#095: Dr. Keith Williams: Tackling Selective Eating in Children with Autism

selective eating

A very common concern among parents of children with autism is selective eating. In fact, it’s such a common concern that it’s become a diagnostic marker for autism spectrum disorder. Many parents want to pass healthy eating habits on to their children, but the limited diets their children prefer are causing severe malnourishment, weight gain or loss, and in some cases, impaired learning. 

I have worked with many therapists who recommend that children with autism learn to eat better by simply encouraging them to play with food and look at food, but I’ve found that that approach just doesn’t work. The behavioral approach is different from an oral sensory motor approach, but whatever program you choose is not going to be very successful if the child isn’t tasting the food.

Dr. Keith Williams has taught a parent-oriented approach to feeding, which means he teaches parents how to teach their children how to eat a more varied diet. In today’s episode, he shares some of his short-term and long-term approaches for helping children with autism. He’ll answer some questions that are common in the autism community, like:

  • Should you feed your child snacks?
  • Are smoothies an acceptable way to get vegetables into a diet?
  • What are the benefits and drawbacks of hiding vitamins and medicine in food?
  • What are the long-term problems associated with poor eating habits and selective eating?

Within Dr. Williams’ clinic at Hershey Medical Center, he’s seen children with scurvy, pellagra, rickets, and iron deficiency, but he knows how hard it can be to diagnose children with vitamin and mineral deficiencies. He shares some physical clues that he looks for in his patients’ bodies, but he also talks about the clues he finds in his patients’ diets.

Keeping an eye on the ultimate goal of children with autism eating a variety of food, Dr. Williams shares some strategies that parents can implement today that will realistically address a child’s immediate needs. And he shares some resources and strategies for how to help children with autism stretch their taste buds and try new things in the future.

TODAY’S GUEST

Dr. Williams has been the Director of the Feeding Program at Penn State Hershey Medical Center for 23 years. He is a licensed psychologist and a Board-Certified Behavior Analyst. In addition to providing clinical service, he supervises two Master’s-level therapists. Dr. Williams has over 60 publications, including three books, in the area of childhood feeding problems and pediatric nutrition. Dr. Williams presents at regional, national, and international conferences. He was recently a Fulbright Specialist at the National University of Ireland. Dr. Williams provides outreach training to community providers both locally and nationally. Dr. Williams is a Professor of Pediatrics at the Penn State College of Medicine. He teaches residents, medical students, and graduate students. Dr. Williams has been active with the Pennsylvania Association of Behavior Analysis (Penn ABA) serving as both president and member-at-large. He is the incoming Executive Director.

YOU’LL LEARN

  • How and when to supplement for children who are very picky eaters.
  • My suggestions for how to give medicine or vitamins to reluctant eaters.
  • Signs of vitamin and mineral deficiencies for iron, vitamin C & D, niacin, B12, and folate.
  • The two-pronged approach Dr. Williams takes for teaching children with autism to eat.
Want to get started on the right path and start making a difference for your child or client with autism?
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Transcript for Podcast Episode: 095
Dr. Keith Williams: Tackling Selective Eating in Children with Autism
Hosted by Dr. Mary Barbera

Mary: You're listening to the Turn Autism Around podcast, episode number ninety-five. I'm your host, Dr. Mary Barbera. And today I have a very special guest, Dr. Keith Williams from the Hershey Medical Center Feeding Center. He's been there for 23 years. He is a top international expert on feeding disorders. We are talking today about picky eating. We're talking about nutritional deficiencies, how to get medication and supplements into your child. What are some of the top tips to help you be more successful with teaching your child to eat better and which is somewhat related to talking and to behavior reduction. So we are covering all of this. Dr. Williams is a board-certified behavior analyst at the doctoral level. He's also a licensed psychologist. So he has a wealth of information. I loved the interview. So let's get right to it.

Mary: OK. So, Dr. Williams, I am so excited for this interview. I actually haven't been this excited for an interview in a long time. So thank you for carving out time to join us.

Dr. Williams: Thank you.

Mary: OK, so I have been doing several shows in the past sequence of shows. I, I did an interview with Tamara Casper, who is a SLP BCBA. I did a solo show presenting Dr. Ami Klin's information, a solo show incorporating some of Dr. Carbone's information. These were all from the National Autism Conference, which are which is a free conference that you can get this information. So I heard you speak at the National Autism Conference in 2020. And your talk was a little different than I've heard in the past. And I have followed your work and met you several times. So I was happy to have you on the show. So we are going to link that National Autism Conference talk in the show notes. But I have tons of questions for you because feeding is just such a huge issue for. It seems like every child on the spectrum. So before we dive into the questions about feeding. I always like to start with describe your fall into the autism world and specifically how you became interested in feeding and became an international feeding expert.

Dr. Williams: Well, it was actually an accident. I applied for a job at the Kennedy Krieger Institute and I thought I was going to work on the severe behavior unit. But my resum� went to the wrong unit. And I got offered a job at the feeding program. They were just starting one at the time. Wow. I didn't have a job. I thought I should take it.

Mary: And were you a psychologist at that point or?

Dr. Williams: I was a doctoral student at the University of Maryland, so I was studying to be a psychologist, but was not one yet. So I was the first master's level therapist in the feeding program at Kennedy Krieger. From eighty-nine to ninety-seven. I did take a two-year hiatus and did work on the neuro behavior. And then went back to feeding as a faculty member and then got invited to come to Hershey. And I've been here since 97.

Mary: Wow, that's fascinating. Yes, sometimes these little accidents, you know, you definitely fell into the autism world and the feeding world like by chance. That's awesome.

Dr. Williams: Strictly by chance.

Mary: Yeah. Yeah. That's amazing. OK, so just for the listeners out there, which I think are pretty much half and half parents and professionals, Lucas my son, who is now 24, had very picky eating, especially after he had regression at about fifteen months, 18 months. He used to eat OK, and then he had regression. And at the age of four, four and a half, we decided that he would benefit from a feeding clinic. So we went when we didn't go to Hershey. We're about an hour from Hershey. We went to Children's Hospital in Philadelphia, which were about an hour from there, too, and they did an outpatient 10 day or two week, like I had to drive him back and forth each day. And it really did turn his eating issues around pretty quickly. But it didn't maintain as well as what I've seen at the Hershey Clinic because the Hershey Clinic is not well, you have different levels of care. But for kids that are an hour away, you usually you know, you go for an appointment. Six weeks later, you go for an appointment. I think the overall, you know, maintaining rate of improvement is probably better with a slower approach if it's if it's not an intensive. But would you agree?

Dr. Williams: Well, and our approach. I mean, I, I will speak to theirs. But what we're trying to do is train the caregivers. So we're trying to help the parents or the caregiver implement a plan over time. And I think if the family can do that over time, that's going to matter. And that's gonna be the thing that helps the child learn to eat foods and a wider variety of foods and learn to chew on whatever scale we're working on. So we really do take a parent oriented approach, not a child oriented approach. So in some programs, the kiddo came in and the focus of treatment is working like a therapist working directly with the child. But they don't spend quite as much time trying to help the parent figure out what can we do when we go home. And that's our whole approach, is what is the parent can do once they get in the home setting?

Mary: Yeah, which is great. So you and Dr. Richard Fox published a book called Treating Eating Problems and Poor Children on the Autism Spectrum and other developmental delays disabilities. And that was published in 2007, same year my first book was published. And you just told me that you're doing a revision to this book.

Dr. Williams: And the publisher contacted us about two or three months ago and ask us to write a revision. So I told him that we would start in the winter. So we'll revise and update it hopefully over this winter and maybe over the spring. So I talked to Dr. Fox and he's going to help me. And we're going to.

Mary: Well in my in my opinion, it doesn't need much because it's a great resource. Half of the book is for parents. Half of the book is for professionals. There's all kinds of kind of data sheets and processes. And I really like that book. But you also have a different book called Broccoli Boot Camp, which I didn't know about. So what is. When was broccoli boot camp published? And how is it different than the treating eating problem back broccoli boot camp came out about?

Dr. Williams: It's been just about two years at this point. And the whole book is focused on helping children that are selective eaters. And in that book, it has a number of different plans. So it's kind of got a wider variety of plans than we talked about in the previous book, which kind of talked about all types of feeding issues. But in Brockley boot camp, we specifically look at selective eating and we've got a number of different plans that parents can implement. And, you know, why do these repeated taste exposure work and why do kids with autism, more selective eaters in general? And what are the things you have to think about before an intervention? So we went through a number of different things, but it was written specifically for parents because we've been in the clinic. We have all these handouts and stuff that we hand them and plans and stuff. And I was like, we probably should make this a little more formal and turn it into a book. So Laura Siverling worked with me and she had worked with me. I mean, I worked with her for years. We've written a number of papers together, so we wrote this book and it got published by Woodbine House last year or two years ago.

Mary: OK, great, great. Well, we're going to link all of this in the show, notes Mary Barbara dot com forward slash ninety-five. So what percentage of the kids in the Hershey feeding clinic. So you have a clinic, you work there. What percentage of the kids actually have autism diagnosis?

Dr. Williams: Well, I think we get it, quite frankly. We get a there's a referral bias. So there isn't as many programs right around us in. Like in central P.A. that work with kids with autism, with feeding issues specifically. So we get a lot of the kids in the area. So we do see probably two to three hundred children a year that are on the spectrum. So we see a lot of kids with that are on the spectrum. And by and large, the issue that they present with is that their food's selective. Now, we do see kids that don't chew or we might see kids that are on gastrostomy tubes or that are failure to thrive or many things. But the majority of the children we see that are on the autism spectrum are selective eaters and they're selective. It really is from. Pretty like they're the picky eater, that's a really, really picky eater. To the point where it's they've got nutrient deficiency. So it's like beyond picky eater.

Mary: Yeah. Yeah. And I remember I mean, this is 20 plus years ago. Well, 20 years ago when we took Lucas to CHOP, like he actually was diagnosed with failure to thrive at that point. And I don't know if they did that. I mean, his weight was low, you know, compared to his height. But is there like insurance won't cover unless you're nutrient deficient or have failure to thrive or some big deal? Or is it pretty easy to get a referral for a feeding clinic?

Dr. Williams: It's pretty easy to get a referral. We don't typically have a lot of issues with that. I mean, like we have there are some issues with feeding or with insurance, but. That's not as big of a problem as it was in the past. I can remember 20 years ago when I first started at Hershey. A lot of the insurance companies didn't understand. And why? Why are you doing this? And that whole. So it was a process of educating them. But that's not as big of an issue anymore. Now, many cases, children in Pennsylvania is probably one of the better states for health care insurance, only because you can have a medical assistance backup for kids with special needs. So if their primary doesn't pay, then a lot of times they have a backup. We'll take care of it. So that's usually not as big of an issue. It doesn't have to be so deficient that nutrient deficient.

Mary: Yeah. And you do also see, cause I actually came and did a consult years ago with somebody from out of state who is staying at the Ronald McDonald House nearby and coming to your clinic. So do you have a large percentage of your kids come from out of state or come from internationally even?

Dr. Williams: Well, we've had kids from seven countries outside of the US and from twenty-seven states. So we do get kids from a pretty wide range. We try not to take out of state patients. Not that we don't try not to, but we try to get them services closer to home. We got a referral yesterday from Michigan. So we told them what feeding programs are in Michigan and we told them there's a feeding program in Wisconsin just because that's easier for them. Now, on Monday, we do have a little boy coming here from South Carolina, but they have family that live near the program. So it's not like that's more convenient for them than actually go to another program where they don't have family. So we're trying to figure out what can we do to best serve the family. And I want to try to keep them, if at all possible, close to home so they don't have to travel across the country or whatever. And there's far more programs now than there ever were. And there's a Web site out matters that has all the lists of the programs, I think, internationally, but certainly in the United States.

Mary: So what's the Web site called?

Dr. Williams: Feeding Matters.

Mary: Feeding Matters dot com?

Dr. Williams: I think dot org.

Mary: OK. We'll double check that and put it in the show notes.

Dr. Williams: I think do a good job at least listing all the programs so that people can get services close to home when possible.

Mary: OK. Yeah. Because we have in my online courses and community, we have people from over 80 countries. And, you know, so it's very international. And I tell people, if they're looking for a feeding clinic to search. And it maybe you have additional advice. But to search for, you know, feeding program, their city, state, country or behavior analysts. That which brings me into my next question. So some of the clients I brought to you were initially because they were in the birth to three program, they were referred to an oral sensory motor type of an approach or lot of occupational therapists and speech therapists use like have a different lens on picky eating. And so they say, oh, just expose them to playing with food and to the sight of food. And in my clients with autism with who had severe problems with eating, that just didn't work. So is there a difference between your approach, the behavioral approach, because you're also a BCBAD.? Right. The behavioral approach versus an oral sensory motor approach?

Dr. Williams: Well, at the end of the day, what needs to happen if you want a child to learn to like new foods is they have to taste that. In some cases, the goal of the oral motor program is like the S.O.S program, is to kind of desensitize the child and have them taste the food. The problem is, in some cases, the kid gets stuck. So they'll touch the food or they'll play with the food or they'll maybe sniff the food or lick the food. But they don't ever ingest the food. So it you never get to the point where you're starting to develop preferences for that is because you've never ingested an ingestion is required. There's a lot of research that it showed that you can look at a food, but that doesn't make you like the food. And that's one of the problems with the kids that we see. They make their decisions based on the food�s appearance. And that's a bad way to make a judgment about food. You should make it based on its taste. And we know that repeated tasting will get kids to like foods, but you actually have to taste it. So if you don't taste it, then that program or intervention, regardless of what theoretical orientation, will probably not be very successful.

Mary: I remember one of my clients when I got there, he just turned to just diagnose. They already had an occupational therapist in place and the speech therapist in place. And so now they were adding a behavioral therapist, me and you know, I didn't have the feeding goal. That was the occupational therapist goal. My goal was, you know, behavioral therapy. Which, child wouldn't sit at the table, it took me like three sessions. I was like, what is going on here? And, you know, I'm trying to, like, figure things out. And I don't know what week it was. But all of a sudden, I found out that he had extreme picky eating and aversion to mushy foods. And but that was the occupational therapist goal. And so, like, it was almost like a turf war. And I'm like, you know, I can't just come in here and work on my little slice because if he's screaming when. So we decided to do a joint session together. Me and the OT and Mom and, you know, kind of decide like who was going to work and how we were going to work on this. And so the child, this particular child who is in my new book, who's in my videos, I have video permission to talk about him and everything.

Mary: The sight of mushy food, just freaked him out. So he was good with finger food. He would even eat string beans. He would eat meat. He would eat whatever. You presented mushy foods. And he was screaming. Right. So during our joint session, the occupational therapist. You know, I'm like, OK, well, show me how you're going to desensitize him to mushy food. And she brings the applesauce close to him just in the bowl, not even on a spoon. And he screams and she pushes it back. I'm like, oh, that's how problem behavior gets shaped up around food. And I was just like, OK, because in my opinion, as a nurse, as a behavior analyst, like talking and feeding are so intertwined that we can't just have these little turf wars or goals.

Dr. Williams: I think that's becoming less prevalent now than 20 years ago when I started. I can remember working at Kennedy Krieger and there would be wars between like. Savior psychology and an occupational therapy about what to do and what approach to use and all that kind of stuff. But I think you see it less now than you used to. And I think well, one of the reasons I think I get referrals from early intervention, because what they're doing is either not successful or the kid is vomiting on them or throwing things or whatever, and they're like, hey, that's enough of that. So, well, I'm out. If they thought yeah, they think people are realizing that, you know, some of the approaches they use may not be effective for that particular person and they may need something else.

Mary: So, yeah, yeah. I think we and, you know, the occupational therapist and I, you know, we decided, mom decided, OK, let's try Mary's approach, you know, more behavioral approach for now. And then, you know, it wasn't like, you know, I don't want people to think like I'm and I we have an occupational therapist interview Dorie Blanchet. We have lots of speech therapy. And I'm also seeing I mean, I haven't been doing one to one work for a number of years. And this was, you know, years ago. But I do think that everybody wants to do what's best for the kid. And so I do think we see less turf wars. I also think it's because parents are empowered to really see, like talking and eating and, you know, screaming and it's all related, right?

Dr. Williams: I think that's true. And I I still think, like yesterday I saw a young lady for the first time and she doesn't eat any higher texture foods, but she's been taught to take bites of food and then spit it on the floor, which is not very functional. So I talk to mom about that. And she said, well, we the therapist did get her to bite it and then told her to spit it out. I was like, OK, well, that's a problem. And I kind of backed up and worked on this. So because spitting out your food after you take a bite, you don't get a lot of nutrition from it that way.

Mary: Yeah. And then it becomes a problem behavior. And then it's like, well, we can't take them to the restaurant because all they're doing and we can't preschool, you know, unless we give them their preferred snack foods. It's just a mess. Right. Yeah, so let's talk about your national autism conference talk, where you focused a lot this time and it's two and a half hours again, we're going to link it in the show. Notes that Mary Barbara.com/95. You talked a lot about vitamin and mineral deficiencies, which I think is a good segue into, you know, spitting your food out. You're not going to get the vitamins and mineral deficiencies. And you even talked about how you're seeing kind of rare things come back like scurvy and rickets and things that I hadn't heard since like the 1980s when I was studying nursing and iron deficiency and that sort of thing. And I know you did two and a half hour talk on it. So can you just summarize kind of some of the vitamins and minerals deficiencies and what why you're starting to talk about that more and more?

Dr. Williams: I think I didn't appreciate how limited some of these children's diets were. And several we've certainly seen kids with nutrient deficiencies over the years. But I think in some of the cases, we probably we probably saw more kids with vitamin deficiencies, but we didn't test for it, so we didn't always identify it. I think this year I like have a sticky note on my desk with all the kids I've seen with vitamin C and with a vitamin C deficiency or scurvy. And right now, there's nine kids on that list. And that's from 2020 Wow. We are seeing a lot of kids with vitamin C deficiency. We've seen a kid with Pellagra, which is a niacin deficiency, which is almost unheard of in the United States, except in like sometimes you see it in heart of disease or you see it in anorexia nervosa or maybe alcoholism. But it's almost unheard of in pediatrics. And we've seen, I just got a referral last week of a child with a B 12 deficiency and folate deficiency. So many of the kids that we see that are deficient or deficient in more than one thing, almost all the kids that we see with vitamin C deficiency are iron deficient. And we see a lot of kids that are iron deficient.

Mary: What kind of what kind of blood work do you do, the blood work or do you require families to get the blood work?

Dr. Williams: Well, and kind of goes both ways. We do get, at this point. A lot of kids that are vitamin deficient that are seen in our facility get referred here. If their vitamin deficiency is secondary to their diet, in some cases you'll get vitamin deficiency that's secondary to either a medical condition or medical treatments. But many of the kids, it may certainly all the kids we would see are kids that are just not eating enough to maintain nutrition. And in some cases they've already had it. Or when they call me to refer, I'll ask, well, did you get a vitamin C or have you already checked the iron levels? Or, you know, this is a possible issue. Can you get that blood work so they'll already get it? Or when we get a referral from a PCP and they're kind of telling me some of these things, I'll ask them, get the bloodwork before I see them. When possible we'd like to know before because then tend to help us with treatment on what kind of things do we need to address hospital before?

Mary: Are these are these just traditional blood tests that you're ordering for the most part?

Dr. Williams: Yeah. I mean, it's vitamin C is actually hard to get because it's a frozen sample. So it's a pain in the butt to get that. And sometimes at some labs won't do it. You got to go to like a hospital-based lab or a clinic-based lab and not just like a lab you're going to have in the in a mall or something. So some of them are a little more complicated. And some of the stuff like if you're drawing the blood work that you need to see if the child has appropriate niacin, that's not even a common test. And they don't even have really standards for it for pediatrics. So you typically have to get that done in a hospital setting. So by and large, I mean, one of the biggest things we'd see is kids with iron deficiency. So and that's pretty common blood work. I mean, they'll check your hemoglobin and stuff. And a lot of times in the office or at work or somewhere. So those things are not hard to get. So we're not doing a lot of blood work that only we do in the world, but we do some blood work that has to be done here or another hospital and not that many outpatient clinics.

Mary: Yeah, yeah, I think it's confusing because I know 20 years ago, you know, with Lucas, I mean, nobody was asking for blood work. They were just saying his weight doesn't...Even coming to your clinic with my clients, like there was in my opinion, like a real lack of, you know, looking at that. But so I was surprised and interested in in these vitamin and mineral deficiencies that you're seeing. I did a podcast interview episode number 80 with Denise Boyd, who's a functional medicine nutritionist. And she's very up on all this stuff. So you may want to listen to that lecture as well. But so all of these vitamin and mineral tests, blood tests can be done at a hospital setting.

Dr. Williams: Sure. And some of it. I mean, we don't send every kid for every test. We screen to see which ones like what could be a possible problem. If a child is taking multivitamins or they're drinking four cans of pedia short a day. I'm not worried about some of the vitamins because I know they're getting their nutrition from that. But if a little girl I saw yesterday in the past, she was eating two pounds of yogurt at a serving and not eating very much else, which is what led to iron deficiency in her case. So we can kind of know from the diet, like, oh, my gosh, we've got to look to see if this child's gotta, doesn't have a vitamin C source. So we probably need to find out if this kid has scurvy. Or they're starting to exhibit symptoms like we just published an article this year where the very first sign you have of scurvy is not the... Like in scurvy your gums will bleed and and you'll start getting a little pink, little purple dots all over your body. But the very first sign is looks like it's leg pain. So if you've got kids with an identified leg pain and that didn't twist their ankle or there was not a scrape or a bruise or something like that, one of the things you might want to think about is identifying what's in their diet. And I know the famous cology are doing that now.

Mary: Yeah. Wow. So scurvy is what deficiency?

Dr. Williams: Vitamin C.

Mary: And then rickets are?

Dr. Williams: It gets if you're not getting vitamin D and we see a couple of those because then your bones get softened and you have kids like they still call it this, they call it either Bow-Legged or knock kneed. So your legs will turn out or they'll turn in. Now that we don't see that as much, because that kind of gets caught pretty early. And there really is pediatrics have a huge awareness of vitamin D deficiency now. So they look for that all the time. They give kids supplemental vitamin D, especially like now when you're can't go outside as much. And, you know, we were losing sunshine because it turned into winter. So I think that's you're going to see less of that, I think, because there is an awareness of it.

Mary: Yeah, so sometimes multi vitamins, though. Like, for instance, when Lucas was little, I was giving a multivitamins and he would get agitated like 20 to 30 minutes after I gave it to him. And then, like, one day I forgot to give him his multivitamin. So I gave it to him late and a 30 minutes later, he got agitated. And it turns out that the multivitamin had copper in it. And I know way back. Somebody at Hershey did some research that I found out about years ago on the zinc to copper ratio. Is that something you guys look at? And that and also zinc. Is that important for feeding issues?

Dr. Williams: It is. And if you're a zinc deficient, it decreases your appetite. And if you are zinc deficient and you get zinc off and your appetite will increase, if you're not zinc deficient and you get extra zinc, I don't think it has any effect. But we do pretty rare. We do see we've have had a kid with a zinc deficiency because they get rashes and they're referred to dermatology. But that's less typical because zinc is added to food. So it's in a number of foods that kids would typically eat. We don't look at the zinc to copper ratio as much. I know that was something that Dr Raymer did research on. Right? That is the No. And it certainly it could be that kids are going to get multivitamins and there may be something in there that they don't tolerate, maybe even an additive or something that's part of the vitamin. That's really not the Latterman. And in which case, they may have to take a look at more, what are they deficient? And instead of taking a multivitamin, just take quite a fancy supplement or look at trying to all. Ideally, we don't want them to take a vitamin, but we'd rather have every kid eat a healthy diet that consists of enough foods that are gonna have that. But we know that that's not like what are you gonna do over the shorter term? And so you get everybody to eat fruits and vegetables. Can you do something that's going to at least keep them from not being deficient? So we do try to do that and recommend vitamins and then how can we get the child to take that doesn't want to take it. We go over mechanisms for that.

Mary: So well I know the multivitamins that Lucas still takes to this day. They have copper free. So I do think that avoiding copper for kids with autism is kind of. And, you know, it does affect the zinc to copper ratio. If you get added copper and you can't tolerate it for whatever reason. Yeah. So this kind of segue weighs in. I know I had a lot of problems in the beginning with Lucas, like taking supplements, like for a picky eater. And then also it kind of ties in in your in your national autism conference talk. You talked a lot about cereal, about juice and about milk. And so do you like I don't like to sneak supplements stuff into little kids juice and stuff like that. But I guess sometimes you have to like, what do you recommend for parents who are picky eaters who need supplementation and how to get it into?

Dr. Williams: The only role is that there are no rules, just like you often hear. Like the general rule when pediatricians talk to parents is, OK, your child should be drinking milk and they should be drinking water. And don't give them any juice because it's just a bunch of added sugar.

Mary: And I think, well, I know that I used to give that advice until I heard your NAC talk. I'm like, I have to ask Dr Williams about this because I'm clearly giving the wrong advice.

Dr. Williams: I think that if you look at it like when pediatricians sometimes give that advice, they're looking for these general rules to give or general guidelines to give to everybody. But you've got to realize that not everybody fits in a guide. And some of the kids that we see eat no fruits and they eat no vegetables and they take no multi vitamins. So they have no source of vitamin C unless they're drinking juice. And you do get vitamin C is added the most juices. And in fact, companies have kind of figured out that that's a selling point by adding vitamins to things. And they do put it in juice. So even though if you eat an apple, there's not very much vitamin C in an apple, but they add vitamin C to apple juice and those nasty apples. Well, obviously, the apples you get at McDonald's that never turn brown, they never turn brown because they've got vitamin C added to them.

Dr. Williams: So that's a good thing for some of the kids that we see eat the apples that never turn brown because they put sorbic acid in there, which vitamin C? So I don't tell parents, don't ever give your kid juice unless, you know, if their kids eating a whole bunch of fruits and they eat vegetables and stuff. And I know they've got adequate vitamin C, I'd say, well, your kid probably doesn't need juice unless it helps them poop. But otherwise, you've got to look at things a little bit. Differently and in some cases, we do crush a multivitamin and then we systematically faded into the juice because that's what the kid takes. And I I've got a chance of getting them to do that. But if you just gave them a Flintstone's, they are not going to do that or they might not show up gumming. So it kind of depends on what I mean. In some cases we'll get liquid vitamins and systematically enter two things.

Dr. Williams: So we use shaping and fading all the time to try to get these kids to take their vitamins, just like we would get them to take their food. So we have to, you know, do we've tried to be as creative as we can, trying to figure out how can we get vitamins to these kids to alleviate their nutrient deficiencies, because we know that if we don't, we don't get them to take some kind of iron source. We're going to fix that here. We're going to hematologist is going to give them an infusion. But the problem will be the infusion is going to work and it's going to work great and it'll be way more effective, but it'll only work while you're getting infusions. So at some point, if you stop taking the infusions but you haven't changed your diet and you're not taking any kind of supplementation, you're gonna become deficient.

Mary: Yeah, yeah. So what about weaning from bottles? And then your child refuses milk and cheese. These are just common, common things that happen.

Dr. Williams: And that is one of the, we have typically two issues. One is the child is drinking tons of formula out of a bottle. And then the pediatrician said, OK, your child is old enough. Now switch over to milk. But the child's not taking an adequate number of foods. So they're not getting the nutrition that they got in the formula from the milk. So very quickly and then they get deficient. And it's almost always an iron, because if you look at kids that are iron deficient, it's almost always toddlers. And it's because they've switched off the formula and went on to cow�s milk and there's no and they're drinking too much. Cow�s milk and not eating enough food.

Mary: So what's that? What does iron deficiency cause? Well, like most people might say, well, what's the big deal? What�s the downside of being iron deficient?

Dr. Williams: Well, it affects cognition is the kind of the big one. So it will impair your ability to you know, it'll impair cognitive abilities or impair learning. So that's the huge drawback. So if you've got a child that already has special needs, they certainly don't have any other challenges. So if you get rid of the iron deficiency, it can improve their ability to learn. But you also see some other stuff as well. I mean, a lot of times you hear about kids with restless legs or periodic limb disorder movements and they kick a lot at night or kick in their blankets off. One of the things that that's caused by is iron deficiency. So that's one of the things that we actually ask that all the time now, probably more than we ever have. Is this, you know, not just about sleep problems, but the blankets all end up on the floor in the morning. And do you see your kid thrashing about at night? So they have this and then we'll look at their diet to see if they might be iron deficiency and iron deficiency. I mean, you can get leg pain from it. You can get Pennzoil. How far along? But certainly the big reason not to have it is it impacts your learning.

Mary: Yeah. When Lucas when I wanted him to take supplements and multivitamins and stuff, initially I had like a crush everything. And I, I put it in applesauce and fed it to him, which worked out OK. And then eventually we started dunking his pills, very small pills to begin with. And then capsules. So he now still takes all his medicine capsules, whatever. And he dunks it in applesauce and takes it. And we never taught him. I mean, if a gun was to my head, I could teach him to swallow with water. But it's like his routine and it's not me.

Dr. Williams: I don't know if it's effective. I wouldn't drink it. It works. And a lot of people do that. A lot of adults do that kind of stuff. They'll use something, putting or whatever to swallow their pills. And that's absolutely fine. And I tell parents what we're working on, vitamins or supplements or something that the child needs us. Like, I don't look at this as necessarily something that they'll always need, but it's something we got to do right now because they're deficient or their risk of deficiency. And we would just want to fix that first. I think it would be quicker to get to get your child to do one thing, then get your child to eat a bunch, you know, a sufficient amount of fruits and vegetables where the vitamins are there, but maybe they're not as concentrated. So you have to eat more of them.

Mary: Yeah. So you guys at Hershey, you did some groundbreaking work. Years ago, I was in a study with a thousand other families. And your results and subsequent research has shown that kids with autism, even though their families eat fruits and vegetables, that kids with autism do not. And so you've said that that's very much proven at this point. Right.

Dr. Williams: And we weren't the only I mean, we did a study years ago where we looked at community samples of kids with autism and kids without autism. And the children were thought. And these aren't kids that are referred to feeding programs. They're just kids in schools. The children with autism ate about a third fewer vegetables. Or no, a half fewer vegetables a half fewer fruits. Half fewer meats. About a third fewer starches. And I think it was a half as many dairy products. So like every category, they ate fewer food. So they were more selective. And this is just a community sample. And if you look at like the history of autism in Leo Canter's first work that he described at Johns Hopkins, almost all those kids that are in this initial sample that became autism, they are almost all food selective.

Dr. Williams: Food selectivity or feeding issues of some sort. That should have always been in description of the kids that are on the spectrum. It's pervasive. And tons of other studies have found the same things we were. We didn't find anything unique. Other people found that kids with autism have feeding issues more commonly than kids with autism without autism. So I think it's pretty much settled down that that kids with autism have a high probability of having feeding issues. And it's actually if you look at younger kids like Sue Mays did a study, it's been about a year ago now. She found that one of the things you see is that's one of the diagnostic markers for autism. So is feeding issues. So if you're looking at little kids that may have ADHD or autism or or intellectual disabilities. One of the things that stands out for kids that get identified with autism, they're more likely to have feeding problems. So.

Mary: Wow. Wow. And my book that's coming out in 2021 and we actually have a published date of 3/30, March 30th, 2021 is all for little kids, one to five-yearolds with signs of autism, maybe with a diagnosis, maybe without, because these kids are all facing similar struggles. And we don't know if it's going to turn out to be autism or ADHD or learning disability or nothing or just a speech delay or just they're going to be fine.

Mary: But I do think that parents are really, really struggle with feeding. And, you know, there's a lot of light. When Lucas was struggling with eating, I was a nurse, but I wasn't a behavior analyst. And there's a whole lot that you could be doing like that. You're just trying your best. Like, I was with my client, who with the applesauce coming back and forth for like a month before I realized that he had major issues with feeding because the parents were not reporting it. They were like walking on eggshells in terms of food. They're just like give him the finger foods for the rest of his life. Like, I don't want to have him cry, which I'm not a big fan of crying. Like, I want the kid not to cry either. But the sooner you can address feeding issues, the better.

Dr. Williams: I totally agree. And if you look at it from a developmental perspective, the people that are best at learning new tastes are developing new taste, preferences or influence. If you infants will develop a preference for a novel food within zero to five days or one to five days old, almost immediately they'll pick up a preference for a food. And across the course of development, that actually takes more and more taste. Adults are horrible it to learn to like a new food. Adults have to often taste that particular food up to 40 times. So if you work on it younger, it's easier. Now, it's not easier from the fact that little kids don't talk. So they communicate by yelling at you or throwing things at you. So it's harder in that regard. You don't have language that you can use to mediate some things, but certainly it's easier if you work on some of these things before they build up all these habits and these patterns of eating that are so well established that they've done thousands and thousands of times. So you're right. Younger is better. Maybe not. Yes, we are. But better.

Mary: Yeah, utensil use is another thing that we get asked about a lot. And I know in the early intervention world, when I was in there, a lot of times the goal is for kids to feed themselves. And then when you have an extremely picky eater that suddenly, you know, goes to not taking a bottle or whatever, and then you've got the pressure to eat with utensils, it can become very aversive. And it also can become like, I'm gonna do it myself and I'm gonna eat what I want. And so what advice do you have, especially for really young kids, like under for about utensil use?

Dr. Williams: Well, I think you got to look at what your goals are, because one of the parents had been the child was taught to use utensils, but they don't eat anything. So they feed themselves everything, but they only feed themselves like six things. And the parents said, well, I was told that we don't want to take away any autonomy. I was like, well, OK, but what's going to be the easiest way to get your child to taste these different foods? And they can feed it themselves. Then we can set up, reinforce or whatever. But you've got to realize that having them do that adds another. It makes the response effort higher. So now they not only have to eat this thing, they don't want to eat, but they have to feed it themselves. So it makes it more difficult. Or if you're trying to teach a child to chew and they only feed themself, it's going to be harder to actually hold it on their molars and reinforce that before biting down and starting to teach all these skills that turn into chewing.

Dr. Williams: So, you know, we're not trying to take away their autonomy. We're trying to figure out how to teach them a skill that's the most efficient way. So I'm not against self-feeding. I'm not against doing that. But that's not the only goal. The goal is to get them to eat a wide variety of things. And typically, I tell parents if we can get them to eat a wide variety of foods and get them not to refuse, self-feeding often comes in anyway. You only have to teach it. If they want the food, they'll often be a lot more willing to feed themself that food. But if they don't want the food and you're stopped trying to teach them to feed themself that food, that's always not that easy. Now, and this is typically with much younger kids. Now for kids. Fifteen. Of course, we're not going to necessarily go step back and feed method. They're going to do that themselves. But that's kind of they've got a different history at that point.

Mary: Yeah, one of the biggest things I see, too, that I learned way back when Lucas was in his feeding program 20 years ago, is we have to really get kids to stop grazing all day. We have to stop making them a peanut butter and jelly sandwich after the family meal because, you know, you're worried that they're not eating anything. And you have to stop if they are taking a bottle or drinking milk and juice. It can't be all day long where they're filling up because then they're not really going to want food. So I do think that that's and maybe you have a different, bigger thing. But I think that would be like my number one tip is like stop the grazing and get the children hungry.

Dr. Williams: I think you're absolutely right. And if you look at selective eaters that come into our clinic, most are over the fiftieth percentile. So they're not. Most of the kids that we see for selective eating are not failure to thrive. In fact almost none of them are. Most of them are over the fiftieth percentile. It is not uncommon for us to see kids that are over the eighty fifth percentile and some that are over the ninety-nine percentile. And the parents are still worried that they're not getting enough to eat because they confuse volume with variety. So they give their kids, well they didn't eat anything. So I got to give them something. So I gave them twelve chicken nuggets for dinner and the kid's like two. So I was like, you know, they're getting huge amounts of calories from the things that they do eat, but they only read things. So I think that you're right.

Dr. Williams: And we do see kids and parents very often discount drinking as a form of like they don't consider that eating. So it's not uncommon for us to see kids drink 100 ounces of milk a day and the parents are worried about them getting enough to eat. Well, your kid took one hundred ounces of milk. They're not going to want to eat anything because they're full or they'll drink a lot of juice. I mean, you know, like a court a day or two quarts a day of juice and then not eat at meals. Well, that's because they're drinking juice all day, which is full of calories. It's not about water. So we'd see that kind of stuff all the time. And the snack food that they do graze in snack foods don't tend to be low in calories. There's not much calories in one individual goldfish. But kids don't. Typically, one individual goldfish. They eat a bagful.

Mary: And so my advice usually within my online courses is is, you know, meals and snacks at the kitchen table or at the teaching table. If you want to use edibles, you know, but really monitor quantities and then only water outside of meals and that sort of thing, although with the vitamin C deficiency and that sort of thing, we might, you know, start saying, well, juice is OK, but I still think they need to be seated. They need to be drinking and not just carrying our sippy cup around all day long.

Dr. Williams: Yes, no, I totally agree. And in some cases, parents won't do that like they won't feed, will not give them food. So we do have to look at in that particular case, like what kind of things can we recommend? So parents. OK, well, if you've got to give him something. Can he have some kind of fruit? So at least, you know, if you know your kid's eating fruit, then one fruit is more nutrient rich than a lot of things and fruit tends to be low and caloric density. So I don't see a lot of kids who like, oh, my gosh, you eat so many apples, he's not going to eat any dinner. That usually doesn't work that way. But I have seen it. Well, if they eat so many cookies, they are not getting their dinner. So we will make some adjustments to that. We do try to get them on a meal and snack schedule and then hopefully that because they don't have a hunger satiety cycle. If you're just eating snacks all day.

Mary: Yeah. What about a smoothie? What about like milkshake smoothie where you can blend things in? What's your take on that?

Dr. Williams: We're fine with that. And if that's a way to get in vitamins and minerals, I'm not against that. Do I want that to be their sole source of nutrition? No. But I know that if we can and some of these cases, we're trying to figure out what can we do today to address the issue? And then what are we going to address over the long term? And they're not necessarily the same thing. So we will use smoothies and we'll put vitamins in there. We'll put spinach leaves in there to get iron ore or whatever. But in one family yesterday, put egg in their smoothie. Which I hadn't heard of.

Mary: Raw egg?

Dr. Williams: It's cooked, it's cooked.

Mary: I was like, raw egg. That probably wouldn't be good.

Dr. Williams: That is a good way to get some vitamins, minerals and their protein. But the whole goal will eventually be to get the child to eat scrambled egg, not have it in smoothing smoothie. So, yeah, I know that there's books out there written about like How to hide. Spinach and broccoli or spinach and brownies. OK. I'm OK with that, as you know. But the goal at the end of the day will get the kids vegetables and fruits and not have it always in the form of treated baked good. So.

Mary: Right. Right. And it's a lot of work for parents to be maneuvering. And a picky eater if you hide something and he tastes it and stop, that could backfire, too. So like the sneakiness. That's why I like to, you know, would I recommend like how to give supplements or medication? I mean, that's a whole other issue. Like if you have, you know, seizure meds or something that you have to give. Like, it needs to be on time. It can't be walking around all day with a with a juice cup hidden in there. And you don't even know if they're getting it. So, like, I like to sit them down, do applesauce or pudding or ice cream or whipped cream and be like, you're getting your meds now. And it's going to not taste horrible because I'm mixing it, but like not to sneak it in because I think sneaking may be a very short-term thing. But in the end, like, it's kind of has to be like the child has to accept it and has to take it on time and the full amount. And you need to know that you got it in.

Dr. Williams: I totally agree and I think that you do. I don't see many kids who are on like seizure meds or cardiac meds or whatever, because I think the parents see that that's a medication. They have to have that or else some they we're gonna get this bad health effects. I think it's harder to see food that way, even though it should be seen that way. Because if you don't eat iron you're going to have a problem. If you don't take vitamin C, there's going to be a problem. But I don't think they see it the same way. And I try to tell parents that really, when they say essential items, what they mean by essentially is your body can't function without them. So you have to have them in there. So you have to have vitamins just like you have to have a seizure medication or a cardiac medication or chemotherapy. You have to have these things.

Mary: Yeah. And it is like, yeah, I think just our whole talk, I think we're going to wrap it up. But I think the whole talk, it does really make you aware and hopefully it makes our listeners aware that that food and nutrients are like any other medication. And ah, you know, it doesn't have to be an abrupt we're going to fix everything overnight. But I definitely think, you know, listeners can get your broccoli bootcamp, especially the professionals can try to seek this treating eating problem book.

Mary: And hopefully you will get that revision done, because I think there's going to be a lot of demand for treating eating problem book once my book comes out, because there's a whole feeding chapter and I do reference you and your work, which I think has been incredible over the years. So thank you so much for coming today. Before we wrap up, how can people follow you, follow your work? I know you're an academic. You're in Hershey Medical Center and you are still teaching at Penn State University, Harrisburg campus. So, like, can people follow your work or just get your books?

Dr. Williams: Well, they can. We do have a page on there's a page on Google Scholar that has all the publications there. I'm on Research Gate that has all the publications there so they can see that there's actually a Brockley boot camp dot com Web site. And Laura's good about putting our talks up there. So I'm not good about it, but she is very good about putting up her talks and my talks there so you can follow this stuff there. And certainly you can always get a hold of me here at the Med Center. I'll get you the email address that you can put up there. So if somebody has a question or whatever, they can just call me or e-mail me and ask me.

Mary: Wow. Well, that is very generous of you. I really appreciate your time today. And one last question. Part of my podcast goals are for parents and professionals to be less stressed and lead happier lives. So I'm wondering if you have any stress reduction tips that you give parents or professionals or students that or you use yourself?

Dr. Williams: Well, yeah, I will tell you, a lot of the parents that I work with are concerned about this eating and they're stressed about some of these things. And I'm going to try to tell them that you don't look at any of these things over a single day. We're not going to fix this feeding problem this afternoon. We're gonna start a little bit on it today, a little bit on tomorrow and a little bit the next day and keep working on it over time. And if you can just do that and try it, you're gonna have a bad meal. And what should you say? Well, maybe the next meal will be better. And if you can do that, then I think we're gonna be OK over the course of time. But you've got to really ask, what are the. Shoes that you have to worry about today and which ones can you work for? Work on over the long term. And if you know that, that should make it a little bit easier. But I know this is this is a tough time for everybody with this pandemic. And it's been stressful for a lot of the families I worked with. Cause a lot of them are working at home with their kids and they're working at home for their job so they get no escape from anything. So I try to tell us just work on some things today that are manageable and we'll work on other stuff tomorrow. Baby steps, babies, baby steps, you go.

Mary: All right. Well, thank you so much. I thoroughly enjoyed talking to you today. And look forward to following your work in years to come. So thank you.