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Children with ASDs have the same general nutrition needs as all children and teens. Children with ASDs may be picky eaters, so their parents may be concerned that they are not getting the nutrients they need. For example, if a child doesn't drink milk (because the child refuses or because of a special diet), the child may not get enough calcium and vitamin D. If a child doesn't eat enough foods made from grains, she may not get enough fiber and B vitamins. Some children with ASDs have such a limited diet that they are at risk for nutritional disorders. They may also be at higher risk for low iron intake.
Eating problems are common in children, but for children with ASDs, the problems may last longer, be affected by differences in sensory processing such as how the child can taste and smell, and be the result of learned patterns of behavior. Up to three-quarters of children with ASDs may have problems with mealtime behavior and food choice. These problems include
Limited range of food texture, color, taste, or temperature
Food rituals or obsessions
Eating or mouthing nonfood items (pica)
Packing the mouth with food
Throwing up, gagging, and chewing or re-chewing food for a long time
Limited intake of fiber-rich foods including vegetables and fruits
Gastroesophageal reflux may lead to food refusal. Sensory issues with the setting of each meal may deter eating; for example, the school cafeteria is loud, bright, distracting, and disorganized, with multiple smells. Medication side effects, such as increased appetite with antipsychotic medications and reduced appetite with stimulant medications, may also cause issues. Children with ASDs may have difficulty recognizing when they are full, when they are hungry, and how long they have been sitting at the table. The child might think he is “all done” after a bite or two of food. If your child has felt sick after eating a certain food, he may refuse to eat that food again. This may happen even if the food was not what made your child sick. Your child might also eat a limited number of foods or refuse to eat what has been a favorite food in the past. This may be behavioral, related to preference and obsession, and may have a sensory component.
A great way to work on eating and nutrition issues is to set up a regular structure for mealtimes. Offer your child meals and snacks at about the same times each day. Keep mealtime calm and limit distractions. Sit down with your child and eat the same foods. Your child should feed herself if able. Do not ask your child to come to the dinner table until you are done preparing the food, everything is in place, and you are calm and ready to sit down.
At each meal, be sure to serve at least one food that your child has eaten and liked in the past.
Remember that a food often has to be offered multiple times before it is finally accepted. Offer the new food on multiple consecutive days with food your child is known to eat. This way, your child has something she is likely to eat. You should not be a short-order cook. Ask your child to eat, but do not plead or threaten. Once your child leaves the table, the meal is finished. To encourage eating at scheduled meals and snacks, do not give your child food or drink other than water until the next meal or snack. Incorporate a visual schedule so that the time and place of each meal is known. Your child will learn to eat what the rest of the family eats and behave like their mealtime behaviors. Therefore, the rest of the family will need to model good mealtime behaviors, eat fruits and vegetables, and avoid grazing. Your child will learn the eating habits of other family members.
Social stories can help establish a predictable schedule for the child of what happens at mealtimes and mealtime expectations at home, at school, and in the community. To address special feeding problems like mouth packing, re-chewing of food, and severely restricted diets, you will likely need help from experts in behavior, speech, or occupational therapy. Talking with a registered dietitian may help too.
Your child's pediatrician should review your child's diet at well-child checkups. Let your doctor know if your child has a very limited diet. The doctor should do a history and physical examination to help find medical factors that could be related to eating problems. Eating nonfood items (pica) may be related to low levels of iron in the blood, delayed development (very young children explore by mouthing items), sensory-seeking behaviors, or obsessions and anxiety. Blood lead levels should be checked periodically if your child is at risk for lead exposure and puts things other than food in his mouth. Your doctor should be told if you notice belching, retching, or difficulty sleeping at night. Your child's pediatrician may order tests to check for nutritional deficiencies or food allergies. Tell your doctor if you are giving any vitamins, supplements, or over-the-counter medications.
Keep in mind that what you think children need to eat may actually be too much. Your child's pediatrician should be able to tell you the portion sizes that are best for your child depending on her age and weight. Also remember that a balanced diet is over the whole week, not in one meal. In addition, eating problems do not go away overnight. You will need to keep teaching your child the rules for eating (ask your child's pediatrician about the “Behavioral Challenges” handout).
American Academy of Pediatrics HealthyChildren.org: www.HealthyChildren.org
Ernsperger L, Stegen-Hanson T. Just Take a Bite: Easy, Effective Answers to Food Aversions and Eating Challenges! Arlington, TX: Future Horizons; 2004
Legge B. Can't Eat, Won't Eat: Dietary Difficulties and Autism Spectrum Disorders. London, England: Jessica Kingsley Publishers; 2002
Williams K, Foxx R. Treating Eating Problems of Children with Autism Spectrum Disorders and Developmental Disabilities. Austin, TX: Pro-Ed; 2007
Family handout from Autism: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians, 2nd Edition, developed by the American Academy of Pediatrics (AAP) Council on Children With Disabilities Autism Subcommittee (ASC).
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