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“When he’s hungry enough, he’ll eat.”

How often have we heard this from well-meaning family, friends, and medical providers? While most young children exhibit food preferences and some food selectivity, other children display persistent and highly restrictive eating patterns. Almost 70% of individuals with Autism Spectrum Disorder exhibit selective and restrictive eating patterns. Some children’s food selectivity may be so severe that they only eat one or two foods. Extreme eating patterns can lead to caloric and nutritional deficits, which are especially concerning in young children as growth and brain development may be affected.

In addition to the health and developmental effects of persistent restrictive eating patterns, it also causes disruptions to family life and may interfere with the child’s daily functioning. Eating only certain foods may affect the social activities that a child participates in. Families may be forced to cook special meals each day or to eat at only certain restaurants, if at all. Planning for school lunches can become challenging as well. Mealtimes are often stressful for the family as there may be disagreements between the adults on how to get the child to eat, along with crying and other avoidant behavior by the child.

Children and adults with feeding difficulties may display the following behaviors:

• Eating a limited variety of foods that might be a specific brand, shape, texture, or color or from only one food group
• Difficulty advancing food texture, such as resistance to moving from pureed foods to table foods, or texture selectivity, such as only eating crunchy foods
• Eating only with fingers or specific utensils, dishes, or presentation of food
• Disruptive behaviors such as gagging, batting the spoon, crying, swiping food, or self-injury

Parents of selective eaters are often advised to withhold the child’s preferred foods under the notion that the child will eventually eat. However, this advice may be misguided and even harmful, particularly when used with children who are highly selective eaters. I know a family whose child only ate a specific fast-food brand pizza, with the pizza needing to be fresh from the restaurant at each meal. This certainly was interfering, particularly as his mother traveled across town to deliver a fresh slice of pizza to the child each day at school. The parents were concerned about their son’s eating behavior and aware that this eating pattern was not healthy or functional and was difficult to sustain. The mother followed suggestions to withhold the pizza, under the assumption that the child would eventually eat other foods, “when he’s hungry enough.”  The problem was, he didn’t start eating other foods and went days without eating anything at all.

Withholding preferred foods is not always effective in getting a person to eat non-preferred foods and can result in further complications. This specific child not only refused non-preferred foods, but he also started refusing liquids, ultimately requiring hospitalization for dehydration. While this is an extreme example, just withholding preferred foods is not a surefire solution to increase food intake, and may even be harmful and contraindicated. However, there are safe and effective strategies that can be used to increase food variety.

 

What can I do to help my child eat a wider variety of foods?

Medical evaluation

Start with a thorough medical evaluation. Some restrictive eating habits are related to current or a history of medical conditions such as reflux, food allergies and intolerances, gastro-intestinal abnormalities, oral motor delays, and swallowing problems. Makes sense, right? If eating makes us feel bad or is effortful and difficult, we’re less likely to want to do it. Ensure your medical provider has ruled out any medical complications related to food consumption and all identified medical conditions are being effectively treated and monitored. Consult with your child’s physician or nutritionist on the recommended daily caloric intake for your child. After a thorough medical evaluation has been completed, you can promote healthy eating habits with positive and effective strategies.

Mealtime routine and structure

• The family, including the child, should eat meals and snacks at about the same time every day. Eating and mealtimes should be predictable for your child.
• Have your child sit at a table and in the same seat for meals. Make sure the seat and table are an appropriate size and height for the child. The child should be comfortable sitting at the table.
• Limit your child’s “grazing” and snacks between meals. When people eat throughout the day, they are often less hungry and therefore less interested in eating at mealtimes.
• Have a time limit for the meal, which should not exceed 15-30 minutes for young children. Developmentally, most young children are unable to sit for long periods of time and may engage in disruptive behaviors when made to sit too long.

Food presentation

• Some children may need to get comfortable with having non-preferred foods near them, either near their plate or even at the table. Just having the child sit at the table with family members during mealtimes will provide the opportunity for exposure to new foods.
• Initially, present very small amounts of novel and non-preferred foods. We don’t want the child to be overwhelmed, so don’t fill the plate with a new food. For example, just put one pea on the plate. As the child becomes successful with accepting new foods, slowly increase the amount of food presented to the child.
• Be persistent! It can take a child trying a new food 10-20 times before she readily accepts it.
• Provide choices of novel and non-preferred foods. Allow the child to have some control over the food they consume. For example, ask your child whether they would like to eat chicken or pork at dinner. Similarly, if two vegetables are cooked, present the two options to your child and prompt him to pick the vegetable to put on his plate.
• If your child’s diet still includes jarred baby food, consider making preferred pureed foods. While this is more time consuming, the homemade pureed foods will taste the same as the regular texture foods that are already prepared in the home. Once the child is used to the taste and texture of homemade pureed foods, advancing the texture (that is, moving to more solid food) should be easier because the taste will not change, only the texture. Note: Ensure that your child is safe to advance food texture by consulting with her medical professional.

Develop reward systems to encourage healthy eating

• Some parents may think, “Why should I reward my child for something she should already be doing?” Children who are selective eaters are often not internally motivated to expand their food repertoire. Additionally, some children don’t recognize hunger cues at all. Therefore, we must provide the motivation.
• Reinforce trying new foods. Reinforcement can include extra electronics time after the meal or simply a lot of praise and social attention. You can even use a token board or sticker chart to keep track of bites and then provide rewards at certain levels. Find what works for your child.
• A natural reward may be allowing the child to leave the dinner table early for consuming the food. For example, you tell your daughter once she finishes her meal, including the 3 green beans (non-preferred), she can leave the table to go play. Otherwise she will stay at the table until the time limit has been reached. Use of a timer may be helpful to signify the end of a meal. Ensure the amount of food on the plate is appropriate for the child’s development and be mindful to not encourage overeating. (Be careful using only food consumption criteria to end a meal, because this may be difficult to follow through. For example, you don’t allow your daughter to leave the table until she eats all of the green beans on her plate. Since we cannot make another person accept, chew, or swallow food, and if your child has a lot of stamina and does not want to eat those green beans, she’ll likely wait you out. In the end, it’s either sitting at the table all night (which is not realistic and certainly not recommended) or allowing the child to leave the table without following through (also not recommended). These contingencies often lead to frustration for both the parent and child.)
• Celebrate the success! Make a big deal out of appropriate mealtime behavior. Appropriate mealtime behavior may be taking a small bite of a new food, sitting at the table for 5 minutes, or tolerating a new food on their plate. Don’t be discouraged with slow progress; developing long-term, healthy eating habits takes time. Provide a lot of attention and praise to appropriate mealtime behavior.

Positively frame your language and limit attention to inappropriate mealtime behavior

• Mealtime with children who are selective eaters can be a stressful and frustrating experience for both the child and the parent. Avoid using reprimands to correct the child’s mealtime behavior. Instead, tell him what he should be doing. For example, your son is tapping the fork on the table and not eating. Instead of saying “Stop playing with your fork!” say, “Pick up your fork and eat.” There are a lot of things a child shouldn’t be doing at the dinner table, so let’s tell him what he should be doing.
• Do not talk about your child’s selective eating in front of her. Similarly, avoid lengthy discussions with your child on why she will or will not eat certain foods. Ask family members to limit discussion of selective eating in front of the child. We don’t want the child to learn to get attention from other people through selective eating. Conversely, provide a lot of positive attention when the child eats new foods.
• Limit attention to inappropriate mealtime behavior, such as gagging, crying, and vomiting (not due to illness or choking). Remain calm when these behaviors occur and avoid removing the child or the food from the table following inappropriate behavior. Many children who are selective eaters do not want to sit at the table and be exposed to non-preferred foods. For example, if you remove peas when your son starts crying and allow him to leave the table, he will be more likely to cry the next time non-preferred foods are presented.
• All family members should model appropriate eating behavior for the child. While most people have food preferences, it’s important to be mindful how we, as adults, respond to our non-preferred foods. Family members should avoid making negative comments about their own food preferences (for example, saying “that looks gross” or “broccoli tastes terrible,” making faces, or plugging your nose). Instead, talk positively about food. Children pick up on the behaviors of those around them!

 

I’ve tried it all to get my child to eat, but it doesn’t work. Now what?

The above strategies will work for many selective eaters. However, other children may need more specialized interventions. If your child continues to display restrictive eating patterns, contact a professional who is experienced in treating children with feeding disorders, such as a psychologist, Board Certified Behavior Analyst, or speech language pathologist.  If your child is not meeting their nutritional and/or energy needs, has experience significant weight loss, has a nutritional deficiency, is dependent on tube feedings or oral supplements, such as Pediasure or Boost, or their eating patterns significantly interfere with their daily functioning, contact your child’s physician.

Jessica B. LeBoeuf, Ph.D. is a member of ASNC’s Clinical Services Department.

ASNC’s Clinical Services Department staff is composed of PhD and master’s-level licensed psychologists, Board Certified Behavior Analysts, and former special education teachers. We provide individualized intensive consultation using evidence-based practices to support children and adults across the spectrum in home, school, employment, residential and other community-based contexts. We also deliver workshops to parents and professionals on a wide range of topics including but not limited to, strategies to prevent and respond to challenging behaviors, best practices in early intervention, functional communication training, and enhancing social understanding in individuals with autism.

 

 

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