Helping children with aversive feeding OT/SLT Dept. BOCSS Making food fun! Helping children with aversive feeding OT/SLT Dept. BOCSS

Sensory processing

Session outline 1. What is aversive feeding 2. Possible causes of aversive feeding in ASD 3. Steps in helping my child -Food Diary - Environment - Becoming comfortable with food outside meals 4. Fun with Food programme 5. Checklist for helping my child

“I had a big problem with food “I had a big problem with food. I liked to eat things that were bland and uncomplicated. My favourite foods were cereal- dry with no milk- bread, pancakes, macaroni and spaghetti and potatoes. Because these were the foods I ate early in life, I found them comforting and soothing. I didn’t want to try anything new”. Sean Barron p135 Asperger’s Syndrome: A Guide for Parents and Professionals.

What is food aversion “faddy eating” is a common in children. It can be stressful, but rarely causes any serious nutritional, medical or growth problem’s and is a phase that is grown out of. However, there are some children whose faddy eating continues much longer that the common toddler faddy eating. This is common in children on the Autism Spectrum. Up to 75% of children on the Autism Spectrum present with self-limiting diets. Extreme limiting of the one’s diet can cause: growth problems nutritional deficiencies severe tooth decay dehydration and severe constipation Stressful mealtimes to be extremely stressful. Fatigue Reduced concentration Reduced self-esteem and socialization if they are unable to eat with their peers.

Characteristics of Aversive eaters: Aversive eaters often exhibit one or more of the following: Limited food selection. Total of 10-15 foods or less Limited food groups. Refuses one or more food groups Anxiety and /or tantrums when presented with new foods. Gag or becomes ill when present with new foods. Experience food fads. Requires one or more food to be present at every meal prepared in the same manner.

2. Causes of Aversive feeding in ASD Social Communication ASD Social Imagination/ flexibility of thought Social Interaction

Causes of Aversive feeding in ASD Children on the Autism Spectrum who have food aversions are a mixed group! There are a number of reasons that children may become resistant eaters: Medical issues- eating certain foods hurt, causes discomfort Sensory issues- they are over sensitive to the feel, taste, look, smell of food Oral-motor issues- don’t have the tongue control, chewing or swallowing abilities. Routines and resistant to change- learnt that they only eat certain brands, certain foods, certain colours etc

Food Diary It is important to understand your child’s food patterns and this is best learnt by filling in a food diary. Fill in the diary for 2 weekdays and 1 weekend day. You will find out the best places, times and ways to offer food to your child and which new foods your child might be willing to try. E.g. some children really distracted by bright lights Some children prefer to be distracted by music Some children prefer certain colours, smells, textures etc

Food diary Meal Time Food Description Location Distracters? Who Independence level Anything else

Analysing the Food Diary: Environment What changes do you need to make?

What can I do to help? Top Down: Environmental and behaviour strategies Bottom Up Supporting sensory strategies And Oral motor development

Environment This is the tried and tested standard advice, which helps with common faddy eating. Try these ideas first before moving on the later strategies in this section. Offer 3 meals a day- breakfast, lunch and dinner and 2-3 nutritious snacks Try to eat meals and snacks at the same time each day. Offer small portions to that your child is not overwhelmed, they can always ask for more. Drinks can fill up your child’s small stomach- avoid giving them for at least thirty minutes before a meal or snack. Try giving a drink at the end of the meal or at a snack time instead. Limit milk intake one your child is over 1 year to one pint or 600ml a day. Preserve in offering new foods- a child may need to try it more than 10-20 times before they start to like the taste

Environment Sit together at the table and eat at the same time as your child whenever possible, as they will learn from you. Try not to rush or drag meals. If you child has not eaten their food after 30 minutes, take it away without comment. Offer your child food without coercion. Never try to force feed If you child refuses to eat food, put it in front of them at mealtimes, take it away without comment, and do not offer any other food until the next planned meal or snack. Do not use food as a reward. Better rewards are praise and star charts for good meal time behaviour. Try involving you child in shopping, food preparation and laying the table.

Use visual supports- Visual supports can be very powerful for children on the Autism Spectrum. Examples: Daily timetable showing where meals come in the day- e.g. get up, dressed, breakfast, brush teeth, get bag, car, school. Visuals: Break cards, Stick kids, timers, number of bites to eat etc.

Examples of visuals

Encourage your child to sit at the table If your child finds it hard to sit at the table, be realistic and set your goals small- e.g. 5 minutes. Use a TIMER and praise for good sitting. If you child can sit for other activities but not for eating, try removing their plate from them calmly if they try and leave the table and praise them for returning to the table and sitting and eating well- don’t chase your child around the room. You may have to incorporate sensory breaks into the mealtime routine to help your child to sit.

Considerations around sitting to eat Need for stability Need for movement Difficulty waiting

How to include sensory breaks Incorporate them into the schedule after each activity Allow your child a break when you see him/her gets anxious, distracted, restless etc Decide if your child needs a break away from the table, at the table or a combination You child may need a fidget toy or another sensory activity throughout the session

Why sensory breaks? Prepare the child for the sensory experience (‘wake up’ and focus the system) Calm and desensitise the tactile (touch) system Reduce anxiety and sensory overload before, during and after food exploration

Motivating your child Focus on motivating your child to change one thing at a time. The best motivator is consistent rewards for even the smallest step towards the change. - E.g. allowing the new food on the plate. Rewards should NOT be food related. Use strategies such as praise, star charts or treats such as stickers, comics, watching favourite TV programme, longer on the computer, staying up later etc. Be sure you are clear as to which specific behaviours get a star or sticker, and offer a bigger reward.

Analysing your Food Diary Look at food patterns- colours, textures, food groups etc

Becoming comfortable with food It may take months for your child to feel comfortable with a new food- so PERSEVERE and be patient! 1. Introduce one new food at a time and set small goals. Staying at the table Small piece of food on plate near their plate Small piece of food on their plate Touching food with finger Touching food on arm Smell food Touching food on cheek Touching food on lips Lick food Put it in mouth (and spit out if necessary) Put it in mouth and Swallow

When choosing a new food use your food diary- try a food from an already accepted food group- e.g. a different type of bread , or a food in a similar colour, texture or taste to preferred food. This is called food chaining. Give your child CHOICE but not absolute control. Compare “which of these 3 foods will you try this week” versus “will you try a new food this week”.

Helpful hints Children who are comfortable across all levels of food play make the transition to oral eating more easily. It is worth investing considerable time and effort in this area from the outset. 1. Set up a predictable beginning and end- e.g. putting on aprons, getting materials and end- clearing the table and washing hands etc. 2. Many children find it difficult to progress from dry to wet food play- this transition can be facilitated by Make a barrier between the children hand and the wet food- e.g. manipulating tomato sauce and mayo to make pink sauce when they are in a bag. Allow child to wear surgical gloves and gradually reduce the barrier by cutting some of the fingers from the glove. Use utensil for stirring e.g. spoon. Use the softly, softly approach. Reward your child for playing with food, even if it is for a short period of time i.e. 10 seconds. Always have your break card at the ready so your child can request a break if he/she needs it.

Fun with Food group Fun with Food is a group to support children who have a selective or total aversion to oral eating. It is a multidisciplinary approach that acknowledges the possibility that aversion may be due to multiple factors that are interlinked and often difficulty to distinguish. Components and strategies used in the group include- social stories, sensory food play, visuals, behaviour charts and rewards, sensory breaks and activities with calming sensory elements.

The aims of the group are: 1. Building up the children’s confidence and pleasure around eating and reducing the stress associated with eating 2. Support and peer motivation: Providing an opportunity for carers to share ideas, issues and concerns with other carers in a similar situation. 3. Application: Providing repeated opportunity for carers and children to practise strategies under the guidance of the therapists and in a structured environment. 4. Education: Develop broader understanding of feeding skills and issues.

Some videos of Fun with Food Group!

Making food fun!

Setting goals 1. From your analyses of your child's food diary, look at the patterns you have discovered. Certain times, places, people? Certain food groups, colours, textures etc 2. Decide on the changes you are going to make to the environment and then what food exploration changes you will make. 3. Base your child’s progress on the participation levels below

Levels of participation 0= refused to participate child refused to participate child became distressed when presented with activity child was not able to pay attention to the activity child was not able to sit for activity 1= attends to activity child watched the facilitator and/or peers doing the activity but did not attempt to participate child showed interest in activity but did not attempt to participate 2= attempts activity child tried the activity but stopped child seemed cautious around participating but tried child placed tips of fingers only into food child tried the smell/taste etc but withdrew 3= partial participation child carried out half of the activity only before stopping or leaving. child carried out the activity in a rushed (get it out of the way) manner without fully engaging child carried out activity but subtle difficulties observed e.g. making faces, wriggling etc (see below for more examples) child participated in activity with no obvious difficulty but could not withhold attention throughout activity, got very distracted etc. 4= full participation child had no issues or difficulties with the activity child could maintain attention for most/all of the activity