Dietary Issues and Autism –
Information for parents
by Dr Avril Brereton
Many parents report that their
child with autism is a “fussy
eater” or has “food fads”.
What is fussy eating?
Fussy eating is a common problem
in toddlers and pre-school aged
children, so common in fact that
it is accepted as a normal part
of early childhood development
and growing up. Some children
are “grazers” and eat small
amounts of food throughout the
day rather than at specific meal
times; others eat a limited
number of foods and in small
amounts but continue to grow and
develop normally. Parents
usually notice that the amount
of food their child takes might
even seem to decrease as the
child moves from infancy to
toddler hood. This is because
children are not growing so
rapidly from 18 months to 3
years and do not need as much
food relatively, as when they
were younger.
For most children these eating
habits are transient and normal
eating habits develop as the
child becomes older. It is worth
remembering that a limited diet
with a narrow range of foods
does not necessarily mean that
the child is failing to thrive.
In many countries, children
develop satisfactorily on a diet
that includes only a narrow
range of foods. As long as
children receive a balance of
food groups and essential
vitamins and minerals, they will
thrive.
What about children with autism?
Children with autism frequently
have problems with eating
including:
-
Eating a limited range
of foods
-
Selective eating by type
- e.g. eat only certain
foods or food groups; by
texture - e.g. only soft
foods without lumps or
by colour - e.g. only
white foods or rejecting
all green food
-
Food refusal
Parents often report that it is
the behaviour associated with
meal times and eating that
causes the most problems.
Difficult behaviour at meal
times may include any or all of
the following:
-
Not wanting to sit for
meals (no social eating
experiences)
-
Sniffing and inspecting
food (their own and
others’)
-
Taking food from others’
plates
-
Gorging food, hording
food in their mouth
-
Gagging on food or
vomiting food they don’t
like
-
Obsessive placing of
food on their plates,
e.g. no different types
of food touching
-
Specific cutlery,
crockery or position at
the table
-
Eating only using
fingers
-
Refusal of new foods
These difficulties with eating
are usually not as transitory as
with normally developing
children, and may last into
adolescence or even adulthood.
Making sense of eating problems
All children who are
experiencing eating difficulties
should undergo a medical
examination to rule out a
specific medical problem such as
constipation, diarrhoea or
malabsorption problems, oral
motor problems for example
difficulty with coordinating
chewing and swallowing, food
allergy, for example to milk or
gluten and to check for
inadequate intake of essential
food groups, vitamins and
minerals.
Eating problems and behavioural
problems associated with food
and eating can often be
understood in light of each
child’s developmental level and
profile of autistic symptoms,
particularly those affecting
social skills and rituals,
routines and preoccupations.
Sensory sensitivities also play
a part for some children.
Developmental level
The majority of children with
autism have problems with
development, with an uneven
profile of abilities. For
example a child may be 4 years
of age but have an overall
developmental level of only 2
years. In this case, the eating
habits, skills and behaviour of
a 2 year old toddler are to be
expected. The parents should
therefore not expect this child
to manage cutlery for example.
Impaired social skills
One of the key features of
autism is abnormality in
interpersonal relationships,
such as reduced responsiveness
to or interest in people, an
appearance of aloofness and a
limited or impaired ability to
relate to others. When we
consider eating as a social
activity, with the family
gathered at the table for meals
and conversation, for the child
with autism who is socially
aloof or is distressed by social
contact, meal time can be
stressful. Such a child may want
to leave the table or even the
room when the family is all
together, because the social
demands of the situation are
overwhelming. The mealtime
behaviour in this case is not
about food and eating but rather
it is the social situation in
which food is offered.
Play and Imagination
Children with autism usually
have rigid and limited play
patterns with a noticeable lack
of imagination and creativity.
They may repetitively line up
toys, sort by colour, or collect
various objects such as pieces
of string or objects of a
certain colour or shape. Intense
attachment to these objects can
occur with the child showing
great distress if these objects
are taken away or patterns
disrupted. Children with autism
may develop play patterns with
their food, such as lining up
food on the plate or table
rather than eating it, sort food
by shape or colour or even want
to keep food with them as play
objects, particularly if it is
an interesting shape or texture
such as triangular shaped
biscuits or biscuits with
numbers on them.
Ritualistic and
Stereotyped Interests or
Behaviours
Ritualistic and compulsive
phenomena are common, such as
touching compulsions and rigid
routines for daily activities.
There is often resistance to
change in routine or the
environment so that the child
may become extremely distressed
if, for example, a new route is
taken going to pre-school, the
furniture in the house is
rearranged, or the child is
given new clothes to wear.
Resistance to change can account
for the rejection of new foods,
wanting to eat in only certain
places, eating foods in a
particular order that cannot
change, or eating only one brand
of a certain type of food from a
particular container.
Fascination with movement and
close visual scrutiny of objects
such as spinning the wheels on
toys or examining the edge of a
book, or pattern of spokes on a
wheel is also common.
Fascination with movement can
account for plate spinning
rather than the plate being
there to place food on, or
rapidly moving a fork or other
cutlery in front of the eyes.
Close visual scrutiny can
account for preoccupied looking
at the food, for example
examining closely the grains in
a slice of bread, the table
edge, or pattern on a plate.
These preoccupations can be so
intense that the child actually
forgets to eat the food on the
plate he is studying or refuses
to eat the food because of the
pattern that has been made with
it.
Associated features
Some children also have a range
of sensory sensitivities that
affect their ability to eat and
enjoy new or different foods.
For example, some children will
reject food because of its
texture, consistency, smell,
taste, or temperature. Children
may prefer to feel their food
with their hands (tactile
exploration) rather than eat it.
What can you do?
First, try to determine
what might be causing the eating
problem. Ask yourself these
questions:
-
Is there an underlying
medical or physical
problem?
-
Has your child been
experiencing difficulty
swallowing food, does
he/she have diarrhoea,
has he/she been vomiting
after eating, has there
been a sudden loss of
appetite? Go to the
GP for
a check up.
-
Is the eating difficulty
part of a social
interaction problem?
Does the problem only
occur when he/she is
eating with other
people? Is there an
obsessive or ritualistic
element to the eating of
food or rejection of new
food?
-
Does your child have any
sensory sensitivities
that help to explain the
eating difficulty?
If
you cannot answer these
questions then a team approach
involving a Speech
Pathologist, OT, Dietician and
Educational Advisor can
help to ascertain whether your
child:
-
is at nutritional risk
because of a limited
diet
-
has a sensory
sensitivity
-
has oral motor problems
-
has a specific
behavioural problem
-
is reacting to you
and your
attitude to mealtimes
Members of the team will
probably want to visit you at
home to observe your child at
mealtimes and talk with you
about the eating problems he/she
is having. In most cases
children with autism are eating
an adequate diet even though the
range of foods eaten is small.
Depending on the cause
of your child’s eating problems,
the following ideas may be
helpful to change fussy eating
habits, food refusal or
“autistic” approaches to food:
-
Limit food/drink which
is calorie empty or
nutritionally unhealthy
(junk food)
-
Offer appropriate
serving sizes (not too
much on the plate)
-
Make food attractive
(try different shapes,
colours; e.g. cut bread
into Telly Tubby or
Thomas shapes)
-
Offer new foods early in
the day (not when child
is tired or already
full)
-
Offer different/new
foods when child is
hungry / thirsty
-
Involve child in food
preparation if possible
-
Grind vitamin and
calcium supplements
finely then add to food
(e.g. can mix into
peanut butter, jam or
vegemite without
altering the taste)
-
Make a “super sauce” by
putting vegetables in
the blender and adding
it to preferred foods
e.g. spaghetti Bolognese
– it disappears and does
not change the texture
of the food you add it
to
-
Have a preferred toy at
hand so that it is
played with rather than
the food itself
-
If the child persists in
wanting to drink formula
or milk the child
usually grows out of
this and in the meantime
it remains an excellent
food source (but
remember that
milk/formula is just a
small component of a
balanced diet and is not
sufficient on its own
for a growing child)
To bring about change
you need to:
-
Be persistent and
patient
-
Be consistent (set time
for meals)
-
Have a routine (always
sit at the table to eat)
-
Always offer a non
preferred food at each
meal alongside what your
chid prefers to eat
-
Make gradual
changes to taste,
texture, flavour, smell
and quantity of food
-
Social stories about
food and mealtimes may
be helpful
There
are some things that don’t work
if you want to change your
child’s eating and behaviour:
-
Ignoring the behaviour
will not make it go away
-
Coaxing and pleading for
your child to eat will
fall on “deaf ears”
-
Threats and punishment
usually make things
worse
-
Force feeding may stop
the child eating
-
Always making a separate
meal or multiple meals
for your child with
autism (the child
quickly learns that
he/she will be getting
the preferred food and
hold out for it)
Diet and eating problems in
children are very distressing
for many parents. This distress
might even aggravate the child’s
difficult behaviour and
contribute to mealtimes becoming
a stress for the entire family,
including siblings. At all
costs, parents should avoid
making mealtimes a battle zone.
As long as the GP or dietician
has confirmed that the child is
thriving, then in reality
his/her diet is adequate, even
though it may be extremely odd
or limited. This should reassure
parents and give them permission
to take a more relaxed approach
to this aspect of their son or
daughter’s autism.
If
the dietary problems are severe
and are compromising healthy
development, more intensive
medical intervention might be
indicated including the use of
medications which lower anxiety
and reduce obsessional
behaviour.
Useful books:
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