Children with autism spectrum disorder (ASD) may have restrictive and ritualistic behaviors that affect their eating habits. Some of them limit what they eat, in some instances so severely that it results in nutritional deficiencies1 that lead to weight loss, malnutrition and inadequate growth, said Melissa Olive Ph.D., a psychologist who treats children with ASD with feeding disorders at her practice in New Haven, Connecticut.

Research differs on how prevalent picky eating is in children with autism, but says that children with autism are much more likely than typically-developing children to be selective with food1,2.

Picky eating or feeding disorder?

Dr. Eric Levey, medical director of Pediatric Feeding Disorders Continuum at the Kennedy Krieger Institute, said that feeding problems in children with ASD can range from mild to severe. He said that most feeding problems are often mild at the onset, but in some cases become severe because parents have difficulty managing their child's challenging behavior and end up enabling them.

Some children with severe feeding problems are so selective with their food that it qualifies as a disorder.

Peter Girolami, Ph.D., clinical director of Pediatric Feeding Disorders at Kennedy Krieger, said that typically-developing children may also have preferences, refuse some foods now and then, and throw an occasional tantrum, but in other instances, they try different foods. "Children with autism, however, take selective eating to another level," he said. "For example, a child may want this particular brand of French fry. If the parents don't give that to him, he may respond with a burst of tantrums."

Dr. Olive said children with autism who have feeding problems fear new foods. "We often see that they develop inappropriate behaviors to avoid them—for example, they don't want to use a certain utensil or sit at the table. And the parents naturally let the kids have their way because they just want to get them to eat," she said.

Isaiah Stevens, a non-verbal child with autism, struggled with a severely restrictive diet until he was five. His mother, Audrey Stevens, said he preferred crunchy, yellow foods like goldfish crackers, waffles and toast. However, Isaiah was allergic to gluten (a protein found in wheat) and casein (a milk protein). Since the foods he preferred contained these allergens, Isaiah often had wheezing, asthma and constipation when he ate them.

"I eventually found an organic waffle recipe that was basically rice flour, honey and almond oil. I would make 30 of these a day and Isaiah would eat this throughout the day," Audrey Stevens explained. "He would also eat crunchy, salty bacon and drink almond milk, but nothing else besides these foods."

Dr. Olive said children with autism who are picky eaters limit themselves to five foods or fewer in some extreme cases. "Typical children get fussy but they never restrict themselves to so few foods," she explained.

Like Isaiah, some children with autism may be selective with the color of the food, eating only yellow or white foods such as rice, potatoes and pasta. Others may prefer a particular texture—some may like smooth foods while others may eat only crunchy foods3.

"A lot of children with autism tend to prefer foods that are high in carbs, high in calories and low in fiber. This interferes with their gut function and leads to constipation," Dr. Levey said.

Dr. Girolami and Dr. Olive said that children with autism tend to go days without eating when they do not get the foods that they want.

Audrey Stevens said several health care professionals initially suggested not feeding Isaiah the foods he ate, and change his diet to include whole foods, with different drinks like coconut water or rice milk, for three days.

"They told me, 'He will starve, but after three days, he'll have no choice but to eat,'" she said. "Well, that just landed him in the ER [Emergency Room] dehydrated and so pale. His mouth was sticky. Even then, when I offered him some coconut milk in the hospital, he would move his head and have a meltdown." Audrey Stevens said after that plan to improve Isaiah's feeding habits failed, she and Isaiah's medical team felt that there was no other option but to put him in an intensive feeding clinic.

Interventions for problem behaviors in autism

Health care professionals say that interventions that eliminate problem behaviors and re-teach feeding can help children with autism eat a healthy, balanced diet.3

Dr. Girolami said that while some children with autism may be selective with their diets due to compulsive behaviors, others may face motor and sensory challenges that restrict their ability to eat a variety of foods. A child with motor deficits may have trouble chewing and swallowing, which is why they may develop a preference for smooth foods that would not require much of either.

"Imagine if you had difficulty with the physical ability to put food into your mouth and move it around," Dr. Girolami explained. "Food is no longer fun to eat when you put it in your mouth and all of a sudden, you're gagging and you can't swallow it. You would naturally gravitate towards foods that would be easy for you to eat."

Some children may have a sensory intolerance to foods that make a loud noise, such as biting into a crunchy apple.3 In this case the child may acquire a preference for soft foods.

Gastrointestinal problems in asd

Dr. Olive said that some children with ASD also learn to avoid certain foods because they exacerbate gastrointestinal (GI) problems such as reflux and abdominal pain that they may be suffering from. "These children associate eating with pain," she explained.

Children with autism who are verbal or those who can communicate their abdominal discomfort may tell their parents about it. Research shows that some children, particularly those who are non-verbal like Isaiah, engage in repetitive behaviors suggestive of pain.4

Other children may engage in problem behaviors such as self-injury, aggression or having a meltdown when their caregivers give them foods that are uncomfortable for them to eat. "I treated a little three-year-old boy who was Hispanic. He cried every time he ate and he hit himself in the head many times every day. During meals, the father had to restrain him in a chair while the mom force-fed him," Dr. Olive said. "I asked the family to complete a GI screening. The doctor found an ulcer in the child's esophagus the size of a softball! He needed to be on an anti-acid diet, but his family was feeding him garlic, peppers, and tomatoes. So, imagine the pain that little guy was in."

Dr. Olive said that for this reason, she begins every intervention for challenging feeding behaviors in a child with autism with a screening for underlying GI problems and oral or motor issues that the child may have. When health care professionals rule out medical conditions, she adds that they can be certain that the reasons for the child's feeding problems are behavioral.

However, Dr. Levey said that most health care facilities do not perform a GI evaluation before starting treatment for feeding problems.

Interventions for feeding problems in autism

Dr. Levey said most children with mild feeding issues can benefit from outpatient treatment with an occupational or behavioral therapist, or a speech and language pathologist.

Health care professionals treat feeding disorders caused by motor problems or sensory preferences by evaluating a child's diet, Dr. Girolami said. He added that this would give them a clue into the possible causes for the selective eating.

Dr. Levey said that speech and occupational therapy can treat obvious motor deficits. He explained that speech pathologists may work with the child to strengthen jaw muscles, and the muscles they use to move their tongues, bite, chew, swallow and perform other functions involved in eating food. Occupational therapists may teach the child to use utensils, good posture, and other supports they may need to eat their meal. They may use aids such as chewy tubes to help with motor functions involved in getting food from the child's plate and into their mouths.

Cause of feeding problem in autism may be unclear

However, Dr. Girolami said, the cause of the feeding problems sometimes may not be as clear. "For example, if the child is eating only fries, they're chewing, and you can rule out motor issues. Then the resistance to other foods may just be a preference," he explained. "But if you have a child who is only eating smooth food, we don't know if he/she has an oral/motor issue or if it's just a preference."

In such a case, Dr. Girolami said, health care professionals present the child with different foods and observe their reaction. If the child who only eats smooth food and seems averse to other textures, health care providers judge the child to have motor deficits, such as jaw weakness that may prevent them from chewing his/her food. On the other hand, if the child seems open to trying other types of food, eating smooth food may be a preference.

"If we don't get a reaction to some of the foods, we can assume that the child is not averse to trying it," Dr. Girolami explained. "We can say, 'Hey, he didn't seem too put off by the carrot or he picked up that pear and sniffed it'. This can be helpful for us to get going with some kind of treatment."

Treatments can help children overcome sensory problems by repeatedly exposing them to a food item they may be refusing until they eat it. This reduces their defensiveness to unfavorable sensory input, such as sound, light or color5.

"We keep presenting the child with a certain type of food item they may have an aversion to, and as they get practice, their adverse response diminishes over time. So, it's not always clear if we've cured a sensory issue or a behavioral problem," Dr. Levey said.

Dr. Girolami said that most times, health care professionals introduce foods by gradually slipping in food types that the child does not usually eat.3 He explained that in the case of an 11-year-old boy with autism who only had a gray-colored smooth drink at every meal, professionals on one occasion added a peach to the smooth drink, and then an orange and then a green-colored food item. Over time, they gradually increased the amount of the food item that was different from the original gray drink.

"After a while, the child knew that the food was drastically different from what he was used to. But by then, he had already had stuff in the gray food that was orange and green that he didn't mind anymore," Dr. Girolami explained.

Dr. Olive, however, uses a different technique that teaches children with autism to overcome their fear of new foods. "The first step is to have them touch the food to their lips," she explained. "It teaches the kid to overcome the fear of the food in general. Pair that with reinforcement, praise or an incentive, such as time on the iPad or whatever, and over time, conditioning them to think that this food is associated with good things. When they get comfortable with new food, and they start taking small bites. Then we increase the expectations with the bites of food getting bigger and bigger."

Dr. Olive used this technique with Isaiah Stevens. "He went from tolerating the look of his food to putting it in his mouth to chewing it and eating it," Audrey Stevens said. "By Day 3, he was successfully eating different foods. His biggest incentive was getting to play with Thomas the Train on the tracks. He also wanted the iPad. For every minute worth of therapy, he would get a minute worth of play time."

Parents can reinforce good feeding habits

There are many ways parents can reinforce good feeding habits in their child with autism.5

They could have their child try at least one mouthful of a food item they do like at every meal, and perhaps make it more palatable by adding condiments that the child likes, such as ketchup or honey. They could also change the texture of the food by chopping food into smaller pieces or pureeing them according to the child's preference.5

Another technique involves an adult physically guiding a spoon to the child's mouth by putting their hands over the child's hands, and giving positive reinforcement when the child accepts the food. In other instances, the caregiver may remove the food item that the child refuses to eat, but would not allow them to escape from eating other foods on their plate. Research has found that this technique works when parents attempt to expose their children to new food items.5

A method called differential reinforcement involves alternating positive reinforcement when the child behaves in a desirable way and removing reinforcement for undesirable behaviors. For example, if children refuse food to get attention, adults would attend to them when they eat but not do so if they are throwing a tantrum.5

Most parents unwittingly use a popular intervention called 'Grandma's Law'. They motivate their children to eat foods that they do not like and offer a reward for eating them. For example, 'If you eat your vegetables, you get to have dessert'.5

Dr. Girolami said that it is important for parents and caregivers to scale back the reward once they notice the child eating more variety.

"We give reinforcement until the point when the child re-learns that broccoli is a good thing or, 'Oh, look! Beans are actually yummy!'" Dr. Olive explained. "At that point, the food itself becomes reinforcing, mealtimes are no longer stressful and everybody is happy at the table."

Dr. Girolami said that children with autism often thrive after their feeding problems are treated. "Children with autism are the most rewarding to work with because, once you introduce them to different varieties of food, they really get going and flourish by enjoying a lot more types of food," he explained.



Isaiah is now a healthy seven-year-old who enjoys different types of foods. "Isaiah is so much happier. He's gained some weight, his digestive system is working better," Audrey Stevens said. "He has enough energy to run or participate in gymnastics. The color in his face is bright. He used to be thin and frail, and now, he's a lean, strong boy."