What to Do When A Child Won’t Eat Feeding Disorders &Developmental Disabilities
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What to Do When A Child Won’t Eat: Feeding Disorders & Developmental Disabilities
Katharine Gutshall, MA, BCBA Center for Autism & Related Disorders
Center for Autism & Related Disorders
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)
Expanding CARD’s Vision
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
Challenging Behavior Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.)
Challenging Behavior Clinic (C.B.C.)
Providing services for individuals who display self-injurious, aggressive, and other severe behaviors (i.e., vocal/physical stereotypy, property destruction, pica). Utilizing Functional Assessment procedures, function-based interventions are developed to replace the challenging symptoms with appropriate skills. These newly mastered behaviors then able to be generalized to the home, school, and community settings.
Medical Facilitation Clinic
Feeding Clinic
Medical Compliance Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.) Medical Facilitation Clinic
Challenging Behavior Clinic (C.B.C.)
Feeding Clinic
Providing services to assist with the administration of oral medication pill endoscopy, , and other medical procedures. Families are required to show documentation of a thorough physical by a licensed medical doctor After a . review of medical history, personalized interventions are designed to teach individuals to swallow pills or adapt to medical procedures . Once mastery has been achieved with our trained staff, training to conducted with caregivers so that they are able to independently implement the child’s intervention.
Feeding Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.)
Challenging Behavior Clinic (C.B.C.)
Medical Facilitation Clinic
Feeding Clinic
Providing services to individuals who display partial or total food refusal, food or texture selectivity, and lack of self-feeding. Through systematic assessment, appropriate feeding behaviors are developed. Caregivers are trained to independently implement the feeding interventions in both the clinic and at home.
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
What is a Feeding Disorder?
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
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.
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
Autistic Disorder & Eating
• Dr. Kanner’s original diagnostic criteria included aberrant eating patterns – Not included today’s diagnosis • Suggested reasons: – Concentration on detail – Perseveration – Fear of novelty – Sensory impairment – Biological food intolerances
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
Where Does it Start? Medical & Behavioral Interactions
Where does it start?
• Etiology is still unknown • Multiple hypotheses:
– Learned behavior – Biological factors – Interaction
Biological factors
• Physical complications
– Cleft palate – Oral motor difficulties
• Medical complications
– Reflux – Allergies – Constipation/diarrhea
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
The Interaction of the Two
• It’s not uncommon for a problem to morph
– Medical → Behavioral
What Happens Next Time???
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
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.
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.
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
When Should I be Concerned?
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
Realistic expectations
0-12m. Chews without rotary/grinding motion 0-12m. Feeds self cracker or snack 0-12m. Drinks from cup held by adult 0-12m. Feeds self finger foods 0-12m. Chews and swallows semisolid foods 0-12m. Chews with rotary/grinding motion 0-12m. Chews and swallows solid foods Drinks from cup held with both hands, with 0-12m. assistance 1- 4yrs Chews with mouth closed 1-2yrs. Chews with ease and rotary motion. 1-2yrs. Lifts glass/cup from table to drink 1-2yrs. Returns cup/glass to table after drinking 1-2yrs. Manipulates spoon to "scoop" food Drinks from cup held with both hands, 1-2yrs. without assistance may spill Takes spoon from plate to mouth, with some 1-2yrs. spilling 1-2yrs. Sucks from straw Inserts spoon in mouth without turning it upside 1-2yrs. down, moderate spilling Drinks from cup or glass held in one hand without 1-2yrs. assistance/spilling 1-2yrs. Uses a fork for eating, may spill 2-3yrs. Uses fork for eating 2-3yrs. Spoon feeds without spilling 3-4yrs. Uses napkin 3-4yrs. Uses side of fork for cutting soft food 3-4yrs. Wipe his/her face and hands during/after a meal 4-5yrs Holds fork in fingers 4-5yrs Holds spoon, fork and knife correctly 4-5yrs Uses knife for spreading 5-6yrs. Uses knife for cutting softer foods 5-6yrs. Uses knife for cutting 6-7yrs. Uses spoon, fork, and knife competently
Realistic expectations
Realistic expectations
How bad is it really?
• • • • • • • Missed meals Malnourishment Failure to thrive Lack of growth Tube dependence Added family stress Problematic mealtime behaviors
USDA Food Guidance
Food for Young Children
1992 1940s 1970s
1916
2005
1950s-1960s
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.
Determine Caloric Needs
3400 3200 3000 2800 2600
ACTIVE
Calories
2400 2200 2000 1800 1600 1400 1200 1000 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
SEDENTARY
Age
*From the National Academy of Sciences, Institute of Medicine Dietary Reference Intakes Macronutrient Report
Growth Curves
• Shows where a child compares to chronologically aged peers for: – Height – Weight
Boys 2 to 5 years
4 year old 35 lb. 41”
Extreme cases - Enteral feedings
G-Tube with Mickey
NG-Tube
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?
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
Before you Begin Intervention…
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
Rule Out Medical Problems
• • • • • • • Gastro esophageal reflux Constipation Diarrhea Food intolerances/allergies Oral motor delays Dysphasia Delayed gastric emptying/motility problems
Addressing Behavior Problems
• May need to be dealt with prior to intervention
– Sleep dysregulation – Aggression – Tantrums
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
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
Long-term Planning
Possible Treatment Goals: • Increase texture • Increase variety • Increase amount • Become a self-feeder • Decrease the “fight” • “Happy Meal™” goal
Family Contribution
Determine family requirements during intervention • Prepare food? • Run session? • Take data? • Emotional upheaval? • Withhold specific reinforcers at other times? • Transportation to session?
Motivation
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
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
Find Out What the Child Likes
•Complete a mental inventory •Ask the child •Physically assess
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.
A Quick Preference Assessment
•Gather 5-6 possible reinforcers the item worked for at that The item chosen first should be moment •Show the child all of the items •Place them in front of the child at equal distances •“Pick one”
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
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
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
Once you know what someone wants, How do you get them to do what you want?
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
The Daily Schedule…
…ABSOLUTELY IMPACTS MEALTIME BEHAVIOR! •Sleep regulation •Set mealtimes •Limited portions •Set snack times •Medication side effects •Arrange tube feeds
The Eating Environment
Everything Around you Matters
It’s more than feng shui… Make the environment work for you! •Seating arrangement •Physical seats •Utensils
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
Seating!
The Highchair •Height •Recline •Wheels •Tray •Straps •Fabric •Up to 45-50 lbs The Booster Seat •Attachment •Tray •Straps •Up to ~3 years
Seating!
Just a Boost Up •Size •Age/Weight The Kitchen Chair •Size •Age/Weight
Utensils and Such
Yes! It matters!
Utensils and Such
Priorities when picking a spoon: •Width •Bolus amount •Curvature •Lip closure
Cups!
Nosey Cups •Liquid •Amount •Head tilt Sippy Cups •Age •Supervision Tumblers •Age •Amount
Plates & Bowls!
Plates •Suction •Rim Bowls •Suction •Scoop ability
Is that bite too big?
Bolus Size - Solids
The amount of food on a spoon during one bite
Level
Rounded
Heaping
Bolus Size - Liquids
1 ounce ¾ ounce ½ ounce ¼ ounce
The amount of liquid in a cup during one drink
Texture
Texture
Baby food / Puree •Absolutely smooth •Think of: pudding, applesauce
Wet Ground •Small lumps •Relatively liquid •Think of: soupy oatmeal
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
Texture
Bite Size •Typical age-appropriate bite •Think of: size of a dime
Preference Assessments
Let’s find potential reinforcers! Start with your own brain storming Ideal items are ones that: Can be presented immediately Easy to remove Can be used in short periods of time Are mobile
Daily Schedule
What does your week look like? Sketch in sleep Sketch in activities Sketch in planned meals/snacks Sketch in times when eating actually takes place
Self-Monitor
Take the mind set of a child…
What is your current status?
Goal Planning
Scenario goals What should we work toward for Sarah?
Personal goals Where are you hoping to go?
Can’t you just make us a decision tree?
Child Characteristics
Age
Seating Apparatus
High Chair
Assessments
Tangible Preference Assessment
Treatment Evaluation
DRA
Booster Seat Developmental Level Chair / Table
Time / Money Continuum Time / Money Continuum Time / Money Continuum
$
YIELD
Escape Extinction
Edible Preference Assessment
NCR
Food Selective
Fade by Texture
Presentation Selective
Feeding Style
Self Feeder
$
Texture Assessment
Fade by Taste
Refusal Non-Self Feeder Total Refusal Partial Refusal
Fade by Color
Oral Motor Assessment
Changing Criterion
Problem Behaviors
Food Texture
Baby Food
$
Response Cost
YIELD
Family Support
Puree
Volume Assessment
Sequential Presentation
Medical Complications Nutrition Enteral Feedings Allergies Reflux Oral Motor Deficits Aspiration
Wet Ground
$
Ground
Simultaneous Presentation Food Characteristic Assessment Taste
YIELD
Redistribution
Chop
Color Food Group
YIELD
Jaw Prompt
Bite Sized
Caregiver Training & Generalization
Introducing New Foods
The Introduction • Relax!
– After all, it’s just food
• Pick something mundane or similar
Simple Reinforcement • Reinforcer given immediately for eating a bite of food
WHAT HAPPENS IF HE NEVER TAKES A BITE?
(2-3 seconds)
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
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
Demand Fading
Jeffrey eats French fries. We want him to eat broccoli.
Day 1 3 2
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
Mixing Foods
Courtney eats applesauce. We want her to eat peaches.
Day 1 Days 2-3 Days 4-5 Days 6-7 Days 8-9
Sa
Applesauce 100% 90% 80% 70% 60%
le p m
Peaches 0% 10% 20% 30% 40%
What happens if things go astray? How fast can I move? Do I tell Courtney about the mix?
Pairing Foods A non-preferred food is presented with a preferred food Simultaneous or sequential presentation???
Pairing - Sequential Non-preferred bite is immediately followed by preferred bite
Pairing - Simultaneous Both non-preferred and preferred foods are presented at the same time (same bite)
Pairing - Simultaneous
Ethan eats pie. We want him to eat green beans.
Day 1 Day 2 Day 3
Self-feeding
Self-Feeding
Why? • Lack of skills • Simple food refusal What? • Someone else feeds child • Finger feeding only • No transition from bottle
Teaching Self-Feeding
• May be beneficial to address food refusal and self-feeding independently • Manipulation of prompting and consequences
Prompting
• Cues to a person that you want him/her to perform a certain task • Prompts come in various forms:
– Gestures – Verbal – Model – Physical
How to Deliver a Prompt
• Authoritative voice
– No questions – No yelling
• Prompts delivered approx. every 5 seconds • No extraneous statements, questions or demands
Ultimate Prompting Goal
• Eliminate the needs for prompts • Avoid “prompt dependency”
– When a child only engages in a behavior after a prompt
Least to Most Prompting
Steps: 2. Gestural – Parent points to bite of food 3. Verbal – Parent gives verbal instruction to child 4. Model – Parent shows child what to do by modeling movement 5. Physical – Parent uses hand over hand guidance to ensure the behavior is completed
Least to Most
Pros Allows greatest independence Cons Child can make mistakes
Behavior will always Child can “escape” be completed during prompting time Good with child who can display skill
Most to Least Prompting
Level 1: Verbal prompt, “Take a bite” Level 2: Physically guide child to scoop food Level 3: Physically guide child to bring food 2” from mouth Level 4: Physically guide child to place bite in mouth
Phase A: Caregiver completes levels 1, 2, 3, 4 Phase B: Caregiver completes levels 1, 2, 3. Allow child to complete level 4 Phase C: Caregiver completes levels 1, 2. Allow child to complete levels 3, 4 Phase D: Caregiver completes level 1. Allow child to complete levels 2, 3, 4 Phase E: No prompting at all
Most to Least
Pros Child not allowed to make mistakes Cons More intrusive prompting used
Behavior will always Possibly longer to teach be completed Good when a child Must track performance does not show ability to
Graduated Guidance
Full Graduated Guidance: Keep your hand in full contact with the child’s hand throughout the behavior. Increase guidance if child stops. Decrease guidance if child behaves independently. Shadowing: Have your hand within an inch of your child’s hand. As child continues to move independently, caregiver should move hand further away. Come closer in if independence decreases.
Most to Least
Pros Cons Caregiver must be very Allows independence aware Behavior will always be completed Caregiver physically close to “catch” incorrect behaviors Can vary greatly between caregivers
Praising during Prompting
Rule #1: Never praise physical guidance Rule #2: Decide what gets praise Rule #3: Be consistent Caveat: Sometimes tangible reinforcement may be necessary to fade prompts
General Strategies
Is it really a question?
Simon has turned into a super-hero today. In order to obtain the best take offs, it seems necessary to climb on the washer and dryer - repeatedly. Simon’s mother repeatedly asks him, “Are you sure that’s the right thing to be doing?”
Paper or plastic?
Which shirt today – the red or the blue?
Some things in life are questions…
Are you going to come with me or stay with your Dad?
Would you like fries with that?
Take your medicine.
Put on your shoes.
Make sure you know if you …other things aren’t. are asking or telling.
Hold my hand while we’re in the parking lot.
Put on your seatbelt.
Think Before you Speak
As a rule, IGNORE inappropriate behaviors Do not beg, coax, pled, 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?
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
Children with autism tend not to display imitative behavior Attention may have to be drawn to the modeled behavior.
How to Model New Food
Model with enthusiasm “Yummy! I love kiwi!” Silent modeling is not effective Modeling with competing statements is not effective Do not have people at the table who will make negative comments and/or refuse food
Addressing Behavior Problems
Keep this in mind…
You will be asking a child to do a non-preferred task Expect unhappiness
Meals can be Hard
Unhappiness can take the form of: •Crying •Tantrums •Throwing food/utensils •Hitting •Self-injury
Rule of Thumb
Wonderful job! I’m so proud of you!
If you like it, praise it.
Fantastic! High five! I can’t wait to tell Grandma that you… Nice sitting! Great work!
If you don’t, block and/or ignore it. Move on.
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
Give Attention When Due
Give the child attention only when he is behaving appropriately Look for the “good things”
Stop interaction when behavior deteriorates.
Modify your Surroundings
Keep items out of the child’s reach. Have extras on hand Stay in close proximity.
Melody kicks the base of her highchair during meals. Even when ignored, the problem continues. POSSIBLE ENVIRONMENTAL SOLUTIONS?
Time Out
Tricky to use… Time out involves no fun things and no social contact. 3. Remove child from table for predetermined time 4. Turn chair around at table for predetermined time 5. Remove plate/glass for predetermined time
What happens if my child likes to escape the meal already? Use at conclusion of the meal
Modify your Surroundings
Keep items out of the child’s reach. Have extras on hand Stay in close proximity.
Melody kicks the base of her highchair during meals. Even when ignored, the problem continues. POSSIBLE ENVIRONMENTAL SOLUTIONS?
Making Change Last – Preventative Changes
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”
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
Why Interventions Sometimes Fail
Failure Should Not be an Option
• Interventions discussed have shown to be successful
– Not all interventions are successful for every child
ST Be Prepared: Things Can Worsen IR TF A
• Child may show displeasure with new rules
– Temporary increase in crying, tantrums
• Behaviors do subside over time
– If ignored while intervention is continued
Discontinuation
• Interventions discontinued prematurely
– It may take time to see huge results – Continue even when you do see huge results!
Child’s Resistance
• Consistency of intervention • Past history • Amount of effort required by the child
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
Different Approaches
• Multiple therapists = Multiple plans? This can cause confusion and lack of progress with any of the interventions
Outcome Study – CARD Austin, TX
Clients and Setting
• Clients
– Total of 13 clients – All had diagnosis of Autistic Disorder – Age range 2 y,10 m to 9 y, 10 m
• Setting
– Treatment provided in 3 rooms – Client’s family usually in town for approximately one week
• Treatment
– Individualized to child’s needs and abilities
Clinic rooms???
Individual Treatment Evaluation
• Parent Involvement
– Asked to observe all sessions – Trained to implement meals for last 3-5 sessions
• Data tracking
– Data collected on acceptance, swallowing, inappropriate behaviors
35 30 Number in Hours 25 20 15 10 5 0 1 2 3
Length of Treatment in Hours Three Hours Treatment Per Day Therapy Supervision
4
5
6
7 Client
8
9
10
11
12
13
Baseline v. Intervention
• Baseline sessions
– Occurred during first day of therapy – Child allowed to escape from bites
• Intervention sessions
– All non-baseline sessions
• We expect to see changes over time
Food Variety 65 55 Total Number 45 35 25 15 5 -5 1 2 3 4 5 6 7 Client 8 9 10 11 12 13 Baseline Intervention
Average Number of Disruptions Per Bite
4 Average Number Per Bite 3.5 3 2.5 2 1.5 1 0.5 0 1
Baseline First 3 Last 3
2
3
4
5
6
7 8 Client
9
10
11
12
13
Common Questions & Discussion
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
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
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
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
Common questions
• Why are you data obsessed?
– Objective measurement shows if intervention is working or needs tweaking – Subjectivity is often wrong
Common questions
• What about restricted diets?
– We’re flexible – As long as it is nutritionally sound
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
Common questions
• What is the research on long term success?
– Currently, limited published research – Follow-up probes show promise – Dependent upon protocol implementation
Center for Autism and Related Disorders Specialized Outpatient Services 19019 Ventura Blvd Suite 300 Tarzana, CA 91303 CARDSOS@centerforautism.com
What to Do When A Child Won’t Eat: Feeding Disorders & Developmental Disabilities
Katharine Gutshall, MA, BCBA Center for Autism & Related Disorders
Center for Autism & Related Disorders
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)
Expanding CARD’s Vision
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
Challenging Behavior Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.)
Challenging Behavior Clinic (C.B.C.)
Providing services for individuals who display self-injurious, aggressive, and other severe behaviors (i.e., vocal/physical stereotypy, property destruction, pica). Utilizing Functional Assessment procedures, function-based interventions are developed to replace the challenging symptoms with appropriate skills. These newly mastered behaviors then able to be generalized to the home, school, and community settings.
Medical Facilitation Clinic
Feeding Clinic
Medical Compliance Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.) Medical Facilitation Clinic
Challenging Behavior Clinic (C.B.C.)
Feeding Clinic
Providing services to assist with the administration of oral medication pill endoscopy, , and other medical procedures. Families are required to show documentation of a thorough physical by a licensed medical doctor After a . review of medical history, personalized interventions are designed to teach individuals to swallow pills or adapt to medical procedures . Once mastery has been achieved with our trained staff, training to conducted with caregivers so that they are able to independently implement the child’s intervention.
Feeding Clinic
C.A.R.D. Specialized Outpatient Services (S.O.S.)
Challenging Behavior Clinic (C.B.C.)
Medical Facilitation Clinic
Feeding Clinic
Providing services to individuals who display partial or total food refusal, food or texture selectivity, and lack of self-feeding. Through systematic assessment, appropriate feeding behaviors are developed. Caregivers are trained to independently implement the feeding interventions in both the clinic and at home.
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
What is a Feeding Disorder?
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
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.
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
Autistic Disorder & Eating
• Dr. Kanner’s original diagnostic criteria included aberrant eating patterns – Not included today’s diagnosis • Suggested reasons: – Concentration on detail – Perseveration – Fear of novelty – Sensory impairment – Biological food intolerances
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
Where Does it Start? Medical & Behavioral Interactions
Where does it start?
• Etiology is still unknown • Multiple hypotheses:
– Learned behavior – Biological factors – Interaction
Biological factors
• Physical complications
– Cleft palate – Oral motor difficulties
• Medical complications
– Reflux – Allergies – Constipation/diarrhea
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
The Interaction of the Two
• It’s not uncommon for a problem to morph
– Medical → Behavioral
What Happens Next Time???
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
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.
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.
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
When Should I be Concerned?
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
Realistic expectations
0-12m. Chews without rotary/grinding motion 0-12m. Feeds self cracker or snack 0-12m. Drinks from cup held by adult 0-12m. Feeds self finger foods 0-12m. Chews and swallows semisolid foods 0-12m. Chews with rotary/grinding motion 0-12m. Chews and swallows solid foods Drinks from cup held with both hands, with 0-12m. assistance 1- 4yrs Chews with mouth closed 1-2yrs. Chews with ease and rotary motion. 1-2yrs. Lifts glass/cup from table to drink 1-2yrs. Returns cup/glass to table after drinking 1-2yrs. Manipulates spoon to "scoop" food Drinks from cup held with both hands, 1-2yrs. without assistance may spill Takes spoon from plate to mouth, with some 1-2yrs. spilling 1-2yrs. Sucks from straw Inserts spoon in mouth without turning it upside 1-2yrs. down, moderate spilling Drinks from cup or glass held in one hand without 1-2yrs. assistance/spilling 1-2yrs. Uses a fork for eating, may spill 2-3yrs. Uses fork for eating 2-3yrs. Spoon feeds without spilling 3-4yrs. Uses napkin 3-4yrs. Uses side of fork for cutting soft food 3-4yrs. Wipe his/her face and hands during/after a meal 4-5yrs Holds fork in fingers 4-5yrs Holds spoon, fork and knife correctly 4-5yrs Uses knife for spreading 5-6yrs. Uses knife for cutting softer foods 5-6yrs. Uses knife for cutting 6-7yrs. Uses spoon, fork, and knife competently
Realistic expectations
Realistic expectations
How bad is it really?
• • • • • • • Missed meals Malnourishment Failure to thrive Lack of growth Tube dependence Added family stress Problematic mealtime behaviors
USDA Food Guidance
Food for Young Children
1992 1940s 1970s
1916
2005
1950s-1960s
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.
Determine Caloric Needs
3400 3200 3000 2800 2600
ACTIVE
Calories
2400 2200 2000 1800 1600 1400 1200 1000 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
SEDENTARY
Age
*From the National Academy of Sciences, Institute of Medicine Dietary Reference Intakes Macronutrient Report
Growth Curves
• Shows where a child compares to chronologically aged peers for: – Height – Weight
Boys 2 to 5 years
4 year old 35 lb. 41”
Extreme cases - Enteral feedings
G-Tube with Mickey
NG-Tube
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?
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
Before you Begin Intervention…
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
Rule Out Medical Problems
• • • • • • • Gastro esophageal reflux Constipation Diarrhea Food intolerances/allergies Oral motor delays Dysphasia Delayed gastric emptying/motility problems
Addressing Behavior Problems
• May need to be dealt with prior to intervention
– Sleep dysregulation – Aggression – Tantrums
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
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
Long-term Planning
Possible Treatment Goals: • Increase texture • Increase variety • Increase amount • Become a self-feeder • Decrease the “fight” • “Happy Meal™” goal
Family Contribution
Determine family requirements during intervention • Prepare food? • Run session? • Take data? • Emotional upheaval? • Withhold specific reinforcers at other times? • Transportation to session?
Motivation
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
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
Find Out What the Child Likes
•Complete a mental inventory •Ask the child •Physically assess
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.
A Quick Preference Assessment
•Gather 5-6 possible reinforcers the item worked for at that The item chosen first should be moment •Show the child all of the items •Place them in front of the child at equal distances •“Pick one”
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
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
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
Once you know what someone wants, How do you get them to do what you want?
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
The Daily Schedule…
…ABSOLUTELY IMPACTS MEALTIME BEHAVIOR! •Sleep regulation •Set mealtimes •Limited portions •Set snack times •Medication side effects •Arrange tube feeds
The Eating Environment
Everything Around you Matters
It’s more than feng shui… Make the environment work for you! •Seating arrangement •Physical seats •Utensils
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
Seating!
The Highchair •Height •Recline •Wheels •Tray •Straps •Fabric •Up to 45-50 lbs The Booster Seat •Attachment •Tray •Straps •Up to ~3 years
Seating!
Just a Boost Up •Size •Age/Weight The Kitchen Chair •Size •Age/Weight
Utensils and Such
Yes! It matters!
Utensils and Such
Priorities when picking a spoon: •Width •Bolus amount •Curvature •Lip closure
Cups!
Nosey Cups •Liquid •Amount •Head tilt Sippy Cups •Age •Supervision Tumblers •Age •Amount
Plates & Bowls!
Plates •Suction •Rim Bowls •Suction •Scoop ability
Is that bite too big?
Bolus Size - Solids
The amount of food on a spoon during one bite
Level
Rounded
Heaping
Bolus Size - Liquids
1 ounce ¾ ounce ½ ounce ¼ ounce
The amount of liquid in a cup during one drink
Texture
Texture
Baby food / Puree •Absolutely smooth •Think of: pudding, applesauce
Wet Ground •Small lumps •Relatively liquid •Think of: soupy oatmeal
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
Texture
Bite Size •Typical age-appropriate bite •Think of: size of a dime
Preference Assessments
Let’s find potential reinforcers! Start with your own brain storming Ideal items are ones that: Can be presented immediately Easy to remove Can be used in short periods of time Are mobile
Daily Schedule
What does your week look like? Sketch in sleep Sketch in activities Sketch in planned meals/snacks Sketch in times when eating actually takes place
Self-Monitor
Take the mind set of a child…
What is your current status?
Goal Planning
Scenario goals What should we work toward for Sarah?
Personal goals Where are you hoping to go?
Can’t you just make us a decision tree?
Child Characteristics
Age
Seating Apparatus
High Chair
Assessments
Tangible Preference Assessment
Treatment Evaluation
DRA
Booster Seat Developmental Level Chair / Table
Time / Money Continuum Time / Money Continuum Time / Money Continuum
$
YIELD
Escape Extinction
Edible Preference Assessment
NCR
Food Selective
Fade by Texture
Presentation Selective
Feeding Style
Self Feeder
$
Texture Assessment
Fade by Taste
Refusal Non-Self Feeder Total Refusal Partial Refusal
Fade by Color
Oral Motor Assessment
Changing Criterion
Problem Behaviors
Food Texture
Baby Food
$
Response Cost
YIELD
Family Support
Puree
Volume Assessment
Sequential Presentation
Medical Complications Nutrition Enteral Feedings Allergies Reflux Oral Motor Deficits Aspiration
Wet Ground
$
Ground
Simultaneous Presentation Food Characteristic Assessment Taste
YIELD
Redistribution
Chop
Color Food Group
YIELD
Jaw Prompt
Bite Sized
Caregiver Training & Generalization
Introducing New Foods
The Introduction • Relax!
– After all, it’s just food
• Pick something mundane or similar
Simple Reinforcement • Reinforcer given immediately for eating a bite of food
WHAT HAPPENS IF HE NEVER TAKES A BITE?
(2-3 seconds)
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
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
Demand Fading
Jeffrey eats French fries. We want him to eat broccoli.
Day 1 3 2
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
Mixing Foods
Courtney eats applesauce. We want her to eat peaches.
Day 1 Days 2-3 Days 4-5 Days 6-7 Days 8-9
Sa
Applesauce 100% 90% 80% 70% 60%
le p m
Peaches 0% 10% 20% 30% 40%
What happens if things go astray? How fast can I move? Do I tell Courtney about the mix?
Pairing Foods A non-preferred food is presented with a preferred food Simultaneous or sequential presentation???
Pairing - Sequential Non-preferred bite is immediately followed by preferred bite
Pairing - Simultaneous Both non-preferred and preferred foods are presented at the same time (same bite)
Pairing - Simultaneous
Ethan eats pie. We want him to eat green beans.
Day 1 Day 2 Day 3
Self-feeding
Self-Feeding
Why? • Lack of skills • Simple food refusal What? • Someone else feeds child • Finger feeding only • No transition from bottle
Teaching Self-Feeding
• May be beneficial to address food refusal and self-feeding independently • Manipulation of prompting and consequences
Prompting
• Cues to a person that you want him/her to perform a certain task • Prompts come in various forms:
– Gestures – Verbal – Model – Physical
How to Deliver a Prompt
• Authoritative voice
– No questions – No yelling
• Prompts delivered approx. every 5 seconds • No extraneous statements, questions or demands
Ultimate Prompting Goal
• Eliminate the needs for prompts • Avoid “prompt dependency”
– When a child only engages in a behavior after a prompt
Least to Most Prompting
Steps: 2. Gestural – Parent points to bite of food 3. Verbal – Parent gives verbal instruction to child 4. Model – Parent shows child what to do by modeling movement 5. Physical – Parent uses hand over hand guidance to ensure the behavior is completed
Least to Most
Pros Allows greatest independence Cons Child can make mistakes
Behavior will always Child can “escape” be completed during prompting time Good with child who can display skill
Most to Least Prompting
Level 1: Verbal prompt, “Take a bite” Level 2: Physically guide child to scoop food Level 3: Physically guide child to bring food 2” from mouth Level 4: Physically guide child to place bite in mouth
Phase A: Caregiver completes levels 1, 2, 3, 4 Phase B: Caregiver completes levels 1, 2, 3. Allow child to complete level 4 Phase C: Caregiver completes levels 1, 2. Allow child to complete levels 3, 4 Phase D: Caregiver completes level 1. Allow child to complete levels 2, 3, 4 Phase E: No prompting at all
Most to Least
Pros Child not allowed to make mistakes Cons More intrusive prompting used
Behavior will always Possibly longer to teach be completed Good when a child Must track performance does not show ability to
Graduated Guidance
Full Graduated Guidance: Keep your hand in full contact with the child’s hand throughout the behavior. Increase guidance if child stops. Decrease guidance if child behaves independently. Shadowing: Have your hand within an inch of your child’s hand. As child continues to move independently, caregiver should move hand further away. Come closer in if independence decreases.
Most to Least
Pros Cons Caregiver must be very Allows independence aware Behavior will always be completed Caregiver physically close to “catch” incorrect behaviors Can vary greatly between caregivers
Praising during Prompting
Rule #1: Never praise physical guidance Rule #2: Decide what gets praise Rule #3: Be consistent Caveat: Sometimes tangible reinforcement may be necessary to fade prompts
General Strategies
Is it really a question?
Simon has turned into a super-hero today. In order to obtain the best take offs, it seems necessary to climb on the washer and dryer - repeatedly. Simon’s mother repeatedly asks him, “Are you sure that’s the right thing to be doing?”
Paper or plastic?
Which shirt today – the red or the blue?
Some things in life are questions…
Are you going to come with me or stay with your Dad?
Would you like fries with that?
Take your medicine.
Put on your shoes.
Make sure you know if you …other things aren’t. are asking or telling.
Hold my hand while we’re in the parking lot.
Put on your seatbelt.
Think Before you Speak
As a rule, IGNORE inappropriate behaviors Do not beg, coax, pled, 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?
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
Children with autism tend not to display imitative behavior Attention may have to be drawn to the modeled behavior.
How to Model New Food
Model with enthusiasm “Yummy! I love kiwi!” Silent modeling is not effective Modeling with competing statements is not effective Do not have people at the table who will make negative comments and/or refuse food
Addressing Behavior Problems
Keep this in mind…
You will be asking a child to do a non-preferred task Expect unhappiness
Meals can be Hard
Unhappiness can take the form of: •Crying •Tantrums •Throwing food/utensils •Hitting •Self-injury
Rule of Thumb
Wonderful job! I’m so proud of you!
If you like it, praise it.
Fantastic! High five! I can’t wait to tell Grandma that you… Nice sitting! Great work!
If you don’t, block and/or ignore it. Move on.
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
Give Attention When Due
Give the child attention only when he is behaving appropriately Look for the “good things”
Stop interaction when behavior deteriorates.
Modify your Surroundings
Keep items out of the child’s reach. Have extras on hand Stay in close proximity.
Melody kicks the base of her highchair during meals. Even when ignored, the problem continues. POSSIBLE ENVIRONMENTAL SOLUTIONS?
Time Out
Tricky to use… Time out involves no fun things and no social contact. 3. Remove child from table for predetermined time 4. Turn chair around at table for predetermined time 5. Remove plate/glass for predetermined time
What happens if my child likes to escape the meal already? Use at conclusion of the meal
Modify your Surroundings
Keep items out of the child’s reach. Have extras on hand Stay in close proximity.
Melody kicks the base of her highchair during meals. Even when ignored, the problem continues. POSSIBLE ENVIRONMENTAL SOLUTIONS?
Making Change Last – Preventative Changes
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”
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
Why Interventions Sometimes Fail
Failure Should Not be an Option
• Interventions discussed have shown to be successful
– Not all interventions are successful for every child
ST Be Prepared: Things Can Worsen IR TF A
• Child may show displeasure with new rules
– Temporary increase in crying, tantrums
• Behaviors do subside over time
– If ignored while intervention is continued
Discontinuation
• Interventions discontinued prematurely
– It may take time to see huge results – Continue even when you do see huge results!
Child’s Resistance
• Consistency of intervention • Past history • Amount of effort required by the child
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
Different Approaches
• Multiple therapists = Multiple plans? This can cause confusion and lack of progress with any of the interventions
Outcome Study – CARD Austin, TX
Clients and Setting
• Clients
– Total of 13 clients – All had diagnosis of Autistic Disorder – Age range 2 y,10 m to 9 y, 10 m
• Setting
– Treatment provided in 3 rooms – Client’s family usually in town for approximately one week
• Treatment
– Individualized to child’s needs and abilities
Clinic rooms???
Individual Treatment Evaluation
• Parent Involvement
– Asked to observe all sessions – Trained to implement meals for last 3-5 sessions
• Data tracking
– Data collected on acceptance, swallowing, inappropriate behaviors
35 30 Number in Hours 25 20 15 10 5 0 1 2 3
Length of Treatment in Hours Three Hours Treatment Per Day Therapy Supervision
4
5
6
7 Client
8
9
10
11
12
13
Baseline v. Intervention
• Baseline sessions
– Occurred during first day of therapy – Child allowed to escape from bites
• Intervention sessions
– All non-baseline sessions
• We expect to see changes over time
Food Variety 65 55 Total Number 45 35 25 15 5 -5 1 2 3 4 5 6 7 Client 8 9 10 11 12 13 Baseline Intervention
Average Number of Disruptions Per Bite
4 Average Number Per Bite 3.5 3 2.5 2 1.5 1 0.5 0 1
Baseline First 3 Last 3
2
3
4
5
6
7 8 Client
9
10
11
12
13
Common Questions & Discussion
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
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
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
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
Common questions
• Why are you data obsessed?
– Objective measurement shows if intervention is working or needs tweaking – Subjectivity is often wrong
Common questions
• What about restricted diets?
– We’re flexible – As long as it is nutritionally sound
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
Common questions
• What is the research on long term success?
– Currently, limited published research – Follow-up probes show promise – Dependent upon protocol implementation
Center for Autism and Related Disorders Specialized Outpatient Services 19019 Ventura Blvd Suite 300 Tarzana, CA 91303 CARDSOS@centerforautism.com
