Transcript Journal of Autism and Developmental Disorders, 44

Food Fights – Help for Eating
Challenges for Children with Autism
Spectrum Disorder
Emily LeRose, MA/CCC-SLP
Krysten Isabell, MA/CCC-SLP
Mariana Fraga, M.Ed, BCBA
Rachael Mcmanaman, MA, LLPC
Brittany Blake
Becky Moua
Helen Attar
Presentation outline
 Applied Behavior Analysis
 Henry Ford Center for Autism and
Developmental Disabilities
 Feeding challenges vs picky eaters
 Good nutrition
 Types of feeding challenges
 Basic interventions
What is Applied Behavior Analysis
(ABA)?
 The most effective, evidence-based therapeutic
approach for helping individuals with Autism
Spectrum Disorder gain communicative, social
and behavioral skills
 Data collection
 Breaks behavior down into small parts so that
individuals with ASD can learn and accomplish
things easier
 Positive reinforcement
 Withholds reinforcement for problematic
undesirable behaviors
What do we work on in our ABA
program?
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Communication
Play skills
Behavior management
Tooth brushing and flossing
Hand washing
Nail clipping toleration
Feeding therapy
Chores
Anything that will improve their quality of life
Feeding challenges vs picky eaters
What is good nutrition?
What is good nutrition?
 The child will eat:
– Fruits
– Vegetables
– Grains (bread)
– Protein foods (eggs, chicken, beef, pork, etc)
– Dairy (cheese, milk, yogurt)
– Oils
Types of Feeding Challenges
Most common eating problems
 Selectivity by type of food
 Selectivity by color
 Selectivity by brand
 Selectivity by texture
 Selectivity by appearance
Types of Feeding challenges
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Chewing-skill deficit
Excessive fluid intake
Adipsia (refusal of liquids)
Insistence on eating with only certain utensils
or dishes
 Refusal to sit at the table
 Refusal to self-feed
Types of feeding challenges
 Selectivity by type: A 9 year-old ate only bacon
and drank formula
 Selectivity by color: A 5 year old only ate beige
and light brown foods
 Selectivity by brand: A 5 year old girl would only
eat certain brands of foods
 Selectivity by texture: A 5 year old who only eat
baby food
 Self-feeding deficits: A 5 year old will not eat
indepedently
Importance of beginning work on
eating problems as soon as possible
 To ensure long term health
 Children who do not eat with their families or
peers can miss opportunities to develop social
skills and friendships
 To improve other skills such as speech and fine
motor
Importance of beginning work on
eating problems as soon as possible
 Eating and mealtime problems are
significantly more common among children
with ASD than typical children
 Eating problems of children with ASD do not
simply disappear over time
 Sometimes parents only serve foods that they
are confident their child will eat but this may
affect both their nutrient intake and that of
their families
Possible Causes of Feeding Challenges
 Medical or behavioral
– Sensory Processing Issues
– Gastrointestinal (GI) Issues
– Repetitive/Ritualistic Behavior
– Inflexibility/ Selectivity
– Fear/Anxiety to trying new foods
What does the research say?
 Feeding challenges are found to occur in up to
90% of kids with an ASD, in some cases
 Food selectivity by type is the most common
feeding challenge
– Strong preferences for starches and snack foods
 Increased risk of nutritional/medical issues
related to feeding challenges
What does the research say?
 Children/adolescents with ASD experience
obesity at higher rates than neurotypical
peers, as well as peers with other
developmental disabilites
 Possible causes:
– Medication
– Associated syndromes
– Lack of physical activity
– Altered eating habits
Obesity can increase the risk of…
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Asthma
Sleep Apnea
Orthopedic issues
Menstrual issues
Hypertension
Diabetes
Social Stigma
Other issues related to Feeding
Challenges
 Being underweight
– Possible causes:
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Dietary restrictions
Food aversion
Medication
GI issues
 Vitamin deficiencies
Identifying your child’s eating problem
 What foods does your child currently eat?
– The Food Diary
– The Food Preference Inventory
How does the child’s diet match the family’s diet?
Simple strategies to improve eating
habits at home
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Follow daily routines
Set approximate times for meals and snacks
Eliminate eating between meals
Limit liquid intake between meals and snacks
to water
 Limit the intake of milk or juice at meals and
snacks
Simple strategies to improve eating
habits at home
 Use favorite toys and preferred items as
reinforcers and not as distractors
 Make a big deal out of trying new foods
 Always start with very small bites
 Model what you want them to do
General Behavioral and Environmental
Strategies
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If it is not really a question, don’t ask
Use attention contingently and sparingly
Take advantage of modeling
Create eating-related habits
– Minimize distractions
– Eat at a specific place (kitchen/dining room)
Introducing new foods
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Mixing preferred foods and new foods
Pairing preferred foods and new foods
Reintroducing previously eaten foods
Starting with a single bite
The single bite of a new food on a separate
plate
Motivating your child to eat new foods
 Grandma’s rule
 Using preferred foods as rewards
 Using tangible nonfood rewards
 Exit Criterion
 Token programs
Interventions for Specific Eating
Problems
1. Escape prevention or “waiting out”
2. Expulsion
3. Re-Presentation
4. Food holding
5. Underweight children
Procedures for introducing new
textures
 Beginning-texture meals should consist of
food presented at the texture the individual
has been consuming at home (or at the
texture recommended by an OT
Teaching Self-feeding
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Prepare supplies ahead of time (food, spoon, etc.)
Place a rubber placemat underneath the plate to prevent it from sliding
The caregiver should sit behind the individual
Tell the individual to take a bite
Begin with full physical prompting: hand over hand scoop the food and place
the bite into the individual’s moth. Do this 10 times
6. Fade the prompt: Rather than placing the bite, stop hand-over hand just
before inserting the bite (about 10 inches away, to encourage the individual to
insert it himself)
7. If the individual is successful in inserting bites independently, gradually let go
of hand-over-hand-guidance
8. Fade the prompting even more if the individual continues to do well. Rather
than guiding his hand, move your physical guidance to the wrist until the
individual is successful in inserting bites independently
Feeding Program At Our clinic
 Procedures
– Introduced vegetable to each child’s snack time
– What we did
• Offer the carrot with another non-preferred food
• Ask, “what do you want?”
– Offer identified reinforcers
• First carrot then _____
Feeding Program At Our clinic
• Once the child consumed the carrot we asked them to
show us a “clean mouth”
– Clean mouth refers to the child completely consuming the
carrot.
• Once we saw that the child’s mouth contained no more
traces of the carrot we offered the child his/her choice
of reinforce
– The child could have the reinforcer for 2-5 minutes
 Goal
– Our ultimate goal is to start a healthy snack group
within our clinic.
Case Study: Johnny
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About Johnny: age, edible and tangible reinforcers
Goal of feeding program: eating vegetables
Baseline: refusal
Introduction of reinforcers: acceptance, progress
– Steps: touching tongue, licking, and then
swallowing bites.
 Change in behavior: refusal and escape
Case Study: Johnny
 Escape was more reinforcing than anything
 Changed his feeding program – used escape as
the reinforcer
 Exit criterion – method
 Increasing size of vegetable
 Duration of trial (bite)
 Current progress
Resources
 Myplate.gov
 Williams, K. E., & Foxx, R. M. (2007). Treating
eating problems of children with autism
spectrum disorders and developmental
disabilities: Interventions for professionals and
parents. Austin, TX: PRO-ED.
References
Groundhuis, S.N. & Aman, M. G. (2014). Overweight and obesity in youth with
developmental disabilities: A call to action. Journal of Intellectual Disability Research, 58,
787-799.
Phillips, Keydra L., Schieve, Laura A., Visser, Susanna, Boulet, Sheree, Sharma, Andrea
J., Kogan, Michael D….Yeargin-Allsop, Marshalyn. (2014). Prevalence and impact of unhealthy
weight in a national sample of US adolescents with autism and other learning and behavioral
disabilities. Maternal and Child Health Journal, 18, 1964-1975.
Twachtman-Reilly, Jennifer, Amaral, Sheryl C., & Zebrowski, Patrecia P. (2008).
Addressing feeding disorders in children on the autism spectrum in school-based settings:
Physiological and behavioral issues. Language, Speech, and Hearing Services in Schools, 39,
261-272.
Zuckerman, Katharine E., Hill, Alison P., Guion, Kimberly, Voltolina, Lisa & Fombonne,
Eric. (2014). Overweight and obesity: Prevalence and correlates in a large clinical sample of
children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 44,
1708-1719.