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Section 1
Parent–Child Interaction and Autism Spectrum Disorder

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Have you ever had the parents of an autistic child who aren’t sure how to teach the child table manners? 

In this section, we will discuss teaching Table Manners.  This will include how to get an Autistic Child to Sit Down and Eat, Eating Pace, Insisting on Proper Utensil Use, Cutting Down the Mess and Restaurants.  As you listen, compare the techniques you might use with the ones listed on this section.

Saul, age 45, and Nadine, age 40, came to me regarding their daughter Rachel, age 11, who had diagnosed as having autism. 

Nadine stated, "Eating with her can be a real hassle…at home, we usually let her come and go during the meal.  She’ll come into the kitchen, grab a few bites and leave, and then come back for more when she’s ready. The problem is, she’s a mess when she eats!  I’ve tried to get her to use utensils, but she just reverts back to using her fingers! There’s always food everywhere, and I’m constantly cleaning it up! And forget restaurants. We can’t go out as a family when eating problems are this big." 

Saul stated, "Something else about Rachel’s eating habits is that her teachers have told us she eats abnormally slowly during her lunch period at school. Someone has to stand beside her and wait until she’s done, and often it’s not until recess is over! Then she’s missed any opportunity for playtime she might have had otherwise. What can we do?"

Understanding 5 Key Table Manners

♦ #1 Getting Rachel to Sit Down and Eat
I stated, "First, let’s discuss getting Rachel to sit down and eat. Some of your stress might be decreased by being able to monitor Rachel during the entire meal. You might start by letting Rachel know that she can only eat at the table. Rachel can’t take her plate of food and sit in front of the TV. If she leaves the table, she can’t take pieces of food with her. Stop her from taking the food by firmly repeating ‘no.’.  If Rachel leaves and comes back a half hour later and the food is still on the table, you can have her sit down again for another helping, or you can decide to only offer food at the beginning of the meal. You need to decide when the meal is over."

Nadine stated, "But what if she doesn’t eat enough?  I don’t want to starve her!"  I stated, "Don’t worry about her starving—if she doesn’t eat enough, it just means that next time she’ll come to the table even hungrier and sit down even longer. The idea is that Rachel has to learn that meals are eaten at the table."

Saul asked, "This is going to be a gradual process, right?"  I stated, "At first, Rachel may stay in her seat only a few seconds, but you can gradually work this up to longer periods, until she’s remaining for the whole meal. This can be done with the amount of food Rachel eats, by gradually increasing the number of bites she takes before getting the reward of leaving. You may even want to serve Rachel very small portions, especially of foods she likes, so that she can use her communication skills to request more helpings. 

"Not only will this reinforce her language, it will also give her an opportunity to interact socially at the table. Some families find it helpful to have a timer at the table with a treat, such as a cookie or other dessert, placed nearby.  If Rachel remains calmly at the table until the timer goes off, she may then have the treat.  Again, the length of time can gradually be increased until Rachel is able to spend the whole meal with the family."
 
♦ #2  Eating Pace
Saul and Nadine appeared very receptive to the smaller portions and the timer, so I continued, "Second, let’s discuss Rachel’s eating pace. Even if she’s able to sit down nicely at the table with others, Rachel has probably not picked up on the social cues related to the pace of eating, which is not uncommon for autistic children. Some children actually eat too quickly for the same reason. As you have already picked up, this interferes with Rachel’s social time.

"Obviously, before taking action, you need to assess the situation and figure out why Rachel is eating so slowly. For example, one of my clients described her autistic son to me. He ate excessively slowly at school, so that he could avoid social interaction on the playground after lunch. However, some children are simply not paying attention or ‘spacing out,’ and still others are getting some attention from adults for eating slowly." 

Saul asked, "If Rachel were eating slowly for attention, do you mean that by asking her to eat more quickly we would only reinforcing her slow eating habits?"  I stated, "Exactly."  Nadine asked, "Well then how can we teach her to eat more quickly without giving her the message that it’s ok to eat slowly?"

I stated, "You may choose to only give Rachel the attention when she eats at a faster pace.  You might talk to her, praise her with ‘Good job!  You finished your carrots!’ or give her any other type of attention she desires—but make it contingent on the eating. If you do this at home, it might be a habit that carried over to her school life. I believe you said Rachel has an aide?"  Saul stated, "Yes the school provided Rachel with an aide last year." 

I stated, "You might ask the aide if she praises Rachel regularly for finishing quickly.  Also, if Rachel is eating too slowly because she is either avoiding what comes after lunch or simply spacing out, you might ask the aide to try putting away her lunch when the other children finish.  Rachel could learn pretty quickly that if she wants to fill up, she will have to eat more quickly." 

♦ #3  Insisting on Proper Utensil Use
Nadine asked, "What about teaching her to eat with a knife and fork?" I stated, "In addition to Rachel to sitting down while eating and her eating pace, let’s discuss insisting on proper utensil use. In my experience, children with autism often have an unfortunate tendency to prefer using their fingers to utensils for eating. You might start by putting just one bite on Rachel’s plate, and only let her eat that bite if she picks it up with either a fork or spoon. 

"If you need an intermediary step, you can place the bite on the spoon or fork itself. You’ll probably want to make sure that Rachel likes whatever you put on the plate, so she’ll want to eat it. Rachel may need a little help at first getting it on the utensil or into her mouth. With practice, she may learn to do it on her own. Once she’s eating one bite, add another. Slowly and gradually add to the number of bites Rachel eats with the fork or spoon. The great thing about eating is that there is a natural reward associated with the task, especially if it’s yummy food, so Rachel will be likely to continue the task of learning to eat properly, even in the initial stages when it’s most difficult." 

How might you encourage an autistic child to use utensils?  Do you have another method other than the one I suggested.

♦ #4 Cutting Down the Mess
Saul stated, "And now, let’s discuss the most pressing issue, cutting down the mess when Rachel eats!" I stated, "Again, Rachel may not be socially aware enough to understand the repercussions of being messy. This will be very step-by-step.

3 Steps to Cutting Down the Mess
-- First, you may want to observe exactly how Rachel eats." Nadine stated, "One thing I’ve noticed is that she tends to grab food with her whole hand instead of pinching it with two fingers. Of course, that makes her whole hand messy…"  I stated, "You might prompt Rachel to pick food up with her thumb and pointer finger.
-- Also, you may want to prompt her to wipe her face with a napkin every few bites. Is Rachel very verbal?"  Saul stated, "Oh yeah. She’s developing quite a vocabulary."  I stated, "If she does well with verbal instructions, you can just ask her to use her napkin rather than having to physically hand it to her or point. As I mentioned before, you may want to try again to teach her to use utensils. 
-- Finally, at the end of meals, you may want to prompt her to go to the restroom, look in the mirror, and wash off any remaining food." 

Have you ever worked with an autistic child who was an extremely messy eater? How did you respond to the parents who are experiencing stress due to messy eating habits?

♦ #5  Restaurants
Nadine asked, "Will we ever be able to go out to eat as a family?"  I stated, "Once Rachel is comfortable sitting during meals, keeping herself clean and will eat a variety of foods, you might try a restaurant. Fast food restaurants might be a good place to start, because they tend to be used to noise and there is minimal waiting time." 

Nadine stated, "We would bring toys and other activities for Rachel anyway. She doesn’t tend to do well with waiting for long periods of time." I stated, "Once Rachel can sit at one of these less formal restaurants, you can try going to a restaurant where you have to order from a waiter, but there are still quite a few families with small children. And remember, you’re not alone. Most parents have to deal with restaurant behavior."

Do you have a Saul or a Nadine who is trying to teach his or her autistic child how to eat in a socially acceptable manner? Would playing this section be helpful for him or her?

In this section, we discussed teaching Table Manners.  This included Getting Rachel to Sit Down and Eat, Eating Pace, Insisting on Proper Utensil Use, Cutting Down the Mess and Restaurants.

In the next section, we will discuss Sleep Issues.  These will include Keeping Your Child Awake During the Day, Bedtime Routines, Not Giving In and Dark versus Light.
Reviewed 2023

Peer-Reviewed Journal Article References:
Arnaud, S. (2020). A social–emotional salience account of emotion recognition in autism: Moving beyond theory of mind. Journal of Theoretical and Philosophical Psychology. Advance online publication.

Blackman, A. L., Jimenez-Gomez, C., & Shvarts, S. (2020). Comparison of the efficacy of online versus in-vivo behavior analytic training for parents of children with autism spectrum disorder. Behavior Analysis: Research and Practice, 20(1), 13–23. 

Chlebowski, C., Magaña, S., Wright, B., & Brookman-Frazee, L. (2018). Implementing an intervention to address challenging behaviors for autism spectrum disorder in publicly-funded mental health services: Therapist and parent perceptions of delivery with Latinx families. Cultural Diversity and Ethnic Minority Psychology, 24(4), 552–563.

Kasari, C., Gulsrud, A., Paparella, T., Hellemann, G., & Berry, K. (2015). Randomized comparative efficacy study of parent-mediated interventions for toddlers with autism. Journal of Consulting and Clinical Psychology, 83(3), 554–563.

Lesack, R., Bearss, K., Celano, M., & Sharp, W. G. (2014). Parent–Child Interaction Therapy and autism spectrum disorder: Adaptations with a child with severe developmental delays. Clinical Practice in Pediatric Psychology, 2(1), 68–82.

McDonald, N. M., Baker, J. K., & Messinger, D. S. (2016). Oxytocin and parent–child interaction in the development of empathy among children at risk for autism. Developmental Psychology, 52(5), 735–745.

QUESTION 1
What are four steps to teaching Rachel table manners? To select and enter your answer go to Test.