What are feeding deficits and what do they look like?

Feeding problems varies between 2% and 35% in typically developing children and is more frequent (estimated between 33% to 80%) among children with developmental delays (Babbitt, Hoch, & Coe, 1994; Burklow, Phelps, Schultz, McConnell, & Rudoph, 1998; Munk & Repp, 1994; Palmer & Horn, 1978). Proper food consumption is important for a child’s developmental growth both physically and cognitively. Inadequate food intake can lead to both short- and long-term consequences including weight loss, malnutrition, poor immune system and physical and cognitive impairment. Additionally, inadequate food consumption generally co-occurs with inappropriate mealtime behavior, such as negative vocalizations or physical refusal, all of which generate high levels of stress for family members as well as prevent socialization between children and their friends and family (Williams and Foxx 2007).

Food selectivity refers to the consumption of a limited variety of foods, refusal to consume foods from at least one major food category, or refusal to consume novel foods (Levin and Carr 2001). Food selectivity is often called Avoidant/Restrictive Food Intake Disorder (ARFID). The DSM-5 defined Avoidant/Restrictive Food Intake Disorder (ARFID) as a failure to meet nutritional needs leading to low weight, nutritional deficiency, dependence on supplemental feedings, and/or psychosocial impairment. This is not an exact definition in the sense that it does not say how many foods or which food groups a child is not eating that determines if they will have this diagnosis. Below are areas to think about when it comes to this diagnosis. This is not an exhaustive list.

• How does my child act when new foods are presented. (Ex. yell, turn away, refuse to eat, run away, push food away).
• How many of the 4 main food groups does my child eat? (Proteins, starches, fruits, vegetables)
• How many foods does my child eat from each main food group? (Ex. More than 3?)
• Does my child refuse to eat when different brands of foods are introduced? (Ex. Will only eat McDonalds French fries)

Chewing

Food selectivity is not the only mealtime behavior that can be worked on. A portion of children with pediatric feeding problems may have oral motor skills deficits that impact eating (Field et al., 2003; Selim, 2016). Chewing deficits can also differ in how it looks. Below is a list of some chewing deficits from Volkert, Piazza, Vaz, and Frese 2013.

• Premature swallowing
• Attempting to masticate food by pressing the bite to the roof of the mouth with the tongue
• Immature munching pattern.

Packing

Another inappropriate mealtime behavior is packing. Packing (holding food in the mouth without swallowing) is a problem behavior that may result in decreased oral intake, longer meal durations, and aspiration (Gulotta, Piazza, Patel, & Layer, 2005).

Where to go from here?

In the field of Applied Behavior Analysis (ABA) it is understood that children with feeding deficits can cause an additional stress upon a family. Through ABA procedures these deficits can be worked. At our clinic we will work alongside caregivers in determining what the deficits are and create an individualized treatment package that works best for the child and the family. We will also work to train any caregivers on the procedures to make sure that the new skills will work not just in the clinic but also in the home.

Pretreatment

• Brief Autism Mealtime Behavior Inventory (BAMBI)
• Parent Feeding Inventory
• Week Food log
• Video of Inappropriate mealtime behavior
• Meeting with treatment team
  • During this meeting all information gathered will be gone over along with any other relevant information. Possible procedures will be gone over, and any questions answered.

Assess possible treatments

During this time each procedure will be tested for effectiveness. All initial sessions will be video recorded. Treatment team will start with the least intrusive procedure and work up to most intrusive procedure.

• Positive reinforcement
• Non-contingent reinforcement
• Video modeling
• Stimulus presentation with a stimulus fade
• Shaping

If none of the above procedures are effective, then non-removal of the spoon will be tested. This procedure will usually be done alongside another procedure (ex. positive reinforcement, stimulus presentation with a stimulus fade).

• Non-removal of spoon

Generalization

Once an effective procedure is run it will be continued while working on the mealtime deficit. Mastery for a novel food will be five consecutive sessions of 100% acceptance without problem behavior. Once novel food has been mastered with therapists, caregivers will be brought in to be trained and run the same procedures. Mastery for caregiver training will be three consecutive sessions of 100% acceptance without problem behavior and 100% agreement of procedure being run correctly. Once caregivers master procedure caregivers will run procedure in the home with child with therapist present. Mastery criteria for in home is three consecutive sessions of 100% acceptance without problem behavior and 100% agreement of procedure being run correctly. Novel foods will continue to be introduced in clinic with the child until he or she is accepting all novel foods that range from all food groups.

Pretreatment

Assessments

Generalization

Interventions

Positive reinforcement: Premack, big reward (Foods, toys, praise) for taking a small bite first

Non-contingent positive reinforcement: Being able to watch the iPad continuously throughout the meal

Video model: Show video of someone else eating food with the instruction to take a bit

Simultaneous presentation with a stimulus fade: small bite of non-preferred food blended with a large bite of preferred food.

Shaping: Shape consuming foods to the terminal goal (touch lips, touch tongue, chew…)

Non removal of spoon: Not allowing escape