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Archive for the ‘Feeding Intervention/Feeding Therapy’ Category

Needless to say, Rebecca and I were running on fumes at this point in our week. We started the day hoping that 3 of 5 clients would graduate if all goes well. Because of his great success, Jackson was scheduled for only 2 meals: Breakfast with his brother and dinner with his father watching.

Breakfast with Brother

For breakfast, Kendall brought bananas, yogurt (coconut milk), gluten-free hot cereal, and raspberries. Jackson engaged in quite a few behaviors today which is common each time we change the conditions. He engaged in 20 verbal/vocal refusals, 6 physical refusals, and he cried two times. His brother, on the other hand, gagged a few times and had to leave the room several times. Hmmmm, maybe we should enroll another client in feeding therapy!

Dinner with Dad

Jackson was ready to show off his mad skills to his dad. Kendall brought sauerkraut and wieners, quinoa, beets, pears, and dried cranberries. What a champion! Jackson ate everything and he had only 2 gags! (beets would make us gag as well!) Throughout the meal, Jackson engaged in only 5 instances of verbal/vocal refusal. Dad was floored! He could not believe how much progress his son had made in just 4 days.

We also taught Jackson how to eat potato chips without making a mess. In the past, he ate them like a wood chipper with chip crumbs flying around. We taught him how to place the entire chip in his mouth without making crumbs.

Be sure to tune in tomorrow to see how Jackson handles going to the mall when he cannot eat his favorite Auntie Annie pretzels!

 

 

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Feeding therapy has been going great. So well, in fact, that one of our clients has transitioned to eating at home with his mom! Two other clients are eating with their moms at the clinic. Jackson is one of those two!

Kendal came in bragging about the standoff she had with Jackson the night before. When asked who won, she replied, “me, of course!”

Breakfast Day 2

Jackson started the day by generalizing his eating skills to a new therapist. Jackson ate gluten-free waffles, bacon, blueberries, and hash browns. He also started working on cutting his food. He consumed a total of 36 bites.

He engaged in only 21 verbal or vocal behaviors and only 1 attempt to elope.

Lunch Day 3

At lunch, we transitioned Kendall in to the driver’s seat. She supervised Jackson as he ate tuna sandwich on gluten-free bread, apple slices, and salad with dressing. His sitter, Chardonnay, made humus and he ate that with cucumbers and corn chips.

During lunch, Jackson realized that his mom was “in on it”. He cried for the first time. In fact, he cried 26 times. He laid on the floor and he refused to eat for 3 minutes. He also engaged in verbal/vocal refusal a total of 26 times. But, he continued to eat. He ate a total of 53 bites of food with only 1 gag and 4 expels.

At one point, Jackson reached out to grab his mom and she showed him her open palm indicating that he could push his chin on her hand for deep pressure. He pushed his chin into her hand over and over. He leaned back up in his chair and was ready to eat again. Kendall looked around at her fan club (therapists, interns, and sitters) with tears in her eyes. Then she said beneath her tears of joy, “In the past he would have attacked me.”

Dinner Day 3

Kendal and Jackson came back for dinner with baked ham and pineapple, baked sweet potato, raisins, and green beans. In this meal, he didn’t cry, not even once. Instead, we saw the opposite. Jackson was happy and laughing and felling wonderful. He ate a total of 58 bites. He engaged in 10 verbal and vocal behaviors and he pressed on his eyes a few times. He did not try to elope and he did not gag at all. He tried to expel just one bite. He started engaging in some eye pressing but we coached Kendall how to interrupt the behavior without calling attention to it.

As if all this learning was not enough, Jackson learned how to drink from a straw! A few years ago, he knew how to drink from a straw but he lost the skill. Using coconut milk, a newly acquired beverage, Jackson quickly re-mastered it!

Day 3 was a continued success. Check back tomorrow to see how Jackson handles eating with his brother, going to the mall, eating at a restaurant, and having Dad observe.

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The feeding clinic was busier than we had expected (or perhaps we were too ambitious to think we could post every day). So, we will post Jackson’s daily progress each day this week.

For starters, we could not believe all of the progress that our clients made in the first 2 days. By the end of day 2, three children were eating well! One child was having severe withdrawals from his gluten and dairy. If you have not heard of this (his physicians had not either), you can read more about what another little girl went through as she came off her addicting Sonic Grilled Cheese here. The other little boy who is still struggling to eat has a combination of physiological (he has oral motor delays) and non-physiological feeding difficulties (behavioral issues around food preferences for flavor and texture).

Changing Reinforcers

Meanwhile, we tried to move Jackson from fluff to a different, more natural reinforcer. Jackson loves Lay’s potato chips so we tried to see if he would eat new foods in exchange for a few chips. Again, Kendall had to keep Jackson from having chips during other times of the day and this is not an easy task but she was a champ and she made it happen.

Breakfast Day 2

Jackson had gluten-free pancakes, sausage, strawberries, and grilled tomatoes for breakfast. He consumed a total of 30 bites. After the 8th bite, we began requiring Jackson to eat 2 bites before he could get his reinforcer. As his food acceptance and consumption increased, his behaviors decreased. He expelled only 4 bites, he tried to elope only twice, and he had only 12 instances of aggression towards Missy. Jackson engaged in 9 instances of verbal and vocal refusal and he engaged in 8 instances of physical refusal. How many adolescents do you know who will eat grilled tomato for breakfast? What a champ!

Lunch Day 2

Lunch on the second day of therapy included coconut milk yogurt with gluten-free granola, ham sandwich with gluten-free bread, oranges, and gluten-free cookies for dessert. Jackson consumed another 30 bites during lunch. He expelled food on 9 times but he did not elope at all. He stood up once as if to elope but he sat down when Missy asked. Jackson had 2 gags during lunch and both were with oranges. Fruit has proven to be hard for him. This is probably due to its wet texture. Jackson has dyspraxia so he obviously has some oral motor issues as well. He is learning to chew and keep his lips closed but this will take continued practice.

Jackson engaged in 20 instances of verbal and vocal refusal and 12 instances of physical refusal (e.g., turning his head or pushing the spoon). Jackson started a new behavior of bouncing up and down in his seat. It was unclear to us if this was a new avoidant behavior or if he was happy about learning to eat these new foods. He engaged in this behavior 22 times.

Dinner Day 2

For dinner on the second day of therapy, Jackson ate cooked carrots, white rice, chicken, and grapes. He ate 3/4 of an entire chicken breast, a portion of rice, and several carrots. After dinner, Jackson ate a gluten-free cupcake with dairy free icing. In the past, he only wanted to lick the icing so Kendall wanted him to learn to eat the cupcake and icing together. He ate about 1/2 of the dessert.

Jackson’s behaviors improved dramatically for this least meal of the day. He engaged in only 1 vocal refusal. He stood up 3 times (but he sat down when asked). He tried to take Missy’s gloves off once (as if to finish the meal). Jackson gagged only once during this meal (over the carrot). After the first 8 bites, we moved Jackson to a fixed ratio schedule meaning that he had to eat 3 bites of new food before he could have a chip.

Jackson’s sitter, Chardonnay learned to help with data collection during this session (thanks for the help–any chance you want a job?!?!). Meanwhile, Kendall will learn to implement the intervention tomorrow. Stay tuned to see how Jackson progresses!

 

 

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We have completed the first day of our intensive feeding clinic. Needless to say, teaching 5 children to eat over the course of the day adds up to 15 meals in the day. Between two people, it is exhausting. All we can say is “Thank Goodness for staff who are there to assist!”

Thanks!

Thanks to Dr. Tom Zwicker and The Eastern Seals for hosting the clinic.

Thanks to Yolanda, Applied Behavioral Strategies Office Manager,  for bringing us lunch.

Thanks to Maria, Applied Behavioral Strategies intern for taking data.

Thanks to Laura for videotaping, assisting with data collection, serving as a generalization therapist, and for all around good emotional support.

Thanks to the parents for having faith in us to help your children. And thank you Kendal for bringing the strawberry fluff!

Focus on Jackson

As much as we would love to share the stories of all of our clients, we are going to focus on one client for the entire week. We are going to introduce you to Jackson and his mother Kendal.

Jackson is an adolescent male with autism. Jackson is about 5’9″ and weighs about 120 lbs. He towers over Missy and he is eye-to-eye with Rebecca.

Jackson is mostly non-verbal and he has only a handful of words and word approximations in his vocabulary. Let’s get this clear, the boy can say “NO!” as plain as day! Jackson can also type and spell and he has a fairly large and accurate written vocabulary.

Jackson: Breakfast

Jackson greeted Missy with his upbeat “NO!” and he used that word for everything including following simple instructions such as “sit down” and “it’s time to eat.”

When they entered the therapy room, Jackson continued his cordial behaviors by grabbing Missy by the hair on her head (what little she has). He also attempted to shove her so that he could escape the room. You should see Missy hold her own against someone bigger than her!

It’s All About Reinforcement!

Then, Kendal whipped out the strawberry flavored fluff. Instantly, Jackson sat down and indicated his interest in this new activity. (note: parents know their children! Kendal knew that Jackson would work for Fluff–and he can almost say “fluff”).

Jackson was not happy about this new arrangement. He was not interested in eggs, Gluten Free toast, breakfast potatoes, or watermelon. He tried to pack up his mother’s things to GET OUT! He turned off the iPad. He turned off his communication device. He wanted no part of this—until the fluff. Missy told him, “Want fluff? Then eat. First egg, then fluff”. Jackson thought about it. He had not had fluff in quite a while thanks to Kendal’s determination to help her child. HE WANTED THE FLUFF! So, he accepted the egg. In it went, out it came. He accepted the egg again, and again. Finally, he chewed it and swallowed it. SUCCESS! Then Jackson savored his fluff.

Missy repeated this with each of the remaining foods. First take a bite, then fluff. In behavior analysis, we call this DRA or differential reinforcement of an alternative behavior. The alternative behavior is eating (instead of food refusal). This is also contingent reinforcement. When Jackson eats, he receives the preferred item instantly.

During breakfast, Jackson grabbed Missy’s hair multiple times (10-15 is the best guess without looking at the data sheet). He also attempted to elope multiple times. But the biggest success is that Jackson ate new and healthy foods for the first time in many years!

Jackson: Lunch

Jackson did not want to come back for lunch. He typed on a phone notepad: car, lays potato chips, fluff. Jackson knows what he wants! And given his size and challenging behaviors, he often gets it.

For lunch, Missy used the same intervention. Jackson at a turkey sandwich. His first sandwich EVER! This time, Missy started increasing the demands. She expected Jackson to eat two bites before receiving fluff. Within this same session, she was able to get Jackson to eat three bites of new foods before eating fluff.

During lunch, Jackson grabbed Missy’s hair less and he attempted to escape less.

Jackson: Dinner

Jackson ate a hamburger, broccoli, mashed potatoes, and cantaloupe for dinner and he drank coconut milk! Missy continued to increase the expectations and she decreased the size of the fluff bites.

During dinner, Jackson grabbed Missy’s hair only once and he did not attempt to elope until the end of the meal.

What an amazing first day of therapy for Jackson! Check back tomorrow to see how Jackson responds to Day 2 of intensive feeding therapy.

 

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We hope that you all are enjoying your summer as much as we are enjoying ours. We have each taken time off to spend non-work time with our families. Time off means that our blog suffers. Despite our absence, we truly appreciate the fact that readers are continuing to visit and have not given up hope on “fresh posts”.

This week we are going to do something a  little different. Historically, we have used our “What Works Wednesdays” to focus on our clinical success stories. Since we are running a clinic for intensive feeding therapy this week, we are going to take one of our clients, and highlight his/her progress each day.

Please check back each day for a brief summary of the child’s progress from the previous day. We think the results will surprise you.

 

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Hi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question comes from a parent whose child received treatment from us for feeding problems. The parent writes:

Hi Missy, James is doing well following feeding therapy. We couldn’t be more thrilled. Do you know if eczema is associated with milk? We ask because James had horrible eczema. Once we weaned him off the milk as you suggested, his eczema cleared right up.

Thanks for the update on James! We love hearing how great our clients do following treatment for feeding therapy! Maybe we will feature James in an upcoming What Works Wednesday!

As much as I would love to give you a definitive answer, medical conditions such as this are out of my scope of practice. Some people such as medical professionals at the Mayo Clinic, claim that the reasons for eczema are unknown. However, the UK Dairy Council suggests that milk may be directly associated with eczema. Other groups such as Talk Eczema suggest that dairy is associated with eczema.

I can tell you that I have met a number of children in our practice whose medical conditions improved as a result of moving some type of food. For some children, removing milk improved sleep whereas for others removing milk stopped seizures. But I also know from my clinical experience that other foods and allergens may be guilty culprits. Foods like gluten, soy, peanuts, seafood, and other allergens like pet dander, pollen, and mold have all been associated with eczema.

The best strategy is for you to remove one food at a time. Because Jack’s eczema cleaned up when you removed milk, chances are milk may be the evil substance for him.

If you have a behavioral question for me email me directly at askmissy at applied behavioral strategies dot com. Thanks!

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Hi and welcome to Ask Missy Mondays where I respond to a question from readers regarding a behavioral problem. Recently, Rebecca and I were contacted by a parent who is struggling with their child’s picky eating habits. She desperately wanted her child to receive feeding therapy and she 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 available to participate with her child.

Need Summer Feeding Therapy

Unfortunately, this mother is not alone. We have been contacted by 6 or 7 other parents who are desperately seeking services and they need the services this summer. Addressing feeding behaviors during the summer offers many benefits.

  1. Children are often out of school
  2. Parents may have a modified work schedule during the summer
  3. Many outdoor activities are available to get children out of the house and distract them between meals

Summer Clinic

As a result of these requests, Rebecca and I have decided to offer a summer feeding clinic. We have teamed up with Dr. Zwicker at The Easter Seals in Stamford. Their office will supply the space for therapy and Rebecca and I will provide the therapy.

Clinic Versus Home Therapy

In the clinical model, we run two concurrent feeding sessions each hour. Rebecca is 1:1 with a child in one room and I am 1:1 with the child in another room. We generalize therapy from us to one and/or both parents as well as any other individuals in your child’s life (e.g., speech therapist, behavior therapist, grandparents, or nannies). We also generalize therapy to community settings such as a restaurant or to your home if you live near Stamford.

Additional Information

The clinic is set to run from August 13 through August 17. During that time, your child will receive up to 15 sessions including generalization sessions to restaurants or home. Sessions also include parent training. The cost for the feeding clinic  includes the intake and record review, an exit report, and any follow-up consultations that are needed after therapy has finished. We require parent participation at every session. We also make accommodations for other individuals to participate as often as they are interested and available (e.g., spouses, grandparents, teachers, ABA therapists, etc).

Please contact us if you have questions or need additional information. We look forward to sharing the success of the clinic in our What Works Wednesdays postings.

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The ARI Conference was held this weekend in Newark, NJ. If you have never made it to an ARI Conference, you should put it on your list of things to do if you are a parent or caregiver of someone with autism.

The Conference Overview

The conference offers practitioner seminars on Thursday and Friday. A nutrition session is available on Saturday. Then, there is a General Session available on Friday, Saturday, and Sunday. This year, an adult track was offered on Sunday. If that is not enough, the conference also offers free workshops on Thursday and Friday evening plus Demo Room sessions are available throughout the day on Friday, Saturday, and Sunday. Plus (yes, there is more) there are many wonderful exhibitors including TACA, Autism Speaks, and Nourish Life, the makers of the Speak supplement (just to name a few).

Learning in Action

As a practicing behavior analyst with many years of education and experience “under my belt”, I (Missy) continue to learn something new at each conference. This year:

  • I picked up a complimentary copy of Dr. Herbert’s new book, The Autism Revolution.
  • I also learned about the importance of seeds. Who knew that ground flax seed was such an excellent source of prebiotic in addition to fiber and Omega 3s?
  • I learned that acid reflux may not always be caused by overproduction of acid. In fact, it could be caused by under production of acid!
  • I also learned that nutritional deficiencies (e.g., zinc) can alter the way food tastes and smells. This may lead to picky eating which may exacerbate nutritional deficiencies.
  • I ran in to several families who have successfully graduated from one of our feeding clinics. I love hearing about client progress and maintenance!
  • Finally, I learned that rice may have arsenic in it!

Picky Eating Free Workshop

I co-presented on Thursday evening with Vicki Kobliner of Holcare Nutrition. We covered the topic of dealing with picky eaters, a problem we see in as many as 50% of the children with autism. Vicki talked about the importance of evaluating any underlying medical issues before starting feeding therapy. This includes things like reflux or constipation. Vicki also talked about the importance of assessing for nutritional deficiencies and food allergies prior to starting therapy. I presented on the behavioral procedures for getting children to eat. This included changing antecedents to make sure the child is hungry, teaching new behaviors such as sitting at the table to eat, and changing consequences such as reinforcing children for trying new foods.

Who is in charge?Challenging Behavior Free Workshop

I presented on how to address challenging behavior on Friday evening. In this workshop I helped participants understand that behavior is supposed to be addressed through the IEP process. I helped them learn what to look for in an FBA. I taught them how the FBA is used to develop an IEP. The participants learned how to develop a BIP together with school staff and behavior analysts. This included learning to modify the antecedents to prevent the behavior from happening, teaching a replacement behavior such as communication, and changing the consequences so that we stop reinforcing challenging behavior.

Pill Swallowing in the Demo Room

I taught several parents how to teach their children to swallow pills. I taught them to use a stimulus fading approach so that their child learns to swallow small things without chewing. Over time, the objects get bigger until they are swallowing placebo capsules. I enjoyed my time in the demo room where other practitioners taught parents how to shop safely for gluten free and dairy free products, how to inject B12 shots, and how to prepare for your doctor’s appointment.

Education Plans

On Sunday, I taught parents how to make the most of their educational programs. Children under the age of 3 have different rights and policies than children over the age of 3. It is important for parents to know their rights so that they may advocate effectively for their children. Parents learned about a few resources to help them in this process. Some of the resources included COPAA, PACER, NICHCY, and Wright’s Law.

If any of my readers attended and want to chime in, please comment about what you learned or what your favorite part was. Mark your calendars for the fall conference to be held in Orange County October 11-14, 2012.


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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?

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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 “Jack”. Today’s post is slightly different from previous posts because it was written (and illustrated) by Jack’s 8-year-old sister. Please note that Jack and his mother participated in feeding therapy for a total of 5 days.

Before!

Oh no! Mom is trying to feed Jack mush, but Jack is crying, hitting, and pushing the spoon away!

Now!

Yay! Mom is turning on Wonder Pet Shows on the iPad and putting cookies and parsnips on his plate and Jack is feeding himself!

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