Mealtime Challenges Mealtime Challenges and the Autism and the Autism Spectrum Spectrum Marsha Dunn Klein MED Marsha Dunn Klein MED OTR/L OTR/L Mealtime Connections, LLC, Tucson AZ Mealtime Connections, LLC, Tucson AZ Mealtime Notions, LLC, Tucson AZ Mealtime Notions, LLC, Tucson AZ www.mealtimeconnections.com www.mealtimenotions.com www.mealtimenotions.com
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Mealtime Challenges and the Autism Spectrum Marsha Dunn Klein MED OTR/L Mealtime Connections, LLC, Tucson AZ Mealtime Notions, LLC, Tucson AZ .
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Mealtime Challenges and Mealtime Challenges and the Autism Spectrumthe Autism Spectrum
Marsha Dunn Klein MED Marsha Dunn Klein MED OTR/LOTR/L
Mealtime Connections, LLC, Tucson AZMealtime Connections, LLC, Tucson AZ
All about All about sseennssoorry y All about social & All about social & communicationcommunication All about All about ttrraannssiittiioonn
Autism SpectrumAutism Spectrum
All about All about sseennssoorryy All about social and All about social and communicationcommunication All about All about ttrraannssiittiioonn
And ORDER….And ORDER….SamenessSameness
DSM IV Diagnostic Criteria Autism DSM IV Diagnostic Criteria Autism DisorderDisorder
• Qualitative impairment in Qualitative impairment in social social interactioninteraction
• Qualitative impairments in Qualitative impairments in communicationcommunication
• Restricted Restricted repetitive and stereotyped repetitive and stereotyped patterns of behavior, interests and patterns of behavior, interests and activitiesactivities
• Inflexible adherence to specific, Inflexible adherence to specific, nonfunctional routines or ritualsnonfunctional routines or rituals
Feeding Issues Commonly Feeding Issues Commonly Associated with ASDAssociated with ASD
Developmental Disabilities Williams et al Developmental Disabilities Williams et al 20082008
Feeding Issues Commonly Feeding Issues Commonly Associated with ASDAssociated with ASD
• Social Skill DeficitsSocial Skill Deficits– Poor response for following directionsPoor response for following directions– Less imitationLess imitation
• Communication Skill ChallengesCommunication Skill Challenges• Difficulty Transition and Novel SituationsDifficulty Transition and Novel Situations
Developmental Disabilities, Williams et al 2008Developmental Disabilities, Williams et al 2008
Eating Habits of Children with AutismEating Habits of Children with AutismWilliams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259,
6p6p
• 344 parent questionnaires344 parent questionnaires• Reported factors that influenced food Reported factors that influenced food
• 37% Relationship between eating and 37% Relationship between eating and behaviorbehavior
Eating Habits of Children with AutismEating Habits of Children with AutismWilliams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3,
p259, 6pp259, 6p
• Largest challenges Largest challenges (by parent report)(by parent report)
– Trying new foods 69%Trying new foods 69%– Taking medicine 62% Taking medicine 62% – Eating new foods 60%Eating new foods 60%– Mouthing objects 56%Mouthing objects 56%
Eating Habits of Children with Eating Habits of Children with AutismAutism
Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6pIssue 3, p259, 6p
• Social AspectsSocial Aspects– Situations and people influence eating 35.5%Situations and people influence eating 35.5%– Child ate differently in different settings 41%Child ate differently in different settings 41%– Fewer reported frequenting fancy Fewer reported frequenting fancy
restaurantsrestaurants– 87% drive through restaurant87% drive through restaurant
• Degree FrustrationDegree Frustration– 13% Upset a great deal of the time13% Upset a great deal of the time– 19% Easy going19% Easy going– 68% Upset with reason68% Upset with reason
Moderately u
Eating Habits of Children with Eating Habits of Children with AutismAutism
Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. Williams, P. et al, Pediatric Nursing; May/Jun 2000, Vol. 26 Issue 3, p259, 6p26 Issue 3, p259, 6p
67% Described child as picky eater67% Described child as picky eater
73% Good appetite for foods they liked73% Good appetite for foods they liked
6% Reported poor appetite for most foods6% Reported poor appetite for most foods
19% Good appetite for most foods19% Good appetite for most foods
97% Not picky more often described as good 97% Not picky more often described as good nutritionnutrition
69% Not trying new69% Not trying new
Picky eaters equally divided between adequate Picky eaters equally divided between adequate and inadequate nutrition.and inadequate nutrition.Moderately u
Parent Challenges Parent Challenges
• Picky eating?Picky eating?• CanCan’’t change the t change the
menu, texture?menu, texture?• Unable to eat Unable to eat
with family?with family?• Poorly balanced Poorly balanced
diet?diet?• Huge emotional Huge emotional
impactimpact
• CanCan’’t change t change environment?environment?
• Doctor not Doctor not concerned?concerned?
• Family/friends Family/friends do not do not ““get itget it””??
• Choices are not Choices are not logicallogical
• Isolation?Isolation?
Child ChallengesChild Challenges
• Poor nutritionPoor nutrition• High stress and High stress and
anxietyanxiety• Difficult Difficult
transitioning to transitioning to mealsmeals
• Highly Highly suspicious of suspicious of changechange
• No mealtime No mealtime enjoymentenjoyment
• Skill deficitsSkill deficits
Food ListFood List
• Safe FoodsSafe Foods• Sometimes FoodsSometimes Foods• Used to foodsUsed to foods• Never/no way foodsNever/no way foods
• Personal logicPersonal logic• Change is very difficultChange is very difficult
Common parent solutionsCommon parent solutions
• Offer the same foods in the same Offer the same foods in the same way in the same environment with way in the same environment with the same brands so as not to create the same brands so as not to create mealtime stressmealtime stress
““BehavioralBehavioral””• Schreck et al. (2004) Schreck et al. (2004) ““Separation of Separation of
physiological aspects of feeding physiological aspects of feeding difficulty from behavioral aspects is difficulty from behavioral aspects is especially difficult in ASD because especially difficult in ASD because physiologically based difficulties in this physiologically based difficulties in this population are often subtle and difficult population are often subtle and difficult to pinpoint, and to pinpoint, and ““behavioralbehavioral”” difficulties difficulties are not always behavioral (i.e., willful or are not always behavioral (i.e., willful or volitional acts of noncompliance), but volitional acts of noncompliance), but rather a reflection of the characteristics rather a reflection of the characteristics and symptoms of this multifaceted and symptoms of this multifaceted disorder.disorder.””
Research is beginning to define the Research is beginning to define the complex pattern of neuro- biological complex pattern of neuro- biological
differences that characterize ASD as well differences that characterize ASD as well as its influence on behavior. as its influence on behavior. (Just, Cherkassky, (Just, Cherkassky,
““At a basic level, this research has con- At a basic level, this research has con- firmed that the atypical behavior that is firmed that the atypical behavior that is exhibited by people with ASD is a direct exhibited by people with ASD is a direct result of neurobiological differences.result of neurobiological differences.””
• Neophobia…Neophobia…’’Fear of the newFear of the new””– Neo- Neo- ““NewNew””– Phobia- Phobia- ““Irrational FearIrrational Fear””
• Irrational Fear of Food Irrational Fear of Food • Common for two year olds. Common for two year olds.
• ““When two year olds were given When two year olds were given varying numbers of opportunities to varying numbers of opportunities to consume new foods their consume new foods their preferences increased with preferences increased with frequency of exposure.frequency of exposure.””
• 5-10 Exposures to a new food 5-10 Exposures to a new food necessary to increase preference for necessary to increase preference for it it (Birch, LL, McPhee L, Shoba, BC, Pirok, E., (Birch, LL, McPhee L, Shoba, BC, Pirok, E., Steinberg, L., 1987 What kind of exposure reduces Steinberg, L., 1987 What kind of exposure reduces childrenchildren’’s food neophobia? Appetite 9:171-78)s food neophobia? Appetite 9:171-78)
• Neophobia changes during Neophobia changes during development. Evidence for familial development. Evidence for familial similaritiessimilarities
• Linked to other temperament and Linked to other temperament and personality characteristicspersonality characteristics
• Mothers who were more neophobic Mothers who were more neophobic food environment with new and food environment with new and presented uncommon foods less presented uncommon foods less frequently. (frequently. (Hursti and Sjoden 1997, Food and Hursti and Sjoden 1997, Food and General Neophobia and thei relaionship with self General Neophobia and thei relaionship with self reported food choice, Appetite 29, 89-103)reported food choice, Appetite 29, 89-103)
Olfactory Memory Olfactory Memory
• Nature of Olfactory Nature of Olfactory systemsystem
• AlertingAlerting• AccommodationAccommodation• Limbic SystemLimbic System• EmotionsEmotions• Memory and Memory and
memory storagememory storage
Where to focus?Where to focus?
• Diet..............?Diet..............?• Sensory………………..?Sensory………………..?• Oral Motor…………………..?Oral Motor…………………..?• Behavior……………………………?Behavior……………………………?• Rituals, Fear, Anxiety, OCD………..?Rituals, Fear, Anxiety, OCD………..?• A A
Various Treatment ComponentsVarious Treatment Components
• Oral MotorOral Motor• SensorySensory• Applied Behavioral AnalysisApplied Behavioral Analysis• Behavioral TherapyBehavioral Therapy• Nutrition/DietNutrition/Diet• ““PhobiaPhobia”” support support• DesensitizationDesensitization• Exposure TherapyExposure Therapy• Individual work with childIndividual work with child• Family workFamily work• TeamTeam
Life Long Learning SkillsLife Long Learning Skills
• People eat things you do notPeople eat things you do not• Be at the table (in the same room?) Be at the table (in the same room?)
with others who eatwith others who eat• Balance the diet (vitamins, new food Balance the diet (vitamins, new food
groups)groups)• Discover how to try a Discover how to try a ““NewNew”” food food• Learn how to refuse an offer politelyLearn how to refuse an offer politely
Motility Motility • Brain-Gut Connection (Brain-Gut Connection (The Second The Second
BrainBrain, Michael Gershon), Michael Gershon)• Fight /Flight does not work well with Fight /Flight does not work well with
digestiondigestion
Mealtime PeaceMealtime Peace
• Start with peaceful and tip toe Start with peaceful and tip toe towards new experiences so as towards new experiences so as not to disrupt the whole family.not to disrupt the whole family.
• New food trying time may New food trying time may need to be NOT a family meal need to be NOT a family meal to start.to start.
Change HappensChange Happens
• Rigidity, ritual and routine is commonRigidity, ritual and routine is common• For peace, we reinforce For peace, we reinforce
that…..become routine that…..become routine ““enablersenablers””• Eating can become comfortable if Eating can become comfortable if
child knows exactly what is next. child knows exactly what is next. • Child needs to learn that change Child needs to learn that change
happens at mealtimes and they can happens at mealtimes and they can deal with it. deal with it.
Change ContinuumChange Continuum
• Start with safe and less emotional Start with safe and less emotional parts of the meal.parts of the meal.
• Start with change that does not Start with change that does not effect the entire diet effect the entire diet
• Tip toe towards changeTip toe towards change• At mealtime or non mealtime?At mealtime or non mealtime?
• TableclothsTablecloths• WhereWhere• Food shapes or Food shapes or
sizessizes• NapkinsNapkins• Containers Containers
An important CHANGE goalAn important CHANGE goal
• GraduallyGradually eliminate eliminate PACKAGING and Brand PACKAGING and Brand specific presentations. specific presentations. (or avoid it (or avoid it from the start)from the start)
Sample Change Sample Change SequencesSequences
• Cup……sticker to color to shape?Cup……sticker to color to shape?• Waffle…….Strip off edge, strips, Waffle…….Strip off edge, strips,
Rectangles…..Squares….bite Rectangles…..Squares….bite size…….or even triangles. size…….or even triangles.
• Favorite foods in Favorite foods in containers………containers………
Multiple ExposuresMultiple Exposures
• Safe Pretend Food or Non Real Food Safe Pretend Food or Non Real Food InteractionsInteractions– Looking at pictures of foodLooking at pictures of food– Reading books about food and eatingReading books about food and eating– Play with plastic foodsPlay with plastic foods– Matching food picturesMatching food pictures– Watch video about food Watch video about food (www.Cosmeo.com)(www.Cosmeo.com)
Help put food in grocery cartHelp put food in grocery cart
Help put away groceriesHelp put away groceries
Multiple Exposures #3Multiple Exposures #3
• Non-Eating Real Food InteractionsNon-Eating Real Food Interactions– Food PreparationsFood Preparations– Serving foods to others with spoons, Serving foods to others with spoons,
tongs, forks, fingerstongs, forks, fingers– Cooking and clean upCooking and clean up– Incorporating food into playIncorporating food into play– Incorporating food into pre-academicsIncorporating food into pre-academics
Mealtime Jobs Mealtime Jobs
• Menu plannerMenu planner• Grocery shopperGrocery shopper• Grocery Grocery ““put put
In the same room?In the same room?At the same tableAt the same table
Near the plateNear the plateServing/ Helping prepareServing/ Helping prepare
On the plate On the plate SmellingSmelling
Touching hands/mouth Touching hands/mouthHanding to othersHanding to others
LickingLickingTry and spit outTry and spit out
Mousebites Mousebites Eat someEat some
Juice Stretch
• Juice• Different cup…..straw?• Ice cube acceptance• Colored ice cubes?• Flavored ice cubes from dilute to
concentrated• Nectars to purees/yogurt?• Popsicle??
New Food ExposureNew Food Exposure
• Looking Dish Looking Dish (K. Toomey)(K. Toomey) • Tasting dishTasting dish• Divided platesDivided plates• Present the foodPresent the food• Teach child to remove it if necessaryTeach child to remove it if necessary•
Picking New FoodsPicking New Foods
Is the new food worth the effort??Is the new food worth the effort?? • • Nutritional value?Nutritional value?• • Food Group? Food Group? • • Dairy? Gluten?Dairy? Gluten?• • Careful with current dietCareful with current diet
Reintroduce previously rejected or Reintroduce previously rejected or previously enjoyed foods.previously enjoyed foods.
Compare various food qualitiesCompare various food qualities
Chart sames and differentsChart sames and differents
Foods that float/sinkFoods that float/sink
Mixing food colorsMixing food colors
Designing with foods Designing with foods (Colorforms)(Colorforms)
MeasuringMeasuring
Photo BooksPhoto Books
• Kiss BookKiss Book• Lick BookLick Book• Noisy Lick Book Noisy Lick Book • Mousebite bookMousebite book
Food SelectionFood Selection
• Similarity to preferred?Similarity to preferred?• Stretch from preferredStretch from preferred• Minute changes (add to familiar)Minute changes (add to familiar)• Safe Skill trainingSafe Skill training• Nutrition groupNutrition group• Repetition then KEEP it in the food Repetition then KEEP it in the food
rotation so as not to lose it.rotation so as not to lose it.
Ways to Support FamiliesWays to Support Families
• Parent Support GroupParent Support Group• Issues unique to ASDIssues unique to ASD
• Team Discussions (Combine input Team Discussions (Combine input from dietitians, psychologists/ABA, from dietitians, psychologists/ABA, sensory therapists, speech, MD, sensory therapists, speech, MD, with parents as the center!)with parents as the center!)
• Way of lifeWay of life• Direct therapeutic supportDirect therapeutic support• Combine with direct ABA Combine with direct ABA
Team WorkTeam Work
The The ““Just Right Just Right ChallengeChallenge””….….B. B.