By Debra Lobato, PhD
Although feeding problems were included in the first descriptions of autism, they have received much less attention than the social, behavioral, and language deficits we have all come to recognize. This article reviews the types of feeding problems associated with autism, the commonly related nutritional and medical concerns, and the interventions that have been developed.
May 2011 Vol. 27, No. 5
This article was published in the Brown University Child and Adolescent Behavior Letterin cooperation with Bradley Hospital.
Case example: Feeding problems in a 3-year-old with autism Abigail presented to a multidisciplinary clinic when she was 3 years old due to feeding problems and failure-to thrive. She had been difficult to feed since infancy, when she was diagnosed with reflux. Abigail frequently had “meltdowns” at mealtimes and refused what other members of the family (including her 5-yearold sister) ate. Abigail acted as if her parents were poisoning her whenever they put something on or near her plate that she did not want to eat. Abigail’s diet consisted solely of small amounts of toasted cheese sandwiches (white American cheese only), chicken nuggets (only one brand), and potato chips. She consumed no fruits or vegetables. She drank apple juice and a milk shake once per day. There were foods that Abigail once ate but had stopped eating.
Abigail was malnourished and surgical placement of a g-tube was being considered. She was significantly underweight (<3rd percentile for weight, 50th percentile for height) and had deficiencies in calcium, Vitamin D, and iron. Finally, she had chronic constipation but would not accept the high-fiber foods or laxatives prescribed by her pediatrician.
The feeding problem most commonly associated with autism is selective or restrictive eating whereby a child consumes a very narrow range and number of foods. Estimates are that 60%–89% of autistic children are selective eaters. Foods are often refused based on their characteristics (e.g., texture) or presentation (e.g., placement on a particular plate). All parents of children with autism (100%!) report that introducing new foods is very challenging. Further, many parents report that their child with autism has difficulty sitting for family meals (89%); spontaneously eliminates previously eaten foods from their diet (56%); or refuses to touch food or utensils (11%; Ledford, 2006).
A few hypotheses have been offered to explain the high prevalence of feeding problems in autism. One is that selective eating is another manifestation of the “insistence on sameness” and restricted interests which characterize autism. Others hypothesize that sensory disorders or variations in perception of flavor and texture underlie restricted eating.
One study compared families of children with and without autism to determine if autism severity or family food preferences play a role in selective eating (Schreck 2006). The children with autism had more selective diets than the children without autism, but there were no group differences between the family diets. Family diet was a better predictor of a child’s eating than autism severity. Families who ate a more varied diet had children who were relatively less restrictive in their eating.
Children with autism generally achieve similar heights and weights as children without autism, suggesting that they usually consume sufficient calories for ageappropriate growth. In part, this may explain why the issue of feeding has received less professional attention — feeding issues might only become a priority if the child experiences failure-to-thrive.
However, highly selective eating places children at risk for specific nutritional deficiencies. Almost two thirds of children with autism eat fewer than 20 foods and accept fewer foods from the basic food groups than typically developing children. Similar to typically developing children, children with autism consume starches and carbohydrates more than any other type of food. They are most often selective against fruits and vegetables (58–71%), meat or beans (24–35%), and milk and dairy (18%). Results from studies examining nutritional intake and deficiencies among children with autism have been mixed. Deficiencies in daily intake have been reported most often for calcium, iron, fiber, and VitaminsC and D.
Comprehensive evaluation of any feeding problem should include the identification and consideration of medical problems that might contribute to or result from the child’s diet (Schreck, 2006). Estimates are that 17% of children with autism experience observable symptoms of reflux (e.g., vomiting), while the number of children who experience unobservable symptoms (e.g., heartburn) is unknown. Rates of weekly vomiting among children with autism are almost double that found among typically developing children, suggesting that reflux may play a role in food refusal for some children.
Almost two thirds of children with autism eat fewer than 20 foods and accept fewer foods from the basic food groups than typically developing children.
Bowel problems such as diarrhea and constipation affect children’s appetites, and such problems are common among children with autism. Approximately 24% of children with autism experience loose stools, 24% experience constipation, and 33% strain to move their bowels. Both diarrhea and constipation are often addressed through dietary changes and/ or oral medications, which are particularly challenging to implement given the child’s refusal.
Comprehensive evaluation of feeding problems generally requires a multidisciplinary approach, including a physician to assess contributing medical conditions, a dietitian to assess nutritional intake and needs, a speech and language pathologist to assess oral motor skills, an occupational therapist to assess fine motor and selffeeding abilities, and a behavioral psychologist to assess child and family eating and mealtime behavior.
Successful intervention requires devotion and daily practice. Components of successful interventions often include:
Initially, the child might be expected only to touch or smell a food but gradually would be expected to eat increasing amounts of it. A very small amount of a nonpreferred food may be paired or mixed with a preferred food; gradually the proportion of nonpreferred food increases. Shaping procedures are often combined with escape extinction whereby the child is allowed to leave the table (or end a practice session) only after s/he has touched or eaten a small amount of nonpreferred food. Contrast this to what often happens when a child refuses a food at home — parents remove the refused food and replace it with something the child is more likely to eat. Unfortunately, presenting preferred foods in response to refusal can inadvertently encourage more refusal.
A multidisciplinary treatment program was implemented with 3-year-old Abigail, who was managed on an outpatient basis by a team consisting of her parents, a pediatric gastroenterologist, a dietitian, and a psychologist. Given her failure-to-thrive, improving caloric intake and nutrition was the first goal. This was accomplished by increasing her milk shake from once to twice a day. To manage her nutritional deficiencies and constipation, very small amounts of Vitamin D and Miralax were added to her milk shake and gradually increased over the course of one month.
Behavioral strategies including shaping and simultaneous pairing of nonpreferred and preferred foods were conducted, beginning with the reintroduction of yogurt, which Abigail used to eat. Once she learned to eat that one new food, we varied the flavors of the yogurt and finally began to introduce other new foods that were staples in the family diet. Over the course of months, we gradually replaced apple juice with a fruit/vegetable juice, and then began to introduce vegetables. The family participated in weekly outpatient treatment for 2 years. She returned 2 years later for another 4 months of treatment when she regressed following an acute gastrointestinal illness.
Abigail is now 10 years old. She eats small portions of the family meal along with her preferred foods. Her vitamin deficiencies have resolved and she no longer has constipation. She now is at the 10th percentile (rather than <3rd) for weight and a g-tube was averted. Although she maintains strong food preferences and requires verbal prompts from her parents to eat nonpreferred foods, Abigail has learned to eat those foods in spite of her strong preferences.
Although not described as such in the scientific literature, a fundamental ingredient in implementing any feeding program is patient persistence. Whether on the part of a therapist or a parent (or both), maintaining a calm feeding environment and persisting in the face of the child’s resistance is critical to treatment success.
Debra Lobato, PhD, is director of child psychology at Rhode Island Hospital and Hasbro Children’s Hospital, professor of psychiatry and human behavior (Clinical) at The Warren Alpert Medical School of Brown University, associate director of the division of clinical psychology at The Warren Alpert Medical School of Brown University, and a psychologist within the Pediatric GI Feeding Program at Hasbro Children’s Hospital.
Ledford JR, Gast DL: Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental Disabilities 2006; 21(3):153–166.
Schreck KA, Williams K: Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities 2006; 27:353–363.