Practical Strategiesfor Feeding Aversions inChildren with AutismA special creation for you from the team ofSpeech and Occupational Therapists atAll About Speech & Language

For adults and childrenalike, mealtimes are knownto provide rich sensoryexperiences, full of various smells,sounds, tastes, temperatures,textures, and interactions withothers.Mealtimes can be very pleasantand fun experiences when sensoryprocessing is going well. However, formany of our children with Autism,significant sensory challenges are oftenexperienced including heightenedsensitivities or sensory overload whichturn mealtimes into very stressfulexperiences. Furthermore, difficultieswith communication (verbal andnonverbal) and focus of attention poseadditional challenges for a child withAutism and their parent at mealtime.As a way of coping with the sensoryand communication stresses associatedwith mealtimes, often our children withAutism develop strategies that mayinclude trying to limit sensory inputor withdrawing from the social andcommunicative demands of the meal by:being overly selective in their selectionof foods/textures, becoming inflexible ortrying to control the mealtime routine,refusing to eat or eating limited amountsso as to reduce the number of transitionswith which they must cope, escaping thesituation, covering ears or closing eyes,or repetitive/stereotypic behaviors tohelp manage this perceived “chaos”. It isno wonder that this mealtime stress andinflexibility causes concern for parentswho are working hard to ensure theirchild has a well-balanced and nutritionaldiet. Forcing your child to suddenlychange his eating patterns or to eatspecific foods doesn’t help him to learnto eat and enjoy meals but rather createsadded stress to an already stressfulexperience. As a busy parent jugglingmany different roles and responsibilities,we hope that this resource helps toequip you with more manageable stepsand at-home strategies for expandingyour child’s food inventory and breakingthe cycle of feeding aversions.Elements of Feeding:There are a variety of motor, cognitive,and speech and language milestonesthat go hand-in-hand with feedingdevelopment. While these will not beoutlined specifically, if you do haveconcerns about your child’s generaldevelopment, please seek furtherassistance from your child’s physicianwho may provide a needed referralto an Occupational and/or SpeechLanguage Therapist. Assessments inthese areas, and referrals made to othermedical professionals (i.e. nutritionist,or ABA therapist for behavioral feedingsupport), can assist your child acrosshis/her development in order to makesure he is growing and achieving theappropriate developmental milestones!It is important to understand thevarious components of feeding in orderto identify any stages your child maybe having trouble with that could beaffecting their appropriate intake offood. These elements include:Oral-Motor Componentsof Feeding:The lips, jaw, teeth, tongue, along withcertain reflexes, sucking/clearing, andswallowing are all vital parts of yourchild’s ability to sustain proper feeding.Stages of Swallowing:There are 4 stages of swallowingwhich are important for successfulfeeding, in which a child, or adult,may have impairment. Again, iffeeding difficulties are suspected, pleaseseek assessment from an appropriatemedical professional.Feeding Development:Just like all areas of development, frominfancy through childhood, childrengrow in their ability to eat a variety offoods and drink liquids. In early stagesof toddlerhood it is quite commonfor children to demonstrate strongpreferences and dislikes for certaintastes and textures. By two years old,toddlers are typically able to tolerateall food textures (chewy, crunchy, soft,pureed), and eat foods from all foodgroups. During this time, childrenshould also be demonstrating the abilityto use a spoon and fork, drink from aregular cup, and finger feed themselvesindependently. If a child over the ageof 2 years old is not meeting thesemilestones, he/she may benefit fromoccupational therapy evaluation toidentify underlying concerns.Signs of a Possible Feeding/Swallowing Disorder:Presented below are some signs thatyour child may be struggling withspecific feeding related issues. If youhave these concerns, it is importantto get your child assessed by theappropriate medical professional (i.e.a Speech-Language Pathologist whospecializes in swallowing/feeding).This will confirm or rule out if thereis an impairment contributing tothe feeding issues as a whole or ifthe difficulty is more sensory orbehavioral in nature (best addressedby an occupational therapist or ABAtherapist, respectively). There could bea larger problem at hand that may bestbe addressed by a trained professional,who can then guide you in the bestplan for management.Some of the more critical signs andsymptoms to take note of include: Refusing to eat (i.e. in general orcertain foods/textures), spittingout food, or taking a long time toeat a small amount of food (typicalmeals should take no more than15-20 minutes) Frequent coughing, throatclearing, gagging, and/or chokingwhile eating Excessive drooling Pocketing food in the cheeks Trouble to coordinate chewingand swallowing resulting in foodleaking from the mouth Vomiting and/or spitting up largeamounts after eating An overall “wet sounding” voice orcry after eating Concerns with meeting appropriaterate of growth (height to weightcomparisons given a child’s age) Your child may demonstrate amotor-planning deficit whichcan add to mealtime frustrationsif coordinating chewing andswallowing is a struggle orunderstanding how to make theirhands work for scooping food andfeeding themselves.

Practical Strategies toTry At-Home:After we rule-out or begin to manageany underlying difficulties or trueimpairments in the structures andfeeding process as a whole, then variousstrategies can be used in the home withgreater success to shape positive feedingexperiences and behaviors. Describedbelow are three strategies that haveproven to aid the introduction andacceptance of new foods. If yourchild is struggling during mealtimewith his/her ability to tolerate new orvaried foods, these strategies would bebeneficial for you to incorporate intoyour routine.3 Strategies forAt-Home Support:1. Pairing Preferred andNon-preferred Foods witha Token System:Positive reinforcement can beincredibly powerful in helping toreduce negative behaviors associatedwith mealtimes. When using positivereinforcement, it is key to praisepositive behaviors and ignore negativebehaviors. Positive reinforcementmay include verbal praises, clapping,continued interaction with you, and/or immediately receiving a preferreditem or other motivating tangiblewhen a child completes what is desired.This focus on acknowledging andreinforcing only the desired behaviorwill slowly begin to extinguishundesired behaviors and teach yourchild a new action or behavior.To get started, select a nonpreferred food item that isdevelopmentally appropriate andsimilar to a food already in yourchild’s inventory. This will be yourintroductory item.As your child attempts or completesa desired behavior with this nonpreferred food item (see list of possiblebehaviors under “Desensitization”section, with the goal of workingtoward eating the item), immediatelyreward their attempt with a preferredfood. Over time, this pairing of nonpreferred foods immediately followedby a preferred reinforcer will leadto increased acceptance of the nonpreferred item.Positive reinforcement may alsoinclude using this token systempaired with a visual behavior chart,which can help your child see and worktoward a goal. For example, after eachsuccessful “pair” of accepting the nonpreferred and receiving the preferreditems, he may earn one smiley face orsticker on a visual behavior chart of 3boxes. After 3 successful trials or “pairs”are completed, and 3 smiley facesearned on his behavior chart, he mayearn an even larger reinforcer such asplaying with a preferred toy. Alternatethese cycles of pairings, graduallyincreasing the number of targetattempts and fading the reinforcementschedule (i.e. the child may now beexpected to take 2 separate bites, thenwork up toward 3 separate bites beforea reinforcer is provided. Or, perhapsyou may increase the number of overalltrials to be completed on the behaviorchart before a final motivating rewardis provided).Pairing a preferred food or drinkin between tastes of a new or nonpreferred food item may help to reducethe aftertaste that many problem eatersfind to be aversive. Overtime, less bitesor sips of the preferred item are providedas the new food item becomes accepted.Remember, have patience and don’tgive up your efforts; it may take onaverage at least 10 exposures to a newfood paired with positive reinforcementbefore the child will accept the food ona consistent basis!When using positive reinforcement, it is key to praisepositive behaviors and ignore negative behaviors.

2. DesensitizationDesensitization is the process by whichchildren are slowly and graduallyintroduced to new and/or nonpreferred food items, with the goal ofexpanding the child’s food repertoirethrough decreased defensiveness andincreased tolerance. This progressiontakes place through repetition, rewards,and engagement. Follow the stepsbelow to help desensitize your child toa new food:Make lists of the foods and drinksyour child will tolerate and foodsyou would like him/her to eat. Youcan organize foods by categories aswell as by properties of the food (i.e.texture, size, color etc.). Select a “new”food item to begin the desensitizationprocess; an item that is closely relatedwith slight variations will have themost success at first (i.e. if your childalready eats yogurt, consider puddingas a food to begin desensitizing to).Begin desensitizing to foods at timesother than main “mealtimes,” forexample during play, snack time, orwithin therapy sessions if your childreceives support services. Perhaps youmay play with toy food, feed it to dollsduring pretend play, or cut out picturesof the food item from magazines. Thesefun experiences will help your childgradually view this item in a nonthreatening way.If the item is wrapped in specificpackaging, work to have your childgradually grow comfortable looking at,touching, holding, or even just opening/unwrapping the item. Eventually, whenworking to have your child toleratetouching this new food, use cookiecutters to explore the new food item,count or sort the food, or finally use theitem to “paint” or create art with.When the food item has becomeincreasingly familiar and tolerated inplay, start by simply having your childsit at the table with the food you wouldlike him/her to eat, placed somewhereon the table. This step will adjust yourchild to the sight and smell of thenew food.After multiple sittings, as the childgets desensitized to the presence ofthe food on the table, gradually bringthe food closer and closer to his/herplate until it is tolerated on the platewithout any expectation to try it.When the food is tolerated on thechild’s plate, begin to explore and“play” with the food by having thefood touch a part of the body (i.e.arm, hand, fingers). Remember thatdesensitizing through food play will beseparate from your child’s meal time(until the food becomes preferred, andtherefore added to a meal rotation.)As the child tolerates having thefood touch parts of his/her body,you can work toward tolerance near theface, cheeks, chin, nose, and lastly thelips. Perhaps your child can hold theitem near his face or kiss the item.As the child tolerates having thefood touch his/her lips, you canwork toward the mouth. First, havethe child simply lick the item. If this istolerated, work toward biting into thefood, then biting and holding the foodAn item that is closelyrelated with slightvariations will have themost success at first(i.e. if your child alreadyeats yogurt, considerpudding as a food tobegin desensitizing to).in the mouth for a few seconds beforespitting it out.Provided with plenty of positivereinforcement and repeatedexposures,from there have your childwork to chew and spit the food out,chew and swallow, and eventuallytolerate eating the food. At this point,the food will then get added into theirmeal rotation.Keep in mind, as these stages aretaking place, your child is still ableto eat his/her regular preferred mealsduring usual mealtimes.

By following the levels of the foodchain, the child will be able to buildupon success with small changes. Thelevels are as follows:Level 1: Maintain & Expand,Current Taste & TextureLevel 2: Vary Taste, MaintainTextureLevel 3: Maintain Taste, VaryTextureLevel 4: Vary Taste, Vary TexturePlease reference the two visuals:“Food Chaining-French Fries” and“Food Chaining- Chicken Nuggets”for specific examples of this leveledprogression).3. Food ChainingWhen we think about our own eatinghabits, we most often eat what we like.Food chaining follows this idea anddescribes the process of introducingnew foods to a child’s diet by selectingitems that have the same flavors orfeatures as foods the child already eatsor prefers. Because you build uponyour child’s existing preferences, thisapproach reduces the chance of anaversive response. By presenting newfood items in a gradual way varyingfrom an already “liked” item by only1 feature at a time, you can slowlyincrease the variety of foods your childis consuming.The first step toward successfullyusing this strategy is to create a listof foods that your child currentlyeats consistently; then create a list offoods (or a chain) of items that havesimilar features such as texture, taste,consistency, or temperature.You will initially introduce newfoods that your child is very likelybecause they are so closelysimilar to the items already eaten. Oncethese foods are tolerated, progress tothe next level of the food chain byintroducing foods that are similar tothe items your child already likes butthat have slightly different flavors andtextures. Often, a food chain consistsof 4 levels that build upon one eatThese food chains are fluid,flexible, and often branch off indifferent directions as your childaccepts or rejects new foods andincreases his tolerance of new tastesand textures. Create a new food chainfor every food in your child’s core diet,however only 2 or 3 foods are targetedat a time along with a slightly modifiedversion of those foods which is offeredonce daily.Consider adding sauces, dips, orcondiments to your child’s newfood chains if your child is likelyto tolerate them; sometimes theseadditions that may already be preferredcan help mask the taste of a new foodand better promote its tolerance.The amount of sauce used should bedecreased over time until the new foodis tolerated easily.Continue slowly and steadily toexpand your child’s food repertoire.Your ultimate goal is for your child toconsistently eat a balanced diet that isfull of new healthy choices and a widervariety of tastes and textures. Thisprocess requires small steps and it maytake time to achieve these goals; remainpersistent and patient in workingtoward this goal. You are working tobuild a trusting feeding relationshipbetween you and your child andrenewing the idea that mealtimes andeating are experiences to enjoy.If you find yourself in need ofsupport, a dietician, occupational,or speech therapist will be able toanalyze your child’s diet in depth anddetermine appropriate food chainprogressions. They may have you usea Food-Chain Rating Scale to moreaccurately assess if the foods selectedfor the food chain are appropriate andin which order to present themOften, a food chainconsists of 4 levelsthat build uponone another.

Other Feeding Tipsto Consider:Pick a time when your child is calmor not feeling stressed or tired so youhave the greatest chance for success.Remember, we want mealtimes tobe fun, positive experiences; avoidengaging in a power struggle betweenyou and your child, resulting in fightsaround feeding.It is very helpful to scheduleOffer and serve small portions of food.atpredictable times with as much routineas possible in the beginning (samelocation using a specific chair, spoon,place mat, etc.). When making changesin food, it will be important to maintainthis familiar and predictable mealtimeenvironment. Over time, we can balancethe need for familiarity with the needfor flexibility as we help the child acceptsmall variations to this routine in orderto widen the circumstances under whichthe child will eat.mealtimes and food introductionsKeep the environment as calm andstress-free as possible with fewsensory stimuli that would contributeto a child’s sensory overload; whenchildren are calm and focused, theyare more effectively able to process thecommunication and sensory challengesof mealtime.Remove external distractors duringfeeding (i.e. tablet, TV, video games,etc.) that would reduce your child’sdesire to participate in this feedinginteraction.Rephrase how you verbally presentitems to eat or drink. Instead of askingwhat the child wants, tell him or her theoptions that are available to choose fromduring a meal (i.e. Do you want yoursmoothie in this cup or that cup?).Offer foods that are nutritiousand developmentally appropriate.Try to time your food introductionswhen you know your child is hungry.Make sure your child iscomfortable, seated in an uprightposition during feedings and providinghim access to a cloth or napkin if hedesires to remove unwanted food fromhis fingers or face.Encourage your child to help in thepreparation of food and/or serving thefood at mealtime.Get creative in the ways in whichyou talk about and engage with foodswhile eating without telling your childto “Take/Eat Another Bite.” Try askinginstead: How loud/soft can you crunch? Which side do you want tocrunch on? I can put my (food) in this sauce/spread! Which part of (food) do you wantto bite first? (i.e. if food is in theshape of a fun cookie cutter likeMickey Mouse, dog, star etc.) Do you want to taste the (food)off the spoon or the straw? Myfinger or your finger? The carrot orthe apple slice? Offer family members to try--Brother/Sister do you want some (food)? Please give me another piece of (food)Through the help of an OccupationalTherapist, it may benefit your childto organize or warm-up his/her systemthrough a variety of sensory-based activities(i.e. jumping, bouncing, deep pressure forcalming, etc.) along with some oral motormassage, if your child presents with oraldefensiveness, to alert his/her mouth to beready for feeding. It may also be beneficialto provide opportunities for young childrento develop positive oral experiences (i.e.mouthing a variety of toys or feedingutensils with different shapes and textures).Consider masking the smell of a newdrink by keeping it in a cup with a lid, orto reduce the smell of new food flavors,using chilled foods when first presented.Keep in mind that a child’s sensoryreaction is real; everything a child doesis a form of communicating to let us knowwhat they are experiencing or what theyneed. We must work to figure out why afood was rejected so that we can offer thesame food again in a different way (perhapsconsidering the original utensils used, thefood’s temperature, what part of the texturemay be contributing to rejection, etc.).Observe your child carefully and noticewhat he or she is trying to communicate.Remember to move slowly with “surprisefoods”. As your child grows moreaccustomed to tolerating a wider varietyof tastes and textures, continue to exposehim or her to new items as a normal part ofmealtimes.

Moving Aheadwith Hope:We hope that this document has given you practicalstrategies and new tools to increase your confidencewhile putting the “fun” back into mealtimes! Try toreframe your perspective to think of a mealtime asan exciting opportunity for broadening your child’ssensory experiences, eventually increasing theirdiet, and even simply allowing time