Selective eating in children

with autism
Gillian Harris, Phd.
Consultant Clinical Psychologist
The Children’s Hospital
Birmingham
 The selective eating behaviour of
children with ASD is observed in
children and adults in the normally
developing population; it is a function
of traits that individuals have in
common rather than specific to a
diagnosis.
 No agreement about what this eating
disorder should be called;

 Selective eating
 Perseverant eating disorder
 Fussy eating
 Sensory eating disorder
 Avoidant eating
DSM V

 New definitions under discussion:-

 Will possibly be called:-

avoidant/ restrictive food intake
disorder. DSM V.

There is, as yet, no standard method

of assessment.
Sub –classifications:-

 No interest in food
 Sensory based avoidance
 Fear based avoidance

Manifest by a persistent failure to

meet appropriate
nutritional/energy needs
 Normal eating development

Infants learn to like the foods that

they are given as a function of
exposure.

 They learn to like the tastes,

 then cope with the textures,
 then recognise the way a food looks

- in the first year of life.

 Foods that are not seen as safe
to eat –and are therefore not
recognised as known foods – can
trigger a disgust response as
early as 18 months old.
 The neophobic stage occurs in all
children at around 20 months of age.

 Food is rejected on sight because

there is a perceptual mismatch
between known foods and new foods
- Or between known foods with a
slightly different presentation
 During the neophobic stage children
attend to local features of foods –

 the writing on the biscuit, the colour of

the toast –

rather than to global features-

 that is a biscuit and is therefore like

other biscuits
 Children grow out of the neophobic
period over the next three years.

 Few children show the neophobic

response at the age of 5 years.

 As they grow out of this stage, they

usually imitate other children’s
eating behaviour and attend more to
global aspects of foods rather than
local detail.
Some children, mainly boys, from the
age of 18 months show extreme
neophobia.

This strong neophobic response is

maintained throughout childhood.
 This response to food is nearly
always seen in boys with strong
cross-modal sensory hypersensitivity.
It is also frequently seen in children
who are on the autistic spectrum.

 These children identify the foods that

they will eat by visual cues, or by
smell.
 Our group of children referred to the
feeding clinic with this problem are:-

 highly neophobic (fear of new foods)

 high on state anxiety
 high on sensory hypersensitivity,
 likely to get a diagnosis of ASD, or
have traits in common with children
with ASD.
 Generally tend to:-
 Dislike having their teeth cleaned
 Get their hands or face dirty
 Dislike getting clothes dirty
 Touch certain substances
This indicates tactile hypersensitivity.

Usually show hypersensitivity to smell,

and noise.
May show hyposensitivity to pain and
temperature.
Children with autism with this style of
eating - when assessed in a small
study – showed differences in local
versus global processing.

This suggests differences in visual

processing may be present.
 Onset of feeding problem
 18 months – visual hypersensitivity,
and onset of neophobia.
 6 months –introduction of solid food
–tactile hypersensitivity within the
mouth.
 4 months – introduction of pureed
foods- hypersensitivity of taste and
smell.
 Eating behaviour of avoidant eaters:-

 will only eat very few foods (range 5-

10).
 extreme anxiety if asked to eat non-
accepted foods.

Extreme neophobic response and

perceptual mismatch.
Often will :-

 only eat specific brands of foods

 only eat one flavour of an accepted
food

Sensory hypersensitivity.
Importance of visual appearance
 The packaging predicts the
sensory qualities and the safety
of the food.
Will not eat accepted food if:-

 over or undercooked (different

colour)
 broken
 marked /burnt

Perceptual mismatch -> neophobic

response
Will not eat foods that are:-

 touching one another

 liked foods if they are combined, (e.g
sandwich)

Strong contamination/disgust
response, perceptual mismatch.
Shows disgust at:-

 smell or -
 sight of non accepted foods,
 others eating non-accepted foods.

Strong neophobic response

Shows:-

 refusal to eat food with lumps in it.

 preference for pureed, or bite and
dissolve foods.
 difficulty chewing at the side of the
mouth.
 rarely – refusal to drink.

Sensory hypersensitivity.
Example diet
Breakfast:- two slices of toast and flora
(no crusts cut into triangles, even brown colour)

Mid-morning - Walkers plain crisps

Lunch - dry bread roll, Walkers plain crisps, Kit-kat (two

fingers,
Ribena in carton (must be tooth friendly)

Evening meal – four Birds Eye fish fingers

Seven Birds eye Alphabites (not burnt)
Pepsi-cola (not diet)

Supper - small tub plain Pringles, Kit-kat (two fingers)

Ribena in carton
 Food eaten tends to be beige, dry,
carbohydrate (safe textures) :-

 Bread toast,
 Dry cereal
 Crisps
 Biscuits
 Fish fingers
 Potato shapes
Plus milk chocolate bars or buttons, and
yoghurt (no lumps)
There is often routine about eating:-

 a certain number of fish fingers

 specific containers which must be
sealed in a certain way
 an arrangement of food on the plate
 an order of eating
 sometimes a method of eating might
be avoided e.g feeding self with
spoon.
 Because these children are highly
anxious, strongly neophobic,
hypersensitive and on the spectrum,
they are less likely to:-

 imitate others eating,

 allow exposure to new foods,
 generalise their food categories.
 Feeding history prior to 18-24
months normal?
 Sensory hypersensitivity?
 Attention to visual detail? e.g.
◦ Notices black mark on crisp
◦ Changes to packaging
 Check height & weight
 Presence of neophobic/disgust &
contamination responses?
 Problems with eating out/at school?
 Difficulties with changes in routine?

Assessment questions
Energy intake must be the first priority.

Dietary balance must take second place.

Children with this eating problem will

regulate their intake to accord with their
needs if given their preferred foods.

If weight is faltering –
Give only the foods that they will eat.

Intervention
 Desensitize

 Encourage category generalisation –

‘spreading the sets’

 Taste trials

 Introduce new foods in new contexts

 Relaxation

 Reduce parental & ‘social’ anxiety.

Intervention ideas
In a young child;

Encourage and promote general

desensitization, such as messy play,
and specific oral desensitization,
textured spoon, allowing fingers in at
side of mouth.

Desensitize
 Expand the child’s range of food by
introducing new foods from accepted
categories, e.g. a new flavour of a known
brand
 Offer small portions of new food frequently

 Allow time for child to desensitise to

smell/taste of new food
 Clinically effective with children across the
spectrum

Category generalisation –
‘spreading the sets’
 Not usually effective until after the age of 8
years.
 Child has to be motivated.
 Combine with relaxation.
 Set time and place.
 Rewards can be used.
 Child records reaction to food with repeated
tastes.
 Can be linked to dietary ‘rules’.
 Use cognitive behaviour therapy.

Taste trials (most effective with

children with Asperger’s Syndrome).
 Children with ASD may try new foods in a
new context e.g. school

 Often less confusing than changing foods

within a familiar context

 Less successful for avoidant children with

diagnosis or traits of Asperger’s Syndrome

 Children with Autism may often try a new

food for a liked teacher.

New foods in new contexts

 Different types of relaxation
technique e.g.

Breathing methods
Progressive muscle relaxation
Imagery & visualisation
n o . o f n e w fo o d s trie d p re a n d p o s t in te rv e n tio n

A recent trial 4 .5
4
showed an 3 .5
3
increase in number m e a n n o . o f 2 .5
fo o d s tri e d 2
c lin ic al
c o ntro l
of new foods tried 1 .5
1
0 .5
0
p re-inte rve nt ion po s t-inte rve nt ion

Relaxation - practice
 Re-assure that child will grow well on
limited diet!
 Help with school healthy eating
programmes!

Reduce parental anxiety:-

What doesn’t work

1) Force feeding, extreme coercion.

This increases child’s anxiety around

food – and this food may be avoided
even when others are accepted.
It may also lead to vomiting, and
weight loss.
2) Trickery and disguise:-

 Putting disliked foods on to the plate

next to liked foods.
 Hiding food or medicines in drink.
 Putting new foods into containers of
accepted foods.

Triggers disgust response – may lead

to loss of foods already eaten.
3) Star charts and reward systems:-

 Will only work when the child is

motivated to move on and is willing
to try tasting foods (taste trials).
4) Imitating other children:-

 Eating pattern will not change at

nursery or school when exposed to
other children.
Food avoidance caused by:-

 Extreme disgust and extreme fear of

new foods,
 Hypersensory sensitivity and high
arousal levels,
 Hypervigilance to changes in foods,
 Extreme desire for sameness,
 Inability to extend food categories
where anxiety is high.