You have probably seen the “ideal” family meal on television at least once or twice. Relaxed parents pass around balanced meals, while hungry children, who always say please and thank you, eat mounds of vegetables and whole grains without complaint.
The scene shows a table washed in a warm glow of smiles and pleasantries. If you have seen this image, it probably won’t surprise you that there are many benefits when families sit down to enjoy meals together.1 Positive influences begin as early as the toddler and preschool years and they extend into adulthood.1 Families that have structured meals may also have children with lower body mass indexes (BMI), decreased rates of overweight, and healthy dietary and eating patterns.2 Adolescents who eat three or more meals per week with their caregivers are less likely to have disordered eating or substance abuse issues.1,2 Talking during meals can improve communication skills, strengthen the family dynamic, and improve children’s self-esteem.1
However, the media has neglected to show a far more typical family mealtime. A realistic portrayal is a parent acting as a short-order cook, food flung onto the floor, children crying, and a general feeling of chaos looming. Mealtimes are hard work for all parents, and they can be especially challenging for families and children living with autism spectrum disorder (ASD). ASD is a complex neurodevelopmental disorder characterized by social deficits and repetitive patterns of behaviors.3 It is estimated that up to 89% of children with ASD experience some challenging mealtime behavior.4 Common issues include food selectivity, fear of new foods (also called neophobia), and disruptive behaviors. Meal challenges can begin early in life and extend through adolescents and adulthood.4
Children with ASD may have increased sensitivities to certain foods.5 For example, foods that are crunchy, brightly colored, or too hot/cold may be difficult to process from a sensory perspective.5 To combat uncomfortable sensations, children may prefer a limited number of foods that they feel safe eating.5
“From the time he was 18 months, my son only ate foods that were yellow, brown, and white: chicken nuggets, french fries, mac and cheese, vanilla cookies. He ate anything in that carbohydrate category. The only green thing he would eat was mint chocolate chip ice cream. If I made green vegetables, like a salad, he would vomit. If I cut lettuce in front of him, he would vomit just from looking at it. He was so overwhelmed by the sight or smell of fruits and vegetables that he couldn’t be around us if we were cooking or eating them.” – A.M. about her son R.M. who is diagnosed with ASD.
Food selectivity means that an individual has a small repertoire of foods that they agree to eat.6,7 These foods are often eaten multiple times throughout the day.6,7 Food selectivity can be challenging because it reduces the variety of foods and puts children at risk for nutritional deficiencies.6,7 Children with ASD are more likely to have significantly lower calcium, protein, and fiber intake than neurotypical children.8 Additionally, food selectivity behaviors often favor high calorie, sugar, and fat foods (e.g., pudding, candy, juice), which may increase the risk of overweight and obesity.6,9 In fact, children with ASD are 40% more likely to develop obesity than neurotypical children.5 They also have an increased risk of developing heart disease and Type 2 diabetes.5,6,9-13 Food selectivity goes hand-in-hand with ‘neophobia’or fear of trying new and different foods.5 Children with ASD may actively avoid trying novel foods, and they may become upset when new foods appear on their plate or if their favorite foods are presented in unfamiliar ways.7 Caregivers frequently report preparing special foods or separate meals to accommodate their child’s preferences.7
Children with ASD may also exhibit disruptive behaviors at or around mealtimes. Challenging behaviors may be a result of increased anxiety, and may include frequently leaving the table, throwing food or silverware, tantrums, crying, and food refusal.14
“I learned that going into meals, my son isn’t able to sit at the table for the whole meal, he won’t eat the same foods that I eat, or have excellent manners. But, I started to ask myself, what is my absolute ‘yes’ for him? What does he have to do? I told him, ‘You have to sit in your chair and you have to eat 2/3 of your meal.’ Finding what was an absolute yes on my end helped establish the minimum. Once he met the minimum, we bumped it up.” – A.M. about her son R.M. who is diagnosed with ASD.
Mealtime disruptions may ultimately decrease the healthful benefits of family meals, and research has shown, unsurprisingly, that caregivers report increased stress and anxiety around eating.14,15 Parents may also shift their attention from the whole family to their child with autism, thus limiting the benefits of mealtimes to their other children.15 However, there are some things caregivers can do to make strides towards happier and healthier meals (see above).
Coming to the Table : Creating a Mealtime Your Family Can Look Forward To
While meal challenges exist for all parents, they can certainly be difficult to manage for children within the ASD community. However, there are some things caregivers can do to make strides towards happier and healthier meals.
First, if you are a parent or caregiver of a child with ASD, you know that you are the absolute expert in your child. You can sense when something is amiss, even when it’s invisible to others. You know your child backward and forwards, inside and out; you can do this. Yet, you do not have to do this alone. Enlist the help of experts! Registered dietitians are uniquely qualified to assess your child’s nutritional status and recommend various strategies to address dietary concerns. Dietitians can also help navigate special diets like gluten or dairy free. They will work with you to mitigate nutritional risks and explore foods you can try. Occupational and feeding therapists are also valuable allies for helping you create a physically comfortable eating environment and bring in any adaptative equipment if necessary.
Before you make any mealtime changes, it is essential to rule out any physical problems interfering with your child’s ability to eat. Dental decay, chewing and swallowing difficulties, constipation, irritable bowel syndrome, and acid reflux are common issues that may make eating unpleasant for your child. Common medications prescribed for children with ASD may affect appetite and cause stomach upset as well. Once any physical problems have been addressed, consider evaluating the meal environment.
Assess the Meal Environment
Children and caregivers may experience heightened stress and anxiety around meals. Try relaxing into mealtimes by spending a few minutes deep breathing or meditating. Going for a quick walk around the neighborhood may help ease uncomfortable feelings and set the stage for a calmer environment. Occupational therapist Jenny L. Clark, ORT/L, suggests talking your child through belly breathing with a beanbag animal (outlined below).
Belly Breathing with Beanbag Animal
“Have children lie on the floor and place a small beanbag animal on their stomach. Cue the children: ‘Breathe in slowly through your nose and feel the stuffed animal rise, breathe out slowly through your mouth and then feel the animal lower.’ Repeat at least 3 times. Play quiet music for increased relaxation.”16
– Jenny Clark, ORT/L
It is vital to build a routine around meals to help decrease fears and implement healthy behaviors. Try to eat meals at the same table and have everyone in the same seat. Minimize distractions such as pets, TV, or other background disturbances. If meals are currently very challenging, start by sitting together at the table as a family (without food), even if it’s for just a few minutes. Make sure your child can sit at the table comfortably. If your child slouches, wiggles, or expresses discomfort, consider seeing if you can improve their seating with rolled towels, a booster, or footstools. Ideally, children should have their feet on the floor or support and sit up without slouching (within the constructs of their physical abilities).
As children become comfortable sitting together, gradually introduce the concept of eating at the table. Try to stick to set times for eating as much as possible. Aim for three meals and one snack per day, with no more than 2-4 hours between meals depending on your child’s age (note: determine the ideal number of meals/snacks per day with your dietitian). If a child experiences hunger between meals, this provides a learning experience to tune into their bodies. By establishing set times for eating, children can learn to accept food at the appropriate times, and they will come to anticipate their daily routines.
Be a role model! Meals are a powerful time to model ideal behaviors. So, parents, eat a varied diet and demonstrate how you would like your child to behave.
Addressing Food Selectivity
Children’s food selectivity comes from a place of fear. It is essential to recognize that new foods are very anxiety-provoking and a source of discomfort for many children with ASD.
Gradual exposure may help improve acceptance of new foods and ultimately improve nutritional intake. If a child is fearful of oranges, start by having the child look at an orange from across the room. Over time, move the orange closer and have them touch and play with it. As their comfort increases, show them an orange in different ways; cut into chunks, slices, and orange juice.
Try food-chaining! Food-chaining is an approach where you introduce new foods to your child while building on previously accepted and successful foods. Dietitian Jenny Friedman, RD, has developed helpful visuals if you need ideas transitioning to new foods. (check her out at www.jennyfriedmannutrition.com).17
Expand on already accepted foods. If your child accepts McDonald’s french fries, try substituting oven-baked fries, then work towards transitioning to zucchini fries. You can also try swapping foods with similar textures (e.g., swap yogurt for pudding).
Focus on the food not the behavior.
– Jenny Freidman
The “ideal” family meal is one where you and your family feel calm and relaxed, and your child consumes a variety of foods. Meals won’t look “perfect” or TV-ready, and it won’t always be easy. Still, hopefully, by making a few small changes, you can create a mealtime that you and your family look forward to.
“I have developed a deeper understanding and appreciation for milestones. These tiny wins over time helped us make progress with food. As he got older, my son became much more tolerant. It was gradual shift, but looking back he has made great progress!” – A.M. about her son R.M. who is diagnosed with ASD.
Special thanks to A.M. for generously sharing her time to discuss her son’s journey with ASD.
ABOUT THE AUTHORS:
Heather Seid, MS, RDN, CPS, CNSC, CLC, is a registered dietitian specializing in pediatric and maternal health, and she is a 2021-2022 Fellow in the New Jersey Leadership Excellence in Neurodevelopmental Disabilities program. She oversees the Bionutrition research core at Columbia University and is a Doctor of Clinical Nutrition student at Rutgers School of Health Professions.
Dr. Jane Ziegler, DCN, RDN, LDN is Interim Chair, Associate Professor and Director of the Doctor of Clinical Nutrition Program in the Department of Clinical and Preventive Nutrition Sciences at Rutgers School of Health Professions. She is a faculty mentor in the New Jersey Leadership Excellence in Neurodevelopmental Disabilities program.
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