Picky eating, and insisting on the same foods over and over again, is developmentally appropriate behaviour for toddlers, and some children will be fussy about food all their lives without any significant impact on their nutrition. However, having sensory processing challenges makes it even more difficult for a child to try unfamiliar foods or to eat foods that have a texture, smell, or taste that offends their senses.
Even the colour and shape of the food may affect their ability to tolerate it. Some children will only eat crunchy foods, or mushy foods. Aversion to a certain texture might be a tactile issue, but it could also be due to low tone in the mouth or a motor planning problem. Some children will actually gag while eating, and avoid foods they fear will make them gag, because their oral-motor coordination is not what it should be.
Problems to look out for
There’s no need to be too concerned if the person is eating foods from each of the main food groups, and if a child, is growing well. Get advice if the person is:
- accepting fewer than 20 foods
- refusing all foods from one or more food groups
- being constipated, or having constipation can have a huge impact on appetite and may require medication
- suffering from tooth decay as a result of their diet
- losing weight or not growing well
- gaining weight excessively
- displaying behaviour, e.g. tiredness or pica (eating non-edible items) that might indicate a vitamin or mineral deficiency (e.g. iron deficiency anaemia)
- missing school due to eating problems
- coughing and choking while eating, or has recurrent chest infections, especially if they have developmental delay or physical disabilities
- missing out on social opportunities, e.g. if they and their family can rarely go out due to the eating problems.
Finding the cause
Start to take note of what is eaten and when. Sometimes, a food diary can be reassuring, you may in fact see that the person eats a wider range of foods than you originally thought.
Here are some examples of what to include:
- What time of the day did they eat? e.g 11.05
- What did they eat? e.g Salt and vinegar crisps
- Where did they eat? e.g In the living room
- How much did they eat? e.g Two bags
- Who was there? e.g Mum, brother
- How did people around respond to the person eating the particular food? e.g Mum praised, brother had no reaction
- Were there any environmental factors? e.g Radio was on in the background
- This could reveal some causes of the eating difficulties, whether over-eating or restricted eating. Try to work out whether it is the amount, type or range of food being eaten which is the core issue, and then what underlying problems, or sensory issues, may be involved.
With any approach, it is important that you communicate in a clear, consistent and calm way.
A social story could help someone to understand why we eat and the function of food, e.g:
- food provides us with fuel/power, which enables us to do things we enjoy
- eating food from all the food groups gives us energy
- missing out food groups can make us tired.
Presenting information visually can also help. You could:
- produce clear daily and/or weekly menus of foods, display the time of next meal in a prominent position
- provide visual tools to help the person express and recognise their needs, feelings and preferences, such as stress scales, hunger and fullness scales, or happy/unhappy face pictures
- have a food group chart, with a rule that they must have at least one food from each group each day
Try not to categorise foods into healthy and unhealthy, or good and bad. This can sometimes be taken too literally and can cause further problems.
Try to be very specific when talking about food or using pictures of food. For example, apples look and taste different, but we call them all apples. It's possible that the person likes golden delicious apples, and dislikes braeburns, but is confused by you showing them a picture of a green apple, and then bringing them a red one.
Using reward systems can be effective. However, avoid using a preferred food as a reward for trying a new or non-preferred food. It could make the preferred food even more attractive, and the new food appear like a chore. Also, ensure the emphasis of the reward is not just on eating a certain amount of a non-preferred food, but on tolerating new food being around, or tasting a new food.
Encourage activities which involve movement and exercise. This can help with weight loss (if that's needed) and reducing stress, which may have contributed to over-eating or under-eating. If the person is reluctant, think about whether there could be any underlying reasons, e.g. difficulty with balance, or socialising.
It can be helpful to model the behaviour you're trying to encourage. This might mean that the whole family takes part in exercise, avoids snacking between meals, or follows a rule about eating something each day from each food group.
Children with autism spectrum disorders and/ or sensory processing difficulties can remain picky eaters beyond the toddler years because they take comfort in the predictability of foods they know they like. You'll need patience, understanding and sensory ideas to introduce new foods.
You can start with some of the basic ''picky eating'' tips that follow:
- Don't give up on introducing new foods. Continue to serve foods even if they're rejected. You may have to serve a food dozens of times before your child will actually try it. Try introducing one new food at a time to increase your child's familiarity with it.
- Allow your child to take just one bite and let them spit it out into a paper towel if they decide they can't tolerate it. You may have to start with praising and even rewarding them for simply licking a food or touching it to their lips.
- You can start the familiarisation process by showing the child photographs of the offending food,
- then working your way up to having them eat at the table with the food in plain sight (and close enough to smell),
- then tolerating it on their plate (don't let the food touch other food on the plate if mixing the textures is repulsive to them),
- touching it,
- then touching it to their lips, then their tongue etc.
- Consider allowing your child to choose a few specific ''repulsive'' foods to be on their forbidden list, and promise that you won't force them to eat these. Stick to your promise!
- If your child avoids mixed textures, separate the food using a partitioned plate or several small plates, even allowing them to use separate forks for separate foods. You can also gradually add texture, they may initially only tolerate a small coating of tomato sauce on their pasta but over time become more accepting of the sauce, eventually sauce with chunks of tomato and bits of meat mixed in.
- Give your child an incentive by awarding them points, redeemable for a small toy or extra TV time, for trying a new food or eating a small portion of food that's not a favourite.
- Vary the temperature of foods. Extra cold food might provide sensory input that wakes up your child's mouth and makes them more willing to eat it. If they prefer their food lukewarm, let them eat it that way.
- Use your creativity and presentation skills to coax younger children to ear. Use cookie cutters to cut foods into fun shapes, or arrange foods on a plate to create animals and faces. Children's cookbooks often have suggestions for creative presentations.
- Avoid serving your child food in the container it came in. Manufacturers frequently change packaging and your child might be convinced that the new package contains a different product and refuse to eat that food again.
Many autistic people experience sensory issues; being over or under-sensitive to sights, sounds, smells, tastes and textures. This can affect a person's experience of meals and relationship with food, and cause anxiety around food.
The person might find it too distracting to eat in a noisy canteen, find out if they could eat in a quiet room instead. The chair they sit on may be too hard, add a cushion.
Playing some favourite music or a story in the background can be relaxing, distracting the person from the usual anxiety around eating.
People who are very sensitive to smells and taste may prefer to eat quite bland food, and may find strong food smells overpowering. Under-sensitivity to taste or smell may mean the person prefers stronger flavours. Particular smells and flavours may be a source of intense pleasure. Some people might find the feeling of hard food, or sloppy food, unbearable.
Try modifying food to improve the sensory experience, for example by puréeing or using food colouring, and introduce a new food or textures in small steps, for a gradual desensitisation.
First let the person just look at it, then touch it, then invite them to put the food on their plate, then smell it, lick it, put it into their mouth, bite it, chew it, and swallow it. Try not to react negatively to food being spat out. This is helping them to become comfortable with different foods being in and around their mouth.
These steps could take months to complete. Try to see the goal as learning about and being comfortable around different foods, rather than getting them to eat all of the different foods presented.
Discomfort and illness
Physical pain and discomfort can affect how a person eats. Gut pain could cause a person to over-eat for comfort. Constipation can dampen appetite. Heartburn can stop someone wanting to continue to eat. Toothache and mouth ulcers can make someone reluctant to put things in their mouth. Some medication can affect appetite (e.g. Ritalin) or cause stomach upsets (e.g. antibiotics). A bloated intestine could cause a person to feel full when in fact they aren't.
Support the person to communicate physical pain or discomfort, e.g. by using a visual stress scale, PECS (Picture Exchange Communication System), pictures of body parts, symbols for symptoms, or pain scales, pain charts or apps.
Attention to detail, and difficulty with change, is characteristic of autistic people. The way the food is presented or positioned on the plate, or the food's packaging, may dictate whether it is eaten or not.
- Has the positioning of the food on the plate been altered?
- Is the food over- or undercooked?
- Are there 'bits' on the food?
- Has the packaging changed?
- Is the logo a different colour?
- Is the box damaged?
- Have you bought a different brand?
Some people eat better in the company of their family or peers. They may be more willing to try new foods if they see other people trying the same food and enjoying it.
For others, the social nature of mealtimes can be stressful. They might be more relaxed, and eat more volume or variety, if they ate alone in another room.
If a meal is not going to be at home, prepare the person in advance by telling them who will be there, who will they be sitting with or next to, what people might talk about, and what they could say to start a conversation.
Obsessions, special interests and routines
Many autistic people have obsessions. If certain foods, or calorie counting, are an obsession, this could lead to over-eating, under-eating or a rigid diet.
But obsessions, or special interests, can also prove helpful.
You could try to channel an obsession with eating, or with weight loss, into something positive such as cooking and writing recipes. You could use a special interest to encourage them to eat more volume or variety, e.g. by eating from a Thomas the Tank Engine plate, cutting food into rocket shapes, or exploring foods from the country or region of their favourite singer or sports team.
Many autistic people rely on routine and sameness. To eat well, they may need to have meals at the same time every day, be seated in the same position at the table, or always use the same plate or cutlery.
This need for sameness could also explain a person's preference for processed foods. Processed foods are predictable, designed to look and taste the same each time. In contrast, there will always be natural variation in fresh food. Introduce new foods or textures in small steps.
Sometimes, what appears as an obsession is in fact a coping strategy. Some autistic people say the world feels overwhelming and this can cause them considerable anxiety. Some people may over-eat, or avoid food, as a result of low self-esteem or anxiety.
Try to minimise any stressful things the food diary has revealed, or encourage a different coping strategy, such as spending time on their special interest, or using the Brain in Hand support app.
The National Autistic Society http://www.autism.org.uk/about/health/eating.aspx
Is it Sensory or is it Behaviour: Behaviour Problem Identification, Assessment, and Intervention by Carolyn Murray-Slutsky and Betty, A. Paris.
Raising a Sensory Smart Child by Lindsey Biel and Nancy Peske.