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Here at Applied Behavioral Strategies, our mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for our readers. Today’s article is titled, Intervention for Food Selectivity in a Specialized School Setting: Teacher Implemented Prompting, Reinforcement, and Demand Fading for an Adolescent Student with Autism (wonder if they could make that a little longer?). A journal called Education and Treatment of Children published the article and Maria Knox, Hanna C. Rue, Leah Wildenger, Kara Lamb, and James K. Luiselli authored it. (If you want to read the entire article, you will find it on www.freelibrary.com)

Background

Many children with autism engage in picky eating or what researchers call “food selectivity“. For example some children live on a white foods diet (chicken nuggets, french fries, and bread) while others remain stuck in pureed foods.

Applied Behavior Analysis (ABA) is one intervention that has been demonstrated repeatedly to be effective at addressing picky eating behavior. However, the intervention often results in challenging behaviors that make it difficult for parents and caregivers to implement on their own. In fact, most of the research to date has been implemented by highly trained therapists.

Purpose of the Study

Thus, authors set out to determine if an intervention could be implemented by school staff in the school setting.

Study Method: Participants

The authors enrolled one child in the study. “Anna” was 16 and had autism. She was verbal and she could follow simple instructions. Anna could feed herself. However, she limited her diet to  a few brand-specific crackers, dry cereal, and apple juice . During the study, Anna’s mother provided new foods including one main food (chicken nuggets, macaroni and cheese, or turkey and cheese sandwich) and two side foods (cheese cubes, vegetable chips, carrots, mandarin oranges, or apples).

The authors implemented all study procedures at the school in Anna’s lunchroom or her classroom. The teacher and the teaching assistants collected all the data for the study.

Study Method: Design

The authors used a changing criteria design which is one type of single subject design. In this design, the expectations are gradually increased across phases. Thus, the teacher required Anna to eat more and more food across the study.

In baseline, the food were presented. If Anna did not eat within 2.5 minutes, the food was removed. After 10 minutes, Anna was allowed to eat her preferred foods.

Study Method: Intervention Technique

The researchers taught the teacher how to implement the intervention prior to the beginning of intervention.

Prespecified Reinforcement (First-Then)

During intervention, the teacher presented the new food on a separate plate and told Anna when she ate the new food (small amount at first), she could have her preferred food.

Reinforcement

Additionally, Anna earned verbal praise and stickers for eating new food. Anna cashed her stickers in for small trinkets.

Prompts

The teaching staff verbally prompted Anna to eat her lunch, if, 30 seconds after swallowing she had not taken her bite.

Demand Fading (Increasing the Volume Slowly)

Gradually, the teaching staff increased the amount of food that Anna needed to eat in order to get her preferred foods.

Results

By the 23rd lunch session, Anna consumed 100% of the new food and she repeated this on the 24th and 25th lunch sessions. The authors came back to assess her eating 2 weeks, 6 weeks, and 7 months later. Anna continued to eat 100% of her new food.

Congrats to Anna and the research team on such a successful intervention. ABA works!

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How did Friday get here so quickly? School starts back for us next week so we are going to try to squeeze every last minute of fun time with our families. In wrapping up our description of a week-long feeding therapy “boot camp”, we thought this cartoon would be perfect! Thanks to Rick Detorie for the wonderful One Big Happy humor.

Readers, what strategies have you tried to distract your children while eating?

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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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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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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 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 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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