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

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

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

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

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

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

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

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%

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

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

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?

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

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

Parentheses Diet Food (……………………………)

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

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!

“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.”

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.”

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

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.

“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)

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, 89-103)

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

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

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

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

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

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.

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.

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?

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

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

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………

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 (www.Cosmeo.com)

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

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

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

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

Food Art

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

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

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

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.

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

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

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

Photo Books Kiss Book Lick Book Noisy Lick Book Mousebite book

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.

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

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