Assessment and Treatment of Pediatric Feeding Problems. Laura Seiverling, PhD, BCBA-D

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Assessment and Treatment of Pediatric Feeding Problems Laura Seiverling, PhD, BCBA-D Disclosure Statement Dr. Seiverling is co-author of the book Broccoli Boot Camp: A Guide For Improving Your Child s
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Assessment and Treatment of Pediatric Feeding Problems Laura Seiverling, PhD, BCBA-D Disclosure Statement Dr. Seiverling is co-author of the book Broccoli Boot Camp: A Guide For Improving Your Child s Selective Eating which will be mentioned in the presentation Dr. Seiverling works at St Mary s Hospital for Children s Center for Pediatric Feeding Disorders Learning Objectives Participants will learn how to assess feeding problems using both direct and indirect measures. Participants will be able to identify the evidence-based behavioral interventions available for treating food selectivity and refusal, packing, choking phobias, and for teaching children how to chew and self-feed. Participants will learn how to use behavioral skills training and general-case training to teach caregivers to implement various feeding interventions. Prevalence of Eating Problems Prevalence of food selectivity or picky eating in typically developing children ranges from 10% to 35% (Reau, Senturia, Lebailly, & Christoffel, 1996; Wright, Parkinson, Shipton, & Drewett, 2007) Between 46% and 89% of children with Autism Spectrum Disorder (ASD) are reported to have some form of food selectivity (Ledford & Gast, 2006) Do children out grow selective eating? It is common for children to have some selective eating phases during development If a child does not outgrow a selective phase, it may be problematic for the child s health and development Why bother treating feeding problems? Limited diet variety may lead to malnutrition Eating problems can limit social interactions and social opportunities for the child and entire family Eating problems may lead to stigmatization Treatment involves reducing a child s aversion to novel experiences and increasing his or her compliance with instructions Why do feeding problems develop? Feeding problems may include medical, oral motor, and behavioral components (Piazza, 2008) Common Medical Issues Associated with Feeding Problems Gastroesophageal Reflux Food Allergies Motility Problems Constipation Diarrhea Dysphagia Prior to implementing a feeding intervention, it is important to rule out medical problems that may be associated with the child s feeding problem Assessment of Feeding Problems Indirect Assessments Questionnaires, food inventories Direct Assessments Direct observation using systematic assessments, experimental analyses Indirect Assessments Questionnaires can help you obtain a standardized set of information Most questionnaires discussed have been standardized on samples of children with eating problems Questionnaires can help guide your assessment and initial intake with caregivers Parent Mealtime Action Scale (PMAS) Parent Mealtime Action Scale (PMAS) assesses: Behaviors parents exhibit during mealtimes with their children The frequency that the parents eat certain foods (e.g. fruits and vegetables) How often these foods are served Patterns of parent mealtime action may be associated with their children's diet and weight status (Hendy, Williams, Camise, Eckman, & Hedemann, 2009) Some PMAS questions Brief Assessment of Mealtime Behavior in Children (BAMBIC) Administered the Brief Autism Mealtime Behavior Inventory (BAMBI) in a population of children referred to a pediatric feeding clinic Scale did not differentiate among children with ASD, children with other special needs, and children without special needs in this type of sample Revised and renamed the scale to widen the clinical usefulness of the measure (Hendy, Seiverling, Lukens, & Williams, 2013) Some example BAMBIC questions The About Your Child s Eating (AYCE) scale Normed on 763 parents of physically healthy and chronically ill children between 8 and 16 years Three factors identified: Child Resistance to Eating, Positive Mealtime Environment, and Parent Aversion to Mealtime (Davies, Ackerman, Davies, Vannatta, & Noll, 2007) Example questions of the AYCE scale Food Preference Inventories A list of common foods that can be used to determine which foods are eaten by both the child and the family Helpful tool for assessing diet variety, selecting target foods, and can also be used as an outcome measure Food Preference Inventory Experimental Analyses Najdowski, et al. (2008) trained caregivers to conduct experimental functional analyses of inappropriate mealtime behavior (IMB) Conditions included no-interaction, attention, control, and demand Rate of IMB was highest in the demand condition for all participants suggesting that access to escape functioned as reinforcement for IMB Interventions how to go from HERE TO HERE Food Selectivity A child s insistence on eating a narrow range of foods on a consistent basis (Williams & Foxx, 2008) Often associated with: An unwillingness to try new foods Insufficient intake and variety to maintain a healthy nutritional status Dependence upon nutritional supplements What has research shown about food selectivity? Food selectivity in children affects parent behavior Parent Mealtime Action Scale (Hendy et al., 2009) Children do not eat what their parents serve, parents serve what their children eat Giving children special meals is related to a proneness for overweight and decreased diet variety Does tasting foods get easier over time? Researchers tracked the number of tastes required before 6 children with food selectivity ate a small serving of a food in probe meals (i.e. meals in which the child was not required to taste the food) The number of tastes decreased as more foods were added to a child s diet It gets easier!!! (Williams, Paul, Pizzo, & Riegel, 2008) What we know about increasing diet variety and developing taste preferences To develop a preference for a food, the food must be tasted, not looked at, sniffed, or licked And tasting new foods gets easier over time as new foods are added into one s diet! Teaching children to play with food is often messy and a waste of time Tastes must occur repeatedly, once or twice is often not enough Antecedent approaches for treating food selectivity Structuring meals/snacks and avoiding special meals Simultaneous presentation Behavioral Momentum Structuring meals/snacks and avoiding special meals Children s appetites often improve if they start eating on a schedule (develops hunger-satiety cycle) Serve meals/snacks in kitchen or dining room Limit the length of meals and snacks Do not allow grazing Many of the snack foods are high in caloric density so it does not take much to affect appetite Do not give alternative meals Adjustments we often make for children with Autism Spectrum Disorder Avoid feeding from the original container Rotate through dishes, cups, and utensils Visual clocks can sometimes be helpful Simultaneous Presentation Mix new foods into preferred foods in tiny amounts, slowly changing the ratio of new to preferred food E.g., add ground fruit to yogurt or applesauce Place new and preferred food on the same utensil Ahearn (2003) 14-year-old boy with ASD with mild selectivity Increased consumption of non-preferred vegetables by adding simultaneous presentation of preferred condiments Behavioral Momentum Strategies Present a demand that is likely to be performed by the child before asking the child to engage in the less likely behavior of eating a new or non-preferred food. Types of high-probability responses depend on the child E.g. accepting an empty spoon (Patel et al., 2007) E.g. accepting bites of a preferred food (Gentry & Luiselli, 2009) E.g. asking the child to engage in non-feeding related tasks (Dawson et al., 2003) Common multicomponent interventions for treating food Differential reinforcement Stimulus Fading selectivity Escape Prevention/Extinction (Freeman & Piazza, 1998; Anderson & McMillan, 2001; Najdowski et al., 2003; McCartney et al., 2005; Ahearn et al., 2001; Ahearn, 2002) Contingent Reinforcement Clip Sequential Presentation Plate A-Plate B interventions Present two plates and set a timer for 10 to 20 mins Plate A: contains tiny specks of 2-3 new foods Plate B: contains bites of 2-3 preferred foods Child instructed to eat a bite from Plate A before eating a bite from Plate B and drinking a preferred beverage Over time, bite sizes of novel foods are increased Access to preferred foods restricted prior to Plate A-Plate B meals Plate A-Plate B interventions 16-year-old with ASD in residential facility with limited diet variety and history of self-injurious behavior and aggression Sequential presentation in the absence of escape extinction (Pizzo, Coyle, Seiverling, & Williams, 2012) Plate A-Plate B clip Plate A-Plate-B Case Study 3-year-old boy with ASD who was reported to eat 17 foods (primarily starches) participated in one week intervention at pediatric feeding clinic History of chronic constipation and GERD (Seiverling, Kokitus, & Williams, 2012) DRA, EE, and Fading Series of single-bite taste sessions occurred after first 5 treatment meals Jeremy was required to accept a single bite to access a 3 min break outside of the treatment room Initial taste sessions, pea-sized bites of preferred food presented and then target foods were presented Bite sizes of target foods gradually increased Modeling Caregivers who DO NOT model drinking soda, eating sweets, and salty snacks regularly are more likely to have children with healthier diets and weight (Hendy et al., 2009) Modeling Examined the effects of the Plate A-Plate B intervention with and without feeder modeling on one child s acceptance of new foods Typically developing 4-year-old boy with ageappropriate imitation skills Caregivers reported 11 foods in his pre-treatment diet (Seiverling, Harclerode, & Williams, 2014) Escape Extinction Escape extinction involves not removing feeding demands contingent on refusal and inappropriate behaviors Typically entails requiring the child to eat a single bite or small portion of food Successful interventions often involve some form of escape extinction Food Selectivity Interventions that Use Escape Extinction Implementing single-bite taste sessions Paul, Williams, Riegel, & Gibbons, 2007; Pizzo, Williams, Paul, & Riegel, 2009; Seiverling, Williams, Sturmey, & Hart, 2012) Single-bite taste sessions Used to treat two children with extreme selectivity Intervention consisted of two components: probe meals and taste sessions (Paul, Williams, Riegel, & Gibbons, 2007) Taste Sessions Each bite is presented until eaten, inappropriate behavior is ignored, and elopement is blocked After each bite is accepted, the child is given a break Stimulus fading is used to make it easier for the child; the initial bite size for each food is pea-sized or even smaller Probe Meals Ten minute probe meals are used to measure the progress of the intervention over time The child is offered novel foods and praise is given for taking bites, but the child is not required eat any of the food presented No attention is provided for inappropriate behavior Variety increased and these increases were maintained # of food Eaten Before Tx Foods Presented Eaten After Tx Eaten Before TX Foods Presented Eaten After Tx Jim Kim Jump Start Exit Criterion In the original study, two children were exposed to 13 and 15 days of intensive treatment Same intervention implemented across 4 to 5 days Participants 4-year-old boy with ASD 5-year-old boy old boy with reflux 9-year-old boy with ADHD (Pizzo, Williams, Paul, & Riegel, 2009) Foods Eaten Number of Foo Patient 1 Patient 2 Patient 3 Before Tx End Tx Follow Up Inappropriate Behaviors Average per meal p Monday Tuesday Wednesday Thursday Friday Day of the Week patient 1 patient 2 patient 3 A variant of escape extinction using a s eating sheet visual cue The use of visual cues. Often used with children with ASD to promote independence and to decrease problem behavior associated with schedule changes Carnahan, Musti-Rao, and Bailey (2009) Reinforcement criterion made clear for the learner Can also be used as a token economy Often helpful to increase reinforcement criterion Some final comments regarding taste Reduce response effort sessions. Try first introducing foods similar in taste, color, and texture to foods in the current diet The size of the taste does not seem to matter, small is okay even if it is just a few molecules If applicable, use foods previously eaten or even preferred foods Move to new brands of familiar foods May want to start with low textures What about food selectivity in older Behavioral Contracts children? Suggestion Provide as much child choice as possible! Children often like to be in control You can allow them to choose the new foods that they try You may need to provide restricted choice And, you have to allow choices that you can live with! Interventions for Total Food Refusal Perhaps the most severe feeding problem Child refuses to eat enough to sustain growth Often accompanied by inappropriate mealtime behavior Often have at least one medical condition, most often GERD Problems with appetite are common Often dependent upon tube feedings or oral supplements Treatment for Total Food Refusal Typically involves hunger induction, escape extinction for refusal and inappropriate behavior, and positive reinforcement for acceptance Often also involves a structured meal and snack schedule, and gradually increasing response effort (Williams, Field, & Seiverling, 2010) Interventions for Chewing Teaching a child how to chew can be challenging A child s failure to chew may be due to: Oral motor deficits Aversion to a certain texture (e.g. will chew certain textures, but not others) A combination of both There is an emerging literature in our field on how to teach chewing (Volkert et al., 2014; Eckman et al., 2008; Volkert et al., 2013) Chewing Is it documented that the child has oral motor problems or neuromotor problems (e.g. weak muscle tone)? May need to reach out to speech language pathologist or physician Does the child have the physical abilities to chew? Is the child able to imitate or follow 1-step instructions? Chewing How do chewing skills develop? Typically parents present soft and easily dissolvable foods between 7-9 months Children typically start to eat table food diet by 24 months Develop mature chewing skills by age 4 years (Volkert et al., 2014) Teaching a child to chew Often involves teaching the following skills Tongue lateralization Lip control Chewing practice (i.e. biting up and down) Texture fading (Williams & Foxx, 2007) Tongue Lateralization Ability to move the tongue from side to side inside the mouth Some children do not lateralize at all! Put a small amount of preferred food in the corner of the child s mouth and instruct the child to touch or lick it May need to start by just having the child stick out his or her tongue May need to use a nuk brush or spoon to push the child s tongue to the side at first Provide reinforcement! Tongue Lateralization Clips Lip Control Ability to keep the mouth closed when eating and drinking (helpful when moving food around in the mouth) May be improved by teaching a child to drink from a cup or straw Present a small drink (i.e. 5 ccs) from an open cup or cup with a straw. Provide reinforcement! Gradually increase the size of the drink Chewing Practice Provide the opportunities to bite and produce up and down movements of chewing Start with dry, easily dissolvables (e.g. cheese doodles, veggie sticks) that provide feedback as the child chews Place a tiny bite onto the child s teeth until the child bites it (followed by reinforcement!) Gentle physical prompts (pushing upward on the child s chin and release) or modeling may help Move foods back onto the child s molars as the child bites down without inappropriate behavior Increase from 1 bite to 2, 3, etc. before reinforcement Gradually increase bite sizes Biting Down Clip Tools may be helpful It s easy to get your fingers bitten! Chewy Tubes are oral motor devices may be helpful to use when initially placing food onto the child s teeth Can purchase or make your own We tend not to work on chewing if a child exhibits high levels refusal with purees The refusal is likely to interfere with learning the skill of chewing Volkert et al. (2014) Texture fading May be helpful to do texture fading if the child only eats purees Solids are usually classified as Stage 1 and Stage 2 baby food (purees) Stage 3 baby foods (junior texture) Ground Chopped fine Regular Texture fading (con t) Ways to increase texture Add baby cereal, wheat germ, crushed graham cracker Use a food processor to alter regular textured food Often follow fading progression such as the one below: 100% pureed 75% pureed/25% junior 50% pureed/50% junior 25%pureed/75% junior 100% junior Interventions for Packing Packing involves holding food in the mouth for protracted durations (generally longer than 30 seconds) For some children, packing can be an avoidance behavior, similar to crying or head-turning For other children, packing is the result of inadequate oralmotor skills Increased response effort of eating the higher texture food Simultaneous presentation, differential reinforcement, & response cost to treat packing Nine year-old girl with ASD who packed bites of new or non-preferred foods regardless of texture Response cost was implemented by presenting a preferred video for 30 s prior to the first presented bite and removing the video if packing occurred Video was returned following a mouth clean (Buckley & Newchok, 2005) Additional interventions for packing Differential reinforcement for clean mouth Using a liquid wash or a smooth food chaser Alternating bites and drinks to prevent packing Lowering the texture of the food to prevent packing Re-distribution Interventions for Self-feeding There is an emerging literature in our field on how to improve self-feeding Rivas et al. (2014) Vaz, Volkert, & Piazza (2011) It is difficult to work on self-feeding and refusal at the same time Often, if a child s food acceptance improves, so does his or her willingness to self-feed Self-feeding Failure to self-feed can take many forms Reliance on caregivers to feed all bites and drinks Refusal to use utensils (e.g. will only finger feed) Refusal to drink from a cup (e.g. only drinks from a baby bottle) Refusal to self-feed in order to avoid eating Refusal due to skill deficits required for self-feeding May be helpful to consult with occupational therapist to determine if adaptive equipment will be helpful (Williams & Foxx, 2007) Self-feeding Common prompting strategies Least-to-most prompting Graduated guidance Self-feeding Least-to-most prompting Gestural cue: Pointing to the food Verbal prompt: Take your bite! Partial physical prompt: Placing the child s hand on the utensil or cup Full physical prompt: Using hand-over-hand physical guidance to ensure the child self-feeds Self-feeding clip Self-feeding Graduated Guidance: Adjustment in prompting level from moment to moment, according to the child s performance Full graduated guidance: Hands in full contact with the child s hand and only use as much guidance as necessary Shadowing: Keep hands within an inch of the child s hands Tips for Self-feeding Set families up with a feasible plan! Require the child to self-feeding for a small portion of the meal to start (e.g. first 5 mins) Alternate! Have the child self-feed and the caregiver then present a bite Visual supports may be helpful Choking Phobias Fear and avoidance of swallowing foods, liquids, pills, or a combination of these in the absence of a true organic medical problem affecting swallowing and feeding (Burklow & Linscheid, 2004) May stem from a choking incident, a negative experience with distasteful food/medicine or even a sore throat A Behavioral Intervention for Treating Participant a Choking Phobia 4-year-old girl who developed a fear of choking after an acute choking episode Refused almost all solids foods for 3 months prior to evaluation and was consuming primarily chocolateflavored pediatric formula Intervention Food selectivity intervention of single-bite
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