Throwing up from overeating

This answer is by developmental pediatrician Amanda Bennett and behavior analyst Megan Carolan Tomkinson. Dr. Bennett is the director of the Autism Speaks Autism Treatment Network (ATN) Center of Excellence at Children’s Hospital of Philadelphia, where Dr. Tomkinson also practices.

Our 10-year-old ASD kiddo will eat until he throws up and then start all over again. How can we break this cycle?

Behaviors around food often create challenges for children with autism and their families. In our ATN center, eating is a frequent topic of discussion. We’ve developed a number of strategies to help manage problematic food behaviors – both those that involve overeating and those that involve refusal.

One of the first considerations for any child eating excessively is whether there are underlying medical issues. Is your child taking prescribed medications for challenging behaviors? If so, discuss your concerns about his eating with the prescribing physician. This is important because some behavioral medications can significantly increase appetite. This is particularly true for the newer antipsychotic medications. These include risperidone and aripiprazole, the only two medications currently FDA-approved for treating extreme irritability in children with autism. 

In addition, we suggest that your child’s healthcare team assess for other potential causes of overeating. Many ATN centers have “feeding teams” that consist of medical, behavioral and nutrition experts. Together, they can provide recommendations based on a detailed history and behavioral assessment of your child.

The nutritionist, for example, can provide guidance on healthy food choices, portion control and recommended calorie intake for your child. A behavioral psychologist or behavior analyst can identify any emotional triggers and that may lead to overeating and vomiting behaviors. Once these triggers are known, the therapist can help create a personalized plan to find healthier responses to relieve the emotional stress.

Strategies to help autistic children with throwing up from overeating

While you and your son’s healthcare team work on a personalized treatment plan, we suggest trying the following general strategies, which many of our families have used successfully.

Portion control

Many individuals with autism respond well to visual cues. For portion control, try using smaller plates that prompt your son to reduce how much food he takes at one time. Similarly, you can have smaller glasses for beverages – even smaller utensils, within reason. If you think it wiser that you do the serving, try reducing how much food you put on your son’s plate at any one time. Don’t be shy about scaling back to, say, three or four bites per serving.

Slow it down

Is eating too fast part of the problem? Here are some ways to slow things down: * Limit serving size. As we mentioned above, try placing just a few pieces of food on the plate at a time. Explain to your son that the serving needs to be eaten slowly and safely before receiving more.

• Use a timer or vibrating watch. Have your son use such a tool to space out appropriate intervals between bites. First, you may need to watch how long it takes him to safely and completely chew and swallow one bite of food. Adjust the timer setting accordingly. Generally speaking, 10- to 20-second intervals are about right.

Motivate

We’ve found that small, appropriate rewards will help most children master new behaviors. This includes motivating your child to accept controlled portions and learn appropriate spacing between bites. One approach is to provide small rewards for each small step in the right direction. These small rewards can be tokens that your child later cashes in for a desired activity or toy.

Or you can try a favorite activity as the reward. For instance, “First a mealtime without vomiting, then.…” The activity can be a favorite game, a walk to the park with you, some screen time, etc. (Note: We did NOT include dessert in this list of rewards.) We suggest reviewing the reward plan right before mealtime so your child understands that a favorite activity will follow a meal that stays down.

These strategies should serve as a springboard for additional behavioral supports that enlist the help of professionals. As we describe above, we want to encourage you to take advantage of autism specialists and resources in your area. 

Related resources

• ATN/AIR-P Guide to Exploring Feeding Behavior in Autism
• ATN/AIR-P Parent's Guide to Applied Behavior Analysis
• ATN/AIR-P Visual Supports and Autism Spectrum Disorder