TechniquesToExpandFoodVarietyforChildrenwithASD.txt

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Techniques to Expand Food 
Variety for Children with ASD 
Webinar 


MCj02328300000[1]
MCj02328300000[1]
MCj02328300000[1]

 Jocelyn Warren, MEd, OTR/L 

jwwarr01@louisville.edu 



Objectives 
�Understand common issues of feeding problems for 
children with autism 
� When to seek professional help for your child 
�What strategies can you do at home to expand food 
variety 




Defining Feeding Disorder 

Feeding Disorders 


Variations in ingestive behavior that are 
sufficiently divergent from the norm to 
result in personal or familial distress, 
social or developmental risk, or negative 
health consequences. 

 (Kedesdy & Budd, 2001) 




Symptoms of Feeding Disorders 
�Limited food selection � less than 20 
different foods, limited food groups 
�Averse reaction to new foods 
�Feeding skills inconsistent with child's 
developmental age 
�Food jags 






Food Jags 


�Insistence on eating the same foods in the 
same manner over long periods of time 
�Child will eventually tire of the food and 
not replace it. Food variety increasingly 
narrows 




DSM-IVTR Feeding Disorder 
definition 


�Persistent failure to eat adequately as 
reflected in failure to gain weight or weight 
loss for greater than 1 month 
�Not GI or general medical condition 
�Not accounted by mental disorder such as 
rumination 
�Not lack of food in the home 
�Onset before age 6 







DSM-5 Proposed definition 
(2013) 
�Avoidant/Restrictive Food Intake Disorder 
�Eating or feeding disturbance (including but 
not limited to apparent lack of interest in 
eating or food avoidance based on sensory 
characteristics of food; or concern about 
aversive consequences of eating) as 
manifested by persistent failure to meet 
appropriate nutritional and/or energy needs 
associated with�. 







DSM-5� 


�Significant weight loss 
�Significant nutritional deficiency 
�Dependence on enteral feeding or nutritional 
supplements 
�Marked interference with psychosocial 
functioning 






 Up to 25% of typical children and 
up to 80% of children with 
developmental disabilities have 
feeding disorders. 
(Manikam & Perman, 2000) 

Feeding Obstacles 
for Children with Autism 
�Social interaction surrounding food 
�Repetitive patterns in food preferences 
�Opportunities for varied food experiences 
�Communication about food 
�Hunger and satiety 
�Food preferences 







Symptoms of feeding disorders in 
children with autism 
�Limited food selection (57%*) 
�Limited food groups (72%*) 
�Averse reaction to new foods 
�Food jags 
�Feeding skills inconsistent with child's 
developmental age (23.2% have oral motor 
problems*) 




*percentages from parent report of 175 children with autism 
and feeding problems. Schreck, & Williams 2005 




Problem Eating Behaviors 
�Trying new foods (69%) 
�Taking medicine (62%) 
�Eating new foods (60%) 
�Mouthing objects (56%) 
�Rituals surrounding (46%) 
�Insisting on routine (44%) 


(Williams, Dalrymple & Neal 2000) 




 Review of studies has shown that 
between 46% and 89% of children 
with autism spectrum disorders 
have a feeding disorder. 
Ledford & Gast 2006 

Causes of Feeding Disorders 


�Medical concerns 
�Oral motor issues 


 

�Sensory differences 
�Behavioral factors 




Medical Concerns 
�Pain with feeding 
�Reflux 
�Early fullness 



�Diarrhea 
�Constipation 




When to see the doctor 



�History of or current reflux 
�Complaints of pain with 
eating 
�When eating gets full too 
quickly 
�Vomiting 
�Anemia 
�Bad breath 



�Pain or strain with bowel 
movement 
�Constipation 
�Diarrhea 
�Frequent bowel accidents 
�Poor weight gain or 
weight loss 


 



Symptoms of oral motor 
deficits 
�Long feeding times (30 min+) 
�Difficulty chewing 
�Food stuck in palate 
�Multiple/inefficient swallows 
�Wet Sounds 
�Difficulty managing mixed food textures 




When to see a speech therapist 
�Consistent Gagging/Coughing 
�History of pneumonia 
�Drooling/pocketing of food/food stuck 
�Multiple/inefficient swallows 
�Has trouble eating tough foods 



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Nutritional Consequences of 
Feeding Disorders 
�Deficit of any nutrient 
�Nutritional risks 
�poor growth 
�brain development 
�metabolic processes 
�bone health 
�immune status 







When to see a Registered Dietitian 
�Growth or weight issues 
�Very limited diets 
�Medically restricted diets 
�Complex allergies 
�Food intolerances 



�Risk of nutrient deficiencies 
�Use of formula or tube feedings 


 



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Behavioral Issues 


�Disruptive behaviors 
�Anxiety 
�Parent-child interaction issues 
�Developmental concerns 




When to see a Psychologist 


�History of anxiety in family, leading to 
avoidance of various activities also 
including food 
�Rigidity regarding food, 
obsessive/compulsive behaviors 
associated with eating 
�Family dynamics that contribute to 
restricted eating patterns 




When to see a Occupational 
Therapist 
�Won�t eat certain textures of foods 
�Won�t touch foods � doesn�t like hands to get 
dirty 
�Difficulty using utensils, opening food 
packages, drinking from an open cup, or 
drinking from a straw 
�Rituals surrounding or insisting on routine of 
mealtime impacts function (social, nutrition, 
self-care) 




Strategies you can try at home 



Choose the right strategy 
for your child and your 
family 
Don�t tackle everything at 
once 



Mealtime Structure 
�Dinner Table 
�Sitting 
�Food interaction 
�Modeling from others 







Sitting at the table 

Sitting at the 
table 

 
Where to start 

 



Food interaction 

Ideas for food interaction 
�Assist with grocery 
shopping 
�Help put food away 
�Cooking 
�Food preparation 
�Serving food 
�Put non-preferred 
food on plate � don�t 
have to eat it 



�Pick up food item and 
throw away in 
garbage 
�Kiss the food item 
good bye before 
throwing it away 
�Take bite of food item 
but you can spit it out 




Modeling from others 



Mealtime Structure 
�Hunger planning 
�At least 1 1/2 to 2 hours between 
meals/snacks 
�Come to dinner table hungry 







Time to eat!! 
Messy baby eating

Feeding Intervention for 
Children Diagnosed with ASD 


�Most research utilized behavioral 
strategies. 
�differential reinforcement of alternative 
behaviors (DRA) 
�simultaneous presentation 
�fading 
�behavioral momentum 
�response cost 
�sequential presentation 
�negative reinforcement 







Differential Reinforcement of 
Alternative Behaviors (DRA) 
Reward (positive 
reinforcement) 


�Sitting at the table 
�Having new food on their 
plate 
�Taking a bite of the new 
food 
�Helping prepare new food 



Ignore 


�Negative comments � 
yuck, I don�t like that 
�Spitting food out 
�Not eating the food 
�Gagging/vomiting non-
preferred food 


 



How to use reinforcer 
�Make sure they want the reinforcer � may 
need to change it frequently 
�Reward box 
�Stickers 
�Small food items � mini m&m�s, fruit chews, skittles 
�Puzzles 
�Light up toys 
�Favorite video game � 1 short turn 
�Extra tv, video game time � can earn minutes 










How to use reinforcer 
�Immediately 
�Consistently � when learning to eat new 
food 
�Contingently � they do not get the reward 
unless they demonstrate the behavior you 
are teaching (sitting at the table, touching 
food to lips, etc) 




First/Then Board 

First/Then Board 
�First 



�First 



�Then 




If it doesn�t work 
Decrease work 


�Decrease number that 
they have to eat 
�If refuse to eat � touch 
lips, teeth, tongue, take 
bite and spit out 



Increase reward 


�Increase number of 
rewards they get � 
instead of 1 skittle�5 
skittles 
�Change the reward 
�Let them pick the reward 




First/Then Board 
�First 



�Then 




Simultaneous Presentation 
Pairing preferred with 
non-preferred 



Pairing Preferred 
Food with Non-Preferred 
Food 
Example: dipping cookie in 
applesauce, very small piece of 
lunch meat between 2 crackers 

 

Do not hide it!!! 



Pairing preferred with non-preferred 
Preferred 

 
Non-preferred 

 

If it doesn�t work 
�Decrease the amount of non-preferred 
food � start with a VERY SMALL amount 
�Give them a reward for eating it 




Fading 
�Use this with DRA and pairing preferred 
with non-preferred 
�Decrease frequency of reward 
�Example: reward every bite reward every 2 bites 



�Increase non-preferred food and decrease 
preferred food 
�Example: 1 cup juice with � teaspoon milk 1 cup 
juice with 1 teaspoon milk 
�2 ritz crackers with � tsp peanut butter 2 ritz 
crackers with 1 tsp peanut butter 










How to prevent/break food jags 


�Preventing or breaking a food jag: 
�Food/meal rotation 
�Changing shape, color, taste, and finally 
texture 







Change shape 

Change Shape 

Change color 

Change taste 

Change texture 

Some of our favorite foods 



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 Any 

 questions? 


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Websites and Newsletters 


Ellyn Satter Associates www.EllynSatter.com 

 

Mealtimes www.new-vis.com 

 

POPSICLE (Parent Organized Partnerships 
Supporting Infants and Children Learning 
to Eat) www.popsicle.org 



Resources 
�Satter, E. (1987). How To Get Your Child To Eat�But 
Not Too Much. Boulder, CO: Bull. 
�Toomey, K. (2002). When Children Won�t Eat: The SOS 
Approach to Feeding. Denver: Toomey and Associates. 
�Ernsperger, L. & Stegen-Hanson, T. (2004). Just Take A 
Bite. Arlington, TX: Future Horizons. 


 




References 
�Kedesdy, H. & Budd, S. (2001). Childhood Feeding 
Disorders. Baltimore: Paul H. Brookes Publishing., Inc. 
�Ledford, R. & Gast, G. (2001). Feeding Problems in 
Children with Autism Spectrum Disorders: A Review. 
Focus on Autism and Other Developmental Disabilities, 
21 (3), 153-166. 
�Hall, K. (2001). Pediatric Dysphagia. DeKalb, IL: 
Singular 
�Manikam, R. & Perman, J. (2000). Pediatric Feeding 
Disorders. Journal of Clinical Gastroenterology, 30 (1), 
34-46. 
�Fishbein, M., Cox, S., Swenny, C., Mogren, C., Walbert, 
L., & Fraker, C. (2006). Food Chaining� A systematic 
approach for the treatment of children with feeding 
aversion. Nutrition in Clinical Practice, 21 (2), 182-184. 




Therapy Settings 


�Therapy to address feeding in school or 
community setting 
�Intensive Feeding Therapy Program 


 

See slides at end of presentation 



Therapy services � Feeding 
Teams 


�Cincinnati Children�s Feeding Clinic 
�Regional Child Development Clinic 
(Bowling Green) 
�St. Mary�s Center for Children (Evansville) 
�University of Louisville Autism Center at 
Kosair Charities 
�Weisskopf Child Evaluation Center 
(Louisville) 


 



Feeding Team Evaluation 

Feeding Evaluation 

 


�Interview 
�Nutritional evaluation 
�Feeding observation 
�Oral Structure and 
function evaluation 
�Team planning 
�Determine treatment 
plan 


 


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Interview 
�Current Status 
�Diagnosis, Feeding Concerns 



�Social History 
�Family meal pattern, feeding environment 



�Medical History 
�Prenatal, perinatal, infant & childhood 
�Sleep patterns, ear infections, allergies 





 




Interview (continued) 
�Feeding & Swallowing History 
1.Medical procedures impacting oral experiences 
ie. Feeding tubes, assisted ventilation 
2.Experiences effecting feeding patterns ie. 
Prolonged hospitalization, prematurity 
3.Aversive behaviors associated with eating 
4.Communication associated with eating 




Nutritional Evaluation 

 


�3-Day food diary or usual daily intake 
�Nutritional adequacy 
�Meal pattern: grazing vs defined meals 
�Hunger/Satiety cycle 
�Feeding Environment 
�Self-feeding skills and opportunities 
�Food allergies and intolerances 
�Bowel and bladder function 






Feeding Observation 


�Motor Skills � postural stability, muscle tone, 
strength, endurance, range of motion and 
coordination of both oral area and whole body 
�Child/parent interaction 
�Self-care skills � use of utensils, opening 
containers, washing hands 
�Sensory processing skills � food preferences, 
touching/smelling/looking at food 
�Ingestion of food in a coordinated efficient 
manner 




Oral Structure and Function 
Evaluation 


�Size and symmetry of oral structures 
�Strength and tonicity of structures 
�Range and coordination of oral 
movements 




Team Planning 
�Based on findings of all team members 
�Further testing 
�Home environment 
�Nutritional adequacy 
�Food variety 
�Diffuse stress at mealtime 
�Therapy 




Making a Treatment Plan 
�Family/team meeting 
�Review findings 
�Review treatment 
plan 
�Family input 
�Follow-up 
discussion 









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