In my last post we talked about nutrition, more specifically the effects of sugar. Sugar, along with many other fake, harmful, synthetic ingredients in your child’s food could be holding your child back from gaining their full potential.
Don’t for one second think that marketing and big companies don’t know what they are doing, they do! Unless we make that change, with our knowledge and our wallets. There is a second obstacle to overcome too, the behavioral aspect. The goal of this article is to look at behavioral strategies to help your child eat more variety and healthier food!
I hope you’ve cleaned out your cupboard since our last post, “Health, Food, and Disabilities.” This will be the first step in having a successful transition. Behaviorally, a parent doesn’t have the option to be negatively reinforced by giving in when their child starts to tantrum, if the food just isn’t there to give and before, I move onto the behavioral components of an eating program, I’d like you to check out this article. I think it will give you a good overall picture of the importance of food and what it can do for your child, even if your child isn’t diagnosed with a spectrum disorder. Another great resource is Dr. Natasha McBride-Campbell. I would be here all day if I went into the nutritional and chemistry components. The three articles listed above should give you enough to get started and provide hope.
Where does behavior fit into all this? As many of the families I work with can tell you, I feel fairly strongly that nutrition and behavioral therapy have to go hand in hand for the most successful outcome. I don’t feel like a child will reach their potential without these two components combined. Given that there are no structural, physiological, or medical conditions preventing a child from eating food, our next step is to look at behavior. In my experiences, most picky eaters have learned this behavior because it comes down to a history of what they’ve been eating (chemical imbalances, sweet factor reinforcement) AND a history of reinforcement for eating that food (behavior working to gain access to food they want) AND history of escape motivated behavior working (engaging in undesirable behavior to not have to eat certain foods). Most eating issues have developed a rather extensive intermittent reinforcement history, making it more difficult to use a complete extinction based approach. Not to mention, choking, gagging, or flat our verbal and physical behavioral refusal typically puts the mother-child relationship at risk for more negative feeding interactions (Gueron-Sela et.al. 2011). With a some time, commitment, and conditioning significant gains can be made. Allison et. al. 2012 tested interventions of reinforcement and extinction -”differential reinforcement (DRA) plus escape extinction (EE) to non-contingent reinforcement (NCR) plus escape extinction (EE) to treat food selectivity exhibited by a young child with autism.” They found “interventions were equally effective for increasing bite acceptance and decreasing problem behaviors. However, a social validity measure found that non-contingent reinforcement (NCR) was favored by the child’s caregiver (2012).” Several other studies have reported that differential reinforcement or noncontingent reinforcement used alone to be ineffective in creating behavior change (Piazza et al, 2003 & Reed et al. 2004), escape extinction is still an important piece of the puzzle.
For the rest of the article we will talk about “How do a treat a child with a feeding or eating difficulties” through the following steps:
1. Rule Out Medical
2. Environmental Modification
3. Preference Assessment
4. Desensitization
5. Behavioral Approach
Let’s get at it… here is a quick synopsis of each area:
Environmental Modification:
These are antecedent interventions, meaning things you can do before the behavior occurs BUT there is a big difference between antecedent events (right before the behavior occurs) and setting events (although still under the umbrella of antecedent there is more distance in time before the behavior). In terms of environment, this is more changing a setting event, changing the environment for the long-term (setting events are usually more ongoing as well as increased distance of time between event and behavior). Some simple setting event modifications I recommend: (1) clean out the cupboard, processed food is no longer in there, (2) pair the table with fun activities outside of meal time, and (3) start eating meals together at structured times with structured snacks (if mealtime is too difficult together, at least have your child eat at a table during structured meal times- say good bye to grazing all over the house). These strategies do two things (1) increases motivation for food because a child has an opportunity to feel hunger, (2) makes the “bad” food less available by removing it, so it is no longer an option.
Preference Assessment:
You may ask, “what is a preference assessment?” In simple terms, this is an inventory of your child’s favorite items or the things/activities/edibles they prefer most over other things! Come up with a list of your child’s favorite items. There are several different types of preference assessments but for the purpose of your work and this blog, I encourage you to put your child’s favorite items all out on the floor and write down what your child gravitates towards first and spends time with. After several minutes take that item out of the mix and record his or her second choice and so forth. These items will later be used as reinforcers for taking a bite and increasing size of bites or variety of foods during the feeding program, if needed.
Desensitization:
Desensitization is a bit controversial but I add it here because… I think it is gentler for parents than a straight up escape extinction procedure, we’ll get there soon enough. It is a bit simpler to implement (especially for parents), it lessens the effects of an extinction burst (significant increase in undesirable behaviors for a short period of time), it is more accepted across other treatment disciplines, it has demonstrated fairly good generalization, and more appropriate it for little ones (under the age of 3). I also think it teaches kiddos not to just tolerate but also to enjoy the experience! However, with all that being said, it is an added step, meaning it takes more time, and the effectiveness is not proven to be as effective as extinction alone. So…what do you do (1) Create a “hierarchy” of anxieties or aversives, and (2) write down the events, forward chain, from simplest to most difficult, each step of the process (task analysis, if you will). For example: if you won’t look at it, you won’t touch it, which means you likely won’t pick it up and never put it to your lips, let alone swallow. Our goal is to get you tasting and swallowing a variety of food. So a systematic desensitization may look something like this:
1. Looks at food, or can of food
2. Opens the food, or touches the food
3. Touches the food, forks the food, spoons the food
4. Allows food to touch his lips or tongue
5. Puts food in mouth and closes lips
6. Chews food
7. Swallows food
The Behavioral Part:
Using a behavioral escape extinction approach alone WILL BE much faster period! However, at least for the little ones, it teaches tolerating and makes meal time a “have to” verses an “enjoyment.” Behaviors will increase until you get a burst (most extreme) which can be very upsetting (to child and parent). Using systematic desensitization alone takes, on average, years to master. Do we have that much time if a child isn’t getting enough food?
But using the system hierarchies of desensitization outlined above and behavioral approaches, we may find the best of both worlds. So, lets look at reinforcement. Remember, the major reinforcer here likely is escape, because the food being presented is an aversive. Therefore, each step outlined above will be rewarded with a reinforcer until mastery, then the next step implemented. That reinforcer may be escape and praise alone, or it may be additional items (remember the preference assessment)! Allison et al. (2012) research indicated that a more socially acceptable and easier approach for parents may be noncontingent reinforcement (NCR) plus escape extinction (EE) versus differential reinforcement (DRA) plus escape extinction (EE). Both methods demonstrated increase in food bite size and a decrease in disruptive behavior, but parents reported on a social validity scale that NCR + EE was more palatable and easier to implement. I personally prefer DRA + EE, however; my primary goal is that parents can and will continue the interventions when I am not there. Therefore, we’ll talk briefly about NCR + EE. Noncontingent reinforcement simply means reinforcement is provided on a fixed-ish time schedule versus contingent upon a behavior occurring. Escape extinction means that reinforcement for “escape behavior” when presented food is halted; the behavior no longer works to make the food go away–the food stays. Instead, the food will be removed when a child performs the task (depending on where you are in the hierarchy of desensitization).
Let’s walk through our example:
Setting event: cupboards only filled with “good” food
Antecedent events: play a game at the table (pair the table with good things), have food ready at the table, have multiple utensils ready, stay calm and happy, timer, reinforcing items
Step 1:
Food presented ->Child looks at food -> adult praises, hugs, gives high-five–>good goes away (EE)
(Reinforcement is on a contingent schedule because this is an easy task). Stay here until this mastered. Your behaviorist can help you determine mastery
Step 2:
Food presented —> child touches the food —> praise, reinforcer–> food goes away
NCR component- you may have a timer set or count in your head, reinforcers may be available at time allotments –not contingent on behavior BUT food does not go away until child touches food. Move onto step 3 after mastery.
Step 3:
Follow this pattern until you’ve got mastery at all steps.
Resources:
Addison, L., Piazza, C., Patel, M., Bachmeyer, M. Rivas, K., & Milnes, S. (2012). A Comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.
Allison, J., Wilder, D., Chong, I., Lugo, A., Pike, J, & Rudy, N. (2012). A Comparison of differential reinforcement and noncontingent reinforcement to treat food selectivity in a child with autism. Journal of Applied Behavior Analysis, 45, 613-617.
Dubois, L., Diasparra, M., Bedard, B., Kaprio, J. Fontaine-Bisson, B., Tremblay, R., Boivin, M. & Perusse, D., Genetic and environmental influences on eating behaviors in 2.5-and 9-year-old children: a longitudinal twin study. Journal of Behavioral Nutrition and Physical Activity, 2013, 10:134.
Gueron-Sela, N., atzaba-Poria, N. Meire, G. & Yerushalmi, B. (2011). Maternal worries about child underweight mediate and moderate the relationship between child feeding disorders and moth-child feeding interactions. Journal of Pediatric Psychology, 26, 827-836.
