Challenging Case Blog

Viewpoints from the interdisciplinary leaders in optimal developmental and behavioral health for all children.

Tuesday, September 6, 2016

Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder

Kendra is a 4-year-old girl with Autism Spectrum Disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. Kendra is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with GERD associated with persistent bottle refusal, and the acceptance of few pureed foods. At 13 months, milk and peanut allergies were diagnosed. Following a feeding clinic evaluation at 24 months, Kendra was prescribed a soy milk supplement and an H2 blocker. There was no concern for oral-motor dysfunction. She was also referred to Early Intervention for feeding therapy. However, her parents terminated participation after six months because she became anxious and tantrumed prior to treatment groups.


Kendra was seen in another feeding program at age 3 years;zinc, folate, thyroid, and a celiac panel were normal and an endoscopy was negative for eosinophilic esophagitis. She began individual feeding therapy, where concerns for rigidity, difficulty transitioning, and limited peer interactions led to a neuropsychological evaluation. Kendra was diagnosed with an ASD and Avoidant/Restrictive Food Intake Disorder (ARFID). Her cognitive skills were average, and expressive and receptive language skills were low average.


Kendra’s diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines two months prior. She controlled other aspects of feeding, insisting on a specific parking spot at a fast food restaurant and drinking from a particular sippy cup. Her parents accepted these demands with concern about her caloric intake, which they tracked daily.


Following diagnosis with ARFID, Kendra resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, Kendra kissed and licked two new foods without gagging. Her mother appeared receptive to recommendations that included continuing the “food game” at home, replacing one ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands. [does this describe elements of  the “food game”?]


Currently, Kendra’s parents plan to discontinue feeding therapy with concerns that the treatment was “too harsh.” Her father produces logs of Kendra’s caloric and micronutrient intake as evidence that Kendra did not replace missed formula with other foods, and reports that Kendra subsequently became more difficult to manage behaviorally. Kendra’s father now demands to see randomized-controlled trials of feeding therapy approaches. Kendra’s weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?