Children with Autism Spectrum Disorders and Feeding Disorders

First: What are feeding disorders?

They are disorders associated with the feeding process: starting from attempting to handle food by hand and ending with its digestion. They recur at all mealtimes and negatively affect the child's health and emotional/social relationship with their parents due to the psychological burden and stress parents experience when they have a child who refuses to eat. They can be clinically divided into three types:

1. Pediatric eating and swallowing disorders across the three swallowing phases: oral, pharyngeal, and esophageal.

Their symptoms manifest in the child having difficulties with sucking/nursing, chewing, grinding, forming a bolus and/or controlling the bolus in the mouth, food regurgitation from the mouth or nose while eating, choking or coughing during meals, inability to complete a meal due to fatigue, insufficient weight gain, and occasional fever spikes. It is often diagnosed during infancy by a speech and swallowing specialist, and an appropriate treatment plan is developed for them.

1. The child may have digestive disorders, manifested by persistent pain, gas, colic, elimination problems, and crying and screaming accompanying feeding or elimination. It is often diagnosed during infancy by a pediatrician, and they may be referred to pediatric gastroenterology.

2. Behavioral/sensory feeding disorders, which are the most common in children on the autism spectrum.

They are characterized by not being organic (the child does not suffer from a medical illness), but having a set of negative behaviors and hypersensitivity related to mealtime and eating in general. It is diagnosed and treated by a speech and swallowing specialist, an occupational therapist, and an applied behavior analyst.

What is the relationship between feeding disorders and autism spectrum disorder?

46–89% of children on the autism spectrum have feeding disorders

This is reinforced by the characteristics of autism spectrum disorder that exacerbate behavioral/sensory feeding disorders, which include, but are not limited to:

- Repetition

- Fear of trying new things

- Sensory processing disorders (whether hyper- or hypo-reactivity)

- Difficulties in communication and social interaction

- Reinforcement of negative eating patterns

- Often restricted interests

What are the characteristics of behavioral/sensory feeding disorders in a child on the autism spectrum?

- Selecting a specific type/texture or consistency and sticking to it (they often prefer carbohydrates and dislike vegetables and fruits)

- Insisting on food of a specific brand / specific appearance / specific arrangement

- Inappropriate pace of food intake

- Disordered eating patterns (obsessive in nature)

- Refusal to accept new types of food

- Inappropriate mealtime rituals

- Extended mealtime duration (exceeding half an hour)

- Unhealthy weight (wasting or extreme obesity)

Does a gluten-free and casein-free diet help resolve my child's behavioral/sensory issues?

To date, there are no studies with strong scientific/statistical evidence recommending this diet to improve sensory/behavioral disorder symptoms associated with autism spectrum disorder and/or proving its effectiveness with children on the autism spectrum (who do not have wheat and/or milk allergies). However, it is worth noting that if the family wishes to adhere to this dietary pattern, we encourage them to consult a clinical dietitian and follow their guidance.

How does receiving therapy from a speech and swallowing specialist and/or an occupational therapist and/or an applied behavior analyst benefit us?

- Accepting eating types of food that were previously rejected

- Tolerating eating a few bites of foods the child did not accept at all

- Accepting new food types from food groups

- Increasing the amount of food that reaches the stomach and gets digested

- Increasing the amount of swallowed bites instead of spitting

What therapeutic solutions can I adopt to support my child, and are they helpful?

- Provide the child with visual schedules to clarify the meal's events and expectations in order, reinforcing the mealtime routine

- Use simple language for instruction and avoid complexity (simple sentences not exceeding 3–4 words supported by pictures)

- Offer choices to the child so they feel in control, whether choosing a reinforcer and/or choosing the item to be tried

- Use the principle of therapeutic sensory hierarchy and do not rush

- Present reinforcers preferred by the child to ensure continued motivation

- Use the Premack principle: the child performs a non-preferred activity (eating a bite of the scheduled food), then you reward them by performing a preferred activity (playing with their favorite toy for one minute)

Practical tips for parents and teachers:

- Repeat the activity until the child gets used to it and anticipates it, and avoid surprises.

- Help the child initiate the meal activity and sequence the motor activities.

- Plan your goals gradually: the first goal sometimes starts with the child tolerating being in the same room with the non-preferred food.

- The child must sit properly in their chair with something solid under their feet (the child's feet should not be dangling in the air) to achieve a sense of balance and security.

- Collaborate with an occupational therapist to learn therapeutic methods for dealing with sensory/behavioral disorders.

- Pay attention to the child and try to read signs of their stress or meltdown before they happen, such as: splaying their fingers, elopement, and aggressive behaviors, and de-escalate them by giving them an opportunity to express themselves using communication, whether through speech or picture cards for a non-verbal child.

- After 6–8 weeks, begin modifying familiar foods into other forms or making them close to non-preferred foods.

- Always consider generalizing acquired skills across more than one context, for example: achieving the goal of eating a specific food at home and at school.

- Do not rush results, and remember that the slow and persistent tortoise is the one that won the race. ☺

Prepared by: Ms. Noura Al-Ghusun - Senior Speech, Language, and Swallowing Specialist

References:

• Picky Eaters in the Preschool Classroom: 7 Tips for Teachers, Melanie Potock, MA, the ASHA Leader Live
• 3 Tips for Parents to Help Kids With Autism Eat, Melanie Potock MA - the ASHA Leader Live, 2013
• When Your Eyes Are Bigger Than Your Stomach: Use of Visuals in Feeding Therapy. for Children with Autism Spectrum Disorders JoAnn Barton, MS, CCC-SLP ,Franciscan Hospital for Children
• Feeding and The Child with Autism Spectrum Disorders, Jeanne Marshall & Pamila Dodrill, Queensland Children’s Medical Institute
• Sensory Processing and Impact on Feeding, Sue Delport OT-MSc. November 2012
• Carruth and colleagues (1998)
• Fischer and Silverman (2007)
• Mascola and colleagues (2010)

Originally published in Arabic. This English version was produced with AI-assisted translation; the Arabic original remains the reference.