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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. 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 post is a follow-up for a case we have described previously. You should read the original post first to gain a full understanding of how far this child and his family have come.

Many blogs do Wordless Wednesdays where they simply post a picture with no words. Yes, we realize we have already written words, but you need them to fully understand the photo. February marks one year since Nathan had behavioral feeding therapy. This is a picture from his meal from last week. As you can see, he is going strong! This meal consists of  artichoke hearts, roasted red peppers, Brussels sprouts, olives, brown rice, chicken, sausage, and garlic. What you cannot see is the side of broccoli steamed with lemon juice. Bravo Nathan! You are doing great and your mom and dad are an invaluable support team.

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Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from Bobby’s mom. In case you are new to our blog, we wrote about Bobby last year. You may read his story here.

Bobby’s mom asked,

“Bobby is over-stuffing his mouth with food and chewing for long periods. He is not swallowing, but adding more food until he can no longer add more. We ask him to swallow and we prevent him from adding more. Then he melts down and soupy, half-eaten food goes everywhere. A simple dinner is now lasting 2 hours and this has been happening for about the last 2 weeks.”

So, if you’ll remember from our previous post, Bobby is one of those kinds of children who like to control. It is important to prevent him from controlling the meals like he has done in the past. On the other hand, because this behavior is fairly new, it tells me one of two things:

  1. Is he sick or having a reaction to something?
  2. Is everyone in all environments following protocol? All it takes is for one person to let him get away with not eating and he will attempt it with everyone.

Assess

Before you start anything new, rule out underlying medical conditions. Is he sick? Does he have any cold symptoms? Has his bowel movements changed suddenly? (e.g., more constipated? looser? more often?) Does he have a rash or other physical sign of a reaction to something?

If all of that is clear and there is no underlying medical condition causing the behavior, then assess the environment. Is there a new teacher? a new assistant teacher? a new behavior therapist? Is everyone on the team following the protocol?

Intervene

Once you have completed your assessment, then it is time to make changes. The fact that he has been doing this for 2 weeks means that you need to intervene quickly so the behavior stops sooner and does not become engrained in his mealtime.

  1. I know it is hard but you (and school staff) will need to sit next to him for a few meals in a row until this behavior is back under control. Make sure that he takes an appropriate size bite. He does not get any more food until he finishes the first bite. Move the plate away from him if you need to.
  2. If he continues to chew slowly, then put on a timer and say, if you chew and swallow within 30 seconds, you can have ________. Then give him the reinforcer when he swallows. Do not give the reinforcer until the food is completely swallowed.
  3. Any food that is expelled must be represented unless it is contaminated. If it is contaminated then you need to replace the bite with an identical clean bite.
  4. Consider using a short picture schedule that shows:
  • small bite
  • chew
  • swallow
  • reinforcer

Fade Reinforcement and Proximity

As Bobby begins to experience reinforcement for appropriate behavior, you will begin to see an increase in appropriate behavior. This should also result in a decrease in the inappropriate behavior, especially when expelling results in an identical bite.

As Bobby is able to eat one bite, then put two bites on the plate and teach him to wait to take the second bite until he swallows the first bite. He will need to put the utensil down on the table while he is chewing. At this time, he will only receive tangible reinforcement when he chews and swallows both bites. Be sure to provide verbal praise when he swallows the first bite.

When he is able to eat two bites, then increase it to 3 bites on the plate. Begin fading the verbal feedback after the first bite and move to verbal feedback after the second bite with tangible reinforcement after the 3rd bite. If he can safely eat 3 bites without assistance and without stuffing, then begin fading the proximity of the helper.

Good luck and please let us know how it goes!

If you have a question about behavior, email Missy at askmissy at appliedbehavioralstrategies dot com.

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Hi and welcome to Ask Missy Mondays where I respond to email questions from readers who have questions about behavior. Today’s question comes from a team of professionals who provide feeding therapy to children who are struggling with eating. The team writes,

“Hi Missy, we run a feeding clinic and have recently been receiving calls from a number of parents with very young children. How young is too young to start feeding therapy?”

I thought this was a great question but I wasn’t sure that I had enough information. So, I emailed back and asked them to elaborate. Specifically, what ages are the children? The team responded,

“Well, one child is 11 months old and the other child just turned 2.”

I was stunned. It broke my heart to learn that a mom was struggling with such a very young baby. My first response was that 11 month old clients are still, technically, infants. Thus, my recommendation was for the mother to seek support from her pediatrician or even mid-wife. Of course, the team should recommend a good nutritional, gastrointestinal (GI), and allergy work up. If, after all of those referrals and support, the mother still struggled with feeding, perhaps the child and parent could attend behavioral feeding sessions. However, I would want to exhaust all support services for infants before starting services that are primarily targeted for preschoolers.

We have treated several two year olds in our clinic. However, each client approached or celebrated their third birthday during clinic. Additionally, we modify our intervention strategies slightly due to their young age. There is a big developmental difference between a 34 month old and a 24 month old. So, I urged the team to use caution.

Assess

First, teams should carefully assess all participants prior to commencement of feeding therapy. This is especially true for very young children. The assessment should include a thorough record review of the medical history including assessing for any history of reflux or other GI issue. Swallowing function should be assessed by an appropriate professional. Chewing function should be assessed to ensure that the child knows how to manipulate food appropriately in his/her mouth without choking.

Rapport

Given the child’s young age, the team should first establish rapport with the child so that he/she feels comfortable with each therapist. Second, the child needs to feel safe in the therapy environment. Of course, his/her parents should be present at all times. Finally, be sure to include play time before and after therapy so the child maintains positive associations with the environment. We recommend providing services in the home if possible. However, if not possible, the clinic area should be modified to meet the needs of very young toddlers.

Instruction

The team should take some time to teach the child some basic compliance skills like gross motor imitation, singing songs, or playing together on the iPad. Once the child has demonstrated an ability to follow basic instructions and he/she has learned that fun things happen following compliance, then it is safe to begin therapy.

Feeding Therapy

Staff should take care to utilize child-friendly approaches during feeding therapy. Staff should never trick the child to eat or sneak food in when he/she is not looking. Staff should, instead, focus on teaching the child to tolerate new foods and to pair new foods with reinforcers such as hugs, cheers, high 5s, and even songs or games on the iPad.

Good luck helping those very young children. We know that the sooner you start, the better the long-term outcome. Please keep us posted on their progress. We know they are in good hands!

If you have a behavior question that you need assistance on, please email: askmissy at appliedbehavioralstrategies dot com.

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We try to review a research article each week. Today, since one of us is conducting a 4-hour workshop on feeding in Dubai, it seems appropriate to review a study related to feeding. William Sharp and his colleagues at Marcus Autism Center (David Jaquess, Jane Morton,  and Caitlin Herzinger) authored the study titled, “Pediatric Feeding Disorders: A Quantitative Synthesis of Treatment Outcomes”. The Journal Clinical Child and Family Psychology Review published the study in 2010.

Literature Review

This paper is a literature review or literature synthesis. In research papers like this, the authors search for all the studies on a particular topic and then they analyze the results collectively and use those results to make treatment recommendations. These authors did just that. They identified the topic of interest and consulted a search on all studies of treatment for severe food refusal or selectivity. We have written about this topic on several occasions because many of the children we see have food selectivity (where they will eat only a few things) in addition to their autism. You can read more about our case studies here, here, or here.

Food Refusal and Food Selectivity

The Journal publishing this paper, is a peer-reviewed research journal. This means that a review panel of experts read the paper and deemed it scientific and valid. Thus, the authors only included studies in the review that utilized strong experimental control or what you, as readers may call, a good experiment. With these criteria in place, the authors identified 46 published studies wherein a total of 96 children received treatment for food refusal or food selectivity.

Outcomes

The authors noted that the majority of studies in the review had been published after 2000. Many of the children in these studies were male and most had a developmental issue of some sort including global developmental delay or autism. Over half of the children in these studies also had an underlying medical condition including Failure to Thrive (FTT), Gastroesophageal Reflux Disease (GERD), and gastrointestinal problems. Treatment occurred in hospitals, homes, schools, and outpatient centers and was provided by highly trained therapists. The majority of studies reported extremely favorable outcomes (large effect size) for participating children. Authors reported other positive changes such as a decreased need for tube feeding, complete removal of tube feeding, weight gain, discontinuance of bottle feeding, and improved consumption.

Behavioral Therapy

The authors reported that for all reviewed studies, researchers used a behavioral approach to feeding therapy. The authors noted that they could not locate any well-controlled studies utilizing other treatment methods.Within behavioral treatments, the authors noted that escape extinction (not getting out of the non-preferred bite) was the most widely used treatment with over 83% of the studies utilizing it in some form. Non-removal of the spoon and physical guidance were also used to prevent escape or avoidance of non-preferred foods. Also within behavioral treatments, authors used differential reinforcement of alternative (DRA) behaviors. Specifically, when the child engaged in eating, he was provided with a reinforcing toy, game, or possibly even food.

Recommendations

The authors of the review noted the continued support for behavioral treatment to address food refusal and selectivity. While a great number of studies utilized escape extinction procedures, it should be noted that the authors reviewed the literature on severe feeding disorders. As such, milder cases may not require the use of escape extinction. In our practice, many of our children arrive eating 5 foods or fewer. In our opinion, that is a severe situation and prompt treatment is warranted.

The review authors also point out that escape extinction was never used in isolation but was rather, a part of a complex package of intervention treatments. This is also important because we know from other research that extinction alone can result in an increase in problem behaviors and that when extinction is paired with reinforcement, the severity of the behaviors is reduced.

We want to hear from you. Did your child participate in feeding therapy? Were behavioral procedures used? Was feeding therapy effective?

If you are interested in behavioral feeding therapy, we offer this service in the convenience of your home. We also collaborate with your child’s school and ABA team to ensure successful maintenance of behaviors following intervention. Please contact us for additional information: info at appliedbehavioralstrategies dot com.

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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.

Nathan

Today’s success story is about a little guy named Nathan. At the time of intervention, Nathan was 6. Nathan had beautiful black hair, a heartwarming smile, and a contagious belly laugh. Nathan also had a pretty healthy belly–his nutritionist diagnosed him as obese. So, you ask, how could a picky eater be obese?

We cannot answer that question. However, we can tell you that Nathan was diagnosed with a genetic deletion syndrome as well as autism. Nathan demanded food at all hours of the day. If his parents did not feed him, he screamed, tantrummed, and hit himself in the head (also known as Self Injurious Behavior or SIB). When his parents offered him a non-preferred food, the tantrum and SIB worsened. As parents, they did not know what to do so they fed him preferred foods.

Nathan’s mother reported that Nathan would wake as early as 3 or 4 demanding food. He had never slept through the night. As you can imagine (or possibly even relate if you are a parent of a child with autism), this lifestyle caused a great deal of stress for Nathan and his family.

Given the presentation of demanding food at all hours of the day, combined with the fact that he was overweight and had low tone, we first suspected that “little” Nathan had Prader Willi Syndrome. However, his mother reported that he had been tested for this condition on more than one occasion and doctors had confirmed this was not the case.

Before Our Therapy Started

Nathan had been receiving feeding therapy for about 2.5 years from a speech therapist who specialized in feeding disorders. Nathan also had feeding objectives in his IEP. However, Nathan failed to make progress in eating a variety of foods. Thus, his mom contacted us. Prior to our services, we suggested that Nathan be seen by a nutritionist. As part of the services there, the nutritionist discovered that Nathan had a milk allergy. Nathan’s mom stopped all dairy products the weekend before we started therapy. Nathan was not happy about this change so you can imagine his distaste when he discovered that we had additional plans for him. Surprisingly though, Nathan immediately started sleeping through the night once dairy was removed! (Since Nathan started a dairy free diet, he has experienced a couple of dairy infractions. Each time this occurred, Nathan awakened during the night.)

Our Therapy

We originally scheduled 5 days of therapy with three one-hour sessions each day (one for each meal). However, Nathan was sick on the first day so we postponed therapy leaving 4 days of scheduled therapy. (More therapy is always provided when necessary.) We started therapy by finding a highly preferred item that Nathan wanted to work for (interactive book on the iPad). This is also called a preference assessment. We allowed Nathan to play with the item and then we removed it and told him that when he tried his new food, he could have the item back.

At first, we only asked Nathan to touch the new food to his lip. This is called shaping. Nathan screamed, cried, and attempted to hit himself in the head. We simply blocked the behavior from happening by inserting our hand between his fist and his head. He also attempted to bang his elbows on the table. We blocked this behavior as well. Soon, Nathan decided that he should put the food to his lip and we praised him and gave him access to his iPad book. After a few trials, Nathan decided that the new food was not so scary and he ate it. Soon, Nathan was willing to try (and eat) all of the foods we presented to him. He continued to show his distaste for the new foods by screaming and crying. He also gagged a few times. However, it did not take long for him to realize that these new foods actually tasted good.

Generalization (Transferring the Behavior to New Situations)

Nathan’s challenging behaviors subsided and it was time to transfer therapy to Nathan’s parents. Nathan’s mom started therapy on the 3rd day of services. As we often see when the parents take over, Nathan attempted to scream, cry, and hit his head. His mom knew how to block the behaviors and she held strong. By the end of lunch on the 3rd day, Nathan ate willingly with his mother so Nathan’s dad joined Nathan and his mom for dinner. For the first time, Nathan and his family shared a meal with all family members eating the same foods!

On the last day of therapy, Nathan and his parents celebrated by going out to eat. The family enjoyed a healthy meal free from challenging behaviors. The following week, we accompanied Nathan to school to show his teachers how to support him during lunch and snacks. Sadly, Nathan’s classmate brought in pizza for lunch. Poor Nathan! He could no longer eat his favorite food. He cried briefly but his teacher showed him the wonderful new foods in his lunch box and ate his meal. Over time, Nathan began enjoying healthy foods. In fact, we recently posted a picture of a meal Nathan ate when we dropped by for a visit 7 months after feeding therapy. Nathan ate grilled chicken, Texas Caviar, raspberries, blackberries, and grilled vegetables with no challenging behaviors. In fact, he is now learning to eat slowly without stuffing and he is learning table manners such as wiping his mouth and putting his silverware down between bites.

Way to go Nathan! You worked hard to learn to eat such healthy foods! Giving up milk was not easy for you. Give your mom and dad a huge hug for their support through this difficult phase! It was not easy for them either.

Side Note

We often see children in our clinic who have food sensitivities, allergies, and gastrointestinal issues. As such, we require the support and consultation of appropriately trained professionals prior to the commencement of feeding therapy. We see observable changes in behavior when milk or other allergens are removed from the diets of some (but not all) children. If you are interested in reading more about the Devil in the Milk, we found the book to be informative.

 

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Today’s post was developed in response to an article that originally appeared in the Austin American Statesman. You may read it here. You may read the original research article discussed in the paper here. This post is the original opinion letter that we sent to the editor at the Statesman. We were ultimately asked to shorten the letter and it appeared as a simple Letter to the Editor.

Ms. Roser’s recent article highlighting the Malloy and colleagues’ new study regarding gluten- and casein-free diets for children with autism spectrum disorders (ASD) puts special diets in the spotlight once again. Special diets are not new and they are not solely for children with ASD. In fact, special diets are necessary for many people.

For example, people diagnosed with phenylketonuria (PKU) require a highly specialized diet to prevent the development of mental retardation. PKU is a genetic condition wherein individuals lack an enzyme to digest certain amino acids. This is such a serious issue that every child in this country is screened for PKU via a heel prick at birth. Those who test positive during the test are required to follow a life-long reduced-protein diet.

A second example of a condition requiring a specialized diet is celiac disease. Those affected are allergic to gluten, a protein found in grains such as wheat and barley, and they must refrain from consuming gluten throughout their lifetime. Consumption of gluten can have many harmful side effects including anemia, osteoporosis, and intestinal cancers.

Finally, individuals with food allergies must also follow specialized diets. For those who are allergic to nuts, exposure to them may be deadly. Such was the case when a young woman with peanut allergies died after kissing her boyfriend shortly after he ate a peanut-butter-and-jelly sandwich. The most common food allergies for children include milk, egg, soy, wheat, peanut, tree nut, and seafood. If any of us had to give up these foods, particularly without effective guidance, we would feel restricted! Unfortunately, for people with food allergies, food restriction is the only way to prevent negative side effects.

Unfortunately, what Ms. Roser, as well as Malloy and colleagues, failed to mention in their writings was the fact that children with ASD often go on specialized diets because of gastrointestinal (GI), nutrition, and/or immune disorders, not because of the condition or diagnosis of ASD. The GI disorders that children with ASD often experience may be related to food allergies or intolerances, autoimmune conditions, or other environmental variables. Among physicians and psychologists who regularly treat individuals with autism, there is an understanding that such individuals may experience gastrointestinal disorders and lack the communication skills to express their discomfort. In response to this growing recognition, a team of 27 medical doctors and doctoral-level psychologists published a consensus report in the journal Pediatrics (Buie et al., 1/4/2010)”. The team stressed the importance of completing a proper and thorough work-up in determining the cause of GI symptoms for children with ASD. Instead of discussing the GFCF diet as a medical treatment for children with ASD, Ms. Roser, as well as Malloy and colleagues, imply that the specialized diets for children with ASD are designed to “normalize autism.” In fact, on page 4 of the Malloy paper, the authors actually state that they included only studies that examined “the amelioration of ASD symptoms.” It is no wonder their review of 14 studies found only 4 studies with positive effects from the diet; the authors excluded all the studies that examined changes in GI functioning!

To those parents of children with ASD, heed not the advice of the researchers who merely summarized a small set of studies. Instead, if your child displays symptoms of GI disorders (e.g., reflux, diarrhea, constipation, stomach distension, etc.) or other health concerns, schedule an appointment with a knowledgeable clinician for appropriate treatment of symptoms.

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