You only need search the phrase ‘picky eating’ on any search engine and you’ll be bombarded with sites offering to ‘uncover the myths’ about foods and why we eat the way we do. Some suggest it’s a lack of adventure, others it’s ‘a power struggle in the kitchen’ while one or two I came across even declare it’s in our DNA.
The truth is, as generalist as many of them are, there is indeed an element of truth in all, but they fail to address the nuances of society.
For years parents around the world have been challenged by their offspring when it comes to mealtime and the food that is served. As a generalist myself, I accept that it is in the nature of children to question what it is they’re eating and to be somewhat reluctant to embark on new adventures. There are some that embrace the chance to experience new things, but often their peers are less forthcoming.
However, more often than not a child or young person on the autistic spectrum will have a very real aversion to new foods. Understanding why that is can make a difference when it comes to making sure they have the nutrition they need to stay healthy.
Autism has some common indicators such as the need for routine and difficulty in communicating, among a raft of others, though its manifestation can also be unique.
And it is anxiety that is arguably the most challenging of the factors. Anxiety can be brought on by a myriad of reasons, each individual to that person, but its ripple effect (sometimes more of a tsunami) can have a far-reaching impact on their life and on those around them.
The need for routine and familiarity are compounded by sensory issues, which make mealtimes an even more difficult prospect. Sensitivities are a major characteristic of autism, and can include tastes, smells and textures.
“The first thing to say is that with the majority of people on the spectrum, not everybody, but the predominant pattern, they have a limited range of accepted foods,” explains child psychologist Dr Elizabeth Shae.
She began her career as a primary school teacher before working with the National Autistic Society specialising in eating difficulties in autism.
Today she is co-founder of the Birmingham Food Refusal Service, supporting parents and professionals across the public and third sectors.
Those sensitivities can also stretch to foods the autistic child has previously accepted. It may be that even if a child likes all the food groups on their plate, these might be presented in a way they don’t find acceptable: perhaps foods are touching each other, for example.
The challenges
“These foods tend to be safe and predictable to that person. Most are maybe eating five or ten foods,” Dr Shae explains, adding that children with autism can show extreme reluctance, anxiety, an almost phobic response to new foods making it difficult to introduce them into their diet.
However, it goes beyond that, in some cases simply being near foods that aren’t pleasant to the individual can be a challenge. Putting someone next to a food they really can’t stomach can lead to what Dr Shae calls a ‘disgust response’, strong responses that may result in gagging or even throwing up.
Avoidant/restrictive food intake disorder (ARFID) – previously selective eating disorder – is also very common for those with autism, particularly through their formative years. It limits the diet and ‘acceptable’ foods because of appearance, smell, taste, texture, brand, presentation, or even a past negative experience.
“ARFID is driven by sensory hypersensitivities and anxieties about food,” says Shae. “We know that sensitivities are a major factor in children that refuse foods, across the board, children with or without autism. But young people on the spectrum usually have very strong sensory issues.”
The eating environment can also be a major contributor to food refusal. It’s here that schools might have particular difficulty in accommodating a child with autism.
“I was in a primary school a few days ago doing an observation … The noise level in the dining room was unbelievable. I thought ‘I can’t tolerate this and so how would a child on the spectrum deal with the amount of noise, clatter, and overload’ in terms of smells and sounds,” says Shae.
“Overload is a real issue and can lead to problems eating with other people. When you’re in a school environment or other social setting that can be very difficult.”
Rigidity and inflexibility, not wanting to deviate from the foods enjoyed for something new, or not wanting to do things in a different way to that which is usual is also common. So how do schools, particularly mainstream where there has been limited experience of autism, manage?
The answer?
First and foremost it’s important to communicate with the child, according to the National Autistic Society (NAS), and take steps to reduce the levels of anxiety associated with foods.
If the canteen environment is too overwhelming for them, seek alternative rooms to eat in. Perhaps, Dr Shae says, bring in a favoured member of staff to share the mealtime with the individual.
Other helpful strategies include providing visuals ahead of the day such as a menu so the child is prepared for what lunch will include. The important thing is to reduce anxiety as much as possible in a way that works for the individual; not a ‘one size fits all’ approach.
“What we know about sensitivity is that it rises when we become anxious. That leads to more sensory issues, which raise anxiety further. And as you get more anxious you notice a difference in your foods, your appetite disappears and you’re less likely to eat,” she says.
Food and diet for those with autism require a more holistic approach. Parents should be encouraged to work with the school, providing a food diary from which the school can see what foods are preferred and what has been eaten recently.
Schools, likewise, should return the diary home each day. Desensitisation strategies are also beneficial; allowing children to get ‘hands on’ with their foods in a controlled setting such as a classroom or at home. This allows them to smell, feel and even taste new foods, but only at their pace.
Challenging convention
While there has been much success in recent years in promoting awareness of autism, and educating people about how they can take a more accommodating attitude towards people with it, there is still more to do says Dr Shae.
“It’s difficult for mainstream schools to address the sensory issue, but I think it goes back to inclusion. A child with a physical or learning disability – or even food allergies – would be accommodated. I think for a child with something like ARFID, that needs to be accommodated too,” she says.
“This could be done by bending the rules slightly. Allowing different foods to come into school or allowing that child to eat separately might help.”
Such flexible strategies are what Dr Shae calls her “really!” moment. “It doesn’t matter what food it is as long as it’s a food. We have calories and we have calories, we want these children to simply have calories. So I’m often asking schools ‘can you offer a high calorie amount food?’.
“That’s a food that, even if eaten in only small amounts, delivers a high calorie load. This can be biscuits, chocolate or cake etc. If you think about a child eating cucumber, you’d have to eat an awful lot to get the same calorie load as you would from a square of chocolate or a biscuit.
“It’s about finding a balance. We don’t talk junk food or healthy food in my clinic, we talk about high calorie per mouthful food. This would benefit learning too as it means children have energy.”
The challenges of providing food for someone on the spectrum are many and varied. It’s difficult to provide one piece of advice that will solve all the challenges.
But a combination of understanding the child’s needs, their autism and its impact on them, and working holistically, with parents and other staff members, going at a pace that best suits the individual are the first steps to getting it right.
* Dr Shae has co-authored ‘Food Refusal and Avoidant Eating in Children With Autism and Other Conditions: A Practical Guide for Parents and Professionals,’ which explores the issues of food refusal and strategies with colleague Gillian Harris. The book is available from publisher Jessica Kingsley.