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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.

Today’s case highlights the struggles of a little peanut who reminded us of a cherub–hence the name Little Cherub. She was angelic, beautiful, and gentle (except when you asked her to eat). She was fair-skinned, fair-haired, and fair-tempered (unless you asked her to take a bite).

Little Cherub was a twin who developed normally until she was 18 months old. She once spoke 30 words–until she regressed in to autism. Then one day, the words started disappearing one by one. What a horrible nightmare for families to live. Our sympathy goes out to each and every one of you who have lived (or who are living that nightmare).

Not only did Little Cherub lose her words and her desire to live in our world, she lost all of her eating skills. She no longer loved salmon. She no longer enjoyed cantaloupe. In fact, by the time we got our hands on her, she had whittled herself down to just two foods. Yes, you heard us correctly–just two foods. Can you imagine the stress for her family? (yes, some of you may be living that stress right now.) She loved pretzels and she loved peanut butter. She drank her almond milk from a bottle and she refused to drink it from a cup (although she could drink water from a cup).

As if her case wasn’t hard enough, Little Cherub had been diagnosed recently with celiac. Celiac is a condition when a person cannot digest the protein found in gluten. If you are uninformed on this topic, you should know that gluten is found in almost every yummy food: bread, pasta, crackers, cookies, batter-fried food, and anything else with flour. Living a gluten-free (or GF) lifestyle is not that hard but it can certainly complicate matters–particularly when you only eat 2 foods.

Little Cherub’s parents agreed to have us come in to their home for a week of therapy. During that time, Little Cherub stayed home from school and focused on eating and toileting. Yes, we sought to address both eating and toileting because we have found in our practice, that children respond well when they are challenged. So, with that, we started both treatments on the same day.

The first day started with Little Cherub putting on her big girl panties. She had the cutest little panties–Hello Kitty and Cinderella. She was not particularly interested in her new panties though. We put her on the toilet and she didn’t produce. We made the mistake of putting her clothes on and turning our backs. Bam! She wet herself. We quickly rushed her to the potty and told her that pee goes in the potty. She did not produce since she had already peed it all out. So she got dressed and washed her hands. Oh yes, toilet training is a great time to work on those self-help skills because you get to practice them over and over and over.

Then she proceeded straight to breakfast. Little Cherub was somewhat confused as to why she wasn’t having peanut butter. She was angry when she found out that eggs were on the menu instead. During breakfast we tried to shape up a self-feeding response. We wanted her to pick up the spoon, touch it to her lips and put it back down. In return, she could watch her favorite movie, The Backyardigans.

We also threw away the bottles. If she wanted her almond milk, she would have to drink it out of a cup. She fought this for at least two days straight. It was almost as if the cup had cooties—except she drank water out of an identical cup. It made no sense to us either. We are certain that when she starts talking one day, she will tell us. None the less, the first meal was not easy but she soon figured it out. Breakfast lasted over an hour.

Next it was time to potty again. We had learned from her teachers that Little Cherub could hold it all day so we did not need to stop breakfast to potty. She did not produce after breakfast either. This time we kept our eyes on her while we waited for lunch. During this time she asked for pretzels and peanut butter. We simply told her that breakfast was over and that lunch would be soon. Then the crying ensued. She was clearly unhappy about these new rules.

We finally got her to pee on the potty after what seemed like hours (oh yeah, it really was hours). We sprinkled warm water down there and she made the connection. We gave her GFCF pretzels as a treat. She was happy. She managed to pee on the potty once each day and then she would have a soaker over night. This is pretty common when children are rigid and have already learned to hold it. Eventually, she will figure out that the only way she is going to get pretzels is to pee on the potty. By the time we left after 6 days (thanks to a snow storm that kept us longer), she had peed on the potty at least once each day and sometimes twice depending on her liquid consumption.

The feeding was turning out to be much more difficult. In fact, Little Cherub proved to be the toughest case we have had to date (we reserve the right to change that–though we hope to never meet anyone more difficult). As we said, on the first day, she was willingly picking up the utensil and touching it to her mouth. On the second day, she would willingly eat a food if it was mixed with the peanut butter. We were also successful at putting some food on a chip–a once favored food. However, after two days, she was still not interested in eating food that was not accompanied with another preferred food. So, on day 3, we got tough. We no longer allowed mixing foods. She needed to eat it plain. She put up an awful fight. You would not believe us even if you saw it on video. For a tiny little peanut, Little Cherub was fierce. She fought us for the first meal on Day 3 and then it was as if nothing had happened. She came to lunch ready to eat.

Thus, lunch and dinner on Day 3 were great. She was eating all the foods (we ask parents to bring 4 NEW foods to each meal–protein, fruit, vegetable, and starch). She was feeding herself all the foods. So, at dinner, Mommy took over with us coaching. She tried to fight it but she soon realized that Mommy was no longer playing the old way–she meant business. On the 4th day, Daddy did breakfast. It is funny because Little Cherub thinks she can convert people back to her world. That is until she realizes that they have been trained. No more peanut butter, no more pretzels. Uh oh.

During breakfast we discovered that Little Cherub does not like eggs. She fought and fought and eventually self-fed the eggs. (Sadly, even after 6 days, she was still not thrilled with eggs. Her parents will continue presenting eggs for a few more weeks before deciding if they are simply non-preferred).

Next, we were off to school. It is important to generalize these skills to new people. Remember, Little Cherub put up a fight for Mommy and then Daddy. You know she is going to fight her teachers. We arrived at school during snack. Little Cherub tried to eat her friends’ snacks! What a pleasant surprise! However, due to her allergies, she cannot eat her friends’ food. We started off the lunch session and after a few bites, we transitioned in her assistant teacher. Wouldn’t you know, Little Cherub decided to try out the fight again. Quickly she realized that all the teaching staff were “in on it” so she settled down and ate her blueberries, coconut milk yogurt, and chicken soup with carrots and chunks of chicken.

When the snow cleared and we could travel, we said our good byes. We arrived home to the most brilliant email. Little Cherub ate (and I quote you from Dad’s email), “Steak sautéed in onions, home fry style potatoes and onions, peas, and strawberry for dinner. She loved the steak and potato and asked for several helpings!” We wanted to know if she ate them willingly or if she put up a fight. To this, Dad replied, “she grabbed that steak like a hungry NFL lineman. I started with a few small pieces and she probably ate about 2 oz in total. I had to push with the potato for the first bite but that was her second favorite food of the meal”

Let’s pause to cheer for our Little Lineman. Way to go Little Cherub! Hats off to your Mom, Dad, Grandpa, Mimi, and wonderful teachers. You have the best army possible fighting for you. Mom and Dad, it was a wonderful journey. Thanks for taking us along for the ride.

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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 we want to introduce you to Jack. Jack was an adorable little guy about 6 years old. When we say he was little, we mean it. He did not even register on the weight chart for children his age. That means that 99% of all children his age weighed more than he did. Jack did, however, love Dora more than any other child we have met! He loved Dora so much that he was willing to do anything to get more Dora, especially after his mother took Dora videos away for a lifetime an entire week while preparing for feeding therapy.

Jack came to us because his mother was concerned about his height and weight. He showed signs of extreme food selectivity. He loved chocolate chip cookies, chips, and pepperoni. He was not interested in eating too much else. Jack also had food allergies. He was intolerant to gluten and dairy/casein which meant that his mother had to make special cookies for him to eat.

Jack received feeding therapy from Missy in 2007 while she was employed at CARD. Jack’s story is interesting because if it were not for him and his mother, we would have never developed our short-term, intensive feeding program that is so successful today. You see, Jack’s mother lived over an hour away from the office where feeding therapy was provided. She could not fathom the thought of driving back and forth for therapy each week for up to 6 months. So she challenged Missy. She said,

“Missy, you told me that intensive ABA is better for my child when it is provided at higher frequencies. Would the same thing hold true for feeding therapy? You told me feeding therapy is ABA to address feeding? So why wouldn’t intensity matter?”

So, thanks to Jack’s mom, we thought outside of the box to develop a model that works. Our sessions have changed a great deal since then, but the basic format remains. We started with 3 sessions each day; one session for each meal of the day. We also started using a simple shaping strategy. In behavior analysis, shaping is reinforcing successive approximations of the desired behavior. Initially, we didn’t ask Jack to eat the bite, we simply wanted him to pick it up the bite and touch it to his lips.

Sweet little Jack was, quite honestly, not happy about any of it. In fact, he refused to eat pepperoni and chips (his favorites!) for Missy. But Dora, oh that little Dora talked him in to it. For just 30 seconds of Dora, Jack decided that he would try the food. You see, Jack had not seen Dora for over a week (Thank you Mom!!!). This made Dora more appealing to Jack. So it did not take long for Jack to realize that the only way he was going to get Dora was to try it our way. Soon, Jack warmed to the idea of trying new foods, not just the chips and pepperoni slices.

Jack was funny in other ways too. I think the best part of the feeding therapy was when he picked up the bite, ate it, and then popped Missy on the mouth as if to say “There! That’s for you making me eat this yucky food!”

Jack went on to make great strides. He met the criteria for graduation in 5 days. On the 5th day, he was eating foods while his mother supervised. He tried to go back to his old ways but his Mom was too smart for that. She had observed every single session. She knew he could eat the new foods so she dug her heels in. She told him that he could not have Dora until he ate his food.

It is important for readers to know that ALL children, regardless of age, ability, or trait, have battles over food. When given the choice, many children would choose processed foods such as chips, crackers, and fast food, over health foods such as whole fruits, vegetables, grains, and proteins. So, even after feeding therapy is over for the picky eater or selective eater, work will still be required from time to time. Does that mean that former picky eaters should be denied access to tasty processed foods? No, not at all. The answer for follow-up to feeding therapy is moderation. Once the intensity of feeding therapy is over, the process of moderation begins. It is fine to allow your child to have chips. However, chips should be available 1-3 times per week rather than 1-3 times per day.

Thank you Jack and thanks to your mom for pushing us (and you) to new heights–literally (Now, Jack registers on the height and weight chart for children his age!)

Happy Eating!

P.S. Now that back pack song is stuck in my head!I will forever associate that song with you, Jack.

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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 we would like to introduce you to a cute little fellow named Mikey. Mikey was 33 months old when we started intervention. Mikey was a typically developing toddler in every way except for his eating. Mikey preferred to drink his milk and he drank lots of it. His mother reported going through a gallon of milk in just one weekend. Mikey had some sensory processing issues which led to oral motor therapy from a speech and language pathologist (SLP). During oral motor therapy, he learned to tolerate having a toothbrush in his mouth and he learned to eat a few new foods.

Before we started intervention, Mikey occasionally ate cream cheese and jelly sandwiches on white bread. He also occasionally ate cheese sandwiches on white bread. His mother reported to us that she was very interested in Mikey becoming toilet trained.

We sent Mikey’s mom some written instructions on how to toilet train her child. We suggested that she start toilet training the weekend before we started feeding therapy. We have found, in our clinical practice, that children respond well when multiple areas of growth are targeted simultaneously. For Mikey, we could say that he was becoming a “big boy”. Big boys learn to pee on the potty and they learn to eat big boy food!

Mikey’s mom was a champion. She followed the toileting protocol that we provided and by the time we arrived for feeding therapy, Mikey was already urinating regularly on the toilet. He was also accurately reporting if he had to urinate when asked! His daytime diapers were gone and he was wearing big boy underpants.

The other curve ball we threw Mikey was that he was no longer allowed to drink from a sippy cup. He was starting preschool and big boys drink out of regular cups. We told Mikey that he could only have his sippy cup if he needed to drink while riding in the car to keep from spilling.

Prior to therapy, we encouraged Mikey’s mom to work with a nutritionist to determine if Mikey had any food sensitivities. Unbeknownst to her, Mikey was reactive to a number of common foods such as avocado. Additionally, Mikey suffered from a zinc deficiency. So, prior to therapy, Mikey’s mom started him on a few nutritional supplements. We believe that well-rounded nutrition is one of the best mechanisms to ensure success in our therapy sessions.

For Mikey, we provided all services in his home and his mother was present for every session. Mikey’s father attended one session to ensure that he knew how to support Mikey when therapy was finished. In addition to having well-rounded nutrition, we have found (along with other researchers) that hunger inducement is one of the best strategies for feeding intervention. When children are hungry, they are more likely to want to eat. For Mikey, this meant that multiple cups of milk were eliminated each day. Unfortunately, Mikey’s mom had to deal with Mikey’s unhappiness about this change in the early morning hours before the first session. As we said previously, she is a champ and she handled this challenge like a true fighter. Mikey was definitely hungry at mealtime and he soon learned to get along without all that milk.

Mikey received services over the course of 4 days. On the first and second day he received services at breakfast, lunch, and dinner. Mikey’s mom took over the meals starting at dinner on the second day. On the third day, Mikey received services for lunch and dinner. On the final day, he received services for breakfast. So in just 9 one-hour sessions, Mikey learned to eat new foods when asked.

We had several pleasant surprises when working with this client. First, Mikey had never eaten protein in solid form. We were all pleased that protein was becoming a fast favorite for Mikey. Additionally, Mikey loved fruits. We couldn’t find a fruit that he disliked. Despite the great progress that Mikey made in such a short period of time, Mikey will still need to work on chewing his new foods. As his mouth becomes accustomed to all the textures and flavors, he will become desensitized and more willing to use all of his mouth when eating. Additionally, as he learns to use his mouth to chew all of these foods, his overall motor function should improve.

Mikey, congrats on your progress. And to Mikey’s mom—he could not have done it without you. Now go get yourself that manicure, pedicure, or date night that you deserve. Tell your husband “it’s the doctor’s orders!”

Happy Eating!

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The topic of #pickyeaters has received a lot of attention lately. You can search for it on twitter (#pickyeater), there are blogs about it like this one,  and even Dr. Oz talked about it here.  Everyone has an opinion about how to help picky eaters.

After searching the internet to learn what others had to say, I found this great link on Whole Foods. I have to say, I really like the advice that was offered. I’ll summarize it here:

First, the author, Paige Brady, suggested talking to your children. Children are bombarded daily with advertisements for junk food, fast food, and candy. Paige is right! We have to get in as much good food talk as we can.

Next Paige suggests that we get real with our meals. I like that too! Serve food that looks like real food. Real food is more appetizing than processed foods. My mouth is watering as I’m typing.

Paige also suggests that we serve a rainbow. Look at your child’s plate. Is it all white? Strive to have varied colors for each meal. Real food has color. Let it shine.

Paige tells readers to hand over the reigns. In the intervention world, we call it choice making. Give children choices. You will eat a vegetable tonight. Is it going to be broccoli or brussels sprouts?

In our house, the kids help shop. They pick out the fruits for the week, they pick out the vegetables for the week, we allow them to pick the meats that will be cooked. By including them in the shopping and meal planning, they are much more likely to want to eat what is served. Moreover, when they are older, they will be empowered with the ability to make good choices on their own.

Happy eating!

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Bobby is a beautiful brown-eyed 5-year old who came to visit our clinic in 2011. His parents had contacted Applied Behavioral Strategies because they were concerned that his extremely limited diet (only rice waffles and bacon) was doing great harm to his health. They explained that he would eat up to 5 pounds of bacon at a sitting and restricted drinking only to a specific sippy cup. The only other food he allowed in his diet was Ruffles ® potato chips.

When Bobby first arrived in the clinic, he spent most of his time trying to keep away from all adults. He definitely preferred to manage his own time in his own way!  Getting him to try anything new usually led him to try to escape from the room. Mom even had to sit in front of the closed door to prevent him from running out.  In the initial stages of intervention, we target an easy skill to ensure that the child will get access to the preferred items or activities (also known as reinforcers). For Bobby, we chose to start off trying to get him to drink his preferred drink from an open mouth cup rather than his preferred Sippy cup. Every time we approached him with the new cup he ran in the opposite direction. When he eventually touched the cup to his lips (with our assistance), Bobby got to play a game on the iPad. He soon learned that trying new things were amply rewarded! Getting food to his lips was the next challenge.

We realized then that Bobby had a difficult time any change was introduced. On each trial, he attempted to elope (run out the door). After many attempts, Bobby finally allowed us to touch food to his lip. Each new food brought a new round of elopements. On our second day, we asked his father to assist us as we physically prompted him to come to the table and sit down, rather than us bringing the food to Bobby. He was prompted to remain in his seat until he accepted a small morsel of food in his mouth. Just for trying new foods, Bobby got a pile of reinforcement! We showed him he could spit the morsel out if he allowed the morsel in. He also learned that he could have his favorite food reinforcer—bacon!— just for trying the new food. We repeated this procedure many times until Bobby became more comfortable with the procedure.

The next day, the bar was raised again for Bobby when he was asked not only to accept new foods into his mouth, but that he would have to chew and swallow as well.  Understandably,  he was not happy about this change in expectations. Because the challenge was greater, the reinforcement offered was greater too.  Bacon was still being used as a reinforcer for meeting his eating goals, and in addition Bobby was allowed to escape from the eating table and go play with his favorite toys – Thomas the Tank Engine trains and track. Essentially, he would be allowed to leave the table (negative reinforcement) to play with the train (positive reinforcement). After he played for about 1 minute, he was asked to come back to the table. Soon, he was coming to the table with only a verbal reminder (“it’s time to come take a bite”).  Everyone was so excited when it became clear that Bobby was beginning to accept and even enjoy his new routines.

By the fourth day, Bobby was independently coming to the table and independently feeding himself bites of food. His parents were elated and began to take over the feeding process from the therapists. Even though his parents had observed every session, we still reminded them to provide praise, prompts, and reminders as needed.  By our fifth and last day of clinic, Bobby was taking charge of his own meals. He was able to independently select which foods he wanted to eat, in which order, and to handle his own utensils.   Our celebratory dinner was one that would make grandmother’s all over the world cry: our little friend ate steamed kale with Tahini sauce, pureed lentils, pickled cabbage, vegetable soup, mixed vegetables, and brown rice. Moreover, he did this at a local restaurant with both parents and his siblings. The family had never eaten at a restaurant successfully until this day.

His mother recently contacted us to show us pictures of his continued success. Check this out! This is a meal he ate at home!

Congratulations Bobby and to your parents as well! Persistence and bravery carry their own rewards. Happy Eating!

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