Monday, July 26, 2010

Autism: Feeding Issues and Picky Eaters

Judy McCrary Koeppen
www.septar.org
www.sagetherapy.com
www.sagetherapy.blogspot.com

Having your child diagnosed with autism can be overwhelming. Adding to an already challenging parenting experience is that children with autism are often very picky eaters or have eating issues -- yet many of those children's parents aren’t aware that they may face this struggle. Having your child refuse to eat any foods that are not white and soft in consistency can be maddening, but as a speech therapist and parent I’ve found that having a clear understanding of why a child self-limits their diet goes far in managing and coping with this often trying behavior.

Eating is a multi-sensory experience. Each mouthful brings the possibility of a variety of flavors, textures and temperatures. A feeding specialist would break this down further, identifying "Flavors" including sweet, sour, salty, spicy, bitter and neutral; "Textures" including crunchy, chewy, soft, mixed, puree, thick liquids, and thin liquids; and "Temperatures" including cold, room temperature, warm, and hot. In addition, we experience food odors, and often the way they feel in our hands. Many children who are picky or problem eaters may have Sensory Processing Disorder (SPD). In her book The Out of Sync Child: Recognizing and Coping With Sensory Processing Disorder, Carol Stock Kranowitz, MA defines SPD:
Sensory Processing Disorder is difficulty in the way the brain takes in, organizes and uses sensory information, causing a person to have problems interacting effectively in the everyday environment ... SPD is an umbrella term covering several distinct disorders that affect how the child uses his senses.
As I see it, a child with SPD may by hypersensitive, hyposensitive, or a mixture of both. The hypersensitive child may experience flavors, textures, temperatures, and smells to a degree that is not perceived by most others, or they may under experience them. The smell and texture of grilled chicken may elicit the same noxious sensory response as being stuck in a room with skunk stench. “GET OUT OF HERE!” is the message the body will send. The hyposensitive child may seek out strong flavors and crunchy, hard textures to make up for experiences they are missing. They may like spicy food, sour flavors (lemon, vinegar), and only crunchy foods.

Food choices are based on individual children’s sensory experiences. Foods providing a favorable sensory experience will be selected over those that provide a noxious sensory experience. Because a child with SPD can have eating experiences that are altered and different from their parents', it can be very difficult to understand their preferences.

Children with autism can have SPD, but autism has its own factors that can contribute to picky eating. Children with autism are often uncomfortable with a change in routine. This preference for sameness can show up at meal time as well. Children may want foods to be from same container, the same brand, served on the same plate. So they may want a steady diet of McDonalds chicken nuggets (no other brand), Snapple raspberry tea (only from the Snapple bottle), and Dannon vanilla yogurt (no other brand or flavor) served on the same plate.

Eating involves the integration of a variety of sensory experiences and is influenced by the “mealtime experience.” So what is a “typical” eater and when is eating a problem?

The Continuum of Eating Types

A "typical eater" will usually:
  • eat a variety of foods
  • show interest in foods
  • tolerate the presence of new foods and try new foods
A "picky eater" can:
  • Have aversions to some foods, but still eat a variety
  • Eat foods from each texture group and food group
  • Tolerate the presence of new food
  • Be willing to touch or try new foods
A "resistant" or "problem" eater will often:
  • Eat 15 to 20 foods or fewer
  • Refuse of one or more food groups (often preferring carbohydrates)
  • Refuse of one or more texture type (often preferring crunchy or soft foods, not both)
  • Tantrum or melt down at meal times
  • Prefer one flavor (often sweet or salty)
  • Prefer strong flavors OR bland flavors
  • Prefer foods of the same color
  • Prefer certain foods to always be the same brand. For example, only chicken nuggets from McDonald’s.
  • Gag when trying new foods
  • Display anxiety over the presence of new foods on their plate, on the table or even in the room
  • Find the smell of certain foods to be noxious
A child who may become a problem eater often starts to refuse foods when parents introduce chunky baby food. The presence of a solid requiring chewing and puree (or liquid) that does not require chewing is often perceived as noxious. This can play out in a child refusing to eat vegetable soup of diced vegetables and broth, but then eating the same soup when pureed. Many fresh fruits can present the same way. Citrus fruits, watermelon, ripe peaches and pears consist of a solid and juice combination. These are also often refused. Children may have “food jags” where they will request and eat the same food at every meal. The problem with this is that often children will suddenly refuse this food. For a child with a severely limited diet the elimination of a key diet item can be problematic.

What parents of problem eaters need to understand is that they did not create the feeding problem. Problem eating is the result of very real physical and neurological responses on the part of the child. Usually the parent of a problem eater has continually offered their child a large variety of healthy foods. When given the choice of a food perceived as noxious or not eating at all, these children will choose to not eat. They would do so over consecutive meals if made to. Withholding food or physically forcing a child to eat is never a successful method to get them to eat. In her book How to Get Your Kids to Eat ... But Not Too Much, Ellyn Satter defines the role of a “good parent“ when feeding their children:
Good Parents are responsible for feeding their children ... Parents and professionals working with children are responsible for preparing and providing a well balanced meal at an appropriate schedule and setting. The child is soley responsible for whether they eat and how much they eat.
What You Can Do
  • Create the Best Schedule and Setting for Successful Eating
    • Have meals and snacks at predictable times. A written or picture schedule can be helpful.
    • Eating and drinking done at the table during snacks and meals
    • Offer water to drink between meals
    • NO GRAZING. If children are allowed to eat through out the day they will not be able to regulate sensations of hunger and satiation. They may also snack on preferred foods during the day to fill themselves and eat fewer healthier foods at meal time.
  • Rotate foods and when they are served. For example, If a child can predict always having a large glass of milk before bed, they will eat fewer foods offered earlier in the day.
  • Meal time should be a non-stressful experience for a child. Stress decreases appetite and children will avoid mealtime if the perceive it as a stressful time.
  • Don’t use dessert as reward-reinforces idea of having to eat “bad food” to get “good food.” Incorporate small amounts of dessert items into meals.
  • It’s okay to leave food.
  • Mix it up. It is okay to have pancakes for dinner.
  • If needed, post behavior rules (written or pictured) near table. For example, no throwing food.
  • Include preferred foods at every meal.
  • Be a model. Eat with your children. Talk about the foods and their textures, flavors, smells etc.
  • Have children participate in meal planning and preparation as is developmentally appropriate. Include them in: shopping, choosing foods, preparing and cooking foods, setting the table, serving food etc.
  • Let children chose the plates and cups they use at meal times.
  • Redefine “Success.” Children are taking risks and showing progress when they do any of the following with new foods: smell, touch, poke with a fork, touch to lips, touch to chin, or lick. Even tolerating a new food in the same room or on the table is success. All of these activities are worthy of big praise. It is important to recognize these as signs of success, even though they have not actually taken a bite.
  • PRAISE, PRAISE, PRAISE any participation in food-related experiences.
Rethink What Foods to Offer

The "Food Chaining" method for working with problem eaters looks at individual child’s eating habits. In their book Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet, Cheri Fraker, Mark Fishbein MD, Sibyl Cox, and Laura Walbert offer a common sense approach to dealing with problem eaters. In short, an analysis of a child’s eating is done by looking at the characteristics of their preferred foods. Characteristics examined include: food groups, textures, flavors and textures. Foods which are highly similar to the preferred foods are selected to be introduced. I have had wonderful success in my practice using this approach and recommended their book for both parents and professionals. The Food Chaining courses are excellent as well.

An additional approach that has had excellent success is the the Sequential Oral Sensory (SOS) feeding program created by Dr. Kay Toomey. This program integrates sensory, motor, oral, behavioral/learning, medical and nutritional factors and approaches in order to comprehensively evaluate and manage children with feeding/growth problems. It is based on the “normal” developmental steps and skills of feeding. Information on this approach is available to professionals (and possibly parents) who attend SOS training.

What Else Can I Do?
  • Consult your pediatrician and/or nutritionist with concerns regarding adequate growth, nutrition and hydration.
  • Continue to educate yourself about SPD and problem eaters (see Resources, below)
  • Seek out support from other parents of problem eaters
  • Incorporate developmentally appropriate food experiences and education into your child’s day:
    • Songs about food: “Apples and Bananas”
    • Children’s books about food and eating (see Reference List)
    • Play with plastic foods. Sort by food groups, create pretend balanced meals
    • Paint with food. Make potato or melon stamps to use with paint
    • Use carrot, celery and other foods to paint with condiments
    • Avocado (or banana) can be cut up peeled and squished to use as finger paint or “shaving cream”
    • Load and dump toy trucks with various crackers, nuts. Talk about textures, colors, smells
    • Create a picture by gluing dry foods on paper (crackers, dry roasted soy nuts, dried fruit, freeze dried fruit)
    • Make necklaces of diced, pierced fresh, or dried fruits and veggies
    • Look at and experience foods in various forms: whole carrot with greens, peel the carrot, shred it, dice it, cook it, carrot juice, freeze dried carrots (can do with apples, peaches)
Professional Help

Quite often parents need to seek out professional help for their children. When pursuing an evaluation and treatment, it is important to find a feeding specialist who has experience with problem eaters. Speech or Occupational Therapists often seek out specialization in this area. Ask to have a phone consult with a therapist to gain information about the approach they use. While the use of one-to-one reinforcement for eating a new food (for example a bite of non-preferred saltine cracker earns a bite of preferred fish cracker) can be acceptable, forcing a child to eat is never acceptable. These therapy services can be expensive and it is reasonable to ask a therapist about their approach, training, and experience with problem eaters.

References
  • Ernsperger, Lori and Stegen-Hanson, Tania (2004). Just Take a Bite: Easy, Effective Answers to Food Aversions and Eating Challenges! Arlington: Future Horizons.
  • Ernsperger, Lori and Stegen-Hanson, Tania (2005). Finicky Eaters: What to Do When Kids Won't Eat. Arlington: Future Horizons.
  • Fraker, Cheri, Mark Fishbein MD and Sibyl Cox (2007). Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. New York: Marlow and Company.
  • Kranowitz, Carol Stock M.A (2005). The Out-of-Sync Child Recognizing and coping with Sensory Processing Disorder. New York: Penguin.
  • Morris, Suzanne Evans and Marsha Dunn Klein (2000). Pre-Feeding Skills, A Comprehensive Resource for Mealtime Development. Texas: Pro-ed.
  • Piette, Linda (2006). Just Two More Bites! Helping Picky Eaters Say Yes to Food. New York: Crown Publishers.
  • Satter, Ellyn (1987). How to Get Your Kids to Eat ... But Not Too Much. Bull Publishing
Websites
Children’s Books:
  • Brown, Marc (1997). D.W. The Picky Eater.
  • Elhert, Lois (1996). Eating the Alphabet.
  • Fleming, Denise (1996). Lunch.
  • Tenzyk, Judy (2009). Mommy What Do Carrots Do?: A Children's Book on Food.