Eating…how hard can it be?

Golden fries with the right crispness, warm pita bread, lentil soup with freshly ground pepper on top — what’s not to like! Turns out eating can be very challenging for some kids —especially those with special needs. And it can turn out to be an everyday battle for parents. No — there is no magic bullet here, every kid is very different.

Why do we need to eat? There are many expert explanations, but I can think of 2 reasons. The obvious one is that we eat to get nutrition for our bodies. The not so obvious reason is that eating is a social event. There is a lot of explict, and implicit rituals around mealtime —talking about what’s on the menu, preparing food, laying out the table, chatting while eating, and arguing about who does the cleaning. Talking about difficulty eating — many neurotypical kids also experience this, but it fades away with growing up. When a 9 year old kid insists on just eating fresh fries from McDonalds for every meal, and throws a tantrum if you suggest anything else  — you know the situation could be improved.

Is there a physical issue?

We first need to check if any physical issue is causing eating difficulties. The Pediatrician will typically enlist the help of a Feeding specialist or a Speech Language Pathologist (SLP) who will diagnose oral motor disorders. It may be surprising why a speech specialist may help with eating issues — but of course, the common connection is the mouth. If a person’s tongue is weak, it affects both eating and speaking. 

Typically, the next big area to rule out is the Gut. The person may feel acute discomfort when the food travels through their digestive system. Worse, they may not be able to express how they feel, eventually resulting in temper tantrums. But how do you figure out if it’s the gut? Don’t worry, even Sherlock will get stumped with this. Things parents try include consulting a Gastroenterologist, full panel allergy test, Gluten free diet, Mirolax or similar for constipation. As you work through this detective challenge, it is best to change one thing at a time —so you know if that change had an effect, although it is very tempting to throw the whole arsenal at the problem. And, it is always useful to keep track of things —even gross things like the frequency/quantity and texture of poop — so you know for sure things did change. Some people may figure out the big issue quickly —lucky you — but for many it is a journey.

Is there a sensory issue?

Some neurotypical people don’t like to eat eggplants or oysters because they are slimy. This is also a sensory feeling, but the person could politely avoid these food items and choose other options. Imagine how the slimy texture of Jell-O may trigger an intense aversive response, resulting in a mealtime meltdown. Many of these neurodivergent individuals are unable to express how they feel, so caregivers are left clueless. On the flip side, you cannot keep feeding just potato fries to your 9 year old — since it doesn’t have all the nutrients needed. Plus there is this gnawing need to find the source of the problem. 

Also, Neurotypicals usually enjoy combinations of foods without a second thought. A key to figuring out sensory issues around eating is to disentangle foods. Say, start with a Taco with just cheese, before adding that lettuce or tomato. 

Is there a behavioral issue?

A person may laugh loudly when eating, and spill half the food on their pant. Another person may play with the food for a full minute or more between every spoonful — and eating every spoon needs prompting. Behavioral issues can effortlessly transform the dining table into a battlefield. So, how do we tackle it? Come up with ‘peace-time’ routines — practicing eating regularly — so that meal times can get smoother. There are various techniques to try. First, do a food preference assessment — try 10 foods, and systematically rate each of them. Think counting the number of times the food was picked up, put in mouth, chewed, spit, swallowed etc. Then, you try small amounts of highly preferred food — and baseline how the intake is. Then, you pair preferred and non-preferred foods . You can also try ‘first then’ routines — a much more rigorous version of ‘eat your veggies before the dessert’. From all this analysis, which takes a few weeks, evolves an eating plan you can try.

Applied Behavior Analysis (ABA) is all about data driven action. And is well suited to behavioral issues related to eating. I saw this first hand when I interned at Seattle Children’s Autism Center —evaluating the effects of a treatment package on mealtime behaviors in children with Autism Spectrum Disorder and severe food selectivity. We face a mix of the above issues every day with our son who is on the Autism spectrum. Although far from ideal, Manu’s food preference mix has expanded over time, and continues to evolve. Last week, everyone in the family ate his favorite mix of Methi roti, Lentil soup and Oreo icecream — thanks Manu!