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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? 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 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… Asthma Sleep Apnea Orthopedic issues Menstrual issues Hypertension Diabetes Social Stigma Other issues related to Feeding Challenges Being underweight – Possible causes: • • • • 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 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 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 1. 2. 3. 4. 5. 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 1. 2. 3. 4. 5. 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 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.