s healthy eating by establishing a schedule for meals, encouraging them to independently regulate the amount they eat (teaching them to honor their hunger and satiety cues), providing them with opportunities to experience a variety of healthy foods, praising attempts to try new foods, and avoiding mealtime battles. For the most part, these basic interventions prevent children with common picky eating patterns from developing into more pervasive feeding challenges.

Clinical research studies have shown that childhood feeding problems are quite common in typically developing children, but show an increased prevalence in children with ASD and other developmental disabilities. ^14,15  Food challenges become a feeding disorder when the child does not consume enough calories to grow or fail to consume a wide variety of foods to grow in a healthy way. This is a broad definition and captures a group of children with very different presentations and causes for their feeding difficulty. Children with feeding disorders present with a set of problems that might include difficulties consuming adequate calories, growth failure, skill deficits, oral motor deficits, and/or behavioral challenges. ¹¹ Some cases of severe food refusal can result in weight loss, malnutrition, medical complications, hospitalization, delays in development, family stress, and use of enteral feeding for supplemental intake.^2,4

Below are some examples of common forms of feeding challenges:

Food Refusal

When I offer foods to my child, he frequently turns his head, pushes away the spoon, cries, and refuses to eat.

Selectivity by type

My child only eats one brand of chicken nuggets with a particular breading. If I buy anything else he refuses to eat it. This also occurs for other food types.

Selectivity by texture

My child won’t progress beyond pureed food. When I offer textured foods, she may gag and spit-out the food.

Liquid or tube dependence

My child is dependent upon a tube/bottle for caloric needs and is having a difficult time transitioning to oral feeds.

Limited food intake

My child will try new foods and eat a variety, but does not eat enough to grow.

Oral motor difficulties

My child has great difficulty chewing table foods due to deficits in oral motor abilities.

Dysphagia

My child has difficulty swallowing and has a history of aspirating on liquids.

What causes feeding disorders?

It is important to look more broadly at why feeding disorders occur in all children before looking more specifically at children with autism. As you may know, eating is a highly complex multisystem skill that we often take for granted. Thus, it makes sense the causes of feeding disorders are often multifaceted. Feeding disorders are often not due to one variable alone but to a complex interaction of both biologic and psychological variables. In fact, research has shown that most feeding disorders can be characterized by medical, oral-motor, or behavioral problems. ^{12, 13}

Individuals with autism spectrum disorders (ASD) are more likely to have feeding difficulties compared with children without ASD.1 These challenges include increased refusal of foods, insistence on particular preparation of foods, demands for specific utensils, consumption of a limited range of food types, and preference for lower textured foods.^1,2,3 Hypotheses for this increased prevalence in children with ASD include sensory impairments, perseveration, restricted interests, increased focus on details, impulsivity, and biologic food intolerances.^2,8 I think it is wrong to assume that children with ASD only present as picky eaters due to sensory impairments. This assumption may lead to implementation of interventions without identification of other underlying variables contributing to the feeding problem and result in ineffective treatment. Children with ASD may also present with medical variables that contribute directly to their current feeding challenge (e.g., reflux, constipation, food allergies). Therefore, appropriate and thorough assessment of all potential variables is imperative prior to treatment.

I suspect my child might have a feeding disorder. What do I do?

Due to the complex interaction of factors that impact an individual’s ability to eat, assessment is best completed within a multidisciplinary team using a bio-psycho-social framework. This approach underscores the role that each of the multiple factors (medical, oral-motor, psychological) may play in the etiology of a feeding disorder. Contributions from all disciplines are imperative for identification of the underlying causes of your child’s feeding challenges in order to identify effective treatments.

An important first step is to discuss your concerns with your Pediatrician and other therapists involved in your child’s care. Your pediatrician can help facilitate other evaluations necessary to help your child. Clinicians that might be involved in the assessment of your child’s feeding disorder might include medical personnel (a pediatrician, dietician, gastroenterologist, and other medical specialists), oral-motor therapist (speech-language pathologist, occupational therapist), and a child psychologist who specializes in the assessment and treatment of pediatric feeding disorders.

Components of a comprehensive feeding assessment should include evaluation of the following:

1. general medical history and presenting illness,
2. assessment of growth, oral-motor and swallowing skills, cognitive, and behavioral functioning,
3. feeding history and current mealtime habits,
4. current dietary intake
5. direct meal observations to quantify the nature and extent of feeding problem and social interaction styles,
6. psychological functioning, and
7. child and family stressors.^{10, 11}

What are treatment options for my child with ASD?

Once biologic factors have been either ruled out or treated and the type of feeding difficulty has been identified, a treatment plan can then be developed. Treatment can also be multifaceted with psychologists, oral-motor therapists, and medical providers all collaborating and developing treatment goals together. An important first step is to develop your treatment team following identification of the problem. Once you develop your team, develop goals with your child and team that are individualized and measurable so that you can track your child’s progress. Make sure the individuals on your team feel that they can help you and your family reach your goals.

As a psychologist, many of the empirically validated psychological treatments for children with feeding disorders and ASD emphasize the use of applied behavior analytic techniques. ^5,7,9,11 For example, if your child is a picky eater you may begin by positively reinforcing small approximations to taking a bite of one healthy food option once a day. Depending upon your child’s starting point and skills related to your eating goal determines how to gradually progress them forward. You may have to reconsider what it means “to take a bite” and gradually utilize behavioral shaping to reinforce closer and closer approximations to taking a bite overtime (e.g., touching the lips, tongue, and finally placing a small bite in the mouth). There are also several other environmental interventions that target biologic (medical, oral-motor, diet, etc) with behavioral variables related to eating (e.g., child’s appetite or motivation during meals, oral motor skill level and the meal characteristics, sensory properties of foods, repeated exposure/tasting of targeted foods, etc). Each treatment plan depends upon the child and family’s goals, the presenting problem and associated psychological variables.

Last, but certainly not least, providing support and assistance to families caring for children with ASD who also have feeding difficulties is crucial. As mentioned at the beginning of this blog, parents watching their children grow and thrive through feeding can result in some of the happiest moments experienced as a parent. However, parents can be devastated if if the process does not result in a happy, healthy young eater. Families often report feelings of sadness about mealtime challenges, anxiety about their child’s nutritional health, and guilt about the stress encountered during meals Therefore, providing support, not only to the child, but also the family is essential.

Additional support to families includes providing education about feeding disorders, supporting and validating their experiences around meals with their child and connecting them with other parents, and finally assisting in reducing the stress of meals through treatment with their child and themselves.

If you have any concerns about your child or would like to learn more about treatment options, contact your pediatrician for referrals. In addition to the reference articles cited below, you might consult some of these books on the topic at your local public library:

1. Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities: Interventions for Professionals and Parents by Keith Williams, Ph.D. and Richard M. Foxx, Ph.D.;
2. Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet by Cheri Fraker, CCC-SLP, CLC, Mark Fishbein, MD, Sibyl Cox RD, LD, CLC, and Laura Walbert, CCC-SLP, CLC; and
3. Just Take a Bite: Easy, Effective Answers to Food Aversions and Eating Challenges by Lori Ernsperger, Ph.D. and Tania Stegen-Hanson OTR/L.

References

1. Schreck, K.A., Williams, K., & Smith, A.F. A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders. 2004; 34(4): 433-438.
2. Ledford, J.R. & Gast, D.L. Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and other developmental disabilities. 2006; 21(3): 153-166.
3. Schreck, K.A. & Williams, K. Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities. 2006; 27: 353-363.
4. Babbitt, R.L., Hoch, T.A., Coe, D.A., Cataldo, M.F., Kelly, K.J., Stackhouse, C., & Perman, J.A. Behavioral assessment and treatment of pediatric feeding disorders.