‘One cannot think well, love well and sleep well if one has not dined well’-said Virginia Woolf. We know that food is critical for our ability to work, move, live, fight infections, to heal and to stay healthy. Therefore, it is vitally important to address eating and feeding disorders in our children.
There are various kinds of eating disorders that occur in children with Autism/Autism Spectrum Disorder (ASD). These disorders could be restricted food intake, pica, overeating, anorexia, bulimia, and sensory difficulties relating to food. Sensory based avoidance of food or eating problems secondary to sensory difficulties surrounding food, are by far the commonest issues and are very frequent in my clinical practice.
Hence, in this article, I have provided strategies to address sensory feeding difficulties that prevent children with Autism/ASD, from trying new foods. Children with Autism have difficulties in processing certain sensations, as part of their condition. Consequently, they can be either be hypersensitive or hyposensitive to sensations of smell, taste, texture, colour, or appearance of their food. These sensory difficulties result in them either accepting or rejecting food(s).
Just as every child is unique, so is every child with ASD. In my clinical experience of over two decades, I have assessed over a thousand children with ASD. And each one of them had a distinctive sensory profile. So, I have seen children who prefer just beige or cream coloured foods, children who like only soft or chewy food, children who prefer just spicy or sweet food, children who prefer only cold or hot food, and children who prefer only solid food and cannot even go near slimy food. These sensory-based food avoidance behaviours become complicated further by their preference for sameness, their rigid thought processes and occasionally their obsessions.
So, here are my top 10 tips that I wish to share with you, from my 20+ years of experience:
1. Keep a diary:
To solve the enigma of sensory-based food avoidance, it is important to think along the lines of What? Where? When? Why? and How? Writing your responses to these questions, in a diary would help in many ways. Firstly, such an exercise will make it clear whether there is a problem, and if so, can help you recognise the size of the problem and any potential solutions. Secondly, such a food record or a 24-hour diary can help to either reassure you or give you a reason to seek help. Moreover, such a journal can help professionals identify whether your child is at risk of missing any nutrients and will enable them to address the problem.
2. Think of the whole process:
Food can bring the family together on many levels. Hence, involve your child in choosing the foods during your shopping. Try to engage them in preparation, cooking, and serving food. Doing so would help to lessen their anxiety and improve their tolerance to foods. You could also be a model for your child by having family meals together, thus giving them the opportunity to copy and emulate others. Having meals together could also make them feel supported and make mealtimes an enjoyable experience.
3. Aim for small steps:
Working with Autism and not against it, would help you reach your goals sooner. Once one understands ASD, you will avoid any sudden or drastic changes. Aim for small steps and gradual change, as children with ASD find it difficult to cope with change. Therefore, complement them for each small step, e.g. for looking at the food, for smelling it, for tolerating it on the table, for touching it, for biting it, for chewing it, and finally for swallowing it. Even if they spit the food out, this should still be acknowledged and credited as they tried it. Doing so may help them try that food again. This entire process could take weeks to months, and hence patience is the key.
4. Use social stories:
You can improve your child’s understanding of food using social stories about buying, preparing, serving, and eating food. Stories about the role food play in giving us energy, keeping our bodies working and in sustaining our health, help. Social stories help them guide, to cope, and to understand others perspective. Avoid labelling food as healthy or unhealthy, especially in the beginning, as children with ASD can take this literally. Any communication should be in a calm, clear and consistent manner.
5. Make it visual:
Children with ASD can process the information presented to them visually, far more effectively than information presented to them by auditory instructions alone. Presenting information by use of pictures or collection of images of food into a book will help their understanding enormously. Use of PECS (Picture Exchange Communication System), a visual timetable and or a visual calendar would them understand what you are trying to achieve. Similarly, the use of a ‘timer’ to show when the dinner activity will be finished will give them certainty and could help reduce their anxiety.
6. Meet their sensory needs before:
Seek to understand them first, and you will then be understood. Meeting their sensory needs through play and activities they enjoy before mealtime, helps remove any built-up anxiety and reduce their sensory defensiveness. Activities that provide deep pressure will help them to explore and experiment new sensations at the dinner table without getting sensorily overloaded.
Do not ignore the role environment plays in our meals. Every one of us who has had a good dinner date would remember the role atmosphere played in that experience. Children with ASD could be bothered by either the loud sounds, the bright lights, the strong smells, or certain colours and textures in the environment that we may have not even noticed. Hence it is important to remove the offending agent that is causing sensory overload to your child. Soft music and dim lights may help. Thinking of the ambience in which food is consumed, would help in having a relaxed and enjoyable mealtime together. The ‘diary’ exercise would help you identify and address the stimuli that your child does not like.
8. Do not force and stay calm:
Children with ASD need more time to process new information and to tolerate new sensations. Like any other child, children with ASD can also notice your anxiety and stress, which in turn will cause them to become anxious and stressed. Therefore, stay calm and do not insist on your child eating a certain amount of food. Recognise any build-up of anxiety early, and then act by either distracting, changing, or stopping the activity. Do not punish. Do not trick or hide the food items they do not like in the food items they do like. This can compromise their trust. Instead, you could consider blending the vegetables they did not tolerate, pureeing certain foods they did not like or offering fruits in the form of milkshakes.
9. Seek help from professionals:
If you are concerned or worried about your child’s very restricted food intake or if your child is not eating any food items from a whole category of foods, e.g. fruits, vegetables, or dairy, then you should seek help. Professionals such as a dietician, or a paediatrician, can identify the nutritional deficiencies your child is at-risk of and advice you on suitable vitamin and or a mineral supplement. An occupational therapist can give your de-sensitising activities, and a clinical psychologist could help by providing you with behaviour modification techniques. A speech and language therapist could help with swallowing difficulties or if your child is coughing and choking on certain foods. Once again, a diary or a food record would provide professionals with crucial information and enable them to help you better.
10. Reach out for support:
Joining a self-help group will help you receive the necessary information and valuable support. Revisiting all the tips mentioned above from time to time could help you find strategies that may have fallen off your radar. Being patient and persevering in your efforts in bringing gradual change will bring success. Continue to build upon your child’s strengths as you look to ways in which to accommodate, adjust and adapt to their weaknesses. Hence there is everything to hope for.
As you can see, various above mentioned effective and evidence-based strategies can be put in place to address your child’s eating and feeding difficulties. Working on their diets to make it well-balanced, would help their physical health, improve their mood, enhance their functioning, and boost their attainments. Doing so will also prevent the profound and potentially harmful effects on their long-term health.
- Can’t eat, won’t eat: Dietary difficulties and Autism Spectrum Disorder by Brenda Legge. Paperback book.
- Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions: A Practical Guide for Parents and Professionals. By Gillian Harris and Elizabeth Shea
- National Autistic Society: https://www.autism.org.uk/advice-and-guidance/topics/behaviour/eating
- Food selectivity and sensory sensitivity in children with autism spectrum disorders. Sharon A. Cermak et al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601920/
- Gada S. Community Paediatrics. Oxford Specialist Handbook in Paediatrics. Oxford University Press. ISBN 978 0 19 969695 6. Published Sept 2012.