Treating Feeding Challenges in Autism

Turning the Tables on Mealtime

Jonathan Tarbox, Taira Lanagan Bermudez

• Publisher: Academic Press
• Year: 2017
• Print ISBN:
  9780128135631
• eBook ISBN:
  9780128135648
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Treating Feeding Challenges in Autism: Turning the Tables on Mealtime distills existing research on feeding disorders treatment into the very best, most effective and most practical strategies for practitioners to implement with their clients who have autism and other developmental and behavioral disorders. The book focuses on the few but highly effective feeding treatment procedures that work in the large percentage of cases. The book describes each procedure in practical, how-to language, with the goal of explaining how to implement them in the real-life settings in which practitioners actually work. The book includes a large variety of sample datasheets, intervention plans and graphs of sample data to serve as practical examples to guide clinicians through the process of selecting, implementing, analyzing and troubleshooting feeding interventions. - Summarizes the basic behavioral principles underlying feeding disorders - Discusses the origin and function of feeding disorders - Details the assessment of feeding disorders - Covers practical issues related to feeding environment - Lists materials needed for implementing feeding interventions - Explains how to transfer strategies and procedures from the practitioner to parents and caregivers - Includes sample datasheets, intervention plans and graphs of sample data

Chapter 1

Introduction

Abstract

This chapter is the introduction to a work intended primarily for board certified behavior analysts who treat feeding disorders in patients with Autism Spectrum Disorder.

The text is written in technical, yet practical, language to be used in everyday situations. The topics discussed include common feeding problems and their long-term effects. The information in this chapter is based on observable deficits in eating, not on psychiatric diagnoses.

Avoidant/restrictive food intake disorder is the diagnosis that is the center of discussion in this publication. Feeding problems, medical involvement, and the reinforcement of strong healthy feeding behaviors are incorporated in the chapter.

Keywords

Autism Spectrum Disorder; applied behavior analysis; avoidant/restrictive food intake disorder; selectivity; skill deficits

The goal of this book is to provide the most effective and practical strategies available for clinicians to treat feeding disorders in their clients with Autism Spectrum Disorder (ASD) and other developmental and behavioral disorders. This book uses straightforward language to explain how to implement procedures in real-life settings. In writing this book, we attempted to strike a delicate balance between writing technically enough to satisfy the researchers who will read this book and writing practically enough for this book to be useful to those who work with individuals with autism everyday. When in doubt, we have deliberately chosen to err on the side of practical. For those with the skills and inclination to consume the research literature, the list of references at the end of the book contains a list of research articles not to be missed. The list of further readings in Appendix A also contains review articles, books, and book chapters that are an invaluable resource for treating feeding disorders.

The primary audience for this book is Board Certified Behavior Analysts (BCBAs) who already possess a foundational knowledge of behavioral principles and procedures. However, we assume no previous knowledge or experience with treating feeding disorders. All of the procedures described in this book are taken from research published in peer-reviewed scientific journals. Where research on details is lacking, we draw from our own clinical experience and training we have received from others who are recognized experts in treating feeding disorders and who have worked in leadership roles at feeding centers of excellence, such as the Kennedy Krieger Institute in Baltimore, Maryland and the Marcus Autism Center in Atlanta, Georgia.

A brief note about practicing within your scope of expertise is worth discussing. Most BCBAs work with individuals with autism and most individuals with autism display some kind of challenges with feeding. All of the empirically validated treatment procedures described in this book are derived from basic behavioral principles and all are relatively straightforward. One might expect that all of the facts combined together would imply that most BCBAs should be able to treat feeding disorders effectively. However, understanding principles is not enough to make one competent in expertly executing procedures. Like other specialties within applied behavior analysis, treating feeding disorders requires practical experience under the supervision of someone who is already an expert. Therefore, merely reading this book is not going to make you qualified to treat feeding disorders. We highly recommend that you seek out some form of consultation or mentorship, in-person or over videoconference, to help guide and develop your ability to implement the procedures described in this book.

Feeding disorders comprise a continuum, ranging from picky eating all the way to total food and liquid refusal, resulting in complete g-tube dependence and constituting a major threat to health. To treat the most severe cases, you need direct training and ongoing mentorship from those who are already experts in that level of severity. In addition, you likely should be practicing in a hospital setting, or at the very minimum, in close daily collaboration with an entire medical interdisciplinary team. This book is not written for those cases, although all of the procedures contained in this book are relevant for the most severe cases as well. This book is written for clinicians who are treating less severe feeding cases, which constitutes the vast majority of individuals with ASD who have challenges with feeding. There are no black and white rules to follow regarding when a case is “too severe” for you to treat, but a good rule of thumb is that, if the primary feeding concern is medical (e.g., the individual has a feeding tube, the individual’s weight is in the bottom fifth percentile, etc.), then you should refer the family to medical experts. If the feeding challenges you work with are not this severe, this book is for you and we hope you find it inspiring and useful.

1.1 Common Feeding Problems

Common feeding problems include challenges with eating and/or drinking that affect an individual’s weight or nutrition, food or fluid refusal, food or fluid selectivity, challenging behaviors during mealtime, and feeding skill deficits, among others. The effects of feeding problems range from mild (e.g., missed meals) to more severe (e.g., tube dependence or failure to thrive). Most feeding problems have both medical and social implications. We describe each in greater detail below.

Feeding problems are recognized by medical professionals in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In addition to eating disorders (e.g., binge eating, anorexia nervosa, and bulimia nervosa), which are less relevant to the subject of this book, the DSM describes Avoidant/Restrictive Food Intake Disorder (ARFID). ARFID is the DSM diagnosis that is most applicable to the feeding disorders covered in this book and the diagnostic criteria are as follows: (1) An eating or feeding disturbance exhibited by failure to meet appropriate nutritional and/or energy needs and associated with at least one of the following symptoms: significant weight loss/failure to gain expected weight, significant nutritional deficiency, dependence on enteral feeding or oral supplements, interference with psychosocial functioning; (2) Not better explained by lack of available food or cultural practices; (3) Does not occur exclusively during the course of other eating/feeding disorders (e.g., anorexia or bulimia nervosa); and (4) Not attributable to other medical conditions or mental disorders.

This book approaches feeding challenges based on observable deficits in eating and excesses in challenging behaviors, not by psychiatric diagnoses. Depending on the severity of the clients you work with, if their parent took them to a medical doctor, they may receive a diagnosis of ARFID, but this has little or no impact on the behavioral intervention procedures that are likely to be effective. This is not to say that the ARFID diagnosis is irrelevant, but merely that it affects behavioral intervention very little. In Chapter 2, Medical and Behavioral Origins of Feeding Problems, we discuss the importance of specific medical assessments and determining whether it is safe for you to work on feeding with a client.

1.1.1 Selectivity by Type

Some individuals consume all or most foods from specific food groups and will not eat other types of food. Selectivity by type is defined as an individual “consuming a narrow range of food (often involving rejection of one or more food groups) resulting in a nutritionally inadequate diet” (Sharp, 2016). In feeding literature, foods are generally categorized into four groups: fruit, vegetable, starch (aka, “carbs”), and meat/protein. A client, who is selective by type, might consume foods from only or mostly one food group. For example, he may mostly eat starches or meats and not fruits and vegetables. These clients often eat mostly junk food and only a small number of healthy foods. Despite a diet lacking in various food categories, many individuals with ASD fall within an appropriate range on the body mass index. However, they are at risk for vitamin and mineral deficiencies, as well as diet related diseases, such as obesity and cardiovascular disease (Sharp et al., 2013). Some amount of pickiness with food is completely typical for children (e.g., most children would rather not eat their vegetables), but when the pickiness becomes severe enough to impact the client’s nutrition and/or their family’s daily functioning, it may be a problem that is worthy of your intervention.

1.1.2 Selectivity by Texture

Individuals who are selective by texture are picky about the texture of foods they eat, meaning they more consistently consume foods of a specific texture (refusing developmentally appropriate textures), or that they only eat certain types of foods if presented in a specific texture. For example, Johnny will only eat vegetables in a pureed consistency, not when presented as an age-appropriate bite. Texture selectivity often presents as individuals displaying a preference for baby food or smoothies over regular, developmentally appropriate, table food textures. Texture selectivity is common in children who were born very prematurely and never had the opportunity to breastfeed. In severe cases, children may be 4 or 5 years old and still completely dependent on eating baby food. Such cases often require gradual texture fading and explicit training on how to chew, as we describe in Chapter 5, Treatment Components: Antecedent Variables.

1.1.3 Selectivity by Presentation

Some individuals display a strong preference for food being presented in a specific way and refuse the same foods presented in a different way. For example, specific materials (e.g., favorite dishes or utensils), type of container (e.g., bottle vs cup), packaging (e.g., French fries in fast food bag), food positioning (e.g., a separate plate for each food), or self-feeding versus adult spoon-feeding.

1.1.4 Food/Fluid Refusal

Another common feeding problem is food refusal, which includes partial or total rejection of foods and/or fluids. Fewer individuals with autism have food refusal than food selectivity (Field, Garland, & Williams, 2003). Food refusal often results in failure to meet nutritional needs, which can result in failure to thrive or malnourishment. Many individuals, with and without autism, whose feeding problem is categorized as food refusal, require medical intervention, including enteral feeding tubes. The two most common types of feeding tubes used for individuals with feeding problems are nasogastric (from the nose to the stomach) and gastrostomy/“g-tubes” (tube inserted into the abdominal wall directly to the stomach). The type of enteral tube used is determined by medical professionals and depends on many individual client factors.

1.1.5 Behavior Problems

It is common for individuals with food selectivity or refusal to also engage in challenging behavior during mealtimes. Problematic feeding behaviors include expelling (i.e., spitting food out), packing food in cheeks, turning head away from food, pushing or “batting” feeding utensil away, gagging, and vomiting. Accompanying disruptive mealtime behaviors include crying/tantrums, vocal protesting, elopement, aggression, throwing food or other objects, and self-injury.

1.1.6 Skill Deficits

Feeding skill deficits may include lack of chewing skills, poor lip closure, dysphagia (problems with swallowing), and lack of self-feeding skills. These skill deficits can have multiple origins, including individual physical characteristics (e.g., cleft palate or severe overbite causing nonaligned teeth), delayed motor skills or related muscle development (e.g., poor oral motor skills), or lack of opportunities to develop skills (e.g., child only eats baby food, so has not yet learned to chew; cultural preference to eat mostly with hands, so child has limited experience using a fork).

1.1.7 Medical Involvement

Whether it be the etiology or the result, many medical variables are relevant to feeding problems. These problems may include weight loss or lack of weight gain, lethargy, and malnutrition. Many gastrointestinal symptoms are often present as well, including reflux, vomiting, diarrhea, and constipation. Such problems can create barriers to growth and development. In some cases, food refusal resulting in medical problems requires medical interventions such as gastrostomy or nasogastric tubes. While sometimes medically necessary, feeding tubes have been shown to interfere with typical oral feeding behaviors (Babbitt et al., 1994).

1.2 Prevalence and Social Significance

Difficulties surrounding feeding are common in the typically developing population but even more so in the ASD population, with estimates of between 46% and 87% of children with ASD displaying significant feeding problems (Ledford & Gast, 2006). It is also worth noting that feeding problems and atypical feeding patterns were part of the earliest diagnostic descriptions of autism (Kanner, 1943).

Although feeding is often thought of as primarily a medical or nutritional issue, the social effects of feeding problems should not be underestimated. Eating a variety of foods, of varying textures, across people and settings is critical to successful social functioning in daily life. Eating in the community is a large part of most people’s social lives, including activities like going to restaurants with family and friends, eating at birthday parties, meals at school, snacks at the park, etc. For an individual with autism, who by definition already has social challenges, feeding problems can make social contexts all the more challenging. Establishing the ability to eat in a varied and flexible manner around peers and family can therefore have far-reaching positive effects on daily quality of life for the whole family.

Strengthening healthy feeding behaviors helps to establish lifelong eating patterns. Healthy eating is associated with proper physical growth and development, promotion of fine and oral motor skills, and more successful academic performance (National Center for Chronic Disease Prevention and Health Promotion, 2014). Finally, flexible eating is a source of great pleasure for most typically developing people. In a very real sense, when we help our clients learn to enjoy a greater variety of foods, we are giving them the gift of the lifetime of rich and varied enjoyment that food has to offer. The procedures described in this book, when implemented with proper supervision and support, can help establish a lifetime of happy and healthy eating and therefore have a very meaningful impact on overall quality of life.

Chapter 2

Medical and Behavioral Origins of Feeding Problems

Abstract

This chapter investiga...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Biography
• Series Foreword: Critical Specialities in Treating Autism and Other Behavioral Challenges
• Acknowledgments
• Chapter 1. Introduction
• Chapter 2. Medical and Behavioral Origins of Feeding Problems
• Chapter 3. Preparing for Meals
• Chapter 4. Treatment Components: Positive Reinforcement and Escape Extinction
• Chapter 5. Treatment Components: Antecedent Variables
• Chapter 6. Common Treatment Packages
• Chapter 7. Treatment Management
• Chapter 8. Caregiver Training and Follow-Up
• Chapter 9. Troubleshooting
• Conclusion
• Appendix A. Further Reading
• Appendix B. Sample Feeding Protocol
• Appendix C. Sample Feeding Protocol
• Appendix D. Sample Feeding Protocol
• References
• Index