Mealtime Challenges and Mealtime Challenges and the Autism Spectrumthe Autism Spectrum

Marsha Dunn Klein MED Marsha Dunn Klein MED OTR/LOTR/L

Mealtime Connections, LLC, Tucson AZMealtime Connections, LLC, Tucson AZ

Mealtime Notions, LLC, Tucson AZMealtime Notions, LLC, Tucson AZwww.mealtimeconnections.com

www.mealtimenotions.comwww.mealtimenotions.com

What is a What is a ““mealtimemealtime””……….?….?

All about All about sseennssoorry y All about social & All about social & communicationcommunication All about All about ttrraannssiittiioonn

Autism SpectrumAutism Spectrum

All about All about sseennssoorryy All about social and All about social and communicationcommunication All about All about ttrraannssiittiioonn

And ORDER….And ORDER….SamenessSameness

DSM IV Diagnostic Criteria Autism DSM IV Diagnostic Criteria Autism DisorderDisorder

• Qualitative impairment in Qualitative impairment in social social interactioninteraction

• Qualitative impairments in Qualitative impairments in communicationcommunication

• Restricted Restricted repetitive and stereotyped repetitive and stereotyped patterns of behavior, interests and patterns of behavior, interests and activitiesactivities

• Inflexible adherence to specific, Inflexible adherence to specific, nonfunctional routines or ritualsnonfunctional routines or rituals

Feeding Issues Commonly Feeding Issues Commonly Associated with ASDAssociated with ASD

• Sensory processing difficultiesSensory processing difficulties– Smell Smell (36%) (36%) , touch, visual, touch, visual

• Oral sensory hypersensitivityOral sensory hypersensitivity– Uncomfortable with touch to mouth Uncomfortable with touch to mouth

or toothbrushingor toothbrushing– Tastes Tastes (45%)(45%), texture , texture (69%) (69%)

– Temperature Temperature (22%)(22%)

Developmental Disabilities Williams et al Developmental Disabilities Williams et al 20082008

Feeding Issues Commonly Feeding Issues Commonly Associated with ASDAssociated with ASD

• Social Skill DeficitsSocial Skill Deficits– Poor response for following directionsPoor response for following directions– Less imitationLess imitation

• Communication Skill ChallengesCommunication Skill Challenges• Difficulty Transition and Novel SituationsDifficulty Transition and Novel Situations

– Prefer routines (46%)Prefer routines (46%)– Sameness (69%)Sameness (69%)

Developmental Disabilities, Williams et al 2008Developmental Disabilities, Williams et al 2008

Eating Habits of Children with AutismEating Habits of Children with AutismWilliams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259,

6p6p

• 344 parent questionnaires344 parent questionnaires• Reported factors that influenced food Reported factors that influenced food

selectionselection– Appearance 58%Appearance 58%– Taste 45%Taste 45%– Smell 36%Smell 36%– Temperature 22%Temperature 22%

• 37% Relationship between eating and 37% Relationship between eating and behaviorbehavior

Eating Habits of Children with AutismEating Habits of Children with AutismWilliams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3,

p259, 6pp259, 6p

• Largest challenges Largest challenges (by parent report)(by parent report)

– Trying new foods 69%Trying new foods 69%– Taking medicine 62% Taking medicine 62% – Eating new foods 60%Eating new foods 60%– Mouthing objects 56%Mouthing objects 56%

Eating Habits of Children with Eating Habits of Children with AutismAutism

Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6pIssue 3, p259, 6p

• Social AspectsSocial Aspects– Situations and people influence eating 35.5%Situations and people influence eating 35.5%– Child ate differently in different settings 41%Child ate differently in different settings 41%– Fewer reported frequenting fancy Fewer reported frequenting fancy

restaurantsrestaurants– 87% drive through restaurant87% drive through restaurant

• Degree FrustrationDegree Frustration– 13% Upset a great deal of the time13% Upset a great deal of the time– 19% Easy going19% Easy going– 68% Upset with reason68% Upset with reason

Moderately u

Eating Habits of Children with Eating Habits of Children with AutismAutism

Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p26 Issue 3, p259, 6p

67% Described child as picky eater67% Described child as picky eater

73% Good appetite for foods they liked73% Good appetite for foods they liked

6% Reported poor appetite for most foods6% Reported poor appetite for most foods

19% Good appetite for most foods19% Good appetite for most foods

62% Adequate nutrition62% Adequate nutrition

49% Fairly balanced nutrition49% Fairly balanced nutrition

35% Food supplements35% Food supplements

97% Not picky more often described as good 97% Not picky more often described as good nutritionnutrition

69% Not trying new69% Not trying new

Picky eaters equally divided between adequate Picky eaters equally divided between adequate and inadequate nutrition.and inadequate nutrition.Moderately u

Parent Challenges Parent Challenges

• Picky eating?Picky eating?• CanCan’’t change the t change the

menu, texture?menu, texture?• Unable to eat Unable to eat

with family?with family?• Poorly balanced Poorly balanced

diet?diet?• Huge emotional Huge emotional

impactimpact

• CanCan’’t change t change environment?environment?

• Doctor not Doctor not concerned?concerned?

• Family/friends Family/friends do not do not ““get itget it””??

• Choices are not Choices are not logicallogical

• Isolation?Isolation?

Child ChallengesChild Challenges

• Poor nutritionPoor nutrition• High stress and High stress and

anxietyanxiety• Difficult Difficult

transitioning to transitioning to mealsmeals

• Highly Highly suspicious of suspicious of changechange

• No mealtime No mealtime enjoymentenjoyment

• Skill deficitsSkill deficits

Food ListFood List

• Safe FoodsSafe Foods• Sometimes FoodsSometimes Foods• Used to foodsUsed to foods• Never/no way foodsNever/no way foods

Parentheses Diet Parentheses Diet

• Food Food (……………………………)(……………………………)• Food Food (……………………………)(……………………………)• Food Food (……………………………)(……………………………)• Food Food (……………………………)(……………………………)• Food Food (……………………………)(……………………………)• Food Food (……………………………)(……………………………)

Diet themes……Diet themes……personal….but…..personal….but…..

• Narrow choicesNarrow choices• Imbalanced dietImbalanced diet• Narrowed color ranges…tan, brown, Narrowed color ranges…tan, brown,

white, or………..white, or………..• Particular sensory aspect importantParticular sensory aspect important

– Visual appearance, smell, textureVisual appearance, smell, texture– Brand specificity?Brand specificity?

• Personal logicPersonal logic• Change is very difficultChange is very difficult

Common parent solutionsCommon parent solutions

• Offer the same foods in the same Offer the same foods in the same way in the same environment with way in the same environment with the same brands so as not to create the same brands so as not to create mealtime stressmealtime stress

• Feed child separatelyFeed child separately• No eating outNo eating out• Seek help!Seek help!

““BehavioralBehavioral””• Schreck et al. (2004) Schreck et al. (2004) ““Separation of Separation of

physiological aspects of feeding physiological aspects of feeding difficulty from behavioral aspects is difficulty from behavioral aspects is especially difficult in ASD because especially difficult in ASD because physiologically based difficulties in this physiologically based difficulties in this population are often subtle and difficult population are often subtle and difficult to pinpoint, and to pinpoint, and ““behavioralbehavioral”” difficulties difficulties are not always behavioral (i.e., willful or are not always behavioral (i.e., willful or volitional acts of noncompliance), but volitional acts of noncompliance), but rather a reflection of the characteristics rather a reflection of the characteristics and symptoms of this multifaceted and symptoms of this multifaceted disorder.disorder.””

Research is beginning to define the Research is beginning to define the complex pattern of neuro- biological complex pattern of neuro- biological

differences that characterize ASD as well differences that characterize ASD as well as its influence on behavior. as its influence on behavior. (Just, Cherkassky, (Just, Cherkassky,

Keller, & Minshew, 2004; Minshew, Sweeney, & Luna, 2002)Keller, & Minshew, 2004; Minshew, Sweeney, & Luna, 2002)

““At a basic level, this research has con- At a basic level, this research has con- firmed that the atypical behavior that is firmed that the atypical behavior that is exhibited by people with ASD is a direct exhibited by people with ASD is a direct result of neurobiological differences.result of neurobiological differences.””

Food NeophobiaFood Neophobia

Food NeophobiaFood Neophobia

• Leann Birch, Leann Birch, Development of Food Preferences, Anna Development of Food Preferences, Anna Review of Nutrition, © 1999 by Annual ReviewsReview of Nutrition, © 1999 by Annual Reviews”” 19:41-62 19:41-62

• Neophobia…Neophobia…’’Fear of the newFear of the new””– Neo- Neo- ““NewNew””– Phobia- Phobia- ““Irrational FearIrrational Fear””

• Irrational Fear of Food Irrational Fear of Food • Common for two year olds. Common for two year olds.

• ““When two year olds were given When two year olds were given varying numbers of opportunities to varying numbers of opportunities to consume new foods their consume new foods their preferences increased with preferences increased with frequency of exposure.frequency of exposure.””

• 5-10 Exposures to a new food 5-10 Exposures to a new food necessary to increase preference for necessary to increase preference for it it (Birch, LL, McPhee L, Shoba, BC, Pirok, E., (Birch, LL, McPhee L, Shoba, BC, Pirok, E., Steinberg, L., 1987 What kind of exposure reduces Steinberg, L., 1987 What kind of exposure reduces childrenchildren’’s food neophobia? Appetite 9:171-78)s food neophobia? Appetite 9:171-78)

• Neophobia changes during Neophobia changes during development. Evidence for familial development. Evidence for familial similaritiessimilarities

• Linked to other temperament and Linked to other temperament and personality characteristicspersonality characteristics

• Mothers who were more neophobic Mothers who were more neophobic food environment with new and food environment with new and presented uncommon foods less presented uncommon foods less frequently. (frequently. (Hursti and Sjoden 1997, Food and Hursti and Sjoden 1997, Food and General Neophobia and thei relaionship with self General Neophobia and thei relaionship with self reported food choice, Appetite 29, 89-103)reported food choice, Appetite 29, 89-103)

Olfactory Memory Olfactory Memory

• Nature of Olfactory Nature of Olfactory systemsystem

• AlertingAlerting• AccommodationAccommodation• Limbic SystemLimbic System• EmotionsEmotions• Memory and Memory and

memory storagememory storage

Where to focus?Where to focus?

• Diet..............?Diet..............?• Sensory………………..?Sensory………………..?• Oral Motor…………………..?Oral Motor…………………..?• Behavior……………………………?Behavior……………………………?• Rituals, Fear, Anxiety, OCD………..?Rituals, Fear, Anxiety, OCD………..?• A A

combination……………………………………..??combination……………………………………..??

Various Treatment ComponentsVarious Treatment Components

• Oral MotorOral Motor• SensorySensory• Applied Behavioral AnalysisApplied Behavioral Analysis• Behavioral TherapyBehavioral Therapy• Nutrition/DietNutrition/Diet• ““PhobiaPhobia”” support support• DesensitizationDesensitization• Exposure TherapyExposure Therapy• Individual work with childIndividual work with child• Family workFamily work• TeamTeam

Life Long Learning SkillsLife Long Learning Skills

• People eat things you do notPeople eat things you do not• Be at the table (in the same room?) Be at the table (in the same room?)

with others who eatwith others who eat• Balance the diet (vitamins, new food Balance the diet (vitamins, new food

groups)groups)• Discover how to try a Discover how to try a ““NewNew”” food food• Learn how to refuse an offer politelyLearn how to refuse an offer politely

Feel WellFeel Well

• Diet – Narrow, wheat, dairy, allergiesDiet – Narrow, wheat, dairy, allergies• Sensory issues-Overload, Transition, Sensory issues-Overload, Transition, • GI issues- Dyspepsia, Constipation, GI issues- Dyspepsia, Constipation,

Motility Motility • Brain-Gut Connection (Brain-Gut Connection (The Second The Second

BrainBrain, Michael Gershon), Michael Gershon)• Fight /Flight does not work well with Fight /Flight does not work well with

digestiondigestion

Mealtime PeaceMealtime Peace

• Start with peaceful and tip toe Start with peaceful and tip toe towards new experiences so as towards new experiences so as not to disrupt the whole family.not to disrupt the whole family.

• New food trying time may New food trying time may need to be NOT a family meal need to be NOT a family meal to start.to start.

Change HappensChange Happens

• Rigidity, ritual and routine is commonRigidity, ritual and routine is common• For peace, we reinforce For peace, we reinforce

that…..become routine that…..become routine ““enablersenablers””• Eating can become comfortable if Eating can become comfortable if

child knows exactly what is next. child knows exactly what is next. • Child needs to learn that change Child needs to learn that change

happens at mealtimes and they can happens at mealtimes and they can deal with it. deal with it.

Change ContinuumChange Continuum

• Start with safe and less emotional Start with safe and less emotional parts of the meal.parts of the meal.

• Start with change that does not Start with change that does not effect the entire diet effect the entire diet

• Tip toe towards changeTip toe towards change• At mealtime or non mealtime?At mealtime or non mealtime?

Sample ChangesSample Changes

• PlatesPlates• CupsCups• ForksForks• SpoonsSpoons• StrawsStraws• PlacematPlacemat

• TableclothsTablecloths• WhereWhere• Food shapes or Food shapes or

sizessizes• NapkinsNapkins• Containers Containers

An important CHANGE goalAn important CHANGE goal

• GraduallyGradually eliminate eliminate PACKAGING and Brand PACKAGING and Brand specific presentations. specific presentations. (or avoid it (or avoid it from the start)from the start)

Sample Change Sample Change SequencesSequences

• Cup……sticker to color to shape?Cup……sticker to color to shape?• Waffle…….Strip off edge, strips, Waffle…….Strip off edge, strips,

Rectangles…..Squares….bite Rectangles…..Squares….bite size…….or even triangles. size…….or even triangles.

• Plate……Color……Plate……Color……picture…..paper picture…..paper

• Favorite foods in Favorite foods in containers………containers………

Multiple ExposuresMultiple Exposures

• Safe Pretend Food or Non Real Food Safe Pretend Food or Non Real Food InteractionsInteractions– Looking at pictures of foodLooking at pictures of food– Reading books about food and eatingReading books about food and eating– Play with plastic foodsPlay with plastic foods– Matching food picturesMatching food pictures– Watch video about food Watch video about food (www.Cosmeo.com)(www.Cosmeo.com)

Multiple Exposures #2Multiple Exposures #2

Distant food interactionsDistant food interactions

Help grocery shopHelp grocery shop

Help put food in grocery cartHelp put food in grocery cart

Help put away groceriesHelp put away groceries

Multiple Exposures #3Multiple Exposures #3

• Non-Eating Real Food InteractionsNon-Eating Real Food Interactions– Food PreparationsFood Preparations– Serving foods to others with spoons, Serving foods to others with spoons,

tongs, forks, fingerstongs, forks, fingers– Cooking and clean upCooking and clean up– Incorporating food into playIncorporating food into play– Incorporating food into pre-academicsIncorporating food into pre-academics

Mealtime Jobs Mealtime Jobs

• Menu plannerMenu planner• Grocery shopperGrocery shopper• Grocery Grocery ““put put

away-eraway-er””• Food preparerFood preparer• Recipe makerRecipe maker• Appliance operatorAppliance operator

• Garnish putterGarnish putter• Table setterTable setter• Drink pourerDrink pourer• Food serverFood server• Cleaner Cleaner ““upperupper””• Plate clearerPlate clearer• Dish washerDish washer

Food AcademicsFood Academics

• Empty and fillingEmpty and filling• StackingStacking• Counting and mathCounting and math• ColorsColors• Shape sortingShape sorting

• Size sortingSize sorting• AlphabetAlphabet• Pretend PlayPretend Play• Scissor playScissor play• Food artFood art

Food ArtFood Art

Re-Define Re-Define ““Try ItTry It””

In the same room?In the same room?At the same tableAt the same table

Near the plateNear the plateServing/ Helping prepareServing/ Helping prepare

On the plate On the plate SmellingSmelling

Touching hands/mouth Touching hands/mouthHanding to othersHanding to others

LickingLickingTry and spit outTry and spit out

Mousebites Mousebites Eat someEat 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 ExposureNew Food Exposure

• Looking Dish Looking Dish (K. Toomey)(K. Toomey) • Tasting dishTasting dish• Divided platesDivided plates• Present the foodPresent the food• Teach child to remove it if necessaryTeach child to remove it if necessary•

Picking New FoodsPicking New Foods

Is the new food worth the effort??Is the new food worth the effort?? • • Nutritional value?Nutritional value?• • Food Group? Food Group? • • Dairy? Gluten?Dairy? Gluten?• • Careful with current dietCareful with current diet

Reintroduce previously rejected or Reintroduce previously rejected or previously enjoyed foods.previously enjoyed foods.

New Food Decision MakingNew Food Decision Making

• Mouse BitesMouse Bites• Redefine Try itRedefine Try it• Food Science/Food DetectivesFood Science/Food Detectives• Tasting SequenceTasting Sequence

Taste SequenceTaste Sequence

• Smell tasteSmell taste• Kiss tasteKiss taste• Lick tasteLick taste• Noisy lick tasteNoisy lick taste• (In mouth and spit out)(In mouth and spit out)• Bite (Mousebite…..and more)Bite (Mousebite…..and more)

Food Science/Food DetectivesFood Science/Food Detectives

Compare various food qualitiesCompare various food qualities

Chart sames and differentsChart sames and differents

Foods that float/sinkFoods that float/sink

Mixing food colorsMixing food colors

Designing with foods Designing with foods (Colorforms)(Colorforms)

MeasuringMeasuring

Photo BooksPhoto Books

• Kiss BookKiss Book• Lick BookLick Book• Noisy Lick Book Noisy Lick Book • Mousebite bookMousebite book

Food SelectionFood Selection

• Similarity to preferred?Similarity to preferred?• Stretch from preferredStretch from preferred• Minute changes (add to familiar)Minute changes (add to familiar)• Safe Skill trainingSafe Skill training• Nutrition groupNutrition group• Repetition then KEEP it in the food Repetition then KEEP it in the food

rotation so as not to lose it.rotation so as not to lose it.

Ways to Support FamiliesWays to Support Families

• Parent Support GroupParent Support Group• Issues unique to ASDIssues unique to ASD

• Team Discussions (Combine input Team Discussions (Combine input from dietitians, psychologists/ABA, from dietitians, psychologists/ABA, sensory therapists, speech, MD, sensory therapists, speech, MD, with parents as the center!)with parents as the center!)

• Way of lifeWay of life• Direct therapeutic supportDirect therapeutic support• Combine with direct ABA Combine with direct ABA

Team WorkTeam Work

The The ““Just Right Just Right ChallengeChallenge””….….B. B.

ClawsonClawson