G.P.S. Newsletter for August

Mealtime tips for autistic children with eating challenges

Feeding challenges are among the most common issues that bring children with autism and their parents to my practice.

Of course, children’s nutrition and mealtime behavior are common issues for parents everywhere. But research confirms what our ATN parents have long been telling us: Children with autism are far more likely to be overly selective in what they will and will not eat. As a result, many of them have less nutritional variety in their diets than their typically developing siblings and friends. Fear of new foods and outright food refusal are among the most common concerns I hear from parents.

This is why the Autism Speaks ATN, in its role as the federally funded Autism Research Network on Physical Health, developed Exploring Feeding Behavior in Autism: a guide for parents. (Follow the title link to download free of charge.)

Today, I’m glad to share ten of the strategies that, in my experience, prove the most successful in supporting children and their families in their pursuit of healthy eating habits. Keep in mind that it’s a journey that almost always involves some missteps as alongside its successes.

1. Rule out physical problems.

It’s not uncommon for children with autism to have medical issues that make eating unpleasant. These can include dental cavities, physical difficulty with chewing and painful acid reflux. So make sure that your child’s doctor screens for and addresses any such issues before proceeding.

2. Ease into mealtime

Many children who have autism experience great anxiety as mealtime approaches. The underlying reasons can include sensory aversions and fear of unfamiliar foods. Inadvertently, families can make the anxiety worse by trying to force a child to eat, setting up a pattern of mealtime stress. Fear and anxiety can shut down hunger in a powerful way by putting the child’s body in a state of “fight or flight.”

To reverse this pattern, I counsel parents and other caregivers to spend a few minutes helping the child relax before mealtime. One way to do this is to spend five minutes practicing deep breathing together. This can be as simple as slowly and deeply inhaling for a count of four, then slowly and fully exhaling for a count of seven or eight. Alternatively, the two of you can blow pinwheels, bubbles or even a wind instrument such as a recorder or harmonica.

Or, you might use those five minutes doing what we call a “deep pressure tactile exercise.” I like simple exercises like pushing hands against the wall (lean in with your full weight) or having your child push the palms of his or her hands against yours.

3. Sit together at a table for meals

I can’t overemphasize how important it is for a family to eat together as a matter of routine. Environmental cues help all children – and especially those who have autism – learn what they’re supposed to be doing. For example, a child’s bed is an environmental cue for sleeping. Similarly, the family table needs to be for eating.

In addition, eating together helps your child learn through imitation. Children are wired to copy others. And a child will be more likely to put a new food in his or her mouth after seeing you do so.

Often, the first step is to undo habits such as eating in front of the TV, while seated on a parent’s lap, while playing with a touch pad, etc. I counsel families to start by having their child sit at the table with them or another family member – even if it’s just for one minute to start. With praise and small rewards, gradually increase the time at the table to around 20 minutes. At first, reassure your child that eating isn’t necessary. Just keep the food within your child’s reach while the rest of you eat. The idea here is just to increase comfort with the mealtime routine.

I suggest using the same table for all meals and have family members sit in the same chairs to further cue your child where to sit and what to expect.

4. Support your child’s posture

Many children with autism have weakness in the core muscles of the stomach and back. Others have poor body awareness. That is they don’t quite sense where their bodies are in space. Any of these issues can produce poor posture, wriggling and discomfort while sitting at the meal table. By providing support, you can help your child focus more on eating than on keeping his or her body on the chair.

If you see your child slouching, leaning or wriggling at the table, try placing rolled up towels around the back and hips to provide additional support. Also make sure that the feet have support. If they don’t reach the floor, try placing a step stool in front of the chair and under the table.

5. Build acceptance to new foods through gradual exposure

In my practice, I’ve worked with kids who are truly fearful of certain foods placed in front of them. I find that many of these children have particularly strong reactions to a food’s appearance. For example, several of the kids in my practice refuse foods of certain colors. Another has an extreme fear of touching apples because they look “wet.” Yet another child fears even being in the same room as an orange.

It’s important to appreciate and understand that these fears are just as powerful as, say, a fear of snakes or big spiders. With this in mind, I begin to use the principles of gradual exposure to help them learn to control and eventually get rid of these fears.

Take for example, the boy who felt anxious around apples. First we worked on his getting comfortable with just looking at an apple in front of him for a few minutes. I assured him he didn’t have to eat it and encouraged him with praise. We then moved on to touching the apple with a fork, then with a napkin, then with his fingers. We used play-based language like “I challenge you to hold the apple to your cheek for 30 seconds.” He even learned to use a food processor to chop up the apple – all of these steps helping him overcome what had been a very real fear.

6. Have set times for meals and stick to them

As I’ve mentioned in previous advice posts, it’s so important to eat on a schedule. Space meals and snacks every two-and-a-half to three hours through the day. Eliminate snacks – including milk and juice – in between. The idea is to train your child’s internal hunger signals to specific mealtimes. This helps your child’s body expect food and accept food at designated times.

7. Expand what your child already eats

Let’s say that a child’s perennial favorite is white spaghetti with no sauce. You can start “stretching” her food acceptance by offering, say, a different brand of white spaghetti, then trying brown rice or another type of spaghetti. Eventually, you’re moving to spaghetti with a little butter, then a white sauce, etc. The idea is to offer a food that remains familiar looking while building tolerance to small and incremental changes. A change from spaghetti to penne pasta, for example, might be too much to handle simply because it looks too different.

8. Take food out of their brand boxes or containers

My alarm bells go off when I hear of children eating only a specific brand of a specific food. I know of several parents who spend inordinate amounts of time searching out particular brands because their children refuse anything else. I counsel my families to avoid this issue altogether by taking food out of boxes as soon as they unpack the groceries. Put food in clear containers. Rotate brands as much as possible so your child is less likely to get “stuck” on a highly specific taste, look and texture.

9. Encourage your child to explore, play and get messy with food

Children learn through play, and this includes playing with food. This dovetails nicely with the principle of “gradual exposure” that I described above. Encourage your child to interact with food through his or her senses. Talk about the look and feel of foods. Make interesting shapes with cookie cutters, etc.

Think of it as “food school,” and reserve some time each week to engage in food learning through play. Your child may or may not eat the foods he or she is exploring. The idea is to build a foundation that allows greater comfort with foods.

10. Concentrate on the food not your child’s behavior

As much as possible, try to ignore challenging behaviors at the table. Many children learn to escape the family meal by engaging in spitting, whining, banging on the table and the like. I suggest diverting attention from the negative behavior with a conversation about the food. This can involve asking the following questions to get the whole family involved in “food learning.”

Is this a wet food or dry food?
Does this have a big smell or a little smell?
How is this [pita bread] different from [regular bread]?
What sound does this food make when you chew it?
What other foods do we eat that are the same color?

Nutritional Issues and Special Needs Children

If you are a parent to a special needs child and you're all revved up to attend an upcoming Abilities Expo near you, then you're probably ready to discover how findings of the latest research can make a big change in your child's quality of life. One area in which you are perhaps hoping to find the solutions you've been seeking, is that of nutrition. Many special needs kids have a nutritionist who sets specific guidelines for the challenges they are facing; for others, focusing on nutritional goals is a whole-family effort. Here we highlight some of the common nutritional risks special needs children may face and provide suggestions, where appropriate, on how to overcome these challenges. We must bear in mind that nutritional challenges are as varied as each individual child and our aim is merely to provide a general guideline for parents and caretakers.

Obesity: Children with limited mobility or those who have conditions like Down Syndrome can have low muscle tone or bone issues, thereby making it harder keep their weight down. It is vital to establish good eating habits from the start, limiting your children's experiences with sugary, salty and processed foods so that they can develop a taste for fresh, seasonal foods. It is likewise vital to inquire about any children's nutritional programs in your area which focus on the importance of healthy eating. If your child understands how sugar, fat and cholesterol affect their bodies, they are much more likely to embrace a healthy lifestyle than if they are simply told what they should and shouldn't be eating. Parents can help make shopping a fun experience for kids, encouraging them to read food labels and to choose healthy snacks (e.g. kids can be taught to shop for healthy snacks that have less than two grams of saturated fat or more than three grams of fiber per serving).

Children should also be encouraged to find an activity they love and feel confident doing; there are a host of fun, engaging adaptive sports they can sign up for, which will ensure they have a good time while performing a classic cardiovascular workout. The 'winner-loser' mentality should be thrown out the window, as long as kids are having fun in a safe environment.

Being Underweight: Children with special needs can be underweight because of various problems, including difficulties with swallowing. Some kids can have a particularly speedy metabolism, caused by conditions such as cerebral palsy, where muscular spasms burn up a significant number of calories. Swallowing problems (dysphagia) are an issue which needs to be diagnosed by a therapist. In mild cases, the therapist can work alongside your child to improve the swallowing mechanism; in serious cases, a feeding tube may be necessary. The first step for most parents whose kids don't have a hearty appetite is usually experimentation; trying out an assortment of foods that are most likely to stimulate the palate and provide adequate nutrition. If your efforts are proving unfruitful, vitamin supplements can be an ideal way to ensure a child's daily requirements are met.

It is also important to look beneath the surface and analyze whether a child's lack of appetite can be caused by an underlying issue such as depression. This condition is characterized by a lack of interest in activities and hobbies a child used to enjoy, a lack of energy and an avoidance of social occasions and interaction. If depression is suspected, it is vital to obtain help from a psychologist or psychiatrist, who can suggest successful therapies such as cognitive behavioral therapy, medication or a mixture of both approaches.
Having a Complex Relationship with Food: Often, a child with special needs may face specific barriers to having a healthy relationship with food. For instance, a child with autism spectrum disorder may have an intensely negative reaction to particular textures, tastes or colors. Children with Down syndrome, meanwhile, may prefer softer foods because of difficulties encountered when chewing or swallowing. If a child refuses to eat items outside a select list of foods, the importance of a good supplement may again come into play. Many parents report that simply getting their child to eat at all is a big achievement and this should remind us that nutrition should be approached on a step-by-step basis, and that every 'small victory' should be celebrated to the full.
Side-effects of Medication: Some 75% of kids with special needs take medication; some of the latter, especially anti-depressants, anticonvulsants, mood stabilizers, etc., are linked to weight gain. It might therefore be worthwhile for parents to speak to their child's physician, to discover if there are alternative medications with lesser side-effects.
Genetic Factors: It is vital that parents be aware of the link between genetic factors and obesity. The following syndromes, for instance, may place children at a higher risk for weight gain: Down syndrome, Spina Bifida, Autism Spectrum Disorder, Prader-Willi syndrome, Cohen syndrome, Carpenter syndrome, Borjeson syndrome and MOMO syndrome.

Overcoming the biggest nutritional challenges of special needs children is a complex issue that is sometimes within and sometimes beyond a parent's grasp. Yet to the extent we can, it is vital to ensure that our children enjoy the colorful, flavorful, rich-textured world of healthy food, and to get their hearts racing to the inviting rhythm of sport and life.

References:

1.Moira Pena , Mealtime tips for autistic children with eating challenges .https://www.autismspeaks.org/expert-opinion/autism-and-mealtime-therapists-top-ten-tips-success

2.Claire Capaldi ,Nutritional Issues and Special Needs Children. https://www.abilities.com/community/buzz/buzz58-nutritional.html

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