Treatment for Behavioral Aspects of Feeding Disorders:
When we finally found the medical causes to Conor’s feeding problems we also had to deal with the behavioral problems that arose from his conditions. Feeding disorders can be medical and physical in basis and thus result in behavioral issues.
We worked with a Behavioral Psychologist in conjunction with speech & occupational therapists as well as medical doctors to concentrate on all areas of Conor’s problems.
We saw the Behavioral Psychologist for 8 months. At the start Conor would eat NO FOOD and existed on a purely liquid diet. A year later a sample daily diet is as follows:
Breakfast:
3 breakfast sausages
1/2 waffle with syrup
4 oz of yogurt
Mid-morning snack:
4 oz applesauce
Lunch:
1/2 slice of pizza
4 oz pudding
Afternoon snack:
3 cookies
Dinner:
3 oz meatballs in tomato sauce
4 noodles
1 oz Broccoli (hidden in his food)
Granted, Conor’s skills are still poor. He still receives ST and OT and I usually have to put most bites of food into his mouth for him. He takes about an hour to eat each meal and I have to continually remind him to chew. But, his progress has been amazing!
As I said, it is a slow and frustrating process. We would make baby steps of progress with Conor and get so excited only to have him slip back. The set backs were devastating. However, just as our Psychologist told us it would be, Conor would make up those steps again in half the time. It has taken us a year to get where we are.
These behavioral issues can be worked out when a parent works with a qualified behavioral psychologist who is familiar with feeding problems in children. For more information on a program or therapist in your area click here.
Depending on the intervention method your therapist uses the process may be very slow and frustrating, but the long term effectiveness can be amazing. Other methods are more intrusive yet are designed to work more quickly.
I will outline 3 intervention methods I am familiar with. All three have similar components to them. However, it is important to read all the information for each program to determine which method would be most effective with your child and which method you could realistically follow. None of these methods is "simple" and require a great deal of work and determination on the part of the parent.
Behavioral Modification Programs
Positive Reinforcement
Keep a Daily Food Intake Diary. Keep it in a notebook. Write down every bite the child eats (or drinks), what time she eats it and how she acted and how you reacted! Also write down anything out of the ordinary that happened during the day -- to see if it might have an effect on eating (i.e. in car all day travelling -- not much time for structured feeding) Be brutally honest.
This diary will help you see eating patterns and changes in the patterns. It will help you see progress and pinpoint troubles.
Observe the child and the feeding sessions. Our BP didn't need to meet Conor right away, but recommended video taping typical meals in the home environment since this is most natural for the child. Try to be inconspicuous about this. I just laid the camera on the other end of the table. I video taped a few sessions at home with Conor and it really helped me see how I was acting and reacting and helped me to change my process.
Priority is placed on the use of rewards for positive feeding behavior. The rewards be achievable and set at a level that the child can understand.
Minimize disruptive or non-compliant behavior. Ignore negative behavior. Punishment, such as time-outs, should be held until later in the process.
So here's what you need to do:
Encourage but do not badger the child. Suggest she take a bite, then back off. At first your goals will be small -- One bite or 3 -- depending on child's capabilties -- remember rewards must be attainable. Once she takes a bite - reward her immediately. With Conor we used enthusiastic verbal praise at first, then we moved on to chocolate chips, etc then sticker charts as he got older and understood the idea of rewards. You can also use a pop-up toy that will pop up every time the child takes a bite. However, we always continued the verbal praise. Some examples of verbal praise:
It is important to tie the praise to the behavior as opposed to the child. Try to avoid saying things like "good girl" or "Aren't you wonderful".
If the child only eats one particular food on a regular basis, it may NOT be a good idea to use that food as the reward, as that would mean restricting her from them at other times.
Remember, you are rewarding her-- not bribing her!!!! Don't mention the reward to entice her.
Consitency is KEY. The reward should be consistent (EVERY SINGLE BITE give her a huge cheer!!!!!!!!!).
Once the child meets the goal for that sitting, then you can let her down. End on a positive note. If you sense a melt down, cut the session short as long as you’ve met with some success.
If weight gain or maintaining weight is the goal, then concentrate on high calorie foods. Introduction of different types of food might have to be put off for a while. If increasing variety of foods or introducing new textures is the goal then start with foods that have the highest probability of being eaten.
She must sit at the table whenever she is eating or drinking!
Withhold liquids and food for a set time period before and after the eating session. About 1/2 - 1 hour. This way the child will do not learn that she can just get her drink right afterward regardless of her performance.
You must IGNORE her "bad behavior", screaming, biting, crying etc.. Either turn your back on her, leave the room or just don't react. But PRAISE her good efforts!
After a while, when the child is older, Time Outs may be used for negative behavior. Consistency is key, but keep updating you process as the child makes progress.
Use the diary - it is very important. Increase your goal after a few days of success -- if you started with one bite, increase to three. Increase the reward as well -- go from two chocolate chips to five for each goal met -- but continue the verbal praise after each bite! After the eating progresses to a much better point, then you can lessen the reward time frame.
If you can, get someone to take a few feedings a week for you. It really helps to have someone take the pressure off now and then.
Remember, this is a SIMPLIFIED version of what we did -- our tactics changed every week as I would see the psychologist. I had to go, by myself, once a week at first and then every other week. Study the diary to look for patterns to good eating. I highly recommend working with a qualified medical professional.
Click here to proceed to the Differential Reinforcement Program.
The first I will call Positive Reinforcement. This is the program we used for our son. We worked under the guidance of Dr. Julianna Rasic Lachenmeyer for our work with Conor. The other two methods are geared tward changing "food selectivity" issues and are called Differential Reinforcement and Escape Extinction. These two programs were developed by Len Levine, Ph.D. of the Alpine Learning Group, Inc. and are printed here with his permission.
In a simplified version of the process, here is how it works:
You must sit at the table (or a designated feeding place) to feed the child and only the child, 3-4 times a day. A sitting should last about 30-40 minutes. The child may and should sit at the table and play with food at other times when you are eating for socializing. However, the feeding sessions should be very focused. Eliminate all distractions (toys, TV, other people etc).
Hooray!
Clapping & Cheering!
What good eating!
Great job!
Wow, you must be so hungry!
It is OK to switch foods if the child does not respond to the one you first gave her -- but only give 1-3 choices. Start with foods you know she will like -- even if it is the same thing at every single meal, even if it is chocolate chip cookies!
Click here to proceed with the Escape Extinction Program (under construction)