Children with Autism and Feeding Difficulties
July 15, 2017
By Merrill Berkowitz, Ph.D., BCBA-D
Center for Pediatric Feeding & Swallowing, St. Joseph’s Children’s Hospital
For most people, the consumption of food and liquid comes naturally. We are motivated to consume different foods and liquids for a number of reasons. Two of these reasons are to reduce hunger or thirst (ensuring our survival) and to experience the pleasurable tastes of some foods and liquids. Some children, however, never or rarely appear hungry or thirsty and may not consume an adequate amount of food or liquid to grow or remain hydrated. Other children consume only a very limited number of foods, which can result in nutritional deficiencies, or can only consume foods at a texture below what would be considered age appropriate.
Current findings suggest that up to 75% of children diagnosed with autism will have some type of feeding difficulty, including the feeding problems mentioned above. The feeding difficulties children with autism commonly experience include eating a limited variety of foods, difficulties consuming foods at an age-appropriate texture, and at the most severe level, refusing to consume all food. Some children with autism may also be selective with how foods are prepared, only eat from specific plates or when certain utensils are present, or engage in undesirable behaviors during meals.
In 1943, Leo Kanner was the first to describe common characteristics in individuals with autism. Two of these characteristics include engaging in restrictive and repetitive behaviors. Some parents and professionals may believe that feeding problems are just another facet of, or a result of, the tendency of children with autism to have a restrictive number of behaviors or interests. Because of this, they may not seek services to treat a child’s feeding problems. However, centers that specialize in the assessment and treatment of pediatric feeding difficulties provide services to just as many or more children not diagnosed with autism with the same feeding problems as children diagnosed with autism.
Factors that May Contribute to Feeding Problems
Although it is logical to conclude that feeding problems in children with autism can be related to the overall characteristics of autism, other factors have been found to contribute to their feeding problems. These factors include medical and motor issues. For example, many children with feeding difficulties experience gastrointestinal disturbances such as gastroesophageal reflux (GER) and constipation. Because discomfort often accompanies GER and constipation, it can make eating more demanding, generally, and eating a variety of foods or acquiring new oral-motor skills more challenging, specifically. It has been found that many children diagnosed with autism experience GER and constipation.
Development of Feeding Skills in Infants and Young Children
Feeding is believed to be a developmental skill just like walking and talking. Infants and toddlers develop the same feeding skills at generally the same times. We acquire the sucking reflex before birth which allows infants to nurse or drink from a bottle, consume thin puree foods (baby food) between 4 and 6 months of age, slightly higher texture foods shortly afterward, start munching on crunchy foods like puffs and Cheerios around 9 months of age, and start chewing at 12 months of age. Toddlers practice chewing for approximately 1 year before they are efficient at this skill and can consume all textures of food. Many children with autism do not acquire the skills necessary to advance from one texture of food to another. One crucial oral-motor skill needed to consume chewable foods is that of tongue lateralization or the moving of food using one’s tongue. If a child is not able to move food with their tongue, they may only consume puree foods. Many consume only certain higher textured foods.
Other motor factors, such as a child’s breathing patterns, posture, coordination, and muscle strength can also affect their ability to consume food. For example, if a child has poor posture, their tongue may not move efficiently. It is common for children diagnosed with autism to have deficits in these areas.
As described above, children with autism are prone to have GI issues, limited oral-motor skills and other motor problems, which, thereby makes the consumption of new or higher textured foods more challenging. When these foods are presented, children with these issues may exhibit behaviors to avoid their acceptance or consumption. These behaviors may include pushing the foods away, turning the head or body away from the food, crying and screaming, gagging, coughing, and vomiting. These behaviors may also be reinforced or strengthened by the repeated removal of the new or more difficult food and/or by the presentation of a preferred food or another object such as an electronic device (e.g. iPad). These behaviors are likely to continue to occur even when the GI, oral-motor, and motor issues are minimized due to the history the child has with avoiding food.
Using a Team Approach to Address Complex Feeding Issues
Even though the treatment of feeding difficulties exhibited by children with autism is often complex, , improvements are often achieved when the child receives services directly related to those factors contributing to their feeding difficulties. Before starting an intervention designed to improve a child’s oral-feeding, those issues described above should be addressed. To address these issues, specific professionals should be consulted. These professionals typically comprise a pediatric gastroenterologist or another physician who has experience with feeding difficulties, speech pathologists, occupational therapists, physical therapists, and psychologists or behavior analysts. Sometimes these professionals work as a part of a team in a hospital- or center-based program. Other times, professionals work with these children with only minimal communication among the other professionals treating the child’s feeding difficulties.
A number of behavioral interventions have been developed to help children learn to eat new foods or develop the oral-motor skills necessary to consume higher textured foods. Many of these interventions have been extensively studied and descriptions of them can be found in peer-reviewed journals. One common intervention includes providing the child with access to preferred objects during the feeding session, either continuously or for short periods of time after the child engages in an appropriate mealtime behavior. Another intervention to introduce new foods to a child who only consumes a limited variety of foods is to present a new food simultaneously with a preferred food (e.g., a piece of broccoli inside a piece of apple). Finally, a third intervention consists of gradually exposing a child to a new food by first having him or her touch the food, then move the food, then kiss the food and so forth until the child is swallowing the food.
Although feeding difficulties are common in children diagnosed with autism, these difficulties may go untreated, either because they are believed to be a characteristic of autism or because the common factors contributing to feeding problems are not identified. Due to the complex nature of children’s feeding difficulties, multiple professionals with expertise in the area of feeding are often required to help. Many school settings, unfortunately, do not have staff with this expertise. Fortunately, there are centers that do have staff who can provide services to these children either at the center, or provide consultation and develop intervention plans in the child’s home, and/or at the child’s school.
To find referrals in your area for professionals who treat feeding issues, contact Autism New Jersey’s helpline at 800.4.AUTISM, firstname.lastname@example.org or visit our online referral database.
Ahearn W.H. (2003). Using simultaneous presentation to increase vegetable consumption in a mildly selective child with autism. Journal of Applied Behavior Analysis, 36, 361–365.
Hoch, T.A., Babbitt, R.L., Farrar-Schneider, D., Berkowitz, M.J., Owens, J.C., Knight, T.L., Snyder, A.M., Rizol, L.M., Wise, D.T. (2001). Empirical Examination of Multicomponent Treatment for Pediatric Food Refusal. Education and Treatment of Children, 24(2), 176-198.
Hyman, P.E. (1994). Gastroesophageal reflux: One reason why baby won’t eat. The Journal of Pediatrics, 125(6), S103-S108.
Kerwin, M.L., Eicher, P.S. & Gelsinger, J. ( 2005). Parental report of eating problems and gastrointestinal symptoms in children with pervasive developmental disorders. Children’s Health Care, 34, 217-234
Manno, C. J., Fox, C., Eicher, P., & Kerwin, M. (2005). Early oral-motor interventions for pediatric feeding problems: What, when and how. Journal of Early Intervention and Behavioral Intervention, 2(3), 145-159.
Piazza, C.C., Patel, M.R., Santana, C.M., Goh, H.L., Delia, M.D., & Lancaster, B.M. (2002). An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35(3), 259-270.
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36(3), 309-324.
Schreck, K.A., Williams, K., & Smith, A.F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders,34(4), 433-438
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, 233-240.
Wilder, D.A., Normand, M., & Atwell, J. (2005). Noncontingent reinforcement as treatment for food refusal and associate self-injury. Journal of applied Behavior Analysis,38(4), 549-553.