Applied Behavior Analysis in the Treatment of Pediatric Feeding Disorders

Applied behavior analysis has had such a strong track record of success in encouraging appropriate behaviors and extinguishing inappropriate behaviors exhibited by children with autism and other disorders, that it is now frequently used to address feeding issues among these same children.

It is estimated that up to 90 percent of children with autism have feeding problems, so applying ABA techniques to address feeding disorders was a natural evolution for ABA therapy.

A child with a feeding disorder is much more than just a picky eater. Children are only diagnosed as having a feeding disorder if they do not consume enough solids and liquids to sustain growth and healthy development. Although it is estimated that between 25 and 35 percent of all infants and toddlers experience some difficulty with feeding at some point, the diagnoses of a pediatric feeding disorder is only declared when the child’s disorder is found to be severe, persistent and inhibits normal development and physical growth.

Pediatric feeding disorders can lead to growth failure, greater susceptibility to chronic illnesses, and even death.

Some of the underlying physical conditions that lead to feeding problems include:

  • Short gut syndrome
  • Defects of the palate
  • Gastrointestinal disorders
  • Failure to thrive
  • Oral motor dysphagia
  • Dysphagia (difficulty swallowing)
  • Dysfunctional swallow

Feeding disorders are more prevalent among children with physical disabilities, mental retardation, medical illnesses, prematurity, and low birth weight. Although underlying conditions bring on most feeding disorders, they may also occur in children who are otherwise healthy.

Feeding disorders among infants and children may be the result of difficulties with eating or drinking due to skill deficits and/or medical problems associated with these underlying conditions, or simply due to the selective refusal of foods and fluids. Though refusal of this sort is often rooted in biological problems, it is ultimately a behavior, which places it squarely in the domain of applied behavior analysis.

The Link Between Autism Spectrum Disorders and Pediatric Feeding Disorders

Children with autism often refuse food or accept only a very narrow variety of foods:

  • Refusing to eat anything other than very specific foods that lack adequate nourishment (e.g., only mac and cheese)
  • Refusing all foods that do not meet very specific criteria (e.g., foods that are white in color, like bread and pasta)
  • Refusing foods that are not presented in a very specific way (e.g., a sandwich must be cut into perfect squares)
  • Refusing entire food groups (e.g., fruits, vegetables, protein)

These feeding problems may lead to nutritional deficits and malnourishment.

Some of the behaviors common among children with autism spectrum disorders include:

  • Eating pureed foods only
  • Refusing to bite off food
  • Only eating finger foods (won’t use utensils)
  • Only eating when fed by an adult
  • Disruptive mealtime behaviors that affect the family (spitting out food, throwing food, throwing tantrums)

Children with autism often have other biological factors that compound food refusal or selectivity, such as reflux, allergies, constipation/diarrhea, and oral motor difficulties.

Diagnosing Pediatric Feeding Disorders

One of the ways pediatric feeding disorders are diagnosed is by assessing their impact on functioning. Some children with feeding disorders are at risk for aspiration, malnourishment, hospitalizations, and invasive medical procedures, such as the insertion of a nasogastric or gastrostomy tube for the delivery of proper nutrition.

Pediatric feeding disorders may also be assessed by how they affect the child’s social, emotional, and educational functioning and development.

While some practitioners might only diagnose children with feeding disorders if they fail to adequately gain weight, others may follow a different definition of an eating disorder, conferring a diagnosis if they reject food or food categories due to emotional or behavioral issues.

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Using Applied Behavior Analysis in the Treatment of Pediatric Feeding Disorders Among Children with Autism

Applied behavior analysts work to find out what is causing problem behaviors during mealtime. A functional assessment is necessary before applied behavior analysts recommend or develop behavior-change programs. It includes determining a client’s needs and consent, environmental parameters, and other contextual variables.

Applied behavior analysts identify any positive or negative reinforcements that are shaping the child’s behavior. For example, if a child refuses the food and throws a tantrum, the behavior may be negatively reinforced if the parent or caregiver removes the unwanted food or terminates the meal. On the other hand, if the child’s parent or caregiver provides a preferred food in place of the undesired food, the behavior is positively reinforced.

Applied behavior analysts identify if the negative behavior (e.g., throwing a tantrum when an undesirable food is presented) has been unintentionally rewarded (e.g., the parent removing the undesirable food from the child’s plate). The goal of ABA is to reward and encourage positive behaviors, starting small and building up, all the while working to eliminate negative behaviors.

Once the functional assessment is complete, the applied behavior analyst develops the Behavior Intervention Plan, which includes:

  • Modifying the antecedent
  • Teaching a new behavior
  • Replacing the problem behavior
  • Acquiring a new skill
  • Modifying consequences
  • Reinforcing the new behavior

The Behavior Intervention Plan uses the basic ABA techniques of antecedent (what occurs right before the behavior occurs), behavior (the behavior itself), consequence (the consequence of the behavior) – known as the ABC’s of ABA. For example, the child takes a bite of the desired food, the child eats the bite, and the child receives the positive reinforcement.

Some of the most frequently used ABA interventions for children with autism and feeding disorders include:

  • Positive reinforcement: The applied behavior analyst provides the child with a reward (food, toys, praise, etc.) each time the child engages in the desired eating behavior.
  • Escape extinction: Involves not allowing an escape from, or avoidance of, the appropriate eating behavior. An example of this may involve positioning the spoon in front of the child’s mouth until the bite is accepted, thereby preventing the child from escaping or avoiding the bite.
  • Differential positive reinforcement: Involves providing the child with access to small bites of the child’s desired food when he accepts or swallows small bites of other food. The child’s desired food is used as a positive reinforcer, either alone or in combination with social praise. As the child’s consumption of the non-preferred food increases, the proportion of preferred and nonpreferred foods is gradually altered. For example, the child may have to take two bites of the nonpreferred food to receive a bite of the preferred food.
  • Non-contingent positive reinforcement: Involves providing a preferred stimulus (e.g., a small toy or activity) continuously throughout the meal. An example of such a treatment may be providing the child with a video during the meal.
  • Simultaneous presentation: Involves presenting a less preferred food at the same time as a more preferred food is presented. The foods may be presented together or blended together, or the nonpreferred food may be inside or covering the preferred food.
  • Stimulus fading: This involves gradually changing the ratio or concentration of the paired preferred and nonpreferred food or liquid. For example, this may involve first presenting a ratio of a desired food (90 percent) to the undesired food (10 percent). The fading protocol would involve gradually decreasing the desired food and increasing the undesired food ratio.
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Additional Resources for Information on Treating Feeding Disorders with ABA

There are a variety of resources that address ABA therapies for children with autism spectrum disorders and feeding disorders:

The Association for Applied Behavior Analysis International has a special interest group for applied behavior analysts working in pediatric feeding disorders.

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