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Feeding Clinic
Providing services to individuals who display
partial or total food refusal, food or texture
selectivity, and lack of self-feeding. Through
systematic assessment, appropriate feeding
behaviors are developed. Caregivers are
trained to independently implement the
feeding interventions in both the clinic and at
home.
Today’s Overview
• Physical complications
– Cleft palate
– Oral motor difficulties
• Medical complications
– Reflux
– Allergies
– Constipation/diarrhea
Behavioral Learning
• Natural setting
– Watch parents feed their children
– Note consequences provided for problem behaviors
• Clinical setting
– Provide pre-determined consequences for problem
behavior
Piazza, C. C. Fisher, W. W. Brown, K. A. Shore, B. A. Patel, M. R. Katz, R. M. Sevin, B. M. Gulotta,
C. S. & Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of
Applied Behavior Analysis,. 36, 187-204.
Piazza, C. C. Fisher, W. W. Brown, K. A. Shore, B. A. Patel, M. R. Katz, R. M. Sevin, B. M. Gulotta,
C. S. & Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of
Applied Behavior Analysis,. 36, 187-204.
Behavioral Learning
1- 4yrs Chews with mouth closed 3-4yrs. Wipe his/her face and hands during/after a meal
1-2yrs. Chews with ease and rotary motion. 4-5yrs Holds fork in fingers
1-2yrs. Lifts glass/cup from table to drink 4-5yrs Holds spoon, fork and knife correctly
1-2yrs. Returns cup/glass to table after drinking 4-5yrs Uses knife for spreading
1-2yrs. Manipulates spoon to "scoop" food 5-6yrs. Uses knife for cutting softer foods
Drinks from cup held with both hands,
1-2yrs. without assistance may spill 5-6yrs. Uses knife for cutting
Takes spoon from plate to mouth, with some
1-2yrs. spilling 6-7yrs. Uses spoon, fork, and knife competently
Realistic expectations
Realistic expectations
How bad is it really?
• Missed meals
• Malnourishment
• Failure to thrive
• Lack of growth
• Tube dependence
• Added family stress
• Problematic mealtime behaviors
USDA Food Guidance
Food for
Young
Children 1992
1916
1940s
1970s
2005
1950s-1960s
Nutrition
Focus on fruits.
3200
3000
2800
ACTIVE
2600
2400
Calories
2200
2000
SEDENTARY
1800
1600
1400
1200
1000
3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
*From the National Academy of Sciences, Institute of Medicine Dietary Reference Intakes Macronutrient Report
Growth Curves
4 year old
35 lb.
41”
Extreme cases - Enteral feedings
•The
Gather
item
5-6chosen
possible
firstreinforcers
should be the item worked for at that
moment
•Show the child all of the items
•Place them in front of the child at equal distances
•“Pick one”
Top 5 Preference Facts
•Sleep regulation
•Set mealtimes
•Limited portions
•Set snack times
•Medication side effects
•Arrange tube feeds
The Eating Environment
Everything Around you Matters
•Seating arrangement
•Physical seats
•Utensils
The Chair
Is the chair you are currently using the proper one for your
child’s:
1. Age
2. Abilities
3. Physical size
Rule of thumb: No one should have to kneel to reach his dinner plate
Seating!
The Highchair The Booster Seat
•Height •Attachment
•Recline •Tray
•Wheels •Straps
•Tray •Up to ~3 years
•Straps
•Fabric
•Up to 45-50 lbs
Seating!
•Size •Size
•Age/Weight •Age/Weight
Utensils and Such
Yes! It matters!
Utensils and Such
Level
The amount of
food on a
spoon during Rounded
one bite
Heaping
Bolus Size - Liquids
1 ounce
The amount of
¾ ounce
liquid in a cup
½ ounce
during one
¼ ounce drink
Texture
Texture
Wet Ground
•Small lumps
•Relatively liquid
•Think of: soupy oatmeal
Texture
Ground
•Lumps
•Thicker in consistency
•Think of: ground beef
Chopped
•Prepared with knife
•Pieces the size of bacon bits
•Think of: crumbled feta
cheese
Texture
Bite Size
•Typical age-appropriate
bite
•Think of: size of a dime
Preference Assessments
Scenario goals
What should we work toward for Sarah?
Personal goals
Where are you hoping to go?
Can’t you just make us a decision tree?
Child Characteristics Seating Apparatus Assessments Treatment Evaluation
Edible Preference
Assessment NCR
Food Selective
Fade by Texture
Presentation
Selective Feeding Style
Refusal
Non-Self Feeder Fade by Color
Total Refusal
Partial Refusal
Oral Motor
Changing
Assessment
Criterion
Food Texture
Problem $
Behaviors
Baby Food Response Cost
YIELD
Volume
Family Support Puree Sequential
Assessment
Presentation
Taste
Allergies Chop
Color
Reflux Jaw Prompt
Food Group
YIELD
Oral Motor
Deficits Bite Sized
Aspiration
Introducing New Foods
The Introduction
• Relax!
– After all, it’s just food
• Pick something mundane or similar
Simple Reinforcement
WHAT HAPPENS IF HE
(2-3 seconds)
• New Reinforcer
– The reinforcer isn’t powerful enough
• Lower the requirement
– The response effort is too great
• Let him go
• Wait it out for a bit
• Different approach is needed
Demand Fading
Day 1
Day 2
Day 3
Self-feeding
Self-Feeding
Why?
• Lack of skills
• Simple food refusal
What?
• Someone else feeds child
• Finger feeding only
• No transition from bottle
Teaching Self-Feeding
• Authoritative voice
– No questions
– No yelling
• Prompts delivered approx. every 5 seconds
• No extraneous statements, questions or
demands
Ultimate Prompting Goal
Steps:
2. Gestural – Parent points to bite of food
3. Verbal – Parent gives verbal instruction to child
4. Model – Parent shows child what to do by
modeling movement
5. Physical – Parent uses hand over hand guidance to
ensure the behavior is completed
Least to Most
Pros Cons
Allows greatest Child can make
independence mistakes
Behavior will always Child can “escape”
be completed during prompting time
Good with child who
can display skill
Most to Least Prompting
Shadowing:
Have your hand within an inch of your child’s hand.
As child continues to move independently,
caregiver should move hand further away. Come
closer in if independence decreases.
Most to Least
Pros Cons
Caregiver must be very
Allows independence
aware
Behavior will always Can vary greatly
be completed between caregivers
Caregiver physically
close to “catch”
incorrect behaviors
Praising during Prompting
Tricky to use…
Time out involves no fun things and no social contact.
3. Remove child from table for predetermined time
4. Turn chair around at table for predetermined time
5. Remove plate/glass for predetermined time
•Monitor progress
•Avoid eating from original containers
•Vary things up
•Use visual clocks as prompts when able
•Structure when you can
•Repeatedly offer new foods
•Offer foods in age appropriate portions
•Serve meals in “eating locations”
Lots of Tips
• Consistency of intervention
• Past history
• Amount of effort required by the child
Using the Wrong Reward
• Parent Involvement
– Asked to observe all sessions
– Trained to implement meals for last 3-5 sessions
• Data tracking
– Data collected on acceptance, swallowing,
inappropriate behaviors
Length of Treatment in Hours
Three Hours Treatment Per Day
35
30 Therapy
25 Supervision
Number in Hours
20
15
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Client
Baseline v. Intervention
• Baseline sessions
– Occurred during first day of therapy
– Child allowed to escape from bites
• Intervention sessions
– All non-baseline sessions
• We expect to see changes over time
Food Variety
65
Baseline
55
Intervention
45
Total Number
35
25
15
-5 1 2 3 4 5 6 7 8 9 10 11 12 13
Client
Average Number of Disruptions Per Bite
4 Baseline
First 3
Average Number Per Bite
3.5
Last 3
3
2.5
2
1.5
1
0.5
0
1 2 3 4 5 6 7 8 9 10 11 12 13
Client
Common Questions
& Discussion
Common questions