Feeding difficulties are common in typically developing children (2-35%), and are even more common in children with developmental problems (33-80%; Babbitt, Hoch, & Coe, 1994; Burklow, Phelps, et al, 1998). Feeding difficulties in individuals with autism is one of the most challenging presenting problems faced by clinicians. These problems come in several forms, including food refusal and extreme food selectivity. Specific issues may include inadequate intake of food, inadequate range of foods consumed, refusal to consume food, and challenging behaviors. Often, individuals with these issues have had them for many years, have been treated unsuccessfully with a variety of strategies, and have developed health consequences as a result of the longevity and severity of the problem. Efforts to intervene may be met with escalations of challenging behaviors, and with increased refusal to eat. Documented health consequences of food selectivity in autism include rickets, vitamin deficiencies, bone loss, and stunted growth (Williams, 2010).
The effects on caregivers are also significant and family members often express extremely high stress surrounding eating and mealtimes (Singer, Song, Hill, & Jaffe, 1990). Parents and other caregivers often are extremely concerned, and may be genuinely worried about the health impact of the food refusal issues. In addition, they may themselves feel defeated from years of unsuccessful efforts to address the problem. Parental anxiety may also have led to some interactional patterns around eating that are also part of the current problem. For example, parents may often remove the item that is being refused, inadvertently teaching the child that refusal will result in food removal. Also, they may cajole, beg, or otherwise encourage the individual in a way that provides undue attention for food refusal. In many cases, just to get their child to eat something, parents will provide access to preferred foods once attempts to get their child to eat a non-preferred food fail. Multiple researchers have confirmed that escape and attention are the two most common parental reactions that may maintain such behaviors (Piazza et al., 2003; Borrero et al., 2010; Casey et al., 2009). Caregiver training is therefore an essential aspect of treatment, as the protocols are specialized and must be consistently implemented. Furthermore, intervention may initially increase problem behavior, increasing caregiver worry.
Clinicians faced with these issues must possess an impressive set of skills in order to successfully treat feeding problems. Professionals who lack specialized training may not have the skill set to meet these needs, depending on the nature of the problem. It is imperative that clinicians evaluate their ability to intervene effectively and obtain needed expertise when the behavior exceeds their skill level.
Furthermore, these problems are often multifaceted, and may require the expertise of medical doctors, speech and language pathologists, and behavior analysts. It is often the case that feeding issues interact with medical issues, most notably reflux and motility issues (see Williams et al., 2010 for a review of the etiology of feeding problems). The resulting persistent problems may require both medical and behavioral interventions, and treatment should be designed in combination with a simultaneous medical assessment and/or a medical treatment plan.
In this article, we will briefly review some of the specialized strategies that have been shown to improve feeding. The strategies are behavior analytic, and have been empirically shown to reduce refusal, increase acceptance, and widen the variety of consumed foods.
Summary of Effective Interventions
One of the hypotheses in behavior analytic intervention for food refusal is that escape is often a maintaining factor. Children who protest and refuse food often have food taken away (and the expectation to eat is thus removed). The most commonly utilized clinical intervention is positive reinforcement and escape extinction (e.g., Ahearn, Kerwin, et al., 1996; Piazza, Patel, et al, 2003). The positive reinforcement generally involves access to preferred stimuli for desired eating, while the Escape Extinction (EE) contingency involves no longer permitting escape or avoidance.
The EE procedures take a variety of forms. A commonly used procedure is the Non-Removal of the Spoon (Hoch et al., 1994), in which the spoon remains by the individual’s mouth until the bite is consumed. In other words, the individual cannot avoid the presentation of the bite. Sometimes, physical guidance is used in this procedure as well, to facilitate consumption. Behavioral escalations are common in this approach, especially when first implemented. These experiences can be both messy and stressful for caregivers prompting some to suggest that it may not be feasible for all settings or with inexperienced/untrained caregivers.
Alternatives to EE have been developed to address the issue of behavioral escalation. Differential Reinforcement of Alternate Behavior (DRA) procedures provide reinforcement for accepting food or swallowing bites. Non Contingent Reinforcement (NCR) Procedures provide continuous access to preferred stimuli. These procedures work best if highly preferred items can be easily identified, and if the individual can be deprived of those items prior to the sessions. DRA and NCR are often used in combination with EE helping to mitigate the characteristic behavioral escalations (see Piazza et al., 2003 and Reed et al., 2004).
Some clinicians have altered the antecedent conditions (as opposed to focusing on consequences). For example, there is some evidence that simultaneously presenting preferred and less preferred foods can effectively increase the range of accepted foods (e.g., Ahearn, 2003; Buckley & Newchok, 2005). At times, the ratio/concentrations of nonpreferred foods can be systematically changed, to slowly build tolerance for nonpreferred foods. Finally, high probability behaviors are sometimes used to build behavioral momentum and increase the occurrence of low probability behaviors. For example, a child may accept several presentations of an empty spoon, and then accept food presented on a spoon (e.g., Kerwin et al., 1995).
Clinical Application to Increase Taste Exposure
Williams has recently suggested the use of a Plate A/Plate B protocol, in which tiny bits of 2 or 3 new or nonpreferred foods are contained on Plate A and Plate B contains 2 or 3 preferred foods. The child must eat a small bite from plate A to get a food item (or a drink) from Plate B.
In a recent extension of Williams’ work conducted by clinicians at Melmark, an approved private school and residential facility for children diagnosed with developmental disabilities, a Plate A/Plate B procedure was used with two individuals diagnosed with autism, both with a long history of food refusal. One participant was treated previously in an inpatient feeding clinic and prior to treatment received the majority of his daily calories from a gastronomy tube, as he only consumed 3-5 foods consistently. The second participant also had history of severe food selectivity resulting in a diagnosis of Failure to Thrive and was at risk of requiring a gastronomy tube. Both participants had a history of an intervention including escape extinction. The Plate A/Plate B procedure was selected for these participants because it was presumed to be easier for staff to implement with a high degree of procedural integrity and less restrictive as an intervention for the children treated, as it did not contain escape extinction. The Plate A/Plate B procedure was compared with a condition consisting of the Plate A/Plate B with the addition of taste exposure sessions in an alternating treatment design to determine if the taste exposures would enhance the effectiveness of the Plate A/Plate B intervention.
Although one participant showed some progress with both conditions, the Plate A/Plate B intervention did not produce clinically significant results for either participant, regardless of the addition of the taste exposure sessions, probably due to the low frequency of taste sessions. Once escape extinction in the form of non-removal of the spoon was added to the intervention, bite consumption increased for both participants. The intervention was so successful for one student, that he currently eats meals of adult sized portions containing a variety spanning at least 30 foods, and will likely be able to discontinue the need for the gastronomy tube in the near future. This was a significant replication because it extended the Plate A/Plate B research to non-vocal participants with a diagnosis of autism in a private school/residential setting. Future research is needed to determine when escape extinction is necessary.
Summary
Feeding issues are among the most resistant to intervention efforts, but can be successfully treated by highly trained clinicians. Expertise in feeding/food selectivity issues is essential, particularly for more complex and long-standing difficulties. All treatment must be coordinated with family members and caregivers across settings, to ensure that treatment effects are generalized and maintained. There are several behavior analytic treatments that have been demonstrated to be successful in ameliorating these issues. Successful interventions include the use of escape extinction, the use of reinforcement for appropriate eating, the use of stimulus fading procedures to gradually increase the ratio of nonpreferred foods presented in combination with preferred foods, and the use of behavioral momentum to build tolerance for eating nonpreferred items. Procedures that increase the number of taste exposures have also been shown to increase the range of items consumed. Feeding problems are among the most compelling target behaviors to address, as quality of life changes can be dramatic for both the individual and their family. In addition, the health consequences of improved feeding, enhanced variety of foods, and improved nutrition are substantial.
Christopher Perrin, PhD, BCBA-D, is Senior Clinician of the Children’s Behavioral Health Program, Amanda Guld, PhD, BCBA-D, is Director of Professional Development and Training, and Mary Jane Weiss, PhD, BCBA-D, is Executive Director of Research at Melmark. For more information, please visit www.melmark.org.
References
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