Cynthia is a Speech-Language Pathologist trained in the SOS Approach to Feeding, and works with children and their families following this approach. The information and advice in this article are in line with this training, with some information coming directly from Dr. Kay Toomey & Associates Inc., the founder and developer.
The Importance of Food in Growth & Development
We know that eating is only an instinctive drive for the first month of life. From birth to 3-4 months of age, we have a set of primitive motor reflexes (e.g. rooting, sucking, swallowing) which help us eat while we lay down pathways in the brain for voluntary motor control over eating. Between the end of the 5th or 6th months of life, these primitive motor reflexes “drop out” and eating is essentially a learned motor behaviour after six months of age. After 4-6 months, a child has three choices:
- Learn TO eat
- Learn to NOT eat
- Learn to KIND OF/SORT OF eat
During the first few years of life, a child's body grows rapidly and requires an adequate number of healthy foods and beverages for fuel during this period of rapid growth. It has been found that nutrient-dense foods, such as whole grains and leafy vegetables, can improve alertness, focus and memory. Furthermore, good nutritional eating habits in early childhood can have a significant impact on the development of language. Additional benefits of proper nutrition include:
- Greater academic success
- Lower risk of speech or language delays
- Healthy body weight
- Lower risk of illness or disease
- Proper function of the digestive system
- Strong bones and muscle function
- Healthy teeth, skin and eyes
Challenges That Can Arise
There are a confusing number of possible reasons a child may be a picky eater. A 2015 review of several studies that date back to the 1990s looked at kids’ eating patterns and found that fussy or picky eating habits were linked to and affected by everything from personality traits and parental control at mealtime to social influences and maternal eating patterns (Taylor et al. 2015).
A food jag is when a child eats the same food prepared the same way every day or at every meal. The problem with food jags is that children eventually get burned out on these foods and they are typically permanently lost from that child’s food range. In addition to all of these possible challenges, there may be physical and developmental difficulties at play.
When & Why Do Children Become Picky Eaters or Problem Feeders?
There are five major developmental shifts and four specific skills that occur or have to be learned properly in the process of learning to eat. When children shift from one cognitive stage to the next, their sensory functioning regresses, which means their feeding may also regress. In addition to this, when children and their families are undergoing major changes in their lives, whether this is related to stress or a positive life event, any child’s eating or feeding can be easily disrupted.
- At 4-6 months of age, there is a sensory tolerance/exploration shift that occurs when eating changes from being reflex driven to a voluntary motor movement.
- At 12-14 months of age, there is a shift when children are developing the skill of Tongue Tip Lateralisation. This skill is required in order to transition onto textured table foods and to achieve the correct positioning of food onto the back molars for chewing.
- At 18–36 months of age, there is a shift when children are developing Rotary Chewing. This skill is required to eat “real” meat, hard/raw vegetables and hard/raw fruits (especially with peels). There is a cognitive shift from Sensorimotor to Magical Thinking.
- At 5-7 years of age, there is a cognitive shift from Magical Thinking to Logical Thinking, and when children are developing a Positive Mindset.
- At 9-11 years of age, there is a cognitive shift from Logical Thinking to Abstract Thought.
Children who have identified or unidentified (usually mild) physical issues often don’t fully manage these transition times, which can result in picky eating or problem feeding. In addition to this, our family mealtime structure, our ability to be a good role model, and whether we allow our children to food jag, all play a role in the development of our children’s relationship with food.
Understanding Why Children with Autism Spectrum Disorder (ASD) Struggle with Eating
Research estimates that 60-80% of children on the Autism Spectrum will have difficulties with feeding/eating (Severling et. al. 2018; Hubbard et al. 2014). In the SOS Approach to Feeding, we use the analogy of an iceberg to help families and professionals understand why children don’t eat. The Feeding/Eating Problem is actually only the tip of the iceberg. It is the problem that everyone sees. However, it is what is “under the water” that is actually the real problem.
Children with ASD can have difficulties with eating for many reasons. It could also be a combination of the difficulties they are having in areas of human function involved in the process of feeding/eating well. Below are just a few examples:
- Organ Systems – Children with ASD often struggle with medical issues such as constipation, GI problems and/or food allergies/sensitivities.
- Muscles – When our muscle systems don’t work really well (e.g. low muscle tone, hyperextensible joints) we struggle with having good postural stability (which is necessary for being able to stay in a steady, upright seated position for at least 20 minutes).
- Sensory Systems – Sensory processing challenges are very often a part of ASD. These problems include not being able to visually tolerate the look of different/new foods, having touch over reaction to foods on the hands and/or in the mouth, experiencing difficulties with identifying smells correctly (discriminating different smells) and/or overreacting to the smell of foods, as well as being over or under reactive to the tastes of foods.
- Development – There are times in development where we know feeding gets better and worse for all children, as stated above in the 'developmental shifts'. Many children with ASD are developmentally delayed. As a result, they frequently have difficulties moving through the following times of developmental transition without their eating going downhill.
- Learning – Children with ASD learn differently from their peers. They are what is described as 'microscopic' learners. Children with ASD struggle to figure out what is the most important thing in their environment to pay attention to, so they notice EVERYTHING in their environment. This includes little differences from one setting to another and related to feeding, they notice every microscopic difference between foods cooked or prepared slightly differently, or even packaged differently!
Tips for Meal Times
No Pressure – At mealtime, let them decide what they want to eat, how much they want to eat or whether they want to eat at all. Here are some examples of what pressure looks like:
- “Just try one more bite.”
- “You’re not leaving this table until you eat it.”
- “You can have dessert as soon as you try this food.”
Make It Fun – Kids love playing with their food! Get messy, laugh and do silly things with the food (for example, making a carrot moustache). Playing with food can help children explore the sensory side of eating in a fun, no-pressure kind of way. However, don’t be afraid to set boundaries if your child starts to throw food. If that happens, try the phrase “food stays on the table” to set a clear boundary.
An Eating Schedule – It can be tempting to let your child graze on food all day, especially if they are picky eaters and you are just happy that they are eating something! But letting them eat freely like this can backfire for a child who is already considered picky, as they are less likely to feel hungry and, therefore, much less willing to try new foods. If they are asking for food in between scheduled times, try to stall them. For example, “Yes, let’s make some lunch. But first can you help me water the plants outside?”.
Do Not Bribe – When we use dessert to bribe kids to eat dinner, it reinforces to them that dessert is better and dinner is worse. This leads to even less liking of the dinner. However, it does not mean you can never have dessert. The main thing to remember is that getting dessert (or any other reward) should not be dependent on eating a certain amount of the meal or eating a specific food.
Be a Food Scientist – Try not to place labels on foods, such as "good", "bad", "healthy" or "unhealthy". All food is just food, with different nutrition and texture. Instead, become a "food scientist" and discuss the different properties of the food, and what food does in their bodies. Fun facts help kids want to learn more about foods and their bodies, and ultimately having a good relationship with food can also help with picky eating!
Keep Serving It – Even if you have tried a few times, don’t give up! Continue to expose children to different foods by offering the food repeatedly and in a variety of different ways. It does not need to be a big portion, a few pieces will be enough. Some kids need to be exposed to food an extremely high number of times before they will even consider trying it. For each meal and snack, try to serve a minimum of 1 protein, 1 starch and 1 fruit/vegetable (with a mix of preferred and non-preferred foods).
When to Get Help From a Professional
If you have tried the above strategies and you still feel like you need more help, refer to the list below. If your child has two or more of these red flags, reach out to a Speech-Language Pathologist and/or Occupational Therapist for a consultation.
- Ongoing poor weight gain, weight loss
- Ongoing choking, gagging, coughing during meals
- Ongoing problems with vomiting
- More than one incident of nasal reflux
- History of a traumatic choking incident
- History of eating and breathing problems
- Inability to transition to baby food purées by 10 months
- Inability to accept any table food solids by 12 months
- Inability to transition to a cup by 16 months
- Has not weaned off most/all baby foods by 16 months
- Food range is less than 20 foods
- Aversion/avoidance of all foods in specific texture or food group.
Feeding Therapy at KidsAbility
In Feeding Therapy Sessions at the KidsAbility Paediatric Therapy Clinic, they use the “SOS Approach to Feeding”. This is a developmental feeding therapy that allows a child to interact with and learn about foods in a playful, non-stressful way. It helps increase a child’s comfort level by exploring different properties of the foods, including colour, texture, smell and taste. Parent education and involvement are an essential part of this feeding programme.