Oral Motor Institute

«Vol. 4, No. 2




Oral Motor Institute
Volume 5, Monograph No. 1, January 2016

SELF-LIMITED DIETS IN CHILDREN WITH A DIAGNOSIS OF AUTISM SPECTRUM DISORDERS

Talk Tools: Charleston, South Carolina

 

ABSTRACT

The CDC (2014) reports, that Autism Spectrum Disorder (ASD) impacts 1 in 68 children in the United States. They also indicate that in “cluster” states such as New Jersey, as many as 1 in 28 boys are affected. Children with ASD often present with comorbid feeding issues. Studies show that up to seventy percent of children with ASD are selective eaters and up to ninety percent have feeding problems (Volkert & M Vaz, 2010). Researchers at Marcus Autism Center and the Department of Pediatrics at Emory University School of Medicine conducted a comprehensive meta-analysis of all published, peer-reviewed research relating to feeding problems and autism.  Examination of dietary nutrients showed significantly lower intake of calcium and protein and a higher number of nutritional deficits overall among children with autism (Korschun & Edwards, 2013).

Researchers are exploring the possible causes of ASD, but thus far there are many theories regarding this complex disorder, ranging from genetics to autoimmune dysregulation (Merkel-Walsh, 2012). There is also debate regarding methods of treatment for children with autism. Applied Behavioral Analysis (ABA) has the most empirical research to date. Behavior analysis is a scientifically validated approach to understanding behavior and how it is affected by the environment (Autism Speaks, 2014). It has been endorsed by a number of state and federal agencies, including the U.S. Surgeon General and the New York State Department of Health. (Iovannone, Dunlap, Huber, & Kincaid , 2003). Research has shown that ABA therapy is effective at increasing appropriate behaviors and decreasing inappropriate behaviors (Kodak & Piazza, 2008). Therefore, it is reasonable to believe the principles on which ABA techniques are based can help with feeding issues (Volkert & M Vaz, 2010). The problem is that behavioral therapies however, do not often take into account the complexity of the sensory-motor system or medical issues, and how they relate to self-limited diets in children with ASD.


Purpose

This article explores 1) the sensory-motor system as it relates to feeding, 2) the importance of a thorough assessment; 3) biomedical treatment approaches for children with ASD, 4) Applied Behavioral Analysis (ABA) and its’ relevance when treating sensory-motor based feeding disorders in children with ASD.

Method

Numerous texts, journal articles, print articles, internet articles and clinical presentations were reviewed in order to collect information on the etiology, treatment and outcomes of feeding therapy for self-limited diets with children on the autism spectrum, who have comorbid feeding issues. The authors explored current research in speech - language pathology, biomedical and holistic medicine, nutrition, and Applied Behavioral Analysis (ABA). The authors also looked at case studies and the factors that may have influenced the diets of three children with ASD, who seemingly had behavioral issues, but when assessed presented with structural, medical and /or sensory-motor issues.

Results

The authors found that self-limited diets are often not purely behavioral in nature, and there is a future need for more peer reviewed research on this topic.

DISCUSSION

Based on the review of the literature, there are several important factors to consider when a speech-language pathologist (SLP) receives a referral for a child who presents with ASD and a self-limited diet. These factors include:

  1. The sensory-motor system
  2. Assessment protocols
  3. Biomedical treatments
  4. Applied Behavioral Analysis

1-The Sensory-Motor System:

Sensory processing refers to our ability to take in information from our internal environment and the world around us, organize this information and use it to respond in a well-organized way. An infant’s first job in life is self-regulation to calm him or herself, and to become attentive to the environment. Many people with a diagnosis of autism have difficulty with self -regulation and maintaining optimal levels of arousal (Barthels, 2014). Children with a diagnosis of autism also have a wide range of sensory processing difficulties, which may impact safe, effective, nutritive feeding.

Sensory discrimination is the ability to differentiate between sensations. When a person cannot discriminate, issues with modulation of incoming information and sensory-based motor deficits may occur. Individuals with autism may have qualitative differences in motor skills, especially with posture and alignment (Teitelbaum, Teitelbaum, Nye, Fryman & Mauer 1998). Since the sensory and motor systems cannot be separated, issues with posture and alignment may impact the sensory system (Overland & Merkel-Walsh, 2013).

People with intact sensory discrimination skills can differentiate tastes, textures, smells. They are also able to differentiate locations of food in the mouth or on the face. Secondary to deficits in sensory discrimination, children with ASD may not be able to differentiate these sensations, and as a result, may self-limit their diets because eating has become a negative experience. The sensory and motor systems function as a feedback loop. Sensory input impacts motor skills and movement impacts sensory perception. If a child has difficulty differentiating taste, texture, temperature, or locations of food in the mouth it may be difficult to handle food safely (Bahr, 2001). Holding food in the mouth for long periods of time, swallowing foods that are not adequately masticated, eating non-food items, etc. may result in gagging, choking, and vomiting. Food refusal and self-limited diets are often the result of compromised oral sensory-motor skills and negative experiences which result in behavioral responses.

Children with modulation issues may be over -responsive or under- responsive to incoming sensory information (i.e., taste, texture, temperature, sound, etc.) and therefore, their responses do not match the incoming information. For example, a typically developing toddler may react surprised, interested, or slightly dismayed at the introduction of a new food taste. A toddler with a diagnosis of ASD may become hysterical, turn red, and start gagging.

2- Assessment:

When an individual with autism is referred to a Speech-Language Pathologist (SLP) for self-limited diet, a comprehensive feeding assessment is required, including: review of child’s medical status; gross, fine, and oral-motor development; nutritional status; and sensory processing (Arvedson & Brodsky, 2001). Since the sensory and motor systems cannot be separated (Overland & Merkel-Walsh, 2013), it is very important to task analyze the child’s motor skills and determine how they relate to feeding, before assuming that a self-limited diet is purely behavioral (Overland, 2010; Merkel-Walsh, 2012). When interviewing parents of children with ASD in an initial intake, “red flags” may often be present in the feeding history such as “he never progressed from purees to solids,” or “she threw up at the sight of any new food,” or “he eats anything and everything even if it is not food.”

As previously mentioned, sensory processing issues can contribute to feeding disorders (Twachtman-Reilly, Amaral, & Zebrowski, 2008). Children with sensory regulation disorders may not be able to organize themselves for feeding (Morris & Klein, 2000). Those with oral sensory-motor issues may not feel the food in their mouths, or they may be overly sensitive to the feeling of the food in their mouths. They may not feel hunger or satiation. Sensory defensiveness can produce a neurochemical reaction of fear that can quickly become a hardwired automatic response (Overland, 2010). The nervous system triggers a “fright-flight-fight” response even if it is irrational. In addition, once a behavior is inadvertently reinforced, the behavior is likely to reoccur (Brophy, 2013). Seemingly well-meaning parents and therapists may not realize that by reacting to food refusals they are actually increasing the chance for this behavior to reoccur (Brophy, 2013; Overland & Merkel-Walsh, 2013). It is important to remember that every behavior means something (Barthels, 2014). While children with autism are referred for what appears to be behavioral feeding problems, the underlying etiology is often sensory-motor.

In order to understand a child’s diet profile, it is important to collect the necessary data and analyze that data in conjunction with information collected on the child’s oral sensory-motor skill development (Overland & Merkel-Walsh, 2013). To thoroughly understand a child’s taste, temperature and texture preferences, it is helpful to have the caregivers fill out a form reporting all foods consumed over a five day period. When possible, name brands of foods may be helpful in addition to the amount consumed, and the utensils that were used. This helps the therapist establish a “home base” which is a profile of taste, texture, and temperature in a child’s diet. Diet shaping starts with a child’s existing profile and slowly expands taste and texture.


5 Day Baseline Diet

 

1

2

3

4

5

BREAKFAST

 

 

 

 

 

LUNCH

 

 

 

 

 

SNACK

 

 

 

 

 

DINNER

 

 

 

 

 

SNACK

 

 

 

 

 

ADDITIONAL NOTES

 

 

 

 

 

 

Here is Case Study #1: (all names have been changed for privacy)

Jonathan was referred by Dr. Mary Tatum of Quest Learning Group. Chief complaints were speech clarity and feeding issues. Jonathan was diagnosed with mild Autism Spectrum Disorder by Dr. Jones at County General Hospital. Jonathan just started the Spectrum Program, (with regular education in the afternoon with a 1:1 aide), and had previous Early Intervention and ABA therapy with Quest Learning Group. The parents provided the most recent Developmental Pediatric study, along with an evaluation from Dr. Tatum for review.

Family History:
Jonathan resides at home with his mother Colleen (age 30) a homemaker, father Michael (age 38) a financial analyst, and sister Ella (11 months). English is spoken in the home. Jonathan’s maternal aunt was a late talker.

Birth History:
Jonathan was born at 35.5 weeks gestation via vaginal delivery without complications. Though a month early he was 7 pounds, 9 ounces and healthy. He had some difficulty latching for breast feeding and a lactation specialist was consulted. After some unspecified massage techniques feeding improved.

Medical History:
At four days of age, Jonathan was readmitted to the hospital for jaundice and received light therapy. From 6 months to 2.5 years he had a “constant cold. “ He also suffered from constipation. When dairy (milk only) was removed from the diet, his colds and constipation were minimal, and he continues to do well. His hearing and vision were tested in June of 2011 and were normal. He had one ear infection at 19 months.

Developmental History:
Developmental milestones are as follows:

Roll over

11  months

Delayed

Stood

13  months

Average

Sat independently

7.5 months

Average

Walking

18  months

Delayed

Crawl

11 months

Average

Toileting

3 years, 1 month

Average

Finger feeding

11.5  months

Average

Self- fed with utensils

2 years, 4 months

Delayed

Babbling

9 months

Late Average

First words

12-13 months

Average

Combine Words

30 months

Delayed

Talk in complete sentences

3 years, 1 month

Delayed

Oral Motor/ Sensory History:
By parent report, Jonathan is an “extremely picky eater.” He only eats : macaroni and cheese, grilled cheese, Eggo frozen plain waffles (dry), store brand frozen pizza, one brand of chicken nuggets, a homemade fruit smoothie (specific to almond milk, banana and strawberry), almond milk, water, potato chips, and graham crackers. He will not tolerate new brands or any small changes in the presentation of these foods. For example, he eats the frozen “square” pizza, but will not eat a slice of pizza in a restaurant. He never sucked his thumb or used a pacifier. He weaned from the bottle at 13 months old, but did use a sippy cup for more than 3 to 6 months. He can drink from a straw. He grinds his teeth when excited. He has a history of being sensitive to sounds. He is right handed. He sleeps from 6:30 PM to 7:00 AM. He naps on weekends. He is verbal, but only intelligible 50% of the time. He understands most of what is said to him.

Social History:
Jonathan was described as a “pleasant, happy child.” He smiles and greets others. He is quiet with new people and needs to be prompted to say “Hi.” He wants to play with other children, but it is hard for others to understand him. He enjoys playing with play dough, riding his bike, swimming, matching games and puzzles. He has an average activity level and likes to be outside and playing.

Testing Observations:
Jonathan entered the clinic with his mother willingly. He had a tantrum when he was asked to stop playing with the blocks and move into the chair for work. His mother reported he has not had these behaviors in quite some time, and it was thought to be due to the presence of food in the room for the assessment. He transitioned to the chair when his behavior was ignored. His mother also employed ABA strategies throughout the testing to regulate his behavior, such as using her iPhone as a timer, and setting clear expectations. His father came to the assessment a bit later and Jonathan’s behavior improved in his presence.

Jonathan exhibited several preservative behaviors such as the need to complete a building task and to clean up all items before sitting down. Jonathan spoke in sentences throughout, but his responses at times seemed rehearsed or memorized as opposed to spontaneous. Never the less he was able to answer most questions and keep up with the conversation. He had several anxieties, one being the fear of flushing toilets. When he needed to go to the bathroom he would not go with his mother but quickly agreed to go with his father because he thought there will be urinals as opposed to a regular toilet. When upset he would talk about returning to the minivan and going home. He seemed to have his own strategies to self-sooth which help him engage in therapeutic activities.

After a thorough assessment the following summary, diagnosis, and recommendations were made:

Summary:
Jonathan was a 3 year, 1 month old male who recently started a preschool program and had a diagnosis of Mild Autism Spectrum Disorder. He has done very well in ABA and in therapies, but has issues with speech clarity and feeding which prompted this evaluation.

Jonathan had some strengths including: adequate orofacial tone for speech and feeding, positive self-regulation skills even when upset, positive social interaction with the examiner and recent language expansion. Areas of weakness noted in this assessment included: limited lingual mobility, tongue thrusting, and motor planning deficits. Jonathan fixed his jaw in a high posture and often had retracted lips which impaired his overall clarity and resonance.

Feeding issues were the result of a breakdown in the sensory-motor system. One cannot separate one from the other. He had difficulties with latching at birth and this is directly related to the possibility of a restricted lingual frenulum. If a child has reduced lingual mobility this also impacts the ability to handle the bolus when solids are first introduced. Between structural, sensory-motor issues and behavioral challenges associated with ASD, it is not surprising that he has a self-limited diet. Jonathan also met the criteria for Childhood Apraxia of Speech based on his inability to execute non-speech oral postures, blow on command and imitate oral postures. He also presented with atypical and erratic speech sound errors that have not responded to traditional therapy methods.

Jonathan would benefit from a speech therapy treatment protocol that addresses both his feeding and speech issues.

Diagnostic Impressions:
(784.69) Childhood Apraxia of Speech
(783.3) Feeding Mismanagement
(750.0) Rule Out Ankyloglossia (tongue-tie)

Recommendations:

    • Oral Placement/Feeding/PROMPT therapy by a speech pathologist with post graduate training in oral sensory-motor and feeding disorders.
    • Parents will need training to implement carryover in the home. The home ABA team is also welcome to help with this program.
    • ENT evaluation to entertain the possibility of Ankyloglossia (tongue-tie) secondary to limited lingual mobility. Referrals were given to the parents during the assessment.

This case study highlights a few key points when assessing feeding issues in children with ASD. First, there can be concurrent structural issues. This was seen in Jonathan’s case, as the lactation specialist may have missed the possibility of a tongue tie when latching issues occurred. Second, just because a child has a diagnosis of autism does not automatically imply that the feeding issues are purely behavioral. Consider that feeding mismanagement often starts in infancy long before the autism diagnosis (Gillberg, Nordin & Ehlers, 1996). Finally, global sensory-motor issues can spill over into feeding issues. In Jonathan’s case, his sensitivities to sound, and perseverations clearly were reflected in his eating habits.  For example, sensitivity to sounds in the environment impacted his comfort level and subsequently reduced his food intake.

In clinical practice the speech-language pathologist needs to look at how the child with ASD reacts to touch of the extremities, the face, and oral cavity as well as oral habits such as teeth grinding, mouthing objects, and eating items other than foods (Pica). A diet analysis is needed to assess if the child has intolerances to certain tastes, temperatures and textures. This will establish the child's home base and provide a starting point for diet expansion. The therapist must look at the underlying oral sensory-motor skills to support safe, effective nutritive feeding.

3- Biomedical Treatments:

Biomedical treatments are becoming more popular within the ASD community. Since these treatments often involve the diet, the evaluating and/or treating therapist should also be aware of diet restrictions and supplement therapies with which the client is involved. Many of the clients with whom an SLP comes in contact are now on these specialized diets (Defeat Autism Now, 2013).

The Defeat Autism Now (DAN) protocol believes that human genetics haven’t changed over the years. What has changed are environmental factors, including the increasing number of chemicals to which  we are exposed from pesticides, flame retardants, plasticizers, solvents, personal care products, medicines, artificial sweeteners, and flavors. These varied factors may have an impact on the expression of our genes. This coincides with the theory of epigenetics of ASD, in which it appears that autism often results from a combination of genetic susceptibility and environmental triggers (Haliday, 2014). The way these environmental factors impact one person may be different than the way they are expressed in another person even if two people are related (Magaziner Center for Wellness, 2014). It is believed that many children with autism have a defect in their ability to excrete certain chemicals; therefore, they were more genetically susceptible to chemicals’ effects.

The DAN philosophy is very centered on the gut-brain connection. This theory supports that toxins in the gut can greatly impact the brain and certain substances such as gluten (wheat protein) and casein (milk protein), are triggers that negatively impact functions of the brain and increase undesirable behaviors in children with ASD. Therefore, according to the DAN protocol, gluten and casein should always be removed from the diets of children on the autism spectrum (Bock, 2011). Beyond that, there may be additional foods that the child is sensitive to, that require elimination.

The DAN protocol also involves diagnosis and treatment of the gastrointestinal system, treatment of immune system abnormalities, assessment of possible metabolic and genetic abnormalities, and nutrition treatment (Pangborn & Baker, 2005). Suggestions by DAN Physicians may include:

  • Nutritional supplements including certain vitamins, minerals, amino acids, and essential fatty acids
  • Testing for hidden food allergies and avoidance of allergenic foods
  • Treatment of intestinal bacterial/yeast overgrowth (with pro-biotics, supplements and other non-pharmaceutical medications)
  • Detoxification of heavy metals through chelation, a potentially hazardous medical procedure (Willingham, 2012).

While the DAN protocol is commonly known there other biomedical protocols which may be considered controversial, yet antidotal evidence and parent feedback have raised more awareness of alternative treatment methods in the field of biomedical approaches. For example, Stan Kurtz developed the therapeutic use of Valtrex and methylcobalamin (mB12, methyl B12) that reportedly has helped children with autism when other therapies did not.  Valtrex is related to acyclovir and has shown efficacy against many but not all strains of some herpes viruses, including HSV1, HSV2, and VZV (chickenpox), with lesser degrees of effectiveness against Epstein Barr Virus, HHV6, and possibly Cytomegalovirus. The use of Valtrex is based on the theory that children with autism have high titers of these viruses (Autism Society of Larimer County, 2008).

Dr. Michael Goldberg, an autism specialist, argues that ASD is actually a neuro-immune disorder, as opposed to being a psychological or a genetic one (Goldberg, 2011). His treatment is a five- step process that considers possible stresses on the neuro-immune system including: food intolerances, respiratory allergies, activated viruses, and overgrowths of bacteria or yeast. Step one includes an evaluation and workup. Step two involves allergy testing to assess food intolerances and triggers in the diet. Step three targets immune stressors such as yeast overgrowth. Step four looks at the brain through a Nuero Single Photon-Emission Computed Tomography (NeuroSPECT) scan and considers blood flow and the need for Selective Serotonin Reuptake Inhibitors (SSRIs) to restore the correct balance needed for proper neural functioning. Step five involves rehabilitative therapies to work toward recovery. (Goldberg, 2010-2014).

Nutritional supplements are very much a part of biomedical interventions. While speech-language pathologists should not be taking the lead in these biomedical treatments, professionals in our field may be asked to assist with diet conversion, and supplement administration, as well as for professional opinions on these treatments. It is always important to follow the American Speech-Language Hearing Association (ASHA) Code of Ethics in regard to evidenced-based practices, and to be familiar with the latest research available when becoming involved with biomedical protocols. It is not within the scope of practice of an SLP to offer medical advice. We can however, refer to the appropriate specialist when warranted and present the latest research on this information.

For example, the Nourishlife Speak™ supplemental has been widely controversial amongst biomedical professionals. While originally developed to help apraxia of speech, many parents of children with ASD children started using this supplemental with their non-verbal children. A widely published letter from the Food and Drug Administration cited three issues with Speak™ (Schneeman, 2013):

  • First, the supplement is being marketed as a treatment for childhood speech delays, such as apraxia, without proper approval by the FDA and without proper substantiation.
  • Second, Speak’s labeling contains false and misleading claims and does not have adequate instructions for use or warnings.
  • Third, the amount of vitamin E contained in Speak far exceeds the tolerable upper intake level set by the Food and Nutrition Board, and may be hazardous to the health of children.

Therapists need to be educated on biomedical theories because when families and their physicians are implementing a biomedical protocol, SLPs may need to consider those parameters as part of a feeding program. Biomedical theories support the concept that self-limited diets can be more than just a behavior, because biomedical interventionists look at the whole child and issues with the gut-brain connection. Behaviors, including self-limited diets, are treated holistically and not just with behavior modification (Bock, 2011).

4 - Applied Behavioral Analysis:

Consideration of a child’s sensory-motor and medical issues is necessary; however, Applied Behavioral Analysis (ABA) is very useful. ABA is a method of behavioral intervention developed by Ivan Lovaas PhD and Tristan Smith PhD (Lovaas & Smith 1989; Cure Autism Now, 2005). It consists of teaching skills by breaking them down into small steps, while rewarding the correct responses. It is data driven and quite intensive. ABA is often associated with Discrete Trial Teaching (DTT) which uses instruction-prompt-response-reward to help children with ASD complete complex tasks. The principles of ABA can be successful in feeding therapy sessions (Volkert & M Vaz, 2010), as long as pre-feeding and feeding skills are task analyzed and appropriate food choices are made based on a child’s “home base” (Overland & Merkel-Walsh, 2013). Positive reinforcers, as well as restoring the “joy of eating”, can be automatically reinforcing to a child, if the right food choices are selected to present. Random food choices or advancing textures too quickly can result in negative food experiences. By changing foods by only one element at a time, children can expand their diet slowly and successfully.

An example of this procedure was used in Case Study #2:

Daniel was a three year old male with ASD. When he came to the clinic he was only eating a few select purees. Any progression in taste or texture led to emesis. He was previously assessed by a local feeding clinic, as well as a gastroenterologist and dietician. Modified Barium Swallow Study ruled out dysphagia. Upper endoscopy ruled out esophageal dysfunction, but proved positive for mild gastroesophageal reflux disease (GERD). Blood samples proved positive for a mild dairy allergy, which was thought to be linked to his reflux issues.

The initial assessment revealed that Daniel did not have adequate control of a pureed bolus. When a spoon was presented to the lips, he raked the puree off of the spoon and used tongue protrusion in an immature pattern to swallow the bolus. When the examiner attempted to present that same puree to the lateral margins of his tongue he immediately began to gag and his eyes started to water. He kept repeating the words “all done.” Lateral tongue movements were absent. He was not able to compress a Chewy Tube®. Daniel did not have the pre-feeding skills to handle advanced textures, and previous attempts at feedings resulted in gagging and vomiting. These reactions are now habitual anytime he feels a bolus in an area of the mouth that he feels he cannot clear.

Daniel was placed on an intense pre-feeding therapy plan, working on normalizing the oral cavity beginning with the facial area and working from his lips into his mouth. He learned to tolerate non-food stimulation such as a vibrating therapy tool on the lateral margins of the tongue. Jaw strength, lip closure, and tongue lateralization were target goals.

As his pre-feeding skills improved, his accepted purees were added to his treatment plan. This included: side spoon feeding to improve lip closure and syringe feeding to improve tongue lateralization. In addition pre-feeding mastication programs began with the use of “The Chewing Hierarchy” developed by Lori L. Overland. Daniel began to improve jaw strength and developed a munch chew.

Daniel’s ABA therapist helped with the success of the therapy sessions. He was placed on a fixed ratio reinforcement schedule to increase positive behaviors. First, Daniel received reinforcement for every attempt at a sensory-motor task, or with the acceptance of the pureed food. As time progressed and his refusals decreased, Daniel could work with the therapist for longer intervals. If Daniel refused the task, he was ignored for 5 seconds, and then the task was represented with the positive reinforcer present. He usually chose small figurines to hold, or timed breaks with the iPad.

As his sensory-motor skills for feeding improved, Daniel’s anxiety surrounding feedings started to lessen. He was open to the acceptance of a variety of pureed foods and started to accept crushed cookies and crackers in his mouth with a Zvibe, a vibrating oral-sensory tool. The activities themselves became rewarding, and he needed less tangible reinforcers throughout the sessions. He started to accept the combination of textures and various flavors, which eventually led to tasting small bites of easy to melt solids such as Gerber® Puffs, cheese puffs, toddler snacks and small pieces of canned fruit. He is currently working on accepting more solids into the diet.

Daniel’s case study is just one example of sensory- based diet shaping, within an ABA context. Diet-shaping requires the therapist to look at temperature, texture and taste. Changing these elements in regimented, sequential steps may expand the diet. In addition following an ABA program, on a fixed ratio schedule, can also help with progress (Brophy, 2013).

To properly utilize diet-shaping in an ABA context, the therapist should be careful to only change one element at a time. For example, by chilling or freezing fruits, the textures also changes. By mixing foods together, the therapist is changing taste and texture simultaneously and this may be too much for a child with ASD to handle. Many parents will try to “hide” a new food in a preferred food only to find that this causes a major regression in a child’s diet. Children with sensory processing issues can be quite sensitive, and will not be easily fooled by trying to “disguise” new foods.

The following are examples of diet shaping:


Home base

One change

Suggested change

New Food

Mac and cheese

Taste

Add new shredded cheese to recipe

Variety of mac and cheese flavors

Peanut butter

Texture

Buy chunky variety

Chunky peanut butter

Taste

almond

Almond butter

Temperature

Freeze

Peanut butter “ball”

Bread

Texture

Toast it

Crunchy bread

Taste

Add hummus

Bread with hummus

Taste

Add olive oil spread

Bread dipped in a good fat

Taste

Pan fry with egg and butter

French toast

Chicken nuggets

Texture

Oven bake as opposed to fry

Same item new texture

Taste

Dip in mayo add fat/calories same item new flavor

 

Texture

Make with panko bread crumbs

Accept new type of nugget

Leg of chicken

Texture

Broil chicken

Crispier skin, if he will eat adds fat

Taste

Stew in red sauce

Try and add pasta  to the meal as well

French fries

Taste

Use yams or sweet potatoes

Sweet potato fries

Juice

Taste

Use mango nectar and other orange colored juices

Mango nectar
Peach nectar

Texture

Blend with ice+ Greek yogurt for protein

Smoothie

In contrast to diet-shaping, purely behavioral feeding programs use preferred foods, toys, books, or television to reinforce children for eating challenging foods. They do not account for the sensory and motor challenges children may be experiencing. Behavioral components may be essential in a feeding program; however, they should be implemented in conjunction with a sensory-motor approach to provide the most positive outcomes (Roche, Eicher, Martorana, Berkowitz, Petronchak, Dzioba & Vitello, 2011). For example as suggested by Volkert & M Vaz (2010) and Addison, Piazza & Patel (2012), when a child tries a new food and accepts it the child should be praised and reinforced with tangibles. In contrast when a child has a negative reaction to food, it is best to ignore this behavior so it is not inadvertently reinforced.  Since behaviors never occur without reason, feeding therapy must consider that both positive and negative reinforcers can cause a behavior to reoccur (Brophy, 2013).

 

For example, Case Study #3:

Emmett is 3 years old with ASD. He is labeled a very “picky eater” by parent description. The parents also reported that Emmett seemed to avoid eating to “get a rise out of people.” At mealtime he would smash food on the table, throw it on the floor, pocket foods, and refuse to eat. The parents often would yell, bribe him with candy and/or leave him sitting at the table for hours.  Sometimes he was missing his home- based Early Intervention sessions, because his parents would not let him leave the table without eating.

Emmett’s parents actually reinforced his feeding problems by letting him escape work. He also knew if he held out from eating, he would eventually be awarded with candy. In a thorough assessment it was also revealed that he has some mild sensory-motor weaknesses that were impacting bolus management.

The best course of action in Emmett’s case was to work on oral sensory-motor goals and reinforce his feeding positively with tokens and his favorite TV shows as opposed to edibles. The therapist also made sure all of his foods were cut into small foods and placed with a small fork to the back molar to help improve mastication and motility. A timer was set for meals and if he did not eat he had to work and return to the same meal when the therapy was completed. Over time his negative relationship with food decreased and his intake also improved.

SUMMARY:

In summary, children on the Autism Spectrum can often have sensory processing issues and oral sensory-motor deficits that lead to self-limited diets. It is rare that food refusals stem from a purely behavioral etiology. Careful evaluation of the sensory-motor system along with medical history is crucial in successfully treating self-limited diets. Biomedical theories are now more mainstreamed and may be integrated into a feeding program. Applied Behavioral Analysis can be a very useful model for executing the therapy plan; however, the choice of foods selected to be goals for the child must be based on their flavor, texture and temperature preferences to have successful therapeutic outcomes. The principles of “diet shaping” are multifaceted and ever changing based on clinical evidence, current research and anecdotal data. The speech-language pathologist leading a feeding program for a child with ASD must be versed on a variety of treatment methodologies.

 

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Please cite this article as:

Merkel-Walsh, R., & Overland, L.L.. (2016). Self-Limited Diets in Children with a Diagnosis of Autism Spectrum Disorder. Oral Motor Institute, 5(1). Available from www.oralmotorinstitute.org.

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