Improving Food Selectivity of Children With Autism

Improving food selectivity in children with autism

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I am the parent of a 10 year-old boy with autism who has a very limited diet, not due to any food restrictions or allergies; he just refuses to try different types of foods. This makes for really challenging meal times and I worry about the lack of nutrition in his diet. I heard this is common in autism spectrum disorder. What can I do to address it?

Answered by Laura Seiverling, PhD, BCBA-D, Clinical Supervisor of St Mary’s Hospital for Children’s Center for Pediatric Feeding Disorders in Bayside, NY and Keith Williams, PhD, BCBA, Director of Penn State Hershey Medical Center’s Pediatric Feeding program. Drs. Seiverling and Williams are the co-authors of Broccoli Boot Camp: A Guide For Improving Your Child’s Selective Eating.

Please know your concerns are commonly reported by parents of children with autism spectrum disorder (ASD). Below are just a few examples of the statements we frequently hear from parents of children with ASD when describing their children’s eating habits.

“My child only eats foods that are room temperature”
“My child only eats foods that are crunchy”
“My child eats chicken nuggets, but only those from fast food outlets”

While the prevalence of selective eating among children with neurotypical development ranges from 10% to 35% (Reau, Senturia, Lebailly, & Christoffel, 1996; Wright, Parkinson, Shipton, & Drewett, 2007), among children with ASD, prevalence estimates range from 46% to 89% (Ledford & Gast, 2006). Parents of school-aged children with ASD reported their children ate, on average, about half as many dairy products, fruits, vegetables, and proteins as the parents of children without ASD (Schreck, Williams, & Smith, 2004). These parents also reported the children with ASD were more selective by texture, required foods be presented in specific ways, and required particular utensils and dishes at meals. In another study, less than half of parents reported their children with ASD ate the family meal (Collins, Kyle, Smith, Laverty, Roberts, & Eaton-Evans, 2003).

Selective eating and ASD

Selective eating has long been described as a feature of autism. In his initial description of children with autism, Leo Kanner mentioned restrictive diets as being common (Kanner, 1943). In the latest diagnostic manual used by mental health providers, the DSM-5, one of the criteria for autism spectrum disorder includes restricted, repetitive patterns of behavior, interests, or activities. Under this criterion, eating the same food is provided as an example of restrictive or repetitive behavior (American Psychiatric Association, 2013). Restrictive mealtime behavior extends from eating only a few foods to specific mealtime routines, such as only eating foods out of the original containers or eating preferred foods or beverages in ritualistic ways (e.g. touching a food to the mouth several times before eating it or tilting one’s head to the side when drinking out of a cup). Unfortunately, the insistence on eating the same foods reduces children’s opportunities to taste new foods, increasing the difficulty of expanding diet variety as you have mentioned is the case with your son. Problems with social communication may further complicate the expansion of diet variety, as children with ASD may not imitate when other family members are modeling eating a range of foods.

Consumption of a wide variety of foods, especially fruits and vegetables, has a range of health benefits including the prevention of chronic diseases such as diabetes, heart disease, and even cancer. There are also social benefits to increasing diet variety. When children with ASD learn to eat new foods, they are learning how to tolerate change, which may help reduce their insistence on sameness and open them to new experiences. Further, efforts to increase diet variety involve teaching the child to follow directions and just as importantly, it allows parents to practice giving instructions, providing praise, and ignoring inappropriate behaviors.

Improving food preference through taste exposure

Selective eating and autism spectrum disorders At the most basic level, the development of a preference for a new food requires only one thing: repeated tasting of that particular food over time. For many children with ASD, this step is neither simple nor easy. There are, however, a number of interventions which provide this repeated taste exposure and have been shown to be effective at increasing diet variety (for review see Williams & Seiverling, 2014). These interventions often include one or more of the following components:

1) Repeated presentation of small tastes (e.g. crumb-size to pea-sized bites) of each new food across the course of several days or weeks. It is best to start with foods that are similar in taste and texture to the foods already in your child’s diet as well as foods that your child has previously eaten well, but no longer eats. Further, it is sometimes easier to start with foods that do not require chewing (e.g. yogurt or pudding) in order to reduce the likelihood that your child will hold the food in his mouth or spit the food out. It may also be helpful to allow your child to take a sip of a preferred beverage immediately after eating the food on the first several exposures.

2) Stimulus fading, which often involves making gradual increases in the bite size of new foods being introduced (e.g. from crumb or pea-sized to half-spoonful and finally full-spoonful). We recommend increasing bite sizes when your child has accepted at least three consecutive bites of the food within 30 seconds without gagging and disruptive behavior such as crying or screaming.

3) Positive reinforcement for acceptance of new foods and appropriate mealtime behavior in the form of verbal praise as well as access to preferred foods, toys, or activities (i.e., reinforcers) reserved only for when the child accepts new foods. It is helpful to restrict access to these reinforcers in order to keep them motivating to your child.

4) Planned ignoring of child inappropriate mealtime behavior, which involves providing as little attention as possible to the child’s disruptive or unwanted behavior during mealtimes. Planned ignoring can be hard to do after you have spent time and effort preparing a meal or a new food and your child yells, tantrums, and refuses to eat what is presented; however, you do not need to respond in kind. Planned ignoring allows you, not your child, to set the tone of the meal. Ignoring your child’s inappropriate behaviors will result in those behaviors eventually decreasing, but it requires a lot of patience on your part. It is likely that your child has been practicing these behaviors for some time so helping to change them through planned ignoring will also take time. Also, it’s important to know that your child’s inappropriate behavior may also increase initially in frequency and intensity before improving because you are no longer responding to those behaviors. And remember that while you should be ignoring your son’s unwanted mealtime behaviors, be sure to provide positive attention to his appropriate behaviors during the meal.

5) Escape prevention by not removing a new food if the child exhibits mealtime problem behavior (e.g. pushing the food away or screaming) and often involves having a child accept at least a single bite of the food presented before leaving the eating area.

6) Establishment of a meal schedule in order to eliminate the child’s grazing between meals to increase your child’s appetite and motivation to eat during meals.

In order to track your son’s progress when implementing an intervention to expand his diet variety, it may be helpful to use a data sheet to indicate which foods you have introduced, the size of the bites presented (e.g. pea-sized, half-spoonful, or full-spoonful) and if your child accepted the food presented without a problem or if he exhibited behaviors such as gagging or crying. Tracking your child’s mealtime behavior can help guide your decisions regarding when to increase bite sizes of new foods introduced or when to change the intervention you have in place (if progress is not being made).

Several examples of these types of data sheets can be found and downloaded for free at https://bitesfeedingtherapy.com/broccoli-boot-camp-resources/.

Using Visual Supports

Many parents of children with ASD express concerns about intervention success due to their child’s limited understanding (and/or use) of language. Visual supports are an excellent way to address these concerns and have been shown to promote independence and decrease problem behavior associated with schedule changes (Carnahan, Musti-Rao, & Bailey, 2009; Dettmer, Simpson, Myles, & Ganz, 2000). Visual supports may include:

A chart specifying when meals or snacks will be offered across the day;
A chart or token system (e.g., a sticker chart) indicating how many bites of a food need to be eaten before earning a child’s preferred activity, toy or food; and
A detailed list or set of pictures showing which foods will be presented and in which order within a meal.

Establishing a new mealtime routine

When working with children with ASD who have food selectivity, an important goal is to establish a new mealtime routine. This can be done by having parents consistently implement a structured meal plan which will replace the child’s current mealtime routine of eating a limited variety. This plan may include providing reinforcement (e.g., access to a preferred food or toy) consistently for tasting new foods, presenting very small bites of the new food initially, and requiring that the child sit at the table for an established amount of time before being allowed to leave. Once a new routine is established, many children with ASD become comfortable eating new foods as long as the routine is in place. Over time, as your child begins eating a variety of new foods you’ve introduced and is no longer exhibiting inappropriate mealtime behavior, you will be able to fade out the various components of the structured meal plan. In order to maintain the gains made by your child in expanding his diet variety, it may be helpful to put a weekly schedule in place to use as a guide to continue presenting foods that have been successfully introduced to the child. If several weeks or months pass between presentations of a food that has been introduced, a child may start to show resistance to eating that food because it has not been offered regularly.

While food selectivity is common among many children with ASD, the good news is that it can be addressed successfully through targeted, individualized interventions that are implemented consistently. Although we have seen many children progress from eating a few foods to dozens of foods through various behavioral interventions, it is important to understand that one child’s success with a particular feeding intervention does not predict success for another. Further, interventions utilized by some families may not be feasible for others due to such factors as mealtime schedules and parent availability to be present at mealtimes. Identifying which interventions will work best within the context of your family’s mealtime schedule and routines is an important first step in planning. In more severe cases, it is recommended to seek the assistance of a Board Certified Behavior Analyst (BCBA) or Pediatric Psychologist who can help identify your child’s specific feeding issues and develop an appropriate intervention plan. Additionally, you can access many free resources including meal plans, various types of data sheets to track your child’s progress, and visual supports on our website, https://bitesfeedingtherapy.com/broccoli-boot-camp-resources/.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Carnahan, C., Musti-Rao, S., & Bailey, J. (2009). Promoting active engagement in small group learning experiences for students with autism and significant learning needs. Education and Treatment of Children, 32, 37-61.

Collins, M. S., Kyle, R., Smith, S., Laverty, A., Roberts, S., & Eaton-Evans, J. (2003). Coping with the usual family diet eating behaviour and food choices of children with Down’s Syndrome, Autistic Spectrum Disorders or Cri du Chat Syndrome and comparison groups of siblings. Journal of Learning Disabilities, 7, 137-155.

Dettmer, S., Simpson, R. L., Myles, B.S., & Ganz, J. B. (2000). The use of visual supports to facilitate transitions of students with autism. Focus on Autism and Other Developmental Disabilities, 15, 163-169.

Kanner, L. (1943). Autistic disturbances of affective contact. The Nervous Child, 2, 217-253.

Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders a review. Focus on Autism and Other Developmental Disabilities, 21, 153-166.

Reau, N. R., Senturia, Y. D., Lebailly, S. A., & Christoffel, , K. K. (1996). Infant and toddler feeding patterns and problems: Normative data and a new direction. Journal of Developmental & Behavioral Pediatrics, 17, 149-153.

Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34, 433-438.

Williams, K. E., & Seiverling, L. (2014). Assessment and treatment of feeding problems among children with autism spectrum disorders. In Comprehensive Guide to Autism (pp. 1973-1993). New York: Springer.

Wright, C. M., Parkinson, K. N., Shipton, D., & Drewett, R. F. (2007). How do toddler eating problems relate to their eating behavior, food preferences, and growth? Pediatrics, 120, e1069-e1075.

Citation for this article:

Seiverling, L., & Williams, K. (2016). Clinical Corner: Improving food selectivity of children with autism. Science in Autism Treatment, 13(4), 16-20.

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