Overcoming Feeding Difficulties in Children with Autism Spectrum Disorder
Mealtimes are often challenging when your child has Autism Spectrum Disorder (ASD). Many children will struggle with “picky eating,” also called selective eating, from time to time, as they develop and learn new eating skills. However, it is very common for children with ASD to struggle with a more severe form of selective eating that seriously restricts the types and quantity of foods they will eat (Cermak, Curtin, & Bandini, 2010; Rogers, Magill-Evans, & Rempel, 2012). This article will discuss different factors that contribute to selective eating in children with ASD and some strategies that may help expand food acceptance. Treatment for feeding problems in children with autism is based on the individual needs and abilities of each child, not all strategies will be successful for every child.
Picky or Selective Eating in ASD
A high proportion of children with ASD, approximately 75%, have very selective eating from childhood through adulthood (Cermak et al., 2010). Children with ASD often suffer from oral over-sensitivity, which directly contributes to food selectivity among these children (Chistol et al., 2018). Over-sensitivity differs among individuals and often creates dislike of certain textures, tastes, smells, appearance of foods, and temperatures (Cermak et al., 2010). While most individuals have a favorite or least favorite food, individuals with ASD may have particularly intense food likes and dislikes (Nath, 2014). For example, a child with ASD may only eat a certain brand of chicken nuggets, refusing to eat other brands of the same type of food.
Individuals with ASD often prefer processed foods that are high in carbohydrates and often reject fruits, vegetables, slippery, and soft foods (Kuschner, 2018; Ansel, 2018). Additionally, some children with ASD may only eat foods that fit into one of the sweet, salty, sour, or bitter categories (Wheeler, 2004). Children with ASD also tend to prefer a certain texture over another, such as crunchy or smooth, or they prefer to have the same food at the same temperature each time it is served (Wheeler, 2004).
Many children with ASD have trouble focusing on one task for long periods of time, making it difficult for them to sit long enough to eat adequate amounts of food (Ansel, 2018). Less time eating combined with severely restricted diets (20 foods or less) means that children with ASD tend to eat too much of some nutrients and too little of others. More specifically, children with ASD generally eat too many calories, protein, carbohydrates, and fat and they typically do not consume enough vitamin A, E, D, folic acid, and calcium (Ansel, 2018; Barnhill, Gutierrez, Marti, & Hewitson, 2018). Restricted diets may also contribute to constipation, as they often don’t contain food high in dietary fiber (Ansel, 2018). Constipation can often be resolved by consuming more fiber, drinking plenty of fluids, and increasing physical activity (Ansel, 2018). Although, there may also be other problems that contribute to chronic constipation in children with ASD (Cermak et al., 2010; Nath, 2014; Sharp et al., 2013).
Strategies to Expand a Selective Eater’s Diet
Below is a list of strategies that have been found to be effective in helping children with ASD expand their diet. Keep in mind that each child is different and, as a result, will respond differently to the strategies listed. Please consult your child’s pediatrician or a pediatric dietitian before making drastic changes to your child’s diet.
Learn to Use the Division of Responsibility in Feeding
The division of responsibility teaches parents how to feed their child in a way that children are most likely to respond. A few key techniques to this approach include: feeding child on a regular schedule, offering scheduled snacks, providing food the child will eat and new foods to encourage variety, and allowing the child to eat and progress at their own pace (Ellyn Satter Institute, 2019).
If your child is sensitive to textures, smells, etc., work with your child outside of the kitchen to grow accustomed to new foods. Familiarize your child to new foods by visiting the grocery store together, learn about new foods, prepare meals together, explore new foods through food play (squashing, painting, stacking, kissing, smelling, etc.). All of these examples help children be comfortable with food without the pressure of actually eating the food (Ansel, 2014; Coulthard & Sealy, 2017).
Similar to familiarizing, repeatedly exposing your child to a new food can help your child to accept it into his or her diet over time. The key with this strategy is to make this experience calm and allow the child to have a sense of control. It works best if new foods are a good sensory fit, such as having a similar color, texture, or smell to foods your child enjoys. Placing the new food in close proximity to your child’s tolerated food and expressing that there are no expectations attached, other than the food remains on the plate, is one way to introduce a new food (Wheeler, 2004). Another method is to ask your child to smell, lick, or taste the food the first time it’s offered (Kuschner, 2018).
The concept of food chaining seeks to expand the variety of foods accepted by your child. Begin by offering a new food that is very similar to one of your child’s preferred foods. Offer the food to your child and ask them to rate how much they enjoyed it. The key to food chaining is to include your child in the process, not to trick them. Children with ASD will avoid previously accepted foods if they feel forced or coerced or tricked (Frey, 2017; Rogers et al., 2012). For instance, if your child likes to eat Cheerios, try offering Honey Nut Cheerios or other round cereals instead. As your child’s anxiety with new cereals decreases try other shapes of cereals like flakes or squares. This strategy will take time and progress may be slow, but it can be highly effective because it builds off of foods your child already enjoys eating (Frey, 2017; Fishbein et al., 2006). For more information about food chaining, contact your pediatric dietitian or read the book Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet by Cheri Fraker, Mark Fishbein, Sibyl Cox, and Laura Walbert.
Work with Your Medical Team
If your child’s diet is highly restrictive, you may need to work with medical professionals for treatment. Dietitians, occupational therapists, speech language pathologists, and behavioral psychologists can all work together to meet the needs of your child and help improve your child’s diet (Cermak et al., 2010). These professionals are trained to offer advice and supplement options to support you as a parent or caregiver to improve your child’s overall feeding experiences.
Mealtimes may currently be a struggle if your child has ASD. However, making small, strategic changes to how you present food to your child may help increase the variety and amount they eat over time. Finding foods that work best for your child is important and may take time. Typically, dietary changes in children with ASD are slow, so don’t get discouraged if you do not see rapid improvement.
- Ansel, K. (2018). Autism Spectrum Disorders (ASD) and Diet. Retrieved from https://www.eatright.org/health/diseases-and-conditions/autism/nutrition-for-your-child-with-autismspectrum-disorder-asd.
- Barnhill, K., Gutierrez, A., Marti, S.N., & Hewitson, L. (2015). Analysis of dietary intake in children with Autism Spectrum Disorder. Autism Open Access, 5,154. doi:10.4172/2165-7890.1000154
- Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238–246. doi:10.1016/j.jada.2009.10.032.
- Chistol, L.T., Bandini, L.G. Must, A., Phillips, S., Cermak, S.A., & Curtin, C. (2018) Sensory sensitivity and food selectivity in children with autism spectrum disorder. Journal of Autism Development Disorder, 48, 583-591. doi: 10.1007/s10803-017-3340-9.
- Coulthard H., & Sealy A. (2017). Play with your food! Sensory play is associated with tasting more fruits and vegetables in preschool children. Appetite, 113,84-90. doi.org/10.1016/j.appet.2017.02.003.
- Ellyn Satter Institute (2019). The division of responsibility in feeding works for special needs. Retrieved from https://www.ellynsatterinstitute.org/family-meals-focus/67-my-child-has-special-needs/.
- Fishbein, M., Cox S., Swenny, C., Mogren, C., Walbert, L., Fraker, C. (2006). Food Chaining: A systematic approach for the treatment of children with feeding aversion. Nutrition in Clinical Practice, 21(2), 182–184. doi.org/10.1177/0115426506021002182.
- Frey, L. (2017). Food Chaining: A proven technique to double the number of foods your child eats. Retrieved from https://inside.akronchildrens.org/2017/05/24/food-chaining-a-proven-technique-todouble-the-number-of-foods-your-child-eats/.
- Kuschner, E. (2018). What is it about autism and food? Retrieved from https://www.autismspeaks.org/expert-opinion/what-it-about-autism-and-food-0 .
- Nath, S. (2014). Feeding problems in children with autism. Retrieved from https://iancommunity.org/ssc/feeding-problems-children-autism.
- Rogers, L.G., Magill-Evans, J., & Rempel, G.R. (2012). Mothers’ challenges in feeding their children with Autism Spectrum Disorder – Managing more than just picky eating. Journal of Developmental and Physical Disability, 24,19-33. doi: 10.1007/s10882-011-9252-2.
- Sharp, W.G., Berry, R.C., McCraken, C., Nuhu, N.N., Marvel, E., Saulnier C.A., .. Jaquess, D.L. (2013). Feeding problems and nutrient intake in children with Autism Spectrum Disorders: A metaanalysis and comprehensive review of the literature. Journal of Autism Development Disorder. 43,2159-2173. doi: 10.1007/s10803-013-1771-5
- Wheeler, M. (2004). Mealtime and children on the autism spectrum: Beyond picky, fussy, and fads. Retrieved from https://www.iidc.indiana.edu/pages/mealtime-and-children-on-the-autism-spectrumbeyond-picky-fussy-and-fads.
Hali Obray, MS; Mateja R. Savoie Roskos, PhD, MPH, RD; April Litchford, MS, RD; Casey Coombs, MS, RD; Carrie Durward, PhD, RD