STEP 5

Resolve Your Child’s Feeding Problem

Most parents of autistic children are concerned about what they perceive as their child’s “pickiness” about food and negative mealtime behaviors. Autistic children tend to have poor appetites, prefer to drink rather than eat, refuse new foods, accept a very limited variety of foods, crave carbohydrates, and have a need for sameness and rituals around eating. For many families, mealtime is a battleground where their autistic child gags, throws food, or has a major tantrum, and refuses to eat. Parents try everything from forced feeding, bribing, and pleading to distracting their child during mealtime with TV and following him around the house offering bites of food throughout the day. Usually none of these techniques work, and parents are left feeling frustrated, overwhelmed, and defeated.

Unfortunately, many healthcare practitioners don’t understand problem eating and negative mealtime behaviors and are unable to help parents resolve them, which only adds to the frustration. Worse yet, parents are often misinformed and told not to worry—their child will “outgrow his picky eating stage” or he’ll “eat when he gets hungry enough.” This is not true for kids with feeding problems, and most autistic children do have feeding problems as opposed to simply being picky eaters.

PICKY EATERS VS. PROBLEM FEEDERS

In order to help your child overcome his issues with food, you first need to determine whether he’s a picky eater or a problem feeder.

Characteristics of a Picky Eater

Picky eating is a normal part of childhood development. Approximately 50 percent of children aged eighteen to twenty-three months are identified as picky eaters.

• eat fewer than thirty foods;

• eat at least one food from almost every type of food texture;

• will eat the same favorite food every day, but will eventually burn out and stop eating the food. Then they’ll start eating their favorite food again after about a two-week break;

• tolerate new foods on their plate and are willing to touch or taste the food;

• and are willing to eat a new food after they’ve been exposed to it ten or more times.

Picky eaters tend to consume enough calories and continue to gain weight and grow without any problems. If your child is a picky eater, managing his eating is fairly easy:

• Offer your child a variety of foods each day.

• Make sure he eats his meals and snacks at approximately the same time each day.

• Create a pleasant mealtime environment for him.

• Limit his juice to 4 to 6 ounces per day.

• Limit snacks to two to three per day.

These basic strategies are usually all you need to help your picky eater eventually expand his diet to include a wider variety of foods. You can get more detailed information about managing your picky eater from a pediatric registered dietitian. Ellyn Satter, MS, RD, CICSW, BCD—an internationally recognized authority on eating and feeding—has a Web site that contains excellent information on feeding typically developing children, how to handle picky eaters, and developing healthy eating habits for your entire family. You can visit her site at www.ellynsatter.com. (Please note: If you’ve determined that your child doesn’t have a feeding problem, you can move ahead to Step 6, Heal Your Child’s Gut.)

Characteristics of Problem Feeders

Problem feeding is not a normal part of childhood development and is much more complicated than picky eating. Problem feeders tend to eat a very poor diet, may have vitamin and mineral deficiencies, consume inadequate amounts of calories and protein, and their problems may be severe enough to interfere with normal weight gain and growth. Problem feeders

• eat fewer than twenty foods;

• eat fewer foods over time until they accept only five to ten foods;

• refuse to eat foods from entire categories of texture;

• will eat the same favorite food every day, but will burn out and stop eating the food—unlike picky eaters, they won’t eat the food again after a two-week break;

• won’t tolerate a new food on their plate and are unwilling to even touch or taste the food;

• cry and/or throw a tantrum when offered a new food;

• have a need for sameness and rituals around mealtime;

• are very inflexible about particular foods (for example, they will eat only McDonald’s French fries, not Wendy’s);

• and are still unwilling to eat a new food after the typical ten exposures.

If your child has a feeding problem, he will need long-term, extensive feeding therapy from a multidisciplinary feeding team to help resolve his feeding issues.

THE CAUSES OF FEEDING PROBLEMS

Once you’ve determined that your child is a problem feeder, the next step is to figure out why. The only effective way to treat his feeding problem is to identify every single contributing factor to the problem. However, this is easier said than done. There are many possible causes, or combinations of causes, for your child’s feeding problem, such as the following:

• medical conditions

• nutritional problems

• oral-motor dysfunction

• sensory integration dysfunction

• environmental factors

• and behavioral problems

This is where the feeding team comes in. A group of specialists—which includes a physician, registered dietitian, speech-language pathologist, occupational therapist, and behavioral specialist—will work together to identify the causes of your child’s feeding problem and create an individualized treatment program to help him overcome it. A “team” is required because feeding problems are so complex, and each medical professional has a unique role to play in helping your child resolve his problem. The physician is responsible for identifying and treating any medical issues that may be contributing to his feeding problem. Each of the other therapists will conduct their own evaluation of your child to assess his feeding. Based on the results of their evaluations, the team will develop a Feeding Intervention Plan for your child. The plan will explain in detail:

• the factors contributing to your child’s feeding problem,

• the strategies that will be used to address each of the contributing factors,

• specific feeding treatment approaches they will use,

• how often and with which specialist your child will have feeding therapy sessions,

• the goals for treatment and how progress will be measured,

• and how the feeding team members will communicate information to one another and to you.

As I describe the causes of feeding problems below, you’ll see just how each feeding team member fits in to the process.

Medical Conditions

The first step is to have your child’s physician examine him for any underlying medical conditions that could be interfering with his ability to eat. Gastrointestinal problems, such as Gastroesophageal Reflux Disease (GERD), Eosinophilic Gastrointestinal Disorders (EGID), and chronic constipation are some of the leading contributing factors to feeding problems. These conditions make eating physically painful for your child, and eventually he learns to avoid the pain by refusing to eat.

Gastroesophageal Reflux Disease is a condition where acid in the stomach backs up into the esophagus, causing it to become inflamed (esophagitis) and resulting in a burning sensation in the chest. GERD often occurs when the lower esophageal sphincter (the valve separating the esophagus and stomach) doesn’t close properly, allowing acid to back up into the esophagus. Even after GERD has been identified and treated, some children still to refuse to eat because they continue to associate eating with physical pain.

Beware of Aspiration

Some children with GERD also experience aspiration, which is when they inhale the contents of their stomachs into their lungs. Aspiration often causes coughing and choking, but sometimes there are no symptoms. Aspiration is dangerous because it can cause infection in the lungs (like pneumonia), and it can also damage the lining of the lungs.

Eosinophilic gastrointestinal disorders are a chronic and complex group of disorders characterized by having excessive amounts of eosinophils, a type of white blood cell, in one or more specific places in the digestive system. For instance, if your child has Eosinophilic Esophagitis (EE), he has high amounts of eosinophils in his esophagus. If he has Eosinophilic Gastroenteritis (EG), his stomach and small intestines are affected; and if he has Eosinophilic Colitis (EC), the problem is in his colon. The symptoms of eosinophilic gastroenteritis disorder (EGID) vary widely, depending on the area affected, and can mimic the symptoms of other diseases like inflammatory bowel disease, food allergies, irritable bowel syndrome, and GERD. (EE in particular is commonly misdiagnosed as GERD.) The most common symptoms of EGID include the following:

• nausea or vomiting

• diarrhea

• failure to thrive (poor growth or weight loss)

• abdominal or chest pain

• reflux that does not respond to usual therapy

• dysphagia (difficulty swallowing)

• food impactions (food gets stuck in the throat)

• gastroparesis (delayed emptying of the stomach)

• poor appetite

• bloating

• anemia

• blood in the stool

• malnutrition

• difficulty sleeping

If your child has EGID, it can cause him significant pain, which can result in severe feeding problems. EGID can be diagnosed only through an upper endoscopy, colonoscopy, and biopsy. Once the presence of EE, EG, and/or EC is confirmed, food allergy testing is typically ordered by the gastroenterologist. Since reactions to foods can’t always be identified with food allergy testing, your child will also be put on an elimination/challenge diet to help identify problematic foods. The foods that are most likely causing your child’s problem, such as cow’s milk, soy, eggs, wheat, peanuts, nuts, fish, and shellfish will be eliminated from his diet first. Then they’ll be reintroduced one at a time to test your child’s tolerance.

Chronic constipation is typically described as infrequent, hard, and painful bowel movements. Common symptoms include abdominal cramps and pain, bloating, nausea, vomiting, irritability, behavioral problems, poor appetite, and food refusal. Chronic constipation can cause some children to develop megacolon (large intestines gets stretched out of shape), which causes them to pass very large bowel movements. These large bowel movements can result in anal fissures (tears at the anal opening), which are extremely painful. Chronic constipation can also lead to encopresis, or the leakage of stool. Encopresis occurs when the large intestine get stretched to the point where liquid stool leaks around the more formed stool in the colon and passes through the anus into the child’s underwear. If your child has chronic constipation, the pain associated with bowel movements may cause him to refuse to go to the toilet or hold in his stool. Parents of chronically constipated kids often describe them as grazers who eat small amounts of food throughout the day rather than sitting down to eat a meal. When they do sit down to eat a meal, they tend to eat just a few bites and complain they’re full.

If your child’s physician suspects he has a gastrointestinal condition, he will likely refer him to a pediatric gastroenterologist for further assessment. The gastroenterologist may need to administer one or more tests to help identify your child’s gastrointestinal problem, such as an upper GI X-ray, a gastric-emptying study, an upper GI endoscopy, or a pH probe.

It’s also important that your child be seen by a registered dietitian. She can assess whether there are dietary factors contributing to his gastrointestinal problems, such as lack of fluid and fiber intake, medication effects, problematic foods, excess juice intake, and nutrient deficiencies. (Turn to Step 6 for a more in-depth look at gastrointestinal problems in children on the autism spectrum.)

Food Allergies, Sensitivities, and Intolerances

If your child suffers from a food allergy, sensitivity, or intolerance, it may cause him to have several intestinal symptoms, such as reflux, nausea, vomiting, abdominal pain, abdominal distension, gaseousness, loose stools, diarrhea, and chronic constipation. Naturally, these symptoms will make your child feel very uncomfortable, and he’ll learn that eating makes him feel bad. Your child may often refuse food, gradually limit the number of foods he’s willing to eat, and have tantrums and behavioral problems at mealtime. Be sure to rule out food allergies, sensitivities, and intolerances as a possible contributing factor to your child’s feeding problem. (Step 7 discusses in detail how you can identify a problematic food and the appropriate nutritional treatment.)

Medication Side Effects

Many children with autism and related disorders take medication to treat issues like depression, obsessive compulsivity, aggression, tantrums, hyperactivity, and attention deficient. The most common medications used are antidepressants (Anafranil, Luvox, Prozac, Paxil, Zoloft, Lexapro), antipsychotics (Clozaril, Risperdal, Zyprexa), and stimulants (Ritalin, Adderall, Dexedrine). These medications can cause side effects that contribute to a feeding problem. Common side effects include the following:

• decreased or increased appetite

• decreased or increased weight

• nausea

• vomiting

• dry mouth

• altered taste

• abdominal pain

• loose stools

• diarrhea

• constipation

Your child may also have other conditions that are being treated with medication, such as a sleep disorder, seizures, allergies, or digestive problems. If your child is taking one or more medications, you should have a registered dietitian review the potential side effects and assess whether they’re contributing to his feeding problem. Keep in mind that your child should never stop taking a prescribed medication without first discussing it with his physician.

Previous Invasive Interventions

Some children who’ve had an invasive procedure performed around the mouth, such as intubation, tracheostomy, or a nasogastric feeding tube, have ongoing feeding problems for months, and even years, after the tubes have been removed. This can happen when a child is physically unable to eat for an extended period of time and misses the critical developmental stage necessary to build a foundation for feeding skills and normal eating behaviors. It can also occur when a child is traumatized by an invasive procedure and develops a fear of putting things, including food, into his mouth.

Dental Problems

Dental issues such as caries, sore or swollen gums, and mouth sores can contribute to a feeding problem. Your child may limit his diet to soft, smooth foods and refuse crunchy, spicy, or hot foods. Have his dentist rule out dental issues, and be sure your child is going for regular check-ups and cleanings.

Nutritional Problems

Nutritional problems are a common but often overlooked contributing factor to feeding problems. Many times, these problems can be relatively easy to fix. For instance, if your child is drinking too much juice, it can fill up his stomach and make him feel full at mealtimes, preventing him from eating solid foods. Children should have only 4 to 6 ounces of juice per day, but many children drink much more than that. I know kids who sip juice throughout the day and take in as much as 32 to 48 ounces per day. If your child is drinking an excess amount of juice, you should gradually decrease the total amount to no more than one cup per day. You may find that this not only improves your child’s appetite but also his loose stools.

Nutrient Deficiencies

You may remember from Step 3 that a common symptom of vitamin and mineral deficiencies is loss of appetite. This is particularly true of a zinc deficiency. Deficiencies of other vitamins and minerals can have global symptoms, such as irritability, mood and behavior changes, decreased attention, and lethargy, which can interfere with your child’s ability to sit down at the table and eat a well-balanced meal. It’s a vicious cycle: A poor diet causes nutrient deficiencies, which in turn leads to poor appetite, which results in food refusal and mealtime behavior problems. Turn to Step 3 for a refresher on improving your child’s diet with a daily multivitamin and mineral supplement. A registered dietitian can assess your child’s diet to determine specific vitamin and mineral deficiencies and recommend appropriate supplements.

Oral-Motor Dysfunction

Your child may have an oral-motor skill problem, such as difficulty sucking, biting, chewing, swallowing, or coordinating tongue movements, which interferes with his ability to eat and to handle foods of certain textures and consistencies. A speech and language pathologist (SLP) can evaluate your child’s oral-motor function, identify delays and problems, and then guide him through therapeutic activities that will improve his feeding skills. The SLP may have your child undergo an X-ray procedure called a video fluoroscopic swallow study (also known as a modified barium swallow study) to determine whether he’s able to swallow safely without aspirating food or liquid into his lungs. It’s very important that your child be assessed by a SLP before starting a feeding therapy program. This serves two purposes: You’ll be able to rule out or identify and treat any oral-motor problems, and you’ll also reduce your child’s risk for aspiration and choking.

Sensory Integration Dysfunction

One of the leading contributors to feeding problems among autistic children is sensory integration dysfunction, also known as sensory processing disorder. Children with sensory integration dysfunction experience a disruption of the intake and organization of sensory information within the brain. This causes them to have trouble responding appropriately to sensory information from their environment. Sensory processing dysfunction affects children in every facet of their lives, including eating. Eating is a complex act that requires all five of our senses: visual, tactile (touch), smell, taste, and auditory (hearing). Your child must be able to simultaneously integrate all five of his senses during the eating process. If he has sensory integration dysfunction, he likely has a tough time touching, let alone eating, food. He may be hypersensitive to the texture, smell, and temperature of foods and become easily overwhelmed during mealtime, triggering a tantrum and food refusal. Your child may also overreact to noises and be unable to eat at mealtime when family members are talking at the dinner table. Conversely, your child may be hyposensitive and is not sensitive enough to sensory information. This would prompt him to seek out constant stimulation or more intense sensory experiences. Hyposensitive children often stuff their mouths full of food, pocket food in the sides of their mouths, and swallow the food later or spit it out.

Here are some common mealtime responses you may have seen from your child if he has sensory issues:

 

Visual. Your child may prefer foods of a certain color and reject foods of any other color. He may have a tantrum if foods touch each other on his plate. Serving sizes that are too large may visually overwhelm your child and he may totally refuse to eat anything.

 

Tactile. If your child is hypersensitive, he may be unwilling to touch foods with his hands. (Exploring foods with his hands is a critical step to becoming familiar with a new food, putting it in his mouth, and learning to successfully eat it.) He likely rejects new foods, and gags, chokes, or vomits, which reinforces his fear of certain foods.

 

Smell. If your child is hypersensitive to smells, he may become fussy and eventually totally overwhelmed by the odors of food preparation and cooking before mealtime even begins. He may gag or vomit when the food is offered at mealtime.

 

Taste. Strong flavors can trigger the gag reflex in children with taste hypersensitivity. Your child may have very strong taste preferences and prefer bland foods or specific flavors.

Auditory. For children who are hypersensitive to sound, eating food itself can create sounds that are overwhelming. Your child may prefer soft foods and liquids to avoid the sounds created by hard, crunchy foods. People talking at the table, sounds in the environment, television, and other sounds during mealtime may distract your child and he may be unable to eat.

If your child is hyposensitive to sensory input, he may seem oblivious during mealtimes, even in noisy environments. He may have trouble differentiating between different tastes, textures, temperatures, and smells of food. He may also have trouble identifying when he’s full, which can lead to portion control issues.

An occupational therapist (OT) can evaluate your child’s ability to process sensory information, assess if he has a sensory integration dysfunction, and identify how it impacts his ability to eat. The OT plays a major role in developing a feeding therapy program, providing therapy, and improving your child’s tolerance level to sensory input.

Environmental Factors

Your child’s mealtime environment plays an important role in his ability to eat.

 

Distractions. Distractions during mealtime can over-stimulate your child; he may become overwhelmed from the sensory overload, lose focus, and lose interest in eating. Be sure to keep distractions at mealtime to a minimum by limiting noise and turning off the television set.

 

Grazing. If your child picks at food all day long and never sits down for a real meal, he’ll lose his internal biorhythm of feeling hungry and full. He won’t develop normal hunger cues and won’t have the desire to sit down and eat a meal or healthy snack.

 

Lack of routine. Children should have a structured schedule that includes three meals and two to three snacks every day. Otherwise, they can’t fall into a comfortable pattern of expecting meals and snacks. Offer your child his meals and snacks at a designated place where he’s expected to sit in a chair at a table. Consistency, structure, and routine developed around meals and snacks will promote a healthy appetite and improved eating.

 

Mealtime dynamics. Your interaction with your child at mealtime may also play a role in his feeding problem. For instance, trying to coerce, trick, or bribe your child to taste a food will lead to struggles between you that will only worsen his problem.

 

Improper physical environment. Where your child sits, his chair, his posture during mealtime, and the utensils he uses all need to be assessed to make sure they meet his needs. For instance, your child’s utensils may not be age-appropriate. Or he may need a more supportive chair to facilitate eating.

I encourage you to have one of your child’s therapists and/or a behavioral therapist come to your home and observe a mealtime. This is the best way to identify any environment factors that need to be addressed and come up with strategies to resolve them that can be included in your child’s feeding therapy.

Behavioral Problems

Your child’s behavior toward food and at mealtimes is the final piece in the feeding problem puzzle. It’s very important to pay attention to your child’s negative mealtime behaviors because he’s trying to tell you something. If you learn to interpret his behaviors, you’ll be able to figure out where the feeding process is breaking down for him. Common negative mealtime behaviors include the following:

• refusing to come to the table

• not sitting still in his chair and continually leaving the table

• refusing to eat

• throwing food

• crying when presented with food

• throwing tantrums

• gagging and/or vomiting

• spitting out food

• disrupting others who are trying to eat

As you now know, many of these behaviors could be caused by medical conditions, nutritional problems, oral-motor dysfunction, sensory integration dysfunction, and environmental factors. Once all of the issues I’ve discussed in this chapter have been ruled out or identified and addressed in your child’s treatment program, you may find that his behaviors at mealtime improve significantly. However, these negative responses may be so entrenched in your child’s mealtime routine that he continues them even after the root problem has been resolved. I strongly recommend that you have your child assessed by a behavioral specialist. The behavioral specialist will conduct a behavioral functional assessment, which will help determine what triggers specific behaviors at mealtime, and develop strategies for you to handle your child’s behavior. He can also advise the other therapists on your child’s feeding team on how to best handle your child’s behavior problems and offer insight on his feeding intervention plan.

Tyler’s Story

Tyler was a twenty-seven-month-old diagnosed with PDD-NOS. He was also a twin who had been born two months premature. His parents told me he was nonverbal, avoided contact with other people, had severe “meltdowns,” and often spun around in circles. He had been receiving speech therapy once a week through an Early Intervention program and had an Individual Family Service Plan (IFSP) in place.

Tyler’s parents described him as a very picky eater. In reality, Tyler had a severe feeding problem. He only ate Stage 2 baby foods (sweet potato, pears, and vegetable /chicken), chocolate-flavored soy milk, water, and GFCF potato chips, and had never transitioned to regular table foods. He once tried to eat shredded chicken but spit it out after he chewed it. Tyler did not express hunger, refused to try new foods, refused baby foods he used to eat, and resisted going to the table at mealtime. On the other hand, Tyler’s twin brother had transitioned to regular table foods without a problem and was eating a wide variety of foods. In an attempt to get Tyler to eat, he was allowed to “graze” on foods and sip chocolate-flavored soy milk from a sippy cup all day long. His mother said that the only way she could get Tyler to eat at all was to sit him in front of the television and distract him during mealtime. His parents were very frustrated and simply didn’t know what else to do. Tyler was not receiving any type of therapy to address his feeding problem.

To start, I sent a letter to Tyler’s physician explaining that I suspected Tyler was not a picky eater, but rather he had a severe feeding problem that required an evaluation and feeding therapy by a multidisciplinary feeding team. Tyler was then referred to a pediatric gastroenterologist to rule out any medical conditions that may be contributing to his feeding problem, especially since as an infant he had a history of reflux, projectile vomiting, and required an amino acid-based infant formula. Tyler was also evaluated by the occupational therapist with the early intervention program to determine if his sensory integration processes were impacting his feeding. His speech language pathologist expanded on her speech evaluation to assess his oral-motor and swallow skills related to feeding. I also suggested a referral to a behavioral specialist who could evaluate Tyler’s behavior and interactions with his parents during mealtime.

Following my recommendation, Tyler’s mother requested an IFSP meeting, where she asked that feeding therapy be included in Tyler’s IFSP. It was designated that the speech language pathologist would provide two feeding therapy sessions a week. The speech language pathologist wanted to do this, but didn’t feel she had adequate training in the area of feeding therapy. After additional negotiation, the early intervention program agreed to send the speech language pathologist to Dr. Toomey’s two-day seminar to learn the SOS approach to feeding. She returned from the intense comprehensive training prepared and excited to get started with Tyler. Together, the entire feeding team—Tyler’s parents, the speech language pathologist, occupational therapist, behavioral specialist, and the registered dietitian—developed a feeding intervention plan and wrote feeding outcomes and objectives that were included in Tyler’s IFSP. Tyler began his twice weekly feeding sessions and within just eight weeks, significant improvements were made. Tyler accepted six solid foods: GFCF cookies, crackers, and bread, rice cakes, peanut butter, and bacon. After several more weeks, his diet expanded even more to include vegetables, fruit, and meat. With the entire feeding team working together, Tyler accomplished the goal of eating a developmentally age-appropriate meal, sitting in a chair at the table, and using age-appropriate utensils to feed himself.

Tyler’s mother did an outstanding job of pulling together a feeding team with the cooperation of the Early Intervention program. She strongly and successfully advocated for her son and received services that were not traditionally provided by that particular program. Tyler’s mom told me that it was a very hard task to accomplish and extremely frustrating at times, but she was determined not to give up. She said, “Every minute was worth it when my husband and I can sit down at the dinner table and enjoy a normal meal with both our boys.”

INDEPENDENT FEEDING THERAPY PROGRAMS

There’s very little research available on effective therapy to treat feeding problems among young children with autism, and even less information on working with older children. However, there are a few step-by-step feeding therapy programs that have been quite successful with autistic children. Cheri Fraker, CCC-SLP, has created a program called Food Chaining, which is based on the idea that there are specific reasons why your child will eat only certain foods. Your child may find these foods acceptable because of their color, texture, flavor, or even visual appearance. Food chaining determines why your child accepts certain foods, and then shows you how to expand his food repertoire by introducing new foods that have the same features as the ones he currently eats. After your child has expanded his diet with this method, new foods with slightly different features are introduced. You can find a complete description of this method in Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet, by Cheri Fraker, Laura Walbert, Sibyl Cox, and Mark Fishbein.

Another feeding therapy program that has proven effective is the Sequential Oral Sensory (SOS) Approach to Feeding, which was developed by pediatric psychologist Dr. Kay Toomey. The SOS approach is a thirty-two-step plan designed to ease your child into tolerating, interacting, smelling, touching, tasting, and eating a new food. Dr. Toomey offers advanced courses to train therapists in the SOS approach in Denver, Colorado.

If you’re considering trying either one of these treatment approaches, be sure to discuss it with your child’s feeding team first.

FINDING A FEEDING TEAM

Many hospitals, medical facilities, and private clinics in large cities have feeding teams already in place. However, if you don’t live in or near a large city, this may not be a good option for you. Feeding therapy is intensive and can last for months, and it’s unrealistic for you to drive back and forth long distances for feeding therapy sessions for an extended period of time. If you live in a smaller town or a rural area, chances are you won’t find an already-assembled feeding team in your community. This means you’re going to have to put one together on your own. Before you panic at the thought, let me assure you that assembling a feeding team for your child is not as hard as you might think. The following steps will help you get started:

1. Start by looking at the therapists who are already treating your child’s autism. Do any of them have experience with feeding problems? If so, talk to them about becoming part of your child’s feeding team.

2. Ask your child’s physician for referrals to a speech-language pathologist, occupational therapist, registered dietitian, and behavioral specialist.

3. Set up a time to talk with each of the referrals. You want to get to know them a bit, as it’s important for you and your child to feel comfortable with everyone on the feeding team, and you should also find out if they have experience with autism and feeding problems.

4. Once you have selected the members of your child’s feeding team, schedule an appointment with each of the therapists for a comprehensive assessment.

5. Ask the feeding team to develop a Feeding Intervention Plan for your child.

Putting together your child’s feeding team will take some work, but it’s the only way you’re going to be able to resolve his feeding problem and expand his diet. In the end, I know you’ll find that it’s well worth the effort.

AT-HOME STRATEGIES TO IMPROVE YOUR CHILD’S FEEDING PROBLEM

It’s going to take some time to locate or assemble a feeding team, have your child evaluated, develop a feeding intervention plan, and start feeding therapy sessions. In the meantime, here are some very basic strategies you can use to improve your child’s feeding problem.

 

Use positive reinforcement. Praise your child when he does something appropriate at mealtime, and do your best to ignore his negative behaviors. Do the same with your child’s siblings to help reinforce the point. Keep mealtime positive, pleasant, and enjoyable.

 

Use social modeling. Even if your child refuses to eat, have him sit at the dinner table with the rest of the family at mealtime. You and your child’s siblings should model good eating and social behavior and avoid making negative comments and faces at foods. Your child should not be the focus of the mealtime.

 

Limit his juice. Don’t allow your child to drink more than one cup of juice per day.

 

Don’t let him graze. Your child shouldn’t be nibbling on small amounts of food all day long. Offer him three meals and two to three small snacks per day. Offer him water between meals and snacks.

 

Stick to a schedule. Your child’s meals and snacks should be approximately two and a half to three hours apart and offered at approximately the same time and at the same place in your home every day. He needs to learn that there’s a consistent daily routine for meals and snacks. Meals should be limited to no more than thirty minutes and snacks to fifteen minutes.

Limit distractions during mealtime. Turn off the television during meals, and keep the ambient noise level down to avoid auditory over-stimulation.

 

Offer manageable foods. Present foods on your child’s plate in small, easily chewable bites. There should be no more than three different foods on his plate at any one time. Give your child smaller-than-normal serving sizes to avoid visual over-stimulation.

 

Get your child involved. Make your child a part of menu planning, grocery shopping, food preparation, and setting the table for meals. He’s more likely to eat a food if he’s had some sort of interaction with it prior to mealtime.

 

Use appropriate mealtime language. Don’t ask your child a question or make a demand to which he can respond with a “no.” This will lead to a power struggle between you. Avoid “can you?” questions and “don’t” demands. Instead, speak to your child using positive statements, such as “you can” and “do.” Here are some examples:

Instead of saying “Suzie, can you take a bite of peas for Momma?” say, “Suzie eats peas with her spoon.”

Instead of saying “Suzie, please can you drink some milk for Daddy?” say, “Suzie sips milk from her cup.”

Instead of saying “Don’t throw your cup!” say, “Cups are for drinking. Your cup goes here until you’re ready to take a sip.”

Instead of saying “Don’t put so many crackers in your mouth at a time! You’re going to choke!” say, “Johnnie chews one cracker at a time.”

 

Avoid food burnout. If your child eats the same food, the same way, every day, he’ll eventually “burn out” and eliminate the food from his diet. Once an autistic child with a feeding problem eliminates a preferred food, he usually won’t accept it again in the future. If your child continues to burn out on his preferred foods, he’ll soon be left with a very few foods in his diet. To avoid burnout, offer a particular food no more than every other day; and if your child has a very limited food repertoire, and you have no choice but to offer a particular food daily, change one thing about the color, shape, texture, or taste of the food. The change should be very slight—your child should notice a difference but not enough to cause him to reject the food. Even a difference this slight can be enough to prevent food burnout. Here’s an example:

Suzie eats a pancake every day, but her diet is limited to three foods, so her mom has to offer them every day and avoid burnout at the same time.

Monday: Mom should serve the pancake as usual.

Tuesday: Mom should change the shape; for instance, make it oblong instead of perfectly round.

Wednesday: Mom should change the taste; for instance, add two eggs to the batter instead of one.

Thursday: Mom should change the texture; for instance, add a very small amount of fiber powder to the batter.

Friday: Mom should change the color; for instance, add a small amount of fruit preserve to the batter.

Saturday: Mom should change the shape of the butter on the pancake.

Sunday: Mom should change the color of the syrup; for instance, make it darker or lighter.

 

These basic strategies will help you get started improving your child’s eating behaviors and hopefully prevent them from getting worse while you wait for his feeding therapy to begin.

PROJECT NO. 5: DETERMINE WHETHER YOUR CHILD IS A PICKY EATER OR A PROBLEM FEEDER

1. Consult the list of characteristics for picky eaters and problem feeders on pages 61-63. If your child demonstrates characteristics of a picky eater, see a registered dietitian for strategies to handle picking eating.

2. If your child demonstrates characteristics of a problem feeder, take him to his physician for a complete medical exam and ask if he can refer you to a feeding team.

3. If your child’s physician can’t refer you to a feeding team, assemble the team yourself by consulting with your child’s current therapists and/or getting individual referrals from your child’s physician (see page 74 for tips on putting together a feeding team on your own).

4. Start implementing the at-home feeding strategies to help improve your child’s feeding.

My hope is that you come away from this chapter with an understanding of how important it is to address and resolve your child’s feeding problem. You can’t take a “wait and see” approach and hope your child’s feeding problem improves on its own. It won’t. In fact, it will only worsen over time. The sooner you take action, the better. It’s also important to recognize that you cannot solve your child’s feeding problem on your own. Feeding problems are very complex, and your child must be treated by a team of professionals. It’s true that Step 5 is time-consuming, and it will take weeks or even months to achieve. But watching your child’s diet expand, and seeing him eat a variety of healthy foods, probably for the very first time, is a wonderful reward for all your time, effort, and hard work.