Feeding Therapies for Children With Autism Spectrum Disorder: What Physicians and Clinicians Should Know

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, and restrictive repetitive patterns of behavior, interests or activities¹. While food selectivity is not part of the diagnostic criteria for ASD, it is estimated that 50-90% of children with an ASD diagnosis have food selectivity^12,4,14,3,11, and children with ASD are five times more likely to have feeding difficulties than their typically developing peers¹¹. Furthermore, food selectivity has been shown to be detectable in children under 3 years who eventually receive an ASD diagnosis^12,2.

Eating is a complex activity involving many bodily systems (see Figure 1). Children with ASD are more vulnerable to feeding and eating difficulties due to atypical development of many systems. Sensory processing differences in ASD have frequently been cited as one of the reasons for the high prevalence of food selectivity among this population^7,4,5,12,9. Empirical evidence has shown that children with ASD are eight times as likely to have oral sensory sensitivity than their typically developing peers⁵, and children with oral sensory sensitivity and ASD tend to have lower consumption of fruits, vegetables⁵, protein and calcium and more nutritional deficiencies compared to peers without ASD¹¹. Furthermore, gluten and casein elimination diets that may be utilized to manage gastrointestinal issues common with this population can augment the likelihood and severity of nutritional deficits^11,3,10.

Motor, communication and social deficits common among individuals with ASD can also negatively impact engagement in mealtime for the individual and the family. Oral motor muscular weakness and/or dyspraxia may impact intraoral management of foods. Additionally, fine motor skills delays can result in poor self-feeding abilities and difficulty handling utensils, while postural muscle instability may impact sitting and attending during mealtime. Deficits in communication may contribute to an inability to effectively communicate food preferences to caregivers.

Lastly but not the least in importance, due to the inherently social nature of mealtime, feeding difficulties can have a negative impact on family interactions during meals^{14, 13}. In one qualitative study of four white, non-Hispanic mothers of children with ASD, interviews revealed that these families lacked the opportunity for quality time together during meals due to their child with ASD’s mealtime difficulties, and they felt frustrated by not being able to enjoy this time together. All of the mothers reported trying to come up with strategies to improve the mealtime experience for their families but were unsuccessful. None of these families reported having long-term professional guidance to improve mealtime¹³.

In summary, eating and mealtime are highly valued and frequently engaged in activities of daily living and have a significant impact on quality of life for both individuals⁷ and families^{14, 13}. Therefore, it is imperative that addressing feeding difficulties is prioritized for individuals with ASD.

Screening children with ASD for feeding difficulties during a routine well-child visit can help health care providers make an appropriate referral to an occupational therapist or speech language pathologist who specializes in feeding therapy. Available screening tools for feeding difficulties include the PediEAT Screener, available for ages 6 months to 7 years for free from Feeding Flock⁸. Additionally, the Feeding Matters Infant and Child Feeding Questionnaire is available for free online from Feeding Matters⁶ and provides parents and health care providers with tips and guidance on feeding that can be shared and used to determine if feeding difficulties are present.

Feeding therapy can help children with ASD and their caregivers meet their mealtime goals with on-going professional guidance. Approaches utilized by occupational therapists and speech language pathologists for children with ASD include the Sequential Oral Sensory (SOS) approach, Sensory Integration (SI), and Differential Reinforcement of Alternative Behavior (DRA)⁹, in addition to a biomechanical framework to assess and treat oral motor and swallowing functioning. Feeding therapy can help a child with ASD to expand food repertoire, improve intraoral management of foods, increase food volume intake, reduce anxiety and stress around mealtime and manage maladaptive behaviors during mealtimes. When nutritional intake is a concern, it is recommended that a consult from a Registered Dietician or Gastroenterologist is obtained in addition to feeding therapy in order to adequately address the key components of care for children with ASD struggling with mealtime difficulties.

The Boone Fetter Clinic offers feeding therapy for children with ASD, other neurodevelopmental disorders and restrictive eating behaviors. To refer a patient, you can email your referral to boonefetterclinic@chla.usc.edu, or contact us at 323-361-6102.

References

1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
2. Ashley, K., Steinfeld, M.B., Young, G.S., Ozonoff, S.O. (2020). Onset, trajectory, and pattern of feeding difficulties in toddlers later diagnosed with Autism. Journal of Developmental Behavioral Pediatrics, 41(3), 165-171.
3. Babinska, K., Celusakova, H., Belica, I., Szapuova, Z., Waczulikova, I., Nemcsicsova, D., et al. (2020). Gastrointestinal symptoms and feeding problems and their associations with dietary interventions, food supplement use, and behavioral characteristics in a sample of children and adolescents with autism spectrum disorders. International Journal of Environmental Research and Public Health, 17, 1-18.
4. Cermak, S.A., Curtin, C., Bandini, L.G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238-246.
5. Chistol, L.T., Bandini, L.G., Must, A., Phillips, S., Cermak, S.A., Curtin, C. (2018) Sensory sensitivity and food selectivity in children with autism spectrum disorder. Journal of Autism & Developmental Disorders, 48, 583-591.
6. Feeding Matters (2021). Feeding matters infant and child feeding questionnaire. Retrieved from https://questionnaire.feedingmatters.org/questionnaire on 1/14/2021.
7. Leader, G., O’Reilly, M., Gilroy, S.P., Chen, J.L., Ferrari, C., & Mannion, A. (2020). Comorbid feeding and gastrointestinal symptoms, challenging behaviors, sensory issues, adaptive functioning  and quality of life in children and adolescents with autism spectrum disorder. Developmental Neurorehabilitation, 1-10. Retrieved from https://doi.org/10.1080/17518423.2020.1770354
8. Pados, B. (2019). Feeding Flock: Our Assessment Tools. Retrieved from https://www.feedingflock.com/tools on 1/14/2021
9. Reinoso, G., Carsone, B., Weldon, S., Powers, J., & Bellare, N. (2018). Food selectivity and sensitivity in children with Autism Spectrum Disorder: A systematic review defining the issue and evaluating interventions. New Zealand Journal of Occupational Therapy, 65(1), 36-42.
10. Safiza, N.M.N., & Le Couteur, A. (2015) Spectrum of feeding problems and gastrointestinal symptoms in children with autism spectrum disorders: A scoping review. Malaysian Journal of Nutrition, 21(1), 105-119.
11. Sharp, W.G., Berry, R.C., McCracken, C., Nuhu, N.N., Marvel, E., Saulnier, C.A., et al. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: A meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders 43, 2159-2173.
12. Sieverling, L., Towle, P., Hendy, H.M., & Pantelides, J. (2018). Prevalence of feeding problems in young children with and without Autism Spectrum Disorder: A chart review study. Journal of Early Intervention, 40(4), 335-346.
13. Suarez, M.A., Atchison, B.J., Lagerwey, M. (2014). Phenomenological examination of the mealtime experience of mothers of children with autism and food selectivity. American Journal of Occupational Therapy 68(1), 102-107.
14. Zlomke, K., Rossetti, K., Murphy, J., Mallicoat, K., & Swingle, H. (2020). Feeding problems and maternal anxiety in children with autism spectrum disorder. Maternal and child health journal, 24, 1278-1287.

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