Association for Behavior Analysis International

The causes of pediatric feeding disorders are often multifactorial and may include interactions between medical conditions, oral-motor difficulties, and behavioral mismanagement (Babbitt, Hoch, & Coe, 1994; Piazza, 2008). Feeding disorders can range from mild to severe relative to their impact on nutrition and growth. Mild problems might include self-feeding skill deficits or difficulty transitioning to age-appropriate textures (Piazza & Carroll-Hernandez, 2004), whereas more severe difficulties could involve total food and liquid refusal, which may lead to substantial weight loss, malnourishment, and growth impairments (Piazza, & Carroll-Hernandez, 2004). The purpose of the current symposium will be to review effective treatments for pediatric feeding disorders including antecedent interventions and caregiver training. The first presentation will compare variations of redistribution and bolus placement as treatment for packing. The second presentation will compare the effects of demand fading in terms of bolus placement and size, with and without escape extinction to treat food refusal. The third presentation will review the effects of simultaneous presentation of table textured foods to increase chewing and decrease latency to mouth clean. The final presentation will evaluate whether consumption would occur with caregivers following therapist-implemented nonremoval of the spoon with two caregiver-child dyads.

Individuals interested in learning more about the assessment and treatment of pediatric feeding disorders. For BCBAs, BCaBCs, RBTs, and any other practitioners.

Packing (holding food in the mouth) is a problematic mealtime behavior displayed by children with feeding disorders that results in prolonged meal durations and decreased caloric intake (Gulotta et al., 2005). Clinically, packing often emerges following treatment with nonremoval of the spoon, or bite persistence, which is a well-supported intervention for increasing acceptance and reducing refusal behavior. Redistribution represents the treatment with the most empirical support for reducing packing. The procedure involves the feeder collecting the food from the mouth with a utensil after the bite has been deposited and then placing it mid-tongue. Emerging evidence, however, also supports the use of an alternative bolus placement (e.g., flipped-spoon or Nuk presentation) as a treatment to decrease packing and latency to clean mouth (Stubbs et al., 2017). The current study presents data on brief protocol assessments conducted when packing emerged for two children participating in a day-treatment program for total food refusal. We compared variations of redistribution (e.g., different time intervals) and/or bolus placement within or across meal blocks to determine the course of subsequent treatment for each participant. The implications of conducting brief assessments for clinical decision making and the use of redistribution procedures to treat packing will be discussed.

Investigators have shown that manipulating placement and/or size of bite presentations may alter the response effort involved in eating and thus the likelihood of inappropriate mealtime behavior exhibited by children diagnosed with feeding disorders (Dolezal, 2006; Kerwin, Ahearn, Eicher, & Burd, 1995; Sharp & Jaquess, 2009). To our knowledge, no studies have systematically compared the effects of demand fading with and without escape extinction to escape extinction in isolation to treat pediatric food refusal. We conducted an assessment to determine the effects of varying bolus sizes and bite placements on the inappropriate mealtime behavior, compliance, and negative vocalizations of 3 children diagnosed with feeding disorders. Then, we used a combined multielement and reversal design to compare the effects of demand fading along bite placement and/or bolus size combined with escape extinction and escape extinction alone. Results showed that escape extinction was necessary; however, escape extinction combined with demand fading was associated with beneficial effects (i.e., more stable compliance and decreased inappropriate mealtime behavior and negative vocalizations) for all children. Interobserver agreement was collected during at least 33% of sessions and was above 80% for all children. Conceptual and clinical implications of these findings will be discussed.

Children diagnosed with a pediatric feeding disorder may show deficits with oral motor skills necessary (i.e., chewing, tongue lateralization) to consume table textured foods. These children may display skill deficits if they remain dependent on pureed foods for an extended period of time. To address these deficits, it is common to implement a skill training protocol. However, some children may learn the basic skills to chew and swallow but it may not transition to all foods or chewing/swallowing in a timely manner may be problematic. In order to increase consumption of these foods and decrease other behaviors such as gagging, children must learn to chew and swallow efficiently. The purpose of this study was to increase chewing and decrease latency to mouth cleans using simultaneous presentation. The first participant swallowed mixed textured foods without chewing and the second participant would pack soft table textured foods. For both participants, foods that were consumed efficiently were paired with foods that were not. The results of this study showed that when simultaneous presentation was implemented, chewing increased (first participant) and latency to mouth cleans decreased (second participant). These data are discussed in relation to skills training and achieving age-typical eating patterns.

Pediatric feeding problems can occur in upwards of 35% of typically developing children and 90% of children with developmental disabilities. Although the effects of a feeding problem (e.g., weight loss, malnutrition, death) represent drastic long-term outcomes, an increased occurrence of inappropriate mealtime behavior (e.g., aggression, disruption) contributes to increased family stress in the short term. Procedures relying on escape extinction (e.g., Nonremoval of the spoon) are common methods in treating feeding problems given that they are typically maintained by social-negative reinforcement. Although escape extinction is highly efficacious, it remains unclear to what extent children will eat with their caregivers following therapist-implemented procedures in clinics or inpatient-care facilities. The purpose of the current study was to directly test whether consumption would occur with caregivers following therapist-implemented nonremoval of the spoon with two caregiver-child dyads. In addition, we sought to test what procedures were required for caregivers to improve their feeding skills whether generalization occurred or not. Data suggest that some parents might not need to be directly trained. In addition, training (e.g., instructions, role play), when necessary, might be easier for caregivers following therapist-implemented feeding evaluations.