Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions

A Practical Guide for Parents and Professionals

Gillian Harris, Elizabeth Shea

• Publisher: Jessica Kingsley Publishers
• Year: 2018
• Print ISBN: 9781785923180
• eBook ISBN: 9781784506322
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

Many children with Autism Spectrum Disorder (ASD) have a restricted dietary range, and this book provides parents with advice and training on how to deal with this condition and achieve a healthier and more balanced diet. Now described as Avoidant or Restrictive Food Intake Disorder (ARFID), it is due to sensory hypersensitivity, and it can impact upon the health of the child, upon the family, and upon social integration.

Based upon successful training packages the authors provide for parents and professionals, this book enables the reader to understand the condition and work with it, gradually increasing the range of food a child is able to eat. It includes 'box outs' with case studies, points of interest and action points to make this an accessible and resourceful read.

Part 1

Acceptance and
Rejection of New Foods in
Infancy and Childhood

Development Stages

Introduction to Part 1

The first part of the book introduces the developmental stages behind the acceptance and rejection of new foods in infancy and childhood. All of the information outlined in this part of the book is ‘evidence-based’; it describes research studies that have been carried out on children’s or adult’s eating behaviour.

We describe normal development in feeding, but also talk about those children who are often termed ‘fussy’. To begin with, we do use this term because it is so commonly used by parents and health professionals, but this doesn’t mean that we think such children are naughty or deliberately being difficult. Fussy children have problems with food that we need to be able to understand properly if we are to manage their eating behaviour in a helpful way. Fussy children usually have a slightly limited-range diet, but, when asked, parents will report quite a few foods that are eaten. In the first chapters we do therefore give some tips on how best to manage those children who might just be described as ‘fussy’.

As we progress through the first part of the book, we then refer more and more to those children who have greater difficulties with food. To begin with, we term these children as being avoidant around food or having a restricted diet. Later we introduce the eating disorder ARFID (Avoidant and Restricted Food Intake Disorder), which describes children and adults who have a very limited-range diet and who have a fearful response to new foods.

Most of this part of the book is written by Gillian Harris, so when I say ‘I’, I am referring to my own experience, and when I say ‘we’, I am referring to team clinical practice or team research findings.

The second part of the book focuses exclusively on children with a restricted dietary pattern who would gain a diagnosis of ARFID. This is mainly written by Elizabeth Shea. Here she concentrates on factors that maintain the avoidant response to food and describes approaches to intervention. This part of the book also concentrates on children on the autistic spectrum, who are more likely than neurotypical children to gain a diagnosis of ARFID. Similarly, when she says ‘I’, she is referring to her own experience, and when she says ‘we’, she is referring to team clinical practice or team research findings.

Chapter 1

The Early Stages

Why do we eat what we do?

How do babies get to like the foods that they like?

How do they develop the skills that they need to be able to eat?

They sent me home with a baby and no instruction book! I was determined to get it right, though, so I read everything and asked everyone what to do. But when I first gave him food on a spoon, he wouldn’t take it; he just spat it out and turned his head. They said to leave it for a while, because he wasn’t ready. So I left it, but when I tried again, he still spat the food out. I tried making my own food, I tried buying baby food from the shops, but nothing worked. He even began to scream when he saw the spoon. Eventually, I found one jar of food that he would accept, and we went with that. But when I started to introduce lumps, the same thing happened: he just spat them out and cried. This went on and on. He would take a few foods with his fingers, and then would take some yoghurts, and he didn’t mind bread and biscuits. So we got some meals that we could make up. Then when he got to two, he stopped eating some of the few foods that he did eat. I just didn’t know what to do anymore. They said leave him to go hungry or just make him eat the food, but I couldn’t do that because he got too upset. (Mother of a six-year-old boy)

When we meet a family who want help with their ‘fussy’ child, the first thing that we want to know is what they were like as baby. How did they respond to food when it was first introduced? This gives us an idea of how and when the problems might have started. Children don’t want to be fussy; they are not refusing to eat foods because they are being naughty. They refuse food because they don’t like the taste, the texture, or the look of the food; quite often it disgusts them. But this problem with food will have started right back in early infancy; feeding and eating problems start with our first experiences with food.

To begin with, we first have to ask and answer some basic questions. Why do we eat the foods that we eat? How do we get to like them? Why do we get to like them? Why do some people eat practically everything and some people are very fussy? Why is it that some foods are more likely to be rejected than others?

Think of our ancestors, roaming in forests and fields, or by the seashore looking for different things they could eat. When they first moved to a new environment, how did they know what to try and what would be good to eat? Some of the group would have to try a plant or a berry, to see if it would turn out to be safe. Once these adventurous few had found new foods that weren’t poisonous in some way, then it would make life easier for others in the group. The others could just copy the eating behaviour of those who had tried the food and were still alive to tell the tale! Learning about which foods to eat is all about learned safety, and we learn about which foods are safe to eat by copying what others eat.

This learning about which foods to eat has to be flexible; humans could not have evolved with fixed food preferences. This is because we live in such a wide range of climates and environments that we have to get our food from many different sources. It would be of little use if we had all evolved to like fish and berries but our family lived in a land-locked desert where these foods are not available. Some foods, however, are more likely to be rejected even though they are safe to eat, and this is because they have a strong taste such as bitter, or a difficult texture, maybe slimy or stringy.

Tastes

To understand what is going on here, we need to think first about how we have evolved and how taste preferences change and develop. Babies are born with a preference for a sweet taste; this will lead them to like the taste of breast milk which is slightly sweet and a good energy source. Babies learn to get to like three of the other tastes – salt, sour and umami – quite quickly, because they have got used to these tastes either in breast milk or in complementary solid food, when the baby is introduced to them. The more ‘different’ tastes that are given during this early stage, the more likely the baby is to accept new tastes. So the tastes or flavours that are usual in foods in any specific cultural group are the tastes that the baby will get to like, as a result of being given them.

I like sweet; I don’t like bitter

So four tastes are easy to get to like, but the last taste – that of bitter – is more difficult. Most mammals, including humans, have evolved with an inborn dislike of a bitter taste, because bitter tastes are usually associated with toxicity (oleander is an example of this – bitter-tasting and deadly poisonous). Plants that have evolved to have a bitter taste even though they might not be poisonous are less likely to be eaten both by mammals and by small children! So the vegetables that we might want our children to eat, such as Brussels sprouts, kale, cabbage and broccoli, are difficult to get to like because of their bitter taste. It takes more tastes to get a liking for these vegetables than it does for vegetables such as carrots, which are quite sweet.

Fussy children’s usual food preferences

Fussy children tend not to eat foods with a bitter taste.

There are also differences in how horrible bitter tastes are found to be. Some children and adults are born with an extreme dislike of bitter tastes; they are bitter ‘super tasters’. Others find a bitter taste slightly difficult, and yet some can hardly taste it at all. This means that some children will never get to like Brussels sprouts, however hard you try, and yet a brother or sister in the same family will have no problems with them at all.

There are other taste differences that we are beginning to learn about as well. Some people find the taste of beetroot rather earthy and nasty, some find the taste of coriander rather soapy, and yet others happily eat both beetroot and coriander. There are genetic differences now being discovered in response to many other tastes and foods, such as chamomile, vanilla and even Marmite! So we can’t be sure, then, that each of us finds the different tastes of food equally nice; a child who pulls a face at a food that their parent likes might just experience the taste in a different way.

We get to like the tastes of the foods that are safe to eat, because we are given them to eat at an early age, by or around six months. It is often quite easy to get a baby at this early age to accept a new taste. Most babies will take a new taste from a spoon into their mouth without refusing it, or put some finger food in their mouth to try it out. They will accept sweet and slightly sour or slightly salty food quite quickly. But this doesn’t happen when the child is older. Older children and adults have to taste a new food about ten times before they get to like it, especially if the new food has a taste that is unusual for them. So with an older fussy child, it isn’t easy to get a new food accepted. Some children might agree to try one taste of the food and then say ‘I don’t like it’ and refuse to try the food again. It is not the first taste that is so difficult for many children and parents – it is the second taste!

Maddy had been a vegetarian since the age of 14. She didn’t eat meat or fish. Because she had eaten meat as a child, she could touch meat and cook it for her partner, but she did find the smell of the butcher’s shop overwhelming and unpleasant. She read everywhere how good it was to have fish in your diet, and so she thought that she would try to start eating some again. But even though she had eaten fish as a child (very reluctantly!), she was unable to actually put any in her mouth. The smell put her off before she started, and she felt...

Table of contents

• Cover
• Title Page
• Contents
• Introduction
• Part 1.  Acceptance and Rejection of New Foods in Infancy and Childhood: Development Stages
• Part 2.  Avoidant and Restrictive Eating: Strategies and Interventions
• Final Words
• Bibliography
• Resources
• Index
• Join our mailing list
• Acknowledgments
• Dedication
• Copyright
• Of Related Interest