Case Study II: A Closer Look

What are potential feeding problems for typically developing children and children with ASD?

A young boy drinking from a cup

Feeding problems are common in typically developing children and can occur more frequently in children with ASD. When compared to children without ASD, children with ASD tend to:

  • Refuse more foods
  • Require more special utensils
  • Require food be presented in specific ways
  • Prefer food with less texture
  • Eat fewer foods

In addition, children with ASD may have pica, compulsive eating, mouth packing, or gagging and emesis. They may also associate discomfort with a certain food if the pain occurred just before or after consuming the food. Thus, they may repeatedly refuse that particular food item.

When evaluating a child with an ASD who has feeding issues, what medical problems should be considered before assigning a purely behavioral diagnosis?

Medical Problems
A young girl having a snack

Consider the following medical problems

  • Gastroesophageal Reflux Disease (GERD)
  • Dental pain
  • Oral motor dysfunction
  • Food allergy
  • Lactose intolerance
Other problems to consider for a child with ASD and feeding problems include:
  • Developmental delay
  • Obsessions/rituals related to food (color, texture) and environment (silverware, plates)
  • Anxiety
  • Sensory issues
  • Learned behaviors (parental response to escalating behavior)

Feeding Problems video icon

What would your next steps be if you suspect a nutritional deficiency?

Malnutrition
Because children with ASD have narrow food preferences, there is a concern about malnutrition. Adequate evidence to support these concerns is lacking. However, questions about a particular nutrient deficiency (i.e., iron) may require further evaluation.
Feeding Problems video icon

Treatment Plan

Your history and physical exam will determine your diagnostic evaluation and treatment plan.

  • If you suspect a nutritional deficiency, such as anemia, you may consider laboratory studies to evaluate for this.
  • A nutrition consult may help to determine a child’s nutritional needs and make recommendations to the family. Providing the family with strategies to promote healthy eating habits is essential for the picky eater.
  • For severe feeding problems (i.e., resulting in failure to thrive), you may need to employ the help of trained professionals in this area. These can include psychologists, occupational therapists, and speech therapists who are often part of a multidisciplinary team that specialize in feeding problems.

What would you recommend to help a parent encourage positive eating habits?

A little african american girl eating

Encourage parents to establish routine meal and snack times. At mealtime:

  • Minimize distractions (shut off TV, telephone)
  • Keep meals calm and strive for an enjoyable experience
  • Adults should sit down with children and eat the same foods
  • Offer the child what everyone else is eating, but also provide one of their preferred foods
  • Refrain from pleading and threatening to get the child to eat
  • After the family is finished, allow the child to leave the table
  • Food should not be provided until the next scheduled meal/snack

What are some barriers children with ASD may encounter when toilet training?

There are several barriers to toilet training children with ASD.

  1. Most obvious may be their communication delays, which inhibit their ability to verbalize when they have soiled or if they need to use the bathroom.
  2. In addition to expressive language delays, they may have difficulties with language comprehension. Therefore, they may not understand what is expected of them for the toileting process.
  3. A social reward system, used in typically developing children, may be ineffective for children with ASD because of their difficulties with social relationships. During the toileting process, typically developing children are praised for toileting in the potty and have a sense of accomplishment for a job well done. children with ASD may not possess the social motivation to please their parents by stooling in the toilet. They may not understand the difference between their diaper and the toilet.
  4. A strict adherence to routines can also make toileting difficult. Children with ASD often have difficulty with changes in their routine, so adding toileting to their daily schedule can be disruptive.
  5. Although not considered part of the diagnostic criteria for ASD, sensory issues often have a significant effect on children with ASD. Many sensory issues can arise during the toileting process:
    • Sitting on the toilet seat unclothed is a new experience that may require a gradual approach.
    • They may not recognize toileting cues (e.g., urge to defecate) making it difficult to rely on their own body’s signals for using the toilet.
    • Flushing the toilet may be an issue if they are overly sensitive to sound.
  6. Because of the many new experiences that go along with toileting, children with ASD and their parents can become very anxious about the entire process, adding another barrier to successful toilet training.

What medical issues may impact the toileting process?

A happy little boy

For any child with toileting problems, it is important to rule out constipation as a contributing problem. As constipation is a frequent issue, ask parents about it regularly.

  • Remember to review the child’s medication list for potential side effects (e.g., constipation with atypical neuroleptics).
  • Other medical problems to consider include urinary tract infections, tethered cord, or possible sexual abuse or trauma (may result from self-stimulation behavior).

What might you recommend to help Jack’s mother with bowel training?

Bowel Training
Little boy holding his caregiver's hand

Toilet training is an important milestone for any child to reach, but it can be especially challenging for a child with ASD. Providing careful guidance to the family of a child with ASD can make this process less difficult.

There are several techniques that can be employed, including timed sitting, visual supports such as picture icons, and awareness of sensory issues.

Timed Sits
A little boy outside on a fall day in a jacket

If the child with ASD is not able to communicate the need to use the bathroom, timed sits can be introduced.

  • For several days before having the child sit on the toilet, the parent or caregiver should record the child’s bowel habits – times that the child stools and frequency of wet diapers. With this information, they can identify patterns to the child’s stooling.
  • Have the child sit on the toilet fully clothed, then gradually remove clothing with subsequent sits. Provide some type of positive reinforcement for cooperative sitting on the toilet, such as a favorite book or toy. A timer can be used to help the child know how long they are expected to sit there.
Visual Cues

Children with ASD usually respond better to visual cues than to verbal ones.

  • Breaking down the steps of toileting into pictures can help the child understand what is expected of him or her.
  • Parents can use standard pictures or they may take pictures of their child going through the different steps and use those.
  • Parents can post a photograph of a toilet around the house and encourage the child to point to it when he or she needs to go.