By Dr. Travis Whitney and Cece Charlesworth, BSc.
Rare is the parent who does not occasionally have to deal with food-related tantrums or, at the very least, fussy eating behaviors. But for a variety of reasons, children on the autism spectrum — and consequently, the parents who feed them — frequently deal with substantially greater and more complicated challenges with food. Clinical psychologist Stephanie Lee, PsyD, has worked with numerous families to address the feeding difficulties that autistic children may encounter.
When working with children who have rigid eating habits, the objective is to (eventually) enable the child to consume a variety of healthful foods that are consistent with the family’s culture while minimizing the resulting domestic strife.
In order to help kids feel more at ease trying new foods and to make mealtimes more enjoyable for everyone, it is important to first understand what might be causing inflexible eating practices.
Excluding GI issues
A pediatric gastroenterologist should be a parent’s first port of call when a child on the autistic spectrum is having feeding problems because they can rule out organic factors. According to pediatric gastroenterologist Joseph Levy, MD, who treats autistic children at NYU Langone Hospital, autistic children “may not be able to localize or verbalize their pain.” As a result, parents must be proactive in attempting to identify the cause of their child’s discomfort. Sometimes conventional doctors won’t explore GI issues extensively, so make sure you tell them you’d like to screen for other complications you read about in this article. It may be worth it to pay out of pocket at another provider. We screen for GI problems at Innate Healthcare Institute because they are crucial to both children’s and adults’ health! Here are a few of the more typical GI problems that kids could encounter.
Dysbiosis frequently appears in children with autism. When there is an imbalance between the organisms in our small and large intestines, it is called dysbiosis. Good bacteria can be insufficient and ‘bad’ bacteria can be overabundant. Even one or two strains of a virus, bacterium, or parasite can occasionally create an unbalance and result in behavioral and neurological issues in addition to GI issues. A stool sample can be used to test for this.
Food sensitivities can lead to poor GI and behavioral health, including those to gluten, dairy, soy, and other foods.
Acid reflux is a common childhood illness. However, among children on the spectrum, “we have seen that behavioral changes like jumping around, becoming wild, or crying correlate to the exact time that the acid backs up in the child’s throat,” explains Dr. Levy.
Constipation can make eating very difficult for a child who feels full or has a stomachache, whether it’s brought on by a restricted diet or delayed toileting (common in children with autism).
A child who has eosinophilic esophagitis (EoE), an allergic swallowing condition, may experience gagging or choking sensations. EoE is frequently brought on by eating, and it can produce pain and discomfort that almost always leads to behavioral problems in children with autism.
Problems with diarrhea can be linked to a child’s diet, but they can also result from the malabsorption of some sugars or from the GI system moving quickly, which does not give the stool enough time to firm up.
Behavioral problems during meals
For children with autism and their families, problematic mealtime behaviors can include:
Food sensitivities: Children on the autistic spectrum frequently exhibit a strong preference for foods that have a distinct mouthfeel. Others want the stimulation that crunchy foods like Cheetos or, if a parent is lucky, carrots, provide. Some people enjoy soft or creamy foods like yogurt, soup, or ice cream. In either instance, that may severely restrict the range of foods that children are willing to eat.
Underdeveloped oral motor musculature: Children who like soft meals and consume them nearly exclusively as they grow may not have the necessary oral motor musculature to chew tougher foods like steak or hamburger. Dr. Lee notes that frequently parents who don’t realize this is the root of their child’s distress can react by allowing them to forego the meals that would strengthen those muscles, so it creates a vicious cycle. “They get fatigued eating those foods and find it unpleasant,” she says.
Time and table manners: Many parents find it difficult to convince their kids to stay at the table long enough to finish a meal. But the difficulty may be worse for children with autism. The question of safety is another. Dr. Lee continues, “So it’s not just do they stay at the table or where you plan for them to eat, it’s also do they engage in risky or harmful acts or disruptive behaviors in the space that you would like them to eat? Unsafe actions could include throwing objects at the table or frequently getting up and leaving the table.
How these actions get worse
Parents of autistic children frequently prioritize several demands at once, and many of these — speech difficulties, toileting, school placement, and general obedience — take priority over the variety of foods a child is accepting. Feeding problems are put off until they either become unmanageable or parents can devote their attention to them.
“Parents will default to those foods,” says Dr. Lee, “if the child eats 10 foods and those 10 foods are keeping them alive, safe, and fine.” But neglecting these problems usually makes them more difficult to resolve. The longer these harmful eating habits persist, the more established they become and the longer it takes to successfully treat them. The process will undoubtedly take longer and demand more perseverance and tolerance from everyone, but that doesn’t mean parents should give up.
Methods for dealing with problems during meals
Different mealtime behavior difficulties can be addressed using similar strategies, but they must be divided into doable chunks. The helpful advice provided below will assist parents in helping their children reach their goals and lessen the stress associated with mealtimes.
Establish priorities: Far too frequently, parents attempt to address all mealtime habits at once. That is a mistake that will only cause parents and children to become discouraged and give up. Dr. Lee asks families she works with to rank their objectives in order of importance. Will their youngster eat more foods as a result of this? how much they consume? Or is it being more quietly at the table? Parents must decide who their main audience is.
Start small: It’s crucial to begin with modest steps, regardless of the aim. Dr. Lee will start with a tiny amount of a new meal, for instance, so small that the youngster might not even be able to taste it. If the child’s initial goal was to simply try the food, Dr. Lee would give them lots of praise and may even count it as their “no thank you bite,” which means they can skip it for the rest of the meal after taking one bite and saying “no thank you” calmly.
Don’t push your luck: Parents frequently want to push for a little bit longer if a child has been sitting at the table for 10 minutes and that is the aim. That is incorrect. Dr. Lee says, “Sometimes, we feel like they’re doing well, so let’s push it another 10 minutes.” Especially for kids who have been struggling at mealtime, it’s crucial for them to start building up successful experiences to help them shift their attitude about eating and mealtime, says the author. “But really that extra 10 minutes can result in the meal ending in a less successful way.”
Meet your child where they are: It’s probably not a smart idea to start by trying to get them to finish their entire plate if they aren’t currently eating any of the things you put in front of them. Parents must set acceptable expectations for their children’s behavior during meals, starting by accepting them where they are right now.
Give parents, caregivers, and your child a clear understanding of your goals, how the meal will conclude, and what defines “success” (or failure). It is possible to simplify expectations for children, such as by utilizing a visual timer that counts down the number of minutes the child is required to remain seated at the table.
Praise your child generously. According to Dr. Lee, it’s important to acknowledge all of your child’s achievements. And praise can take several forms:
Giving your child general praise entails using phrases like “good job,” “way to go,” or giving them a high five.
Telling your youngster specifically what it was about their behavior that you enjoyed is referred to as praise. Labeled praise is crucial because it reinforces the good habits that parents are trying to instill in their children. Some examples of labeled praise are: “Thanks for sitting so quietly at the table,” “I love how you tried that new food,” “Great job sitting with your fork at the table,” “Thanks for putting your plate in the sink.”
The golden rule at mealtime, according to Dr. Lee, should be that for every instruction or reprimand given, the parent or caregiver should offer the child five “portions” of praise. This is difficult, but it is the recommended ratio. Additionally, Dr. Lee adds, “it shouldn’t be random. We encourage parents to compliment children in a sincere and heavy manner, saying things like, “Thanks for coming to the table! You did a great job of getting going straight away! Great job requesting seconds!’ – things of that nature.
Be consistent, persistent, and patient. Dr. Lee states that it often takes seven to 12 exposures to a new cuisine for children and even adults to truly determine whether they enjoy it or not. Therefore, it’s crucial to be patient and persistent. She explains that just because a child says they don’t like something once doesn’t mean they will always dislike it. Therefore, we’re making sure to go over those items again.
How to handle tantrums: Don’t anticipate your youngster changing ingrained eating habits without a fight. It’s normal to anticipate some resistance, including whining or sobbing as well as verbal or physical hostility. However, that doesn’t imply that you aren’t improving. Dr. Lee instructs parents to use a strategy known as “planned ignoring,” which is purposely ignoring a behavior so long as it’s not risky.
Keep a food journal: As much as possible, parents and other caregivers should keep a written record of what the kid consumes at each meal so that they can monitor the child’s progress and identify any areas where problems are still present. Being patient is much simpler when you have a record you can look at over time, and it keeps everyone on track.
Keep a poop journal: Dr. Lee advises that parents, caretakers, and even teachers keep a written record of a child’s bowel movements because what goes in must come out in some form and with some regularity. A trip to the physician or possibly a gastroenterologist is generally advised if chronic constipation manifests as a problem. Withholding their bowel movements is a common toileting difficulty in children with autism, which can make a youngster feel less at ease about eating, according to Dr. Lee. Children may also suffer if they consume a lot of carbohydrates but not a lot of vegetables that will help them grow. If this is a concern, parents should speak with their pediatrician or GI doctor very away.
Model appropriate behavior during meals: Often, children will pay more attention to what we do than what we say to them. Try new things yourself, try to enjoy mealtime without distractions like phones or television, and those behaviors will probably have a positive impact on your child. “If you say to your kids it’s really important to eat a balanced diet, but then you’re not really modeling that,” Dr. Lee says, “it’s probably unlikely that they’re going to develop those positive habits you’re looking for.”
Tempt Them with Food
A meal that includes probiotic-containing live cultures or fermented foods, according to Jill Castle, a pediatric nutritionist in Massachusetts and the founder and CEO of The Nourished Child, a website that informs parents about nutrition. Jill Castle also thinks that this can increase the number of good bacteria in the gut. She advises including foods that are colorful, zesty, and overflowing with healthy bacteria. Aim to purchase as many organic and naturally colored foods as you can.
The good news is that there are many nutritional, gut-supporting products that kids can consume, she says. “Parents may make sure that they frequently provide a choice of prebiotic and probiotic meals as options to taste and test at mealtimes.
Although kefir typically has a tart flavor, some brands also include strawberry, mango, or peach flavors, according to Castle, I’ve had great success serving this to fussy kids because it’s smooth and creamy and tastes like a smoothie. If you have an Insta-Pot you can make your own homemade yogurt. This is ideal since you can control what’s going into it. You can find an instructional video here: https://www.youtube.com/watch?v=p4uzSa0kPFE
Pickles that have been slowly fermented with salt and water are a good source of gut-healthy bacteria, but while most cheeses are fermented, very few of them contain living, active cultures. Castle suggests using cheddar, mozzarella, or gouda. She also mentions that kombucha, a fizzy, fermented tea with living, active microbes, comes in various varieties that kids find appealing.
Adding fiber covertly
All vegetables are healthy, but those with a lot of galacto- and fructo-oligosaccharide (GOS) and fructo-oligosaccharide (FOS) prebiotics encourage the development of good gut bacteria, according to Dr. Joanne Aponte, a naturopathic physician at Lakeside Natural Medicine in Milwaukee. Beans, lentils, and peas are high in GOS, as are broccoli, cauliflower, and Brussels sprouts, while leeks, g
Aponte also recommends chia, flax, pumpkin, and sunflower seeds, which can be ground in a cheap coffee grinder and added to smoothies, porridge, yogurt, or home-baked goods like cookies, pancakes, or waffles. Aponte also mentions that sunflower butter can be used to make cookies. “I make oatmeal-sunflower butter cookies that are loaded with pumpkin, ground chia seeds, microbiome-supporting oatmeal, and, of course, chocolate chips.”
Offer dipping sauces, such as teriyaki, ranch dressing, or salsa, to entice kids to consume raw vegetables. Vegetable skins should be kept on whenever possible because they contain fiber that supports the gut microbiota. For kids who are picky about their vegetables, Aponte suggests making zucchini or carrot muffins with ground chia seeds or walnuts.
Some children might prefer refried beans or a black bean spread or dip over whole beans. Pastas can also be made from lentils or chickpeas. Small-chopped vegetables like onion or zucchini can be snuck into spaghetti sauce. Aponte advises parents to encourage their children to try a variety of foods because it takes some experimentation.
Include Some Fun
Katrina Lien, a program development specialist who oversees the Sanford Fit children’s fitness program in rural South Dakota, North Dakota, and Minnesota, counsels parents to find ways to empower and inspire their kids to lead healthy lives.
She suggests mixing novel meals with those you are sure your kids will like because “kids are more open to trying the novel or unfamiliar food when you introduce something new or unfamiliar alongside foods that are a well-known favorite.”
“You can achieve this by arranging the food on the plate or by chopping it into various shapes,” advises Lien on how to make eating more fascinating and enjoyable. For instance, use a cookie cutter to cut basic cucumber slices into hearts or stars.
When parents involve their children in snack and supper preparation, Lien claims that children feel involved and are eager to try the foods they helped make. While introducing new foods to children can be challenging and time-consuming, parents should continuously remind themselves to be patient and consistent.
Working with Picky eaters
According to Cece Charlesworth, Innate Healthcare Institute’s Autism Communications Specialist, working with picky eating can be incredibly difficult. However, it is crucial to remember that even the smallest accomplishments are beneficial for both you and your child. As mentioned previously, there are many medical and psychological reasons to ensure your child is consuming a healthy diet. In our experience it is common that children begin to recognize that they can avoid foods successfully.
They do this by simply refusing the food, spitting it out, throwing a tantrum or otherwise evading the food. It’s important to remember that the longer you refrain from adjusting your child’s diet, the more embedded their behavior in regard to trying new foods will become. Understandably, it can be a daunting task to begin the process of introducing new, healthy foods. The first thing we always suggest is giving yourself grace, remaining in a calm headspace, and practicing patience. Changes may not be seen over night but with consistency, successes can be obtained.
Mealtimes should be generally set at regular intervals throughout the day. You want to do your best to provide breakfast, lunch, snacks, and dinner at the same time on weekdays and weekends. Having a different schedule on the weekend is perfectly ok, if the child can begin to pick up on the pattern of eating times throughout the day in association with the rest of their daily schedule. Scheduling can help reduce any uncertainty and anxieties a child may possess around mealtime. Giving your child a warning prior to when it is going to be time for a meal is also helpful. The length of warning time varies from child to child, I often suggest starting with a ten-minute warning before a meal. This also helps the child gauge time and understand that they will discontinue what it is they are doing and will be beginning a new task, in this case – a meal. Keep a consistent warning time until there is no adverse behavior. It can decrease as behavior decreases but until there are no longer issues around eating, it is good to maintain a warning time, even if it is just three minutes.
If your child has difficulty sitting down at the table for a period of time, try starting there. Depending on the intensity of their aversion, ask them to sit for a specific amount of time. This might be two to three minutes for some children and ten for others. The goal is to work up to having your child be capable of sitting at the table for the entirety of a meal, along with other members of the family, and eventually in a public setting. If your child is accustomed to having some form of entertainment at the table, try replacing that with meditation music.
You can also make it clear that food is only going to be eaten at the table, this is very much so for safety as well as the child learning to regulate their behavior. Saying this, may not make any immediate changes, but implementing it as strictly as possible will yield results with practice and consistency.
When at the table, you can simply ask the child to try something. We’ve worked with some children who are motivated to try a strawberry on their plate first, with their preferred foods present, because it’s been made clear they cannot have their preferred food item until they try the new food item. We have also worked with children who have a more “out of sight out of mind” approach. For these children it is best to give them one thing to taste while the remainder of their meal is out of sight. Try both approaches and see if one is more successful than the other. Keep in mind every child is different!
When engaging with the child it is best to stay calm and firm with your requests. Keep in mind that if you veer from your request, the child will learn there is a way out of the situation and will continue to look for it at any given opportunity. You want to ensure you are making a simple request, you do not need to go into a long overwhelming explanation but simply say “we’re going to try ____ today!” Then present the behavior you are asking them for, trying the food yourself. A team effort is often quite helpful.
Children on the spectrum, particularly nonverbal children, are asked or “demanded” to do a lot throughout the day. If they cannot express themselves verbally, these demands can begin to become very frustrating. Swapping your language from “YOU need to” to “we’re going to” can reduce demands and create a more pleasant environment for learning and new experiences. Set clear boundaries about the experience and start small. Ask your child “please try the ____.” You don’t want to change your language when making the ask, as this can lead the child to think that the situation may change if they continue to refuse. This process can take quite a bit of time, it is best to begin when you know you are not in any kind of rush. Remaining calm and keeping the tone of your voice consistent are both helpful in the matter.
If your child spits the food out and does not have any medical reason to do so, be sure to tell them that we do not spit food out. If this occurs again in the future, you can replace the bite with a fresh one. This teaches your child that they cannot evade the situation by spitting their food out.
If your child consumes the food, be sure to become quite excited, understandably this may come naturally! As mentioned, be specific about what it is that you are excited about. “Oh my! Thank you SO much for trying the ____!” It is important to thank your child when they comply with any kind of ask. Your “thank you’s” should be genuine and enthusiastic.
You can always take the opportunity to slowly introduce new foods to your child by mixing them into things they may already prefer to consume. Unfortunately, some kids will immediately detect this however, we have seen success in adding veggies into an already preferred burrito, for example.
Another beneficial routine to begin implementing is the concept of “clean up.” You can begin to teach your child to take care of space by giving them small and buildable tasks after they complete eating. This begins to build a structure for mealtime; warning, sit down patiently, eat, clean up. The task of cleaning up does not need to be difficult, it can be as simple as bringing a bowl to the sink and setting it in a designated spot.
When starting the process of introducing new foods, remember you do not want to overwhelm your child. If you suggest trying three bites the first time you introduce something, stay with a three-bite requirement. If your child begins to eat a new food item without prompting, you of course, may allow this. You do not want to forcefully switch from three bites to five because they seem to be tolerating the food. You want to ensure you are building trust throughout the process and the boundaries you have set apply to both you and your child.
Although managing a picky eater can be difficult, it is worth tackling for the health and wellness of both your child and you. Remember to stay calm, set expectations, and practice patience and consistency.
Though this is a general guideline, it is pertinent to remember every child is different. Often adjustments need to be made to fit the specific needs and behaviors of an individual.
We work with this with all our children receiving stem cell therapy at Innate Healthcare Institute. If you’re curious if stem cell and integrative medicine is right for your child with Autism or other developmental delays, contact t Innate Healthcare Institute at 602.603.3118 or email email@example.com
Sanford Fit offers free online resources like printable books, movies, courses, and games at fit.SanfordHealth.org.