Hi and welcome to What Works Wednesdays where we share a success story from one of our clinical cases. All names have been changed to preserve the privacy of the child and family. Our intent is to show readers how successful ABA can be. Today’s story is about a young man we call “Dennis”.
Dennis came to us just slightly before his third birthday. He carried a diagnosis of autism. Like many of our children, he also had a history of reflux. His reflux was so bad that his parents reported having to place a plastic covering on the floor under his crib to protect the flooring.
Dennis was non-verbal but he had no problem making his needs known. One way that he communicated his wants and needs was by vomiting. Initially, when a non-preferred food was presented to him, he vomited until it was removed. Over time, he began to control what his Mommy ate too. If he saw her eating something he didn’t like, he vomited. By the time he got to us, he had whittled his diet down to only 3 foods: a certain brand of potato chips, peanut butter, and a beverage. His poor Mom couldn’t eat in front of him and was limited to consuming Coca Cola only in his presence. Can you even try to imagine the family stress in that house?
Readers should know that Dennis was the most adorable picky eater. His chubby cheeks were just ripe for the squeezing. His toddler hands and feet were precious. He was the kind of child that you just want to pick up and hug and kiss over and over again. With a child that cute, you know behavioral feeding therapy is going to be a challenge! It is really hard to be firm with a cutie-pie.
Because of the seriousness of the behavior and the extreme food selectivity, we asked that the parents have a complete medical work up prior to starting feeding therapy. Dennis came back clean as a whistle–he had no major issues other than the reflux.
On the first day of feeding therapy, we realized that we needed help. We rushed out to the nearest store to purchase protective gear–plastic aprons. Dennis could vomit without any effort at all and our clothes were doomed without protection. (Dennis is the worst case of vomiting we have seen in our practice to date.) In the first three sessions alone, he vomited 13 times when a total of 30 bites had been presented! When Dennis vomited, we simply cleaned up the area and re-presented a clean but identical bite of food. Dennis tried to use gagging to replace vomiting. When he gagged, we simply closed his mouth by gently pressing his chin up.
Dennis did not give up his preferences willingly. He fought us for the first two days. In addition to vomiting and gagging, he used head turns, crying, spoon batting, and other disruptive behaviors to avoid new foods. We ultimately used physical prompting to encourage him to open his mouth and take a bite. Once he accepted the bite, he discovered that it didn’t taste quite so bad. Keep in mind that Dennis was also hungry for each session. His parents did not feed him before or after therapy so if he didn’t eat with us, he didn’t eat again until the next therapy session a few hours later.
Over time, he began to fight less and less and he began accepting bites willingly. By the third day of treatment (9 sessions) Dennis had stopped vomiting. Across the last three sessions of treatment, Dennis gagged only 2 times out of 142 bites of food and he had no vomits.
On the fourth day of treatment, we transitioned Dennis’ parents in to replace the feeding therapists. On this day, Dennis had begun to feed himself and his parents were there to make sure that his bites were not too big. His parents also reminded him to take a bite if he slowed down or looked as if he might be trying to avoid a food. It was also on this day that we taught Dennis how to eat cake for his upcoming birthday party. We all cried tears of joy to see him willingly scoop up gluten-free (GF) and dairy/casein-free birthday (CF) cake (and yes, GFCF cake tastes delicious)!
Dennis was discharged after only 12 sessions of treatment (4 days)! A few days later, his parents sent us pictures from his 3rd birthday party where he was happily eating his real birthday cake.
This success story did not come without extremely hard work by the parents. It was emotionally draining for them to see their child put up such a fight to avoid foods. It is not easy watching your baby vomit repeatedly at the sight of new/non-preferred foods. It is not easy hearing him cry repeatedly for an entire session. But they stuck with it. They stood their ground and they supported our treatment by not feeding him between meals and by requiring him to participate in therapy 3 times each day despite his tears. Congratulations on your success! The hard work paid off!
We would love to hear from readers. Have any of you worked with children who vomit? Parents, are any of your children vomiting to avoid foods? Parents, teachers, and behavior analysts, would you be able to stick with it like the parents and the therapists did?
This was a wonderful article. I am about to graduate from an ABA undergraduate program and worked with at a camp with kids with various intellectual disabilities and Autism. One boy, who was also nonverbal, would eat too much and eventually vomit. It was nowhere near as severe as Dennis but it was a problem and it seemed to reinforce his behavior of overeating which wasn’t helping his waste line.
Anyway, I limited his food and gave it to him in smaller portions. Some the excess food (and believe me it was excess) that I took away I gave me contingent on verbal utterances. I tried shaping it and by the end of the small snack (chips) he almost said his name for the first time.
It wasn’t perfect and part of the problem was that I was limited being at a day camp and wasn’t certified or insured to be doing interventions. But I do think it is an example where ABA allowed me to have him eat less that day, eat more slowly and digest, and almost say his name!
Thanks for stopping by Michael! I follow your blog on my RSS feeder! It takes some time to learn how to do behavioral feeding, but once you learn, it is so rewarding due to its quick change in behavior.
This is absolutely fascinating. I don’t really have anything intelligent to add…but I just wanted to share that I was hanging off every word of this post. So interesting!
We are glad that you found it interesting. We get to work with some amazing children and families. Sometimes it hardly feels like work. Thanks for stopping by!
Hey gals!! What a great site! I have a feeding question.
Here is some history, I will take any advice/suggestions you might have.
This is 2.5 year old male whose diet currently consists mainly of ice cream, pudding, yogurt, and pediasure via a bottle. He was born via c-section due to complications in the birth canal but was discharged from the hospital with no concerns the following day. We (the school district) first provided services for motor (sitting and crawling) as well as home teaching when he was 1.5 years old. Mom was in denial of any concerns up until that time; thus the late start on services. He does have normal shaped oral structures and normal teeth. He is currently able to walk, mostly wanders, and doesn’t independently play. He does not appear autistic; really he looks like a mobile but moderate to severe cognitively/neurologically impaired child. He is unable to communicate but does make random throaty sounds. It is important to note he has passed every videoflourscopy and upper GI test that has come at him. There is nothing physiologically wrong, so as an OT, I am assuming his difficulties are completely sensory. Take a look at what I have tried and please let me know if I am missing anything.
Mom has recently been able to start grinding fruits in a processor such as raspberries or apples and he is starting to become less resistant to different flavors but still any, and I mean any amount of texture to foods causes gagging and emesis. I have tried to give him single pieces of texture within foods he likes as well as evenly texturizing foods he likes. With either method, way he will react. I have placed the spoon of food at the front of the mouth, back, and sides of the mouth in hopes that he would manipulate the food and have time to process the texture before it gets to the back of his throat thus causing the reaction. I also use textured spoons when feeding and desensitize with a nuk brush.
He craves vibration, deep pressure and is now currently grinding his teeth. He will bite on a chewy tube with his molars and allow a toothette covered in sour candy to rotate in his mouth, with the exception of the roof which elicits the response. He likes the vibrating elephant toy and willingly allows this tool to be used on his cheeks and in his mouth.
I begin each session with brushing, deep pressure, and joint input which does seem to calm him for a short time.
Several weeks ago he would also gag at objects such as koosh balls but with repeated exposure, he is able to willingly play with these now with no response.
He is not gagging at other people’s food but will gag and throw up if he picks up other people’s food. For example, he reached over and grabbed a handful of green beans and reacted.
We have tried feeding both while he wanders through the house and while sitting. It seems that he does best when he can wander and be distracted. When he is sitting, it is almost as if he goes into fight/flight panic mode.
Since I have serviced him, I have managed to get him to tolerate about 5 different pureed fruits. In addition, he can now eat Gerber toddler carrots which are cooked and really soggy. I have tried the Gerber toddler green beans without luck. I am currently working on adding pureed pasta pick ups to his favored foods, which creates a lumpy texture and adds calories. After two weeks, I have managed to get him to eat 10 bites successfully. I have been able to get him to eat fork smashed bananas without reaction but this does make him very stressed.
I have attempted to mix and grade all consistencies with his yogurt and pudding but once a texture is added, the responses begin. I can’t seem get over that initial hurdle.
I took another route and tried crunchy dissolvable foods (Gerber toddler puffs). He either gags and vomits or swallows too fast to get rid of the food and chokes. I have even tried smashing crackers into his yogurt or pudding for minimally invasive textures.
This is probably the first time in my OT history I have tried everything I know and nothing has shown to be the least bit effective. I am not sure how to proceed and what to do next. I would appreciate any suggestions you have, thanks so much!!! ~Jamie
Jamie
Looking forward to our chat next week! Thanks for stopping by!
[…] had heard how great the outcomes in our clinic have been. For case examples from our clinic, read here, here, or here. The problem, she explained, is that she works and summer is the only time she is […]
Hello. Do you have experience with a child expelling pretty much everything? I would be very interested in reading prior stories and meeting with you about our challenging eater.
We love working with expellers! Most of the kids we see expel food and they engage in nasty behaviors such as hitting, screaming, and crying.
Email us to set up a time to talk! We would love to help your child.
What physical prompt did you use for mouth openings?
You’re back! Thanks for reading and commenting!!
We simply prompt the mouth to close using a gentle physical prompt.
Let us know if you have other questions.
Oh my god. I am having the same issues with my son. We are struggling, his child minder is struggling and he starts nursery in a couple of days for a couple of days a week so they aren’t going to have an easy time either. Sick, gagging, refusing, crying/screaming. whether he eats or we eat. If we are eating and he is playing he will walk over look at us and either gag or throw up. We even tried putting him in his room the other day so we could eat but he stood at the baby gate looking down the stairs to us and started gagging. The child minder can’t eat round him either and other children she looks after make him sick too when they eat. Dinner table is now a no god or her.
I am sorry to hear about your child’s vomiting. I hope that you can get help.
Hi Ceris,
I’m sorry that you are having such a stressful time. You definitely need to get an expert in to assist you. Your child needs a medical work up and testing for food allergies before you begin feeding therapy.
Good luck,
My 3 year old son is very similar to the boy in the article. We have done sensory therapy and 4 weeks of SOS therapy with negative effects. We had to stop therapy because my son would refuse to eat for days after the therapist left. We are unable to eat in front of him or go out to eat. He even gags when he can smell me cooking dinner. He is willing to take bites of certain foods if I offer him something he really wants, but it never goes beyond that. My goal is to get him to eat one “real” meal. He currently eats dry cereal, blueberries (breakfast), Sour Cream and Onion Pringles, fruit snacks (lunch) and banana, wheat thins (dinner). If I’m lucky! Where are you located? Can I purchase a book that explains your method, I am willing to try anything. I was just told by an OT there is nothing else she can do for me. I am open to any suggestions. I also have a 1 year old who is limited in food choice and is gagging often.
Hi Brandy,
I’m sorry to hear that you are having these problems. It sounds like you need the help of several professionals. My first recommendation is to see a GI doc to make sure there is not a medical condition. I would also want him screened for any possible food allergies or intolerance issues (the same for your baby! Read my Devil in the Milk post for more info.). Depending on the condition of his oral motor skills, you may also need the assistance of a speech and language pathologist or an occupational therapist who deals with oral motor.
Once those aspects are addressed, then you need the help of a behavior analyst with feeding experience. Obviously, that could be me but there are several people out there who are equally skilled.
Please contact our office if you are interested in our services. We do travel to clients, especially young ones like your child. If you are in a metropolitan area, we could treat a couple of children during the same period and you could share travel costs with another family.
Hello. My five year son gags when he sees people eating something that he doesn’t like. He does not do it that much at home with us but now that he’s in kindergarten, he does it pretty much every day. Is there anything that I can do to help him with this? Thanks!
I am working with autistic children in a public school. The 8 year old boy I work with at lunch has a problem with gagging/vomiting. He is a picky eater and cannot stand to see others eat. I have been working with him to hold his chin up and breathe in through his nose when he is about to vomit. This is working but the process is slow. Here is the kicker…other aides that work with him allow him to vomit whenever he wants to. They sit a waste can in front of him and let him vomit. This really disturbs me as it is working the opposite effect I am hoping to accomplish. The acid in his stomach is now in his mouth and will erode the enamel on his teeth. He has had a fair amount of dental work as it is. Am I on the wrong track in my attempt to correct this problem? Am I the one who is wrong to try to correct this situation. I do not eat at the same time the student is eating lunch. He does not want anyone sitting near him except for me. When he gags I immediately have him look up at me and breathe. Do you have any suggestions?
My daughter gags alot, she also has history of vomiting in childhood. ..she doesn’t want to eat breakfast or any meal..unluckily in our country finding behavioral therapist is deal… so it’s mum n dad work !!
She is a darling daughter but feeding food to 4 yr is big deal n at times v v v frustrating..she cries n gags, the more hungry she would b more gags n chances of vomiting.. she refused solid for 2 n half yr n remained on purees..but vomiting is routine thing…
Plz help me, I don’t know how to stop her gaging on every bite n making her chew it..
If she doesn’t gags, she will not chew it, n if chews then she will not sallow. .each stage is critical n testing patience.. I got two yr old son picking up her sisters stuff..throwing spoons n refusing food
I need help
How to change her behavior towards food n making meal time a happy time rather than a battle ground…first bite till last is like that.. gag n gag..
Hi Mala,
thanks for reaching out to us. It sounds as if you are in need of professional assistance for your daughter. I would recommend 2 things. First, I would find someone with expertise in feeding. You could find someone who is able to provide services using telemedicine. This would be done over a secure system such as WebEx. Given that your daughter vomited in childhood, it seems that a thorough medical workup is warranted. I would want a GI work up along with a food allergy work up. Finally, a behavioral assessment is needed to determine why she is engaging in food refusal particularly by texture as you have described.
Once the initial evaluations are complete, then an appropriate plan could be developed.
Good luck. This does not sound like an easy case.