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4/8/2013
1
Alicia Hart
Overcoming Feeding Difficulties
in the Child with ASD
You are watching because…
Breakfast
Lunch
Dinner
I know this because I have been there.
Meet Ewan Every child has a story.
Take the time to know
the story behind the child.
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Let’s start at the beginning…What is eating? Why do we eat?
The Family Meal
Every meal is a story. It has a beginning, a middle and an end.
There are characters and plotlines unfolding as the meal progresses. There is drama, mystery, humor and sadness.
And every single person sitting at the table has a different, perspective, or point of view.
Elements of the Story
• There are many elements to any story, including:
–Characters
–Relationships between characters
– Environment
–Motivation and intentions
–Perspective
–Context
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Understanding Food
• Every food and meal has a context.
• What is context? It is the circumstances that form the setting of an event in terms which it can be fully understood. Without context, we misinterpret.
• We take for granted the context, or set of events or facts surrounding what we eat, how we eat and where we eat.
Context matters, or else no one would ever ask:
What’s for dinner?
Context works both ways.
The child with ASD didn’t become a problem eater overnight. There are elements of this story that you may not be aware of. You will only learn these by understanding the bigger picture. Ask why, and ask it often.
Before we can learn about food and eating, we have to uncover therest of the story. Before we can teach context, we must learn it first.
Understanding Why Every child has a story.
Medical history
Feeding history
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Developmental History ‐ASD Diagnosis The ASD Point of View
Intervention: Think Developmental
Understand the Language Needs
Address communication challenges and implement AAC strategies. Utilize SLP to help improve communication skills.
If I can’t tell you I hate Diet Pepsi, I will use behavior as a means to get your attention!
Understand the Sensory Perspective
Focus on modifying the environment to adjust for sensory dysfunction. Understand that THIS child’s perspective is VERY different from your own.
What tastes good to you, may simply be overpowering to this child. What smells good to you, may make this child want to gag. Utilize OT to help promote sensory regulation.
Adjust for the Social Demands
Be mindful of the pressure social interactions at mealtime can cause. Remember, eating is a social activity!
One of the worst restaurant experiences for my son with ASD happened at 14 months of age.
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Behavior is communication.
Behaviors at the table must be examined—Functional Behavior Assessment can help determine what these behaviors are trying to communicate!
Behavioral interventions come LAST and are ONLY effective AFTER medical, physical, developmental, sensory and communication issues have been addressed!
Every child is different.
• Understand each child’s abilities & challenges. The child with ASDdoesn’t automatically understand the rules & expectations of meals & eating.
• Social Stories ™, visual schedules, hand‐over‐hand (when tolerated), and sequencing strips may help this child understand what to do and how to do it.
• Understand that sometimes it’s not a WON’T issue, it’s a CAN’T issue.
Augment Table Expectations Intervention: Think Medical
Let three words guide you:
Quality of Life
33‐80% of children with
chronic medical problems
are considered picky or
problem eaters.
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12%
Without medical evaluation, your intervention looks like this…
Evaluation Not Assumption
He APPEARS healthy, right?
Children with ASD don’t always have the skills to communicate pain!
See the big picture. Don’t ignore red flags!
• Vomiting or Retching
• Heartburn
• Diarrhea
• Colic
• Spitting Up
• Gagging on food
• Choking/Coughing
• Difficult or painful swallowing
• Congestion, colds, fevers, URI
Cont>
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Don’t ignore red flags! (cont)
• Constipation
• Pneumonia
• Rash
• Hives
• Lack of appetite
• Food sticking in the throat
• Noisy breathing/wheezing
• Snoring and mouth breathing
Urgent Referral
AspirationFailure to Thrive
Severe Dysphagia
Medical evaluation requires ateam approach.
Evaluations—Feeding Teams
Core Team
• Pediatric GI
• Dietician
• Speech Pathologist
• Occupational Therapist
• Psychologist / Social Worker
• Parent
Other members
• Pulmonology
• Cardiology
• Neurology
• ENT
• Surgery
• Endocrinology
• Radiology
• Genetics
Don’t always have to visit a ‘feeding clinic’ to get quality medical care.
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Nutritional History
Don’t skip this step!
Evaluation Not Assumption
He APPEARS healthy, right?
I bet he eats enough.
Calories came from Liquids The child with ASD often drinksmore than he or she eats.
• While writing down food and liquid intake during a food log, parents often notice their child is DRINKING more than they are EATING!
Nutritional History
Food logs provide crucial elements to the story!
Nutritional History• Problem eaters usually accept
less than 20 foods and exclude entire food groups.
• Nutritional deficiencies are a concern and can change how food tastes.
• Growth assessments may be required.
• Evaluate individually! Formulas and charts do not tell the whole story!
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Parents worry…
• Children do not grow very fast during early childhood and do not need a lot of calories!
• Remember, toddlers do not grow as fast as infants!
• Also, remember that most children do not eat a balanced diet each and every day! What matters most is what happens over the course of a week.
Parents are often too busy for schedules…but…
• Benefits are numerous
– Time to empty the stomach
– Time to become hungry again
– Time to rest and recover
– Will encourage eating a larger amount of food and taking more liquid vs just grazing or nibbling on a small amount of food
– Gives parents multiple opportunities to offer food if child refuses
How MUCH is on your plate?
• Use proper portion sizes
• How big is YOUR stomach?
Feeding History
Go back to infancy,where the story began!
Feeding History• How did the child nurse / bottle feed as an infant?
• How did the child handle the transition to baby cereals? Table foods?
• How did the child handle the transition from bottles to cups? Did the child ever learn to use utensils?
• Is the child able to chew a variety of textures?
• Are there settings where the child eats well? Are there settings where the child does not eat at all?
Cont >
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Feeding History (cont)
• How available is food to the child? Is the child on a schedule?
• How does the family approach food?
• Has the child ever enjoyed eating?
• What is the parent‐child relationship during meals? Is there consistency between meals and parents?
Red Flags
Red Flags Red Flags
Feeding HistoryChanging the way a child with ASD views food and eating is a slow and deliberate process.
The child didn’t become a problem eater overnight. The problem evolved over time and it will change over time.
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Context is everything.
After we learn the howsand whys of problem eating, we must turn to explaining food and eating to the child with ASD.
Food Chaining ™
Food Chaining ™
• AFTER a thorough medical evaluation, nutritional assessment and developmental / feeding assessment, Food Chaining ™ uses what your child already eats and expands outward using flavor mapping, flavor masking and transitional foods while utilizing food education to teach your child what to eat, when to eat, how to eat and why we eat.
Food Chaining ™: Fraker, Fishbein, Cox and Walbert