November 16, 2011

The Pickiest Of Eaters: Part 3

The following is written by Bonnie Marquis, a Positive Behavior Support Trainer for the West Virginia Autism Training Center. Bonnie concludes her series on supporting individuals with ASD who can be described as picky eaters.

If you have made it through parts one and two you should have a reasonable understanding of both why individuals on the spectrum are prone to being picky eaters and how such behaviors can easily be reinforced (meaning we may unintentionally make them more likely to occur).

But what you really want to know is WHAT to do about it! Strategies generally fall into two basic categories: (1) removing the power struggles and (2) increasing motivation to try new foods. No single strategy by itself is likely to be dramatically effective but in combination and with persistence, real gains should be seen over time.

How will you know?

Before you try any of these strategies, make a list of all the acceptable foods that are typically eaten by the picky eater. NOTE: The shorter this list the more difficult your task – if it is less than five foods from all categories you will likely need professional help and support.
Any time a new food is tried add it to the list, along with the date of your success. “Tried” should be defined – does that mean he has taken a bite and swallowed it? For some, it could be smelling and licking a new food. The definition is up to you and will depend on the characteristics of the picky eater. The rate of your success will depend on a variety of factors as well, from how much access you are willing to give (or deny) to the preferred foods, to the individual’s temperament and the consistency of your approach. No single method or timeline fits everyone and you should anticipate the need to make adjustments along the way.
Ideally you should not be tackling this issue alone. A team of professionals including occupational therapists, speech therapists and nutritionists working together is the best recipe for success. Keep in mind the strategies here are behavioral, and if oral motor or sensory issues are major contributing factors,(i.e. lots of gagging, only tolerates one or two textures) they must be addressed with therapies and exercises to develop the necessary skills and desensitization for swallowing a variety of foods. But if you do not have access to those resources and your picky eater can eat and swallow a variety of textures, you stand a good chance of success with the following strategies:

Increasing motivation: There are many strategies that can be helpful in this area and they should be carefully selected and implemented based on your own situation. Not every strategy will be right for you or the picky eater. Much depends on your own eating habits and life style, as well as the age and level of functioning of the picky eater.

• Involve the person as much as possible:
~ Invite the picky eater to help select the menu/parts of the meal to be served
~ Have the person help in preparing the meal as much as possible – from washing & ripping lettuce (even if they won’t eat it) to adding/pouring ingredients or simply stirring.
~ Consider growing some vegetables – even a patio garden – to show where food comes from.
~ Involve them in selecting foods at the grocery store –consider very short trips with only a few items if their tolerance for this is low – or in season try a farmer’s market if there is one in your area.

However you choose to involve your picky eater, doing so will help them be more comfortable with different foods, help them predict what will be on the table and, and combined with other strategies this will help them be more comfortable trying different foods.

• Model Eating and Enjoying New Foods: make an effort to try new foods and praise the family members who do so as well. Prepare foods several different ways and have a ‘taste test’ and vote for favorites. For example try a new vegetable and serve it raw, steamed and roasted and see what people think. If you cannot get it past your picky eater’s lips ask for his opinion on the smell. Or maybe he can record everyone else’s responses and declare the ‘winner.’ Involvement is the key.

• Limit Grazing: This is a common habit among picky eaters and seems to be a “Which came first” scenario. As parents we let them graze because they do not eat very much, but because we let them graze (or sip on milk and juice all day) they never come to a meal all that hungry. And if they are not all that hungry you can be sure it will be that much more difficult to get them to eat anything other than their most preferred food items.

• Play with the Presentation: People on the spectrum are very visual and may be more motivated to eat foods that are visually more appealing. Or, they may respond to foods that are ‘organized and separated’ and like foods that are presented on divided plates or lined up in an ice cube tray! There are endless possibilities to make the presentation fun and appealing – but know your eater! Making a mouse out of your pancake or putting a face on the sandwich might be appealing to some, but could upset another person since it goes against the ‘rules’ for how foods are supposed to look. And this type of strategy might work for young eaters. It may not be effective for mid-elementary age and beyond.

• Make the Experience Predictable: Have a regular routine, place, and schedule for eating. Also give information about what a new food may be like might. You might need to teach the person descriptive words like sweet, salty, savory, crunchy, creamy etc. so that you can describe new and unfamiliar foods. Make comparisons to preferred foods but with added information of how they might be different. “These are sweet potato fries, kind of like French fries but softer and sweeter. They also have lots of vitamin A and are good for your eyes.” If the person has trouble with lots of verbal information limit it and try showing it visually (maybe develop a visual for each of the taste descriptors).

• First/Then – this is an invaluable strategy for many tasks. Related to eating, we all probably remember being told ‘if you don’t eat your dinner you won’t get dessert!’ And while a range of experts shudder at this technique for fear that it teaches children to value sweets over healthy foods, it can be applied without overly stressing that idea. And here, the preferred food just might be chicken nuggets! If needed, the concept can be represented visually:



For these strategies to be effective, however, you need to combine them with the concept of removing the power struggle. You are not forcing (begging or bribing) the person to do or eat anything. But IF they want the preferred food, they will need to at least TRY the non-preferred food first. The choice is theirs and you need not engage them about it any further. The difference with this and no dessert is that no one worries about you if you don’t get dessert. When the picky eater chooses not to try a new food and would rather go hungry, this naturally creates fear and concern (see more on this below). To deal with this initial likelihood you may want to have other, more ‘neutral’ foods available. Neutral foods would be those that are not highly preferred but tolerated (at least sometimes) and hopefully with some nutritional value (peanut butter sandwich or yogurt for example). Know your own limits in what you can handle. But also know the more often you offer neutral foods, the longer it may take to expand the diet. As stated above, anticipate the need to make adjustments based on the needs of everyone and the success, or lack thereof, which you are seeing (based on the list you are keeping).

Removing the Power Struggles: As stated previously, it is only natural to want to control what you eat. The more you feel as if someone is trying to control you, the more you may resist. Maintaining control also helps to reduce anxiety. Removing the power struggle allows the person to maintain some control and you need to set up choices that you can live with no matter what the picky eater decides. You should commit yourself to no longer plead with the person to eat any particular food but stand firm in your expectations of what should be eaten, and in what quantity, to gain access to the highly preferred food. Perhaps a single taste of a totally new food will be enough as that is a huge step. But perhaps after multiple exposures, eating 4 baby carrots (which you are confident he has the skill to chew and swallow) is what is expected. This expectation should be made clear from the start of the meal and is highly individualized. Don’t make the First-food such a challenge that the person cannot achieve success. But also don’t be so worried about hunger or tantrums that you do not stretch the range of foods you expect to be tried.

If the person chooses not to eat, you may need to show indifference, and this may require some acting skills on your part. If whining and tantrums have been effective for this person in the past you can expect he/she will try this (and at an increased intensity) so you should have a plan of how to respond. Ignoring it while making sure everyone and everything is as safe as possible is generally the most effective approach at this stage. But again it is important not to engage with the person during the tantrum as the attention itself can be very reinforcing. If the person refuses to eat stay calm and simply remove the food and offer it again at the next meal/snack time. It should however be fresh or still palatable, the idea is not to punish but to stand firm in your expectations make the person realize healthy foods must be eaten and eating the same foods or only one food is not healthy (convey this in a social story – see below). If you remain calm and persistent the person will realize the behavior (whining or tantrums) will no longer result in the desired food or attention. It is up to him if he wants eats what is offered. There is no power struggle because you have removed it. He may not be happy with his choices but as the care provider you are putting their health and their best interest before their preferences.

Social Story: A social story that gives plenty of perspective for the picky eater may be very helpful. You want them to know why they need to eat new foods and that although different and perhaps scary; they will get used to it and may eventually grow to like the new foods. The social story, as always, should be individualized and as positive as possible. Many resources are available on the internet for examples that you can then tailor to meet your individual needs. Reviewing the story right before meals may make this strategy more effective.

Going Hungry: You should be prepared for the person to be willing to go hungry. This is the most difficult aspect of the entire process and it can strike a parent right at the heart of what they feel is a critical part of a loving and nurturing relationship. And although allowing the person to go hungry may seem like a harsh approach or a failure on your part, it is important to think of the long term consequences of persistent malnutrition and bowel problems (constipation) due to a lack of fiber and other components of a varied diet. Think of it as ‘tough love.’

Understand that the extremely strong willed may be able to go a day or so without food, and such a situation MUST have the direct support and guidance of a professional to ensure the health and safety of the picky eater. In such extreme cases it is vital that the person remain well hydrated and this approach may need to be implemented at a specialized eating clinic so that ongoing observation and support can be provided.

But if the person is drinking plenty of fluids (water is preferable as milk and juice can be ‘filling’) you can try the first/then approach (again with carefully selected foods with high chance of success) and use your judgment about how to define “try” and how strictly to adhere to the concept as well as what neutral foods to offer and when. For example, perhaps the picky eater will eat a relatively substantial breakfast, so you apply the above strategies at lunch and dinner. By dinner the person should be hungry enough to really be willing to try that new food in order to gain access to those chicken nuggets (if you have not given in and provided preferred snacks). “Hunger makes the best gravy” and at that stage those carrots just might taste pretty good. But what if its dinner time and nothing has been eaten since breakfast and he still won’t budge? This is where it gets tricky. Hopefully they’ve been drinking fluids (water or diluted juice) and you might simply offer some milk along with the stated choices. Or, offer a neutral food if there is one with some nutritional value. If he is so picky that there is nothing else to offer other than a highly preferred, nutritionally void item, (like crackers or chips) then he is a prime candidate for professional intervention. Or if you fail to make any progress because he is always having a filling neutral item to ‘fall back on’ you may need to limit the neutral offerings as well.

Again, tantrums and meltdowns will likely occur over this and other issues if the person is hungry. Nobody handles frustration very well when they are hungry and you can expect some significant challenges to occur. With this in mind, schedule your life accordingly. Perhaps try this over a break and with little else planned. Above all remain calm and committed and give yourself a script if you need one. “Trying new foods is hard for you, but your body needs them to grow” (be careful of too much verbal information) or show the social story once the person is calm. In between meals try and offer a great deal of positive love and interaction.

No two people are the same and you may find that your picky eater is a little more willing to try new foods if he is not so hungry, (as this makes them too grouchy and negative) so it is important to know the person and tweak the strategies to meet everyone’s needs. And be patient. Change will not happen overnight. But the really difficult period should not last very long. Once you expand the diet even just a little bit, having those foods at meals and letting them decide what to eat or not will make mealtimes more pleasant for everyone. And finally, remember that this should not be a finite goal with an end number of acceptable foods in mind. Keep ‘trying new foods’ on the agenda and keep modeling the joy of new experiences, but with empathy and understanding of how to make such experiences less stressful for the person with autism.

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