“My son, who has autism, didn't eat for his first four years. After lots of therapy, he began eating and even using silverware. Then at age 5, he started to refuse utensils. Now, at age 7, he eats even ice cream with his fingers! Any advice?”
Today’s Food for Thought response is by pediatric psychologist Elizabeth Pulliam. Dr. Pulliam practices at the University of Arkansas for Medical Sciences & Arkansas Children's Hospital. Both are part of the Autism Speaks Autism Treatment Network (ATN).
Dr. Pulliam also co-authored the Autism Speaks ATN/AIR-P tool kit: Exploring Feeding Behavior in Autism: A Guide for Parents. (Follow the text link for free download.)
Editor’s note: The following information is not meant to diagnose or treat and should not take the place of consultation, as appropriate, with a qualified healthcare professional.
Thank you for your question. You are far from alone. While eating and feeding issues are common among all children, they tend to be particularly common – and often quite intense – among children with autism.
Many parents have come to our ATN clinic with questions about how and when to teach their children to feed themselves – while encouraging socially appropriate utensil use.
There are many things we consider as we help children make progress. I hope some of these considerations and strategies will help your son.
Is my child ready to use utensils?
Most typically developing children can start attempting to use a spoon after 6 months of age – while their parents are still feeding infant cereals and baby foods. However, most of the food will end up on their faces rather than in their mouths until 18 to 24 months. That’s when typically developing children start to develop the fine motor skills and hand-eye coordination needed to independently feed themselves with utensils.
These fine motor and coordination skills include the ability to use their hands and fingers to reach, grasp and aim precisely.
Of course, many children with autism have delays in the development of fine motor skills and eye-hand coordination.
From what you’ve shared, it sounds like your son had some significant early motor challenges. These can, indeed, affect the ability to self-feed. For example, instability in holding up the head and trunk can prevent a child from being able to sit in a stable position for a meal – let alone use utensils.
Like many young children with autism, your son may have had additional delays in oral-motor development. That is, the ability to move food around in the mouth, seal lips around a utensil or cup, chew and then swallow.
In addition, independent eating and utensil use require some problem-solving skills. So cognitive delays and/or intellectual disability can add to the challenge.
Bottom line: Many kids with autism – like your son – either need to be fed or continue eating with their fingers at ages when typically developing children are using utensils.
Of course, you mention that by age 5 your son was using utensils with the help of intensive behavioral therapy.
Why the loss of skills?
Unfortunately, it’s also very common for children with developmental difficulties to lose new skills during times of change or stress – or simply because the old way was easier. Similarly, some children who’ve learned to use utensils revert to eating with their fingers when they are especially hungry or feeling rushed. After all, they can get more food into their mouths faster that way.
It’s also true that many children with autism will go back to easier ways of doing something when a new skill is not being reinforced as strongly as it once was. This may be the case with your son if he no longer has a behavioral therapist working on his eating skills.
Behavioral and sensory issues to consider
Most children on the autism spectrum also prefer routine and sameness. So eating with his fingers may not only be easier for your son in terms of motor skills, it’s also likely to feel more familiar or natural to him. So when you try to re-introduce utensils, it’s not surprising to meet some resistance to the change in his routine.
In addition, as children get older, most will want to assert more independence in aspects of their daily lives. This can include mealtimes. We often see children who become more insistent on what and how they eat, resisting direction from adults. While we love to see these efforts for independence, clearly this can make encouraging utensil use more difficult.
In addition, sensory issues may be playing a role in your son’s return to eating with his fingers. Many children affected by autism have issues with what a food feels like in their mouths. Out of caution, they may want to explore it with their hands. Utensil use may interfere with their sensory exploration of the food.
Lastly, many children on the autism spectrum have difficulty picking up on polite behavior, and this can include polite mealtime behavior. This doesn’t mean that we shouldn’t teach good manners. Good table manners are very important skills for your son’s future independence and social inclusion. But the lack of social consciousness can make it harder to teach dinnertime social skills.
Tips that can help!
Now that we’ve explored some of the issues your son may be facing, here are some strategies that may help.
Play with utensils
In introducing – or re-introducing – utensil use, playing with utensils is a good start.
* Encourage your son to play with spoons and cups of various sizes, allowing him to pour, fill and stir dishes filled with materials of different consistencies. For instance, water or applesauce or sand.
* Toy dish sets are another option to encourage utensil use through pretend play. For example, feeding a doll.
* Give him some playdough and plastic utensils for cutting, scooping and stabbing it.
Video modeling is another good way to teach and encourage skills with children who have autism. Try video-recording someone eating with utensils. The star of the video could be you, a sibling or one of your son’s friends. Make sure the video is close up enough that your son can clearly see you picking up the utensil, arranging it properly in your hand, using it to pick up food and then placing it in your mouth. It can help to exaggerate these motions as you’re modeling them.
Record several “bites” worth of action with both a spoon and a fork. Then allow your son to watch it several times at the table, just before a meal.
Encouraging utensils at mealtimes
Sit and eat with your child, modeling utensil use and praising any and all efforts he makes to imitate you or use his utensils. Here are some specific strategies that I’ve found helpful:
* Make sure your son has a stable and comfortable seat at the table. Use a booster seat or books as needed so the tabletop is between his chest and belly button. Provide a stool in front of his chair so he can brace his feet. This will provide him with a comfortable position for easily reaching food and bringing it to his mouth with a utensil.
* Make sure that the spoon, fork, bowl and plate you give your son are an appropriate size for him. To increase the “fun factor,” consider a child’s dinner set decorated with a theme of interest (e.g., cars, dinosaurs).
* I recommend metal spoons and forks with rubber or plastic handles. The metal makes it easier to cut through food, and the plastic or rubber handle are easier to grip.
* Sit across from your son at meals and snacks and model how you want him to use his utensils. As in the video, slow down a bit to emphasize the steps of using the utensil.
* If your son refuses to eat with a utensil, encourage him to at least hold a spoon or fork in one hand as he eats with the fingers of the other hand. Make clear that it’s okay for him to use the utensil to play with his food. (To minimize the mess, you might want to put a small amount of food in a suction-bottomed bowl.)
* To encourage spoon use, give your son some thick or sticky foods that he likes. They will stay on the spoon more easily.
* To encourage fork use, offer favorite foods in bite sizes that can be easily stabbed and chewed. Examples include cooked vegetables and chunks of soft meats, fruit and bread.
Using praise and rewards to encourage progress
As we’ve discussed in many earlier advice posts, praise and small rewards are important to encourage your son’s progress. The rewards can be a small toy, favorite activity or even a token. Tokens can be magnets on a board or a sticker or stamp on a piece of paper. I suggest giving a token for each small success.
For example, place a spoon next to your son’s plate and encourage him to pick it up and hold it while he eats – whether or not he uses it. When he does so, follow up with enthusiastic praise and a reward token – maybe even a puff of celebratory bubbles. You get the idea.
The next step might be for your son to progress from holding the spoon to using it to eat a spoonful. Again, offer praise and a reward – perhaps a token for each time he attempts to spoon food into his mouth. It’s okay if the attempts don’t quite hit the mark at first.
If your son refuses the utensil and begins eating with his fingers, try gently but firmly placing the utensil back in his hand and then placing your hand over his so you can guide him through the motions of bringing the food to his mouth. With each swallowed bite, offer praise and a token.
At the end of the meal, count up his tokens and allow him to cash them in for a small prize such as a sweet, small toy from a grab bag, video game time or favorite activity with you.
Over time, you can gradually raise the number of tokens your son needs to earn for each reward. Remember to be patient. Small steps add up – though it may take weeks or even months.
I hope this information proves helpful. If your son requires more assistance, I encourage you to enlist a behavior therapist who can work with you on a personalized plan to fit the needs of your son and family.
And please let us know how you’re doing in the comment section below or by emailing us again at firstname.lastname@example.org.
Editor’s note: Also see these helpful feeding advice posts by Dr. Pulliam:
* Help for child who won't eat foods that 'smell'