Roz WEEKS: ASD Outreach Service Manager/SALT

1. NAS AGMUnderstanding and managing fussy eating in children and YP with an ASD21st November 2013 Roz WEEKS: ASD Outreach Service Manager/SALT

2. OUTLINE: • Background and Theory • Sensory issues • Anxiety • Practical strategies

3. What do we know? 62% of parents of neuro-typical toddlers describe more than one ‘feeding concern’ (Reau et al., 1996) 13-80% of children with developmental problems have a ‘feeding disorder’ (Schreck et al., 2004) 90% of children with ASD have ‘mealtime problems’ (DeMeyer, 1979)

4. Activity: myths and facts about mealtimes

5. Mealtime myths and facts for children with an ASD Facts Myths Caused by poor parenting More likely to be underweight/ overweight More likely to lack essential nutrition Choose what they eat to gain attention Have families with a poor diet Are naughty • Most children have some selective feeding • Can be caused by sensory sensitivities • Can be caused by difficulties managing change • Families have a high risk of stress around mealtimes • Children have less awareness of when they are hungry or full

6. Thething I absolutely hate the most is trying anything new. There are hardly any foods I eat at all. I especially hate any foods with bits in it, or things mixed together with each other….I don’t like to eat any food which is the wrong texture….Pringles are my favourite food. I like the way they look, and taste, and the colour, smell and texture of them.” Hall, 2001, p.46-7

7. Understanding feeding in ASD rigid thinking sensory differences Selective feeding Picky, selective feeder (low tolerance) Always eating, never full (high tolerance) Maintaining factors Reluctant feeder, anxiety Learning experiences Highly restricted feeding Adapted from Strudwick and Lister Brook, 2009.

8. Activity • Put foods into one of 3 categories – like, tolerate, dislike • In small groups compare your food preferences. Are they the same or different? • Discuss what it is about certain foods that cause you to either like or dislike them.

9. Sensory differences • “The way a person processes sensory information is just that-the way the person processes sensory information. No way of processing sensory information is inherently good or bad-it just is.” • “People with every pattern of sensory processing are living successfully and unsuccessfully…” • [A sensory difference] “is not a problem to resolve; living a satisfying life is the challenge to address.” (Dunn, 2001)

10. Types of sensory differences Always eating, never full, constantly nibbling or stuffing food. Obsessive / compulsive feeder Doesn’t know when to stop eating Picky / Selective Feeder Never hungry. No interest in food/drink Refusing Controlling behaviour Rigid eating patterns Sensory sensitive/ defensive Low tolerance High tolerance Sensation seeking

11. I was supersensitive to the texture of food, and I had to touch everything with my fingers to see how it felt before I could put it in my mouth. I really hated it when food had things mixed with it like noodles with vegetables or bread with fillings to make sandwiches. I could never, never put any of it into my mouth. I knew if I did I would get violently sick. (Barron, 1992)

12. Appearance of food and it’s importance for some children with an ASD

13. The importance of appearance

15. A different way of thinking that influences feeding patterns Perseveration i.e. inflexibility (Attwood, 1998) Conceptual categories i.e. not making the links between different items e.g. all makes of custard creams (Bogdashina, 2003) Central coherence theory (Frith, 1989) e.g. noticing the bruise on an apple and rejecting the whole apple

16. If my son eats crisps, you have to open the packet a particular way, and it must be a blue packet or he won’t eat them. Kit-kats must be broken a certain way, and he has to have the wrappers laid out next to him to read as he eats. Tomato sauce must be in a bowl beside food not on it.”

17. There is a genuine fear of food. It’s not that he doesn’t want to try it, sometimes his whole body is arching away because of something I’ve put in front of him Fear of new things (neophobia)

18. Neophobia & anxiety Protects us from eating the wrong things Contamination & disgust fears Anxiety in situations where they might be offered food Some foods taste yucky – yoghurt stinks like dog poo” (Carl aged 7) “I don’t like cheese because it’s too milky and it’s only for mice” (Nicolas aged 11) “I wouldn’t try food if it was smelly or coloured brown or green that I didn’t know…the smell gives me a clue as to whether food is good” (Christine aged 10)

19. HOW CAN WE TRY AND ALTER WHAT OUR CHILDREN ARE EATING AND DRINKING? PRACTICAL STRATEGIES

20. We have tried bribery, mixing foods, threats rewards, eating in different places and making lists of foods. We have tried having other children around at mealtimes and try to get her to join in, but she doesn’t. She stopped eating at school when they tried to insist she ate more. Nothing works. In fact the more we try to get her to eat, the less she will do it

21. What doesn’t typically work? Hiding/disguising food Allowing the child to ‘go hungry’ “starve them and they’ll give in” Force feeding Withholding preferred food Insisting on a healthy diet Star charts & rewards Imitating other children

22. Providing information/ reassurance Facts and figures about feeding in ASD How our understanding of ASD helps to explain the differences Books/resources e.g. Can’t Eat, Won’t Eat (Legge 2002) Sharing experiences Giving permission to give child preferred food to maintain weight and reduce mealtime stress Avoiding standard healthy eating advice where this is unsuccessful How we can help by supporting you…

23. What do you do to make mealtimes easier? Talking mat activity

24. Sensory Interventions Addressing sensory needs Calming techniques before meals Oral desensitisation – teeth cleaning How we can help ?

25. Regular mealtimes Familiar mealtime routines Visual supports Pictorial timetables & mealtime activity schedules ‘Eat-up’ book – scrapbook – pages for foods I can look at, smell, lick, nibble, bite, swallow etc. Social stories Picture books e.g. Charlie and Lola How we can help by altering the environment…

26. Introducing new foods Activity • If you were having difficulties eating, put these in the order you think you would find easiest to do

27. For each new food Look at Touch Smell Kiss Lick Nibble Swallow Hierarchy of Eating

28. ‘Eat-up’ book – Scrapbook – pages for foods” I can.......” • look at • Smell • Lick • nibble, • bite • swallow etc.

30. Social Stories.......

31. Choice boards/menu planners

32. CHOOSING BOARD

33. MEAL TIME SCHEDULE

36. Picture books e.g. Charlie and Lola

37. Behavioural interventions Desensitisation Reducing fear of foods Agreed behaviour management strategies Broadening range of foods Broadening food categories Use of suitable rewards – non-food Quantity charts Selective Eating-Interventions

38. Other things that can work? • Category generalisation – ‘spreading the sets’ • Introduce new foods from accepted categories, e.g. a new flavour of a known brand • 10-14 times • Desensitise to smell/taste of new food • Child has control over which foods

39. What can work? • Context specific foods • New foods in new contexts e.g. new class at school, respite • New food & context stored as a new ‘gestalt’ • Often less confusing than changing foods within a familiar context

40. All about food book Food categories e.g proteins, carbohydrates, snacks and sweets Foods in each category that are eaten now Foods in each category that might be eaten in the food Child does survey of what other people eat in each category and selects what to try VISUAL SUPPORTS: HEALTHY EATING

41. It is like being in a restaurant like when father takes me out to a Berni Inn sometimes and you look at the menu and you have to choose what you are going to have. But you don’t know if you are going to like something because you haven’t tasted it yet, so you have favourite foods and you choose these, and you have foods you don’t like and you don’t choose these, and then it is simple : Mark HADDON