Most Autism Moms know that the dining table can become a conflict zone; it usually is so. All of us watch what we eat for a variety of usual reasons: for better skin and hair, to look younger and leaner, feel healthy and live stronger. Autistic kids’ food supervision takes on an altogether different dimension; it becomes Diet Therapy and if carried out successfully can offset many of the inherent strikes against the child, which the condition of autism entails. Lack of an adequate eating response is a barrier to education; while there is a trope of literature on teaching styles, academic and behavioral resources, training on how to support autistic students with healthy eating is scant.
Identification & Planning
Food Aversion, Highly Selective eating, Satiety Processing Disorder (an inability to sense when “full” and/or eating as a soothing sensory behavior) leading to chronic overeating and unhealthy snacking resulting in obesity are commonplace difficulties experienced with autism. According to academic researches on developmental disabilities, 89 per cent of autistic children display challenges related to food intake and absorption.
Besides the sensory and motor factors, the prevalence of medical conditions also ought to be evaluated while doing a diet-nutrition plan for the autistic child. GI issues are very common in children with autism; the problems can range from constipation to irritable bowel syndrome to acid reflux to stomach aches to malabsorption to food revulsions and chronic vomiting.
Children also report flatulence, or a hard belly. If your child is verbal and can describe their physical sensations, they might tell you when they are experiencing GI issues, or they may be able to describe their sensations if you ask. If your child is non-verbal, you can teach through AAC boards to communicate about physical states through real or animated pictures or written labels.
Major GI problems that can affect a child’s nutrient absorption are celiac disease or intolerance to casein/milk protein, gluten sensitivity impacting digestion of wheat based items, constipation, swallowing disorders and diarrhea. According to several studies, both Celiac and Gluten are pro-inflammatory and affects the cerebellum, which is involved in motor and thought coordination. In children with autism, diarrhea is caused by food moving too quickly through the intestines. Rapid transit through the GI tract does not allow enough time for the stool to firm up. This faster passage through the digestive tract can hamper nutrient absorption and many children report undigested food material in their poop, a sign of non-absorption of ingested food in the GI. Constipation is caused either by a limited diet or withholding bowels and has the potential to make eating very uncomfortable for a child who feels full or has a stomachache. An an allergic swallowing disorder observed in autistic children is Eosinophilic esophagitis (EoE) which makes a child feel like they are gagging or choking. EoE is frequently triggered by food and can cause pain and discomfort that would almost certainly result in behavioral issues in autistic kids. And children on the autism spectrum cannot verbalize their pain or discomforts. So parents have to be proactive in seeking consultations with Pediatric Gastroenterologists. Usually tests are recommended for metabolic analysis, oxidative stress markers to start a treatment and supplementation plan.
Gut conditions, nutritional and dietary needs must be necessary disclosures in healthcare profile of the child in schools for effective monitoring, instructions for assistance during mealtimes, teaching the child awareness of symptoms and attaining a level of independence. Gut health is decisive in determining the child’s tolerance and participation in field trips, extracurricular activities, participation in extended assembly and on-track sports.
Most autistics struggle with eating…
Besides medical issues, selective or restrictive eating also emanates from a bucket list of sensory issues, communication difficulties, rigid and repetitive behaviors. Restrictive eating can also be high in severity leading to a condition called Avoidant/Restrictive food intake disorder (ARFID). As pretty much everything else on the spectrum, eating selectivity is unique to each child. When a child consumes a very narrow range of food items selective eating is reported.
Food refusal can be based on texture, smell, presentation, food temperature, brand fixation etc. Some children may eat using only certain plates and cutlery. For many children it is a struggle to transit from liquid form to semi-solid from semi-solid to solids.
Introducing and stabilizing Diet diversity is a time-consuming process and has to be set in motion on the back of solid culinary research. The simple act of eating has to be established as a daily life rhythm. How it is handled can make or mar the life experiences and social encounters of autism families.
The Strategies
Stimulate interest in food through a toolkit of strategies. Involvement, modifications, perseverance are the watchwords. Families can spend screen time together watching food channels, online chefing; the visual-tactile-taste equation has to be tried out several times in a day. For a typically fussy eater, perseverative feeding punctuated with praise should do the trick. Such an eater can take 15-20 times tasting a new food before finally accepting it. Rotational methods of preferred food and pairing with new nutritious items like fruits in finger meal quantities can be tried. These approaches of presenting new items with foods that are liked and accepted usually works.
Few simple fixes related to sensory overload related to food include detecting a pattern of aversion (crunchy versus mushy), hiding ‘must foods’ for example, putting veggies with butter toasts. Consider consulting a sensory integration therapist who has experience with feeding issues. They may be able to help you and your child learn to incorporate a wider range of foods.
As with any intervention this linkage has to be individualized and begun with small steps to win the child’s trust and consent.
Keep a food journal. Written records of what the child eats at each meal at what time enables parents, caregivers and consulting clinicians to keep track of the progress that’s being made and where challenges are continuing to come up. Don’t rely on memory, if it isn’t written, it does not exist. Having a record helps everyone stay on track. What is ingested is also excreted, so keep a poop journal also.
Managing the environment is important. Care should be taken that there is low arousal at mealtimes with little visual, auditory and tactile distraction. If your child is proprioceptive seeking and needs that input, please consult the occupational therapist for calming strategies before or after the meals. Parents and caregivers should model good mealtime behaviors, if parents do not eat balanced diets, binge on phone, television and other distractions during mealtimes, do not expect children to develop the positive habits that you are looking for.
Relaxed mealtime for the autistic child should be a family goal and not solely a mother’s or caregiver burden.
The GI-Brain Alliance
As is a well-established fact, a varied, and nutrient rich diet is important for brain development.
For autistics, sensory challenges, weak oral-motor musculature causing chewing fatigue and rigid eating habits can all make it difficult to include a healthy range of foods into diets. Research also tells us that many individuals with autism tend to have strong preferences for carbohydrates and processed foods, while rejecting fruits and vegetables. Restricted diets and disordered eating can result in poor nutrition, and this can have a range of impacts on health and affect a child’s learning. Not getting the right nutrients can impair the immune system. As a result, students become more vulnerable to illness and increased time off school. Iron deficiency studies show adverse impacts on student’s memory, abilities to concentrate, increased propensity of irritability, inattention and hyperactivity.
Without enough calories learners can become listless, lethargic and withdrawn leading to a spiral of self-stims, isolation and aversion to interactions.
What, and how, children eat can affect their mood, behavior and learning. Poor mood and behaviour are often observed in children who have been without food for too long, for example, children who have not eaten breakfast. The best diet for good mood, behavior and learning is one that includes a regular eating pattern and a variety of food. We need many different nutrients in our diet to support our brain. These include vitamins, essential fats and amino acids, found in protein. The best way to get them is by eating a varied diet.
Nutrients such as iron and vitamin B6 are used to produce ‘happy’ hormones such as dopamine and serotonin. Not having enough of these nutrients can affect wellbeing, reducing motivation and increasing avoidant behaviors.
A large, well-designed study of neurotypical adolescents done by the British Dietetic Association (BDA) showed that “healthier” dietary patterns contributed to better mood, and “unhealthy” dietary patterns led to poor mood. The same study was able to show that poor mood did not cause an unhealthy dietary pattern. This study indicates that there is some evidence that vitamin D and omega-3 supplements can help with mood or attention in some vulnerable children. Omega-3 supplements may improve attention in ADHD and irritability in autism. Vitamin D may help reduce irritability and hyperactivity in autistic children. It may also improve inattention in children with ADHD, especially if they are deficient.
Oily fish like Sardines, Herring, Mackerel and Salmon are good sources of omega-3. For children who do not eat fish, omega-3 can be found in walnuts, flaxseeds, chia seeds and leafy green vegetables.
Macrominerals like Magnesium (found in green vegetables) and trace minerals like zinc (found pulses, nuts, beans, green vegetables, bread and breakfast cereals), iodine (found in fish, milk, yoghurt, table salt and eggs) are important for brain development.
Gut health also needs to be fortified with dietary fiber to promote a healthy microbiome, the billion microorganism ecosystem living in our gut that promotes digestion, absorption, bowel regularity and impacts mood and attention. Most plant-based foods contain dietary fiber. Examples include fruits, vegetables, wholegrain cereals, beans, nuts and pulses. Families need to prepare for an adequate and varied diet. They need to ensure that they are including a variety of foods from each of the food groups on a daily basis. There is a plethora of Dietary and Eatwell online resources that parents can dive into for their research. A consult and detailed evaluation with Nutritional Therapist should not be ignored. Whilst choosing such a Therapist parents should opt for those who are familiar with autistic experiences and are in leadership roles in clinical practice in this domain. Such a therapist should be able to identify your child’ deficiencies, intolerances and help you with advice on dietary management of comorbidities. They will help break the vicious cycle of restrictive, help you with meal planning, probiotic support, understand and implement supplementation plans for your child’s gut health and brain development. All this put together is a resolution charter for your child’s physical health and your family’s mental health.
Behaviors around Food
Challenging behaviors like jumping around, becoming wild, crying, biting, spitting, hitting, throwing utensils, repeatedly getting up and running from the table. Lots of parents experience the frustration of trying to get their children to sit at the table long enough to finish a meal. Parent/caregiver injury during such episodes is not uncommon. If ignored, restrictive eating and concomitant behaviors can escalate.
Often parents are more focused on visible autism issues – therapies, school placement – which takes precedence over feeding issues. The variety of foods the child is accepting is put on the backburner until either the situation becomes untenable or the parents are able to focus on them. If the child eats a narrow range and is able to move around, parents settle for it as a default range. But more they defer dealing with these issues, the tougher it gets to resolve them, they become ingrained negative mealtime behaviors and impact the child’s health and cognitive capacity.
A Guide for Table Manners
Besides being fundamental to survival, eating is also a social act. Ensure your child has good posture when eating. Go for the ideal. Feet should be able to sit flat on the floor or a foot-plate (in a highchair or specialist seating). Knees and hips should be at a 90-degree angle and the back should be straight. The child should be taught to lean over the plate while taking a mouthful; if anything falls, it will land on the plate and not on the child’s lap. Be mindful of the fact that autistics are sensory-defensive, meaning they are easily upset by certain sensory experiences, and avoidance sets in. They may avoid strong smells and certain tactile experiences, specific textures.
Repeated trials are needed for table manners and eating without spilling. Once settled, managing overstimulation when dining out is easy where training must precede for other factors also like lights, noise and other people.
Conclusion
There is growing evidence that a lot of discomfort results from digestive issues in autistic individuals. Restoring balance to the digestive tract, promoting normal absorption and beneficial gut bacteria should be high on parental agenda during biomedical consultations.
For nutrition and lifestyle interventions, work on manageable steps. Do not tackle all mealtime behaviors all at once, it’s a sure recipe for meltdowns and both parents and kids becoming overwhelmed and giving up. So, prioritize your goals after identifying your primary target. Is it increasing the number of foods the child will eat? The amount to be eaten? Or is it sitting at the table less disruptively? And work on each at a time. And no matter what goal you chose, start small. And every aspect of progress, respond with generalized praise and labeled praise directed at the specific action. Have reasonable expectations and do not get into loading scenarios, for example, if a child has been sitting at the table for 10 minutes and that is the goal, parents will often want to push for a little longer. That is a mistake. Similarly, if the child has accepted a healthy diet moderately, do not expect him to clean the entire plate.
All the spokes in the wheel have to be aligned – the dietician’s consult, interesting food exposures, exciting design, parental patience, persistence and consistency. Food has to be viewed as Individualized Nutrition Plan (INP).
Postscript
The reason I chose to write on this pervasive topic is because I have seen enough instances of maternal health burnout and picky eating, problems with appetite of the child is at the heart of it.
Disclaimer: The opinions and views expressed in this article/column are those of the author(s) and do not necessarily reflect the views or positions of South Asian Herald, its editorial team, or its affiliates. South Asian Herald does not endorse any opinions or statements made within the content.
