“Our son, who is 3, is awaiting an autism evaluation. Meanwhile, we’re having serious issues with his aversion to certain food textures. Rather than swallow, he’ll hold it in his cheeks until he vomits. Other times this happens when he’s full, or even when we’re sharing a food he really likes. He’ll shove handfuls into his mouth to keep others from getting them! Then he looks like a chipmunk and keeps chewing until he gags and vomits. Help!
This week’s “Food for Thought” answer is by pediatric psychologist Elizabeth Pulliam, of the University of Arkansas for Medical Sciences and Arkansas Children's Hospital. The university and hospital are part of the Autism Speaks Autism Treatment Network (ATN).
Dr. Pulliam co-authored the Autism Speaks ATN/AIR-P tool kit: Exploring Feeding Behavior in in Autism: A Guide for Parents. (Follow the title link for free download.)
Editor’s note: The following information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.
Thank you so much for sharing your son’s struggles with eating. It sounds like he may have several issues going on at the same time, all of which tend to be common among people who have autism.
Although it’s difficult to offer specific answers without knowing more about your son’s history, I can talk about some of the factors that may be linked to his food behaviors and offer some suggestions.
Texture aversions and picky eating are common among all children, but particularly so among children with autism. Challenges can occur anywhere among the many steps in the feeding process. These include tolerating food smells, allowing a food on the plate, placing it in the mouth, chewing, swallowing and other steps in between.
Stuffing food in the cheeks – also known as “pocketing” or “packing” – is more common among toddlers and preschoolers than you might think. Some pocket food for hours or even all day. It may go unnoticed until a parent sees the child chewing on something long after mealtime.
It’s an important issue to discuss with a speech therapist and/or occupational therapist with expertise in the feeding issues that often affect children with developmental disabilities.
So let’s discuss several possibilities for why your son may be stuffing his mouth like a chipmunk. Then we’ll explore ways to help him with these issues.
You mention your son’s aversion to certain food textures. Such sensory issues are likewise common among people with autism – and we frequently see these issues associated with holding food in the cheeks.
Often, children who dislike how a food feels on their tongue or in their mouth, will push the offending food into that cheek pocket. This is particularly true when certain food textures stimulate a gag reflex – as may be the case with your son. So, pocketing disliked food may well be your son’s way of avoiding the overwhelming unpleasant sensations including gagging and choking.
It sounds like your son pockets food not just to avoid unpleasant textures, but also when overstuffing his mouth with favorite foods. We see this type of overstuffing associated to autism-related sensory issues as well. For instance, some of the children we see have difficulty knowing when their mouths are full and they need to start chewing. In other words, they don’t get that full mouth sensation before they’ve overstuffed their mouth to maximum capacity.
Along similar lines, we also see overstuffing related to a child eating too quickly and/or not understanding how to bite small pieces off of a large piece of food.
All these scenarios can prove overwhelming when the child suddenly realizes that he can’t handle the amount he’s stuffed into his mouth. It sounds like this may be the case with your son: He becomes anxious and afraid to swallow. As a result he gags and vomits.
Sometimes food pocketing stems from under-developed oral-motor skills, which is quite common among young children with autism. This involves weak muscle development of the mouth, jaw and/or tongue. And it can make chewing difficult, especially with tougher foods. For example, it’s particularly common for children with weak oral-motor skills to pocket meat. All the chewing involved can simply prove too tiring.
Some children have particular difficulty moving the tongue from one side of the mouth to the other. We call this tongue lateralization, and it’s a crucial for positioning food between our teeth for chewing. It also enables us to retrieve pieces of food that fall into that pocket between the teeth and cheek. We even use tongue lateralization to wet food with saliva – which helps us chew and swallow without gagging.
Children with weak tongue skills can have particular difficulty scooping food out of that cheek pocket. They end up holding it there awhile.
Of course, most of us give little thought to making all these tongue movements. But they need to be considered when a child habitually packs food inside his or her cheeks.
A speech therapist or occupational therapist with experience in oral-motor feeding issues can evaluate your son for such weaknesses and design a therapy program to address them.
Food pocketing isn’t always related to weak oral-motor skills. It can be a sign that a child is tired of chewing or simply isn’t hungry any more. That’s when you get those last bites “saved” in the cheeks.
Helping your child
Whatever the reason for your son’s food packing and mouth stuffing, it’s vitally important to address the problem. Children who frequently overstuff their mouths, hold food in their cheeks and/or vomit are at risk for choking, aspirating the food into the lungs and tooth decay. In addition, unappealing eating habits can become a major barrier to social acceptance as your son gets older.
For some children, it’s simply a phase that can be curbed by simply drawing their attention to what they’re doing and prompting them to chew and swallow before putting more food their mouths.
For others, it takes more work – with an intervention plan tailored to the “why” behind their behavior. Again, it’s important to consult with a knowledgeable professional such as a speech therapist. Ask your son’s pediatrician for a referral, and/or see if such services are covered by your state’s early intervention program or your school district’s individualized education program.
Meanwhile here are some strategies to try with your son:
*Ask your son to take a sip of water or other drink and swish it in his mouth after he has chewed and swallowed each bite of solid food, “to help wash it down.” Praise him enthusiastically for swallowing and having an empty mouth between bites.
* Using a small mirror, have your son look into his mouth to be sure that he’s swallowed all the food in his mouth before he takes another bite. This kind of visual feedback can help your son become aware of the need to swallow fully between bites. Again, remember to praise him clearing his mouth between bites.
* Have him open his mouth and show you that his food is “all gone” before taking the next bite. Ditto on the praise.
* Consider placing only one or two bites of food at a time on his plate, keeping the rest of the food out of reach. Explain to him that you’ll increase the number of bites on his plate when you see consistent swallowing of the last bite.
* When you see your son pocketing food in his cheek, give him a small spoon and have him scoop the food away from his cheek and put it back onto his tongue. If he can’t do this himself, gently do it for him. Studies have shown this technique often works to decrease food pocketing.
*Brushing teeth right after a meal allows you to check his mouth for any leftover food stuck in the cheeks, and the brush can help scoop out any food left. Making brushing part of the routine following meals may itself help to prompt swallowing of the last bite.
Easing the gag reflex
As mentioned above, strong aversions to certain food textures can lead to gagging. In severe cases, it’s important to get professional help with a personalized program of oral-motor therapy. At the same time, you can try the following strategies at home:
* During your child’s regular tooth-brushing routine, encourage him to move the toothbrush around in his mouth and brush his tongue. This can also be done at any time with a spoon or other safe eating utensil. Model how to do this with a wide mouth so he can see what you’re doing.
* Some children need to ease into the above exercise in a very gradual manner. Try starting with an enjoyable activity such as singing or blowing bubbles, then ask your child to simply hold the toothbrush or spoon to his lips for a few seconds. Praise him when he can do this without gagging. Then prompt him to move the brush or utensil to the tip of his tongue, again holding it there for several seconds. Again offer praise and a prompt to move back to, say, the middle of the tongue.
* If your child gags at any point, simply acknowledge it calmly. For instance, by saying, “Oops, you gagged. It’s okay.” Give him a few moments or minutes to calm down and then say “Let’s try again.”
* This type of gradual approach can be spaced out over several sessions if needed.
When gagging happens at mealtimes
Occasionally, your son may still gag at the table because he’s placed too much food in his mouth or finds a food texture too unpleasant. Here are some hints to help him calm down to prevent gagging or stop the gagging from escalating to vomiting:
* Keep an empty cup by his plate so he can spit out some food if he feels he needs to do so.
* Avoid overreacting. If your son gags or vomits, remain matter-of-fact. You might say something, “Oops, you must have gotten too much,” or “Let’s see if a little sip of water can help you clear your mouth.”
If problems continue after you’ve tried these strategies, I strongly recommend working with a feeding specialist. Many speech pathologists, occupational therapists and developmental psychologists have expertise in this area. There’s simply no substitute for a full, in-person evaluation of your child’s feeding issues with an intervention program tailored for his specific needs.
I hope that some of these suggestions prove helpful and wish you the best with your son. Please let us know how you’re doing with a comment below or by emailing us again at firstname.lastname@example.org.
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