Individuals with developmental disabilities, including those with autism, may display skill deficits and problem behavior associated with eating (Munk & Repp, 1994; Smith, 1996; Ahearn, 2001). These behaviors can be divided into six categories:  (a) acquisition of eating mechanics, (b) proper use of eating utensils, (c) food acceptance, (d) eating etiquette, (e) appropriate mealtime social behavior, and (f) inappropriate or unacceptable behavior associated with eating. Left unaddressed, eating problems adversely affect a child’s health and social competency.  his article will review intervention procedures that have been found to be effective in remediating eating problems in children with autism.

In our experience a small percentage of young children with autism have difficulty learning to bite, chew, and swallow solid food. Adam at age four was still eating junior baby food and drinking from a bottle when he entered our education program.  He consumed all of his food by sucking and swallowing. As a result, he did not learn to use his lips, teeth, and tongue to chew and then swallow food. Semi-solids (e.g., cooked carrots, hot dogs) were selected as the initial target foods when chewing instruction began. We delivered manual prompts (i.e., we lightly prompted him at the jaw to open and then closed his mouth) to prompt him to bite off a piece of food. We then placed a tongue depressor in his mouth to prompt him to use his tongue to move the food between his upper and lower teeth, and manual prompts were delivered to help him open and close his jaws in a chewing motion. When the bite-sized piece of food was sufficiently chewed, he was given a sip of liquid to prompt swallowing.  We slowly faded these prompts through graduated manual guidance (Cooper, 1987; MacDuff, Krantz, & McClannahan, 2001). When prompts were completely faded, new foods were introduced. We programmed for generalization by having his parents participate in teaching sessions at school and later present mastered foods at home.

Learning proper use of eating utensils increases children’s independence and social competency. Instructors deliver hand-over-hand manual prompts to help children learn to properly hold and manipulate utensils when eating. Learning to use a knife to cut and spread is difficult for many children. Begin teaching these skills with soft foods and spreads. When prompts are completely faded harder foods can be added.

Some children with autism establish eating routines that include limited food preferences.  For example, Pete would only eat pizza or a hamburger, French fries, chicken nuggets from McDonald’s – not from other fast food stores. He did not eat any fruits or vegetables. Some professionals believe that these unusual eating patterns are indicative of food tolerance problems and recommend elimination diets (e.g., no dairy products). However at present there is no scientific evidence supporting the effectiveness of diet therapy and these diets are very difficult to follow (New York State Department of Health, 1999; Smith, 1996).  Behavioral interventions published in peer-reviewed journals for increasing food acceptance include: (a) social praise, (b) providing preferred foods as rewards, (c) delivering toys or activities as rewards, and (d) forced feeding (Riordan, Iwata, Finney, Wohl, & Stanley, 1984). We taught Pete to eat the food that his family has for supper. His parents sent food left over from the previous night’s supper to school the next day with his normal lunch. Lunch food was delivered as a reward for sampling and later completely consuming the new food. When Pete was independently eating supper food at school, his parents came to school during his lunch period to observe and have lunch with him. After Pete was eating the new food with his parents in school, he began eating the same meal as other family members.   

Behavior associated with proper eating etiquette includes using a napkin, eating with mouth closed, and eating at an appropriate rate. Many of our students use photographic or written activity schedules (McClannahan & Krantz, 1999) during lunch. These schedules include cues to eat, drink, use a napkin, and talk to classmates or teachers. Instructors deliver manual prompts to help children point to or read schedule entries and complete each task. Praise and tokens are delivered to reward children for following their schedules and eating with their mouth closed. Schedules promote an appropriate rate of eating by interspersing cues for other behavior (i.e., using a napkin and talking). Epstein, Parker, McCoy, and McGee (1976) decreased children’s eating rate by instructing them to put eating utensils down between bites. We have had similar success with this strategy.   

Some parents report difficulty in teaching their child with autism to remain seated when their family goes out to eat at a restaurant. Many of these parents add that their child does not sit down with the family to eat at home. Because families may have two working parents and other children with after school activities, it may be difficult to schedule meals when everyone is present. Typical children learn that while you can eat “on the go” at home, there are different behavioral expectations in a restaurant. However children with autism will benefit from a routine that requires her to remain seated throughout the meal. Reward your child with tokens (Ayllon, 1999) or bite-sized snacks for remaining seated at home and prevent access to food if she gets out of her chair. Tokens can be exchanged for a special reward (e.g., ice cream or a video) at the end of the meal. When your child is reliably staying in his chair at home, he is more likely to be successful in a restaurant.    

Because children with autism have significant developmental delays in language, conceptual, and social skills, they may not understand that taking other people’s food is unacceptable behavior. Teach your child to request food through incidental teaching (Fenske, Krantz, & McClannahan, 2001). When he reaches for food, model a verbal request (e.g., “more” or “French fries please”). When he imitates your model give him the requested item from a serving dish or container, not from your own plate. Older children should learn to ask you to pass the serving dish (e.g., “pass the French fries please”).

As was previously mentioned, mealtime schedules that include cues to eat, drink, use a napkin, and talk promote an appropriate rate of eating, and learning to participate in mealtime conversation is an important pro-social skill. Auditory and written scripts have been found effective in teaching conversational skills to children with autism (McClannahan & Krantz, 2005). Instructors manually guide the child to point to and read written scripts or activate and repeat auditory scripts. Adults who serve as conversational partners respond to child initiations with topic-related comments. For example, after a child reads the script “I like to eat ice cream,” the parent responds by saying “Chocolate is my favorite flavor.” Several published studies have shown that when scripts are systematically faded, children recombine instructor comments, previous scripts, draw upon their existing language repertoires, and generate novel interactions (Krantz & McClannahan, 1998; Stevenson, Krantz, & McClannahan, 2000). 

Inappropriate and unacceptable eating behavior displayed by some individuals with autism and other disabilities include pica (i.e., ingestion of inedible objects) and operant vomiting. Both of these behaviors have been successfully treated by a variety of behavioral procedures (Ginsberg, 1988). During the past 32 years learners in our early intervention, preschool, education, residential, and adult programs have seldom displayed these behaviors. Therefore they will not be discussed in detail in this article. 

Individuals with autism may display a variety of behavior problems and skill deficits associated with eating. Fortunately there are many empirically validated intervention procedures available to address these issues. Successful remediation of eating problems contributes to better health and acquisition of skills that increase children’s social competency. 

References

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