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Techniques to Expand Food Variety for Children with ASD
Webinar
2012 Webinar - Warren OTR/L
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Objectives • Understand common issues of feeding problems for
children with autism
• When to seek professional help for your child
• What strategies can you do at home to expand food variety
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Defining Feeding Disorder
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Feeding Disorders
Variations in ingestive behavior that are sufficiently divergent from the norm to result in personal or familial distress, social or developmental risk, or negative health consequences.
(Kedesdy & Budd, 2001)
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Symptoms of Feeding Disorders
– Limited food selection – less than 20 different foods, limited food groups
– Averse reaction to new foods – Feeding skills inconsistent with child's
developmental age – Food jags
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Food Jags
• Insistence on eating the same foods in the same manner over long periods of time
• Child will eventually tire of the food and not replace it. Food variety increasingly narrows
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DSM-IVTR Feeding Disorder definition
• Persistent failure to eat adequately as reflected in failure to gain weight or weight loss for greater than 1 month – Not GI or general medical condition – Not accounted by mental disorder such as
rumination – Not lack of food in the home – Onset before age 6
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DSM-5 Proposed definition (2013)
• Avoidant/Restrictive Food Intake Disorder – Eating or feeding disturbance (including but
not limited to apparent lack of interest in eating or food avoidance based on sensory characteristics of food; or concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with….
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DSM-5…
– Significant weight loss – Significant nutritional deficiency – Dependence on enteral feeding or nutritional
supplements – Marked interference with psychosocial
functioning
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Up to 25% of typical children and up to 80% of children with
developmental disabilities have feeding disorders.
(Manikam & Perman, 2000)
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Feeding Obstacles for Children with Autism
• Social interaction surrounding food • Repetitive patterns in food preferences • Opportunities for varied food experiences • Communication about food
– Hunger and satiety – Food preferences
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Symptoms of feeding disorders in children with autism
– Limited food selection (57%*) – Limited food groups (72%*) – Averse reaction to new foods – Food jags – Feeding skills inconsistent with child's
developmental age (23.2% have oral motor problems*)
*percentages from parent report of 175 children with autism and feeding problems. Schreck, & Williams 2005
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Problem Eating Behaviors
• Trying new foods (69%) • Taking medicine (62%) • Eating new foods (60%) • Mouthing objects (56%) • Rituals surrounding (46%) • Insisting on routine (44%) (Williams, Dalrymple & Neal 2000)
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Review of studies has shown that between 46% and 89% of children
with autism spectrum disorders have a feeding disorder.
Ledford & Gast 2006
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Causes of Feeding Disorders
• Medical concerns
• Oral motor issues • Sensory differences
• Behavioral factors
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Medical Concerns
• Pain with feeding
• Reflux
• Early fullness
• Diarrhea
• Constipation
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When to see the doctor
• History of or current reflux • Complaints of pain with
eating • When eating gets full too
quickly • Vomiting • Anemia • Bad breath
• Pain or strain with bowel movement
• Constipation • Diarrhea • Frequent bowel accidents • Poor weight gain or
weight loss
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Symptoms of oral motor deficits
• Long feeding times (30 min+) • Difficulty chewing • Food stuck in palate • Multiple/inefficient swallows • Wet Sounds • Difficulty managing mixed food textures
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When to see a speech therapist
• Consistent Gagging/Coughing
• History of pneumonia
• Drooling/pocketing of food/food stuck
• Multiple/inefficient swallows
• Has trouble eating tough foods
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Nutritional Consequences of Feeding Disorders
• Deficit of any nutrient • Nutritional risks
– poor growth – brain development – metabolic processes – bone health – immune status
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When to see a Registered Dietitian
• Growth or weight issues • Very limited diets • Medically restricted diets
– Complex allergies – Food intolerances
• Risk of nutrient deficiencies • Use of formula or tube feedings
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Behavioral Issues • Disruptive behaviors
• Anxiety
• Parent-child interaction issues
• Developmental concerns
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When to see a Psychologist
• History of anxiety in family, leading to avoidance of various activities also including food
• Rigidity regarding food, obsessive/compulsive behaviors associated with eating
• Family dynamics that contribute to restricted eating patterns
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When to see a Occupational Therapist
• Won’t eat certain textures of foods • Won’t touch foods – doesn’t like hands to get
dirty • Difficulty using utensils, opening food
packages, drinking from an open cup, or drinking from a straw
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Strategies you can try at home
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Choose the right strategy for your child and your
family
Don’t tackle everything at once
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Mealtime Structure
• Dinner Table – Sitting – Food interaction – Modeling from others
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Sitting at the table
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Sitting at the table
Where to start
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Food interaction
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Ideas for food interaction
• Assist with grocery shopping
• Help put food away • Cooking • Food preparation • Serving food • Put non-preferred
food on plate – don’t have to eat it
• Pick up food item and throw away in garbage
• Kiss the food item good bye before throwing it away
• Take bite of food item but you can spit it out
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Modeling from others
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Mealtime Structure
• Hunger planning – At least 1 1/2 to 2 hours between
meals/snacks – Come to dinner table hungry
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Time to eat!!
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Feeding Intervention for Children Diagnosed with ASD
• Most research utilized behavioral strategies. – differential reinforcement of alternative
behaviors (DRA) – simultaneous presentation – fading – behavioral momentum – response cost – sequential presentation – negative reinforcement
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Differential Reinforcement of Alternative Behaviors (DRA)
Reward (positive reinforcement) • Sitting at the table • Having new food on their
plate • Taking a bite of the new
food • Helping prepare new food
Ignore
• Negative comments – yuck, I don’t like that
• Spitting food out • Not eating the food • Gagging/vomiting non-
preferred food
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How to use reinforcer
• Make sure they want the reinforcer – may need to change it frequently – Reward box
• Stickers • Small food items – mini m&m’s, fruit chews, skittles • Puzzles • Light up toys • Favorite video game – 1 short turn • Extra tv, video game time – can earn minutes
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How to use reinforcer
• Immediately • Consistently – when learning to eat new
food • Contingently – they do not get the reward
unless they demonstrate the behavior you are teaching (sitting at the table, touching food to lips, etc)
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First/Then Board
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First/Then Board • First • First
• Then
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If it doesn’t work
Decrease work • Decrease number that
they have to eat • If refuse to eat – touch
lips, teeth, tongue, take bite and spit out
Increase reward • Increase number of
rewards they get – instead of 1 skittle…5 skittles
• Change the reward • Let them pick the reward
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First/Then Board • First • Then
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Simultaneous Presentation
Pairing preferred with non-preferred
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Pairing Preferred Food with Non-Preferred
Food Example: dipping cookie in applesauce, very small piece of lunch meat between 2 crackers Do not hide it!!!
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Pairing preferred with non-preferred
Preferred
Non-preferred
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If it doesn’t work
• Decrease the amount of non-preferred food – start with a VERY SMALL amount
• Give them a reward for eating it
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Fading
• Use this with DRA and pairing preferred with non-preferred – Decrease frequency of reward
• Example: reward every bite reward every 2 bites
– Increase non-preferred food and decrease preferred food
• Example: 1 cup juice with ½ teaspoon milk 1 cup juice with 1 teaspoon milk
• 2 ritz crackers with ½ tsp peanut butter 2 ritz crackers with 1 tsp peanut butter
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How to prevent/break food jags
• Preventing or breaking a food jag: – Food/meal rotation – Changing shape, color, taste, and finally
texture
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Change shape
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Change Shape
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Change color
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Change taste
2012 Webinar - Warren OTR/L
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Change texture
2012 Webinar - Warren OTR/L
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Some of our favorite foods
2012 Webinar - Warren OTR/L
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Any questions?
2012 Webinar - Warren OTR/L
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Websites and Newsletters
Ellyn Satter Associates www.EllynSatter.com Mealtimes www.new-vis.com POPSICLE (Parent Organized Partnerships
Supporting Infants and Children Learning to Eat) www.popsicle.org
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Resources
• Satter, E. (1987). How To Get Your Child To Eat…But Not Too Much. Boulder, CO: Bull.
• Toomey, K. (2002). When Children Won’t Eat: The SOS Approach to Feeding. Denver: Toomey and Associates.
• Ernsperger, L. & Stegen-Hanson, T. (2004). Just Take A Bite. Arlington, TX: Future Horizons.
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References • Kedesdy, H. & Budd, S. (2001). Childhood Feeding
Disorders. Baltimore: Paul H. Brookes Publishing., Inc. • Ledford, R. & Gast, G. (2001). Feeding Problems in
Children with Autism Spectrum Disorders: A Review. Focus on Autism and Other Developmental Disabilities, 21 (3), 153-166.
• Hall, K. (2001). Pediatric Dysphagia. DeKalb, IL: Singular
• Manikam, R. & Perman, J. (2000). Pediatric Feeding Disorders. Journal of Clinical Gastroenterology, 30 (1), 34-46.
• Fishbein, M., Cox, S., Swenny, C., Mogren, C., Walbert, L., & Fraker, C. (2006). Food Chaining” A systematic approach for the treatment of children with feeding aversion. Nutrition in Clinical Practice, 21 (2), 182-184. 2012 Webinar - Warren OTR/L
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Therapy Settings
• Therapy to address feeding in school or community setting
• Intensive Feeding Therapy Program See slides at end of presentation
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Therapy services – Feeding Teams
• Cincinnati Children’s Feeding Clinic • Regional Child Development Clinic
(Bowling Green) • St. Mary’s Center for Children (Evansville) • University of Louisville Autism Center at
Kosair Charities • Weisskopf Child Evaluation Center
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Feeding Team Evaluation
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Feeding Evaluation
• Interview • Nutritional evaluation • Feeding observation • Oral Structure and
function evaluation • Team planning • Determine treatment
plan 2012 Webinar - Warren OTR/L
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Interview
• Current Status – Diagnosis, Feeding Concerns
• Social History – Family meal pattern, feeding environment
• Medical History – Prenatal, perinatal, infant & childhood – Sleep patterns, ear infections, allergies
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Interview (continued)
• Feeding & Swallowing History
1.Medical procedures impacting oral experiences ie. Feeding tubes, assisted ventilation
2.Experiences effecting feeding patterns ie. Prolonged hospitalization, prematurity
3.Aversive behaviors associated with eating 4.Communication associated with eating
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Nutritional Evaluation
– 3-Day food diary or usual daily intake – Nutritional adequacy – Meal pattern: grazing vs defined meals – Hunger/Satiety cycle – Feeding Environment – Self-feeding skills and opportunities – Food allergies and intolerances – Bowel and bladder function
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Feeding Observation • Motor Skills – postural stability, muscle tone,
strength, endurance, range of motion and coordination of both oral area and whole body
• Child/parent interaction • Self-care skills – use of utensils, opening
containers, washing hands • Sensory processing skills – food preferences,
touching/smelling/looking at food • Ingestion of food in a coordinated efficient
manner
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Oral Structure and Function Evaluation
• Size and symmetry of oral structures • Strength and tonicity of structures • Range and coordination of oral
movements
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Team Planning
• Based on findings of all team members • Further testing • Home environment • Nutritional adequacy • Food variety • Diffuse stress at mealtime • Therapy
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Making a Treatment Plan
• Family/team meeting – Review findings – Review treatment
plan • Family input • Follow-up
discussion
2012 Webinar - Warren OTR/L