Mealtimes, Eating Difficulties and the Autism Spectrum

Parents of autistic children often finding eating, feeding and mealtimes a struggle. If parents reach out for professional help, they may not be able to find it because of the limited number of specialists dealing with eating and feeding disorders; finding a specialist who understands and has experience with autism spectrum disorders can be even more difficult. Picky eating, food aversions, restricted food intake, sensory issues, and possible medical problems such as dental or pica (ingesting non-edible substances) should never be ignored.

Eating can be a contributing factor to behaviors of concern. Hunger can lead to meltdowns, sitting together for a family meal may cause anxiety, some medications can result in either loss of appetite or overeating, certain foods may increase energy spikes and then crashes, and introducing new foods or how food is presented can make a person feel stressed.

When trying to help an autistic person with eating challenges, it is important to look at the following topics that can impact eating and feeding:

Medical Assessments for Feeding and Eating Difficulties

• Visit the dentist to check teeth and gums for cavities, infection and/or other abnormalities. Oral sensitives may make it difficult to brush and floss teeth.
• Gather a history of eating. This should include details of extensive choking, coughing or gagging when eating, loss of oxygen when eating (turning blue or purple), pattern of liquids or foods that come through the person’s nostrils when eating, and reoccurring respiratory difficulties and/or pneumonia.
• A multidisciplinary team should be involved in a feeding assessment. These professionals include an occupational therapist, speech and language pathologist, and nutritionist or dietician along with a doctor and a nurse. A a social worker or child psychologist may also be part of the team.
• Interoception may play a role in eating. The person may not have the ability to feel or interpret the feeling of hunger so there is no interest in food.
• Food allergies or intolerances can impact eating and should be assessed.
• Looks for gastrointestinal (GI) abnormalities such as constipation or chronic diarrhea. A 2013 study found that autistic children experience gastrointestinal (GI) upsets such as constipation, diarrhea and sensitivity to foods six-to-eight times more often than do children who are developing typically.

Behaviors of Concern That Impact Eating and Feeding

• Avoidant/restrictive food intake disorder (ARFID) is an eating or feeding disorder characterized by a persistent and disturbed pattern of feeding or eating that leads to a failure to meet nutritional/energy needs. ARFID is sometimes called ‘extreme picky eating’.
• Anorexia in autistic individuals is complex. Restrictive food intake may be used as a coping technique to mask emotions and anxiety. Repetitive behaviors can take the form of an intense interest such as calorie counting or excessive exercising which develops into anorexia over time.
• Pica involves eating non-edible substances such as paper, dirt or chewing on plaster or wood. Pica may be caused by nutritional deficiencies, sensory stimulation, lack of ability to discriminate non-edible items, and relief of anxiety.
• Rumination, which is rare, is the persistent regurgitation, re-chewing, re-swallowing, or occasionally vomiting of previously eaten foods. It may be caused by gastro-intestinal disorders and continue due to the self-stimulatory rewards the person experiences.

Environmental Issues that Impact Eating and Feeding

The biggest concern here is sensory processing issues which causes difficulty to take in, process, and respond to sensory information in the environment. The senses of smelling, tasting, listening, seeing, interoception and touching can all affect eating. For example, with taste, some autistic children will eat mostly foods that fit into only one of these four categories: sweet, sour, bitter or salty. It’s not uncommon for a child  to eat mostly or only foods that are salty and not be interested in sweet foods. With touch, some people can only tolerate certain textures like crunchy foods or smooth foods with no lumps. Visually, some foods have to be a certain color like white or they have to be served in a particular bowl or cup.

Extreme food selectivity, defined as eating very small amounts of food and/or restricting foods eaten to an extremely narrow selection of sometimes only one or two items, is often related to sensory modulation and regulation. Extreme food selectivity presents as strong negative reactions to introducing new foods.

How can we make mealtimes and eating easier?

• Expand the diet by introducing new foods. It is important to try and eat a well balanced diet to ensure nutritional requirements are met. I have written a blog post on some ideas on how to expand the diet. There are other good articles available on how to introduce new foods.
• Create predictability by having a mealtime schedule. Predictability lessens anxiety and provides structure. A mealtime schedule means there are certain times during the day when food is available. Regular meals and snacks allows a person to have a more stable blood sugar level throughout the day. Food should not be offered or available all day long.
• Use a visual schedule to help with eating. Put meals and snack times in to a visual schedule.
• Sit down to eat. Sitting down to eat helps keep the focus to eating. If a child can’t sit at the table, figure out why they can’t. Do they need some physical activity before sitting down? Does the time sitting down need to be defined by a timer? Would a fidget toy help with having to wait for a meal to be served or for others to finish?
• Eat with others. Some people don’t like to eat alone so arrange to have another person at the table.
• Have appropriate expectations. It isn’t reasonable to expect a very young child to sit at the table for 30 minutes.
• Minimize distractions. Try not to have the TV on or phones/devices at the table.
• Involve a person in chores around the kitchen and meals to build important life skills. Sometimes becoming involved in the planning aspects and management of food can make a person more interested in meal planning and eating. Some ideas are setting/clearing the table, simple food preparation like stirring or adding in ingredients, making a grocery list, or putting away groceries. You can find more ideas here.

My Own Turning Points – Finding What Worked

Both of my children who are now 24 and 27 have struggled with many of the eating/feeding challenges I have outlined. Over the years, some of our turning points around eating were:

• Introducing new foods – Our son, Marc, expanded his diet in his mid-teens after working at farmer’s market in the summer. He took another dietary leap at age 19 after enrolling in a horticulture class growing his own fruits and vegetables. I never thought he would ever eat a salad or soup but they are now dietary staples.
• Adding fruit – Our daughter, Julia, added fruit to her diet at the age of 22. This happened after her doctor told her she had low blood pressure. She looked up some information about it on the internet and came to the conclusion that it would help if she added fruit to her diet. Julia eats a wide variety of fruits and has been willing to try almost all of them. I respect her preferences of not wanting seeds in fruit such a watermelon or grapes.
• Schedules – Meal and snack times were established early in their lives and they still hold true to that schedule today. For the most part, neither of them has ever been able to feel that they are hungry so knowing that snack time is at 4 pm prompts them to get themselves a snack.
• Building interoceptive awareness. Julia has been able to relate that her rumbling stomach means she needs to eat, but that awareness only came in her twenties.
• Discovering constipation. After an abdominal ultrasound, we learned that Marc was suffering from chronic constipation that was causing him to vomit frequently and lose weight. Once treated, he was able to thrive again.
• The Baking Program – We established an at home baking program for Julia once a week. With assistance, she makes all of the family’s baked goods for the week. Julia also enjoys baking with a purpose such as treats for a group meeting, a fundraising bake sale, or for a community meal program.
• Work Experience – Marc worked at a food bank doing the shopping, shelving and sorting of food for hampers. This built an important life skill.
• Respecting preferences – Our children have very specific preferences which we respect. They like to eat their food from plain white bowls. The food is presented in separate sections as both eat each food all at one time (ex. all potato gets eaten first, then meat, then the veggies). Marc eats everything with a spoon; Julia eats pasta with a fork, but everything else with a spoon. Juice has to be diluted with 50% water.
• Eating Out with Sensory Support – We do eat out and help the children navigate different eating environments with support. Julia always brings her noise cancelling headphones or music to listen to if a restaurant is busy. We try to eat at less busy times or ask for a quiet booth. I look at menus online before going to a restaurant.

References

Cvetnich, L. The Power of the Mealtime Schedule. The Autism Connection

Garcia, A. et al. (May, 2017). Enhancing Mealtimes for Children with Autism: Feeding Challenges and Strategies. Nebraska Extension

Goh, S. Tips to Ensure Successful Mealtimes for Autistic Children. Cortica Care

University of Delaware. Mealtimes on the Spectrum: A Toolkit for Making Mealtimes More Meaningful and Functional 

Wheeler, M. (2019). Mealtime and children on the autism spectrum: Beyond picky, fussy, and fads. Indiana Resource Center for Autism