Intervention Guide For Eating Disorders in Children On The Autism Spectrum (ASD)

Authors: Baratas, M.; Hernando, N.; Villalba, L.; Matas, M.J.; Enrique, M.D.
; Loste,
Ch.; Hijosa, L.; Subijana, E.

INTERVENTION GUIDE FOR EATING DISORDERS
IN CHILDREN ON THE AUTISM SPECTRUM (ASD)

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MADRID AUTISM FEDERATION | INTERVENTION GUIDE FOR
EATING DISORDERS IN CHILDREN WITH ASD

IN CHILDREN ON THE AUTISTIC SPECTRUM (ASD)

PRESENTATION

INTRODUCTION

BLOCK I
NUTRITION IN CHILDREN

1. What dietary habits are healthy and necessary to get proper nutrition?
2. What are the milestones in nutritional development during childhood?

BLOCK II
AUTISM SPECTRUM DISORDERS (ASD)

3. What are Pervasive Developmental Disorders/Autism Spectrum Disorders?
4. What educational intervention is recommended for ASD?

BLOCK III
NUTRITIONAL PROBLEMS IN CHILDREN WITH ASD

5. What is it possible to attribute eating disorders to in children with ASD?
- Sensory disturbances
- Hyper selectivity
- Possible gastrointestinal problems
- Classic negative conditioning
- Illnesses: Allergies and intolerances
- Behavioural problems linked to other areas of development
6. Which nutritional problems are associated with children with ASD?
- Disturbed eating pattern
- Aversion to eating solids
- Extremely limited variety of ingredients
- Marked rituals
- Behavioural problems

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- Pica disorder
IN CHILDREN ON THE AUTISTIC SPECTRUM (ASD)

7. How can we intervene?
- General considerations
- Steps of intervention
- Practical examples
- Support strategies for intervention
8. Health and oral hygiene

APPENDIX

BIBLIOGRAPHY

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PRESENTATION

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The Madrid Autism Federation is made up of a platform of social bodies that work for
people with ASD and their families. They provide an important service in the area of
information and advice in the Community of Madrid. In addition they act as a meeting
point and help promote awareness and research, the formation and defense of the
rights of people with ASD, with the objective of creating a more inclusive, open and
responsible society.

With the aim of providing services and sharing experiences, this Intervention Guide for
Eating Disorders in children with Autism Spectrum Disorders has been created to
respond to the demand for information about nutrition problems from families and
professionals working with our collective, mostly for children in their first years of
school.

This demand has become more and more visible, which could be related to the fact
that the number of cases that result in a diagnosis of ASD are increasing. Currently a
prevalence of one case of ASD per one hundred and fifty births can be expected,
according to recent studies carried out in Europe and the USA.

The enquiries that we make in the information and advice service of the Madrid
Autism Federation are usually aimed at getting answers to questions such as: What do
I do with my child that doesnt eat properly? Why is this happening to them? What can
I do at home to resolve it? Or questions like; who can help us?

The anguish of worried parents who are immersed every day in a battle to get their
child to eat properly results in psychological and physical exhaustion that needs to be
alleviated. Watching over the eating habits and correct nutrition of children in order to
ensure their well being is the common objective of the families, professionals and
bodies related to people with ASD.

After carrying out a theoretical revision of the existing bibliography and realising the
lack of practical materials available, the Madrid Autism Federation considered it
necessary to create a reference guide aimed at families and professionals to address
nutritional problems in children with ASD.

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The intention of this project was to fulfil our duty with the support of an
interdisciplinary team available to work with specific resources. Mara Baratas
(psychologist), Nuria Hernando (educational psychologist and teacher), Luca Villaba
(nutritionist) and M Jess Mata (community intervention specialist) have all worked
towards this and created the material that has now become a reality.

Thanks to this team for their dedication, effort and knowledge they made available to
others, to all the bodies that form part of the Madrid Autism Federation for supplying
their experience, the Social Affairs Council for encouraging the existence of the
Information and Advice Service, the Council of Madrid, specifically Family affairs, Social
Services and public participation for accepting the challenge to edit, format and make
this text accessible to everyone which we hope will be a first step in working more
efficiently for a better quality of life for children in Madrid with ASD and, due to
globalisation, many other areas where its necessary. Our Federation is very proud

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INTRODUCTION

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This guide seeks to offer a theoretical-practical knowledge base thats needed to
successfully tackle nutrition problems that are frequently associated with children with
Autism Spectrum Disorders (ASD).

To do this weve divided the guide into three sections:

The first section describes nutrition in children: defining which eating
habits are proper and healthy amongst children as well as a review of the
milestones of nutritional development that can serve as a reference during
a childs early years.

In the second section we are going to focus on Autism Spectrum Disorders:
what they are and what strategies are recommended in areas of learning.
This will be helpful when it comes to designing a type of intervention.

In the third section we will address the difficulties that are presented in
the nutrition of children with ASD: what are possible triggering factors,
identifying these eating disturbances, and most importantly: in what way
can we intervene, with the help of professionals. Furthermore, we will
present aspects of health and oral hygiene which we consider important
due to their relation with eating disorders.

We hope this guide will serve as a tool to facilitate families and professionals faced
with the arduous task of intervening in any kind of disorder associated with the
nutrition of children with ASD.

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BLOCK I

NUTRITION IN CHILDREN

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Healthy nutrition during infancy is the base for generating energy that the child will
need to face each day and participate in the variety of stimulating and educational
tasks essential for the physical and intellectual development that their environment
offers them. Eating properly and enjoyably without struggle or discomfort is necessary
to achieve well being.

Professionals and parents need to be aware of the importance of following a suitable
nutrition plan and acquiring healthy eating habits from a young age. Because of this, in
this first section we would like to address which eating habits are healthy and
necessary during childhood and also find out which are the nutritional development
milestones during these early stages. These milestones will serve as signs to indicate if
there are disturbances in nutritional development when the child deviates significantly
from the norm.

1. What dietary habits are healthy and necessary to get
proper nutrition?

Life expectancy is increasing in our modern society, and the challenge is to achieve a
high quality of life for these years. The sooner we acquire healthy habits the easier this
is to achieve.

Good health allows us to face the diverse conditions of life with its great benefits and
possibilities of overcoming any difficulties we may have.

Health is a state of complete physical, mental and social well being which largely
depends upon the nutrition and diet that we have. Its vital to have a healthy and
nutritious diet with the necessary amount of proteins, vitamins, carbohydrates and
other nutrients which allow us to function correctly.

The objective of a childs nutrition isnt just optimum growth and avoiding malnutrition
and deficiency diseases but also to optimise the maturing process (motor, cognitive,
perceptive, emotional) establishing healthy eating habits and preventing the
appearance of diseases that can affect adult life.

From their first year of life a child rapidly grows, growing approximately 12cm/per
year, gaining 2.5k/per year until they reach two years old. After the first year they
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reach a steadier period, growing at a rate of between 6 and 9cm/per year gaining
between 2.5 and 3.5k/per year.

In order to maintain a balanced and healthy diet and so these growth conditions are
maintained as comparable to the majority of children at this age, foods from all groups
must be present for the correct amount of nutrients. All of the nutrients are
proportionate to the body, its vital energy so the body can function. Food can be
classified according to its nutrient content. According to this classification we have
protein, carbohydrate and fat.

We mainly classify the nutrients as proteins which come from animals, thats to say
meat, fish eggs Carbohydrates are the nutrients that grow in the ground such as
vegetables, cereals, fruit and fatty nutrients are things such as oil and butter.

Due to this classification, to attend to nutritional needs and establish healthy habits for
life we can consider the following:

a. A variety of foods must be provided often as indicated below.
b. Its important to restrict the amount of salt used for cooking as well as when
eating with the aim of accustoming children to the natural flavour of foods
avoiding future illnesses such as hypertension.
c. Reduce the consumption of sweet products, not just those from industrial
baking, but to avoid a future dependency on sweet flavours.
d. Stimulate the consumption of vegetable products like cereals, legumes, fruits,
vegetables and leaves above products that come from animals.

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These considerations are deduced in a simple way, classifying nutrients by groups and
establishing more precisely the intake quantity of each group. The Food Pyramid
proportions this for us in a visual way.

1
Estrategia NAOS: Estrategia para la Nutricin, Actividad Fsica y Prevencin de la Obesidad dirigida
especialmente a nios y jvenes.
http://www.naos.aesan.msssi.gob.es/naos/ficheros/estrategia/estrategianaos.pdf

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As we can see from the Food Pyramid, food is classified according to its food group.
According to the Spanish Agency for Food Safety the daily or weekly consumption of
these food groups should be as follows:

FOOD CONSUMPTION
Water 6-8 portions/day
Bread At every meal
Olive oil 3-6 portions/day
Fruit and vegetables 5 portions/day
Dairy 2-4 portions/day
Rice, potato, pasta or cereals 2-3 portions/day
Fish 4 portions/week
Meat 3-4 portions/week
Eggs 3 portions/week
Legumes 2 portions/week
Sugar, sweets, sweetened drinks Moderate and limited consumption
Animal fat, cured meats, cakes Moderate and limited consumption

Eating food should be divided into 5 meals, starting with breakfast that should be 30%
of your daily intake, mid-morning snack which should be 10% like supper, whereas
lunch and dinner should respectively constitute 25% of your daily intake.

We will try to ensure that all the nutrition groups are present at each meal,
carbohydrates, protein and fat. In terms of percentage, carbohydrates should
constitute 60% of each intake, proteins 15% and fats shouldnt exceed 30% of total
consumed energy. Food isnt just made up of one component but rather a set of
nutrients; this set of nutrients alone, along with micronutrients such as vitamins and
minerals, doesnt form an appropriate ratio for a balanced diet. Its important to know
the nutrient content in food in order to create balanced and nutritious meals to assist
the proper growth and development of a child.

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To do this we propose examples of healthy meals for healthy eating.

Monday Tuesday Wednesd
ay
Thursday Friday Saturday Sunday
Breakf
ast
Chocolate
milk,
biscuits and
juice
Chocolate
milk, toast
with
margarine
, fruit
Chocolat
e milk,
cereal,
juice
Chocolate
milk,
biscuits,
juice
Chocolate
milk,
toast and
margarin
e, fruit
Chocolate
milk,
cereal,
juice
Chocolate
milk, toast
and jam,
fruit
Snack Bread and
cheese
Bread and
ham
Juice and
biscuits
Fruit and
cereal
Bread
and
cheese
Fromage
frais and
fruit
Bread and
ham
Lunch Pumpkin
soup, hake
with salad,
yoghurt
Vegetable
paella,
roast
chicken
and
potatoes,
fruit
Lentils
and
vegetabl
es,
courgett
e tortilla,
yoghurt
Broccoli
and
cheese,
squid and
tomato,
fruit
Tomato
pasta,
Meatballs
and
vegetable
s, fruit
Chorizo
and beans,
mixed
salad with
ham and
cheese,
yoghurt
Rice broth,
boiled fish
and tomato,
fruit
Snack Juice and
biscuits
Fruit and
cereal
Bread
and ham
Bread and
cheese
Juice and
biscuits
Bread and
ham
Fromage
frais and
fruit
Dinne
r
Mixed
salad, eggs
and tuna,
fruit
Mashed
potato,
sole with
carrots,
glass of
milk
Noodle
soup,
beef and
salad,
fruit
Potato
stew with
runner
beans,
turkey
breast and
courgette,
yoghurt
Roast
aubergin
e, tortilla,
fruit
Soup, fried
hake and
carrots,
fruit
Peas and
ham, mixed
salad,
yoghurt

Include a piece of bread and lunch and dinner
Drink approximately 2 200ml glasses of water at each meal
One of the common problems we often find in children are allergies and intolerances,
the most common among them being gluten and lactose allergies.

For this we also propose an example of a gluten and lactose free menu.

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Monday Tuesday Wednesd
ay
Thursday Friday Saturday Sunday
Breakfast Soya or
almond
milk, gluten
free biscuits
and juice
Soya or
almond
milk,
gluten
free bread
with
margarine
, fruit
Soya or
almond
milk,
gluten
free
cereal,
juice
Soya or
almond
milk,
gluten
free
biscuits,
juice
Soya or
almond
milk,
gluten
free
bread
and
margarin
e, fruit
Soya or
almond
milk,
gluten free
cereal,
juice
Soya or
almond
milk, gluten
free bread
and jam,
fruit
Snack Gluten free
bread and
Serrano
ham
Juice and
gluten
free
biscuits
Gluten
free
bread
and ham
Dried
fruits and
fruit
Fruit and
gluten
free
cereal
Gluten free
bread and
Serrano
ham
Juice and
gluten free
biscuits
Lunch Pumpkin
soup, hake
with salad,
fruit
Vegetable
paella,
roast
chicken
and
potatoes,
soya milk
Lentils
and
vegetabl
es,
courgett
e tortilla,
fruit
Fried
Broccoli,
squid and
tomato,
fruit
Tomato
pasta*,
Meatballs
and
vegetable
s, soya
milk
Vegetables
and beans,
mixed
salad with
ham, fruit
Rice broth,
boiled fish
and tomato,
fruit
Snack Dried fruits
and fruit
Fruit and
gluten
free
cereal
Gluten
free
bread
and
Serrano
ham
Fruit and
gluten
free cereal
Juice and
gluten
free
biscuits
Gluten free
bread and
ham
Juice and
gluten free
biscuits
Dinner Tomato
rice,
meatballs,
soya milk
Mashed
potato or
roast
potato,
sole with
carrots,
fruit
Tapioca
soup,
beef and
salad,
soya milk
Potato
stew with
runner
beans,
turkey
breast and
courgette,
fruit
Roast
aubergin
e, tortilla,
fruit
Tapioca
Soup, fried
hake and
carrots,
soya milk
Peas and
ham, mixed
salad, fruit

The pumpkin soup and meatballs must be homemade as readymade foods may
contain gluten.
The pasta must be gluten free variety
Include a piece of bread suitable for celiacs at lunch and dinner.
Drink approximately two 200ml drinks per meal.
Some of the fish should be oily fish such as salmon, sardines, red mullet, and
swordfish to supplement the lack of calcium available in dairy products.

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What are the milestones in nutritional development
during childhood?

A milestone is a significant event in someones life and serves as a reference for a
certain population.

We will highlight which milestones of nutritional development occur in childhood in
order to guide families and professionals as to whether a child is achieving a normal
nutritional development.

In children with ASD we often see a deviation from these milestones; in these cases its
necessary to inform a paediatrician so they can create a chart for the child.

Landmarks in the nutritional development of children

From 0-3 months From 12-18 months
Suckles when brought to breast, baby
bottle or dummy.
Eats with a spoon, drinks from a cup with
no help.
From 3-6 month From 18-24 months
Holds bottle in hands, closes lips to seal
mouth, moves tongue in and out with
ease, vertical chewing motions.
Chews with rotating motions, eats with a
spoon spilling things, drinks from a cup
alone and without spilling.
From 6-9 months From 24-36 months
Takes food from spoon with lips, cleans
lower lip with teeth, and eats semisolid
foods from a spoon.
Pokes food with fork, can now peel
unwrap or open different kinds of food.
From 9-12 months From 36 months onwards
Chews solid foods, puts food to mouth,
drinks from a cup or glass with help,
controls dribble.
Uses utensils correctly to eat, helps in
chores of cooking and setting the table.
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To finish this first section where weve addressed nutrition in children and before
moving on specifically to nutrition in children with ASD we are going to highlight the
following important ideas:

IMPORTANT

Correct nutrition during infancy promotes optimum growth, avoids
malnutrition that results in deficiency diseases, and optimises correct maturing
and development.

In a childs diet its important that all food groups are present and balanced:
carbohydrates, protein and fats.

Deviation from nutritional landmarks often occurs in children with ASD and its
important to inform the paediatrician to encourage the correct development of
the child.

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BLOCK II

AUTISM SPECTRUM
DISORDERS

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In this block were going to concentrate on understanding Autism Spectrum Disorders.
Aspects like their origin, cause, characteristic symptoms, other associated disorders,
treatment will be explained in the first section. We will dedicate the second section to
understanding the way in which these children learn and recommended educational
strategies will serve as a departure point in which to design a kind of intervention for
these children.

What are Pervasive Development Disorders/Autistic
Spectrum Disorders?

Pervasive Development Disorders also called Autism Spectrum Disorders are a group of
central nervous system disturbances that begin during infancy. To be more exact,
children that suffer from these disorders develop an abnormal neural functioning
causing a lack of social interaction skills, communication, restricted behaviour patterns
and interests that are repetitive and stereotypical; therefore limiting their participation
in daily activities and in important contexts in life.

Regarding the causes, theres still a lot to be researched, but its known to be diverse
and complicated and can vary between children. Biological factors such as genetics and
environmental factors like viral infections, intoxication, obstetric complications,
consumption of harmful products during pregnancy, etc. play an important role,
together interacting and affecting the brains development, giving rise to autistic
spectrum disorders.

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Its appearance occurs during the first years of infancy and can be detected early on,
from when the child is about 18 months old thanks to the application of existing
clinical tests such as The Modified Checklist for Autism in Toddlers along with
information about the stages of infant development (Brunet-Lezine, Bayley) through
the direct observation of the childs behaviour, supporting the families and
professionals that treat them. These tools give us clues or hints so we can detect if we
are faced with a possible case of ASD, although its necessary to continue carrying out
other psychological and biomedical (neuroimaging and laboratory) tests to make a
final diagnosis. Its important to say that sometimes the disorder isnt detected until
much later than 18 months as we have indicated, and a diagnosis may only be
confirmed at primary school age because of the fact that often children with ASD have
a greater intellectual capacity or if the manifestation of symptoms is minor, the
condition can therefore go undetected and characteristics of the disorder can be
masked.

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The diagnostic criteria that specifies if a child has ASD or not is defined by the
classification systems agreed by the scientific community.

One system is the Diagnostic and Statistical Manual of Mental Disorders (DSM)
by the American Psychiatric Association.
Another system is the International Statistical Classification of Diseases and
Related Health Problems (ICD) by the World Health Organisation.

Currently, the term PDD (Pervasive Developmental Disorder) being used less and is
being substituted for the denomination ASD. This change has been caused by the
appearance of a new version of the American Psychiatry Associations manual, the
DSM-V that calls the disorder ASD (Autism Spectrum Disorder). It is preferable to talk
about the spectrum as it is understood that autism is a continuum that can manifest
itself in various ways varying significantly between children in terms of the grade of
severity which they suffer from.

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Understanding the disorder as a spectrum brings a series of changes, as its the
elimination of independent categories that are defined in the DSM-IV under Pervasive
Developmental Disorders (PDD): Autism, Rett Syndrome, Childhood Disintegrative
Disorder, Asperges, Unspecified Pervasive Developmental Disorder that are
encompassed in the new version in one category called Autism Spectrum Disorders
(ASD) adding three grades or levels of severity that allow a more accurate assessment
of the abilities of the child and is reflected in a better adaptation of treatment. It
should be stressed that Rett Syndrome lies outside of the ASD as it has a clearly
different symptomatology because of the gene that causes it (something that doesnt
happen with the other disorders encompassed in this category).

The following table is a scheme of classifying systems that aid us to better understand
what we mean when we refer to PDD or ASD.

We would like to clarify that in this guide we will mainly use the terms ASD and Autism
and through this we refer interchangeably to the same group of symptoms.

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Pervasive Development
Disorders (PDD)

Categories:
Infant autism
Atypical autism
Rett Syndrome
Other disintegrative
disorder during infancy
Hyperkinetic disorder
with intellectual
disability and
stereotyped
movements.
Aspergers syndrome
Other Pervasive
Developmental
Disorders
General Pervasive
Developmental
Disorders without
specification.

Disorders (PDD)

Categories:
Autism
Rett Syndrome
Infant disintegrative
disorder
Aspergers syndrome
General unspecified
Disorder.
Autism Spectrum Disorders as
the only category.

Established three levels of
severity:
Requires support
Requires substantial
support
Requires very
substantial support.

We wont detail the criteria that defines each of the disorders in this guide as this isnt
within our objectives. But we do consider it to be important to review the behaviour or
symptoms that happen frequently to people with ASD that we will divide in function in
the areas where they have been altered: social interaction, verbal/ non-verbal
communication, activities and interests as established in the DSM-V, weve added a
sensory reaction as a fourth area to highlight the importance of this disturbance as a
cause of nutritional problems: we will also make a brief note of the aspects related to
the intervention of these symptoms.

We see:

CHANGE
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Establishing a relationship with them can be difficult. Creating an appropriate
emotional bond (affectionate, permanent, satisfactory and constant) between
the parents, therapists, teachers and the children is essential in order to get to
know them, assess their behaviour and achieve efficient interaction and
intervention if needs be.

Teaching them to know what emotions are, recognise them, control them and
know how to interpret the expressions of others is an essential task for their well
being, improving their interpersonal skills, mental capacity and therefore their
ability to experience better social relationships.

a. Symptoms related to the disturbance of social interaction:

These children show a minimum joint attention, lack initiative and interest in
connecting with other people, sharing interests, experiences, games and arent
interested in things suggested by others.

They feel emotions just as other people do, but have problems identifying
these feelings, understanding the cause, adjusting to them, and controlling
these emotions. These means they react in an erratic way and show these
feelings, emotions and affection in a different way to the rest of us; they also
struggle to interpret the emotions, states and moods of others and act
accordingly.

They have difficulties understanding the social norms established by teachers
at college, parents at home, manners, playing, traffic rules, eating habits,
personal hygiene and how to act when faced with them and how they
correspond with different contexts.

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Teaching them a system of clear, concise and consistent standards, and in all
contexts (due to the difficulty for the generalisation of their learning) helps them
towards a more adapted behaviour, to feel safer and to increase their degree of
autonomy.

Children with autism need to be taught social skills, which other children learn
naturally, in a systematic and structured manner through techniques such as social
stories, role-playing techniques, modelling, etc.

The learning and use of Augmentative and Alternative Communication systems
(AAC) based on signs, pictograms, images, objects or writing; such as Benson
Schaeffer's Total Communication System, Picture Exchange Communication
System (PECS) or pictographic communication system (PCS) among others, allow
children to communicate, but specially those who have not developed speech
and need a way to ask, choose and self-regulate themselves like other children.
These techniques also complement communication systems for children who
have developed speech but this is limited, ineffective or incomprehensible.
Somebody seeking to interact with them must meet their communication system,
which is something essential for communication to be effective.

They have difficulty making friends and maintaining relationships. They tend to isolate
themselves because as we see, they find it difficult to understand the social world.

b. Symptoms related to alterations on verbal and non-verbal communication:

In autism, there is great variability in speech development. There are children who do
not speak at all, others develop language but it is incomprehensible or they develop it
but loose in early years and others that develop it, but with quirks and limitations.

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Teaching them a suitable language at a lexical-semantic, phonological, morpho-
syntactical and pragmatic levels facilitate proper expression.

We need to teach them to be aware of the expressiveness of their bodies, to
control their gestures and interpret them in others when speaking because this
facilitates the proper integration of verbal and nonverbal language. It is important
that when we try and communicate with them, we place ourselves in front of the
child, in their field of vision, to make it easier for them to receive the information
and improve eye contact.

In oral language there are peculiarities that limit its functionality, as stated above,
which are echolalia, saying inappropriate words for their age, referring to themselves
in the second or third person, or by their name instead of using first person "I
"(pronoun reversal), speaking with inappropriate tone (high or low, singing) or not
making a smooth turn-taking in conversation.

Their non-verbal body language (body postures and facial expressions) is poor and they
struggle to understand them in others. Eye contact is also minimal and unusual.

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Simple, direct and literal language enables them to understand us better and make
them less vulnerable socially.
These behaviours, which appear to be useless, stimulate them and serve as a
mechanism for self-regulation. However, there are times that due to their
persistence and intensity, they can become inappropriate and prevent them from
adopting a more appropriate behaviour. This behaviour needs an appropriate
functional use or we must teach them behaviours that are incompatible with
stereotyping and that are best suited to their environment, which should improve
their adaptation.

They show difficulty in language and context relationships in which they are
used. An understanding of verbal language is very literal and they cannot
understand figurative language, irony, morals, jokes, absurd jokes, metaphors
or ulterior motives of others.

c. Symptoms related to changes in behaviour, activities and interests:

Children with autism may have repeated uncontrolled behaviours, like swings, spins,
flapping hands, shaking fingers in front of their eyes. Sometimes they show more self-
injurious behaviours such as pinching, hitting their heads or biting their hands.

They have little tolerance for changes in their daily activities. Changes in
schedules, caretakers, places they go, the paths they take, the clothes they
wear, the food they eat, etc. gives many children a real discomfort, which they
struggle to understand and accept.

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Maintaining a routine or informing them in advance of planned changes that are to
occur in their daily activities, helps them know what is going to happen to them and
thus live more peacefully. This enhances their capacity to anticipate and plan
ahead, as well as their mental and behavioural flexibility to changes.

Encourage small changes to their interests to provoke new experiences that will be
enjoyable for the child. Encourage a broadening of their range of interests, which
can enrich their capacity for fiction and imagination.

Their range of interests and activities are very restricted. They are always
interested in the same toys, music, books, movies, themes (astronomy, letters,
numbers, dinosaurs, trains...) and they always look for the same people, or go
through the same places. The games they play are repetitive and unimaginative
such as aligning objects, rotating pieces, hitting objects, breaking and throwing
bits of paper or throwing sand, turning pages of books, etc. Sometimes they
can also spend a lot of time observing objects with repetitive motions such as a
fan or lights and reflections.

d. Symptoms related to the alteration in the sensory reaction:

Sensory response to environmental stimuli is often atypical in some children,
showing hyper or hyposensitivity to many of them. This excessive or
disproportionate reaction is due to an alteration in the brain linked to
integrating information that is perceived through hearing, sight, touch, taste,
smell and react in an appropriate manner. For example, aurally, sounds that are
natural to us may be really annoying to them and they are then seen to be
covering their ears. Visually, they tend to look at the details of an object rather
than a whole and they generally see details that would be indifferent to us, but
it also seems that they cannot see objects that they have right in front of them.
With respect to the touch, they can sometimes avoid physical contact with
others because they don't like to be touched, even the feel of some materials in
their clothing or bedding can also displease them.

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This alteration is of particular importance in food problems. We found that they
perceive certain tastes, smells, temperatures, colours or textures in foods
differently to the rest us, and some things may seem truly unpleasant, causing
them to reject many types of food. The treatment for these cases shall be seen in
the next block.
.

They have an unusual tolerance towards pain, with high levels of response, as
well as for the cold and heat.

Now that we have seen the characteristics of these children, we cannot forget that
autism is disorder that can occur together with other syndromes or associated
disorders that must also be studied to address the person as a whole. Examples of this
are the Fragile X syndrome, mental retardation, tuberous sclerosis, epilepsy, Tourette
syndrome, learning disorders, attention deficit disorder, and disturbances in sleep,
toilet training, anxiety, depression, or changes in their food.

It is very difficult to predict a true prognosis for these children. Depending on the
degree of their nuclear symptoms, whether they are related to other associated
disorders or not and depending on the degree of neuronal plasticity of the brain in
each child, evolution can be very different and therefore, we can see highly variable
forecasts in terms of interpersonal and intrapersonal prognosis.

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Neural plasticity refers to the ability of the brain to regenerate anatomically and
functionally, being greater when the brain is still immature during the first years of life.
We can say that is the property that allows the damages that children have when they
are young to be corrected to some extent with the help of different treatments. Early
intervention carried out from the moment any of the symptoms are detected is
essential to favour their evolutionary development and improving their quality of life.

Clinical and psycho-educational professionals should assess the variables in each child
and the properties of their environmentin detail and in a qualitative manner, in order
to establish specific objectives and individual treatment, which must necessarily be
modified in the different developmental stages of the children as their needs also
change with time.

The intervention best suited to people with ASD and that which is considered more
effective nowadays, is a combination of psycho-educational and psychological
treatment, social support and drug treatment (where necessary), as established by
the Group for the Study of Autism Spectrum Disorders of the Carlos III Institute,
Ministry of Health. Lets see what each of them is:

Psycho-educational and psychological treatment includes the use of intensive
education programs and behavioural or cognitive-behavioural strategies (for children
with higher capacities). They are aimed at the development of social skills, emotional
and cognitive development, to improve communication skills, the development of
adaptive behaviours and eliminate those that are not appropriate. Its use should be
extended to all environments in which the child develops. It is essential that the
parents are taught how to become familiar with the techniques that work best with
their child and that they use them in different areas and at any time of day. Important:
joint efforts between educational professionals, therapists and family members are
essential for children with autism.

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Social support is considered a key element for any family who has a child with
disabilities and even more so when it is a disorder like autism, which lasts a lifetime
and requires significant physical, psychological and economic effort to families. Social
support can come in two ways, one way is organizations that provide financial
assistance, treatment services, leisure and respite programs, schools, parents, etc. and
the other way are the family, friends, neighbours or parents of other children with
autism, who provide support in a more informal manner. Creating a network of social
support environment is essential for a family caring for their quality of life.

Regarding pharmacological treatment, autism has no cure as we have said and there is
no medical treatment that is specifically aimed at eliminating its characteristic
symptoms (communication, social relationships, flexibility). The treatment is more
aimed at improving adjacent areas that a child may have such as hyperactivity,
aggression, inattention, sleep problems, feeding, epilepsy, depression, etc. and that, if
improved, can make other educational or psychological treatments that are specific to
autism, function better.

Other types of assistance called "alternative", such as sensory integration therapies,
animal assisted therapies, music therapies or art therapies, may favour certain areas of
development in some children (attention, postural control, relationship with the
environment...) but they should always be considered as complementary, not as a
main therapy in place of the abovementioned treatments.

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SUM OF TREATMENT DIRECTED TO ASD

PSYCHO-EDUCATIONAL / PSYCHOLOGIST:
Social abilities
Emotional and cognitive development
Communication
Desirable behaviour

SOCIAL SUPPORT
Physical
Psychological
Economic

Pharmacologic
Related aspects (attention, hyperactivity, sleep, epilepsy, etc.)

ADEQUATE INTERVENTION

Having reviewed those aspects we consider most important and that should be known
about ASD, we should now turn to detailing the recommended educational
intervention and techniques that facilitate the learning process in these children.

4. What educational intervention is recommended to use
with ASD?

When we speak of educational intervention we mean all those educating actions that
contribute to children's learning and the improvement of their autonomy. These
actions may occur in a formal and planned way in schools or in other informal settings,
such as playgrounds, sports facilities, camps, etc. or in a more spontaneous and
informal way, in their daily lives with their family, in the neighbourhood playing with
other children, etc.

Unlike what happens in the majority of children, children with autism benefit from
learning that is spontaneously acquired through imitation, exploration, and the
interest in their own environment and people. However, certain skills like playing to
make a proper use of objects, interacting with others, etc. have to be shown to them
with certain intentionality and structure.

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We will now look at the principles and specific techniques that promote ASD learning,
aspects that are useful for both professionals and parents for the there is a need to
speak with them in all contexts to achieve generalization of learning.

The design of an educational intervention with these children is based on the following
principles to ensure its quality:

It must be based on the global knowledge of the child, their perceptual-
cognitive, communication, motor, social and emotional abilities.

It has to be considered from an integrated and ecological point of view, in
which the relationship of their abilities and the environment is valued. The
measures in the form of visual, communicative, social or architectural support,
if any, enable breaking environment barriers and if they were to be
incorporated, would promote learning and standardization within their
environment.

It must be started early; the sooner one is able to give a response to
symptoms the better the chance of improvement, as supported by the theory
of neuronal plasticity.

It must also be based on the theoretical reference models such as those
supplied by authors such as Leo Kanner, Asperger, Baron-Cohen, Hobson, Frith,
Happe, Ozonoff, Pennington, Rogers, Fivire, etc. who gave the key of their
symptoms and foundations such as the Theory of the Mind, Central Coherence
Theory, Theory of Executive Functions, lntersubjectivityTheory, among others.

The objectives of the intervention should be prioritised, as they cannot cover
all the objectives at the same time. Those that are more maladaptive and
endanger the integrity of the child or the environment or that are the basis for
later acquire learning should be brought forward.

The intervention should last long enough to generate the desired effects. In
children with autism the effects of an intervention are often perceived in
medium to long term, so we must also be very consistent, patient and
systematic in the task.

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It requires a multidisciplinary approach and teamwork. A joint effort from
audition and language professionals, speech therapists, therapeutic
pedagogues, psychologists, occupational therapists, physical therapies and
other health and social professionals to address the challenges presented by
these children and to agree a course of action together with the family.

Family, cultural and economic aspects need to be seen as part of the entirety
of the child.

Action is needed from the individualization point of view, which means
knowing their strengths, such as excellent visual and mechanical memory, and
habitual visual-spatial perception, in order to address their weaknesses; and
adapt to their learning style, this understood as being the way a child
perceives, processes and retains information better, which could be visual,
auditory,kinaesthetic,holistic or analytical, etc.

In response to cognitive, psychological and physiological characteristics of this
population, the recommended techniques that facilitate the learning of these children
focuses on the following aspects:

The environment should be stable, organized and predictable, so that it gives
them a sense of security.

The information presented verbally or visually must be concise, clear, and
permanent, while ensuring to not give non-relevant information and that could
distract their attention.

The activities should be presented in a structured, sequential and orderly
manner.

The preferred communication channel should visual, using pictograms,
pictures or real objects that gives them specific and enduring information.

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It is useful to visually teach them things like menus, standards of conduct, emotions,
the steps to carry out a certain task, and the temporal and spatial structure of the
environment. In this sense, the temporal structure gives rise to the use of agendas,
information boards, schedules or the use of clocks; spatial structure and the use of
pictograms or pictures to put on cabinet doors or drawers to indicate what's inside,
even to indicate different areas at school (play area, reading area, etc.) or house doors
to indicate the use of the rooms (sleeping room, game room, etc.)

The learning must be functional and meaningful and be based on their
interests, motivations, prior knowledge and needs in their daily lives, and try to
give the new knowledge and skills a meaning and a utility for the child.

They learn mechanically, their learning is based on repetitive practice.

Learning should be based on the skill, shaping techniques and the subsequent
permanent fading of our support (backward chaining) encourages the child to
learn without error and to segment a task into simple and accessible steps.

Establishing a backup system in line with behavioural techniquesis useful to
establish what has been learnt,as well as the adequate behaviour in order to
eliminate those that do not fit in. Some of the techniques used to increase
behaviour are:

- Positive reinforcement: after the appropriate behaviour we give the child something
they like, such as a verbal praise, a song, a toy, some sweets, etc.
- Negative reinforcement: after the appropriate behaviour we remove something they
don't like, such as a chore, or something unpleasant in the environment, etc.
- Premack Principle: involves linking two behaviours, one they likes and one they
don't. For example, if all they eat all their food they can then play with a car.

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Techniques used to reduce behaviour are:

Positive punishment: after a bad behaviour,we give them something they do not like,
such as a verbal recrimination.

Negative punishment: after a bad behaviour,we take something they enjoy from
them, like sweets, a toy, etc.

Differential Reinforcement: differentially reinforcingbehaviours and learned and
adapted, so that they occur more often than inappropriate behaviour so they end up
replacing the bad with the good.

Strengthening something incompatible: consists in strengthening a behaviour that is
incompatible with another non desired one, like being in silence instead of screaming,
using a fork correctly instead of turning it or throw it, etc.

Block II, where we have seen the main characteristics of ASD and how they learn
finishes here and we shall continue on to the next block, which will explain how to
intervene correctly when faced with eating disorders.

IMPORTANT...

ASD is a group of disorders of the central nervous system that affects child
development.

Children who suffer this disorder find that three main areas are affected: social,
communicative and the activity and their interests and behaviour seem to be
restricted and repetitive.

With an early intervention based on treatments of a psycho-educational nature,
psychological behavioural or cognitive-behavioural, pharmacological and social
support, children can improve their symptoms.

Any attempt that is carried out with these children should be systematic, structured
and based on principles and techniques specific to ASD.

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BLOCK III

EATING DISORDERS IN
CHILDREN WITH ASD

37

Any eating disorder that may exist in children with ASDcannot be equated in the cause
or the way it is treated, to other eating disorders such as nervous anorexia or bulimia.

Any intervention in this respect must be done fast and early, to reverse the problem as
soon as possible. The most important thing that should be noted is that at first, the
lack of food cannot be considered a serious problem. However, if not taken care of as
soon as possible it can get worse and lead to malnutrition, which would then be a
serious problem that would affect the proper development of the child.

The lack of food or some key nutrients can have serious consequences for child
development. Both the lack of food as well as too much food will make the child's
active life more difficult, not to mention their cognitive development.

It is important to know that certain drugs may exert some kind of side effects
associated with appetite, increasing it or decreasing it, as well as possible changes in
taste.

The following sections discuss more specifically what aspects may account for these
changes, what eating disorders are associated with children suffering from ASD, how
they should be treated and the most effective strategies to try to reverse these
problems, which must be differentdepending on the case.

5. Why do ASD sufferers experience changes in their
eating habits?

Sensory disturbances

Many people with ASD have hypo (low sensitivity) or hypersensitivity (very sensitive) in
one or more senses, causing alterations in their eating habits. The manifestations may
be the following:

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Hearing: intense, acute or continuous noise can cause them extremely annoying and
almost painful sensations. In terms of eating, these noises may be caused by the food,
those we call "crackers" or chewy food, which can cause reject to some foods.

Touch: the perception of textures, such as grainy, astringent, fibrous of jelly food, etc.
can cause the child to reject certain food, either because the do not like the texture in
their mouth or when they touch it with their hands.

Taste: some foods can be very unpleasant and can cause the person to acquire the
habit of limiting themselves to a small number of foods. This is more a matter of taste
and not so much of reactions towards food.

Visual: the presentation of the food, as well as the shape and colour, can be a cause
for rejection or acceptance of certain foods. Foods that are most accepted based on
their colour, are normally reds, yellows, oranges, but greens and dark colours have
little acceptance.

Olfactory: children can sometimes notice certain smells of food that could be virtually
undetectable for other people, making them more sensitive towards food; conversely,
they can show a genuine interest in foods and substances that we may feel have a very
unpleasant smell.

"I had a big problem with the food. I enjoyed eating soft and simple things. My
favourite food was cereals... That was the first thing I had eaten in my life and I found it
was comforting and reassuring. I didn't want to try anything else. I was supersensitive
to the texture of food and had to play around with my fingers to check the feeling they
produced, before putting them in the mouth. I hated mixed foods such as noodles with
vegetables or the mixture of bread withsandwich filler. I could NEVER, NEVER put that
food in my mouth. I knew that if I did, I would feel violently ill. I liked to eat food that I
was accustomed to"

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Hyper-selectivity

Hyper-selectivity in terms of food is associated with the diversity of food the child eats.
Family comments like "they only eat chicken that has been breaded and not in any
other way", "they used to eat a variety of food and but now they are getting to like less
and less types of food", "they only drink milkshakes from a certain brand", "it is
impossible to get them to try something new", etc. are the consequences of hyper-
selectivity. The visual understanding that children have for food, for their shape,
colour, appearance, and the difficulty for their sensory integration as a whole, makes
them reject many types of food; they also manifest mental inflexibility, invariance to
changes and a restriction of their interests are triggered by Hyper-selectivity.

"My son, Thomas, before he could even see, had already selected a scent and he had
given it too much importance, in my opinion. He was only a couple of days old when he
started reacting in an unusual manner. I was breastfeeding him and I found that if I
changed my perfume, he refused to breastfeed and it was not just a whimsical
rejection, because he was hungry. He was losing weight and was furious. It became a
matter of life or death.When I used the right perfume and hugged him, he was a quiet
and peaceful baby.

Possible gastrointestinal disturbances

Autism has often been associated with metabolic and gastrointestinal problems, but it
is true that a recent study published in 2011 called "No association between early
gastrointestinal problems and autistic-like traits in the general population published
in the journal "Developmental Medicine & Child Neurology," shows that there are no
significant differences in gastrointestinal problems among children with autism and
those without.

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Although it should be noted that many children with autism have gastrointestinal
problems, such as constipation due to food restriction, poor mastication as a
consequence of medication, and a sensory problem that arises when using the toilet.
However, these problems are not specific to autism.

In other cases, gastrointestinal problems are determined by the rejection and
limitation of certain foods, such as fruits and vegetables rich in fibre.

Classic negative conditioners

Classical conditioning is the connection between a new stimulus and an existing reflex.
For example, a new stimulus-response relationship is the product of experience.

A negative example of classical conditioning is when a child has a negative experience
after eating a meal, such as abdominal pain, nausea, vomiting, pain This would then
generate a negative reinforcement of that experience, making that memory extensible
to other similar foods, causing the refusal to eat that type of food.

Similarly, sometimes situations of struggles, fights, anger etc. arise when parents try to
get their children to eat, turning these situations into negative reinforcements, which
in turn causes a negative discomfort in the child generating the negativity.

Illnesses: intolerances and allergies

In people with autism, as in the rest of the population, we must also assess possible
illness or diseases that can cause stomach pains, gas build-ups, reactions to certain
foods that have not been detected, etc. These problems may be the cause of their
refusal to eat. It is important to pay special attention to reflux, ulcers, bacteria,
allergies or intolerances, the frequency and appearance of stools, behavioural
problems after meals, vomiting, etc.

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These two concepts must be differentiated for them to be understood correctly.

Food intolerance occurs after the ingestion of one or more foods that cause an adverse
effect on the body, such as poor digestion or poor metabolism. However, food allergy
occurs when, the child's body produces an immune response after eating a certain
type of food, which may jeopardize their health, such as hives, itching, swelling of a
part of the body

Allergies or intolerance could be the reason the child does not want to eat. However, it
is true that when there is an allergy, symptoms are usually visual (rash, redness, hives,
swelling...)and we can see the reaction that the food causes the child, but when it
comes to intolerance there are no visible signs and it must be the child themselves
who warn us that certain food causes pain and/or discomfort when eaten.

The food that is more likely to cause either of the above is: milk and dairy products,
eggs, fish, corn and cereals, foods containing gluten and casein.

One of the most widespread beliefs is that ASD is related to intolerance to gluten and
casein ("... some people with autism have problems in digesting proteins and it also
coincides with excessive intestinal permeability, associated amongst others with the
Thimerosal of vaccines), which would pass to the brain and would damage it as they
are very similar to endorphins in the brain; opioid peptides that act as
neurotransmitters. Proteins gluten and casein ") (Lewis 2002). Although it has been
shown that there is no empirical evidence of improvement with Gluten Free Diet and
Casein, except in specific cases and therefore, gastrointestinal disorders cannot be
associated to autism.

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Behavioural problems related to other areas of development

All other aspects of development such as cognitive, motor, communication and social
behaviour directly influence their eating.

For example, in some cases the eating disorder is caused by a poorly established
"power", which means that the child "seizes" an eating situation as an area of "power
and control", being the child who determines the limits of what he eats and what he
doesn't, when and how much. It is therefore of utmost importance to establish these
limits and the role of each person from the outset.

For example, "O" is a 2-year old girl who expresses an intense eating disorder, limiting
her intake to one feeding bottle a day.
She presents limitations and communication mobility meaning that she will always
depend on the action of an adult.
The more she was given the capacity to move and express herself, her need to be in
control during meal times was reduced as she was getting more power of control in
other areas. This, together with a specific intervention program introducing food,
helped Oto eat all kinds of ground food in a short period of time.

We must not forget that we are dealing with children and that it is the adult who
should have control, especially at meal times. This requires that the child feels
empowered in other situations. We can offer them things that we do not mind if they
reject or times when they can choose what they like most, establishing where they can
decide and when it is up to the adult to decide.

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We can summarize the possible causes of eating disorders in the following table:

POSSIBLE FACTORS THAT CAUSE EATING DISORDERS IN
ASD

Hyper-selectivity
Possible gastrointestinal disturbances
Classic negative conditioners
Illnesses: intolerances and allergies
Behavioural problems related to other areas of development

6. What eating orders can we actually see in people with
ASD?

The main problems associated with eating in people with ASD are related to the intake
of certain foods as well as behavioural issues and child behaviour.

Alterations of the rhythm

One of the common problems is with children that do not seem to ever feel full, eating
compulsively, very quickly and even snacking between meals. The chewing process is
not done correctly, which can cause excessive gas, slow digestion, abdominal pain, etc.
and the obvious risk of overweight. Setting strict meal times, avoiding snacking
between meals, not putting more food on the plate than the necessary and working
towardsestablishing intervals between mouthfuls are key objectives with these
children.

At the other extreme, we can find children for whom the food is not a particularly
motivating stimulus. They eat everything but without appetite, because they are told
"its time to eat" and therefore they eat very slowly and this becomes tedious and
exasperating, especially at certain times of the day when parents cannot provide them
all the time in the world. An example of this is at example at breakfast, when parents
are normally in a rush and the situation finally ends up being tense or parents feed
them to take less time.

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Negativity to eat solid food

The step between taking crushed or pureed baby food to eating solid or semi-solid
food can be much slower and more complicated than it would be for a normal child. In
some cases, families have told us that it was impossible to perform this step, which
normally occurs after 9 months, causing the child to cry, scream or even to reject food
completely. These are cases of children who eat all kinds of food if they have been
pureed and they do not have nutrition problems. The switch towards chewing and new
textures, involves an increased orofacial muscle tone (mouth and face) and a proper
handling of their jaw and dentition, which must be exercised to increase the intake of
food and avoid other problems like constipation.

Extremely limited variety of foods

Tolerance for only certain foods with specific texture, a certain smell, a characteristic
chewing sound, a specific consistency, etc. can limit the food the child accepts. There
are children who only eat food made by a particular brand (e.g. dairy products,
biscuits, pastries, frozen, ready made, etc.), or only cooked a certain way (e.g. deep
fried) or whose menu is extremely limited, for example children who only eat chips,
chocolate and bakery products.

We must bear in mind that this may pose a problem for the child's nutrition, either due
to the lack of supply of certain nutrients or an excessive consumption of food with
inadequate caloric profile. Besides the obvious social constraints involved for the
whole family.

Strict rituals

In some cases food should always be under certain rituals. These rituals can be created
in terms of the form or sequence of the food (e.g., the child is asked to drink from a
bottle, then say a phrase his father and at the same time put their spoon in the food);
in terms of the posture (e.g. the child has to be lying with their head on her mother's
lap when taking the bottle); utensils, food or drink should be in a certain format or
always at the same settings; some people will only eat with a certain person; spaces
(e.g. there are children who will not eat at other people's houses or restaurants even if
it is the same food. The rupture of these rituals can lead to a complete lack of control
for the child.

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These situations pose severe limitations for families. In some cases you can even
create situations of tension between spouses or relatives.

Behavioural problems

Obviously, cases where there is an eating disorder can be considered as behavioural
problems, the food environment usually gives rise to screaming, crying, assaults,
escapes, tantrums, throwing food, etc. But in this section we shall refer specifically to
cases of children who eat all kinds of food in different formats, but that have
behavioural problems that may not directly be related to food or acceptance thereof.
It is frequent to find children who have difficulty to remain seated for a while or to sit
correctly, children that tend to touch their food with their hands and not use cutlery,
or a wide range of provocations or reprimands, as spitting food laughing, spilling
liquids to then clean them compulsively, throwing food or asking the adult to direct
their action consistently even though they know how to use their knife and fork.

Pica

There are cases where children ingest all kinds of substances and materials. Cases
where paper, paint, plasticine, insects, earth, plants, etc are eaten are common. This is
of course considered inappropriate behaviour for this level of development: Eating
inappropriate substances or objects past 18-24 months given that prior to this kids do
this habitually as a mode of exploration and learning about the world that they live in.
Sometimes, the disorder is so intense that they dont even discriminate what is
ingested. The need for intervention in these cases is evident as they put the physical
health of the person in danger of intoxication, choking, allergies or intestinal
perforations.

To conclude, weve established the most common problems for children with ASD:

Eating problems in children with ASD

Disturbances to eating pattern
Negative to eating solids
Limited variety of ingredients
Marked rituals
Behaviour Problems
Pica

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7. How can we intervene?

Before starting to discuss general aspects of intervention, it is important to know that
there are no single or standardised recipes in the intervention of eating disorders in
children with autism. This guide will offer criteria, guidelines, strategies that we will
have to keep testing and changing to adjust to each case, each child and each
situation.
Knowing the possible causes that can result in an eating disorder in a child with ASD
provides us with the necessary knowledge to settle our intervention based on sound
and supported judgements. One goal of this guide is to be able to reduce the
comments that may occur around the fear of they do not eat because they do not
want to, he is very cheeky or he is not eating because he is lazy. Intervening
without prior knowledge produces flawed interventions with effects contrary to
expectations.

Finally we must take into account the side effects of taking medication and that is also
reflected in the food, some of these effects such as change in appetite, impaired
gastrointestinal function (nausea, vomiting, diarrhoea), lesions in the intestinal
mucosa, or psychological/ psychiatric disorders such as depression, agitation, anxiety,
nervousness, apathy and reduced concentration, are some of the variables we should
consider.

Intervention
How?
Causes
Why?
Symptoms
What?
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GENERAL CONSIDERATIONS

People outside of the family and outside the home

Everyone within their own homes has fixations, customs that we probably do not show
and that we can control in other situations. In our house we feel safe, its our space.
The same happens with people; we dont behave the same way with everyone. To our
knowledge of what we can expect from others, we then behave appropriately. The
same happens in children and children with autism. This is called conditioning. They
are conditioned to rules at home, to certain behaviours.

When we start food therapy, it is recommended that it can be achieved by using a
person outside of the family and outside the home just to break these created
constraints. In this way, a new person in a new place means new rules, which is going
to aid with the work which will break the conditioning. In addition, the adult outside of
the family establishes an emotional distance with the child, that often allows their
work to be systematic and with a firm attitude.

When it is not possible that the program can be performed with an outsider, either for
lack of community services or private entities, incompatibilities, due to economic
problems or for any other reason, the guidance provided in this guide is equally
applicable at home, although the effort will be greater and results will probably take
longer to appear.

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Attitude and aptitude of the adult

One of the main keys so that a child with autism starts eating is the attitude of the
person who will conduct the food therapy. It is fundamental, which displays a
confident attitude. They have to be convinced that the child is going to finish eating
because otherwise the uncertainty will manifest in their actions and the child will pick
up on this.

When choosing the person who will carry out the food therapy, we must take into
account other characteristics:

If it is a new person, they would need to establish a good relationship with the
child. The food, especially at first can result in a tense moment, therefore the
child needs to understand that the person will expect certain things during
the meal, but can also be fun, gentle, stable etc. outside of these moments.
With family, children sometimes develop a very special relationship, such as
always laughing whenever that person is angry because the child finds their
expression funny or ignoring the rules that are provided by the given adult.
These are the factors that we must avoid if someone outside of the family is
carrying out the therapy.

Not very talkative. A clear, simple and concise communication needs to be
established. Excess language creates chaos and confusion as well as a nervous
climate.

At mealtimes we want them to stop being afraid and make it an enjoyable
time where they understand that eating is a pleasurable act and that food
tastes good. So we will begin transmitting that feeling ourselves that to the
adult. A calm attitude is fundamental. Sometimes, recording a video can help
us to see how we behave, since we are often convinced to be calm about the
situation and then seeing it makes us realise that it is faked and that this
nervousness is usually due to a lack of security.

Finally we recommend a firm yet caring attitude. Leaving clear rules does not
mean shouting, getting angry or getting nervous.

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On many occasions we come across a case with children who know how to use cutlery
such as a spoon or a fork or that in an intervention where the objectives have not been
adequately prioritised, the child has taught himself before expanding his food options.
What occurs in these cases is if the child eats alone, we have very few options for
increasing the meal repertoire, so that the adult gains control of the food situation. In
many cases, it is therefore appropriate that the adult feeds the child, giving priority to
eating rather than eating alone. In rare cases, we can maintain the childs autonomy so
long as they remain seated in front of the food and work with firm negotiations, so
that it is us who is monitoring the food to which they can have access.

Environment

When the therapy takes place outside the home environment, we break the
conditioning that can be associated with that place. The idea is new place, new rules.
However when this therapy is going to take place in the house this break does not
occur so we have to find a compromise. Sometimes it is very effective to change the
place where you go to eat: if until now you were eating in the living room, change to
the kitchen for example. On other occasions, the childs inflexibility prevents such
changes as it can cause major behavioural problems. If this were the case, we can
exploit other natural settings to set new standards, for example when we go out, if
there is a change at home, moving house etc.

Furthermore, it is important that the environment is peaceful, avoiding settings where
there is a lot of noise. For example, avoid starting food therapy in a school canteen.
Not only because the noise can disturb the child, but also because the setting can
cause us to feel insecure and nervous. At home, we will look for an interruption free
zone or that is not used at that time by family members.

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Another basic rule is that during mealtimes we only eat, they do not watch television
nor play on the computer or with other toys, so that we avoid overstimulation that can
distract or disturb the child.

Prioritise objectives

When we decide to start food therapy, one of the criteria that we have to establish is
an order of objectives. There are usually many aspects that must be improved;
however we cannot address them all at once.

One of the most important aspects is autonomy. In most cases, when a child has a
severe limitation towards the food they eat, it should be the adult that feeds them,
even though they are capable of using cutlery. This way we can establish the power
in the adult and not in the child. The idea is that during mealtimes, the adult is to
decide what, when and how the child eats and not the other way around. It
should therefore provide the child with other times when they can make decisions and
choices, thus transferring control. We can therefore offer them after-hours food and
other items, that if refused does not bother us.

In the same way, if the child will find it difficult to sit still for a while, we will need to
begin to establish this basic behaviour before introducing new foods.

How to place ourselves

When we decide to intervene with a child one of the most frequently asked questions
is how I seat myself with regards to the child. Taking into account everything that has
been said so far, above all we want the relationship with the child to be good, that the
environment is calm and that our attitude is firm. Therefore, it is best to find a space
where we can put ourselves in front of the child and that the child has no chance to
escape. In this way, we can control the space and stimuli allowing us to feel safer. In
addition, we can establish better eye contact with the child, which is especially
important when transmitting strength and reinforcement.

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Position the table to one side and not between you both, sometimes this helps to
prevent the child from spilling, throwing or throwing away the food.

Choosing the intervention moment

We know that the situation can be very serious and the desire and the need to solve it
are great, however we should not intervene at every mealtime. We must choose one
meal a day depending on availability and time that we can use, how tired we find
ourselves and the child or according to the time of day when it appears that the child
has more appetite.
Especially at the beginning of the therapy, the child often eats little food so we have to
ensure basic food during the rest of the meal times. Therefore, in this way we will not
expose the child to a stressful situation producing the opposite effect to that desired.
This approach means that we have to pay special attention to the rest of the day, so
that we avoid eating between hours or eating larger quantities than usual.

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Empty plate rule

An empty plate is going to indicate to the child that that meal time or that this food in
particular is finished. Following this visual aid, when we start food therapy we will start
by putting the minimum amount of food on the plate that we want to introduce.

Imagine the food that you like the least. If you put a heaped plate of this food in front
of you when it is time to eat, when you are at your most hungry, with a closed in
feeling, even nausea overcomes you, increasing your aversion to this food. The same
thing happens in children with autism with an eating disorder, just that it is not a
question of one food.

In addition to controlling the quantity of food that we offer, we need to take into
account its temperature, in this case respecting the childs tastes.

Be careful with this rule once he eats everything! When the person already eats
everything we would have to start working on mental flexibility issues and adequate
communication, since by the very characteristics of the disorder there may be
situations in which a person does not want more food due to a poor appetite or even
pain or not knowing that they can leave food or they can eat less of what is on the
plate, resulting in some cases of manifestations of altered behaviour.

Leisurely pace

One of the factors according to which we will choose the moment in the day in which
we are going to intervene, is precisely the time that we have available as it is important
not to create nervousness or tension. We must avoid hurrying the child. The process
takes time and trying to speed it along will not advance the results, but in fact produce
quite the opposite.

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Especially when the child is starting to chew, they do it at a slow pace especially if they
are not used to it or if they have not chewed up until now. Their maxillofacial
musculature is lax and needs toning up slowly. They will be slow and they will get tired
quickly.
Another error we must avoid making is overfilling the childs mouth to force them to
chew or swallow. We may offer a new spoonful of food whenever the mouth is empty,
which we can help by offering fluids, small pieces of favourite foods or even
stimulating natural swallowing reflex points, such as under the chin.

Eating is nice

Thats the standard that we want to set for the child. This being the quiet atmosphere,
the relaxed attitude and the leisurely pace. However, we should take into account
other aspects:

Prevent the child from being physically uncomfortable so that they will be
more comfortable, therefore we must pay attention to whether they are wet
or stained by food, especially with those children who are annoyed by this
the most.
Do not cheat. Deceptions create distrust which is exactly the opposite of
what we want to create. Behaviour such as taking advantage of when the
child is distracted to place food in the mouth, secretly adding more of the
agreed food, repeatedly putting the same food so that they eat more of the
same or telling them that they are going to get something in return and then
not giving them it, are strategies that we must not use as they are not
effective.
Do not force. In many cases, there is negative conditioning caused by past
experiences of this struggle. These situations cause tension on both sides and
cause the child to feel more aversion towards situations with food. Physically
controlling only when it is absolutely necessary, in an exact moment or
whenever it has previously worked.
Deconditioning around meal time is a resource that must be analysed in
depth according to each case.

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Patience

The intervention of a child with ASD with an eating disorder is a slow and costly
process, in which there are no predetermined or standardised time references. Each
case, each child is different so trying to compare them with other cases will not
provide us with useful information, it is not beneficial.
We must be aware that the intervention will be more effective when we respect these
steps. The small steps that are being made will be the basis of future success. Giving up
due to not seeing the desired results immediately can sometimes cause us to try to
force the pace or we despair and desist. The keys to success are patience and
perseverance. We should have this factor in mind when we ask if at that moment we
are able to take responsibility for the therapy.
As mentioned before there are no standardised plans for all cases, so we have to keep
testing and modifying our performance within the guidelines so that it fits the needs of
each child. We have a large bag of tools; we just have to keep taking the ones we need
for each case. If you see that something is not working, you are not going backwards, it
is just not appropriate; therefore it is important to keep trying as we mark the
evolution of the process.

Understanding the child as a whole

When working with a food disorder, we need to understand the person within a larger
framework, in this way we will understand the necessity of working on food from other
areas of development.

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As you go giving the child communication tools, with systems that help you with their
understanding such as agendas in advance and increasing their expressive capabilities,
it will positively impact on food intervention as it will facilitate any negotiations that
we establish as well as reinforcing systems and conditional times. In addition the child
will learn the value and the meaning of the images and it will help them to trust you
and therefore us. Providing the child with communication tools, among other things,
reduces hyper selectivity and mental inflexibility.

Also, working on relationship skills and games with the adult will facilitate the creation
of the link we need to establish during meal times so that the child understands that
the adult can be fun, they can get many nice things from them but that the adult is also
a predictable being that dictates clear rules that must be followed.

Encouraging autonomy skills in the child in other areas will mean that the child will
have the capacity for control and power at appropriate times, non-disruptive ones,
where he feels good about himself by not depending on anyone.
We have summarised in the following table these general conditions to keep in mind
when intervening:

Communication Tools
Understanding (Agendas in advance)
Expression (Language/AAC)

Food
Relationship

Autonomy

Game

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INTERVENTION STEPS

General Considerations
For Intervention
Person outside of the family and
outside of the home
Attitude and skills of the adult
Environment
How to seat ourselves
Choosing the intervention moment
The empty plate rule
Leisurely pace
Eating is nice
Patience
Understanding the child as a whole

RecordBefore starting the food therapy as such, we need to collect information
that is going to be useful in outlining objectives and strategies for therapy. This
data refers to what food and liquids are ingested, how much, how, when, with
whom etc. and information related to reinforcers i.e. games, toys, objects that
they like a lot and that we can use as reinforcement in the negotiations.

Choosing a momentAs discussed above, it is important, especially at the
beginning of the therapy, that we only intervene during one meal time.

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Some of the criteria to be taken into
account to determine the best time are the
possibility of a systematic and sustained
intervention, availability of time and space,
increased appetite of the child, tiredness of
both adult and child etc. Maybe at first the
child will eat a small amount of this food, so
we have to make sure that they are consuming a basic quantity of nutrients. On the
other hand, we should not subject the child to a stress overload because it can have
the opposite effect. Once the child knows and accepts the rules for that meal,
participates in negotiations and begins to eat new foods, we can have the intervention
at other time of the day with different foods, such as liquids for example.

Prepare the place and tablewareWe will find a quiet place, away from irritating
noises and that can be pleasant. If it is in a school, avoid common dining rooms,
where there is an excess of stimuli and where the adult probably feels as if they
are being watched, which will increase their nervousness. If the intervention is
being done at home, look for an uncrowded place and that won't be disturbed
a lot during the meal time. We can help make the chosen place more enjoyable
for the child by introducing elements or tableware of their favourite characters:
plates with a drawing on the bottom so as they eat the outline slowly appears,
pretty tablecloths, glasses with their favourite colours or individual placemats
with the film characters they like the most.

Prioritise objectives Before putting ourselves in front of the child, we should
have established an order for the goals that we want to achieve. Sometimes
there are so many aspects that we want to improve that we make the mistake
of trying to tackle them all at once. To determine which goal is more important,
we must look at normal developmental milestones and determine those basic
aspects on which the remaining aspects are then built upon.

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SIT DOWN

INTRODUCE NEW FOODS

EAT ALONE

Visual Aids Now from the agenda, we can anticipate the meal time.
Furthermore, we can also tell the child what they are going to eat and what
food they will touch. We can take advantage of this moment to put information
to work about reinforcements.

The demand will vary depending on each caseSometimes it is very effective to
set new rules, break rituals from the beginning as well as introducing a small
demand. According to the child and the goals we have set ourselves as
priorities, we will take the good and therefore reinforce the minimum
approaches to achieve said goal.

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PRACTICAL STEPS
Bring stained spoon or finger closer to the lips.
Ensure that the child touches the food with the tip of their tongue
That the child eats one or more (of mashed up food or new solid)
That the adult eats small amounts of different foods at once so that the
child gets used to having other types of food at the same table, without
feeling anxious or thinking that it is for him. In this way he learns to
trust us, in what we say and in the information that we are showing
him visually.
In the table below, we can see the summarised version:

Intervention Stages
Record
Choose the moment
Prepare the place and tableware
Visual aids
Rate the level of demand in each case

On the next page we will see some practical examples of intervention, taking into
account as we have already said that general formulas do not exist and that we will
have to adapt to each case, because it can be more of a case of simultaneous feeding
and therefore there is more than one cause.

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Classic negative conditioning

Figure 1.In cases where there is markedly negative conditioning at meal time, start
with reinforcing the idea that eating is nice, so the demand will be minimal. We can
start with asking that they approach the place alone, that they sit correctly, that they
are starting to eat their favourite food when they are not crying and reinforcing a lot
the calm attitude. We will always finish with a game.


Figure 2.In cases where there is hyper sensitivity to flavours, we have to analyse what
kind of flavours they prefer, sweet/salty, strong/mild, etc. to start with the most similar
flavours to the favourite ones. Sometimes, using the strategy of mixing their favourite
food with the one that we want to introduce can cause the child to reject this food.
CAREFUL! Because if this is the only thing they eat, we cannot run the risk of them
stopping to eat altogether.

The new one is a pure flavour and we will go desensitising his food by
adding small quantities of this other flavour
OR
Keep the flavour intact, reducing the amount and slowly increasing
the amount of the new flavour

Negative conditioning Minimum demand
Eating is nice
Hyper sensitivity to flavours Start with similar
flavours
Each day the new flavour will be different
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Figure 3.In cases where the child does not chew anything, the process tends to be long
and slow; it does not imply that the objectives are not achieved. On these occasions,
multidisciplinary work is very important, as speech therapists or speech and hearing
teachers can support the intervention working on the desensitisation of the oral zone
(with massages, depressants, specific tongue movements etc.) as educational
technicians can focus on the process of brushing teeth, so that the child accepts a
strange solid element in the mouth that could even lead to nibbling and with this
multiple flavours can be introduced.

The recommended process is to increase the thickness of the mashed food,
introducing small amounts of fork crushed food progressively. Working with products
like yoghurts with individual bits does not usually have very positive results as it tends
to stimulate the gag reflex in children, which leads to vomiting.

Once the child allows us to touch the mouth area, introducing different elements and
starts nibbling on external elements such as a toothbrush or depressants, we can start
to put pieces of bread, fried or boiled potatoes, bananas etc. into the mouth, so that
we can get the tongue moving and even bring the molars into the food situation.
We can also help by carrying net bags intended for food use which are used in the
early stages of chewing for babies, so that they associated the movement of chewing
with food flavours.

Only mashed up food
No solids
Introduce solids
Objective: Achieve chewing
Mashed up foodsCrushed with forkIncrease thickness
Desensitisation of the oral zone
Tiny bits of solid food in the molars between meal and reinforcement
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Hyper selectivity

Figure 4. We will work using the techniques from Figures 2 and 3. Starting from the
mashed up flavour and brand that he likes, we can set an objective of getting him to
eat all kinds of mashed up food. From this point, we will work according to the scheme
of Figure 3.

When the child shows strong constraints to a certain brand of mashed up food, we can
start by showing him the original packaging and pouring its contents before him onto
normal tableware.

Hyper selectivity
Only eat limited mashed up food
All mashed up foods
(e.g. Hero jars)
The new one is a mashed up food or a different brand from the usual
and we will go desensitising his food by adding small quantities of this
other flavour
OR
Keep the flavour intact, reducing the amount and slowly increasing
the amount of the new flavour

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Figure 5.In these cases, having developed mastication, being able to expand the
mashed up and solid foods can practically be done in parallel. From the beginning, we
can offer him a new piece of solid food between the mashed up food that he likes, that
we will thicken gradually and enhancing the solid.

Figure 6.We can start by offering him new solids with similar characteristics to those
which he already eats. For example, if he eats pasta with tomato, we will use the
tomato to introduce him to rice or a piece of fish.

Hyper selectivity
Mashed up food and some solids
Increase solid foods
Positive factor: he can chew
Mashed up foodsCrushed with forkIncrease thickness
Negotiate with a solid that he likes
Hyper selectivity
Some solids
Increase solid foods
Positive factor: he can chew
Negotiate with a solid that he likes
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As in other cases, negotiations may arise alternating the new food with his favourite
food or presenting the enhancer at the end, once he has eaten the presented minimal
quantity, which of course at first is symbolic.

When dealing with behavioural problems, we have to know that they can be in an
isolated form and therefore it would be the main objective of the intervention, or they
can coexist with others like those presented earlier. In these cases, we will have to
prioritise the intervention goal and assess whether or not the behavioural problem
incapacitates or not the improvement in introducing new foods. For example, if the
child does not sit, we will have to use this as the first objective before considering any
other.

Behavioural problems related to other areas of
development

In Figure 7, we have picked the most common behavioural issues surrounding food. As
in other cases, we have to know that each case is different, that there is no single or
universal recipe and therefore based on the recommendations of the intervention, we
can go modifying and adapting to the particular case and its answers. It is also
important to know that for a strategy to be effective, it has to be maintained for a
certain amount of time. If we try something one time and it does not provide the
desired response, we cannot say that said strategy is not effective.

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Behavioural Problem Intervention
Do not sit
Eat quickly
Play with their food
Touching food
Dependent on help
Spitting
Increase time periods
Stronger reinforcement activity
Remove plate between mouthfuls/count
chews
Alternate drink/food
Stronger reinforcement
Social history/ visible social norms/ positive
reinforcement
Positive reinforcement and little help (e.g.
me alone, very good)
Ignore/Continue
Figure 7

As for autonomy, in the cases where that has not yet been acquired, you must work on
that once the child is successfully eating everything and in any form. When the main
objective is autonomy during the meal, the adult will provide physical help but not
verbal, any assistance must finish with withdrawing it, and if we talk at the same time
that we guiding we are providing the child with two kinds of help. The adult will be
positioned on the side of the dominant arm, guiding the action from the most distal
point of the tip i.e. taking his hand and progressively shifting aid towards proximal
points, wrist, forearm, elbow, reaching to withdraw our hand and ourselves from
besides the child.

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In Figure 8 we present a table summarising some guidelines for action

Only put on the plate the amount required
Increase the quantities slowly
Although we are sure he will eat more, do not cheat.If we say 1 and thats
enough, follow it through.
Expect that at first he will not eat anything
When the meal is already underway (we increase quantities), we can allow him
autonomy with the reinforcement
When we are increasing quantities, we can deal with other food moments
Ensure hydration
Provide opportunities to say no at other moments
Be systematic and coherent

Figure 8
Normally when we start food therapy outside of the home and with someone outside
of the family, it sometimes produces a mismatch between the childs behaviour at
school and at home, being able to eat everything at school but maintain their
disordered eating at home. It is a fairly common situation therefore we have to avoid
giving up or feeling guilty. It is because at home there are still conditions that you
would have to break. The therapist will go to the family indicating which food they
should keep trying to introduce and when to do it. Working with videos helps the
family to understand the method being followed and for the therapist to go rectifying
the situation at home.
Once the child eats in a situation and with a particular person, we will have to work on
generalising the objectives, it is to say that the child will eat just as well with anyone
and in any situation.

Whenever possible, by availability make the mother or the father assist intensively for
a few days in a row at meal time. At first, they will just be in the same room but at the
far end away from the child and will gradually move closer until it is the parent who
feeds the child in front of the therapist. This helps the child to understand that the
rules are the same with their parents, having a reference figure in front of them and
providing security for the family that the child will translate this to home, because they
have been shown that it is possible for their child to eat.

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STRATEGIES: From intervention to support

The most commonly used strategies indiet therapy for people with DAS are:

Visual aids. As we have pointed out previously, we must inform the child on
everything from who they are going to eat with to which food. We can add this
information to their daily plan and write it down just before eating. In addition, any
type of talks/negotiations or standards that we can establish we will exhibit visually,
through pictograms, photographs and/or physically showing them the food in its
original form.

Counting. Is a resource very often used to make the person understand that the
situation that is upsetting them is not going to last forever; that there is an end to it. It
is important that we remain true to our word, i.e. if we tell our child 3 spoonfuls and
thats it, no matter how well they have eaten it or however much we suspectthat they
would eat more, we cannot continue, given that they would then be unable to trust
our word. The strategy of counting is not incompatible with the others and can also be
presented visually, by covering up or filling inthe boxes as they eat.

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Negotiations.Everyone always tends to make an effort with something if the
reward is good enough. The same applies to our kids. The list of reinforcements that
we create in the beginning will help us to determine what it is that we can use as a
reward. Evidently, whatever it may be, they will not be able to earn it at another
timeor for another reason. They will only earn it when they eat what we set out. For
us to be sure that the reinforcement is sufficiently effective, we can give them two
things to choose between to see which one they want at that moment and even offer
it to them for free the first time. Then, we will demand that before receiving a
reward, they must try or eat something new. The reinforcement can be an object or
food. We can also use it in a different way (e.g. 1 spoonful of new food = 1 piece of
chocolate) or at the end (e.g. mash first and then yoghurt). Again we have to show that
we are firm with negotiations in order for them to be effective, and adjust them as we
progress according to our childs stage or physical state at the time. For example, they
are not well from the beginning, their requirements will be less strict.

1st
2nd
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Physical Control. It is unadvisable to force or physically control your child to get
them to eat. However, on some very exceptional occasions and after having worked
hard to desensitize the situation of eating, we could use a mild physical control. For
example, we could control the childs head with a one finger to stop them moving it
from one side to the other, always ensuring that it is not unpleasant nor causes them
to completely refuse food. We would do this whilst offering them food with the other
hand. If we carry out this type of strategy in a particular moment, we must know that
control, for the minimum level that it is; must be withdrawn as we do with any other
method of help that we exercise. In addition, we cannot maintain physical control
during the exact moment when the child is eating as we must avoid associations being
made between the two, which would then be very difficult to break.

The Better Option.On occasion, presenting your child with a slight modification to
their food versus a completely different form can work, in such a way that they accept
the small modification as the least bad. For example, we can present them with a
lightly mashed vegetable puree in front of a bowl of broth with some whole
vegetables. The objective is for them to eat the lightly mashed vegetable puree and we
only offer them the broth part from the bowl, but only by presenting it in this way can
the child decide to eat the least visually unattractive food without any problems.

Reinforcement.As we have said previously, we can use reinforcement with a
favourite food or object, either alternately or after our demands have been met. In any
case, the most important point is that that reinforcement(which we have previously
defined in the registers), cannot be obtained in any other place, nor through any
other behaviour. That reinforcement will only be achieved if they eat what we ask
them to. We will also give reinforcement socially through the use of distinct facial
expressions and phrases such as very good, great, champion, etc. each time that
they correctly meet the objective that we want them to achieve. If our objective is not
yet correctly understood, but they lift the spoon to their lips, we should only reinforce
this last step. Reinforcement must be carried out immediately. Be careful to avoid
being too effusive because that can scare your child.

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Materials. There is a multitude of materials and tools that exist on the market
which we can make use of to help us reach the objectives that we have set.
When it comes to helping your child to gainindependence you can use cutlery
withsupport handles, which are thicker and anti-slip, plates with heightened edges and
anti-slip bases or with suction pads,or rims or blocks to add to the plates so that the
food does not fall off. Adapted glasses with suction pads to avoid the contents spilling
out or bibs can also be used so that your child is comfortable and dry.

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In the cases when it is necessary to work on desensitising the oral area or developing
chewing, we can make use of hairnets, or carry baby food, teething rings, wrist bands
to chew on, toothbrushes, soft and hard oral spatulas, etc. This type of equipment can
be used out-with mealtimes or can even be used by different people, such as the
speech therapist. Once we get the child to suck on or bite these objects, we can then
go on to spread different flavours of syrups, juices or jellies over them. We would do
so in order to progressively build up a positive and agreeable association with putting
different flavours or strange objects in the mouth.

In the same way, we can go on to work with hard foods such as liquorice, straws filled
with jelly, breadsticks or toffee sweets.

Games.Another way to desensitise the mouth area is through games. In many
cases, lack of chewing causes slackness in the oral muscles which we can go on to work
on in a similar way through fun exercises at home or in school.

Massages with cream in the area around the
mouth
Spreading a favourite flavour around the lips
so that their tongue comes out
Games of blowing raspberries
Games of blowing bubbles, confetti,
whistles, windmills, etc.
Games of holding paper between the lips, or
pencils on the top lip etc.
Games where we move our lips with a finger
to make noises.
We can even put our finger in their mouth to
massage their molars.

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The following box summarises the previous section:

STRATEGIES: FROM SUPPORT TO INTERVENTION
Visual Aids The Better Option
Counting Reinforcement
Negotiations Materials
Physical Control Games

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9. Dental Hygiene: Health and Prevention

Dental professionals, educational professionals and childrens own parents very often
find real difficulty in succeeding in correctly addressing dental health and hygiene in
children with autism.

In these cases, children present special circumstances such as aversion to certain
textures, sounds or tastes, disturbance at being touched, etc. This means that actions
such as brushing, spitting out water for gargling, opening the mouth to see if there are
cavities etc., can end up being very difficultto carry out and therefore, pose
complications in forming hygienic, correct and healthy habits.

Forming these habits can be a lengthy and at times, complicated process, but once
they are acquired, they provide very positive results that have as much of an impact on
their health as more specifically, on achieving the correct diet.

In the same way that we have got to know the milestones of development in teething,
we want to emphasize that this information is simply a guide, and does not have to be
followed in every case as everything will depend on the development of each child.

AGE
EMERGENCE OF TEETH
DURING TEETHING
From 6 to 12 months 8 milk incisors
From 12 to 18 months 4 first milk molars
From 18 months to 2 years 4 milk canines
From 2 to 2 years 4 second milk premolars
At 6 years 4 adult premolars
From 6 to 8 years 8 adult incisors
From 8 to 9 years 4 second adult molars
From 9 to 12 years
4 adult canines and 4 adult
premolars
At 12 years
4 adult canines and 4 adult
premolars
From 16 to 25 years 4 third molars
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The development of teething can coincide with the appearance of certain illnesses and
pains if hygiene habits are not correctly taken care of. Taking long-term medication can
also have an effect.

The most common ailments which we advise should be treated by a specialist due to
their direct relation to diet are:

Cavities: the destruction of the tissue in the teeth caused by the acids in bacterial
plaque.

Traumatic lesions to the tissue in the teeth, from the jaw bone to the gums.

Bruxism: involuntary pressing down or grinding of teeth.

Halitosis: is identified by bad breath or odour in the mouth.

Gingivitis: is the inflammation and bleeding of the gums.

Periodontal Disease: is infection of the tissues that surround and support the teeth,
caused by plaque and tartar.

To prevent these ailments from occurring in children it is important to:

Create a routine for oral hygiene: which must consist of brushing the teeth after
every meal, restricting the consumption of sugary foods or drinks, chewing food well
so that pieces of food are not left in between the teeth and the consumption of
calcium and protein rich foods.
Children must grasp the importance of brushing even though they have milk teeth,
given that it is proven that dental deficiencies and cavities can be transferred to adult
teeth.
Get to know and be able to differentiate between the different tools used for
brushing: as we have seen mentioned, children with autism sometimes have a major
or minor sensitivity to certain tastes, textures, colours or sounds. We must keep this in
mind in order to determine the most suitable toothpaste, brush or mouthwash for the
child.

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As their first teeth begin to appear, either gauze with a little water or a toothbrush
designed for babies can be used. Subsequently, it is advisable to soft, gentle brushes
with a straight handle so that they do not hurt their gums until they control the
pressure that they must exercise. The use of electric toothbrushes is always suitable
provided that the noise and vibration that it makes does not cause refusal or any
changes in the childs behaviour.

The toothpaste used should be one designed for infancy, with fluoride, calcium and
fruit flavours.

Learn the techniques for correct brushing: brushing must start with the
emergence of your childs first teeth and should always follow an order that ensures
every area is brushed. In this way, we facilitate the childs learning as well. We will
begin with a short brushing time (a few seconds will be sufficient) and we will then go
on to increase it in such a way that your child learns as you go.

There are various techniques for brushing the teeth:

HORIZONTAL TECHNIQUE
A simple technique for the beginning stages of learning in children. It consists of
moving the toothbrush around the surface of the teeth in horizontal movements.
CIRCULAR TECHNIQUE
This technique is the most commonly recommended one for younger children with
learning difficulties as it demands less stress or ability in order to brush the teeth.
It consists in large circular movements and is carried out with a closed mouth,
covering the edges to the gums of frontal and rear teeth.
With this technique it is advisable to remove bacterial plaque and at the same time
massage the gums.

76

Asides from teeth, we must not forget to brush the tongue, which is important for,
above all, eliminating bacteria that deposits and causes halitosis (bad breath). The
same toothbrush is used to brush from halfway down the tongue towards the end -
with or without toothpaste and always very gently so as not to damage the taste
buds.

At times we find that when gargling water, children do not know how to spit. In order
to avoid continuous and excessive ingestion of fluoride which can damage the
digestive system, we should reduce the amount of toothpaste to approximately half a
pea-sized amount, given that it is the brush itself that does the cleaning.

As with other activities that we carry out with children with autism, we must continue
to use the techniques that facilitate their learning. For example, show the child
beforehand through pictograms that after eating they will have to brush their teeth. In
addition, by putting the pictograms in key places to indicate where the toothbrush and
toothpaste are kept, we can also address making a habit of it by carrying it out at the
same time and in the same place.

SEQUENCE FOR TOOTH BRUSHING

Images extracted from ARASAAC

77

To help your child to understandthe amount of time that brushing their teeth will take,
we can tell them in a clear voice, whilst brushing or helping them to brush.

All of theseactions will ensure that your child forms the correct habits and the
condition of their mouth will no longer be an impediment to your child eating, given
that if no pain exists in the mouth, feeding can be carried out correctly (as the mouth is
the entry-way to food).

The same applies for learning other tasks in daily life to achieve continuity between
your child at school and at home it is vital that they be followed.

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ANNEXES

79

INITIAL REGISTER

FOOD DRINK

I DONT LIKE

I LIKE

AMOUNT

HOW I EAT IT

80

DAILY REGISTER

DATE FOOD ATTITUDE/COMMENTS

81

REINFORCEMENTS REGISTER

GAMES

TOYS
SONGS

CHARACTERS

82


BIBLIOGRAPHY

83

Ventoso, M.R. Los problemas de alimentacin en nios pequeos con autismo. Breve
gua de intervencin. Published in Rivire, A. y Martos, J. (comp).(2000). El nio
pequeo con autismo. 10, 120-122. Madrid: APNA.

Carnero J.J., Pastor A., Als F.J. (2002). Intervencin en hbitos de alimentacin en
un nio con Autismo. XI Congreso AETAPI.

Viguria Padilla, F. y Mijn de la Torre, A. La pica: retrato de una entidad clnica poco
conocida. Nutricin Hospitalaria. 2006; 21(5):557-66

Ortiz-Andrelluchi A., Pea Quintana L., Albino Beacar A., Mnckeberg Barros F. y
Serra-Majem L. Desnutricin infantil, salud y pobreza: intervencin desde un programa
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Laud RB, Girolami PA, Boscoe JH, Gulotta CS. Treatment outcomes for severe
feeding problems in children with autism spectrum disorder. BehavModif. 2009
Sep;33(5):520-36. Epub 2009 Sep 10.

California Deparment of Disabilit Services. Autistic Spectrum Disorders: Guidelines
for Effective InterventionsElder et al. 2006; Millward et all., 2004; Kern, Miller, Evans y
Trivedi, 2002

Sharon M., Greis, Ma CCC/SLP, BRS-S Stephanie M., Hunt Ms., otr/l. (2008) Texture
Progression: The Effects of Oral Sensory Defensiveness on Oral Motor Function in ASD.
Pediatric feeling & shadowing center.

Valerie M. Volkert and Petula C. M. Vaz. (2010) Recent studies on feeding problems in
children with autism. Journal of applied behavior analysis.Munroe-Meyer institute and
university of Nebraska medical center. 2010, 43, 155159.

GETEA. Gua de buena prctica para el tratamiento de los trastornos del espectro
autista. REV NEUROL 2006; 43 (7): 425-438

Gortzar Daz, M. Servicio de AT de Lebrija (Sevilla). Favorecer la comunicacin y el
lenguaje en contextos de la vida diaria.
Adams J., Edelson S., Grandin T., Rimland B. (2004) Recomendaciones para los padres
de nios autistas pequeos. En http://www.autism.com/tran_es_advicepaper_rev.asp
Equipo Deletrea. (2011). Los nios pequeos con Autismo. Soluciones prcticas para
problemas cotidianos. Madrid: CEPE

Grandin, T. (1995). Pensar con imgenes. Alba.
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Bogdashina, O. (2003). Percepcin sensorial en el autismo y sndrome de Asperger.
Autismo vila

De Clercq, H. (1999). Mam, eso es un ser humano o un animal? Intermedia Books
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(supl 3): S77-87

Websites:
Agencia espaola de seguridad alimentaria y
nutricin (AESAN)
http://www.aesan.msc.es/
Asociacin Espaola de Profesionales de Autismo (AETAPI).
http://www.aetapi.org/
Programa TEACHH (Programa Estatal de Carolina del Norte)
http://www.teacch.com/
Confederacin Autismo Espaa
http://www.autismo.org.es/
Centro de Referencia Estatal de Autonoma Personal y Ayudas Tcnicas
http://www.ceapat.es
Portal Aragons de la Comunicacin Aumentativa y Alternativa
http://www.catedu.es/arasaac/

FEDERACIN AUTISMO MADRID
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www.autismomadrid.es info@autismomadrid.es Tlf. 910 133 095


Intervention Guide For Eating Disorders in Children On The Autism Spectrum (ASD)

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Intervention Guide For Eating Disorders in Children On The Autism Spectrum (ASD)

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Authors: Baratas, M.; Hernando, N.; Villalba, L.; Matas, M.J.; Enrique, M.D.

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