**4. Treatment**

*Food records* are routinely used by nutritionists to measure energy intake. A systematic review [84] suggests that the 24-hour multiple pass recall conducted over at least a 3-day period that includes weekdays and weekend days, using parents as reporters is the most accurate method for children aged 4 to 11 years and that weighted food records provid‐ ed the best estimates of Estimated Intake for younger children aged 0.5 to 4 years. Cor‐ nish [54] used a three day food record to study a small group of children with ASD, aged 3 to 16 years where 8 had followed a gluten and/or casein free diet for various lengths (1 to 6 months) and 29 consumed a regular diet. Caregivers filled out a 3-day di‐ ary of all foods and drinks consumed. Nutrient intakes in 12 children were lower than recommended in *'Lower Reference Nutrient Intake'* for zinc, calcium, iron, vitamin A, B12 and riboflavin in the regular diet group and in 4 for zinc and calcium in the diet group although these differences were not statistically significant between the 2 groups. The median daily energy intake was 93% of *Estimated Average Requirements* (EAR) in both groups, and did not differ in the contribution of proteins, fats, or carbohydrates. Fruit and vegetable intake was higher and consumption of starches was lower in the diet group. The author notes that parents who followed the exclusion diet found that it iso‐ lated the family socially, food substitutes were difficult to find and costly, meals re‐ quired longer preparation time, and it was very difficult for the child to make the

Observation of the child's mealtime routine in his familiar environment provides insight into the family's daily life and the accommodations made for coping with problems [74]. The family may be so enmeshed in this routine that it does not always realize how it has adapted to the child's problem and to what extent the child's behavior or the envi‐ ronmental setting may contribute to the maintenance of problems. By making several vis‐ its to the home and by changing different variables (person, environment, social demands, sensory stimuli, liked vs non-liked foods…) the observer gets a clearer picture of the situation. If possible the evaluator should have a discussion with the child regard‐ ing his global understanding of eating and his recognition of any problems. If a home visit is not possible, the parent/caregiver should come to the clinic and bring some of the child's liked and non-liked foods. Familiar plates or utensils can also be brought. Evalua‐ tion will then focus on oral-motor skills, reaction to foods, intensity of food aversions, and acceptability of food modifications. A systematic presentation of foods was used by Ahearn et al. [10] for children with ASD. However, a major criticism with this type of evaluation is that it does not measure the severity or the problem experienced in the home, because the context is far from what the child is used to. It is more likely measur‐

ing the child's reaction to novelty or the influence of different contexts.

*The Multidisciplinary Feeding Profile* (MFP) was developed by Kenny and collaborators [85] with a group of 18 children, 6 to 18 years of age, who had neurological disabilities and were 'dependent feeders.' The evaluation is divided into six sections covering: I) Physical/Neurological factors such as posture, tone and reflex activity, 2) Oral-Facial

change to the new diet.

612 Recent Advances in Autism Spectrum Disorders - Volume I

**3.4. Direct observations**

Treatment must take the complete evaluation into account, including the interaction of the person with his familiar environment. Feeding cannot be treated as an isolated problem and the strategies employed should not be limited to mealtimes only. To illustrate: the stress a child experiences during mealtime may decrease his appetite or decrease his tolerance for tactile or olfactory stimuli. Also, if functional analysis reveals environmental contributions to the feeding problems, like inappropriate parental strategies to cope with behavioral issues during mealtime, treatment needs to include these routines as well.

Whether the treatment approach will be interdisciplinary or trans-disciplinary [19, 89] collaboration between different professionals is desirable, given the complex nature of feeding problems and the many factors to be considered [21, 39, 90, 91]. The degree of involvement may vary, depending on the expertise of the individuals involved, the etiol‐ ogy of the problem to be addressed or the relationship the professionals have with the parents [89, 90].

#### **4.1. Parent education**

When professionals help parents recognize the source of the feeding problem, the course of its evolution, and what contributes to its maintenance, the parent can become the pro‐ fessional's strongest ally, because parents know their child best. Engagement is better when parent and professional come to an agreement regarding treatment goals and pa‐ rent involvement is essential in a family-centered approach to treatment [92]. If the child is still young, one would anticipate that the child will become more food selective around the age of two or three years, as seen in typical development, and that this stage will be more challenging for a child with ASD. When parents first learn of the child's diagnosis, it may be wise to show them a number of coping strategies (Table 3), in order to prepare them for the developmental food refusals, or to prevent some problems from getting worse. Particular attention must be paid to prevent intrusive feeding and to assure the child is regularly exposed to variation in the menu and presentation of foods [38, 93]. Pa‐ rents' actions and their relationship with their child influence the course of mealtimes. Eating is not only about food. At the table members of the family enjoy each other's com‐ pany, the meal, exchange feelings and family/cultural values. When mealtimes are not pleasurable and some members do not feel respected with regard to their needs and choices, the relationship may become affected. When the strategies chosen by the parent affect the relationship and contribute to the maintenance of a feeding problem, alterna‐ tives may be suggested and modeling used, to demonstrate different actions and attitudes in response to the child's behaviors. Regardless which treatment approach is chosen, pa‐ rents must learn it and the transfer to different social environments must be carefully planned. It is hoped that regular follow-up with the family can be established, so that pa‐ rent support is ensured and that changes can be made when needed.

**4.2. Nutritional supplementation**

food supplements [94]. These will be described below.

diminish anxiety toward this food and new foods in general.

**4.3. Behavioral treatment approaches**

reinforced [95].

Feeding problems may be long-term problems. This is one reason why nutritional supple‐ ments may be useful to ensure that the child's health is not compromised [94]. This will re‐ quire a nutritionist's evaluation, to determine whether supplementation or modification of the existing diet is indicated. These changes have to be made carefully and follow-up is needed to ensure that they don't suppress the child's appetite or interfere with digestion. Another option is to introduce supplements in small quantities after each meal, or before bedtime. Modification of preferred recipes or the introduction of nutritional supplements to a child who refuses any change to his established mealtime routine may present a major challenge and considerable risk. It is best to try such changes under professional supervision because, if done wrong, children may eliminate another food from their already limited rep‐ ertoire. To increase the chance of success, it will be best not to change the sensory properties of preferred foods and to present modifications as similar as possible to the taste and texture of preferred foods [76]. Fading and desensitizing techniques are usually best for introducing

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Behavioral treatments must be based on a functional analysis in order to determine which behaviors contribute to the maintenance of feeding problems and what function these be‐ haviors serve (avoidance, attention seeking, pleasure seeking, obtaining a reward). Quali‐ fied professionals must supervise interventions so that no undesirable behaviors are

A number of studies have shown the effectiveness of behavioral interventions for increasing acceptance of new foods [15, 16, 96]. However, there are only a few studies demonstrating that acceptance of new foods generalizes to other foods or other environments and that pref‐ erences of the child have been taken into account [97, 98]. Different types of behavioral inter‐ ventions are often used in varying combinations [8, 97]. Positive reinforcement, for example, consists of rewarding the child when he shows the desired response. Sequential presenta‐ tion is a form of positive reinforcement. In this type of intervention acceptance of a non-pre‐ ferred food is immediately followed by a preferred food. In simultaneous presentation the new, non-preferred food is presented together with the preferred food. Although not men‐ tioned in the literature, clinical practice requires great care with this approach. If parents re‐ port that their child can detect the slightest change to a familiar recipe, or reacts negatively to different commercial brands when they look exactly alike, the child may be hypersensi‐ tive to flavors. When new foods are hidden in what is familiar to the child, they are often detected by the child. The danger of this approach is, that if the child has limited communi‐ cation abilities, he may not understand what happened to his food and thus, may refuse to ever eat it again for fear that this problem will repeat itself. It is best not to use this method without the knowledge of the child. First, the caregiver will want to decrease the risk that the child would eliminate one of his preferred foods from an already limited repertoire. Sec‐ ond, the child should be aware that a new food is being introduced, if we want to gradually


<sup>•</sup> Never force feed children

#### **4.2. Nutritional supplementation**

**4.1. Parent education**

614 Recent Advances in Autism Spectrum Disorders - Volume I

• Never force feed children

• Praise 'good' behavior.

• Plan for generalizations

**Table 3.** Principles of feeding

• Never require that children empty their plate

• Each child needs a designated seat at the table.

• Change constituents of menus regularly.

• Schedule regular meal times, to establish a cycle of hunger and satiety • Include activities before and after meals, to establish an anticipated routine. • Use adapted communication and/or visual cues to establish clear expectations

• Avoid commercial containers to facilitate the use of other brands

• Adapt portion size to the age of the child and to his average appetite.

When professionals help parents recognize the source of the feeding problem, the course of its evolution, and what contributes to its maintenance, the parent can become the pro‐ fessional's strongest ally, because parents know their child best. Engagement is better when parent and professional come to an agreement regarding treatment goals and pa‐ rent involvement is essential in a family-centered approach to treatment [92]. If the child is still young, one would anticipate that the child will become more food selective around the age of two or three years, as seen in typical development, and that this stage will be more challenging for a child with ASD. When parents first learn of the child's diagnosis, it may be wise to show them a number of coping strategies (Table 3), in order to prepare them for the developmental food refusals, or to prevent some problems from getting worse. Particular attention must be paid to prevent intrusive feeding and to assure the child is regularly exposed to variation in the menu and presentation of foods [38, 93]. Pa‐ rents' actions and their relationship with their child influence the course of mealtimes. Eating is not only about food. At the table members of the family enjoy each other's com‐ pany, the meal, exchange feelings and family/cultural values. When mealtimes are not pleasurable and some members do not feel respected with regard to their needs and choices, the relationship may become affected. When the strategies chosen by the parent affect the relationship and contribute to the maintenance of a feeding problem, alterna‐ tives may be suggested and modeling used, to demonstrate different actions and attitudes in response to the child's behaviors. Regardless which treatment approach is chosen, pa‐ rents must learn it and the transfer to different social environments must be carefully planned. It is hoped that regular follow-up with the family can be established, so that pa‐

rent support is ensured and that changes can be made when needed.

• Limit the amount of liquids (especially juice and milk), because very small amounts can decrease appetite.

• Introduce changes that are big enough to be recognized, but small enough that they will be tolerated.

Feeding problems may be long-term problems. This is one reason why nutritional supple‐ ments may be useful to ensure that the child's health is not compromised [94]. This will re‐ quire a nutritionist's evaluation, to determine whether supplementation or modification of the existing diet is indicated. These changes have to be made carefully and follow-up is needed to ensure that they don't suppress the child's appetite or interfere with digestion. Another option is to introduce supplements in small quantities after each meal, or before bedtime. Modification of preferred recipes or the introduction of nutritional supplements to a child who refuses any change to his established mealtime routine may present a major challenge and considerable risk. It is best to try such changes under professional supervision because, if done wrong, children may eliminate another food from their already limited rep‐ ertoire. To increase the chance of success, it will be best not to change the sensory properties of preferred foods and to present modifications as similar as possible to the taste and texture of preferred foods [76]. Fading and desensitizing techniques are usually best for introducing food supplements [94]. These will be described below.

#### **4.3. Behavioral treatment approaches**

Behavioral treatments must be based on a functional analysis in order to determine which behaviors contribute to the maintenance of feeding problems and what function these be‐ haviors serve (avoidance, attention seeking, pleasure seeking, obtaining a reward). Quali‐ fied professionals must supervise interventions so that no undesirable behaviors are reinforced [95].

A number of studies have shown the effectiveness of behavioral interventions for increasing acceptance of new foods [15, 16, 96]. However, there are only a few studies demonstrating that acceptance of new foods generalizes to other foods or other environments and that pref‐ erences of the child have been taken into account [97, 98]. Different types of behavioral inter‐ ventions are often used in varying combinations [8, 97]. Positive reinforcement, for example, consists of rewarding the child when he shows the desired response. Sequential presenta‐ tion is a form of positive reinforcement. In this type of intervention acceptance of a non-pre‐ ferred food is immediately followed by a preferred food. In simultaneous presentation the new, non-preferred food is presented together with the preferred food. Although not men‐ tioned in the literature, clinical practice requires great care with this approach. If parents re‐ port that their child can detect the slightest change to a familiar recipe, or reacts negatively to different commercial brands when they look exactly alike, the child may be hypersensi‐ tive to flavors. When new foods are hidden in what is familiar to the child, they are often detected by the child. The danger of this approach is, that if the child has limited communi‐ cation abilities, he may not understand what happened to his food and thus, may refuse to ever eat it again for fear that this problem will repeat itself. It is best not to use this method without the knowledge of the child. First, the caregiver will want to decrease the risk that the child would eliminate one of his preferred foods from an already limited repertoire. Sec‐ ond, the child should be aware that a new food is being introduced, if we want to gradually diminish anxiety toward this food and new foods in general.

In *food fading* a similar approach is used. The intensity of the taste or texture is decreased by mixing the new food with something that the child likes. For instance, one can mix a tea‐ spoon of home-made applesauce in a cup of commercial applesauce. If the child tolerates it, one can add a second teaspoonful at the next meal, and so on. If the child reacts mostly to visual changes he may be a good candidate for this particular approach.

Through analysis of a person's emotional as well as physiologic and autonomic reactions, professionals make a decision whether these constitute a SMD or not. The impact of this sen‐ sory excitatory state on activities of daily living, or on general development, must be signifi‐ cant in order to constitute a problem. The association of SMD with feeding problems has

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Analysis of the sensory components associated with meals is essential. For a child to func‐ tion optimally at meal times, he has to be in a calm and alert state. The clinician assesses the child's overall level of arousal prior to mealtime and may intervene to ensure an optimal state for eating. Exploration and tactile desensitization activities may be recommended, such as exploration of new foods through touch, smell, and taste [109, 110]. Some investigators have found a correlation between anxiety and over-responsivity; heightened sensitivity to sensory information mediates the impact of anxiety on selective eating [106]. If the child's anxiety level is too high, it is appropriate to start tactile exploration of familiar foods or items outside the eating domain. Manipulating foods with subtle differences in texture, smell, temperature and taste can help the child feel more comfortable in their presence and is often a preliminary step before accepting them to eat. When these exercises are done play‐ fully they are often less stressful for the child and facilitate participation. Finally, all compo‐ nents of a meal, e.g. utensils used or food textures, must be included in the analysis and can be modified to better suit the child's sensory profile. Despite the extensive use of these tech‐ niques in the clinical environment, research using appropriate controls is still lacking to cor‐

Graduated exposure food therapy is similar to systematic desensitization, a type of behavio‐ ral therapy used for specific phobias and other anxiety disorders. Treatment consists of sys‐ tematic and gradual exposure to the fear producing stimulus (food), the learning and application of coping strategies, observation of the development of tolerance and mainte‐ nance of the engagement of the child; finally, acceptance without adverse reaction, so that the targeted food eventually becomes an integral part of the child's diet. Another goal of de‐ sensitization is to gradually eliminate the fear/anxiety that is associated with eating and to replace it with more positive sentiments such as pleasure. Graduated exposure may com‐ mence with two types of hierarchy: 1) introducing foods that share some sensory properties with the child's preferred food (e.g. visual, taste, texture) as suggested by Fraker et al. [76] in Food Chaining© or 2) increasing the food's proximity, e.g. tolerating the presence of the food on the table - on the plate – observing it - touching it – smelling it - tasting it – chewing it and, finally, swallowing it [110, 111]. It may be necessary to use both types of hierarchy when introducing a target food. Change can take a long time and it is important that the child does not refuse foods that he previously accepted which can happen when familiar

been documented by some investigators [26, 40, 106-108].

roborate results from anecdotal reports [8].

**4.5. Graduated exposure food therapy**

food is modified without his knowledge.

Objective : Introduction of meat

*Antecedent manipulation* aims likewise at modifying the characteristics of a novel food or its presentation (e.g. texture, bite size, utensil, etc.), to make it more acceptable to the child and to fit the oral-motor skills of the child [8].

Escape extinction is used when the functional analysis shows that problem behaviors during a meal result in avoidance of encountering or having to eat a certain food. Physical guidance and non-withdrawal of the spoon are the general methods used for this situation [15]. The spoon is presented to the child and kept near his mouth until the food is accepted. Physical guidance consists of exerting slight pressure on the chin, to elicit opening of the mouth. Bad behavior is ignored. This approach is very difficult to accept for parents because it can be very taxing emotionally for both parent and child. Professional supervision is strongly rec‐ ommended, to prevent post-traumatic feeding problems or adverse effects on the parentchild relationship. We do not recommend using this approach on a long-term basis but rather for specific identified behavioral problems.

#### **4.4. Treatment based on the theory of sensory integration**

Sensory modulation describes a component of the theory of sensory integration [99]. It is de‐ fined as the ability of adjusting responses to the degree, nature, or intensity of the sensory environment [100]. Sensory modulation disorders (SMD) describe responses that are incon‐ sistent, inflexible and fail to meet the demands and expectations of the environment or a task [100, 101]. One or more sensory systems may be involved, such as touch, vision, hear‐ ing, proprioception, vestibular, smell and taste. According to Miller et al. [101], there are three subtypes of SMD; over-responsivity, under-responsivity, and seeking/craving. Chil‐ dren who are over-responsive react to sensory input more rapidly, and with greater intensi‐ ty and duration than the majority of their peers [101]. Over-responsivity can lead to avoidance or aggressive behavior, to escape discomfort caused by sensory input. Tactile de‐ fensiveness is part of this subtype and is probably the most documented SMD [40, 99, 100, 102-104]. Under-responsivity describes slower, less intense responses to sensory stimuli [101]. Children in this subtype are difficult to engage, they seem lethargic and lack the inner drive to explore their environment or initiate social contact. Sensory seeking/craving is de‐ fined as an 'intense, insatiable desire for sensory input' [100]. Available inputs are not enough for children in this subcategory. They need input of greater intensity. They may take risks and engage in socially unacceptable behaviors, and may have unusual olfactory or gus‐ tatory preferences.

People, in general, react differently to intrinsic (e.g. hunger, pain) or extrinsic (e.g. texture, taste of food) sensations. Reaction thresholds and sensory preferences are part of each indi‐ vidual's unique characteristics. However, these are not easy to measure objectively. Some in‐ vestigators do measure them, but their tools are not readily available to the clinician [105]. Through analysis of a person's emotional as well as physiologic and autonomic reactions, professionals make a decision whether these constitute a SMD or not. The impact of this sen‐ sory excitatory state on activities of daily living, or on general development, must be signifi‐ cant in order to constitute a problem. The association of SMD with feeding problems has been documented by some investigators [26, 40, 106-108].

Analysis of the sensory components associated with meals is essential. For a child to func‐ tion optimally at meal times, he has to be in a calm and alert state. The clinician assesses the child's overall level of arousal prior to mealtime and may intervene to ensure an optimal state for eating. Exploration and tactile desensitization activities may be recommended, such as exploration of new foods through touch, smell, and taste [109, 110]. Some investigators have found a correlation between anxiety and over-responsivity; heightened sensitivity to sensory information mediates the impact of anxiety on selective eating [106]. If the child's anxiety level is too high, it is appropriate to start tactile exploration of familiar foods or items outside the eating domain. Manipulating foods with subtle differences in texture, smell, temperature and taste can help the child feel more comfortable in their presence and is often a preliminary step before accepting them to eat. When these exercises are done play‐ fully they are often less stressful for the child and facilitate participation. Finally, all compo‐ nents of a meal, e.g. utensils used or food textures, must be included in the analysis and can be modified to better suit the child's sensory profile. Despite the extensive use of these tech‐ niques in the clinical environment, research using appropriate controls is still lacking to cor‐ roborate results from anecdotal reports [8].

#### **4.5. Graduated exposure food therapy**

In *food fading* a similar approach is used. The intensity of the taste or texture is decreased by mixing the new food with something that the child likes. For instance, one can mix a tea‐ spoon of home-made applesauce in a cup of commercial applesauce. If the child tolerates it, one can add a second teaspoonful at the next meal, and so on. If the child reacts mostly to

*Antecedent manipulation* aims likewise at modifying the characteristics of a novel food or its presentation (e.g. texture, bite size, utensil, etc.), to make it more acceptable to the child and

Escape extinction is used when the functional analysis shows that problem behaviors during a meal result in avoidance of encountering or having to eat a certain food. Physical guidance and non-withdrawal of the spoon are the general methods used for this situation [15]. The spoon is presented to the child and kept near his mouth until the food is accepted. Physical guidance consists of exerting slight pressure on the chin, to elicit opening of the mouth. Bad behavior is ignored. This approach is very difficult to accept for parents because it can be very taxing emotionally for both parent and child. Professional supervision is strongly rec‐ ommended, to prevent post-traumatic feeding problems or adverse effects on the parentchild relationship. We do not recommend using this approach on a long-term basis but

Sensory modulation describes a component of the theory of sensory integration [99]. It is de‐ fined as the ability of adjusting responses to the degree, nature, or intensity of the sensory environment [100]. Sensory modulation disorders (SMD) describe responses that are incon‐ sistent, inflexible and fail to meet the demands and expectations of the environment or a task [100, 101]. One or more sensory systems may be involved, such as touch, vision, hear‐ ing, proprioception, vestibular, smell and taste. According to Miller et al. [101], there are three subtypes of SMD; over-responsivity, under-responsivity, and seeking/craving. Chil‐ dren who are over-responsive react to sensory input more rapidly, and with greater intensi‐ ty and duration than the majority of their peers [101]. Over-responsivity can lead to avoidance or aggressive behavior, to escape discomfort caused by sensory input. Tactile de‐ fensiveness is part of this subtype and is probably the most documented SMD [40, 99, 100, 102-104]. Under-responsivity describes slower, less intense responses to sensory stimuli [101]. Children in this subtype are difficult to engage, they seem lethargic and lack the inner drive to explore their environment or initiate social contact. Sensory seeking/craving is de‐ fined as an 'intense, insatiable desire for sensory input' [100]. Available inputs are not enough for children in this subcategory. They need input of greater intensity. They may take risks and engage in socially unacceptable behaviors, and may have unusual olfactory or gus‐

People, in general, react differently to intrinsic (e.g. hunger, pain) or extrinsic (e.g. texture, taste of food) sensations. Reaction thresholds and sensory preferences are part of each indi‐ vidual's unique characteristics. However, these are not easy to measure objectively. Some in‐ vestigators do measure them, but their tools are not readily available to the clinician [105].

visual changes he may be a good candidate for this particular approach.

to fit the oral-motor skills of the child [8].

616 Recent Advances in Autism Spectrum Disorders - Volume I

rather for specific identified behavioral problems.

tatory preferences.

**4.4. Treatment based on the theory of sensory integration**

Graduated exposure food therapy is similar to systematic desensitization, a type of behavio‐ ral therapy used for specific phobias and other anxiety disorders. Treatment consists of sys‐ tematic and gradual exposure to the fear producing stimulus (food), the learning and application of coping strategies, observation of the development of tolerance and mainte‐ nance of the engagement of the child; finally, acceptance without adverse reaction, so that the targeted food eventually becomes an integral part of the child's diet. Another goal of de‐ sensitization is to gradually eliminate the fear/anxiety that is associated with eating and to replace it with more positive sentiments such as pleasure. Graduated exposure may com‐ mence with two types of hierarchy: 1) introducing foods that share some sensory properties with the child's preferred food (e.g. visual, taste, texture) as suggested by Fraker et al. [76] in Food Chaining© or 2) increasing the food's proximity, e.g. tolerating the presence of the food on the table - on the plate – observing it - touching it – smelling it - tasting it – chewing it and, finally, swallowing it [110, 111]. It may be necessary to use both types of hierarchy when introducing a target food. Change can take a long time and it is important that the child does not refuse foods that he previously accepted which can happen when familiar food is modified without his knowledge.

Objective : Introduction of meat

a. Kraft Dinner © (the child's preferred food) b. Other pasta, but with the Kraft cheese mixture c. Pasta with home-made cheese mixture d. Pasta with pink sauce e. Pasta with tomato sauce f. Pasta with meat sauce

**Table 4.** Example of Desensitization Based on Sensory Properties as in Food Chaining© [76]

In Food Chaining© [76], the child's food preferences are analyzed in detail to establish a point of departure from which professionals can enlarge the child's food repertoire (Table 4). No studies were found to support the effectiveness of this approach for children with ASD [112]. Nevertheless, it is currently in use in North American clinical environments and several documents addressed to parents and professionals mention it [76, 110, 113]. Hier‐ archical exposure, based on proximity, associated with individualized positive reinforce‐ ment showed promising results for some children with ASD [98]. Validation is needed with a more representative sample of the ASD population [98]. Graduated exposure may be used in combination with other approaches, mentioned earlier, to determine which foods may be easier to introduce first, to structure the progression of treatment, and to ensure that treat‐ ment does not progress too rapidly. Some use these strategies in combination with other trans-disciplinary interventions in group therapies as a means of exploring foods through games [111, 114]. This may be an interesting approach for children who have good symbolic play and imitation skills. Other authors have used graduated exposure with more cognitivebehavioral methods, such as in a competition table or a diary to describe the child's prog‐ ress, or with positive reinforcement or strategies to decrease stress [115]. All children in this last study were 7 years old or older. Some had autistic features, but none had a definitive diagnosis of autism. A self/auto-evaluation scale for the child who has fair insight, as well as an observation scale, are suggested by the authors of Food Chaining© to rate reactions when exposed to a new food [76].

temizing (i.e. categorizing according to who is present or when it is eaten: 'French fries' are eaten after swimming class, at McDonalds, with dad). Because the child with ASD is also hypersensitive, a minor change in cooking duration, a different tablemat, is immedi‐ ately detected and the presence of this new feature (often more than one, considering all the variations possible during mealtime) may no longer allow the child to include the 'new' food in his concept of 'French fries'. This interpretation of autism-related feeding problems could explain amelioration of feeding problems as children with ASD get older, as well as 'miraculously resolved' feeding problems observed sometimes in clinic or re‐ ported by parents. When the child understands and has a better global conceptualization of food and mealtime situations, his feeding issues may resolve very rapidly. Other ap‐ proaches such as sensory integration and graduated exposure may be complementary, be‐ cause the first addresses sensory hypersensitivity, which leads to hyper-systemization, and the second supports how changes can be introduced. According to Baron-Cohen et al. [50], changing one variant at a time is better to support the child in building general con‐ cepts. Another avenue may be inspired by cognitive remediation therapy used for chil‐ dren and adolescents with anorexia nervosa but it would have to be adapted to ASD, and

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Developing a teaching method to learn global concepts of food and eating specific to ASD may be needed. Baron-Cohen et al. [119] found an «autism-friendly» way to teach emotions to children with ASD which may potentially be adapted to the feeding domain. Eating and the socialization associated with it, touches a spectrum of emotions. Children with ASD seem to only recognize 'like vs dislike' and not the broader spectrum of 'tolerate, appreciate, enjoy, love, or crave.' Understanding these may also help them to explore and eat a larger

To achieve acceptable table manners, *Social Storiestm* [120] may be used to describe a meal‐ time situation, a skill or a food concept, that includes expected table manners, and aims at helping the individual with ASD better understand social expectations at mealtimes. A So‐ cial Storytm may be illustrated such that it explains to the child how meals are set up, why one has to eat, or even to explain what table manners are and what is expected at home or outside the home (i.e. formal and informal rules). This type of intervention was shown to be effective in a young boy with Asperger syndrome, for decreasing unacceptable table man‐ ners, such as spilling food and increasing desirable behaviors such as mouth wiping [121]. The TEACCH approach seeks to promote understanding and independence by adapting the environment to better fit the learning style of children with ASD [122]. Visual supports used in TEACCH to enhance predictability and understanding of a task would also be appropri‐ ate for eating. For example, one would place only a tiny amount of a new food on the child's plate, if the goal is only to taste the food. To help the child understand the sequence of the meal, one could place a visual sequence next to the plate, to illustrate what he is expected to do, how/when the meal will end and what will happen after the meal (e.g. sit at the table eat foods on your plate - drink beverage from your glass - wipe your hands - return to play).

maybe also focus more on food concepts and feeding situations [118].

**4.7. Adaptation of commonly used tools/approaches to ASD**

number of foods.

#### **4.6. Cognitive approach**

Sensory hypersensitivities are very prevalent in ASD [56, 116, 117]. Baron-Cohen et al. [50] suggest that excellent attention to detail observed in ASD results from this sensory hyper‐ sensitivity and that it leads to hyper-systemizing, an exceptional capacity to recognize re‐ peating patterns in stimuli; i.e. recognition of the rules that define a system. This theory explains «savantism» as well as non-social features of autism, like narrow interests, or re‐ sistance to change. When applied to feeding, some food selectivity or «illogical rules», like wanting food prepared exactly the same way every day, may be the expression of a strong systemizing capacity; i.e. sameness helps the child build concepts. According to Baron-Cohen et al. [50] a concept is a system and helps to define what items to include as members of the system. Therefore, a child's concept of 'French fries' may rely on visual systemizing (i.e. visual properties of the food are used to categorize: homogeneous light brown, thin and long, in a specific container), or alternatively on social/environmental sys‐ temizing (i.e. categorizing according to who is present or when it is eaten: 'French fries' are eaten after swimming class, at McDonalds, with dad). Because the child with ASD is also hypersensitive, a minor change in cooking duration, a different tablemat, is immedi‐ ately detected and the presence of this new feature (often more than one, considering all the variations possible during mealtime) may no longer allow the child to include the 'new' food in his concept of 'French fries'. This interpretation of autism-related feeding problems could explain amelioration of feeding problems as children with ASD get older, as well as 'miraculously resolved' feeding problems observed sometimes in clinic or re‐ ported by parents. When the child understands and has a better global conceptualization of food and mealtime situations, his feeding issues may resolve very rapidly. Other ap‐ proaches such as sensory integration and graduated exposure may be complementary, be‐ cause the first addresses sensory hypersensitivity, which leads to hyper-systemization, and the second supports how changes can be introduced. According to Baron-Cohen et al. [50], changing one variant at a time is better to support the child in building general con‐ cepts. Another avenue may be inspired by cognitive remediation therapy used for chil‐ dren and adolescents with anorexia nervosa but it would have to be adapted to ASD, and maybe also focus more on food concepts and feeding situations [118].

Developing a teaching method to learn global concepts of food and eating specific to ASD may be needed. Baron-Cohen et al. [119] found an «autism-friendly» way to teach emotions to children with ASD which may potentially be adapted to the feeding domain. Eating and the socialization associated with it, touches a spectrum of emotions. Children with ASD seem to only recognize 'like vs dislike' and not the broader spectrum of 'tolerate, appreciate, enjoy, love, or crave.' Understanding these may also help them to explore and eat a larger number of foods.

#### **4.7. Adaptation of commonly used tools/approaches to ASD**

a. Kraft Dinner © (the child's preferred food) b. Other pasta, but with the Kraft cheese mixture c. Pasta with home-made cheese mixture

618 Recent Advances in Autism Spectrum Disorders - Volume I

**Table 4.** Example of Desensitization Based on Sensory Properties as in Food Chaining© [76]

In Food Chaining© [76], the child's food preferences are analyzed in detail to establish a point of departure from which professionals can enlarge the child's food repertoire (Table 4). No studies were found to support the effectiveness of this approach for children with ASD [112]. Nevertheless, it is currently in use in North American clinical environments and several documents addressed to parents and professionals mention it [76, 110, 113]. Hier‐ archical exposure, based on proximity, associated with individualized positive reinforce‐ ment showed promising results for some children with ASD [98]. Validation is needed with a more representative sample of the ASD population [98]. Graduated exposure may be used in combination with other approaches, mentioned earlier, to determine which foods may be easier to introduce first, to structure the progression of treatment, and to ensure that treat‐ ment does not progress too rapidly. Some use these strategies in combination with other trans-disciplinary interventions in group therapies as a means of exploring foods through games [111, 114]. This may be an interesting approach for children who have good symbolic play and imitation skills. Other authors have used graduated exposure with more cognitivebehavioral methods, such as in a competition table or a diary to describe the child's prog‐ ress, or with positive reinforcement or strategies to decrease stress [115]. All children in this last study were 7 years old or older. Some had autistic features, but none had a definitive diagnosis of autism. A self/auto-evaluation scale for the child who has fair insight, as well as an observation scale, are suggested by the authors of Food Chaining© to rate reactions when

Sensory hypersensitivities are very prevalent in ASD [56, 116, 117]. Baron-Cohen et al. [50] suggest that excellent attention to detail observed in ASD results from this sensory hyper‐ sensitivity and that it leads to hyper-systemizing, an exceptional capacity to recognize re‐ peating patterns in stimuli; i.e. recognition of the rules that define a system. This theory explains «savantism» as well as non-social features of autism, like narrow interests, or re‐ sistance to change. When applied to feeding, some food selectivity or «illogical rules», like wanting food prepared exactly the same way every day, may be the expression of a strong systemizing capacity; i.e. sameness helps the child build concepts. According to Baron-Cohen et al. [50] a concept is a system and helps to define what items to include as members of the system. Therefore, a child's concept of 'French fries' may rely on visual systemizing (i.e. visual properties of the food are used to categorize: homogeneous light brown, thin and long, in a specific container), or alternatively on social/environmental sys‐

d. Pasta with pink sauce e. Pasta with tomato sauce f. Pasta with meat sauce

exposed to a new food [76].

**4.6. Cognitive approach**

To achieve acceptable table manners, *Social Storiestm* [120] may be used to describe a meal‐ time situation, a skill or a food concept, that includes expected table manners, and aims at helping the individual with ASD better understand social expectations at mealtimes. A So‐ cial Storytm may be illustrated such that it explains to the child how meals are set up, why one has to eat, or even to explain what table manners are and what is expected at home or outside the home (i.e. formal and informal rules). This type of intervention was shown to be effective in a young boy with Asperger syndrome, for decreasing unacceptable table man‐ ners, such as spilling food and increasing desirable behaviors such as mouth wiping [121]. The TEACCH approach seeks to promote understanding and independence by adapting the environment to better fit the learning style of children with ASD [122]. Visual supports used in TEACCH to enhance predictability and understanding of a task would also be appropri‐ ate for eating. For example, one would place only a tiny amount of a new food on the child's plate, if the goal is only to taste the food. To help the child understand the sequence of the meal, one could place a visual sequence next to the plate, to illustrate what he is expected to do, how/when the meal will end and what will happen after the meal (e.g. sit at the table eat foods on your plate - drink beverage from your glass - wipe your hands - return to play). Use of alternative and augmentative communication such as the *Picture Exchange Communi‐ cation System* (PECS) [123] may enhance communication and understanding of social set‐ tings between the child and members of the family at mealtimes.

criteria for sensory based food aversions. It is also not yet clear whether some of these feed‐ ing problems are specific to the population with ASD, if they are an associated condition or

Feeding Issues Associated with the Autism Spectrum Disorders

http://dx.doi.org/10.5772/53644

621

In the section on evaluation we noted that the age ranges of evaluations vary from infancy to late adolescence. New assessments may be needed if the age range for a particular do‐ main is not yet available. While a diagnosis of ASD is often not confirmed until a child is 3 to 4 years old, feeding problems are prevalent and often come to attention in infancy [70]. Treatment of a feeding problem does not depend on a diagnosis of ASD. Therefore, it can be dealt with as early as it comes to attention. Such an approach may prevent the serious longterm consequences in terms of weight gain and brain development [46]. Whether early feed‐ ing behaviors may become predictors for a diagnosis of ASD will need further study. However, inclusion of feeding evaluation at the time of the diagnostic work-up is highly rec‐

We proposed the *International Classification of Functioning* (ICF; WHO) as the model for eval‐ uation, in order to ensure that the interactions between the child's body functions and struc‐ tures, his health condition, and some contextual factors (i.e. environmental as well as personal factors) will be included in the global evaluation. As of this writing no standar‐ dized evaluation exists that covers all domains of this model. Some evaluations may cover some domains, e.g. activity/participation and environment, or personal factors and activity/ participation and so, feeding assessments based on all domains have to be accomplished by using several evaluations that in combination cover these domains. Another problem is that some of these evaluations have been developed for typically developing children or children with other diagnoses, and will need to be validated for children with ASD. As stated in the discussion of differential diagnoses, collaboration by an interdisciplinary team to develop a

Many of the evaluation tools reviewed above are questionnaires and may have satisfacto‐ ry psychometric properties [73, 77, 78], while others have only limited psychometric prop‐ erties [13, 85] and need further development. Questionnaires offer the advantage of describing the child's usual abilities. These behaviors are described by a person who is fa‐ miliar with the child, usually a parent or teacher, and reflects the observer's perception of the child's performance. Direct observations of the child's performance in his familiar en‐ vironment are still lacking. This constitutes a significant gap in the treating professional's knowledge, because the treatment plan will be based on results obtained from a question‐

Evaluation of children's nutritional state is based on caloric and nutrient sufficiency of the diet. These are commonly evaluated by food frequency questionnaires, and by 1, or 3-day food records [84]. Food intake is very individual, depending on the child's age and activi‐ ty level, as well as the cultural environment of the family unit. To judge intake adequacy, results are compared to established national standards such as *Estimated Average Require‐ ments, or National Recommended Intake Standards* (NRIS). Evaluation of nutrient adequacy

ommended for the many reasons that have been stated throughout this chapter.

tool comprising all three domains would move the field forward substantially.

naire or from contexts unfamiliar to the child.

a learned behavior complicated by their diagnosis.

**5.2. Evaluation**
