what to do when a child won’t eat: feeding disorders ......chews with mouth closed 3-4yrs. wipe...
TRANSCRIPT
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What to Do When A Child Won’t Eat:Feeding Disorders &
Developmental Disabilities
John GalleCenter for Autism & Related Disorders
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Suite of Services
• Diagnosis• Supervision and Consultation• Direct One-to-One Therapy• School Shadowing• Parent, Teacher, Caregiver Training• Speech and Language Services• Assessment Center (Skill, Functional, and Psychological)• Specialized Outpatient Services
– Challenging Behavior Center– Feeding Center– Medical Facilitation
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Today’s Overview
•Diagnosis
•Why be concerned?
•Medical and behavioral interactions
•Where do you stand now?
•Behavioral interventions
•Looking around the environment
•Motivation
•Introducing new foods
•Different textures
•Becoming a self-feeder
•Mealtime behavior problems
•Making lasting changes
•Why interventions can fail
•Common questions
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What is a Feeding Disorder?
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Feeding disorders by definition are…
• Difficulties with eating/drinking that affect weight and nutrition
• Food or fluid refusal• Food or fluid selectivity• Possible behavior problems during
mealtimes• Skill deficits• Implications from medical problems
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Common Types of Problems
• Rumination• Pica• Solid/Liquid refusal
– Partial– Total
• Solid/Liquid selectivity– Texture– Type– Presentation Method
SIDE NOTE:
Pica: ingestion of non-nutritive substances (e.g., coal, soil, chalk, paper etc.) or an abnormal appetite for some things that may be considered foods, such as food ingredients (e.g., flour, raw potato, starch). The condition's name comes from the Latin word for the magpie, a bird which is reputed to eat almost anything. Pica is seen in all ages, particularly in pregnant women and small children, especially among children who are developmentally disabled.
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How prevalent a problem?
• Up to 25% of ALL children• Up to 80% of children with developmental
disabilities
• But that’s all severities…– Feeding issues can range from a nuisance to a
serious medical problem
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Where the differences lay
• Family food questionnaire (Ledford, 2006)– Children with autism display higher incidence of
feeding problems:• Greater food refusal• Needed specific utensils • Needed specific food presentation• Accept only foods of a lower texture• Displayed a narrower variety of food that would be eaten
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What walks through my door
• Child only eats certain texture
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What walks through my door
• Child is still bottle dependent
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What walks through my door
• Child refuses all protein and vegetables
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What walks through my door
• Specific presentation method
Wonder bread. White.
Smuckers grape jelly
Skippy creamy peanut butter
(not a lot though)
Cut into 4 squares. No crust. On a Thomas the Train plate.
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Does this seem familiar?
Prompting one bite of broccoli.
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Where Does it Start?Medical & Behavioral Interactions
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Biological factors
• Physical complications– Cleft palate– Oral motor difficulties
• Medical complications– Reflux– Allergies– Constipation/diarrhea
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Behavioral Learning
• Consequences, Consequences, Consequences– Ability to get goodies
• Tangible items• Different foods• Parents putting on a show
– Avoidance of “evil” things• The broccoli goes away• Freed from the highchair
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The Interaction of the Two
• It’s not uncommon for a problem to morph– Medical → Behavioral
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What Happens Next Time???
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Functional Analysis of Feeding Disorders
Purpose: To find out what maintains problem behavior during meals
• Natural setting– Watch parents feed their children– Note consequences provided for problem behaviors
• Clinical setting– Provide pre-determined consequences for problem
behavior
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Piazza, C. C. Fisher, W. W. Brown, K. A. Shore, B. A. Patel, M. R. Katz, R. M. Sevin, B. M. Gulotta, C. S. & Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis,. 36, 187-204.
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Behavioral Learning
“Although the current results document the role of negative reinforcement in the maintenance of feeding problems, perhaps the more surprising and interesting finding was that positive reinforcement contributed to the maintenance of inappropriate mealtime behavior in over half the cases. In addition, tangible items functioned as reinforcement for 13% of the children.”
Escape from the bite
Receive attention
Get a toy
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Eating as Behavior(s)?
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Eating as One Behavior?
• Eating is really a process– A chain of behaviors, each
serving as a prompt for the next one
– Use a task analysis to break things down
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Task Analysis of EatingEating
Pick up utensil with proper grip
Scoop/stab food
Bring to mouth
Close mouth around spoon
Chew adequately
Move food to molars
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Task Analysis of EatingEating continued
Move chewed food to center of tongueand back
Swallow
Use tongue to identify residue
Removed residue from parts of mouth
Swallow again
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Now it’s manageable
Overwhelming: “Eating”
Able to be dealt with: A series of smaller behaviors
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Behavior can be seen…
• And data collected upon it!– Visual representation tells us
– What we are doing right,– What we are doing wrong,– And when to make changes
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When Should I be Concerned?
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The Importance of Eating
• Long-term physical health– Establishment of life long eating patterns
• Eating out in the community broadens a child’s world
• Opportunities for socialization• Promotion of fine motor skills
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Realistic expectations
Uses spoon, fork, and knife competently6-7yrs.Takes spoon from plate to mouth, with some spilling1-2yrs.
Uses knife for cutting5-6yrs.Drinks from cup held with both hands, without assistance may spill1-2yrs.
Uses knife for cutting softer foods5-6yrs.Manipulates spoon to "scoop" food1-2yrs.Uses knife for spreading4-5yrsReturns cup/glass to table after drinking1-2yrs.Holds spoon, fork and knife correctly4-5yrsLifts glass/cup from table to drink1-2yrs.Holds fork in fingers4-5yrsChews with ease and rotary motion.1-2yrs.Wipe his/her face and hands during/after a meal3-4yrs.Chews with mouth closed1- 4yrs
Uses side of fork for cutting soft food3-4yrs.Drinks from cup held with both hands, with assistance0-12m.
Uses napkin3-4yrs.Chews and swallows solid foods0-12m.Spoon feeds without spilling2-3yrs.Chews with rotary/grinding motion0-12m.Uses fork for eating2-3yrs.Chews and swallows semisolid foods0-12m.Uses a fork for eating, may spill1-2yrs.Feeds self finger foods0-12m.
Drinks from cup or glass held in one hand without assistance/spilling1-2yrs.Drinks from cup held by adult0-12m.
Inserts spoon in mouth without turning it upside down, moderate spilling1-2yrs.Feeds self cracker or snack0-12m.
Sucks from straw1-2yrs.Chews without rotary/grinding motion0-12m.
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Realistic expectations
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Realistic expectations
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How bad is it really?
• Missed meals• Malnourishment• Failure to thrive• Lack of growth• Tube dependence• Added family stress• Problematic mealtime behaviors
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Nutrition
Focus on fruits.
Vary your veggies.
Get your calcium-rich foods.
Make half your grains whole.
Go lean with protein.
Know the limits on fats, salt, and sugars.
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Determine Caloric Needs
1000
1200
1400
1600
1800
2000
2200
2400
2600
2800
3000
3200
3400
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
Cal
orie
s
ACTIVE
SEDENTARY
*From the National Academy of Sciences, Institute of Medicine Dietary Reference Intakes Macronutrient Report
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Growth Curves
• Shows where a child compares to chronologically aged peers for:– Height– Weight
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Boys
2 to 5 years
4 year old
35 lb.
41”
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Extreme cases
NG-TubeG-Tube with Mickey
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Other than Medical Concerns
• Does your family not go out in public to eat?• Does the child not eat the “family meal”?• Do you find yourself giving in to ritualistic
behavior?• Do you find yourself cooking the exact same
thing everyday?• Is your child eating approximately what
same-aged peers eat?
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When Should I Seek Professional Help?
• Consider the effects of the child’s feeding problem on the child and the family– Minor problems may dissipate over time– Marginal problems may be mediated by parental
intervention– Major cases require attention by behavioral
experts
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Before you Begin Intervention…
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Being a “Safe Oral Feeder”
• Assurance that there is no physical/medical reason child isn’t eating– Barium Swallow– Gastric Emptying Study– Allergy testing– Ph Probe– Upper GI series
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Rule Out Medical Problems
• Gastro esophageal reflux• Constipation• Diarrhea• Food intolerances/allergies• Oral motor delays• Dysphasia• Delayed gastric emptying/motility problems
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Addressing Behavior Problems
• May need to be dealt with prior to intervention– Sleep dysregulation– Aggression– Tantrums
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Step Back and Watch
• Try to see what truly goes on during mealtime• Each feeder has his/her own technique
– Common approaches to meals:• Terminate the meal/avoidance• Coaxing/begging• Games/toys• Change foods• Random threats• Airplane/train method
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Define a Goal
• What do you want out of intervention– Be specific!– Communicate priorities with service provider
• Determine a terminal goal– Find intermediary steps within
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Long-term Planning
Possible Treatment Goals:• Increase texture• Increase variety• Increase amount• Become a self-feeder• Decrease the “fight”• “Happy Meal™” goal
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Family Contribution
Determine family requirements during intervention• Prepare food?• Run session?• Take data?• Emotional upheaval?• Withhold specific reinforcers at other times?• Transportation to session?
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Motivation
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Never Reward a Child for Eating??
•Which children are they talking about?
•For children needing this amount of extra effort, the “internal” motivation of hunger and reward of the taste of food is not enough
•When are rewards used?
•Initial goal: YES!
•Mid-goal: Quite possibly, but maybe not so often
•Terminal goal: Ideally, no
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Rewards ≠ Bribery
Reward = Giving an item to someone after they complete a desired task
Bribery = Giving an item to someone before they complete a (typically) illegal/immoral task in order to induce him to do it
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Find Out What the Child Likes
•Complete a mental inventory
•Ask the child
•Physically assess
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I know what you’re thinking…
I know what my child likes and doesn’t like!
Just because you like something
does not mean that you will work for it.
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A Quick Preference Assessment
•Gather 5-6 possible reinforcers
•Show the child all of the items
•Place them in front of the child at equal distances
•“Pick one”
•The item chosen first should be the item worked for at that moment
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Top 5 Preference Facts
1. Preferences change over time
2. Preferences change when items are put into competition with other items
3. Preferences change with other environmental influences
4. Verbal self-report does not equate to behavioral practice
5. Assess often
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Using Food as a Reward
Use a highly preferred food as the reward
Limit total access to the “reward food” outside of meals
Concerns:
Child will begin to associate preferred food with “bad food”
Simple fact: Literature shows that food rewards increase the consumption of new foods
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Using Toys as a Reward
Sometimes we don’t have “preferred foods”
Easy to give and take away
Limited time access (10-30 seconds)
Concerns:
Disruptive to family meals
Possible Solution: Work during snacks or other non-family
meal times
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Once you know what someone wants,
How do you get them to do what you want?
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Grandma’s Rule
You cannot do something you want to do
until you do something you do not want to do.
“Finish your homework, then you can go outside to play.”
First A Then B
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The Daily Schedule…
…ABSOLUTELY IMPACTS MEALTIME BEHAVIOR!
•Sleep regulation
•Set mealtimes
•Limited portions
•Set snack times
•Medication side effects
•Arrange tube feeds
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The Eating Environment
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Everything Around you Matters
Make the environment work for you!
•Seating arrangement
•Physical seats
•Utensils
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The Chair
Is the chair you are currently using the proper one for your child’s:
1. Age
2. Abilities
3. Physical size
Rule of thumb: No one should have to kneel to reach his dinner plate
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Seating!
The Highchair
•Height
•Recline
•Wheels
•Tray
•Straps
•Fabric
•Up to 45-50 lbs
The Booster Seat
•Attachment
•Tray
•Straps
•Up to ~3 years
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Seating!
The Kitchen Chair
•Size
•Age/Weight
Just a Boost Up
•Size
•Age/Weight
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Utensils and Such
Yes! It matters!
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Utensils and Such
Priorities when picking a spoon:
•Width
•Bolus amount
•Curvature
•Lip closure
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Cups!Nosey Cups
•Liquid
•Amount
•Head tilt
Sippy Cups
•Age
•Supervision
Tumblers
•Age
•Amount
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Plates & Bowls!
Plates
•Suction
•Rim
Bowls
•Suction
•Scoop ability
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Is that bite too big?
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Bolus Size - Solids
The amount of food on a
spoon during one bite
Heaping
Level
Rounded
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Bolus Size - Liquids
The amount of liquid in a cup
during one drink
1 ounce
¾ ounce
½ ounce
¼ ounce
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Texture
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Texture
Baby food / Puree•Absolutely smooth•Think of: pudding, applesauce
Wet Ground•Small lumps•Relatively liquid•Think of: soupy oatmeal
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Texture
Ground•Lumps•Thicker in consistency•Think of: ground beef
Chopped•Prepared with knife•Pieces the size of bacon bits•Think of: crumbled feta cheese
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Texture
Bite Size
•Typical age-appropriate bite
•Think of: size of a dime
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Preference Assessments
Let’s find potential reinforcers!
Start with your own brain stormingIdeal items are ones that:
Can be presented immediatelyEasy to removeCan be used in short periods of timeAre mobile
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Goal Planning
Scenario goals
What should we work toward?
Personal goals
Where are you hoping to go?
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Can’t you just make us a decision tree?
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Assessments
Tangible Preference Assessment
Edible Preference Assessment
Texture Assessment
Food Characteristic Assessment
Oral Motor Assessment
Volume Assessment
Food Group
Color
Taste
Treatment Evaluation
Car
egiv
er T
rain
ing
& G
ener
aliz
atio
n
DRA
Escape Extinction
NCR
Fade by Texture
Fade by Taste
Fade by Color
Response Cost
Sequential Presentation
Simultaneous Presentation
Redistribution
Jaw Prompt
Changing Criterion
YIELD
YIELD
YIELD
Developmental Level
Age
Medical Complications
Food Selective
Refusal
Presentation Selective
Problem Behaviors
Family Support
Child Characteristics
Allergies
Reflux
Oral Motor Deficits
Aspiration
Enteral Feedings
Nutrition
Partial Refusal
Total Refusal
Food Texture
Baby Food
Puree
Wet Ground
Ground
Chop
Bite Sized
Feeding Style
Self Feeder
Non-Self Feeder
Seating Apparatus
High Chair
Booster Seat
Chair / Table$
Tim
e / M
oney
Con
tinuu
m
Tim
e / M
oney
Con
tinuu
m
Tim
e / M
oney
Con
tinuu
m
$
$
$
YIELD
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Introducing New Foods
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The Introduction
• Relax!– After all, it’s just food
• Pick something mundane or similar
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Simple Reinforcement
• Reinforcer given immediately for eating a bite of food
(2-3 seconds)WHAT HAPPENS IF HE NEVER TAKES A BITE?
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Options
• New Reinforcer– The reinforcer isn’t powerful enough
• Lower the requirement– The response effort is too great
• Let him go• Wait it out for a bit• Different approach is needed
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Demand Fading
You only have to work a little bit for a big goodie –at first
The amount of work needed increases as the child performs better
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Demand Fading
Jeffrey eats French fries. We want him to eat broccoli.Day 1Day 2Day 3
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Mixing Foods
• a.k.a. simultaneous presentation or blending
• This may seem strange, and at times unappetizing– It is also incredibly effective for solids and liquids
• Mix the new into the old, then fade out the old
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Mixing Foods
Courtney eats applesauce. We want her to eat peaches.
Applesauce PeachesDay 1 100% 0%
Days 2-3 90% 10%Days 4-5 80% 20%Days 6-7 70% 30%Days 8-9 60% 40%
What happens if things go astray?How fast can I move?Do I tell Courtney about the mix?
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Pairing Foods
A non-preferred food is presented with a preferred foodSimultaneous or sequential presentation???
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Pairing - Sequential
Non-preferred bite is immediately followed by preferred bite
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Pairing - Simultaneous
Both non-preferred and preferred foods are presented at the same time (same bite)
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Pairing - Simultaneous
Ethan eats pie. We want him to eat green beans.
Day 1
Day 2
Day 3
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Self-feeding
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Teaching Self-Feeding
• May be beneficial to address food refusal and self-feeding independently
• Manipulation of prompting and consequences
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Prompting
• Cues to a person that you want him/her to perform a certain task
• Prompts come in various forms:– Gestures– Verbal– Model– Physical
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How to Deliver a Prompt
• Authoritative voice– No questions– No yelling
• Prompts delivered approx. every 5 seconds• No extraneous statements, questions or
demands
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Ultimate Prompting Goal
• Eliminate the needs for prompts• Avoid “prompt dependency”
– When a child only engages in a behavior after a prompt
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Praising during Prompting
Rule #1: Never praise physical guidanceRule #2: Decide what gets praiseRule #3: Be consistent
Sometimes tangible reinforcement may be necessary to fade prompts
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General Strategies
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Think Before you Speak
As a rule, IGNORE inappropriate behaviors
Do not beg, coax, plead, or threaten!
You really want to say:
“Oh, come on! It’s not that bad! Even your brother eats it.”
Ask yourself: Is what you are about to say really going to benefit someone? Or is it really counterproductive?
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Be a Model Caregiver
Observational learning = learning from others by watching them perform a behavior
Both good and bad behaviors can be learned and imitated
There is a better chance that a child will try novel foods if he sees someone else eating it
Attention may have to be drawn to the modeled behavior.
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How to Model New Food
Model with enthusiasm
“Yummy! I love kiwi!”
Silent modeling is not effective
Do not have people at the table who will make negative comments and/or refuse food
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Addressing Behavior Problems
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Problem Behaviors
Keep this in mind…
You will be asking a child to do a non-preferred task
Expect unhappiness
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Meals can be Hard
Unhappiness can take the form of:
•Crying
•Tantrums
•Throwing food/utensils
•Hitting
•Self-injury
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Rule of Thumb
If you like it, praise it.
If you don’t, block and/or ignore it. Move on.
Fantastic!
I’m so proud of you!
High five!
Wonderful job!
Nice sitting!
Great work!
I can’t wait to tell Grandma that you…
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Every Intervention Should Include
1. A way for the child to earn “good stuff”
2. A way for the child to avoid “bad stuff”
It should always pay off to follow the new food rules
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Modify your Surroundings
Keep items out of the child’s reach.
Have extras on hand
Stay in close proximity.
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Time Out
Tricky to use…
Time out involves no fun things and no social contact.
1. Remove child from table for predetermined time
2. Turn chair around at table for predetermined time
3. Remove plate/glass for predetermined time
What happens if my child likes to escape the meal already?
Use at conclusion of the meal
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Making Change Last –Preventative Changes
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Lots of Tips
•Monitor progress
•Avoid eating from original containers
•Vary things up
•Use visual clocks as prompts when able
•Structure when you can
•Repeatedly offer new foods
•Offer foods in age appropriate portions
•Serve meals in “eating locations”
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Lots of Tips
•Do what you say AND what you do
•Ignore minor issues
•Shoot for 15 minute snacks and 30 minute meals
•Encourage independence
•Limit environmental distractions
•Use mealtime to engage in pleasant interactions
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Why Interventions Sometimes Fail
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Failure Should Not be an Option
• Interventions discussed have shown to be successful– Not all interventions are successful for every child
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Be Prepared: Things Can Worsen
• Child may show displeasure with new rules– Temporary increase in crying, tantrums
• Behaviors do subside over time– If ignored while intervention is continued
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Discontinuation
• Interventions discontinued prematurely– It may take time to see huge results– Continue even when you do see huge results!
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Child’s Resistance
• Consistency of intervention• Past history• Amount of effort required by the child
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Using the Wrong Reward
• Hold the reward for eating only• At first require small effort behaviors• Make sure you use the “best” item• Rotate items
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Different Approaches
• Multiple therapists = Multiple plans?
This can cause confusion and lack of progress with any of the interventions
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What does Feeding Therapy Look Like?
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It’s not magic
• Problems are targeted one at a time• If we make 2 changes at once, how do we know
which one made a difference? • Start with a few foods, show success, then add
more• Explicit caregiver training• Explicit generalization
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It’s honest
• No dressing up food in funny costumes• No hiding food
• The rules state exactly what will happenApple Broccoli Chicken
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It’s messy
• Food is thrown• There is always extra
• Sometimes kids vomit• We don’t wear our best clothes
• Sometimes fine motors skills aren’t quite there• That’s just practice
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It’s loud
• New rules are being established• The child did not create these rules
• I anticipate some yelling and crying to some extent at the beginning• If it maintains, it needs to be addressed
• It varies from kid to kid
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18 months
Failure to Thrive, Reflux, Speech delays,
100% G-tube dependence
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(the extinction burst)
• We all have them…• When there is a change in our “rules”, we test
them out:1st – an increase in behavior2nd – behaviors go down3rd – random increases, then decreases
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It’s realistic expectations
• Ask for something a child has the ability to do• Does not coddle
• It’s just an apple!• Celebrates success• No sub-age appropriate expectations unless there
is a REALLY good reason
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It’s exciting
• We tend to see progress quickly and often in “jumps”
• This often makes caregivers want to spring way ahead!!!• A decent therapist will curtail you, not your
enthusiasm
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It can even be fun
• Begins with a dense schedule of reinforcement• One-on-one attention• Experience of pride in achievements
• Visual charting can be used for older kids• Experiencing true consistency• Novel foods even become preferred
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22 months
Autistic Disorder
Ate only select baby foods
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Common Questions& Discussion
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Common questions
• What foods do you start with?– Nutritional needs
• Work from fruits, vegetables, starches, proteins– Family needs
• What does the family usually eat?– Set # (depends on protocol)
• Ranges from 3 – 16 new foods
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Common questions
• How long is a meal/session?– Depends on child’s age– Depends on approach used
• Trial based versus time based• Time cap on escape extinction sessions?
– Shorter sessions allow multiple attempts– You can only eat for so long/so much
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Common questions
• Which behaviors do you reinforce?– If the child refuses totally, acceptance– If the child accepts but doesn’t swallow, fast
swallowing– If the child disrupts or gags, the absence of the
problem behavior
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Common questions
• What do I do at home when my child is in treatment?– Until parents are fully trained, we ask that they
continue life as normal– Treatment gains generalized to caregivers– Treatment gains generalized to different settings
• Small steps tend to bring greater success
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Common questions
• Why are you data obsessed?– Objective measurement shows if intervention is
working or needs tweaking– Subjectivity is often wrong
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Common questions
• What about restricted diets?– We’re flexible– As long as it is nutritionally sound
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Common questions
• What if it doesn’t work with my child?– There are numerous approaches to take
• The first approach may not work– Data collection is imperative
• Figure out the parts that do work– Find specific reinforcers, establishing
operations, and consequences that make each child successful
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Common questions
• What is the research on long term success?– Currently, limited published research– Follow-up probes show promise– Dependent upon protocol implementation
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Center for Autism and Related DisordersSpecialized Outpatient Services
19019 Ventura BlvdSuite 300
Tarzana, CA [email protected]