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

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Presentation on theme: "Mealtime Challenges and the Autism Spectrum Marsha Dunn Klein MED OTR/L Mealtime Connections, LLC, Tucson AZ Mealtime Notions, LLC, Tucson AZ www.mealtimeconnections.com."— Presentation transcript:

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

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 impairment in social interaction Qualitative impairments in communication Qualitative impairments in communication Restricted repetitive and stereotyped patterns of behavior, interests and activities Restricted repetitive and stereotyped patterns of behavior, interests and activities Inflexible adherence to specific, nonfunctional routines or rituals Inflexible adherence to specific, nonfunctional routines or rituals

5 Feeding Issues Commonly Associated with ASD Feeding Issues Commonly Associated with ASD Sensory processing difficulties Sensory processing difficulties – Smell (36%), touch, visual Oral sensory hypersensitivity 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 Social Skill Deficits – Poor response for following directions – Less imitation Communication Skill Challenges Communication Skill Challenges Difficulty Transition and Novel Situations 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. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p 344 parent questionnaires 344 parent questionnaires Reported factors that influenced food selection Reported factors that influenced food selection – Appearance 58% – Taste 45% – Smell 36% – Temperature 22% 37% Relationship between eating and behavior 37% Relationship between eating and behavior

8 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) 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. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p Social Aspects 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 Degree Frustration – 13% Upset a great deal of the time – 19% Easy going – 68% Upset with reason Moderately u g

10 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. Moderately u g

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

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

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

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

15 Diet themes……personal….but….. Narrow choices Narrow choices Imbalanced diet Imbalanced diet Narrowed color ranges…tan, brown, white, or……….. Narrowed color ranges…tan, brown, white, or……….. Particular sensory aspect important Particular sensory aspect important – Visual appearance, smell, texture – Brand specificity? Personal logic Personal logic Change is very difficult 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 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 Feed child separately No eating out No eating out Seek help! 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.” 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 Personal Logic???? Personal Logic????  Nightline show

20 Food Neophobia Leann Birch, Development of Food Preferences, Anna Review of Nutrition, © 1999 by Annual Reviews” 19:41-62 Leann Birch, Development of Food Preferences, Anna Review of Nutrition, © 1999 by Annual Reviews” 19:41-62 Neophobia…’Fear of the new” Neophobia…’Fear of the new” – Neo- “New” – Phobia- “Irrational Fear” Irrational Fear of Food Irrational Fear of Food Common for two year olds. 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.” “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) 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. Evidence for familial similarities Neophobia changes during development. Evidence for familial similarities Linked to other temperament and personality characteristics 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, 89-103) 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, 89-103)

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

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

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

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

28 Feel Well Diet – Narrow, wheat, dairy, allergies Diet – Narrow, wheat, dairy, allergies Sensory issues-Overload, Transition, Sensory issues-Overload, Transition, GI issues- Dyspepsia, Constipation, Motility GI issues- Dyspepsia, Constipation, Motility Brain-Gut Connection (The Second Brain, Michael Gershon) Brain-Gut Connection (The Second Brain, Michael Gershon) Fight /Flight does not work well with digestion 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. 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. New food trying time may need to be NOT a family meal to start.

30 Change Happens Rigidity, ritual and routine is common Rigidity, ritual and routine is common For peace, we reinforce that…..become routine “enablers” For peace, we reinforce that…..become routine “enablers” Eating can become comfortable if child knows exactly what is next. 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. 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 safe and less emotional parts of the meal. Start with change that does not effect the entire diet Start with change that does not effect the entire diet Tip toe towards change Tip toe towards change At mealtime or non mealtime? At mealtime or non mealtime?

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

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

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

35 Multiple Exposures Safe Pretend Food or Non Real Food Interactions 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 (www.Cosmeo.com)

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

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

40 Food Art

41 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

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

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

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

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

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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 Kiss Book Lick Book Lick Book Noisy Lick Book Noisy Lick Book Mousebite book Mousebite book

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

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

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


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