A concern parents of children diagnosed with Autism Spectrum Disorder often experience is in the area of feeding and nutrition. Initially, it may seem as though a child is just being difficult or a picky eater, which most demonstrate at some point in their childhood as they explore their independence and autonomy. The concern grows when the child refuses to eat anything but a handful of items and shows excessive reactions to new foods.
These behaviors can include
- Verbal refusal
- Excessive meltdowns
At this point, parents may begin to notice the food battles affecting other areas of life, such as their child’s growth. Depending on the circumstances, parents may observe their child losing weight, gaining weight, or not growing much at all. One may ask, how is a child’s nutrition affected if they’re still agreeable to eating some foods?
Unfortunately for many children, the handful of times they’ll eat aren’t typically the most nutritious of foods. Too many are reliant upon items such as mini muffins, bags of chips, cookies, etc. These processed foods are severely limited in nutritional content and may make the child feel full, even when their body hasn’t received proper nutritional intakes. This may cause the child to gain weight and potentially lead to childhood obesity and other long-term health impairments. Conversely, the child could be given a failure to thrive diagnosis and experience a stunt in their overall physical and cognitive growth.
As with all issues presenting to ABA for behavioral health treatment, it is imperative that the clinician, healthcare team, and caregiving team for the child have ruled out all medical causes of the feeding difficulty. Behavioral interventions will not help with feeding if the child is experiencing something that otherwise needs to be treated medically with medication, surgery, or other type of physical therapy that would be more appropriate.
Behavior modification programs should only continue after any and all medical causes have been explored and treated, if applicable. Some symptoms/conditions that may not be appropriate for behavioral services include:
Food allergies including symptoms of diarrhea, vomiting, blood in the stool, reflux, or constipation
Oral motor issues
Interventions for pediatric feeding therapy will likely include more than just a child’s behavioral health team. They may also include the child’s pediatrician, gastroenterologist, occupational therapist, physical therapist, and/or speech and language pathologist, depending on the child’s physical and cognitive circumstances and limitations.
A case study following a 28-month-old female child with ASD demonstrated success in using an intervention package that consisted of shaping, differential reinforcement, prompting, and escape extinction. Shaping was used to teach the child that access to her preferred reinforcers would be available when she ate the food presented to her.
Differential reinforcement was used to reward the girl for all successful bites of the presented food- meaning she chewed and completely swallowed the bite of food with no adverse behaviors. If she had a successful bite of food, she was reinforced via high praise and access to her preferred reinforcer. As she progressed, the number of bites she had to consume before she received her reinforcer grew. The intervention also utilized escape extinction, which no longer allowed the girl to escape having to eat by engaging in problem behavior such as spitting or inducing vomiting.
The spoon would be represented with another bite, and she would then be told that if she could not do it herself, she would be physically helped to eat the bite. The criteria developed to determine successful completion of the feeding intervention was that she would consume 80% of food bite presentations with zero instances of behavior. She met the criteria within 4 days of the intervention’s start.
Another case study involving a five-year-old boy also successfully utilized differential reinforcement of alternative behavior and escape extinction to increase food acceptance and decrease maladaptive behavior during mealtimes. Parents wanted to increase their child’s acceptance of fruits, as he was only reportedly eating yogurt, applesauce, or mashed potatoes.
Differential reinforcement was used to introduce strawberries into the child’s open mouth. Whenever the child opened their mouth to accept a bite, yawn, or cry, the spoon with a small piece of strawberry was placed onto his tongue. High praise was given immediately and if the bite was swallowed, the child received a sip of milk, a preferred drink. Escape extinction did not allow the child to escape having to take a bite of food if he expelled the food. Instead of immediately putting another bite into his mouth, parents felt more comfortable giving him an immediate bite of a favorite food and then trying the process of taking another bite of the new food. By the end of the study, the child was eating an age-appropriate portion of strawberries, approximately 4oz.
Still another case study followed 3 boys of preschool age who had food selectivity and mostly preferred baby food, jarred or homemade, and nothing else. Using positive reinforcement, differential reinforcement, and escape extinction, all 3 children demonstrated an increase in food acceptance and a decrease in maladaptive behaviors, such as emesis or crying. As demonstrated in all 3 case studies, escape extinction combined with differential reinforcement and/or positive reinforcement can be used to significantly increase food selectivity and decrease problem mealtime behaviors. Other pediatric feeding therapy methods referenced in current research include:
- Escape extinction
Involves the non-removal of the spoon/fork presented to the child and denying their desire to leave the table or distance themselves from the non-preferred food item. If or when food is expelled from their mouth, scoop it back up and represent it, ensuring that any problem behavior such as screaming or crying is ignored. Highly praise any successful bites (and swallows!).
- Differential reinforcement
Present the child with the contingency that every non-preferred bite of food earns them a bite of preferred food, while ignoring attempts to escape or other inappropriate behavior
- Physical guidance
Explain to the child that if they do not feed themselves, they will receive assistance in eating their food. Physically guide the spoon/fork into their mouth, placing slight pressure on the bottom lip to get the food inside their mouth. If they expel the food, scoop up and represent with physical guidance.
- Antecedent manipulations
Simple strategies to manipulate how mealtime will go can help parents before the mealtime session even begins. Strategies like keeping mealtime short and the table clear of other distractions are good places to start. Parents also show success with eliminating snacks/milk between meals and allowing their child to “fail” a meal, so that the natural consequence of hunger may work to their advantage come the next mealtime
One of the lesser, high-stress techniques, desensitization allows parents to play with and distract their child upon sitting down at their meal location. Parents present the child with a swift “bite” on an empty food, then resume playing/distracting. The next swift “bite” will be just a tiny bit of the spoon dipped in the food with return to play after. The bite gradually gets bigger and the idea is for the positive interaction between parent and child to be paired with eating. This method also is less-intrusive and may help to build a more positive mealtime experience for all.
Another form of desensitization that typically works well for older children (4+) is gradual exposure to a new food. For example, parents could use a token economy and begin the introduction of a new food with the contingency that every time he “looks” at the food, he gets a token. 5 tokens gives him a preferred food item or reinforcer. Next time, he/she must “smell” the food 5 times, earning a token each time. Next will be “touching” and the next will be “bites”. If at any time a step causes inappropriate behaviors, revert to the previous step and start again there. This method is a fun way for parents to introduce a new food in a non-threatening manner and build rapport as they find silly ways to touch, look at, smell, or take a bite of the food.
Simple though it may seem, sometimes just modeling the proper way to eat a food can be helpful to a child struggling to eat a variety of food. For example, noodles have a particular way they’re most easily eaten, which is being twirled on a fork or slurped up from a spoon. Teaching your child “tricks” to eat food, while modeling the correct way yourself, may encourage them to try the new, modeled method of eating.
- Backwards chaining
If a child highly prefers instant gratification, the method of teaching the last steps of eating first might be beneficial. For example, teach them the “first” step of putting the spoon in their mouth. Then, remove it. Then, place it into the bowl or onto the plate of food. Teach how to scoop or pick it up with the utensil, then dump the food off the utensil and place it down on the table. Your child, depending on their age, may or may not see this as a “silly” method and will hopefully pair the positive parent interaction with eating/self-feeding.
These methods are not fool-proof and of course, what works for one child might not work for another. Further, many methods listed here can be combined with a token economy and/or positive reinforcement to foster positive parenting relations and a healthy relationship with food. Pediatric feeding therapy is a complex topic that can have an array of underlying causes stemming from medical, cognitive, or behavioral impairments. It is important to have a child fully evaluated using a multidiscipline approach, that is, a medical professional from various fields of study.
For example, it is recommended that parents contact their child’s pediatrician for referrals to any medical specialist, a neuropsychologist for a full neuropsychological evaluation, and so on.
Agazzi, H., Shaffer-Hudkins, E., & Tan, S.Y. (n.d.) Mealtime meltdowns: behavioral feeding strategies. University of South Florida. Retrieved from https://health.usf.edu/-/media/Files/Medicine/Pediatrics/early-steps/MealtimeMeltdownsBehavioralFeedingStrategies.ashx
Anderson, C. M., & McMillan, K. (2001). parental use of escape extinction and differential reinforcement to treat food selectivity. Journal of Applied Behavior Analysis, 34(4), 511-515. https://doi.org/10.1901/jaba.2001.34-511
Barnhill, K., Tami, A., Schutte, C., Hewitson, L., & Olive, M. L. (2016). Targeted Nutritional and Behavioral Feeding Intervention for a Child with Autism Spectrum Disorder. Case reports in psychiatry, 2016, 1420549. https://doi.org/10.1155/2016/1420549
Gale, C. M., Eikeseth, S., & Rudrud, E. (2011). Functional assessment and behavioural intervention for eating difficulties in children with autism: A study conducted in the natural environment using parents and ABA tutors as therapists. Journal of Autism and Developmental Disorders, 41(10), 1383-96. doi: https://doi.org/10.1007/s10803-010-1167-8