Transcript Is keeping a child at the table during mealtimes

“Just take a bite!”
Is keeping a child at the
table during mealtimes
REALLY the best way to get
them to eat?
Evidence Based Practice, Feeding Disability
Who are we?

The 2011 group is comprised of:
9 speech pathologists from ADHC and
Cerebral Palsy Alliance
 1 occupational therapist from ADHC

Why did we include an OT

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This is the first year a professional outside
of speech pathology has been involved in
the EBP network.
The purpose was to:
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Widen our access to resources
Widen the field of experience to those who have
trained experience in people with sensory
processing disorders
A genuine interest by the occupational therapist
to support her professional development and
use of EBP.
Our Clinical question

Began with searching for the best
intervention strategies for supporting fussy
feeders.
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20 articles

Our initial search, developed our interest in
the strategy of Escape Extinction/ new
direction for our EBP
Our clinical question
To increase feeding outcomes
for children with fussy eating, is
escape extinction more effective
than other interventions?
To increase feeding outcomes for
children with fussy eating, is
escape extinction more effective
than other interventions?
1.
What is the current best evidence?
Engaging in EBP to learn more about EE.
2.
What does our clinical expertise tell us?
Look at our policies and procedures
Survey current practice
3.
Where do client values fit in with this topic?
Discussing and considering how families may view EE.
Escape Extinction
‘Escape extinction is a term that has been used to describe procedures that
prevent the child from escaping the feeding situation’ (Piazza et al, 2003).
Goal is for the child to no longer be able to use inappropriate behaviours to
escape the mealtime. It is Often used in combination with reinforcement
procedures.
Includes
Physical guidance
When a bite is not accepted, gentle pressure may be applied to the mandibular
joint, physically guiding a child to open their mouth so food can be
deposited inside (Ahern et al, 1996)
Non removal of the spoon
‘Consists of a feeder presenting a bite of food on a spoon in that position until
the child consumes the food.’
(Tarbox et. al 2010 pg. 223)
Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010).
Paediatric feeding disorders: A quantitative synthesis of
treatment outcomes. Clinical Child and Family Psychology
Review, 13, 348-365.
Method

A Systematic review of the literature for treatment
of paediatric feeding disorders.

Inclusion criteria:
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An experimental design with a control group.
Published in an English language peer-reviewed journal
between Jan 1970 and June 2010.
Evaluated intervention for children with a severe feeding
disorder.
Intervention aimed at improving solid food intake.
The dependent variable was a measure of food intake
(e.g. acceptance, grams).
The children did not meet the DSM-IV criteria of an eating
disorder.
…Sharp et al. 2010
Method (continued)
 The articles were then classified based on their:
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Treatment elements.
Setting.
Primary therapist.
Generalisation.
Statistical analysis

Percentage of non-overlapping data (PND) and nonoverlap of all pairs (NAP) used to evaluate the
effectiveness of treatments.
…Sharp et al. 2010
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Out of 124 possible studies, 48 met the criteria.
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All of the studies emphasised behavioural interventions:
 Escape extinction was the most widely used (83%) - non-removal of the
spoon was used in 48%, a prompt to open the mouth if the bite was not
initially accepted was used in 21% and non-removal of the food was
used in 25%.
 Differential reinforcement (reinforcement of acceptance) was the second
most-common intervention strategy implemented (77%).
 10% of studies involved punishment-based procedures.
 90% of studies involved more than one element in a “treatment
package”.

Acceptance of food into the mouth was the most frequent measure of food
intake (72.9%). Swallowing the bite was used as an outcome measure in
27% of studies.
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PND and NAP scores (M=88%) put the behavioural interventions as a whole
into the effective treatment range
Strengths and Limitations of
the Systematic Review
Strengths
 It is a systematic review.
 Good statistics, scientific principles
 Multidisciplinary
Limitations
 It does not compare behavioural interventions to nonbehavioural interventions.
 It does not compare the effectiveness of each of the
treatment elements (e.g. EE vs punishment, EE vs
reinforcement schedules).
 It is only relevant for children with severe feeding
disorders.
Limitations and Strengths of the
articles within the Systematic
Review

Strengths
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Some follow up on effectiveness of parent
training
Limitations
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Long term follow up in the articles (5, 10 years
later??)
Some articles did not appear to look at
generalisation – training of the parents, follow
up at home, family views/perspectives,
qualitative data
…back to our question
We cross referenced initial articles we
found against systematic literature
review
 Developed selection criteria to refine
list to articles to answer our question.

No Clear comparison
between EE vs other
methods in our available
articles.
Outcome measures used
inconsistent across our
articles.
What other interventions are there?
What is the evidence for these?

No published studies to compare the clinical efficacy or cost
effectiveness of interventions for assisting children with
feeding difficulties and/or a limited dietary intake.
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Other interventions for children with feeding difficulties
include:
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Graz Model (EAT and No-tube program)
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Sequential Oral Sensory (SOS) Approach to Feeding
Graz Model
(EAT and No-tube program)

Developed by Professor Marguerite Dunitz-Scheer and Professor Peter
Scheer from University of Graz

Psychosomatic approach that aims to remove the tube and for the child
to sustain themselves in a nutritionally sufficient way
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Three week intensive course with three different ways of participating
(NET coaching, Outpatient or Inpatient)
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Fast reduction of tube feeds under medical supervision
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Interdisciplinary therapy sessions with specific therapy around food
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Daily play picnic, a specialized eating therapy based on
psychoanalytical nondirective play therapy with various kinds of food.
Graz Model - Evidence
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Level IV Evidence, Case Series
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tube feeding with sufficient oral feeding after treatment (defined as the
child’s ability to sustain stable body weight by self motivated oral feeding).
92% were completely and sufficiently fed orally after treatment.
Tube feeding was discontinued completely within a mean of 8 days, the
mean time of treatment was 21.6 days.
6-8% could not be weaned and remained fully or partially tube fed.
These children deemed “not weanable” (i.e. children with tube primarily for
intake, most children with severe disabilities, hx aspiration, lack of mobility
and independence)
Limited long term data.
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Sequential Oral Sensory (SOS)
Approach to Feeding
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Designed to ax and address all factors involved in feeding difficulties
4 Major Tenets:
1.
Myths about eating interfere with understanding and treating feeding
2.
Systematic desensitisation is the best first approach to feeding rx
3.
Typical feeding development gives the best blueprint for rx
4.
Food choices play an important role in feeding treatment
General Treatment Strategies:
1.
Social Modeling
2.
Structuring Meal/Snack Times
3.
Reinforcement
4.
Accessing the Cognitive
No published research available but is currently being conducted by Children’s
Nutrition Research Centre, QLD.
Clinical Bottom Line
Behavioural interventions are
effective in improving intake in
children with severe feeding
disorders. The most common
interventions use a combination of
behavioural strategies.
 Escape extinction in combination
with other behavioural techniques
was the most widely used and
successful approach.
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EE and Workplace Policies &
Procedures
ADHC Policies
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Disability Service Standards (NSW Disability
Services Act 1993)
Nutrition and Swallowing Policy (Amended Sept 2010)
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Behaviour Support Policy
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Nutrition and Swallowing Decisions about Nutrition- attachment (Sept 2010)
Nutrition in Practice Manual (Oct 2003)
(Jan 2009)
Behaviour Support Policy and Practice Manual (Jan 2009)
Speech Pathology Practice Package
(June 2010)
What do your policies and procedures
reflect?
Disability Service Standards
(NSW Disability Services Act 1993)
Standard 3 - Decision making &
choice
"Each person has the right to make
their own decisions wherever possible
and have choice “
Nutrition & Swallowing Policy
September 2010
“A prevention and risk management
approach to individual nutritional
health is required.” pp5
“Balancing tensions between individual
choice and duty of care” pp6-7
Behaviour Support Policy
(Jan 2009)
“The Department promotes a positive
approach to behaviour support, based
on comprehensive assessment and analysis
of the meaning and function of behaviour
in a whole-of-life context. The aim of
positive approaches to behaviour support is
to provide a respectful and sensitive
environment in which the Service User is
empowered to achieve and maintain their
individual lifestyle goals.” pp7
Speech Pathology Practice
Package June 2010
Eating Behaviour Problems: Practice Manual from
the Centre for Child Community Health 2006
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“Appropriate and successful eating in children also
demands a division of responsibility. Parents choose food
that is safe and appropriate for the child, offer it in a
positive and supportive fashion and allow the child to
determine how much and even if he or she will eat at all.”
pp12
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“Encouraging children to experience new foods is assisted
by familiarity and lack of pressure to eat.” pp16
“Bribery is counterproductive.” pp16
“Allowing the child to maintain control of intake may have
important long-term positive health implications.” pp16
Speech Pathology Practice
Package June 2010
Eating Behaviour Problems: Practice Manual from
the Centre for Child Community Health 2006
“Interventions that have been most successful in promoting healthy
eating behaviours in children include:
 Repeating the exposure of a new or novel food to improve
acceptance through increased familiarity
 Modelling behaviours, that is, parental and peer consumption of a
food increases consumption and preference of it by the child
 Allowing the child to determine (control) how much food is eaten
from a selected menu, which results in consistent and adequate
energy intake despite meal-to-meal variation in intake
 Ensuring that the social context in which food is offered is one that
is likely to increase preferences for a variety of foods, including
new foods

Making positive statements to encourage the child to taste novel
or new foods.” pp28
Speech Pathology Practice
Package June 2010
Expanding Children’s Diets by Suzanne Evans
Morris 2009
“Children need to learn about new foods in an
unthreatening way…Mealtimes frequently are
associated with expectations for eating and
drinking. Many children are on guard and spend a
great deal of energy protecting themselves from
new sensory experiences that feel dangerous.
Comfort and safety are the most important
aspects of the mealtime. When children feel safe
and comfortable, they are more willing to risk and
participate in new experiences.”
Survey

In following the E3BP model we collected
data from therapists to review what
interventions they were mostly likely to use
for our paediatric feeding clients.

115 responded to the survey however we
could only view 100 responses due to
account limits on survey monkey.
Participants and workplace
11%
Speech
Pathologist
Occupational
Therapist
29%
Psychologist
60%
70
Number of participants
60
50
40
30
20
10
0
NSW Health
Ageing Disability and Home
Care
Non-Government
Organisations
Workplace
Private Practice
Other
Ella is a six year old girl with autism. She is a fussy eater and will only eat
white food. Her mother would like for Ella to eat all the food presented to her
at each meal. Which of the following strategies are you MOST likely to
recommend?
60
Number of responses
50
40
30
20
10
0
Keep Ella at the table until
she finishes her meal
The whole family eat
Introduce non-preferred foods
together to provide modelling
to Ella in play activities
Intervention options
Using a first, then chart to
encourage her to eat nonpreferred foods followed by a
reward
Skipped question
Case Study 1: Mrs Mack (teacher) reports that the only way she can
get one of her students to eat, is by holding a spoon in front of them
until they take a bite. What other strategies would you suggest to Mrs
Mack? You could select more than one answer.
2%
3%
For her to continue to use her
current strategies
18%
19%
Involve the student in mealtime
preparation
Offer the student more choices at
mealtime
Increase opportunities for the
student to engage in "messy play"
with real food
10%
16%
Encourage the student to engage
in pretend play with food items
(eg: feeding dolls)
Use a reward system (eg: after
each bite of food the student can
access a preferred activity)
Increase opportunities for the
student to observe other students
and the teacher eating
17%
15%
Skipped question
What about Client/Patient
Values?
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Possible that escape extinction has already been
trialled by parents prior to intervention from
trained therapists
Possible that that clients have already associated
“negative” feelings around mealtimes/food intake.
Parents sharing their own experiences and
learning from other parents who may have a
typically developing child.
For our own children/grandchildren, it is possible
we have implemented escape extinction
techniques and observed some success without
even realising it.
What about Client/Patient Values?
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Does the ADHC practice package allow therapists
implement escape extinction?
Does the Disability Services Act (1993) support the
use of escape extinction?
Restrictive practice guidelines
Ethics – do we feel comfortable making
recommendations using escape extinction?
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What if the child is malnourished and the family is
desperate?
Comparison to medications which are sometimes forced to
be consumed?
Is it ethical to withhold a treatment that has proven to be
effective?
Do we use some of the concepts within our daily lives?
Consulting the EBP triangle
Escape extinction
combined with other
therapy techniques
seem to achieve the
‘best’ results.
Current Best Evidence
I just want my child
to eat so their
nutritional needs
are met and I want
this to happen in
the easiest
possible way!
Are we comfortable
with
recommending
escape extinction
for children who
are regarded as
fussy eaters?
Clinical Expertise
Client/Patient Values
(ASHA, 2004)
In 2012…
Meetings will rotate between ADHC Metro
South offices.
Please contact:
 Emma Minchin
[email protected]
8344 2700
 Tsen Levsen
[email protected]
9701 6300
Next year for paed feeding
(disability)
•Transitioning from a
gastrostomy to oral feeds
•Efficacy of specific therapy
approaches (e.g. SOS)
•Group therapy for problem
feeders
•Laura Mobbs (ADHC, Penrith)
•Tsen Levsen (ADHC, Burwood)
•Emma Minchin (ADHC, Rosebery)
•Rachel Cummins (ADHC, Rosebery)
•Kylie Ryan (ADHC, Hurstville)
•Jean Chan (ADHC, Rosebery)
•Katharine White (ADHC OT, Rosebery)
•Maria Andreadis (ADHC, Fairfield)
•Amanda Khamis (Cerebral Palsy Alliance, Kingswood)
•Jill Rosen (former member from ADHC)
References
Ahern et al (1996) An alternating treatments comparison of two intensive interventions for food refusal,
Journal of Applied Behavior Analysis 29 (3), pp 321-332
Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M. (2006). Tube weaning according to the
Graz Model in two children with Alagille syndrome. Pediatric Transplantation, 10, 934–937.
Piazza.C.C, Patel. M.R, Santana. C.M, Goh. H.L, Delia. M.D & Lancaster. B.M (2002) An evaluation of
simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity.
Journal of Applied Behavioural Analysis, 35(3), 259-270.
Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Paediatric feeding disorders: A
quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-365.
Tarbox J., Schiff A., Najdowski A. C. Parent-Implemented Procedural Modification of Escape Extinction in
the Treatment of Food Selectivity in a Young Child with Autism. Education and Treatment of Children, 33.2
(2010): 223-234.
Thomas T, Dunitz-Scheer M, Kratky E, Beckenback H and Scheer P (2010). Inpatient tube weaning in
children with long-term feeding tube dependency: A retrospective analysis. Infant Mental Health Journal,
31(6), 664–681.
Any questions?
By Lauren Child