Picky eaters, over-eating, eating non-food materials, restriction to certain food groups or certain environments, anxiety related to eating, problems with different textures and weight loss /gain can be problems for all children but are significantly raised in children with an Autism Spectrum Disorder. Appropriate management of these difficulties is very important as eating behaviours can become entrenched in the individual and more difficult to change as time progresses. The links between obesity in childhood and increased risk of high blood pressure, cardiovascular disease and cancer in adulthood is well known and it is important to begin intervention as early as possible to lower these risks. It is also very important to be realistic about the individual’s dietary intake and accept that it may be a long process made up of very small steps leading to improvement.
Eating can be a stress inducing activity for people with Autism. This is not at all surprising when you consider the number of variables involved such as different flavours, different textures, lack of uniformity (in the foods, eating utensils, environments and preparation of meals) and sensory issues of the particular individual. Difficult behaviour around mealtimes or refusal of certain foods can then be misinterpreted or mismanaged unknowingly.
As a Paediatrician I encounter Children with Autism who are both underweight and but more commonly in recent years obesity is more of a common problem at my Clinics. After physical examination and consideration of the possibility of other underlying conditions such as genetic syndromes, thyroid difficulties, chest and cardiovascular conditions and coeliac disease, I then consider diet and environmental factors. There are a small number of children with restricted eating patterns (those are who are very limited in their dairy intake or take only one food group, those with decreased energy levels/tiredness and those who are eating non-food substances) that require a nutritional screen to ensure they are not deficient in minerals such as Iron, magnesium or calcium or vitamins such as Vitamin D which is important for maintenance of healthy bones. The majority of children with even very restricted diets I find end up not being deficient of any minerals or vitamins but it is important to check particularly if the young person is symptomatic. In Northern Ireland all young people should be supplemented with Vitamin D during the Autumn and Winter Months due to decreased levels of sunlight. The next important step is the provision of a food diary ideally over a one month period and it is particularly helpful if this can be completed by School also. If possible it is also very important to get the Child/young person’s views on eating, foods they prefer and any difficulties they experience during eating.
The food diary is helpful in identifying the number of different foods that are eaten and which food groups are represented as well as any supplements given. Some families have also implemented a gluten and casein free diet for their children with ASD however there is no firm medical evidence in favour of this diet and it should only be implemented with the support of a dietician. Sometimes it is possible to provide reassurance from the food diary as often the Young people are getting enough variety over the week from each setting. It is also help to see if there are other factors that influence the child’s eating such as environment, timing and who is around.
Worrying features of eating problems would be accepting fewer than 20 foods, eating only one food group, excessive weight gain or loss, constipation or diarrhoea, not growing well, tooth decay secondary to intake and missing school or social opportunities due to difficulties with eating.
This refers to the eating of non -edible food items such as stones, soil, metal, fluff and sand. This can be dietary, sensory or behavioural in origin. Pica may be due to seeking out sensory input, lacking awareness of the differentiation between edible and non-edible, stress relieving or due to dietary mineral deficiencies. If this is an ongoing problem it is important to seek medical attention to ensure no harm has occurred due to eating non-food substances. A nutritional profile may be considered as well as consideration of sensory issues and a possible onward referral to Occupational Therapy.
Education and Communication
Even with very young children it is important to give a basic understanding of the role of food and the benefits to us all. This may be provided in visual format but avoid using the terms good and bad foods instead talking about healthy and unhealthy foods. The traffic light system on foods can also help with this. Making it a fun activity to do together such as placing pictures in a scrap book and separating them into food groups and healthy and unhealthy. Discussing the benefits of activities such as walking, going up stairs, swimming, running, riding bikes/scooters and going to the park is also important. There may only be one activity that a child enjoys doing but encouraging staying mobile and active is very important for all children. Using the young person’s Special interest as a reward after a period of exercise has been completed is an option. For children who complain of pain or discomfort on walking gentle graded exercise is still important to build up their exercise tolerance provided there are no medical contraindications.
Social Stories may also be helpful to explain why we eat. Visual tools to help the young person describe how they feel about eating certain foods or at mealtimes such as happy/sad faces may also be of benefit. Rewards can be used for when the young person tolerates the food being around or tastes a small amount and not just for eating it. Avoid giving unhealthy foods as a reward for eating healthy ones. Modelling is also very important so wherever possible ensure you all eat together and are eating a balanced diet yourself. Minimise distractions in the environment wherever possible and try to ensure that mealtimes are as stress free as possible, being firm but avoiding being emotional/confrontational or showing signs of stress. Consider presentation of food, if it needs to be separate this is fine and using the child’s special interest such as Thomas plate etc may help. Avoid excessive snacking between meals and limit fizzy drinks/juices/milk to ensure a good appetite at mealtimes.
For excessive eaters using smaller plates, having clear rules such as if you have starter then no dessert, allowing snacks only at certain times such as 10 am and 3pm and 7pm and ensuring these are lower fat/as healthy as possible. Increasing activity levels and ensuring school aren’t giving double portions is also helpful.
The most important thing is to be consistent and realistic and remember things won’t change immediately but stick with it and you will see rewards over time. Allowing the whole family to be involved in the preparation of meals or baking together can be fun and also can help remove stress from eating and showing mealtimes can be fun.
Other sources of information
Can’t eat won’t eat :dietary difficulties and autism spectrum disorders Brenda Legge 2002
The eatwell guide NHS
Food…fun,healthy and safe, Books Beyond Words
NAS- Autism and sensory experience online training module
Network Autism – Autism and controlled eationg making sense of food and feeding Lucy Skye