Feeding Therapy for Autism: A Paediatric Dietitian approach to introducing new foods to children with ASD

One of my clinical specialities is supporting children with Autism Spectrum Disorder (ASD), specifically helping them accept new foods. It's a challenging situation for the child and the family but it's not impossible. I'm able to provide you with solutions and proven clinical techniques to overcome the obstacles to new foods children with ASD experience.

Before we dive in, check out my page on Feeding Therapies to better understand the basics of the first two feeding therapy consultations with Cubs Paediatric Dietetics.

Children with Autism experience food from a heightened perspective. Their unique sensory profiles drive their behaviour and thus their food experiences. I help families identify those profiles so we can work out their comfort levels with certain foods. We then gradually build on their tolerance through exposure.

The diagram below explains the steps I follow to help a child progress gradually and positively to the end goal of eating. The very first step is 'tolerates'. Building tolerance means reducing anxiety around new foods. Children who do not tolerate new foods cannot be expected to move to the next step, 'interacts with' that food. The next step up is 'smells', followed by 'touch', then 'taste', eventually reaching the goal of 'eating'. It might seem a long process, but by working at the child's pace, they develop their own level of acceptance and confidence.

Supporting parental anxiety around mealtimes

It is stressful isn't it? Trying to avoid a breakdown at every meal. Trying to make sure your child is having a nutritionally balanced diet. Trying to do the best for your child. What I support in my consultations are working on parental expectations of their children's abilities during a meal.

Alongside identifying the medical issues that can disrupt feeding, I help families reset their expectations of their child's progress. It's very easy to assume a child should sit down and eat. Often parents focus on their child not eating or swallowing. I focus on understanding where your child sits on the 'steps to eating' framework, giving you specific strategies to help your child work their way up these steps.

I often find a parent's anxiety reduces when they see progression on the steps. If a child cannot bear a plate of food directly in front of them then we cannot expect them to 'chew and swallow'. Instead we reset the expectation to 'looks at food when directly in child's space' (step 5) or 'assists in preparation/set up with food' (step 6).

Once your expectations are reset, you'll celebrate the little wins along the way and feel more relaxed. And the more relaxed you are, they more relaxed they will be.

How to start feeding therapy at home

We start with implementing the division of responsibility. This means reframing the parent's responsibility during a mealtime and understanding your child's responsibility at mealtimes. I have discussed this further, on my Feeding Therapy page, so will only briefly summarise it here. Basically we're providing children with more options and independence during a mealtime. We're trusting our children to make their own decisions on 'if they want to eat at all' and 'how much they want to eat'.

Why do we do this? To reduce a child's anxiety.

Imagine your partner saying to you - 'finish the meal or I won't give you dessert' or 'just take one more bite for me'. That would get pretty annoying, fast. I'd definitely get frustrated with someone telling me how to eat. Instead, if we thought that the amount a child wants to eat at a mealtime is their responsibility alone and we allow them to make that decision for themselves, your child will start to feel more at ease at the table.

The job of the parent is to provide 'what' the child eats and 'when'. You pick their food and the time they eat. Instead of allowing them to graze throughout the day, you set mealtimes. And you make the decision on what is for dinner, rather than asking them what they want. Now they get to decide how much they eat.

Does this idea make you feel anxious? Stressing about the breakdowns that will ensue. Rest assured, I have solutions to these worries. I'll teach you how to create a 'family meal' for your child who finds certain foods difficult. For more on this, read my Feeding Therapy page.

Steps to improve fussy eating at home

Below is a handout from the 'SOS Feeding' course I give to my families to help them through the steps to eating. These are distinct activities you can do with your child in order to get the ball rolling with progression. You can do this during the meal, at snack time or during play.

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FAQ's: Your questions answered.

Who else might be involved in supporting my child to eat?

Well depending on your child's medical history will be dependent on what extra help your little one might need. For example if your child has an issue with textures then you may need a speech pathologist to perform an oral motor assessment. This will provide guidance on what exactly is going on in your child's mouth and will determine what skills they need to work on in their mouth.

If your child has sensory issues or emotional regulations problems you might need an occupational therapist to support you with helping your child with their individual needs. Whether this is for toileting, routines, calming strategies or proprioceptive/ vestibular support.

Depending on the assessment you may also get a referral to an immunologist or ENT.

What to do when my child only drinks milk?

I often find when children resort to drinking milk there is often an oral motor or air way issue affecting your child's feeding. Of course there are other things that could be going on but this is a good starting place. When children have a preference for milk often it means they are struggling with other textures. Struggling with textures calls for a meeting with a Speech Pathologist to review their oral motor skills.

On the other hand an air way issue might be making it difficult for your child to breathe and/ or swallow certain textures. For examples if adenoids or tonsils are swollen this can make feeding difficult. In consult I will be able to identify these issues and make appropriate referrals to get your child on the right pathway.

Why do children with sensory issues have trouble eating?

This is related to a child having a response to the taste, texture, temperature or the smell of food. It is an over reaction to the sensory element they are struggling with. This is important to identify which sensory component they are responding to in order to direct therapy. Often the solution to these issues is exposure. Exposing children in a graded response at their own comfort level to allow them to feel calm to these sensory properties.

I would like to also point out that I feel people or clinicians can often 'over explain' a child's feeding behaviours on solely their sensory profile. In my experience it is more imperative to work out a child's medical issues first before delving into their sensory profiles.

How can I increase variety in my autistic child's diet?

Firstly we need to do all of the above! Then when this is done we can work on expansion. What I really should be saying is this. Expansion and variety actually is a natural bi product of doing all the work I discussed on my feeding therapy page. When we work on breathing, medications, gut health, posture, division of responsibility we are creating a child who is more calm and relaxed. When they have achieved this variety follows naturally.

I have strategies to get the ball rolling anyway. This is what we call food chaining. Food chaining is where you look at all the foods your child eats and find another food very similar to it. All you need to do is change one thing about the new food. This could be shape, colour, texture or taste.

Examples include:

Chips --> same chip but different shape

Oreos --> big and little oreo

Yoghurt --> blueberry yoghurt Vaalia --> blueberry yoghurt Tamar Valley

Capsicum --> yellow capsicum to red capsicum slices

When you try and change one aspect of the food no matter how small you start to double your child's menu variety. Make sure it is obvious to your child your are not 'hiding' this sutble variation. You are open and honest about this and you offer both options on the plate. Eating the new foods yourself in front of the child also is a great tool too.

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