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Posts Tagged ‘behavioral feeding therapy’

Technically, Jackson met our requirements for graduation at breakfast on the 4th day. He successfully ate breakfast with his mom and his brother and he engaged in almost no challenging behavior. However, before we discharge, we like to make sure that our clients can generalize their behaviors to school or to a community restaurant (or both!). So, we used Friday to work on generalization.

Pretzel’s at the Mall

Kendall told us that one of the most difficult times had been when they went to the mall and Jackson tried to get pretzels. Since starting the gluten-free diet, he would not be able to eat those pretzels and she worried that he would have a tantrum if she told him no. So, we agreed to meet her at the mall to work on an intervention.

Jackson walked right past the pretzels to meet us in the middle of the mall. However, when we arrived, he took off walking. He was a man on a mission! He went straight for the pretzels. We told him “no pretzels today, we are going to eat lunch”. He grabbed his communication device and typed out “PRETZEL”. We affirmed his request and simply restated that we would not be having a pretzel but instead we would go to lunch and he could eat pizza (we had already selected a gluten-free pizza place). We showed him the picture of a pizza.

Jackson took off walking through the mall. He had one things on his mind: Pretzels! After circling the mall and arriving at the pretzels again, he walked over to the display and pointed. We reminded him again that we would not be having pretzel and that we were going to lunch. With that, he decided it was time to leave and he proceeded to his car.

Well that seemed a little too easy.

Planet Pizza

 

When we arrived at Planet Pizza, the manager was restocking the chips. Yes, you remembered correctly. Jackson has a thing for Lay’s potato chips. He was super excited! He went over, picked up a bag of chips and appeared happy as a clam. We reminded him that he was here for pizza and not for chips. We asked him to put the chips back. At first he was reluctant but we remained firm. Please put the chips away, we are going to eat pizza. Jackson put the chips away and we asked him to pick out a drink.

Prior to starting feeding therapy, Jackson only drank water. He drank water out of a faucet and out of the Long Island Sound. Wherever he could find water, Jackson drank it! We told him, “No water today, pick something else.” He told us no but we held up two types of juice and he picked one.

Then we escorted him to find a table while the pizza cooked.

  1. Note: Kendall brought her own dairy free cheese and the staff cooked the gluten-free crust with the special cheese.
  2. Note: Bring things to do in restaurants while you wait!

While we are great at helping kids in the community, we have so much knowledge and training that we have a hard time remembering to teach the parents all that we know. We forgot to prep Kendall for the things that Jackson would need to keep himself busy. Luckily, we had iPhones so he tried to watch YouTube while waiting.

Jackson made a few noises during his wait. Unfortunately, restaurant patrons stared at us. The staring makes all parents uncomfortable. We let Kendall know that bringing Jackson out actually helps to educate others. Plus, Jackson has every right to be there too!

Success

The pizza arrived after only a 15-minute wait but then we had to wait for it to cool. Finally, Jackson could try pizza for the first time in many, many years. He loved it! He didn’t mind the spinach or the broccoli. He even picked up his fork and stabbed a few pieces on his own. He ate the entire piece that Kendall had prepared for him. He did this without aggression and without any expels!

Jackson still has some skills to work on:

  • cutting his own food
  • stabbing his own food using the fork
  • scooping his own food with a spoon
  • learning to wait quietly at restaurants
  • wiping his mouth with a napkin without reminders

However, he has come a tremendous distance in only 5 short days. Congratulations Kendall on all of your hard work. Jackson is a champion eater and you are a champion mom!

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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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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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It occurred to us one day not too long ago, that parents are turning to the internet when they need help with something. This can include searching for help on getting pregnant, cooking delicious low-fat meals, training pets to stop barking, and many other things.

Then it hit us! People may be searching for help when their child won’t eat! We have been posting success stories from our clinical practice regularly in our “What Works Wednesday” posts. Several  of those posts include success stories from our behavioral feeding therapy. For example:

  1. We had the little girl who only ate Sonic grilled cheese sandwiches (we recently had a little boy that only ate Sonic grilled cheese too! Maybe they should meet up!)
  2. We described a little boy who would only eat bacon and rice waffles.
  3. We introduced you to our hardest clinical case, a little girl who would only eat peanut butter, pretzels, and jalapeno chips.
  4. We helped an adolescent boy who had suffered from 9+ years of picky eating.
  5. We shared the success of our first intensive case.

Clearly, behavioral feeding therapy works!

For those of you who stumbled across our site because your child won’t eat and you need help, you’ve come to the right place! Help is available for you and your child. You just need to know how to find it. In order to find help, you need to know what you are looking for. For starters, why is your child having difficulty with feeding?

  • Was he born prematurely and everything has been hard?
  • Does your child have gastrointestinal issues (e.g., having trouble with bowel movements or having too many)?
  • Does your child have a feeding tube or did he have one in the past?
  • Does she have an identified disability that may be contributing to the problem (e.g., Down syndrome, Cerebral Palsy)?
  • Has your child ever been treated for reflux?
  • Does you child have a structural problem such as a cleft lip or swallowing difficulty?
  • Is your child allergic to certain foods?
  • Does your child have preferences for certain brands, colors (or lack thereof), or textures?
  • Is your child on the white diet (chicken, french fries, and chips)?

Assess First

If you are here looking for help, chances are, your child needs an assessment. Any good feeding program will complete an assessment prior to starting therapy. The assessment should be multi-pronged in that underlying medical issues should be diagnosed, potential mechanical problems (e.g., swallowing or chewing) should be pinpointed, and any nutritional deficiencies should be identified. In addition to those areas, a good behavioral assessment is also warranted. While your child could have developed a feeding problem because of an underlying medical or mechanical issue, he or she may have learned to control mealtimes.

Is Feeding Therapy Warranted?

If you learn from the assessments that your child is medically, mechanically, and nutritionally OK, you may not need a treatment program. We generally say that if a child is eating 30 or more foods, that the problem is minor and can most likely be addressed with due diligence. We will post some helpful steps that you can do to help if you believe that your child’s case is minor.

If your child has limited himself to fewer than 30 total foods, or she has limited herself to only one type of texture (e.g., puree only or liquid only or crunchy only), if your child engages in inappropriate mealtime behavior such as aggression, self-injury, or disruption, or if your child is really behind on the height and/or weight chart compared to other children in the same culture, a feeding program may be needed.

Treatment Planning

Once a comprehensive assessment has been completed, and it has been determined that feeding therapy is necessary, it will be important to develop a treatment plan. Depending on the results of the assessment, your child may need regular and on-going therapy to learn to chew. She may need medication to treat inflammation in the GI tract. He may need to go on a special diet due to a food allergy. The results of the assessment(s) will drive the treatment.

Parent, Family, and School Involvement

A good feeding program will work collaboratively with the parents, other family members, and school personnel as needed. Feeding does not occur in a bubble but in many environments. Thus, everyone who interacts with your child during mealtimes should be involved in the therapy program.

Data Driven Program with Results

Finally, any quality program will have data documenting the effectiveness of their treatment. This may be limited to the success of your own child but it may also include success rates of graduates of their program. Do not be too shy to ask for this information. Embarking on a journey of feeding therapy is stressful, time-consuming, and expensive in many cases.

Of course, we would love it if you come to us for help. We offer a variety of feeding services including direct therapy with you and your child in the comfort of your home. Please check out our website for additional information about our services. You may also email us for information. Info at applied behavioral strategies dot com.

We wish you luck in helping your child eat. We know first-hand how stressful it can be.

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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 Boost (you will see why a bit later in this post).

Boost came to us with a long history of feeding difficulties and he was only 7. He was diagnosed with autism and he was also non-verbal. Boost had previously eaten food but only in wet ground form. By the time he got to us, he consumed only Boost and apple juice. Both liquids were consumed from a bottle with the top of the nipple cut off so the liquid would literally pour into his mouth.

Prior to any behavioral feeding therapy, we require a thorough record review and assessment to assess for any possible underlying issues. (Honestly, all intervention programs should be preceded by a thorough assessment to help with program planning. We have written about that previously here.) For Boost, we completed a record review to determine if any assessments were needed prior to therapy. Boost had a long history of gastrointestinal (GI) issues so we referred his family to a gastroenterologist for a thorough work up.

The gastroenterologist completed an endoscopy during which the gastroenterologist inserted a pill camera to complete an assessment of the entire small bowel. He discovered that Boost had serious inflammation in his GI tract. Specifically, Boost’s pylorus was so inflamed that even the pill camera would not pass. You heard us correctly. A tiny pill camera would not pass through his pylorus. And we all wondered why he had limited his calorie consumption to a pure liquid diet.

You see, Boost was non-verbal. He could not tell us that he had GI pain. He could not tell us that it hurt to eat. Had we started therapy without the GI Assessment, we could have caused Boost a great deal of pain. This case is an excellent example for demonstrating the importance of assessment prior to treatment.

The GI Doctor placed Boost on an elemental formula and anti-inflammatory medication so that Boost could obtain appropriate nutrition while allowing his GI tract to heal, a process that took 6 months.

Parents, if you have a picky eater, please make sure that you obtain assessment in all areas to rule out underlying issues. Behavior analysts, do due diligence in the assessment process to ensure that you do no harm in your behavioral feeding therapy.

We would love to hear from readers. Please share what types of information you have gained from the assessment process prior to behavioral feeding therapy.

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Hi and welcome to “What Works Wednesdays” where we share a success story from one of our clinical cases. Our intent is to show readers how successful ABA can be.

Today’s post will be slightly different from our previous What Works Wednesdays. We received inspiration from a guest blogger over at Yeah.Good Times. If you don’t know Jillsmo, you should. She is a mom of two, blogger, and cartoonist. She is also funny. Before you go visit her site, however, be prepared to see foul language.

You Might Be an Autism Parent If

Anyway, Jillsmo asked Sunday, another mom and autism blogger here, to write a guest post. We should give you some background. If you tweet, you may have picked up on the #youmightbeanautismparentif. If you don’t tweet, you should know that many parents have been posting comments where they fill in the rest of the phrase (e.g., you might be an autism parent if your child is 8 and he still doesn’t sleep through the night.)

Picky Eaters

So, Sunday described her feelings about how someone responded to her comment about her picky eater. You will find her guest post here, and it’s called Your Child is Picky: My Child is Stalin. It is an awesome post. After reading her post (and the 57 comments about her post), I became very frustrated. Sunday’s child eats only 4 foods. Many of the commenters shared how their children also suffered from picky eaters. Then we completed some of our own research and clearly, we have a pervasive problem on our hands. Parents of children with autism are posting on websites such as CafeMom, Parenting, and MDJunction, in search of help for their picky eater.

Behavioral Feeding Intervention Works

How can children with autism get to a point where they are only eating 10 foods, 5 foods, or even 3 foods and yet no one refers them to a behavioral feeding clinic? Behavioral feeding intervention is effective. We just summarized a research review last week showing how effective therapy is. If you missed it, you may find it here.

However, intervention can only be effective if implemented. Thus, parents need to be referred to agencies with extensive training and experience in pediatric feeding disorders combined with a specialty in autism spectrum disorders. Many such programs exist. Obviously, we provide behavioral feeding services. The Center for Autism and Related Disorders (CARD) also provides behavioral feeding services, as does Clinic 4 Kidz. Each of these agencies have staff available to travel to your home to help you and your child overcome picky eating. Other centers are available but families will have to travel to them. These include Kennedy Krieger, The Marcus Autism Center, and the Cleveland Clinic to name a few.

Start Early

We also know that intervention works best when implemented as soon as possible. While we have treated children of a variety of ages, younger children respond more quickly because their behaviors are less engrained than older children. Physicians, teachers, and related service therapy personnel should refer families to help as soon as they notice a child limiting her foods.

Paying for It

Behavioral feeding therapy can be expensive depending on the type of program, how many therapy sessions are provided, and where services are provided. However, funding options do exist. First, try using health insurance to cover the costs. If that is denied, check with your state developmental services office to see if special funds are available for your child. Finally, if your child has an IEP or an IFSP, you may be able to write a feeding goal for your child and that goal will be used to design services to address your child’s feeding needs.

We know that having a child with autism is stressful. Having a child with autism who is also a picky eater is even worse. However, behavioral feeding intervention works.

Do you have a picky eater? Have you experienced behavioral feeding therapy? Tell us about your experiences.

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