Food Selectivity in Children with Autism Spectrum Disorder

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Introduction:

Selective eating has long been described as a feature of autism spectrum disorder (ASD). In his initial description of children with autism in 1943, Leo Kanner the American psychiatrist mentioned restrictive diets as being common (Kanner, 1943). In the latest diagnostic manual used by mental health providers, the DSM-5, one of the criteria for autism spectrum disorder, includes restricted, repetitive patterns of behavior, interests, or activities. Under this criterion, eating the same food is provided as an example of restrictive or repetitive behavior (American Psychiatric Association, 2013). Restrictive mealtime behavior extends from eating only a few foods to specific mealtime routines, such as only eating foods out of the original containers or eating preferred foods or beverages in ritualistic ways (e.g. touching a food to the mouth several times before eating it or tilting one’s head to the side when drinking out of a cup). Also, the term “Selectivity” extends to a range of concepts including food refusal, a limited repertoire of accepted foods, and high-frequency single food intake. Unfortunately, the insistence on eating the same foods reduces children’s opportunities to taste new foods, increasing the difficulty of expanding diet variety.

Consumption of a wide variety of foods, especially fruits and vegetables, has a range of health benefits including the prevention of chronic diseases such as diabetes, heart disease, and even cancer. There are also social benefits to increasing diet variety. When children with autism spectrum disorder learn to eat new foods, they are learning how to tolerate change, which may help reduce their insistence on sameness and open them to new experiences.

Potential Reasons Behind Food Selectivity in Autism Spectrum Disorders:

1- Behavioral issues:

Behavioral problems play an important role in food habits of children with autism spectrum disorders. Their eating patterns tend to be governed by food aversion/refusal or preferences for certain types of food at the expense of others. Some of the factors involved include the texture, color, taste, shape, and temperature of food, as well as shape and color of the packaging.

2- Development and fine-gross motor issues: –

Both delayed development and more severe impairment of fine and gross skills are more common in children with autism spectrum disorders. That is, children with autism spectrum disorders might not have the necessary motor skills for handling food and the resulting behavioral response can be fear, aggression, or escape. It is important that interactions between the sensory and motor systems are not ignored because an exclusively behavioral approach to treating these children could underrate the impact of oral sensory problems on their feeding habits.

3- Physiological and medical issues: –

With regards to physiological and medical issues, higher rates of gastrointestinal disorders were observed in autism spectrum disorder than typically developing children. The prevalence of food selectivity in autism ranges from 17% to 83% of children with ASD. This variability of results is attributable, on the one hand, to the different survey methods used by previous studies and, on the other hand, to the lack of a common, unambiguous, and standardized definition of food selectivity.

Moreover, certain behaviors associated with autism spectrum disorder, such as food refusal, were significantly associated with gastrointestinal disorders, although these behaviors were common regardless of the presence of gastrointestinal problems, suggesting that these associations could be of limited diagnostic value. Another, no less important issue, is chewing difficulties due to dental problems such as caries and tooth decay.

First Steps:

Prior to initiating a feeding intervention, it is important to rule out any underlying medical conditions that may be perpetuating the child’s feeding difficulties. Common medical concerns include gastroesophageal reflux disease (GERD) and/or food allergies or intolerances. Any underlying medical issues should be treated prior to implementing a feeding program. Once any medical treatment is implemented, you can begin to tackle the child’s food selectivity from a behavioral standpoint. If a multidisciplinary nutrition clinic is nearby, encourage the parents to consider scheduling an appointment for him/her to be evaluated.

When treating any child with food selectivity, the first step is to take a very detailed feeding history. Ask about the following areas: –

1. Child’s first experiences with breast or bottle feeding?
2. Transitioning to baby food and how they handled the transition to more highly textured foods.
3. Setting in which the child eats: Does he/she sit at the kitchen table for all meals or is he/she allowed to graze throughout the day?
4. Are mealtimes predictable and do they occur at regularly scheduled intervals and at the same time each day?
5. Is the child “brand specific” and eat only a specific brand of food?
6. Will the child eat only one flavor (e.g., strawberry/banana yogurt)?
7. How is the food presented?
8. How long is a typical meal?
9. What are the child’s refusal behaviors? The more specific the information the better!

Impact of Food Selectivity on Children and Adolescents with Autism Spectrum Disorder: –

• Food selectivity might reduce the quality of life of autistic children and their families, with possible detrimental effects on their future development.
• Increase the risk of malnutrition and significant nutritional deficiencies due to restricted diet and refusal of various foods that provide nutritional value and benefit.
• Increased conflict, stress and frustration in mealtimes.

Management for food selectivity in autism spectrum disorder: –

It is evident that the various factors contributing to food selectivity and feeding difficulties require targeted interventions to be performed by different specialized professionals, below are multi-specialty interventions that could be followed in managing food selectivity in autism spectrum disorder. In addition to that, given the wide-ranging consequences of food selectivity, interventions need to be sensitive not only to the child’s sensory and psychological preferences but mindful of the home environment, family dynamics, and parental/caregiver well-being. Moreover, family involvement in intervention implementation has been deemed beneficial in addressing anxiety resulted from their child’s atypical eating habits, improved to other mealtimes, and creating more positive family interactions, also enhancing self-efficacy. Furthermore, family involvement can enhance the effectiveness of other interventions (initially delivered by professionals) and provide opportunity for a greater benefit of interventions due to significant time spent with their child.

Behavioral Interventions: –

Behavioral interventions are currently supported by the strongest scientific evidence, and multiple studies link them to significant improvements in feeding behavior and food consumption. These evidence-based practices involve strategies such as functional assessment of behaviors associated with mealtime and positive reinforcement. Which can be applied when the child accepts new food and appropriate to enhance positive mealtime behavior and it could be in the form of praise, access to preferred toys, foods, and activities (reinforcers).

Sensory Interventions:

Sensory-based interventions are important since individuals with autism spectrum disorder are very sensitive to sensory factors, e.g. taste, texture or appearance of foods, leading to food rejection. Moreover, systematic desensitization is commonly used as a treatment therapy for feeding difficulties, yet it is rarely documented in the literature. systematic desensitization works by reinforcing successive estimations of gradually increased exposure to targeted food while engaging in relaxation or play activities. It is a treatment package composed of three steps: relaxation training, the construction of the graded exposure fear hierarchy and desensitization to the fear-invoking stimulus. It has been effectively used to treat various fears and phobias from dental procedures, needle phobia, medical procedures, and food intake.

Mixed approach:

“Food chaining” incorporates behavioral and sensory aspects of feeding, aiming at familiarizing individuals with autism spectrum disorder with new foods that share similarities in taste, temperature or texture to the ones they already like and accept. These food similarities are used to create “food chains” or links between the foods that are considered acceptable to the child and the new ones. Based on this approach, anxiety level will be contained, enabling children to become more familiar with the new food that will be included in their diet later. If they don’t like certain textures, slowly show them new forms of foods they like until they learn the taste is the same, even when the texture changes. For example, if they like red apples, have them try sliced red apples or maybe a green apple. Let them turn an apple into juice or applesauce and have them try it. Once they can expand their idea of apples, they can try them in different forms.

Nutrition education programs:

Nutrition education is defined as “any set of learning experiences that are intended to facilitate the voluntary adoption of eating and other nutrition-related behaviors that are beneficial to their health and wellbeing”. In fact, a properly designed nutrition education program has the potential to enhance the preference for consuming different foods and to facilitate the implementation of appropriate dietary practices. Nutrition education programs can be classified based on the following: –

1. Presence of visual aids (visualized education) like visual mealtime charts, meal order set of pictures, step-by-step visual recipes, food sorting and categorization charts.
2. Practical hands-on activities (experiential learning) like involvement in meal preparation and tasting sessions.

In conclusion:

Food selectivity in autism spectrum disorder is one of the most associated feeding difficulties which has a significant impact in the wellbeing of the child and family. Thus, acquiring a professional multi-disciplinary approach has significant positive outcomes in addressing and managing this issue. Also, future research needs to address the effectiveness of the interventions. Collaboration and early intervention by professionals in addressing and managing food selectivity is also essential in designing individualized intervention programs and in delivering successful outcomes.

References:

1. Breda, C., Santero, S., Conti, M. V., & Cena, H. (n.d.). Programs to manage food selectivity in individuals with autism spectrum Disorder. Nutrition Research Reviews, (2024).
2. Association for Science in Autism Treatment “ASAT” https://asatonline.org/research-treatment/clinical-corner/improving-food-selectivity/
3. Autismspeacks.org https://www.autismspeaks.org/expert-opinion/what-it-about-autism-and-food#:~:text=For%20instance%2C%20many%20children%20and,a%20narrow%20selection%20of%20foods
4. Esposito, M., Mirizzi, P., Fadda, R., Pirollo, C., Ricciardi, O., Mazza, M., & Valenti, M. (2023). Food Selectivity in Children with Autism: Guidelines for Assessment and Clinical Interventions. International Journal of Environmental Research and Public Health.
5. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5, American Psychiatric Association.
6. Visual Autism Meal Planning: Strategies for Autism-Friendly Menus https://neurolaunch.com/autism-food-visual/
7. Gover, H. C., Hanley, G. P., Ruppel, K. W., Landa, R. K., & Marcus, J. (2023). Prioritizing choice and assent in the assessment and treatment of food selectivity. International Journal of Developmental Disabilities, 69(1), 53–65. https://doi.org/10.1080/20473869.2022.2123196
8. Blennerhassett, C., Richards, M., & Clayton, S. (2023). Caregiver-Implemented Feeding Interventions for Autistic Children with Food Selectivity: a Systematic Review. Review Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s40489-023-00378-2.
9. Ripple, H. E., Smith, H. M., & Bates-Brantley, K. (2023). Strategies to promote positive mealtime behavior in early childhood. Deleted Journal, 7(1). https://doi.org/10.58948/2834-8257.1033