When does autism-related picky eating cross line to feeding disorder?

This answer is by pediatric psychologist Kimberly Brown, director of the Pediatric Feeding Disorders Program at the Kirch Developmental Services Center of the University of Rochester, New York. The university and its developmental center are part of the Autism Speaks Autism Treatment Network (ATN).

I know that food aversions and picky-eating are common among kids on the autism spectrum. When does picky eating cross the line and become something more serious that calls for professional help?

You’ve probably heard it before when talking with doctors and others about your child’s eating. “He’ll grow out of it.” “So long as weight is okay, no problem.” “She’s just picky.” However, if your child’s eating is distressing to you, I encourage you to trust your instincts and seek help.

Fortunately, there are some clear differences between picky eaters and children with feeding disorders. Not to be confused with “eating disorders,” feeding disorders typically involve extreme selectivity and sensory-related aversions to food tastes and/or textures. Sometimes they also involve difficulty with chewing and swallowing. By contrast, “eating disorders” include conditions such as anorexia and bulimia that relate to problems with body image and fear of weight gain.

Below, I’ve provided a checklist for distinguishing picky-eating from a feeding disorder that warrants intervention. This evaluation and intervention should involve a referral from your doctor to a pediatric feeding specialist or, even better, a comprehensive program such as ours in Rochester.

Our comprehensive feeding evaluation and intervention team includes a dietitian, speech language pathologist, nurse practitioner and social worker. We conduct assessments over two visits. During the first visit, we discuss parental concerns.

During the second session, we observe the child eat and gather further information to determine the basis of the feeding disorder. It might involve medical or neurological issues affecting the ability to chew and/or swallow. Alternately, it could stem primarily from a behavioral and/or sensory issue such as an intolerance to change or an aversion to certain textures or flavors. This information is crucial for designing a personalized treatment plan.

When designing a feeding therapy program, we begin by developing a personalized set of goals and strategies to improve the child’s eating. With one child, we may begin by working on chewing and swallowing skills. For another, we may focus primarily on building tolerance to food textures and consistency. 

In these and other ways, our goal is to increase willingness to try new foods, expand food variety and improve nutrition. The strategies we use to reach these goals include positive reinforcement to improve basic eating skills and the gradual introduction of new foods. When introducing new foods, we begin with those similar to the foods already acceptable to your child. We keep parents involved in every step of the treatment process. This way, they can learn the strategies and practice them at home.

A helpful checklist: Picky eating vs. feeding disorder

If your child meets two or more of the following criteria for a feeding disorder, I encourage you to seek out a pediatric feeding evaluation that can guide a personalized intervention program.

Food groups

• Picky eating: Willing to eat at least one or two foods from each food group (e.g. fruits, vegetables, grains, protein).
• Feeding disorder: Avoids entire food groups such as vegetables, protein or fruit.

Selectivity

• Picky eating: Has favorite foods, but will tolerate some variation in these favorites. For example, will eat a few different kinds of macaroni and cheese or hot dogs.
• Feeding disorder: Will eat only a specific brand of a favorite food or only foods of a particular shape or color.

Degree of resistance

• Picky eating: Resists certain foods with relatively mild behaviors such as whining, pouting and/or some arguing.
• Feeding disorder: Exhibits extreme anxiety when pressed to eat certain foods and/or acts out with highly disruptive mealtime behavior.

Effect on daily life

• Picky eating: Can find something to eat outside of the home – e.g. at parties, sleep overs, restaurants, etc.
• Feeding disorder: Has to bring desired foods when going out or has to eat at home beforehand.

Response to motivation

• Picky eating: Can be motivated to try a food by seeing friends eat it or with a promise of reward such as, “Eat you peas if you want ice cream.”
• Feeding disorder: Does not respond to rewards or seeing other people eating something. Shows no interest in foods outside narrow preferences.

Chewing and swallowing delays

• Picky eating: When evaluated by a professional, shows no significant problem with chewing and/or swallowing.
• Feeding disorder: When evaluated by a professional, may have missed developmental milestones for chewing and/or related feeding skills.

Nutritional deficiencies

• Picky eating: Daily diet, perhaps with a multivitamin, provides the majority of nutritional needs.
• Feeding disorders: At risk for nutritional deficiencies, as assessed by a nutritionist or other health professional.

Finding services

Your pediatrician or family doctor may be able to refer you to a feeding specialist or program in your area. If your child is under age three and receiving Early Intervention Services, you may also be able to add feeding assistance to his or her early intervention program. Find your state's Early Intervention office.

You can also contact the Autism Speaks Autism Treatment Network ATN center nearest you. Even if you are distant from the nearest ATN center, the staff may be able to help you find specialists or programs in your area. Find the ATN center nearest you.

Editor’s note: The above information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.