Autism and Picky Eating

It is the rare parent who doesn’t at some point have to deal with temper tantrums over food or, at the very least, picky eating habits. But kids on the autism spectrum — and therefore, the parents who feed them — often face significantly greater and more complex issues around food for a variety of reasons. Stephanie Lee, PsyD, a clinical psychologist at the Child Mind Institute, has worked with many families to tackle the eating issues autistic kids may experience.

The goal in working with children who have rigid eating behaviors is to (eventually) enable the child to eat a healthy range of food that’s consistent with the culture of the family while reducing related household conflict.

Understanding what might be behind rigid eating behaviors is the first step in enabling children to get more comfortable with new foods and making mealtime more relaxed for everyone.

When a child on the autism spectrum is dealing with eating issues, the first stop for a parent should be a pediatric gastroenterologist who can rule out organic causes. Autistic kids may suffer from many of the same childhood GI disorders as other kids, notes Joseph Levy, MD, a pediatric gastroenterologist at NYU Langone Hospital who works with autistic children, but kids on the spectrum “may not be able to localize or verbalize their pain.” As a result, parents need to be proactive about trying to find the source of their child’s discomfort. Below are some of the more common GI issues kids may experience.

• Acid reflux is a common childhood disorder, but in kids on the spectrum “we have seen that behavioral changes like jumping around, becoming wild or crying correlate to the exact time that the acid backs up in the child’s throat,” says Dr. Levy.
• Constipation, caused either by a limited diet or delayed toileting (common among kids with autism), has the potential to make eating very uncomfortable for a child who feels full or has a stomachache.
• Eosinophilic esophagitis (EoE) is an allergic swallowing disorder, which makes a child feel like they are gagging or choking. EoE is frequently triggered by food and can cause pain and discomfort that would almost certainly result in behavioral issues in autistic kids.
• Issues with diarrhea can be related to a child’s diet but may also be caused by malabsorption of certain sugars, or to rapid transit through the GI tract, which does not allow enough time for the stool to firm up.

Mealtime behaviors that cause problems for autistic kids and their families can include:

Kids on the autism spectrum often express a strong preference for foods that feel a certain way in their mouths. Some prefer soft or creamy foods like yogurt, soup or ice cream; others need the stimulation that crunchy foods like Cheetos or — if a parent is lucky, carrots — provide. In either case, sensory issues can put significant limitations on the different foods kids are willing to eat.

Kids who have a strong preference for and eat almost exclusively soft foods as they develop may actually lack the muscle development that it takes to chew foods like steak or hamburger. “They get fatigued eating those foods and find it unpleasant,” says Dr. Lee, who explains that often parents who don’t know this is the cause of their child’s distress will respond by allowing them to forgo the foods that would strengthen those muscles, so it becomes a vicious cycle.

Lots of parents experience the frustration of trying to get their children to sit at the table long enough to finish a meal. But with autistic kids the challenge can be magnified. And there is also the issue of safety. “So it’s not just, does your child stay at the table or in the place that you intend for them to eat,” Dr. Lee explains, but “are they engaging in dangerous or unsafe acts or disruptive behaviors in the space that you would like them to eat?” Unsafe behaviors might include throwing utensils or repeatedly getting up and running from the table.

Often parents who have children with autism are focused on a number of different needs at the same time and many of those — speech issues, toileting, school placement, overall compliance — take precedence over the variety of foods a child is accepting. Feeding issues get back-burnered until either they become untenable or parents are able to focus on them.

“If the child eats 10 foods and those 10 foods are keeping them alive and safe and fine, then parents will default to those foods,” says Dr. Lee. But ignoring these issues tends to make them tougher to solve. The longer these negative mealtime behaviors go on, the more ingrained they become and the longer they take to treat successfully. That doesn’t mean parents should give up, just that the process is probably going to take longer and require more persistence and patience on everyone’s part.

Techniques for addressing various mealtime behavior issues are similar but they have to be broken down into manageable steps. Below is a practical guide for parents that will help both parents and their kids achieve their goals and reduce mealtime stress.

Too often parents try to tackle all mealtime behaviors at once. That’s a mistake and just leads to both kids and parents becoming overwhelmed and giving up. When Dr. Lee works with families she asks them to prioritize their goals. Is it increasing the number of foods their child will eat? The amount they eat? Or is it sitting at the table less disruptively? Parents need to identify their primary target.

No matter what the goal, it’s important to start with baby steps. For example, when trying a new food with a child, Dr. Lee will begin with a miniscule amount — so small the child might not even be able to taste it. If the initial goal was simply trying the food, once the child tries the bite, Dr. Lee would provide significant praise and might count it as the child’s “no thank you bite.” Meaning, Dr. Lee says, “you take a bite and then you say ‘no thank you’ calmly, and you don’t have to have it again for the rest of that meal.”

If a child has been sitting at the table for 10 minutes and that’s the goal, parents will often want to push for a little longer. That’s a mistake. “Sometimes, we feel like they’re doing good, let’s push it another 10 minutes,” Dr. Lee says. “But really that extra 10 minutes can result in the meal ending in a less successful way.” Especially for children who have been struggling at mealtime, it is important for them to start building up successful experiences to help them change their attitude toward eating and mealtime.

If your child currently isn’t eating any of the foods that you place in front of them, it’s probably not a good idea to start with the goal of them cleaning their entire plate. Parents have to have reasonable expectations that start by meeting their child where they currently are with regard to mealtime behaviors.

Your goal, how the meal is going to end and what constitutes “success” all need to be clear to parents, caregivers and your child. There are ways to make expectations easier for kids to understand, like using a visual timer that counts down the minutes the child is expected to stay at the table.

Praising your child for every aspect of progress is key, Dr. Lee explains. And praise comes in different forms:

• General praise means telling your child things like “good job,” “way to go,” or giving them a high five.
• Labeled praise, is telling your child exactly what it was about their behavior that you liked. Examples of labeled praise include statements like: “Thanks for sitting so quietly at the table.” “I love how you tried that new food.” “Great job sitting with your fork at the table.” “Thanks for putting your plate in the sink.” Labeled praise is especially important since it reinforces the positive behaviors parents are trying to instill.
• Five to one ratio: It’s challenging but Dr. Lee says the rule of thumb for mealtime should be that for every direction or reprimand given, the parent or caregiver should give the child five “portions” of praise. And, says Dr. Lee, “it shouldn’t be arbitrary. We want parents to be laying on the praise in a really heavy and genuine way: ‘Thanks for coming to the table!’ ‘Great job getting started right away!’ ‘Great job asking for seconds!’ — that kind of thing.”

Keep in mind that it takes most kids and even adults numerous exposures to a new food — Dr. Lee says seven to 12 times — before someone can really tell if they do or don’t like something. So being persistent and patient is really important. “Just because kids say one time they don’t like it doesn’t mean that they’re not going to like it forever,” she says. “So, we’re making sure we revisit those things.”

Don’t expect your child to change long-standing mealtime behaviors without putting up a fight. A certain amount of resistance — verbal aggression or disruptive behaviors, whining or crying — are all to be expected. But that doesn’t mean you’re not making progress. Dr. Lee teaches parents to practice “planned ignoring,” a technique which involves purposefully ignoring a behavior as long as it’s not unsafe.

As much as possible, parents and other caregivers should keep a written record of what the child eats at each meal so that they (and the child’s clinician) can keep track of the progress that’s being made and where challenges are continuing to come up. Having a record you can see across time makes it much easier to be patient and helps everyone stay on track.

What goes in has to come out in some form and with some regularity, so Dr. Lee suggests that parents, caregivers and even teachers keep a written record of a child’s bowel movements. If chronic constipation seems to be an issue, a visit to the pediatrician or even a gastroenterologist is probably a good idea. “Often children with autism are more likely to have toileting issues that involve withholding their bowels, which can result in a kid feeling less comfortable about eating,” Dr. Lee says. In addition, if your child eats lots of carbs and not a lot of vegetables that are going to move them along, kids can become impacted. Parents should consult with their pediatrician or a GI doctor immediately if this is a concern.

A lot of times what we model for kids is what they pay attention to more than what we say to them. “If you say to your kids it’s really important to eat a balanced diet, but then you’re not really modeling that,” Dr. Lee says, “it’s probably unlikely that they’re going to develop those positive habits you’re looking for.” So, try new things yourself, do your best to enjoy mealtime without distractions like phones or television and those behaviors will likely have a positive effect on your kid.