As a parent of a child on the spectrum, you probably understand the difficulties in providing proper diet and nutrition when eating habits ranging from quirky to truly bizarre is not uncommon. While at first these difficulties with eating may seem like a normal phase, over time eating issues can become a detriment to not only the child themselves, but the family as a whole. Proper diet and nutrition are the foundation for a healthy lifestyle, and prolonged exposure to a monotonous diet can lead to poor nutrition, which can affect other aspects of your child’s development beyond his or her physical growth. Whether your child is a picky eater who insists on putting ketchup on everything or is experiencing adverse reactions to specific food items indicating the need for dietary restrictions, addressing your child’s eating troubles is imperative. Prolonged feeding issues are dangerous and should be addressed immediately. This article will discuss nutrition and diet for children on the autism spectrum, with a focus on recognizing eating issues, exploring dietary concerns, and non-food related problems.
If you have a child on the spectrum who is experiencing or has experienced challenges with eating, then you are not alone. In fact, a 2013 study found that children with autism are “five times more likely than other kids to have feeding issues, such as being especially picky eaters or having ritualistic behaviors or extreme tantrums during meals.”1 These struggles are of great concern because they tend to serve as the root cause of other problems often associated with autism. According to the same study, “chronic feeding troubles increase a child’s risk for problems such as malnutrition, poor growth, social difficulties and poor school performance.”1 Mealtime doesn’t only function as a means for promoting healthy eating habits, but also serves as an opportunity for socialization. Moreover, poor eating habits can have adverse effects on other members of the family, causing parental stress or influencing what other members of the family eat.2 To quote from Recent Advances in Autism Spectrum Disorders, “eating is not only about food. At the table members of the family enjoy each other’s company, the meal, exchange feelings and family/cultural values. When mealtimes are not pleasurable and some members do not feel respected with regard to their needs and choices, the relationship may become affected.”3 In almost all cultures, mealtimes offer your child the opportunity to organically learn socialization, a concept with which individuals on the spectrum commonly struggle with.
The issues that stem from a child’s eating habits can slowly erode others’ perceptions of the child. For example, a study found parents of children with high food selectivity “reported high levels of parental stress and a larger degree of their children’s behavioral problems.”5 Essentially, parents with children on the spectrum who are picky eaters “perceive their children to be significantly more impaired by their autism symptoms than do parents of more typical eaters.”5 The study also found that parents of picky eaters report higher levels of personal stress.5 However, there is a difference between your child being a picky eater and having a serious eating issue. According to Autism Speaks, parents should be concerned with their child’s eating habits if one of the following is occurring:6
Your child is losing weight or showing signs of poor health
Your child is eating fewer types of food or has few foods in their diet
Mealtime behaviors are causing stress
If your child or your family is experiencing any of these scenarios, then you should consider meeting with your primary care physician (PCP) or certified nutritionist immediately to discuss the root cause and ways to manage these problems.
Origins of Eating Issues
Determining why your child adversely reacts to their diet is key to implementing the proper course of treatment. Before exploring and introducing potential treatments, Faye Elahi, MS, MA, a special needs nutritionist and bestselling author, recommends conducting a nutritional and digestive tract assessment from professionals via a stool sample test.7 Additionally, she recommends an allergy test to determine if the child suffers from any gluten, casein, soy, or other intolerances as well as a number of food allergies.7 Some of the tests nutritionists may use include:7
Organic Acid Test: A comprehensive test for vitamins, minerals, pancreatic enzymes, yeast overgrowth, and liver status
Comprehensive Toxic Element urine test: This test will determine the levels of specific toxic metals in your child
Gastrointestinal stool test: Used for detecting bacteria, yeast , parasite, and enzyme status
IgG/IgE/Leap food allergy tests
Serum or Stool Test: Detects gluten, casein, and/or soy intolerances
Depending on the results of these tests, you may want to consider implementing a specialized diet for your child. For further information regarding these biomedical tests and specialized/restrictive diets, view National Autism Network’s “Autism Diet & Nutrition: Which Diet if Right for My Child Diagnosed with Autism?” webinar.
Only through a professional assessment can you rule out specific abnormalities that underlie the cause of your child’s eating issues. Some children with autism may be over sensitive to certain tastes and smells, causing certain foods to overwhelm their palate. Others on the spectrum have other physical challenges, such as motor difficulties or gastrointestinal disorders at the root of the issue.3 It is also possible that feeding problems arise “from a limited ability to communicate of from poor social and cognitive skills. Eating skills and mealtime manners are learned by observation and imitation, yet these associations have not been correlated with autism.”3 A common eating problem, food refusal, may be categorized in a number of different ways, from medical complications to being fear-based.3 Fortunately, some food issues can be assessed rather simply. For example, the dangerous eating habit of Pica, which is “the recurring ingestion of nonnutritive substances,” can be commonly traced to one of three identified causes:8-9
Sensory feedback: Children eat non-food items because they get a pleasurable of enjoyable feeling.
Inability to differentiate from non-food items: Some children simply believe that the items they are ingesting are indeed food.
Low levels of iron or zinc: Some children have low levels these minerals, but a change in diet or supplementation with vitamins may help. Behavioral treatment may also be required to eliminate pica from your child’s diet.9
Pica is a dangerous eating disorder that is “relatively common in children and adults with autism and other developmental disabilities.”10 So much so that Autism Speaks developed two toolkits on the subject: “Pica: A Guide for Parents” and “Pica: A Guide for Professionals.”
Non-food Related Eating Issues
Not all of the problems parents encounter around mealtime center around the child’s aversion to specific food items. It is common for children to be wholly regiment when it comes to their meals, having to follow a strict routine.11 Another common occurrence are individuals on the spectrum feeling uncomfortable eating away from their home, preferring to starve rather than eat in a foreign environment.11 Other times it’s a matter of simply persuading your young one to sit at the table and join the family for dinner, especially when it means waiting for others to arrive or waiting for everyone’s food to be plated before digging in.12 One recommendation is to address this inability to wait with special toys or activities so they have something to focus on while waiting.12 For children who have difficulty sitting in one place, “a timer needs to be set to show more concretely that sitting is expected at mealtime, at least for a few minutes until the timer rings. The length of times a child is expected to sit and eat at the table may be gradually lengthened so success is built up slowly.”12 Your child’s eating issues may stem from a combination of personal and environmental factors. To assess these problems, parents may be asked to fill out any number of mealtime or nutritional questionnaires to help pinpoint the underlying issues surrounding your child’s poor eating habits:3
Mealtime Behavior Questionnaires:
Children’s Eating Behavior Inventory (CEBI-R)- This questionnaire “is a 40-item caregiver report measure intended to assess eating and mealtime problems across a wide variety of children with medical and developmental disorders.”13 Two scores are derived from this measure:13
Total Eating Problems: Measures the frequency of 19 different eating behaviors through the use of a 5-point rating scale
Total Perceived Eating Problems: Asks caregivers to evaluate whether or not each behavior presents a problem for the family
Brief Autism Mealtime Behavior Inventory (BAMBI)- Measures the frequency of mealtime behavior problems in children with ASD between ages 3 and 11. The test contains 18 questions pertaining to “limited variety of foods,” “food refusals,” and “autistic behaviors.”3
Parent Mealtime Action Scale- This 31-item test measures parent’s action regarding their children’s mealtime behavior in nine dimensions. Originally developed with a sample of 2000 typically developing children, a research has shown its applicable to children on the spectrum as well.3
Eating Profile- This is the largest of the assessments, comprised of 11 domains (145 items), used to “compare mealtime behavior (ASD vs typically developing) in the same family.”3 A study of feeding problems in children with ASD using “The Eating Scale” found that “children with ASD had more eating problems as infants. Older children tended to have fewer problems than younger children. This study point to the importance of screening for mealtime problems.”14 In comparing children with ASD to their neurotypical siblings the study found that “although typically developing children also had some mealtime problems, children in the same social and physical environment but with ASD, had significantly more such problems than their siblings. Lack of variety of foods,… an inadequate number of meals, not eating at the table, or not staying seated during the meal, as well as showing some oral-motor deficits were the most significant differences between the two groups.”3
Nutritional Assessments:
Youth/Adolescent Questionnaire (YAQ)- A self-report inventory for food frequency with 148 items to determine the nutritional intake of 9 to 18-year-olds and the average food serving frequency of six food groups. A modified version of the YAQ can be utilized for children with ASD to quantify food refusal and food selectivity.
Food Records- These are used by nutritionists to measure energy intake. Parents report their child’s food intake for an average of a 3-day period, including one weekend day, and report their findings to their nutritionist.
Direct Observation
Multidisciplinary Feeding Profile (MFP)- This evaluation is divided into six sections:3
Physical/Neurological factors
Oral-Facial Structure
Oral-Facial Sensory Inputs
Oral-Facial Motor Function
Ventilation/Phonation
Functional Feeding Assessment
Schedule of Oral-Motor Assessment (SOMA)- Measures the oral-motor and feeding skills of children 8 to 24 months. The early intervention aspect of this test makes it especially attractive for at-risk children.
With professional intervention, these assessments can be an important tool for diagnosing the source of your child’s eating issues. By educating yourself on the types of mealtime evaluations, you can work with a professional to determine which intervention approach might be most appropriate for your child. As a parent, your input is invaluable when it comes to these types of assessments as you know your child and their eating routines and habits better than anyone. Work in cohesion with your nutritionist or primary care physician to develop treatment goals. A family-centered approach is critical for attaining these goals.3 By addressing and resolving your child’s eating issues, you can improve the overall quality of your family’s mealtimes.
If we were to refer back to our “bizarre” list of eating habits, you will notice quite a few that truly illustrate how it’s not necessarily the food that is the source of your child’s limited palette. One example would be of the child who had the misfortune of the manufacturer changing the style of the jar that their food would come in, causing him to refuse to eat it. As a solution, the parent had to take the food out of the newly-styled jar and place it in the old jar before the child will commence to consumption.15 Another example would be the child who would only accept their meals if they came served in either a “Lightning McQueen” bowl or plate.15 Some children will only eat foods that are “arranged properly,” in this case a child rearranged a sandwich his mother had prepared for him and rearranged it “correctly” before ingesting it.15 If you have a child who exhibits these types of quirky non-food related issues, share with our community in the comment section below.
Conclusion
Children on the autism spectrum can demonstrate a myriad of feeding issues, from the ordinary to the complex, which may be observed even before an official diagnosis of autism is made. Feeding is a complex human behavior with varying levels of success depending upon the individual’s developmental level.6 A poor diet and nutrition can affect your child in a number of ways, including poor physical and emotional health. When confronted with these issues you should first meet with your child’s primary care decision for how to further proceed.6 The Autism Speaks’ Toolkit: Exploring Feeding Behavior in Autism has a number of recommendations for food-related challenges, including steps you can take at home. To find a reliable professional, search the National Autism Network Provider Directory for dietary specialists and nutritionists in your area.
References:
1. “Don’t Overlook Eating Issues Tied to Autism, Study Warns.” U.S. News World Report: Health. February 9, 2013. Accessed August 4, 2015. http://health.usnews...ism-study-warns.
2. Curtin, C., K. Hubbard, S.E. Anderson, E. Mick, A. Must, and L.G. Bandini. “Food Selectivity, Mealtime Behavior Problem, Spousal Stress, and Family Food Choices in Children with and without Autism Spectrum Disorder.” Abstract. Journal of Autism and Developmental Disorders (June 2015). Accessed August 4, 2015. http://link.springer...803-015-2490-x#.
3. Nadon, Geneviève, Debbie Feldman, and Erika Gisel. “Feeding Issues Associated with the Autism Spectrum Disorders.” Recent Advance in Autism Spectrum Disorders – Volume 1 (March 2013): 599-623. Accessed August 4, 2015. http://cdn.intechope...fs-wm/43414.pdf.
4. Postorino, V., V. Sanges, G. Giovagnoli, L.M. Fatta, L. De Peppo, M. Armando, S. Vicari, and L. Mazzone. “Clinical Differences in Children with Autism Spectrum Disorder with and without Food Selectivity.” Abstract. Appetite 92 (September 2015): 126-132. Accessed August 4, 2015. http://www.sciencedi...195666315002433.
5. Nuwer, Rachel. “Picky Eating Sways Parents’ Views of Children with Autism.” Simons Foundation Autism Research Initiative (SFARI). July 3, 2015. Accessed August 4, 2015. https://sfari.org/ne...ren-with-autism.
6. “Exploring Feeding Behavior in Autism.” Autism Speaks Autism Treatment Network, Inc. January 2014. Accessed August 4, 2015. http://www.autismspe...eding_guide.pdf.
7. “Autism Diet & Nutrition: Which is Right for My Child Diagnosed with Autism?” Webinar. National Autism Network. December 11, 2014. Accessed August 4, 2015. http://nationalautis...s/webinars.html.
8. “Diagnostic Criteria According to the DSM V.” Help for Pica. Accessed August 4, 2015. http://helpforpica.w....com/dsm-v.html.
9. “Pica: A Guide for Parents.” Autism Speaks Autism Treatment Network, Inc. May 2014. Accessed August 4, 2015. http://www.autismspe...rents_guide.pdf.
10. Cole, Lynn. “The Pica-Autism Connection: Help & Perspective in ‘Got Questions?’” Got Questions? (blog), Autism Speaks, Inc. Accessed August 4, 2015. https://www.autismsp...e-got-questions.
11. Moran, Paddy-Joe. “Autism and Food – Part 1 – Issues That May Arise.” Autism Daily Newscast (ADN). May 7, 2015. Accessed August 4, 2015. http://www.autismdai...6638/paddy-joe/.
12. “Autism Spectrum Disorders Fact Sheets: Eating and Feeding Issues.” Synapse. Accessed August 4, 2015. http://www.autism-he...ding-issues.htm.
13. Laud, Rinita B., Peter A. Girolami, James H. Boscoe, and Charles S. Gulotta. “Treatment Outcomes for Severe Feeding Problems in Children With Autism Spectrum Disorder.” Behavior Modification 33, no. 5 (September 2009): 520-536. Accessed August 4, 2015. http://feedingdisord...f/Laud_2009.pdf.
14. Nadon, G., D.E. Feldman, W. Dunn, E. Gisel. “Mealtime Problems in Children with Autism Spectrum Disorder and Their Typically Developing Siblings: A Comparison Study.” Abstract. Autism 15, no. 1 (January 2011): 98-113. Accessed August 4, 2015. http://www.ncbi.nlm....pubmed/20484003.
15. McGlensey, Melissa. “30 Autism Parents Describe their Kids’ Bizarre and Funny Eating Habits.” The Mighty. July 27, 2015. http://themighty.com...n=Facebook_Page