The mother of a two year-old boy diagnosed with an ASD for whom we had been providing early behavioral intervention services, reported that he rejected most foods and gagged when a spoon with food was brought near his mouth. He was participating in a feeding clinic that attempted to desensitize him to food in his mouth, and particularly certain textures. A swallowing study conducted by the clinic revealed no physical or mechanical reason he was having difficulty swallowing food, which is a common finding among children with autism who have feeding problems. The boy’s parents were very apprehensive about his feeding difficulty and devoted several hours per day working with him on his food refusal under the direction of the staff at the feeding clinic. Gagging was a conditioned response to the sight and smell of food in the spoon which in the past had been associated with choking when trying to swallow.
Around 2/3ds of parents of children with autism report their child is a finicky eater and report meal time difficulties, but only around 6-7% consider their child to have a “feeding disorder.” Feeding disorders affect a child’s ability to properly function at home, school and other social settings, impacting physical, social and psychological development.
Common signs and symptoms of a feeding disorder include:
• Poor weight gain
• Feeding tube dependence
• Bottle or formula dependence
• Mealtime tantrums, or mealtimes exceeding 40 minutes
• Distress and anxiety with new foods
• Inability to increase textures
• Inability or refusal to feed oneself
• Extreme pickiness (eating fewer than 12 foods)
Causes: Several reasons have been suggested for the prevalence of feeding problems in children with ASD, including compulsivity, impulsivity, fear of novelty, exaggerated sensory responses, deficits in social compliance, and biological food intolerance (Cumine, Leach, & Stevenson, 2000). Parental anxiety, reinforcement of negative feeding patterns, and communication difficulties have been suggested as social factors that contribute to the maintenance of maladaptive feeding behaviors.
A very common scenario occurs when a child who eats only a few foods is given access to his favorite foods when he rejects non-preferred foods, the child is being positively reinforced for food refusal. In treating feeding problems, the behavior that is reinforced is generally acceptance or swallowing of food. Hoch et al. (2001) suggested that reinforcement alone is effective only when food refusal occurs solely because of insufficient positive reinforcement for eating foods.
Testing: Evaluating food refusal in autism begins with a physical examination for oral motor apraxia (inability to coordinate tongue, mouth and swallowing) and ruling out other physical problems such as gastroesophageal reflux disease (GERD) and constipation, diarrhea, or other symptoms resulting from food allergies (Volkmar & Wiesner, 2004). A small percentage of children with autism are diagnosed with dysphagia, who have difficulty swallowing and may experience pain while swallowing. Some may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva. Eating becomes a challenge. Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body. Such children are usually underweight and may have lost their appetite almost entirely. Physicians and speech-language pathologists who test for and treat swallowing disorders tests that allow them to view parts of the swallowing apparatus. One test, called a fiber optic laryngoscopy, allows the doctor to look down the throat with a lighted tube. Other tests, including video fluoroscopy, which takes videotapes of the child swallowing, and ultrasound, which produces images of internal body organs, can painlessly take pictures of various stages of swallowing (Ledford, and Gast 2006; Twachtman-Reilly, Amaral and Zebrowski, 2008).
Behavioral Treatment: If physical causes can be ruled out or treated medically, the most effective treatment is generally Escape Extinction. Escape extinction is designed to treat feeding problems based on the principle of negative reinforcement. Negative reinforcement for food selectivity is usually the removal of non-preferred foods after the child exhibits refusal behavior. When escape extinction is implemented, the child is not allowed to escape from eating. One form of escape extinction is non-removal of the spoon, in which an adult holds the spoon in front of the child's mouth until he or she takes a bite of food. Upon acceptance, positive reinforcement is usually provided in the form of descriptive praise or tangible items (Ahearn, Kerwin, Eicher, Shantz, & Swearingin, 1996). Another form of escape extinction is physical guidance, in which an adult physically guides the spoon into the child's mouth and physically assists him or her in opening the mouth. Again, acceptance of the spoon results in positive reinforcement. Parents often prefer escape extinction involving
Several studies have shown differential reinforcement involving escape extinction is effective in improving feeding in young children with varied cognitive abilities and medical problems who were dependent on tube feedings (Coe et al., 1997; Didden, Seys, & Schouwink, 1999). Additional studies have also indicated the usefulness of differential reinforcement for a variety of children, including those with gastrointestinal problems and total food refusal, language delays and failure to thrive. Patel, Piazza, Martinez, Volkert, and Santana (2002) demonstrated the effectiveness of escape extinction--regardless of the presence or absence of differential reinforcement--with children from 15 months to 4 years of age who had various medical conditions and limited food intake.
Conclusion: A child with an autism spectrum disorder and a significant consistent feeding problem should be evaluated by a pediatric gastroenterologist, a speech pathologist, nutritionist and a behavioral specialist to rule out a physical causes, evaluate nutritional status and possible psychological contributions. Many children with autism and feeding problems have Gastroesophageal Reflux problems, which can be treated with medication. The research literature reveals predominant feeding problem in autism is food selectivity, not dysphagia. Around 2/3rds of children with autism exhibit some food refusal but less than 10% have physical causes for their feeding difficulties. A subset of children, usually with multiple developmental and health challenges (e.g.cerebral palsy, epilepsy), may also have oral motor difficulties. Which can often be treated by speech pathologists working in feeding clinic. Some severe mechanical problems are treated surgically.
Parental reactions to their child’s food refusal, motivated by anxiety, often make matters worse. Parents usually coax, cajole, plead and threaten, and eventually offer the child his/her most preferred food items in lieu of typical health foods consumed by most children. Parents are often very concerned their child will go hungry and perhaps be malnourished. Parental attention to food refusal positively reinforces the very behavior they wish to eliminate, and providing an alternative preferred food negatively reinforces food refusal, making matters worse.
If physical causes can be ruled out or treated medically, the most effective treatment for food refusal is Escape Extinction combined with positive reinforcement for food acceptance, and planned ignoring of behavioral outbursts. Children with autism thrive on routines, so once the following procedure is in place, many children begin to accept it as part of their everyday schedule. In its simplest form, this involves presenting a very small amount of finely blended typical food on a spoon and physically guiding the spoon into his/her mouth. Begin by creating a smooth blend of a food item (to minimize a texture the child will not accept). Select a food with mild flavor and minimal food fragrance, such as mashed potatoes blended with diluted chicken broth or milk (if lactose isn’t a problem). Some parents and feeding clinic staff members use a Nuk Brush to present food, that is often easier to manipulate and deposit the food in the child’s cheek pouch. As soon as the child has accepted a small amount of a non-preferred food item and not spit it out, an equally small amount of a preferred food is made available. Over successive repetitions (usually several times daily over weeks), larger amounts of the non-preferred food item are presented, and usually multiple spoons of non-preferred food before a preferred food item is offered.
The greatest mistake parents or other caregivers make with this procedure arises from becoming impatient, and increasing the amount of the non-preferred food too rapidly or changing the texture prematurely. During this escape extinction procedure the child will likely cry, turn away, may hit and scream, which should all be ignored. The child will try all of the negative behaviors that have worked in the past. Such behavior is very difficult to ignore, but with support most parents can tolerate the tantrums, which will eventually wane and stop. Wait until the child turns facing the parent or caregiver again and repeat this procedure. Over time, the oppositional behavior will slowly decrease and food acceptance will increase. Parents should assume this process will take weeks, not days to be successful. For some cases of extreme food refusal, overcoming the problem requires months of consistent follow through.
Throughout this process, the child should be weighed regularly to make certain weight is either constant or gaining. Often physicians prescribe vitamin and mineral supplements to assure the child is receiving adequate nutrition. Because this procedure is very difficult for most parents, I encourage caregivers to work closely with a behavioral practitioner, speech pathologist and nutritionist who can provide support and encouragement when the task becomes too difficult to do alone.
References
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Ahearn, W. H., Kerwin, M. E., Eicher, P. S., Shantz, J., & Swearingin, W. (1996). An alternating treatments comparison of two intensive interventions for food refusal. Journal of Applied Behavior Analysis, 29, 321–332.
Coe DA et. al (1997) Use of extinction and reinforcement to increase food consumptions an reduce expulsion. Journal of Applied Behavior Analysis. 30: 581-3.
Cumine, V, Leach, J. & Stevenson, G.(2000) Autism in the Early Years: A Practical Guide. David Fulton Publisher.
Didden, R., Seys, D. and Schouwink, D. (1999), Treatment of chronic food refusal in a young developmentally disabled child. Behavioral Interventions, 14: 213–222.
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Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363–374.
Piazza, C. C., Fisher, W. F., Brown, K. A., Shore, B. A., Patel, M. R., Katz, R. M., et al. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 36, 187–204.
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Volkmar, F. R., & Wiesner, L. A. (2004). Topics in autism: Healthcare for children on the autism spectrum: A guide to medical, nutritional, and behavioral issues. Bethesda, MD: Woodbine House.