I am a behavior analyst working with a 6-year-old child with a very limited food repertoire. Do you have any assessment and treatment recommendations that can guide my efforts to address this area?
Answered by Jill K. Belchic-Schwartz, PhD Pediatric/Child Psychologist, Childhood Solutions, PC, Fort Washington, PA
Food selectivity is a fairly common issue with children who have an autism spectrum disorder (ASD). Many children with ASDs have difficulties with rigidity and a need for sameness, and this holds true for their food preferences as well. This can be very distressing for parents and caregivers.
Often it is not a matter of the child actually disliking a new food but rather that s/he hasn’t tasted it enough times to decide whether s/he likes it or not. Regardless of whether a child’s selectivity is due to a lack of exposure to new foods, it is important to rule out any underlying medical conditions that may be perpetuating the child’s feeding difficulties. Common medical concerns include gastroesophageal reflux disease (GERD) and/or food allergies or intolerances. Any underlying medical issues should be treated prior to implementing a feeding program. Once any medical treatment is underway, you can begin to tackle the child’s food selectivity. If a multidisciplinary feeding clinic is nearby, encourage the parents of the child with whom you are working to consider scheduling an appointment for him/her to be evaluated.
When treating any child with food selectivity, the first step is to take a very detailed feeding history. Ask about the child’s first experiences with baby food, how they handled the transition to more highly textured foods, and what they are eating now. Gather information about the setting in which the child eats. Does s/he sit at the kitchen table for all meals or is s/he allowed to graze throughout the day? Are meal times predictable? Do meals occur at regularly scheduled intervals and at the same time each day? Will the child eat only a specific brand of yogurt or will s/he eat any brand? Will the child eat only one flavor (e.g., strawberry/banana yogurt)? How is the food presented? How long is a typical meal? What are the child’s refusal behaviors? The more specific the information the better!
There are a variety of techniques available that can be helpful in expanding a child’s food repertoire. However, in order to identify the most appropriate treatment, you must first understand the etiology of the selectivity. For instance, is the child’s food selectivity due to a frank refusal to try all new foods or is it due to a failure to progress to more advanced textured foods? The food refusal behavior may look the same (e.g., screaming, hitting, etc.), but the treatment would be quite different based on this information.
Once you are satisfied with your assessment, treatment can begin. Try to stick to a daily predictable schedule of meals and snacks and eliminate grazing/snacking in between meals. Hunger can be a powerful motivator! It is also important to limit the child’s access to liquids in between meals, as some children prefer to drink rather than eat. Set a 15-20 minutes time limit for meals. When introducing new foods for the first time, it is usually helpful to start with a "formerly preferred food," that is, a food that the child used to eat or a food that is similar in taste/texture to something s/he currently eats.
When presenting the "new" food to the child, start with a very small bite of the new food (e.g., sometimes as small as a pencil point) so as not to overwhelm the child and to ensure a greater likelihood of success. Some feeding therapists use the child’s preferred food as a "reward" for eating the "non-preferred" food, while others use toys/activities as a reward for tasting the new food. What works for one child may not necessarily work for another. Therefore, in order to find the most salient motivators, several different options will likely need to be explored. Additionally, reward systems may need to be changed periodically in order to maintain their effectiveness.
When introducing new foods to a child, it is often easier to start with naturally occurring pureed or smooth foods first (e.g., yogurt, applesauce). The reasoning behind this suggestion is that once the child accepts a bite of pureed food into his/her mouth, swallowing it is almost guaranteed. With a piece of chopped food, the child may accept the bite into his/her mouth but chewing and swallowing may not necessarily occur and the child may expel the food. For instance, suppose you are introducing fruits and/or vegetables to a child who eats only carbohydrates. The child is more likely to demonstrate success with a ¼ teaspoon of applesauce than it is with a bite of an actual apple. Once the child is accepting a one-fourth teaspoon of applesauce consistently (e.g., nine out of ten opportunities), you can begin to increase the bite size to one-half teaspoon. Moving along in a systematic and stepwise fashion ensures a greater likelihood of success. Additional foods can be introduced in a similar fashion once the child is eating a reasonable volume of the new food.
Food selectivity is just one example of feeding problems that may be experienced by children on the autism spectrum. These difficulties often pose a significant challenge to parents, as nourishing typically developing children is expected to be one of the easier, and more enjoyable, tasks of parenthood. Help is available for parents experiencing this challenge, and behavior analysts are a great resource for assessing and treating these disorders because of their specific skill sets in understanding behavior and motivation. For more detailed information, a great resource is, "Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities" by Keith E. Williams and Richard M. Foxx.
Williams, K. E. & Foxx, R. M. (2007). Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities. New York, New York: Pro-Ed Inc.