1. Mealtime Challenges and the Autism Spectrum
Marsha Dunn Klein MED OTR/L
Mealtime Connections, LLC, Tucson AZ
Mealtime Notions, LLC, Tucson AZ

2. What is a “mealtime”…….? All about sensory All about social & communication All about transition

3. Autism Spectrum
All about sensory All about social and communication All about transition
And ORDER….
Sameness

4. DSM IV Diagnostic Criteria Autism Disorder
Qualitative impairment in social interaction
Qualitative impairments in communication
Restricted repetitive and stereotyped patterns of behavior, interests and activities
Inflexible adherence to specific, nonfunctional routines or rituals

5. Feeding Issues Commonly Associated with ASD
Sensory processing difficulties
Smell (36%) , touch, visual
Oral sensory hypersensitivity
Uncomfortable with touch to mouth or toothbrushing
Tastes (45%), texture (69%)
Temperature (22%)
Developmental Disabilities Williams et al 2008

6. Feeding Issues Commonly Associated with ASD
Social Skill Deficits
Poor response for following directions
Less imitation
Communication Skill Challenges
Difficulty Transition and Novel Situations
Prefer routines (46%)
Sameness (69%)
Developmental Disabilities, Williams et al 2008

7. Eating Habits of Children with Autism Williams, P
Eating Habits of Children with Autism Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p
344 parent questionnaires
Reported factors that influenced food selection
Appearance 58%
Taste 45%
Smell 36%
Temperature 22%
37% Relationship between eating and behavior

8. Eating Habits of Children with Autism Williams, P
Eating Habits of Children with Autism Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p
Largest challenges (by parent report)
Trying new foods 69%
Taking medicine 62%
Eating new foods 60%
Mouthing objects 56%

9. Eating Habits of Children with Autism Williams, P
Eating Habits of Children with Autism Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p
Social Aspects
Situations and people influence eating 35.5%
Child ate differently in different settings 41%
Fewer reported frequenting fancy restaurants
87% drive through restaurant
Degree Frustration
13% Upset a great deal of the time
19% Easy going
68% Upset with reason g
Moderately u

10. Eating Habits of Children with Autism Williams, P
Eating Habits of Children with Autism Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p
67% Described child as picky eater 73% Good appetite for foods they liked 6% Reported poor appetite for most foods 19% Good appetite for most foods 62% Adequate nutrition 49% Fairly balanced nutrition 35% Food supplements 97% Not picky more often described as good nutrition 69% Not trying new Picky eaters equally divided between adequate and inadequate nutrition. g
Moderately u

11. Parent Challenges Picky eating? Can’t change the menu, texture?
Unable to eat with family?
Poorly balanced diet?
Huge emotional impact
Can’t change environment?
Doctor not concerned?
Family/friends do not “get it”?
Choices are not logical
Isolation?

12. Child Challenges Poor nutrition High stress and anxiety
Difficult transitioning to meals
Highly suspicious of change
No mealtime enjoyment
Skill deficits

13. Food List
Safe Foods
Sometimes Foods
Used to foods
Never/no way foods

14. Parentheses Diet
Food (……………………………)

15. Diet themes……personal….but…..
Narrow choices
Imbalanced diet
Narrowed color ranges…tan, brown, white, or………..
Particular sensory aspect important
Visual appearance, smell, texture
Brand specificity?
Personal logic
Change is very difficult

16. Common parent solutions
Offer the same foods in the same way in the same environment with the same brands so as not to create mealtime stress
Feed child separately
No eating out
Seek help!

17. “Behavioral”
Schreck et al. (2004) “Separation of physiological aspects of feeding difficulty from behavioral aspects is especially difficult in ASD because physiologically based difficulties in this population are often subtle and difficult to pinpoint, and “behavioral” difficulties are not always behavioral (i.e., willful or volitional acts of noncompliance), but rather a reflection of the characteristics and symptoms of this multifaceted disorder.”

18. Research is beginning to define the complex pattern of neuro- biological differences that characterize ASD as well as its influence on behavior. (Just, Cherkassky, Keller, & Minshew, 2004; Minshew, Sweeney, & Luna, 2002) “At a basic level, this research has con- firmed that the atypical behavior that is exhibited by people with ASD is a direct result of neurobiological differences.”

19. Food Neophobia “Neo”………New “Phobia”……..irrational fear Nightline show
Personal Logic????
Nightline show

20. Food Neophobia
Leann Birch, Development of Food Preferences, Anna Review of Nutrition, © 1999 by Annual Reviews” 19:41-62
Neophobia…’Fear of the new”
Neo- “New”
Phobia- “Irrational Fear”
Irrational Fear of Food
Common for two year olds.

21. “When two year olds were given varying numbers of opportunities to consume new foods their preferences increased with frequency of exposure.”
5-10 Exposures to a new food necessary to increase preference for it (Birch, LL, McPhee L, Shoba, BC, Pirok, E., Steinberg, L., 1987 What kind of exposure reduces children’s food neophobia? Appetite 9:171-78)

22. Neophobia changes during development
Neophobia changes during development. Evidence for familial similarities
Linked to other temperament and personality characteristics
Mothers who were more neophobic food environment with new and presented uncommon foods less frequently. (Hursti and Sjoden 1997, Food and General Neophobia and thei relaionship with self reported food choice, Appetite 29, )

23. Olfactory Memory Nature of Olfactory system Alerting Accommodation
Limbic System
Emotions
Memory and memory storage

24. Where to focus? Diet..............? Sensory………………..?
Oral Motor…………………..?
Behavior……………………………?
Rituals, Fear, Anxiety, OCD………..?
A combination……………………………………..??

25. Various Treatment Components
Oral Motor
Sensory
Applied Behavioral Analysis
Behavioral Therapy
Nutrition/Diet
“Phobia” support
Desensitization
Exposure Therapy
Individual work with child
Family work
Team

27. Life Long Learning Skills
People eat things you do not
Be at the table (in the same room?) with others who eat
Balance the diet (vitamins, new food groups)
Discover how to try a “New” food
Learn how to refuse an offer politely

28. Feel Well Diet – Narrow, wheat, dairy, allergies
Sensory issues-Overload, Transition,
GI issues- Dyspepsia, Constipation, Motility
Brain-Gut Connection (The Second Brain, Michael Gershon)
Fight /Flight does not work well with digestion

29. Mealtime Peace
Start with peaceful and tip toe towards new experiences so as not to disrupt the whole family.
New food trying time may need to be NOT a family meal to start.

30. Change Happens Rigidity, ritual and routine is common
For peace, we reinforce that…..become routine “enablers”
Eating can become comfortable if child knows exactly what is next.
Child needs to learn that change happens at mealtimes and they can deal with it.

31. Change Continuum Start with safe and less emotional parts of the meal.
Start with change that does not effect the entire diet
Tip toe towards change
At mealtime or non mealtime?

32. Sample Changes Plates Cups Forks Spoons Straws Placemat Tablecloths
Where
Food shapes or sizes
Napkins
Containers

33. An important CHANGE goal
Gradually eliminate PACKAGING and Brand specific presentations. (or avoid it from the start)

34. Sample Change Sequences
Cup……sticker to color to shape?
Waffle…….Strip off edge, strips, Rectangles…..Squares….bite size…….or even triangles.
Plate……Color……picture…..paper
Favorite foods in containers………

35. Multiple Exposures Safe Pretend Food or Non Real Food Interactions
Looking at pictures of food
Reading books about food and eating
Play with plastic foods
Matching food pictures
Watch video about food (

36. Multiple Exposures #2
Distant food interactions Help grocery shop Help put food in grocery cart Help put away groceries

37. Multiple Exposures #3 Non-Eating Real Food Interactions
Food Preparations
Serving foods to others with spoons, tongs, forks, fingers
Cooking and clean up
Incorporating food into play
Incorporating food into pre-academics

38. Mealtime Jobs Garnish putter Menu planner Table setter Grocery shopper
Drink pourer
Food server
Cleaner “upper”
Plate clearer
Dish washer
Menu planner
Grocery shopper
Grocery “put
away-er”
Food preparer
Recipe maker
Appliance operator

39. Food Academics Empty and filling Stacking Counting and math Colors
Shape sorting
Size sorting
Alphabet
Pretend Play
Scissor play
Food art

40. Food Art

41. Re-Define “Try It” In the same room
Re-Define “Try It” In the same room? At the same table Near the plate Serving/ Helping prepare On the plate Smelling Touching hands/mouth Handing to others Licking Try and spit out Mousebites Eat some

43. Juice Stretch Juice Different cup…..straw? Ice cube acceptance
Colored ice cubes?
Flavored ice cubes from dilute to concentrated
Nectars to purees/yogurt?
Popsicle??

44. New Food Exposure Looking Dish (K. Toomey) Tasting dish Divided plates
Present the food
Teach child to remove it if necessary

45. Picking New Foods Is the new food worth the effort??
• Nutritional value?
• Food Group?
• Dairy? Gluten?
• Careful with current diet
Reintroduce previously rejected or previously enjoyed foods.

46. New Food Decision Making
Mouse Bites
Redefine Try it
Food Science/Food Detectives
Tasting Sequence

47. Taste Sequence Smell taste Kiss taste Lick taste Noisy lick taste
(In mouth and spit out)
Bite (Mousebite…..and more)

49. Food Science/Food Detectives
Compare various food qualities Chart sames and differents Foods that float/sink Mixing food colors Designing with foods (Colorforms) Measuring

50. Photo Books
Kiss Book
Lick Book
Noisy Lick Book
Mousebite book

51. Food Selection Similarity to preferred? Stretch from preferred
Minute changes (add to familiar)
Safe Skill training
Nutrition group
Repetition then KEEP it in the food rotation so as not to lose it.

52. Ways to Support Families
Parent Support Group
Issues unique to ASD
Team Discussions (Combine input from dietitians, psychologists/ABA, sensory therapists, speech, MD, with parents as the center!)
Way of life
Direct therapeutic support
Combine with direct ABA

53. The “Just Right Challenge”….B. Clawson
Team Work
The “Just Right Challenge”….B. Clawson