By Jill K. Belchic-Schwartz, PhD Pediatric/Child Psychologist, Childhood Solutions, PC, Fort Washington, PA
Food selectivity is a fairly common issue with children who have an autism spectrum disorder (ASD). Many children who have been diagnosed with an ASD have difficulties with rigidity and a need for sameness, and this holds true for their food preferences as well. This can be very distressing for parents and caregivers.
Prior to initiating a feeding intervention, it is important to rule out any underlying medical conditions that may be perpetuating the child’s feeding difficulties. Common medical concerns include gastroesophageal reflux disease (GERD) and/or food allergies or intolerances. Any underlying medical issues should be treated prior to implementing a feeding program. Once any medical treatment is underway, you can begin to tackle the child’s food selectivity from a behavioral standpoint. If a multidisciplinary feeding clinic is nearby, encourage the parents of the child with whom you are working to consider scheduling an appointment for him/her to be evaluated.
When treating any child with food selectivity, the first step is to take a very detailed feeding history. Ask about the child’s first experiences with breast or bottle feeding, transitioning to baby food and how they handled the transition to more highly textured foods. Get a current detailed feeding diary. It is also very important to gather information about the setting in which the child eats. Does he sit at the kitchen table for all meals or is he allowed to graze throughout the day? Are mealtimes predictable and do they occur at regularly scheduled intervals and at the same time each day? Is the child “brand specific” and eat only a specific brand of food? Will the child eat only one flavor (e.g., strawberry/banana yogurt)? How is the food presented? How long is a typical meal? What are the child’s refusal behaviors? The more specific the information the better!
There are a variety of techniques available that can be helpful in expanding a child’s food repertoire. However, in order to identify the most appropriate treatment, you must first understand the etiology of the selectivity. For instance, is the child’s food selectivity due to a frank refusal to try all new foods or is it due to a failure to progress to more advanced food textures? The food refusal behavior may look the same (e.g., screaming, hitting, spitting out food, etc.), but the treatment would be quite different based on this information.
Once you are satisfied with your assessment, treatment can begin. Try to stick to a daily predictable schedule of meals and snacks and eliminate grazing/snacking in between meals. Hunger can be a powerful motivator! It is also important to limit the child’s access to liquids in between meals, as some children prefer to drink rather than eat. Set a 15-20 minute time limit for meals. When introducing new foods for the first time, it is usually helpful to start with a “formerly preferred food,” that is, a food that the child used to eat or a food that is similar in taste/texture to something he currently eats.
When presenting the “new” food to the child, start with a very small bite of the new food (e.g., sometimes as small as a pencil point) so as not to overwhelm the child and to ensure a greater likelihood of success. Some feeding therapists use the child’s preferred food as a “reward” for eating the “non-preferred” food, while others use toys/activities as a reward for tasting the new food. What works for one child may not necessarily work for another. Therefore, in order to find the most salient motivators, several different options will likely need to be explored. Additionally, reward systems may need to be changed periodically in order to maintain their effectiveness.
When introducing new foods to a child, it is often easier to start with naturally occurring pureed or smooth foods first (e.g., yogurt, applesauce). The reasoning behind this suggestion is that once the child accepts a bite of pureed food into his mouth, swallowing it is almost guaranteed. With a piece of chopped food, the child may accept the bite into his mouth, but chewing and swallowing may not necessarily occur, and the child may expel the food. For instance, suppose you are introducing fruits and/or vegetables to a child who eats only carbohydrates. The child is more likely to demonstrate success with a one-fourth teaspoon of applesauce than he or she would with a bite of an actual apple. Once the child is accepting a ¼ teaspoon of applesauce consistently (e.g., nine out of ten opportunities), you can begin to increase the bite size to ½ teaspoon. Moving along in a systematic and stepwise fashion ensures a greater likelihood of success. Additional foods can be introduced in a similar fashion once the child is eating a reasonable volume of the new food.
Food selectivity is just one example of feeding problems that may be experienced by children on the autism spectrum. These difficulties often pose a significant challenge to parents, as nourishing our children is expected to be one of the easier, and more enjoyable, tasks of parenthood. Help is available for parents experiencing this challenge, and behavior analysts are a great resource for assessing and treating these disorders because of their specific skill sets in understanding behavior and motivation. For more detailed information, a great resource is, “Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities” by Keith E. Williams and Richard M. Foxx.
Jill K. Belchic-Schwartz, PhD (http://childhoodsolutions.com/) is a Licensed Psychologist who received her Doctorate in Clinical Psychology from Rutgers University in 1995. Dr. Belchic completed her pre-doctoral internship in pediatric psychology at The Children’s Hospital of Philadelphia (CHOP), where she remained on staff for seven years. While at CHOP, she co-directed the Regional Autism Center and was a Program Manager in The Feeding and Swallowing Center. Dr. Belchic’s specialty areas include early assessment of developmental differences, including language delay and diagnosis of autism spectrum disorders (ASD). She also provides psychoeducational assessments for children/adolescents who are struggling in school. She provides community-based consultation and treatment for kids with a variety of psychosocial issues. Dr. Belchic has been in private practice since 2004 and is a partner in Childhood Solutions, PC.
Williams, K. E. & Foxx, R. M. (2007). Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities. New York, New York: Pro-Ed Inc.
Citation for Original Article:
Belchic-Schwartz, J. (2011). Clinical corner: Food selectivity. Science in Autism Treatment, 8(3), 11-12.