Autism and Restrictive Eating–What You Need to Know

My son Andrew has a healthy appetite but doesn't like textured foods and is highly selective about what he eats. He has eaten the same peanut butter and banana sandwich daily for years.  For autistic children, restrictive eating is very common.

Dr. Sharon Smile, Division Head of Developmental Pediatrics, Sunny Hill Centre at B.C. Children's Hospital says feeding difficulties, such as food selectivity, can emerge as early as one to two years of age and are often parents' top concern. Transition periods can be the most challenging, like starting solids or going to daycare or school for the first time. Many autistic children gravitate towards a narrow range of foods, causing distress and anxiety for caregivers.

Moira Pena, occupational therapist and Autism Programs and Projects Team Lead at Holland Bloorview Kids Rehabilitation Hospital, echoes this concern. She notes that up to 90% of autistic children experience atypical eating. Many strongly prefer sameness, including colour, texture and temperature.

Other common concerns include

• Staying seated at the table for more than a few minutes
• Refusing to eat
• Grazing during the day rather than eating meals at specific times
• Only eating a particular brand of food or at a specific restaurant rather than at home

Many autistic children have expected weights and heights, making it difficult to tell if they are undernourished simply by looking at them. 30% or more can be overweight or obese from eating all those calorie-dense, processed foods, which can lead to potential future medical complications with hypertension, diabetes and weight management.

Is it my fault?

It's important to remember that parents are not causing these issues. Ms. Pena reiterates, "It's nothing the parents have done; it just shows up." There can also be biological and genetic factors: Dr. Smile points to emerging research findings of atypical taste receptors in some autistic children.

She empathizes with how distressing this can be for parents. Practicing self-compassion is essential; there is no reason to feel shame or embarrassment.

How can clinicians help?

I was surprised to learn that autistic children often need to be exposed to a new food almost 30 times before they will try it. As Ms. Pena says, "This is a marathon, not a race, so explore and expand." Unfortunately, there is no quick fix.

Dr. Smile strongly believes in humility and listening to parents. She often asks them to keep a food diary or mealtime videos. Once no medical or physiological reason is determined for the food issues, professionals like Kerry's Place Autism Services' Clinical Supervisor, Ailya Jessa, complete an assessment and intervention plan. They identify patterns in food preferences, evaluate mealtime behaviours, and collaborate with caregivers and multi-disciplinary teams to select goals. Then, they design an individualized treatment plan.

Behaviour Analysts like Ms. Jessa prioritize a compassionate approach and create an environment in which the child engages with food gradually and receives frequent reinforcement and choices. Mealtime may be broken into small, reinforced steps, slowly building towards an agreed-upon goal. The child can opt out and rejoin the session at any time.

What is the MOBSE approach?

Dr. Smile's research team pioneered Holland Bloorview's MOBSE framework. Based on the premise that parent-child relationships and parental anxiety around eating affect all aspects of feeding, it assesses:

Medical factors and nutritional deficiencies

The priority is ensuring your child is nutritionally and medically stable. Did you know autistic children are four times more likely to report gastrointestinal concerns than neurotypical children? Does the child experience constipation, acid reflux, ulcers, irritable bowel syndrome or esophageal inflammation? Are there food allergies? Vitamin deficiencies? Are they meeting their growth and weight expectations? Anxiety is a common co-occurring condition, so treatment must look at the mental health/well-being of the child and family as well.

Oral-motor challenges

Does your child have difficulty chewing or swallowing? Do they have dental cavities that may make eating painful? Do they drool, cough or choke while eating?

Behavioural interaction with food

What behaviours do you observe during mealtimes? And what is the function of these behaviours: to escape from eating, seek attention, obtain a desired food or fulfill a sensory need? Are they self-injurious during mealtimes? If so, does this occur at other times as well? What is your response to disruptive mealtimes?

Sensory processing differences and skills

Can your child use cutlery, or must they be fed? Are they sensitive to specific tastes, textures, smells, appearances or sounds? Do they realize when they are hungry or full? Andrew eats so quickly that he never knows he is full.

Environmental factors

Does your family have a set mealtime schedule? Can your child remain seated at the table? Waiting until everyone has finished can be excruciating. How anxious are you and your partner during mealtimes? Are you withholding food, hoping your child will get hungry and eat non-preferred food? Dr. Smile emphasizes that allowing a child to go hungry doesn't work as a strategy to expand their range of foods: never withhold food.

What about Ms. Pena's BEST Strategies?

In concert with MOBSE, Ms. Pena recommends the following practical strategies:

Body Strategies

Many autistic children have low muscle tone and must work extra hard to control their bodies and maintain an upright posture. They need to feel supported at the table, with their feet on the floor or some support. Help them relax if they become anxious before mealtimes through a soothing routine, such as deep breathing, singing a favourite song or blowing bubbles. Once they feel safe, it's easier for them to focus on eating.

Emotional Strategies

Food and love are often intertwined. You might react if you spend time cooking and your child refuses to eat. Do you insist that your child finish everything? Eat all food groups? Ms. Pena says we must challenge our beliefs and behaviours to increase the child's comfort and safety and enjoy more peaceful mealtimes. A good mantra to keep in mind is the Division of Responsibility rule:

• It's the parent's responsibility to decide which food to provide, when and where.
• It's the child's responsibility to decide whether to eat the food and how much.

Sensory Strategies

Set up consistent routines and sit together at the table at scheduled mealtimes. Your child might only be able to stay seated for one minute to start, but that's OK. Praise and reward them and gradually increase time at the table. Similarly, build acceptance of new foods through gradual exposure. Encourage them to get messy and play with food to become comfortable. Children learn through play, and this includes playing with food!

Thinking Strategies

Allow your child to make confident choices, such as which spoon or colour napkin to use. Add as much predictability into the day as possible. Visuals that show what meals are planned during the week or a calendar that shows when you will be serving their favourite meals might help decrease overall anxiety around eating.

As in all areas of our children's lives, we benefit when we learn how to address their challenges and are consistent and supportive. Believe they are doing their best, and remember to praise their success at completing the most minor task. This will go a long way towards creating a positive mealtime experience.

Now, if only I could get Andrew to eat spinach.

Author:

Jan Stewart is a highly regarded mental health, autism and neurodiversity advocate and Chair of Kerry’s Place Autism Services, Canada’s largest autism services provider.

Her brutally honest memoir Hold on Tight: A Parent’s Journey Raising Children with Mental Illness describes her emotional roller coaster story of parenting two children with multiple mental health and neurodevelopmental disorders.