Autistic Spectrum Disorder -
Picky Eaters and Pica
Food selectivity is common in ASD, the theories about the causes are many and diverse. Parents or caregivers whose concern it is to ensure the health and well being of the person with food selectivity can find this issue extremely concerning. Sometimes, an additional challenging behavior such as pica, the preference or need to ingest inedible substances such as sand, plants or petroleum jelly, accompanies food selectivity, making it even more disturbing for the parents or caregivers.
Some of the reasons for food selectivity that have been put forward include:- people with ASD often have a need for sameness and predictability and do not like change or anything new; sensory issues are also common in ASD with a type of tactile defensiveness (over sensitivity to certain levels of touch or the feel of certain substances) creating an aversion to certain food textures; certain vitamin or mineral deficiencies which could lead to the craving of certain foods to the point of exclusion of all other foods; food intolerances and allergies are common in ASD (gluten, casein, soya and corn being the most common culprits) that have a drug like effect- again resulting in a craving for those foods and exclusion of other foods; medical conditions such as gastroesophagal reflux disorder (GORD) might be triggered by certain foods, or the person's throat may be inflamed due to overexposure to the acid from the reflux- making certain foods unpleasant to swallow; it may be a learnt behaviour where certain foods have either been positively or negatively paired with an experience creating a rigid hate/ love for certain foods.
Pica is a medical term used to describe the eating of inedible substances. In the past it has been most commonly seen in pregnant women and has been said to be caused by a deficiency in the mineral iron, which if left untreated could lead to anaemia. Pregnant woman have been known to crave chalk, sand or bricks. It has been suggested that when our body is deficient of any vitamins or minerals it can lead to cravings- our body’s way of attempting to get us to eat more so that we hopefully ingest the required substances. Many people with ASD have vitamin and mineral deficiencies. Pica is also common in ASD.
Often more than one treatment is required to eliminate food selectivity or pica. It would probably be a good idea to first find out if the cause is medical, checking for GORD, vitamin and mineral deficiencies and food allergies. Homeopathic treatments have also been found to be particularly useful for the treatment of pica. If the causes are either sensory or learnt behaviours, an individualised program by a behaviour analyst could help alleviate the food selectivity. From my experience with my daughter’s pica, a combination of:- specialized diet, short term homeopathic treatment, specific vitamin and mineral supplements, together with a behavior program have all helped to completely eradicate the pica and has increased her food acceptance exponentially. Time and perseverance on the parent’s/ caregiver’s part, are key to how successful any program is. Techniques of motivation, desensitization, reinforcement, replacement and positive pairing have all been used to treat food selectivity and pica.
Some children snack all day or fill up on drinks thus decreasing their appetite (motivation to eat). One of the principles of keeping motivation high is that of deprivation and therefore it is helpful to place a limit on, or else ban, snacks and drinks that are consumed before mealtimes, especially while you are trying to eliminate food selectivity. It is advisable to set up regular routine mealtimes. Ensure the undesired food is offered first before the other food so that their appetite is at its highest.
There is a saying that if you try put a frog into a pot of boiling water it will immediately jump out, but if you put it in while the water is cold and slowly heat it up, it doesn’t notice the change and boils to death. While this concept is horrible to even think about, it also highlights the power of introducing very small gradual changes over time, desensitizing one to certain stimuli. Practically this could mean:- mixing a preferred but similar food with the undesired food and gradually increasing the percentage of the avoided food; it may mean you only expect your child to initially just touch the undesired food on their tongue, leading to holding a pea size piece of food in their mouth for five seconds, to chewing and swallowing the pea size piece of food, to gradually increasing the amount you expect them to eat. Each stage of desensitization should be repeated several times before moving to the next stage to ensure they are sufficiently desensitized. Impatience and moving on too quickly can set the program back and perhaps make the issue worse. Desensitisation may mean for example that you have to move from completely puréed foods and gradually decrease the smooth texture moving towards more coarse food, or gradually moving from wet to dry foods, or from soft to crunchy foods or vice versa.
Reinforcement is when a consequence delivered after a specific behavior results in the increase in that behavior in the future. For example if you give your child ten minutes on a computer game for taking his plate to the kitchen he is more likely to want to take his plate to the kitchen again next time. The key is to find things that your child finds highly reinforcing and increase their value by only making them available when they eat certain foods. It is advisable to use reinforcement in conjunction with a desensitization program. An example would be to ensure your child does not have access to sweets and a specific Nintendo DS game they like, throughout the day. Cut one small sweet into smaller pieces (you do not want to ruin their appetite by using too many sweets) and at the start of the meal put, for example, three small sweet pieces in view and say they can have one sweet for every mouthful they have of the undesirable food. If they complete the expected number of mouthfuls for that mealtime they can have a certain amount of time on the DS after the meal. Make the reinforcement differential, in that you
give them an extra sweet or extra time if they do exceptionally well. You may want to rotate the type of sweet and DS game so that they do not get tired of the same ones and their motivation stays high.
If your child is eating foods or inedible substances (pica) because of sensory reasons it is sometimes helpful to replace those foods/ substances with foods that are similar but more desirable. An example would be if your child likes to eat crunchy substances like uncooked pasta/ dog biscuits/ sand, then one could find other crunchy foods like carrots, dry cereal or tortilla chips, while you are working on the desensitization program to get them to accept less crunchy foods. Sometimes when a child likes crunchy foods you may find that they also clench their jaw/ grind their teeth/ bite on objects/ body tense- these are all signs that they need extra sensory feedback that stimulates their proprioceptors. Massage, rough and tumble games, big squeezes and hugs, biting on chewy toys, having weighted coats or blankets, dancing or physical exercise are all ways of providing this extra feedback. In some cases certain vitamin and mineral deficiencies (like calcium and magnesium) have been known to cause muscle tensing.
In the same way that we can sometimes come to dislike certain things because of it being associated with something negative, we can use something positive to help create a new like for something. For example your child might hate peas but absolutely love oven baked chips and watching Barney videos. You could ensure that every time they have chips they also have peas and watch a Barney video- chips and Barney should not be made available any other time. This can be done in conjunction with a desensitization program with reinforcement. Barney video can be paused and as soon as a pea is eaten you can play Barney for a few minutes and allow them to eat a few chips before pushing pause again for the next pea.
It goes without saying that every child and every family is different. By adapting and using the above techniques, it is possible through targeted treatment to gradually increase a child’s food repertoire. It is advisable to only work on one or just a few foods at a time .Once certain foods have been happily mastered and accepted, you can introduce new foods. It is advisable that you ensure you maintain the acceptance of the previously mastered foods by regularly including them in their diet. There is hope, a light at the end of the tunnel. Remember that a healthy balanced diet is one of the main factors that will affect your child’s health, and therefore ability to learn. The time, patience and perseverance that you put into eliminating food selectivity is well worth their improved quality of life in the future.