Mealtime Challenges and the Autism Spectrum
By: Marsha Dunn Klein MEd., OTR/L
Not all children diagnosed with Autism Spectrum Disorders have challenges with mealtimes, but those who do can affect the mealtime for the entire family.
The very aspects of mealtimes that make them enjoyable for most people can make them very challenging for the child with Autism Spectrum Disorder. Most of us look forward to gathering with family and friends for the socialization, communication and rich variety of sensations available during mealtimes. However, challenges with socialization, communication and processing of sensory information are central to the diagnosis of autism. In addition, change is difficult for these children. Many want things around them to be the same, in a certain order, and therefore transitions from one activity to the next can be overwhelming. The smells, tastes, touch, temperatures, sounds, visual appearances of mealtimes combined with the talking and socialization and the constantly changing environment can not only reduce enjoyment, but for many can lead to major stress or a desire to escape.
Mealtime characteristics
Common reactions to mealtimes for children on the spectrum who have mealtime challenges can be food refusal, extreme limitations in diet and disruptive behavior. From the family perspective, there is disruption because the child wants to eat the same foods from the same plates, prepared in the same way, with diminished tolerance for change. Change in any of the variables can cause refusals or tantrums. To avoid the total disruption to the family meals, many parents repeatedly serve the exact foods that the child can accept predictably. These often are the same very few foods, the same preparation and presentation, and even the same name brands.
From the child’s perspective, there is a need for SAME. They may notice when any part of the meal changes. A highly sensitive sense of smell may let them know that the food is new, that it is prepared differently or is a different brand. The sensitive visual system alerts to change in presentation, changes in color, utensils, cups or plate. A highly sensitive sense of touch feels texture and temperature change. To further complicate eating, every bite taken off the plate makes the plate LOOK different. Every chew of the food makes the mouthful FEEL different. The child may constantly feel bombarded with change, change, change, CHANGE!
Narrow spectrum of food choicesFor one child, the diet may be only baby food apricots, in the tall jar from Gerbers®. Another may eat any food as long as it is presented in a folded tortilla. Other children may eat any food as long as it is in a certain bowl and in a blended texture. Another child may eat waffles (a certain brand), pancakes (a certain brand), French fries and chicken nuggets (from a certain fast food chain) or milk (from a certain cup) . Some parents have affectionately referred to their child’s diet as the “Parentheses Diet” because the parenthetical descriptors are such a requirement to the diet. This diet tends towards shades of browns or whites, and may look less visually stimulating. Notice there are often no colors or big visual variations. Color specific, brand specific and presentation specific diets can cause significant challenges as parents strive to find any balance to the diet. Fruits and vegetables are commonly missing or scarce in these diets. It is often hard to know whether it is the color intensity, smell or flavor variable that triggers the refusal. We can describe the neophobia (fear of trying anything new), the dietary restrictions and mealtime quirks as a personal logic. Each child may have his own logic that parents may not understand. A small change in the food that others may not even notice can be very important to the child on the spectrum.
Feel Well
To complicate the whole process of eating for these children, there seems to be a higher incidence of gastrointestinal disorders for children on the autism spectrum. With communication challenges it may well be hard for parents to figure out the cause of the discomfort. Many families have seen mealtime improvement and changes in behavior and communication with special diets (such as gluten-free and casein-free diets) or special supplements. Each family will decide for themselves as they look at the “big picture” of their child’s mealtime.
Is it sensory?
Absolutely, but perhaps not in the traditional sense. Mealtimes are sensory, but for many children on the autism spectrum the issues go well beyond sensory. Change. Change is hard for many of these children. Sensory change can be upsetting. They find a food that feels safe, and THAT is the food they want. Period. It may well be a certain texture, but it is the whole package of color, texture and taste that is the preference in many situations. A child who likes baby food apricots (Stage 2 Gerber®!) might not prefer that food because of the texture. Baby food pears, applesauce, plums may all be rejected despite the similarity in texture because they are different color, smell or jar. The rejection of the new food may come because the new food is simply NOT THE FAMILIAR, SAFE baby food apricots. Many children on the spectrum are excellent “Sensory Detectives”. They can be incredibly capable of smelling a change in food (or food brand), seeing the slightest visual variation and feeling the most minute texture variation. They are not easily tricked!
Many families worry that the problem is strictly an oral motor problem. A child who eats only vanilla yogurt (Dannon brand®), cheese pizza (from Pizza Hut) and chicken nuggets (from MacDonalds) and soda has a variety of oral motor eating skills. The problem might not be a specific sensory problem (ie. texture), or a specific oral motor skill problem. The child may be saying, “I do not want anything NEW”, rather than “I cannot chew that new food!” As we look at the complicated influences on the food choices these children adamantly make, it is probably an intricate combination of neophobia, sensory, oral motor experience and environment.
Keep options open
We need to reoffer foods that have been rejected. Many times we offer a child a new food and it is rejected. We take it off the “List“of foods to offer because we are looking for mealtime peace. If we continue to take each food off the list that the child rejects, we narrow the options each day and end up with a diet offering only a very few foods. By offering again and again with multiple exposures to new foods we increase the chance of adding new food to the child’s diet.
Multiple Food Exposure Opportunities
Typically developing toddlers may need multiple exposures, perhaps 10-12, to a new food before it is familiar enough to try (Leann Birch). Children on the autism spectrum may need considerably more exposures than that. Consider how we help people who have phobias, or irrational fears. We help that person gradually become comfortable with the feared item by tiny distant exposures to it until they become comfortable. When these children are afraid of new foods, we can incorporate many exposures to the new food in everyday activities without requiring them to actually eat the food. Eventually they may become familiar enough with it to try it.
Here are ways to provide multiple food exposures:
* Mealtime Jobs
Consider providing your child with age appropriate mealtime jobs where there can be active participation with foods and the whole mealtime routine. Planning menus, helping to grocery shop, preparing foods, setting the table, serving the foods and cleaning up are all mealtime jobs that give the child the chance to be near foods without the pressure to eat a whole plate of it. The experiences can start with safe non-food interactions such as picking out pictures of food in a magazine. There can be distant interactions where the child grocery shops and just puts food from the grocery shelf into the cart. Non-eating interactions can include the preparation, serving and cleaning up. Direct food interactions can include handing it to others, smelling, licking and tasting. The hope is that with multiple exposures and interactions with the food it will gradually be familiar enough to “try.” (See Multiple Food Exposure Opportunities Handout)
* Food Play
Incorporate food into the play activities of the child. Food can be used in pretend play, the cargo for dump trucks or trains. Balls can be made out of grapefruit or cantaloupes. Onion rings can be stacked on a stacker. (See Food Play Handout)
* Food Academics
Food can be used in teaching colors, shapes and sizes and in teaching math concepts. Cookie cutters can be used with a variety of types of foods to make a variety of different shapes out of bread, cheese, and even some vegetables. Green and purple grapes can be sorted. Foods can be counted in a cupcake tin, or counted as they are strung on coffee stirrers. Thinking creatively, there may well be a way to incorporate food into most academic learning tasks! (See Food Academics Handout)
* Food Art
Food is an excellent medium for art projects. Children can finger paint or paint with brushes with wet foods such as yogurt or pudding. They can use colored crumbs to make a crumb picture on a coloring book page. Some fruits and vegetables can be used to make block print painting. Macaroni can be glued on a picture to make a design. (See Food Art Handout)
* Food Preparation
Children can assist in food preparation including set up, preparation and cleanup. Can the child help stir a drink, or put frozen fruit “ice cubes” into a drink? Could the child provide help in making that salad, or putting green beans into a pan? How about slicing cookies, or decorating a homemade pizza? Preparing foods helps the child get used to the smell, the touch, and maybe even the taste! (See Food Preparation Handout)
Re-Define “Try It”
When we ask someone to “Try It” we often mean,” here is a mouthful, and I hope you like it!” For the very sensitive or neophobic child, trying a whole mouthful may be far too scary. We may need to break down “try it” into a series of tiny, more achievable steps for children on the autism spectrum and their parents to experience small steps of identifiable success. For some children, success may be just being in the same room as a new food. For others, trying it may mean licking it but not tasting it. There is a whole continuum of little steps that can be broken down into even tinier steps so children can succeed WHEREVER their starting point of trust. Here are just some of the options for “trying it.”
Stretch from Familiar
We try to help children build from their safe foods. We want to be sure that when we help a child try a new food, we start with many opportunities to be around it, and we consider redefining “try it.” Additionally, we want to consider, “is it worth it?” Some families feel as though they have worked and worked to help their child like a snack food such as Cheetos® only to realize that food is not rounding out the diet well. Others have worked to help their child like a new cracker, only to realize it may be just another wheat product and perhaps they are not sure if wheat is digested well in their child. By asking “is it worth it?”, parents can consider the big picture of their child’s diet and mealtime experiences and determine if the choice makes sense.
When a child eats one main food, it can be challenging to try to change that food. Each decision to “try” foods for children with these challenges needs to be considered carefully. For some children, simply changing the cup the favorite milk is offered in can worry the child enough that the milk is refused altogether. This will be distressing for all. For other children, milk can more easily be the basis for introduction of a new flavor. We call the introduction of a change in the mealtime STRETCHING from the familiar. (See Stretch from Familiar Handout). It is a gradual method of helping the child handle a comfortable change in the mealtime, using aspects of the meal that are familiar. For example, Johnny likes apple juice. How could we help him S-T-R-E-T-C-H from there? Could he drink the familiar apple juice at a park instead of at the table, or from his favorite cup with a sticker added to the cup, or from a new cup altogether? Could he drink it from a lidded cup with a straw? (A lid is helpful as it reduces the smell as well as the visual changes that may occur and worry the child). Could we add an ice cube of a different juice so that he starts the drink with the familiar apple juice flavor and then the ice cube gradually melts to change the flavor in a less drastic way. (See Ice Cube Meltables Handout). Gradually more ice cubes could be added to increase the flavor concentration. As the child accepts and is familiar with the more concentrated flavor, perhaps yogurt ice cubes could be added, or a pureed fruit to stretch the initial apple juice into a smoothie. Could the stretch then move towards purees of the fruit, a vegetable/fruit drink (with avocado or carrot juice added) or towards popsicles?
Another child may start with waffles as a familiar food. Could we STRETCH from that familiar food by cutting the waffle in different shapes, or adding a small amount of a new ingredient to the mixture (like pureed applesauce or carrots), or using waffle strips as a dipper to dip in a new dip. (See Dips, Dippers and Dipping Cubes and Crumbs Handout). When we help children STRETCH from their familiar foods, we can offer tiny changes in environment, or bowls and utensils, or shape, color, texture, food group or taste. Some children can take months to become familiar with a change and others can move through changes more comfortably. Each child is different and their relationship with food has its own PRIVATE LOGIC.Lifelong skills
Our autistic children live in a world where people gather at mealtimes to eat. We would like to expand diets and increase the number of foods they find safe, but we also need to do that in an environment that is comfortable and in a way that teaches them the lifelong skills needed to be around foods. We can push a child to eat broccoli, but in the big picture of that child’s life, we want to be teaching HOW to deal with situations where food is offered. -- how to say “no thank you” or eat a meal when an unfamiliar, worrisome food is offered. No, it is not okay to run from the table flapping hands or dump the plate full of food. But it is possible to help the child learn that they can appropriately remove that worrisome food and put it in a “looking bowl” or “tasting bowl” near the plate, or that it can be carefully wrapped in the napkin. We don’t like all foods, and our children won’t like all foods either. We just want them to be more comfortable with more foods, and to learn strategies to interact with foods, so they can eat what they like and politely ignore the rest. This takes time and this takes training and support.
Make mealtimes peaceful
We want to support families in an environment of peaceful mealtimes. When therapists recommend a strict mealtime protocol that creates stress or causes the child to be completely off balance (running from the table, throwing food, hiding under the table, tantrums and refusals), what are we achieving? We want to support family mealtimes and use strategies that help create family meals that are pleasant for all.
© Marsha Dunn Klein , MEd., OTR/L Mealtime Connections, LLD 2009 www.mealtimeconnections.com
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