Recognising signs of disengagement or distress during mealtime in children with autism can be essential for ensuring a supportive and positive dining experience. Children with autism may exhibit a range of behaviours that indicate they are uncomfortable, overwhelmed, or simply not engaged during meals. Understanding these signs can help caregivers address their needs effectively. These signs may vary from child to child, but here are some common indicators:

1. Physical Signs

• Avoidance or escape behaviours: The child may try to leave the table, turn their body away from the food, or push the plate away.
• Shutting down or freezing: The child may become very still, avoid eye contact, or go quiet, which can be a sign of feeling overwhelmed.‍
• Increased fidgeting: Repetitive movements, such as jittery, jerky or thrashing movements, hand flapping, rocking, or tapping, may increase when the child is anxious or disengaged.‍
• Gagging or vomiting: Some children with autism may gag or vomit in response to certain textures, smells, or tastes.‍
• Other physical signs can include hiccupping, sneezing or yawning in infants and toddlers, arching back, limp posture and decreased level of alertness that can present with a drowsy or glazed expression.

2. Verbal Signs

• Refusal or rejection phrases: They may say "I don't like this," "I'm not hungry," or "I don't want to eat" repeatedly, even if the food was previously accepted.
• Monotone or reduced speech: If the child usually speaks during meals but suddenly becomes quieter or speaks in a flat tone, it could indicate discomfort.
• Echolalia: Repeating phrases or words instead of engaging in typical conversation may be a sign of stress.

3. Behavioural and Emotional Signs

• Crying or fussing: Grimacing, crying, fussing, or yelling can indicate distress or sensory overload.
• Irritability: Becoming irritable or angry for seemingly no reason may indicate discomfort with the food or environment.
• Withdrawal: The child might retreat inward, appearing emotionally distant, avoiding interaction, or staring off into space.
• Throwing food or utensils: Tossing items off the table is often a sign of frustration, discomfort, or sensory overload.
• Hyperactivity: A sudden increase in energy, such as bouncing, running, or pacing, can be a response to feeling overwhelmed by the environment.

4. Sensory Responses

• Covering ears or eyes: Sensitivity to noise or visual stimuli (e.g., bright lights or too many colours on the plate) may lead to covering ears or eyes.
• Strong smelling or unfamiliar food or brands: They may avoid or reject foods that have strong smells and may reject meals if there are unfamiliar foods mixed with preferred foods e.g. a child may prefer plain pasta or spaghetti but may reject spaghetti bolognaise. Children with autism can experience hypersensitivity and can reject unfamiliar brands of their preferred food due to flavour profile variations. 
• Aversion to specific textures: Certain textures might cause avoidance or refusal, even if the taste is accepted.

How to Respond:

• Respect boundaries: Avoid forcing the child to eat or interact with food they are uncomfortable with. Offering meals on a plate with dividers to separate challenging goods with familiar foods can be helpful, and for school lunchboxes, using bento-style lunch boxes can offer similar mealtime strategy. 
• Create a calm environment: Minimise distractions, dim the lights, and reduce noise levels to prevent sensory overload.
• Offer familiar foods: Providing foods that are safe and familiar can help reduce anxiety. Having the option of a ‘discard bowl’ for the child to dispose of any challenging food that they’ve tried can help reduce anxiety and increase their sense of safety around mealtimes. 
• Follow the child’s lead: Observe their cues and allow them to engage with food at their own pace.
• Task specific praise: Avoid punishments or the promise of rewards/bribes. Instead offer task specific praise to increase their confidence in interacting with new type of food and offers validation of their achievements in learning a new skill. 

Understanding and responding to these cues can help make mealtime more comfortable and less stressful for both the child and their caregivers.

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References:

Sharpe WG, et al. Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. J Autism Dev Disord [Internet]. 2013 Sep [cited 2024 Aug 30];43(9):2159-73. Available from: https://link.springer.com/article/10.1007/s10803-013-1771-5 

Margari L, Marzulli L, Gabellone A, de Giambattista C. Eating and Mealtime Behaviors in Patients with Autism Spectrum Disorder: Current Perspectives [Internet]. 2020 Sep 11 [cited 2024 Aug 30];16:2083–102. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7504729/ 

Adams SN. Feeding and Swallowing Issues in Autism Spectrum Disorders. Neuropsychiatr Dis Treat [Internet]. 2022 Oct 14 [cited 2024 Aug 30]18:2311–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9579053/ 

Leader G, Tuohy E, Chen JL, Mannion A, Gilroy SP. Feeding Problems, Gastrointestinal Symptoms, Challenging Behavior and Sensory Issues in Children and Adolescents with Autism Spectrum Disorder. J Autism Dev Disord [Internet]. 2020 Jan 18 [cited 2024 Aug 30];50(2020): 1401–10. Available from: https://link.springer.com/article/10.1007/s10803-019-04357-7?fromPaywallRec=false 

Williams KL, Campi E, Baranek GT. Associations among sensory hyperresponsiveness, restricted and repetitive behaviors, and anxiety in autism: An integrated systematic review. Res Autism Spectr Disord [Internet]. 2021 May [cited 2024 Aug 30];83(101763):1-14. Available from: https://www.sciencedirect.com/science/article/pii/S1750946721000386?via=ihub 

Raising Children Network (Australia). Anxiety: autistic children and teenagers [Internet]. [place unknown: Raising Children Network (Australia)]; c2006-2024 [updated 2023 Apr 17; cited 2024 Aug 30]. Available from: https://raisingchildren.net.au/autism/health-wellbeing/mental-health/anxiety-asd 

The Royal Children’s Hospital Melbourne. Cocoon Parent’s Guide: Cues [Internet]. Melbourne: The Royal Children's Hospital Melbourne; c2024 [cited 2024 Aug 30]. Available from: https://www.rch.org.au/cocoon/project/getting-to-know-baby/Cues/ 

Stewart R. Handbook of Maternal and Paediatric Dietetics. 2023 ed. Auchenflower: Australian Dietitian; c2023. Chapter 7, Medical Nutrition Therapy; p. 319-29.

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