Next up in the Classic Rebroadcast Series is a favorite episode with Dr. Keith Willams, BCBA-D and Director of the Hershey Medical Center Feeding Program. Dr. Williams helped me while I was writing the solving picky eating chapter in my book, Turn Autism Around. In this episode recorded in 2020, we cover all things autism and eating disorders. Whether you want to know more about feeding therapy, what to do if your child or clients aren’t eating, or if selective eating might be making a child sick, you don’t want to miss this episode.
Is Picky Eating a Sign of Autism?
A very common concern among parents of children with autism is eating. In fact, it’s such a common concern that it’s become a diagnosis marker for the autism spectrum, with most individuals having some form of selective eating. 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. A behavioral approach to solving feeding issues is very different from the oral sensory motor approach, but whatever program you choose is not going to be very successful if the child isn’t tasting the food.
Hershey Medical Center Feeding Program
Dr. Keith Williams at the Hershey Medical Center Feeding Program has taught a parent-oriented approach to feeding, which means he teaches parents how to teach their children what to eat. 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?
Autism and Iron Deficiency
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. Dr. Williams goes over the blood work required to diagnose these 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.
Be sure to check back next week for a follow-up episode with our current Top 5 frequently asked questions all about autism and feeding!
Dr. Keith Williams on Turn Autism Around Podcast
Dr. Keith Williams has been the Director of the Feeding Program at the Penn State Hershey Medical Center for 23 years. He is a licensed psychologist and a Board-Certified Behavior Analyst. In addition to providing direct 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 (PennABA) serving as both president and member-at-large. He is the incoming Executive Director.
H: (717) 625-3285
W: (717) 531-7117
M: (717) 466-4092
- Is picky eating a common sign of autism?
- How and when to supplement for children who are very picky eaters.
- Mary’s 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 in which Dr. Williams teaches children with autism to eat.
- The parent centered approach at the Penn State Hershey Medical Center Feeding Program.
- Workshops – ABA Help for Professionals and Parents
- Turn Autism Around®️ – New Book from Mary Barbera
- Feeding Problems in Autism Spectrum Disorder: Home and Community-based Solutions Disclaimers
- Treating Eating Problems of Children w/ Autism Spectrum Disorders and Developmental Disabilities: Interventions for Professionals and Parents: Williams, Keith E
- Broccoli Boot Camp: Basic Training for Parents of Selective Eaters Paperback
- Broccoli Boot Camp on Facebook
- Feeding Matters
- The Role of Functional Nutrition and Medicine in Autism
- Mary Barbera
- Mary Barbera on TikTok
- Mary Barbera (@turnautismaround) on Instagram
Dr. Keith Williams – Turn Autism Around Podcast Transcript
Transcript for Podcast Episode: 192
Classic Rebroadcast: Autism and Eating Disorders with Dr. Keith Williams
Hosted by: Dr. Mary Barbera
Guest: Dr. Keith Williams
Mary: You're listening to the Turn Autism Around podcast episode number 192. In 2022, we decided to start a classic rebroadcast series where we bring back our favorite podcast episodes and replay them for you. And we usually follow up with a question and answer the Top Five Questions segment. And this is really worked out well. So when I started the classic rebroadcast, I knew that this podcast with Dr. Keith Williams all about feeding issues and picky eating would be brought back very soon. So it used to be podcast number 95 and now it's going to be rebroadcast as 192. There's so much gold in here. Dr. Williams helped me with Chapter ten of my book. He read the drafts. He added some things and taught me some things that I didn't know about feeding. So we talk about the draft of my book. This podcast was originally recorded and aired back in 2020, so it's a couple of years old, but there's so much gold in it. Hope you love it as much as I do. Let's get to this important podcast with Dr. Keith Williams all about feeding.
Narrator: Welcome to the Turn Autism Around podcast for both parents and professionals in the autism world who want to turn things around, be less stressed, and lead happier lives. And now your host, autism mom, behavior analyst and bestselling author Dr. Mary Barbera.
Mary: Okay. 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: Okay. So I have been doing several shows in the past sequence of shows. I did an interview with Tamara Kasper, who's a SLP, BCBA. I did a solo show presenting Dr. Army cleanse information, a solo show incorporating some of Dr. Karp Bones information. These were all from the National Autism Conference, which is a free conference, and 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 dove into the questions about feeding, I always like to start with describing your fall into the autism world and specifically how you became interested in feeding and became an international feeding expert.
Dr. Keith Williams on the Turn Autism Around Podcast
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 resume went to the wrong unit and I got offered a job at the feeding program. They were just starting one at the time. I didn't have a job. I thought I should take it.
Mary: 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.
Mary: Oh, wow.
Dr. Williams: From 89 to 97. I did take a two year hiatus and did work on the neuro behavior unit 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. Yeah. Sometimes these little accidents, you know, you definitely fell into the autism world and the feeding like, by chance, that's that's awesome.
Dr. Williams: Yeah, it was strictly by chance. It was.
Mary: Yeah. Yeah. That's amazing. Okay. So just for the listeners out there, which I think are pretty much half and half parents and professionals, Lucas, my son, who's now 24, had very picky eating, especially after he had regression at about 15 months, 18 months. He used to eat okay. 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....we didn't go to Hershey. We're about an hour from Hershey. We went to Children's Hospital in Philadelphia, which we’re about an hour from there, too, and they did an outpatient for ten days or two weeks. 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 not intensive. Would you agree?
Penn State Hershey Medical Center Feeding Program
Dr. Williams: Well, and our approach I mean, I won't 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 going to be the thing that helps the child learn to eat foods and a wider variety of foods and learn to chew and whatever skill we're working on. So we really do take a parent oriented approach, not a child oriented approach. So in some programs the kid will come 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 gonna 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 for 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 and hopefully....
Dr. Williams: The publisher contacted me about two or three months ago and asked us to write a revision. So I told him that we would start in the winter, so we'll revise and update hopefully over this winter and maybe over the spring. So I talked to Dr. Fox and he's going to help and we're going to have a lot..
Mary: 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 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 when was Broccoli Boot Camp published and how is it different than the Treating Eating Problem book.
Dr. Williams: Broccoli boot camp came out about it's been just, 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 that we talked about in the previous book, which kind of talked about all types of feeding issues. But in Broccoli 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 does 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 Seiverling 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 Wood Buying House last year or two years ago.
Mary: Okay, great, great. We're going to link all of this in the show notes MaryBarbera.com/95 (MaryBarbera.com/192). 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 an autism diagnosis?
Dr. Williams: Well, I think we get, quite frankly there's a referral bias. So there aren'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 200 to 300 children a year that are on the spectrum. So we see a lot of kids that are on the spectrum. And by and large, the issue that they present with is that they're food selective. Now, we do see kids that don't chew or we may see kids that are on gastrostomy tubes or that are failing to thrive or many things that the majority of the children we see that are on the autism spectrum are selective eaters. And their selectivity really is from the picky eater that's a really, really picky eater to the point where they've got nutrient deficiencies. So it's like beyond a 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 compared to his height, but. Is it is there like insurance won't cover unless you're nutrient dificient 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 are you doing this and that whole thing. And so it was a process of educating them. But that's not as big of an issue anymore. Yeah, in 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 MA back up, will take care of it. So that's usually not as big of an issue. It doesn't have to be so deficient, so nutrient deficient.
Mary: Yeah. And you do also see because I actually came and did a console years ago with somebody from out of state who was staying at like the Ronald McDonald House nearby and coming to your clinic. So do you have a large percentage of your kids that come from out of state or come from internationally even?
Dr. Williams: Well, we've had kids from seven countries outside of the U.S. and from 27 states. So we do get kids from a pretty wide range. We don't 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. So if 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 gone 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 website Feeding Matters that has all the lists of the programs, I think, internationally, but certainly in the United States.
Mary: So what's the website called?
Dr. Williams: Feeding Matters
Dr. Williams: I think that'll work.
Mary: Okay, well, we'll double check that. Put it in the show notes, I think.
Dr. Williams: It does do a good job at at least listing all the programs so that people can get services close to home when possible.
Mary: Okay. 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 to search and maybe, maybe you have additional advice, but to search for, you know, feeding program their city, state, country or behavior analyst which brings me into my next question. So some of the clients I brought to you were initially because they were in the first two three program, they were they were referred to an oral sensory motor type of an approach or a lot of occupational therapists and speech therapist use like, like have a different lens on picky eating. And so they, they say, oh, just expose them to, to playing with food and to the sight of food. And in my clients with autism who had severe problems with eating, that just didn't work. So is there a difference between your the approach, the behavioral approach, because you are also a BCBA-D, right. The behavioral approach versus an oral sensory motor approach?
The Behavioral Approach Vs 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 food. 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 you never get to the point where you're starting to develop preferences for that food because you've never ingested an ingestion is required. There's a lot of research that has showed that you can look at a food, but that doesn't make you like the food. And that's 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 it's 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 I got there, he just turned two, just diagnosed. They already had an occupational therapist in place and a 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 was in my new book, who's in my videos. I have video permission to talk about him and everything. 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, okay, 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, okay, 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 behavior psychology and 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.
Mary: I'm out!
Dr. Williams: Yeah. I 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: And you know, the occupational therapist and I, you know, we, we decided, mom decided okay, 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 anti and we have an occupational therapist interview Dorie Blanchard we have lots of speech therapies and I'm I'm also seeing I mean, I haven't been doing 1 to 1 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.
Dr. Williams: Right. I think that's true. And 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 taught her to spit it out. I was like, Okay, well, that's a problem. You've got to kind of back up and work 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 at MaryBarbera.com/95 (MaryBarbera.com192). You talked a lot about vitamin and mineral deficiencies, which I think is a good segway into, you know, spitting your food out. You're not going to get the vitamins and minerals 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 vitamin and mineral deficiencies and what why you're you're starting to talk about that more and more.
Vitamin and Mineral Deficiencies
Dr. Williams: What 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 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 up 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 B12 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 deficienct and we see a lot of kids that are iron deficient.
Mary: What kind of blood work do you do the blood work, or do you require families to get the blood work?
Dr. Williams: Well it kind of goes both ways. We do get it 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 a medical treatment. But many of the kids I mean, 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 ferretin and 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 to get the blood work before I see them. When possible we like to know before because then kind of help us with treatment on what kind of things do we need to address. So if it's possible to get before...
Mary: Are these just traditional blood tests that you're ordering?
Dr. Williams: For the most part, 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 that some labs won't do it, you got to go to a like a hospital based lab or a clinic based lab and not just like a lab you're going to have in a mall or something. So some are more 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 but by and large, I mean, one of the biggest things we see here is kids with iron deficiency. So and that's pretty common blood work. I mean, they'll they'll check your hemoglobin and stuff and a lot of times in the office or at WIC 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 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 bloodwork. They were just saying his weight doesn't, you know, even even coming to your clinic with my clients, like there was there was a, in my opinion, like a real lack of, you know, looking at that. But so I was surprised and interested in these vitamin and mineral deficiencies that you're seeing. I did a podcast interview, episode number 80 with Denise Voit, who's a nutritional functional medicine nutritionist, and she's very up on all that 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 screened to see which ones like what could be a possible problem if a child is taking multivitamins or they're drinking four cans of pediasure a day. I'm not worried about some of the vitamins because I know they're getting their nutrition from that. But if I mean the little girl I saw yesterday in the past, she was eating £2 of yogurt in 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 got to look to see if this child's gotta it 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 or the very first sign you have of scurvy is not the like in scurvy. You get your your gums will bleed and and you'll start getting little pink little purple dots all over your body. But the very first sign, it looks like it's leg pain. So if you've got kids with unidentified leg pain and they didn't twist their ankle or there's 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.
Mary: Yeah. Wow. So scurvy is what deficiency?
Dr. Williams: Vitamin C.
Mary: And then rickets are?
Dr. Williams: Rickets if you're not getting vitamin D and we see a couple of those because then your bones get softened and you have kids, they still call it this. They call it either bow legged or not meade. 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're losing sunshine because it's turn in the winter. So I think that's you're going to see less of that, I think, because there's an awareness of it.
Mary: Yeah. So sometimes multivitamins though like for instance, when Lucas was little, I was giving him 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 in 30 minutes later he got agitated and it turns out that the multivitamin had copper in it. 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's something you guys look at. And also zinc. Is that important for feeding issues?
Dr. Williams: It is and if you're zinc deficient, it decreases your appetite. And if you are zinc deficient and you get zinc, often your appetite will increase if you're not zinc deficient. You get extra zinc and 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 that's less typical because zinc is added to foods. So it's a 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.
Mary: Right. That's the name.
Dr. Williams: 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. It may be even an additive or something t hat's part of the vitamin. That's really not the vitamin. And in which case they may have to take a look at more. What are they deficient in? Instead of taking a multivitamin, just take vitamin C 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 going to have that. But we know that that's not like what are you going to 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 them that doesn't want to take it? We go over mechanisms for that.
Mary: So well, I know they and 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 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 segways in I know I had a lot of problems in the beginning with Lucas like taking supplements like for a picky eater and and it also kind of ties in and 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 supplement stuff into little kids juice and stuff like that, but I guess sometimes you have to like, what do you recommend for parents who have picky eaters who need supplementation and how to get it?
Dr. Williams: And the only rule is that there are no rules like you often hear. Like the general rule when pediatricians talk to parents is, okay, your child should be drinking milk and they should be drinking water and don't get many juice because it's just a bunch of added sugar. And I think.
Mary: Well and 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 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 the general guidelines to give to everybody. But you got to realize that not everybody fits in a guideline. And some of the kids that we see, eat know fruits and they eat 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 to 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, obviously. The apples you get at McDonalds that never turn brown, they never turn brown because they've got vitamin C added to them. So that's a good thing for some of the kids that we see eat the apples that never turn brown because they put asorbic acid in there, which vitamin C? So I don't tell parents, don't ever give your kid juice unless the kid's eating a whole bunch of fruits and they eat vegetables and stuff. But 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 got to look at things a little bit differently. In some cases, we do crush a multivitamin and then we've systematically faded into the juice because that's what the kid takes. And I've got a chance of getting them to do that. But if you just gave them a Flintstones, they are not going to do that or they might not chew a gummy. So it kind of depends on what I need. In some cases we'll get liquid vitamins and systematically added things. 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, 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, you know, 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 the hematologist is going to give him an infusion but the problem will be now that fusion 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 an infusion. 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 going to become deficient again.
Mary: Yeah. Yeah. So what about weaning from bottles and then your child refuses milk? I mean, these are just common, common things that happen.
Dr. Williams: That's one 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, okay, 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 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 cows milk and there's no and they're drinking too much cows milk and not eating enough food.
Mary: So what's the what does iron deficiency cost? Well, people might say, well, what's the big deal? What, what, what? 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 will 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 kicking their blankets off. One of the the things that that's caused by is iron deficiency. So that's one of the things that we actually miss that all the time now, probably more than we ever have is it's not just about sleep problems, but the blankets all end up on the floor in the morning and 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. Depends on how far along. But certainly the big reason not to have it is it impacts your learning.
Supplements and Multivitamins
Mary: Yeah. When Lucas when I wanted him to take supplements and multivitamins and stuff. Initially I had like a crusher thing and I, I put it in applesauce and, and fed it to him, which worked out okay. 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, 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...
Dr. Williams: It's effective, I wouldn't change it. Yes, it works. And a lot of people do that. A lot of adults do that kind of stuff. They'll use something, pudding or whatever, and just swallow their pills. And that's absolutely fine. And I tell parents, when we're working on vitamins or supplements or something that the child needs, I was 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 they're at risk of deficiency. And we just want to fix that first. And I think it would be quicker to get the get your child to do one thing than 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, the kids with autism do not. And so you've said that that's that's very much proven at this point, right?
Autism and Picky Eating
Dr. Williams: Yeah. We weren't the only I mean, we did a study years ago where we looked at a community samples of kids with autism and kids without autism and the children with autism. 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 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, you know, a community sample. And if you look at the history of autism in Leo Kanner's first work that he described at Johns Hopkins, almost all those kids that are in this initial sample that became autism, they were almost all food selective. 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 have found that kids with autism have feeding issues more commonly than kids without autism. So I think it's it's pretty much settled now that the kids with autism very are have a high probability of having feeding issues. And it's actually if you look at younger kids like Sue Maze 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 intellectual disabilities, one of the things that stands out for kids that get identified with autism, they're more likely to have feeding problems.
Mary: So, wow. Wow. And my book that's coming out in 2021, we actually have a published date of 3/30, March 30th 2021 is all for little kids, 1 to 5 year olds 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. But I do think that parents are really, really struggle with feeding. And, you know, there's a lot of like when Lucas was struggling with feeding, I was a nurse, but I wasn't a behavior analyst. And there's a whole lot that you can be doing, like that's you're just trying your best. Like, I was with my client 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 or developing new taste preferences or infants for infants will develop a preference for a novel food within 0 to 5 days or 1 to 5 days. Almost immediately they'll pick up a preference for a food. And across the course of development that actually takes more and more tastes. Adults are horrible at 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 back that, you know, 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, you know, 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 easier. Yes, 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 a an extremely picky eater that suddenly, you know, goes to not take 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 going to do it myself and I'm going to eat what I want. And so what what advice do you have, especially for really young kids like under four 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 parent said, well, I was told that we don't want to take away any autonomy. I was like, Well, okay, but what's going to be the easiest way to get your child to taste these different foods and they can feed it themselves and 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 time. So now they not only have to eat this thing, they all want to eat, but they have to feed it by themselves so it makes it more difficult. Or if you're trying to teach your 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. 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 don't I'm not against healthy eating and 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 the refuse self-feeding often comes in any way. You don't even have to teach it. If they want the food, they'll often be a lot more willing to feed themselves that food. But if they don't want the food and you're not trying to teach them to feed themselves that food, that's always not that easy now. And this is typically with much younger kids now for kids 15, of course, we're not going to necessarily go step back and have better 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 say to 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 maybe 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 50th percentile. So they're not most of the kids that we see for selective eating are not failure to thrive, but almost none of them are. Most of them are over the 50th percentile. It is not uncommon for us to see kids that are over the 85th percentile and some that are over the 99th 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 get them something. So I gave them 12 chicken nuggets for dinner and the kids 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 three things. So I think that you're right 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 that drink 100 ounces of milk a day and the parents are worried about them getting enough to eat. Well, your kid took 100 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 quart a day or two quarts a day of juice and then not needed meals. Well, that's because they're drinking juice all day, which is full of calories. It's not not water. So we'd see that kind of stuff all the time. And the snack food that they do graze and 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 bag full. So.
Mary: Yeah, correct. And so my 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 okay, 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. Now, 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 now? So parents. Okay, well, if you've got to give them something, can you have some kind of fruit? So at least you know your kids 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 through 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 and we will use smoothies and we'll put vitamins in there. We'll put spinach leaves in there to get iron or whatever. But in one family yesterday, put egg in their smoothie. Which I hadn't heard of, but a raw egg cooked and cooked.
Mary: I was like a rag that probably wouldn't be so nice.
Dr. Williams: That is a good way to get vitamins and minerals in their protein, but the whole goal will eventually be to get the child eat scrambled egg, not have it in a smoothie. So. Yeah. Yeah, I know that there's books out there written about, like, how to hide. Spinach and broccoli or spinach and brownies. I'm okay. I'm okay with that as a no. But the goal at the end of the day, we'll get the kid, the vegetables and fruits and not have it always in the form of a treated baked goods. So.
Mary: Right. Right. And it's a lot of work for parents to be. Yes. Maneuvering and and a picky eater. If you hide something and he tastes it and stuff, that could backfire, too. Absolutely. And so like the sneakiness, that's why I like to you know, what I recommend, like how to give supplements or medication. I mean, that's a whole nother issue is like if you have, you know, seizure meds or something that you have to give like E, 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 you, it's kind of has to be like the child has to accept it and 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 were going to get this bad health effects. I think it's harder to see food that way, even though it shouldn't be seen that way, because if you don't eat iron, you're going to have a problem. If you don't take in 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 vitamins, what they mean by essentially is your body can't function without them. So we 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. Yeah, it is.
Mary: I, I, 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 boot camp, especially the professionals can try to seek this treating eating problem book and hopefully you will get that revision done because I think there's going to be a lot of demand for the 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 you're an academic. You're in Hershey Medical Center and you are still teaching at Penn State University, Harrisburg campus. And so, like, can people follow your work or just get your books?
Dr. Williams: Well, they can. We do have a page on Google Scholar that has all the publications there. I'm on ResearchGate that has all the publications there, so they can see that there's actually a broccoli bootcamp dot com website. And Laura is 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 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 and or email 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 got 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 going to start a little bit on it today and 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 to, you're going to 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 going to be okay over the course of time. But you 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 a tough time for everybody with this pandemic has been stressful for a lot of the families I work with because there 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, let's just work on some things today that are manageable and we'll work on other stuff tomorrow.
Mary: Baby steps.
Dr. Williams: Baby steps. There 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.
Dr. Williams: I'll see you, Mary. Bye now.
Mary: If you're a parent or an autism professional and enjoy listening to this podcast, you have to come check out my online course and community where we take all of this material and we apply it. You'll learn life changing strategies to get your child or clients to reach their fullest potential. Join me for a free online workshop at MaryBarbera.com/workshop where you can learn how to avoid common mistakes. You can see videos of me working with kids with and without autism. And you can learn more about joining my online course and community at a very special discount. Once again, go to MaryBarbera.com/workshop for all the details. I hope to see you there.
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