Question & Answer - Feeding, Eating, & Drinking

How do feeding therapists address selective eating in children with autism spectrum disorder (ASD)?

Answer from Lori Nachtigal Rothschild, Speech-Language Pathologist in New York, USA

The estimated prevalence of feeding problems in children with autism has been reported to be as high as 90% with close to 70% of children described as selective eaters (Kodak & Piazza, 2008; Merkel-Walsh & Overland, 2016; Twachtman-Reilly, Amaral & Zebrowski, 2008; Volkert & Vaz, 2010). Many children with ASD have trouble accepting small changes in food textures, flavors, colors and temperatures. Sensitivity to food textures was reported to be the most common reason for food refusals. Children with ASD were significantly more likely to accept only low-texture foods such as purées (Cermak, Curtin, & Bandini, 2010).

Although, texture or consistency of food was often cited as the underlying factor in the choice of many foods, the visual characteristics of foods such as the brand, product name, or packaging/wrapping were also reported as determining factors (Cermak, Curtin, & Bandini, 2010). Furthermore, many children experience gastrointestinal (GI) discomfort which can impact the desire to eat. While there is conflicting research regarding the prevalence of GI symptoms in children with ASD (e.g., gas, abnormal stool, constipation, and diarrhea), the percentage across studies was found to be somewhere between 23% and 70% (Chaidez, Hansen, & Hertz-Picciotto, 2014). 

A diagnosis of ASD is frequently accompanied by other underlying issues with sensory processing and integration (e.g., sensitivity to sounds, lights, touch, and personal space) which can impact self-regulation and the ability to maintain a calm state. Subsequently, helping a child remain calm and seated may be incorporated as part of a therapy program. 

When working with a child with ASD who has selective eating, it is important that the team of professionals including occupational, physical, speech, and behavioral therapists work together to meet the needs of the individual child. Some families may also work with medical teams including GI doctors, nutritionists, and functional medical physicians/neuropaths. Each professional has his or her own expertise, thereby helping to connect pieces of what can be a very complicated puzzle.  

Occupational therapists (OTs) may provide strategies to help with overall organization and self-regulation. Speech-language pathologists and ABA therapists may consult with OTs to tailor individual strategies such as appropriate movement and proprioceptive input (e.g., gentle but deep pressure) before beginning feeding sessions. While evidenced-based research is still needed to support the amount and efficacy of sensory input, most therapists can attest to positive changes in attention and state in children who receive this type of input. 

Repeated exposure and family modeling of positive mealtime behaviors is just one approach to food expansion. Modeling may include activities such as caregivers tasting new foods, using exaggerated chewing, and pairing eating with animated expressions of enjoyment. With this approach there is no specific requirement for the child to try the novel food in any way. For many families accustomed to their child receiving Applied Behavioral Analysis (ABA) therapy, which requires a behavioral response to input and is typically measurable, this approach can seem unattainable or too ambiguous. 

A technique referred to as Escape Extinction has been commonly used with children with an ASD diagnosis (Patel, Piazza, Martinez, Volkert, & Santana, 2002). Of 23 studies analyzed from 2000-2013 by Marshall, Hill, Ziviani, & Dodrill, P (2014) 100% used some form of this technique. Escape extinction (Tanner, & Andreone, 2015) can best be explained as removal of the reinforcer that is maintaining the challenging behavior (e.g., The child throws food followed by the parents removing the child from the table. The child gets a desired response which is not having to consume the target food).

The challenge is how to use a Replacement Approach and what should be accepted as an Alternative Behavior. Should we consider the ethical implications of prompting the child to chew and swallow as the only acceptable response (Tanner, & Andreone, 2015)? Also, Replacement or Alternate Behavior will look very different for a child who exhibits total refusals of new food versus a child who tastes but never chews and swallows a new food (Valdimarsdóttir, Halldórsdóttir, & Sigurådóttir, 2010). It can be much more difficult to attain food acceptance for a child who exhibits total refusal to try a food than for a child who will taste the food.

Also, reinforcement which typically increases the likelihood of a behavior occurring is often paired with a target response in traditional behavioral intervention. However, using reinforcement during feeding tasks can be a challenge. While taking a turn with a toy may be appropriate to get a child to try a new food, some children only respond with edible reinforcers. Using a snack or a preferred food as a reinforcer may send the wrong message. 

While there still needs to be more research on the best methodologies to use with young children who have ASD and selective eating, typifying or normalizing feeding through Graduated Exposure shows promise. Graduated Exposure consists of breaking up a targeted goal into incremental acceptable responses.  

Amy Tanner and Bianca E. Andreone (2015) published an article in the Journal of Behavioral Analysis in Practice demonstrating it took  a 3.5 year old child, with a limited diet, 28 days to consume a first new food texture (after exhibiting total refusal). Subsequent trials advanced more quickly. Trials consisted of tolerating a new food in the room, tolerating a new food at the table, tolerating a new food 1 foot away, touching a new food and then discarding it, smelling and then discarding it, kissing and then discarding it, licking and then discarding it, biting and then discarding it, chewing 5 times and then discarding it, chewing and swallowing a small piece, and then chewing and swallowing an entire piece. 

While this process may appear slow, fewer negative responses, like food stuffing, in order to get to a desired reinforcer, may occur. Also, a child may be more likely to maintain long-term enjoyment of new foods with this method than when pure chewing and swallowing is expected as the only acceptable response. 

About the Author
 

Lori Nachtigal Rothschild has a master’s degree in speech-language pathology from the Teachers College-Columbia University. She has worked for over 20 years specializing in pediatric speech and feeding disorders. Lori, also, has served as a clinical supervisor and quality assurance manager for several New York City agencies. She recently published a children’s book on selective eating entitled Picky Patty Learns not to Be so Picky.  Website: http://www.speechandfeedingadvice.com/

References

Cermak, S. A., Curtin, C., & Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the Academy of Nutrition and Dietetics, 110(2), 238-246.

Chaidez, V., Hansen, R. L., & Hertz-Picciotto, I. (2014). Gastrointestinal problems in children with autism, developmental delays or typical development. Journal of Autism and Developmental Disorders, 44(5), 1117-1127.

Kodak T, & Piazza C.C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child and Adolescent Psychiatric Clinics of North America, 17, 887–905.

Marshall, J., Hill, R. J., Ziviani, J., & Dodrill, P. (2014). Features of feeding difficulty in children with Autism Spectrum Disorder. International Journal of Speech-Language Pathology, 16(2), 151-158.

Merkel-Walsh, R., & Overland, L. L. (2016). Self-Limited Diets in Children with a Diagnosis of Autism Spectrum Disorder. Oral Motor Institute, 5(1). Available from www.oralmotorinstitute.org. 

Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35(4), 363-374.

Tanner, A., & Andreone, B. E. (2015). Using graduated exposure and differential reinforcement to increase food repertoire in a child with autism. Behavior Analysis in Practice, 8(2), 233-240.

Twachtman-Reilly J, Amaral S. C, & Zebrowski P. P. (2008). Addressing feeding disorders in children on the autism spectrum in school-based settings: Physiological and behavioral issues. Language, Speech, and Hearing Services in Schools, 39, 261–272.

Valdimarsdóttir, H., Halldórsdóttir, L. Y., & Sigurådóttir, Z. G. (2010). Increasing the variety of foods consumed by a picky eater: Generalization of effects across caregivers and settings. Journal of Applied Behavior Analysis, 43(1), 101-105.

Volkert, V. M., & Vaz, P. (2010). Recent studies on feeding problems in children with autism. Journal of Applied Behavior Analysis, 43(1), 155-159.