Nutrition and Feeding Issues in Autism Spectrum Disorders Elisabeth Ceysens, MS, RD Mary Boehm, MA, CCC-SLP December 3, 2010
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Autism Programs at the CDD, HSC, UNM
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Autism Programs at the CDD, HSC, UNM
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Asking questions There are two forums to ask questions: 1. Public-chat: In the ‘Chat’ box type in your question in the ‘Public-chat’ tab—please note your question and name will be viewable by all participants. 2. Private-chat: Click the ‘Private’ tab and double click on the moderator (Paul Martinez) NOT the presenter-they will not take questions sent to their profile. Again, type in your question in the ‘Chat box’ to the bottom left of your screen. Please Note: Depending on the volume of questions not all question may be answered. Autism Programs at the CDD, HSC, UNM
Nutrition and Feeding Issues in Autism Spectrum Disorders Elisabeth Ceysens, MS, RD Mary Boehm, MA, CCC-SLP December 3, 2010 Autism Programs at the CDD, HSC, UNM
Feedback Question #1 True or False? All children on the autism spectrum have some kind of feeding problems. Autism Programs at the CDD, HSC, UNM
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Feedback Question #2 Do you agree? Yes or No? The gluten-free, casein-free diet is helpful to decrease symptoms of autism spectrum disorders. Autism Programs at the CDD, HSC, UNM
Feedback Question #3 True or False? Problem eaters on the autism spectrum can not learn to eat new foods.
Autism Programs at the CDD, HSC, UNM
Course Objectives • Describe nutrition and feeding concerns related to autism spectrum disorders • Introduce procedures to assess and treat feeding problems • Explain research and recommendations regarding dietary interventions for ASD
Autism Programs at the CDD, HSC, UNM
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Common Nutrition and Feeding Concerns • • • • • •
“Picky” or “problem” eating behaviors Difficulty with transitioning to age-appropriate diet Increased sensory/texture sensitivities Short attention span Limited variety in diet Need for routine
Autism Programs at the CDD, HSC, UNM
Eating Preferences • • • • •
Preference for dry, crunchy foods Refusal of soft, smooth textures Dislike of fruits and vegetables Preference for finger foods Preference for certain brands and preparation methods • Preference for food of particular color(s)
Autism Programs at the CDD, HSC, UNM
Picky versus Problem Eater Picky – Eats less than 30 foods – Eats at least one food in each food group – Tolerates new food on plate – Willing to try a new food after 10+ exposures
Problem – Eats less than 20 foods – Eats fewer foods over time – Refuses entire food group(s) – Need for sameness – Rigid eating behaviors – Unwilling to try a new food after 10+ exposures
Autism Programs at the CDD, HSC, UNM
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What about Growth? • The majority of children with ASD are of average height and weight
Autism Programs at the CDD, HSC, UNM
Bone Health • A study of 75 boys with autism ages 4 to 8 showed that the bones of the boys with autism was significantly thinner than bones of boys of the same age without autism. • Conclusion: selective food preferences and dairy-free diets put children at risk for calcium and vitamin D deficiencies. J. Autism Dev Disord (2008) 38:848-856 Autism Programs at the CDD, HSC, UNM
Other Nutrition Concerns • Vitamin and mineral deficiencies • Gastrointestinal concerns (reflux, constipation, diarrhea) • Drug-nutrient interactions • Food allergies and Celiac disease • Alternative therapies (CAM)
Autism Programs at the CDD, HSC, UNM
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Drug-nutrient Interactions • Medications decrease appetite and weight, and may stunt growth (stimulants - Ritalin) • Medications may increase appetite and weight (anti-psychotics - Risperdal) • Seizure meds affect calcium, vitamin D and folate metabolism (Dilantin, Tegretol) • Antibiotics may affect the intestinal flora. • Some medications cause GI distress
Autism Programs at the CDD, HSC, UNM
Diet Adequacy: What Do We Know? • Some studies show no difference in nutrient intake with typically developing children. • Other studies show children with ASD eat less than the recommended amounts of vitamins C, D, several B vitamins, iron and calcium. • A 2008 study* showed lower intake of vitamin A and calcium than controls. * J Amer Dietetic Assoc (2008) 108:1360-1363 Autism Programs at the CDD, HSC, UNM
Questions ?
Please type your questions into the Public Chat Box. Autism Programs at the CDD, HSC, UNM
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Feeding Assessment • • • • •
Parent/caregiver questionnaires Food diaries Sensory Profile Direct observation Functional behavioral assessment (2010) Seiverling et al, Journal of Physical and Developmental Disabilities.
Autism Programs at the CDD, HSC, UNM
Challenging Mealtime Behaviors • Food refusal – – – –
Crying or screaming Turning away from food Expels food from mouth Disruptive behavior
• Food selectivity – Refuses to try new foods – Refuses categories of foods (i.e. fruits & vegetables)
• Food Jags
Autism Programs at the CDD, HSC, UNM
Association between ASD and Eating Disorders • Anorexia and ASD may share genetic and neurobiological traits • Teen girls with Asperger’s syndrome showed higher risk for eating problems than typically developing peers (2009) Kalyva, Journal of Autism and Developmental Disorders
Autism Programs at the CDD, HSC, UNM
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Sensory Interventions • Food Play – Sensory exploration of foods outside of meal time to develop tolerance for appearance, textures, smells or tastes
• Food Chaining – Systematic presentation of foods that have similar properties to preferred foods
Autism Programs at the CDD, HSC, UNM
Visual Supports and Structure • • • • •
Develop functional mealtime routines Mealtime rules Portion sizes Visual Boundaries Visual supports for reinforcement
Autism Programs at the CDD, HSC, UNM
Behavioral Interventions • Intervention to target function of the behaviors – Reinforcement strategies: access to reinforcers during mealtime, simultaneous or sequential presentation of preferred foods – Escape extinction: ignore challenging behaviors and prevent escape/avoidance
Autism Programs at the CDD, HSC, UNM
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Caregiver Behaviors • Parent behaviors associated with increasing variety of foods the child eats – Schedule regular meals and snack times – Not preparing alternative meals – Encouraging daily intake of fruits or vegetables – Parents eat a variety of foods (2008) Williams et al, Journal of Developmental and Physical Disabilities Autism Programs at the CDD, HSC, UNM
Eating Strategies That Work • Avoid overwhelming the child • Introduce foods in forms that are similar to foods child already eats • Make small, gradual changes • Expect slow changes, but do expect changes
Autism Programs at the CDD, HSC, UNM
Questions ?
Please type your questions into the Public Chat Box. Autism Programs at the CDD, HSC, UNM
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Alternative Nutrition Therapies • No evidence-based research to show effectiveness of alternative treatments • Select alternative therapy with caution and be aware of possible toxicity
• Vitamin B6 and magnesium supplement • DMG • Antioxidants • Zinc • Coenzyme Q10 • B12
Autism Programs at the CDD, HSC, UNM
Gluten-Free, Casein-Free Diet • Leaky gut hypothesis: the gut allows peptide metabolites of casein and gluten to cross into the blood and then into the spinal fluid. • These peptides act as opiates in the brain and interfere with CNS function. • The implication is that this causes autism.
Autism Programs at the CDD, HSC, UNM
GFCF Diet: Studies • A meta analysis in 2004 showed no evidence for efficacy of GFDF diet. • A 2002 study of 10 children with autism (and 10 controls) showed significant improvement in autistic behaviors. • A 2006 double blind, crossover study found no differences between study diet and placebo diet. •Cochrane Database Syst Rev, 2004 •Knivsberg, Nutr Neurosci, 2002 •Elder, J Autism Dev Disord, 2006 Autism Programs at the CDD, HSC, UNM
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GFCF diet: Impact on Families • Extra time needed to buy and prepare foods/meals • Diet makes child “special” or “different” • Diet makes peer/social interactions more difficult • High cost of alternative foods
Autism Programs at the CDD, HSC, UNM
GFCF Diet: Nutrition Implications • Children on the GFCF diet eat more fruits and vegetables and less bread and cereals • Risk of nutrient deficiencies: – Gluten-free diet: Iron, zinc, B vitamins and folate – Dairy-free diet: Calcium, vitamin D,vitamin B2 and protein
Autism Programs at the CDD, HSC, UNM
Autism Programs at the CDD, HSC, UNM
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GFCF Diet: What to Do? • Weigh the pros and cons and decide if the diet may be an option for your child. • Start slowly. Start with CF or GF diet first, making a few changes at a time – watch your child! • Keep log of ASD symptoms, start diet, log symptoms again on diet several weeks later. • Supplement calcium and vitamin D. • Give a children’s multivitamin with minerals. • Talk to your pediatrician. • Consider consultation with a registered dietitian. Autism Programs at the CDD, HSC, UNM
Other Resources • Eating for Autism. The 10-step Nutrition Plan to Help Treat Your Child’s Autism, Asperger’s, or ADHA by Elizabeth Strickland, MS, RD. 2009 • Just Take a Bite. Easy, Effective Answers to Food Aversions and Eating Challenges. Lori Ernsperger and Tania Sten-Hanson. 2004 • Food Chaining. The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. Cheri Fraker. 2007
Autism Programs at the CDD, HSC, UNM
Supplements to Consider: Probiotics • Probiotics are live microorganisms (bacteria) that have beneficial effect on the gut flora. • No link between probiotics and autism symptoms • Used for general gastrointestinal health. • Each probiotic strain has a different mechanism of action and different effect on the body.
Autism Programs at the CDD, HSC, UNM
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Supplements to Consider: Omega-3 Fatty Acids • Omega-3 Fatty Acids: – inhibit the body’s inflammatory response – may help reduce childhood asthma, heart disease and rheumatoid arthritis – important in infant brain development – recent reports of altered FA metabolism in boys with ADHD
• Found in fatty fish, walnuts, flax seeds, canola and flaxseed oils
Autism Programs at the CDD, HSC, UNM
Omega-3 Fatty Acids Recommended Amounts*: DHA/EPA Combined • • • • •
1-3 years 4-8 years 9-13 years 14-18 years Adults
700 mg 900 mg 1200 mg 1600 mg 1600 mg
Note: Maximum amount for adults is 3000 mg or 3 grams per day. * Food and Nutrition Board, Institute of Medicine, Adequate Amounts (AI), 2002. Autism Programs at the CDD, HSC, UNM
When to Ask for Help? • Talk to your doctor and/or ask for referral to a pediatric nutritionist when – You are concerned about your child’s growth – Your child is a “problem eater” – You are considering starting alternative nutrition therapies and/or GFCS diet
Autism Programs at the CDD, HSC, UNM
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Questions ?
Please type your questions into the Public Chat Box. Autism Programs at the CDD, HSC, UNM
Contact information: Elisabeth Ceysens, MS, RD Voice Mail: 272-0285 email:
[email protected] Mary Boehm, MA, CCC-SLP Voice Mail: (505) 925-6024 email:
[email protected] Center For Development and Disability 2300 Menaul Blvd, SE, Albuquerque, NM 87107 Autism Programs at the CDD, HSC, UNM
Evaluations • Please fill out our online evaluation of the webinar, you will be directed there automatically at the conclusion of the webinar. – If you are sharing a computer to view the webinar, the others will need to access their emails and click the link provided to complete their survey.
• Please complete the evaluation by Wednesday 12:00 noon. Thank you! Autism Programs at the CDD, HSC, UNM
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