How to manage loss of appetite in patients with autism spectrum disorder (ASD)?

Managing Loss of Appetite in Patients with Autism Spectrum Disorder

Loss of appetite and food selectivity in patients with ASD should be managed through a systematic approach: first exclude medical contributors (gastrointestinal disorders, pain, medication side effects), then implement behavioral interventions as first-line treatment, specifically operant conditioning with functional behavioral assessment, followed by sensory-based occupational therapy approaches if needed. 1, 2

Step 1: Identify and Address Medical Contributors

Before implementing behavioral strategies, systematically evaluate for underlying medical conditions that may be causing or worsening appetite problems:

• Screen for gastrointestinal disorders (constipation, reflux, abdominal pain), as these are common in ASD and directly impact appetite and eating behaviors 1
• Assess for pain sources that may make eating uncomfortable, including dental problems, oral motor difficulties, or other sources of discomfort 1
• Review all current medications for appetite-suppressing side effects, as many psychotropic medications commonly used in ASD can reduce appetite 1
• Evaluate nutritional deficiencies that may have developed from restricted eating patterns, as these can perpetuate poor appetite 3
• Consider psychiatric comorbidities including anxiety and depression, which frequently manifest as changes in eating behavior in children with ASD 1

Step 2: Implement Behavioral Interventions as First-Line Treatment

After excluding or treating medical contributors, behavioral approaches are the primary evidence-based treatment:

Operant Conditioning Approaches (Strongest Evidence)

• Apply operant conditioning techniques as the most efficacious psychotherapy for feeding difficulties in ASD, using positive reinforcement for food acceptance and escape extinction for food refusal 2
• Conduct functional behavioral assessment to identify what triggers food refusal and what consequences maintain the selective eating pattern 4, 2
• Implement differential reinforcement strategies where desired eating behaviors are systematically rewarded while problematic behaviors are not reinforced 4

Systematic Desensitization

• Use gradual exposure protocols for children who show sensory-based food aversion, breaking down food acceptance into small incremental steps 2
• Incorporate taste and cooking sessions as educational interventions, which have demonstrated effective results in promoting food acceptance 5

Step 3: Address Sensory Processing Factors

Children with ASD commonly have sensory sensitivities that contribute to food selectivity:

• Involve occupational therapy to address sensory-behavioral aspects of food selectivity, as sensory processing difficulties and delayed oral motor skills often predispose individuals with ASD to restricted eating 5, 6, 3
• Target specific sensory sensitivities (texture, temperature, appearance, smell) through sensory integration techniques and gradual desensitization 6, 3
• Utilize occupational therapy techniques as part of a multidisciplinary approach, though these interventions should be combined with behavioral strategies rather than used in isolation 6

Step 4: Establish Structured Mealtime Routines

Leverage the ASD preference for routine and predictability:

• Create consistent mealtime schedules and routines using visual supports, as children with ASD often adapt well to establishment of routines when visual schedules are implemented 1
• Implement visual communication systems showing the sequence of mealtime activities, which can reduce anxiety and improve cooperation 1
• Minimize mealtime distractions and establish clear expectations, as children with ASD require entertaining and diverting attention less when structure is provided 7

Step 5: Engage Family as Co-Therapists

• Provide parent training in behavioral management techniques for mealtimes, as combining behavioral interventions with parent training is more efficacious than interventions alone 4, 8
• Ensure parents understand the rationale for behavioral approaches and receive hands-on instruction in implementing strategies 1
• Address family barriers to implementation, including difficult daytime behaviors or financial concerns that may prevent consistent application of strategies 1

Multidisciplinary Team Composition

• Coordinate care among psychology, speech therapy, occupational therapy, and nutrition professionals, as this multidisciplinary approach is acknowledged as key to addressing food selectivity in ASD 5, 6
• Include speech-language pathologists when oral motor difficulties or communication deficits contribute to feeding problems 1, 6
• Involve registered dietitians to monitor nutritional adequacy and prevent malnutrition from restricted eating patterns 5, 3

Common Pitfalls to Avoid

• Do not attribute all eating problems solely to autism without evaluating for treatable medical conditions like gastrointestinal disorders, which are highly prevalent in this population 1
• Avoid premature use of appetite stimulant medications before implementing adequate trials of behavioral interventions, as behavioral approaches should be first-line treatment 1
• Do not implement interventions in isolation—ensure sufficient intensity and that communication needs are adequately addressed through augmentative systems if needed 4
• Recognize that nutrition education alone is often ineffective in ASD; behavioral and sensory-based interventions have stronger evidence 5