Avoidant and restrictive eating is hugely emotive. Eating difficulties are not exclusive to the Autistic population, but studies have shown that Autistic children exhibit more food refusal than typically developing children. (Bandini et al, 2010)
During our son’s autism assessment we expressed our concerns around his eating in quite some detail. We received an acknowledgement that William’s eating difficulties and sensory sensitivities are a common feature of Autism. Unfortunately though, there was nothing available in terms of support and guidance. The reality of the limited resources in the NHS, is that unless children are losing weight and becoming poorly, there really isn’t any provision for avoidant and restrictive food intake.
William’s eating is and has always been highly sensitive and restrictive. Despite this, his growth and weight are fine.
HistoryWe followed all of the usual advice about healthy eating from birth, including baby led weaning, but our boy’s sensory sensitivities and struggle to move from purees to more textured food was very clear.
We persisted, gained medical advice, read lots, but he continued to dislike the feel of many foods on his hands and his mouth. He struggled to touch anything wet or slimey and had a clear preference for a narrow range of flavours and smooth, non mixed textures. Of course we expected him to spit out or refuse new foods whilst weaning, but his disgust and refusal of a great many foods simply continued.
We kept trying and worrying and trying some more. We made many meals and pureed them, but they continued to be refused. We offered lots of finger foods and grazing plates but he would only accept a very small number of foods and one particular brand of pureed food and smoothies, which we kept in the cupboards, in bulk.
The fact that William breastfed well was such a great relief to us, as this allowed him to continue to gain additional calories and nutrition as well as much needed connection, reassurance, love and safety.
We continued to persevere with offering both the rejected foods and other new foods. We put a small bowl of something new, alongside his plate of preferred and safe foods. And we just kept trying. I presented the food on the plate in fun and appealling ways, bought plates with cars on; his great passion at the time. We baked and cooked together, played with foods creatively, touching, smelling and licking new foods.
The former stages of touching and smelling progressed, whilst the licking and tasting stood still. William is hypersensitive to the way food feels and tastes in his mouth.
Over time and instinctively, once we were able to tune out much of the advice given from a neurotypical perspective, we realised that it was crucial for William to be able to have his preferred foods.
If we had witheld William’s safe foods and followed a more traditional route, believing he would eat when he was hungry, we would have had a very poorly boy.
William’s relationship with food was not something we could tell him to “do” differently. This struggle was not an intentional or willful one. It was also not similar to other children who might be described as “fussy”.
William still has very strong responses to food now and there is only a short list of foods that he will accept. His short list of safe foods are mainly beige in colour. He gags and recoils at strong food smells, covering his nose and mouth. Certain textures repulse him and any mixed textures are off limits.
Any food that looks different from his safe foods cause him great anxiety. He is intolerant of uncertainty and he experiences sensory overwhelm when faced with new tastes and textures.
His safe foods all need to be presented in a certain way with different food types never touching. His brand loyalty is ferocious and we dread it when the manufacturers change their packaging or when a product becomes out of stock. Being able to keep a good stock of William’s foods is so important.
William’s process of eating is also very specific and ritualistic in ways that are individual to him.
I spent so many hours feeling that this must be my fault, that I had failed in some way. I had my own significant difficulties with food growing up and as an adult, perhaps I had somehow transferred these?
But in reality, despite the propensity many of us have for Maternal guilt, it is really important to know that some things are outside of our control. These kinds of eating difficulties are not behavioural, they are not a product of a child’s environment or parenting, they are part of a child’s neurology. William’s nervous system responds to sensory information in a very specific way and respecting and understanding this, is such an important part of our role as parents.
That doesn’t mean that we can’t help however. William’s private OT assessment in 2017, which led to a diagnosis of sensory modulation disorder and him having what is referred to as a sensory diet, was really helpful in terms of developing our understanding of William’s eating difficulties. (At this stage I had limited insight into my own sensory needs and sensitivities and so this process was really important for me as a parent and as a person).
William’s assessment identified his sensory sensitivities and inability to tolerate and organise the complex sensory information that was overwhelming him during meal times. He was given an individually tailored sensory diet to address his sensory sensitivities around food, with a range of sensory integration activities.
*It is important to add that William’s sensory diet targeted all of his body’s sensory needs, because so many other aspects of sensory processing difficulties, for example difficulties with sitting, posture and knowing where the body is in space (propriocpeiton), can also have a significant impact on eating.
Implementing William’s sensory diet did, very gradually, help improve his readiness to eat. It has not yet impacted the range of foods William will try, but there is no hurry up button in this process. Just improving William’s readiness to eat has been a really significant part of this very long journey.
Sensory Activities That Support Eating Readiness.
Readiness to eat requires the body and nervous system to be in the right state too. Supporting William to gain the right balance of vestibular input (through swinging, rolling, spinning and so on) and increased proprioceptive input (through pushing, pulling, crashing into bean bags, deep pressure and use of a vibration plate) supports his nervous system to eat.
This is about gaining the right balance of ‘activation’ so that he is both alert and calm enough to start his food.
His body and nervous system need to be in the goldilocks “just right” state to be ready to eat.
As well as getting the balance of activities right, William also needs the rest of his environment to be just right. His body and nervous system need calm and quiet to feel safe enough to settle to eat. A calm and quiet environment, down regulates William’s nervous system, allowing his neuroception of threat to quieten.
Understandably this makes it more likely for William to feel ready and able to eat.
When the nervous system feels under threat, fighting, fleeing or freezing are priorities, eating is not. This is a neurobiological truth for us all.
We regularly build on William’s original sensory diet. There are a wide range of sensory integration activity ideas online, that help keep choices new and interesting. Knowing that novelty can be really engaging for children with PDA, means that choice and new offerings can be really helpful. Once we understood William’s sensory profile (and this is where I would always recommend an independent sensory assessment) we gained a deeper sense of what his individual body needs. This allowed us to feel much more equipped to support and empower him.
For us, this was about understanding the sensory input William needs more of and the sensory input he needs less of, in order to function at his best.
Being able to offer William choice, creativity and flexibility is the difference between active curiosity and engagement and a strong “No, I’m not doing it!”.
We also found that attending sensory processing training, delivered by the specialist OT team, really helped us to develop our toolkit. Feeling empowered enough to implement the sensory diet at home, with confidence, has been so important.
We have also found that continuing to read and research has given us more confidence. There is a wealth of research information available online and a range of really helpful books too. The work of Kranowitz and Ayres were key starting points for us.
THE INTERSECTION BETWEEN AUTISM, PDA, SENSORY PROCESSING DIFFICULTIES AND ARFID
It became increasingly apparent, that addressing the sensory aspects of William’s eating difficulties was only one part of the picture. We began to realise that William’s PDA, his need for autonomy and freedom, was also playing a role in his relationship with food.
With this in mind, we tuned in more closely to what William’s interactions around food were communicating. His behaviour was screaming:
Back off, I really NEED to be in control of this! When I have no control I feel threatened and too anxious to eat!
There was also a clear pattern of decreased food intake whenever we failed to provide the right level of choice and control that our boy needed.
We increased our flexibility, by removing expectations such as the need to eat at the table, or to sit down whilst eating (all demands most of us will have grown up being expected to meet).
We are relaxed about William wanting to watch his TV or tablet whilst eating; this clearly distracts him from the demand of eating.
We also found that being as relaxed and “unconcerned” about what William was choosing to eat, really helped. With time, I could see more clearly that William could sense my need for him to eat and how demanding and off putting this was to him. (I have no idea, with hindsight, how I didn’t know this in the beginning, because I hate being out of control of my own eating.)
Providing choices, but not too many is also really effective at times, whilst at others it is more helpful to just leave a plate of safe/preferred foods by William while he watches TV. When he is already at his demand limit, we will just leave the plate without talking. At other times we might say something really low key such as “I was making myself some snacks and I’ve done a few for you too.”
We also refocused on improving our use of declarative language at mealtimes, categorically avoiding phrases such as you “must” or “need to” eat.
Using a food divider plate, so that different foods do not touch each other, has also been a practical and helpful strategy.
The many considerations involved around supporting William to eat, took on new meaning for us when William was assessed by a Specialist Educational Psychologist with expertise in PDA. As a result of this very comprehensive assessment, we learnt that the eating difficulty William has is consistent with:
“Avoidant and Restrictive Food Intake Disorder” (ARFID).
We hadn’t come across ARFID before and it felt incredibly helpful to have a name and framework to refer to.
ARFID was introduced into the fifth edition of the Diagnostic and Statistical Manual (DSM-5) in 2013 and so it is still relatively new. This new information sent us off on another really helpful learning curve of reading and researching.
You may have seen articles describing the link between Autism and Anorexia:
This link is becoming more widely accepted, but there is much less research about the relationship between Autism and ARFID and none, that I have found, specifially about the relationship between PDA and ARFID.
Since reading more about ARFID, I feel we have a much clearer framework from which to understand William’s eating difficulties and crucially from which to help and support him.
The following book was a fundamental part of being able to gain this insight:
“Food Refusal and Avoidant Eating in Children, including those with Autism Spectrum Conditions: A Practical Guide for Parents and Professionals” https://www.amazon.co.uk/dp/1785923188/ref=cm_sw_r_cp_apa_i_Xn5GCb6ZE6M5G
The book explains the core features of ARFID which in summary are:
Sensory hypersensitivity: Visual, texture, smell, taste and noise.
Neophobia: Rejects foods that look different.
State anxiety at mealtimes: Rigidity, routines, and rituals.
Rigid food categories: Brand loyalty and the importance of packaging.
It also explores strategies that have been shown to work including:
Allowing preferred foods in order to maintain expected growth trajectory, managing appetite, sensory hypersensitivity, rigidity, routines & rituals and crucially managing anxiety.
The book acknowledges how difficult ARFID can be to deal with in relation to PDA and how it requires a distinct and different approach.
The book explains that the majority of children with ARFID maintain their expected growth pattern IF they are allowed their preferred and safe foods. And whilst very often; a child with ARFID may not be underweight, it is incredibly important that recognition is given to the difficulties they have around eating.
Non recognition of ARFID can lead to a dismissive approach where the child is described as “just being fussy”, or having “something they will grow out of”. ARFID is not something a child will easily grow out of without the right support. Gaining the right help and information allows children to be supported appropriately and not denied their preferred foods or “made” to follow the rules, just because everyone else has to.
Following an accepting and validating approach can also help to increase the range of foods a child may be able to try in the short and long term.
This is very much where we are. Now that we recognise William’s eating difficulties are consistent with ARFID we feel more informed about how to balance the different aspects.
Our plan includes:
Maintaining the regularity and frequency of William’s sensory diet.
Continuing to use a PDA friendly approach.
Providing open invitations to engage in messy play which focuses on the hands.
Offering opportunities to join in with activities that help to stimulate the face and lips, through shared activities where different materials are explored together, such as brushes, rollers and feathers.
Experimenting with other activities such as blowing through straws and using face paints also offers different, less threatening opportunities to explore different textures by and around the mouth.
This whole process of reflecting on our relationships with food, has led me to wonder about the intersection between ARFID, Autism, Sensory processing difficulties and the PDA profile of Autism, where intolerance of uncertainty, anxiety and avoidance all feature highly.
I would love to hear your thoughts and experiences on this topic. It would also be great to hear about any resources or research that specifically relate to PDA and ARFID that you may have come across.
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Bandini, L. Anderson, S. Curstin, C. “Food Selectivity in Children with Autism Spectrum Disorders and Typically Develop Children”. Journal of Paediatrics. April 1, 2010
Harris, G and Shea, E. Food Refusal and Avoidant Eating in Children. London: Jessica Kingsley Publishers, 2019
Link to a very helpful video by Dr Elizabeth Shea: