Parents of young children more than likely have experienced various levels of pickiness when it comes to getting their children to eat or experience new or different foods. And if you are wondering: “is it just me?” studies have found that this is a rather common problem. About 25% of typically developing children display some forms of picky eating. If you are a parent of a child with developmental disabilities, chances are you have encountered this more often, as it is estimated that 33% of children with disabilities present with feeding difficulties. And if you are a parent of a child with autism, well, you more than likely have a breadth of experience with feeding difficulties as some estimates place the rates of prevalence at about 70% for this population.
What is a Feeding Disorder?
The DSM-5 has broken down problems surrounding feeding and eating into six categories. The focus of this post will be on one particular category labeled as Avoidant/Restrictive Food Intake Disorder (ARFID). It is defined as a disturbance in feeding or eating such that there is a persistent failure to meet appropriate nutritional or energy needs associated with significant weight loss or failure to thrive, significant nutritional deficiencies, dependence upon feeding tubes or supplements and/or interference with interpersonal and social relationships without a direct medical or other psychological (e.g. anorexia or bulimia) cause.
As of yet, researchers have not determined what causes ARFID. Some contributing factors may include conditioned responses due to underlying gastrointestinal tract issues (e.g. eating certain foods/textures may result in vomiting or discomfort), low oral muscle tone or coordination, increased sensitivities to textures (seen primarily in autism) or a traumatic event such as choking. When faced with a child presenting with these symptoms, parents will often turn to their pediatrician first and return home with the advice to “wait it out,” that the child will “grow out of it” or to “starve them out.” However, for a child who does not display hunger signs or who has significant restrictive patterns in feeding, this is dangerous and can potentially spiral into chronic feeding problems, putting the child at risk to develop a swath of detrimental medical and developmental issues. These can include malnutrition, growth retardation, developmental, psychological and social delays and may even result in invasive medical interventions such as placement of a feeding tube.
So where should parents turn when faced with a child they are struggling to feed?
Some Common Treatments of Pediatric Food Refusal
There are a number of specialists who include the treatment of feeding disorders into their scope of practice. These include:
Pediatric gastroenterologists – the primary role of these medical professionals is to assess any physiological or structural conditions that may be causing or contributing to the problem. Based on the medical assessment or diagnosis, medicine may be prescribed, and surgery to correct structural abnormalities or to place a gastro-intestinal tube may be recommended.
Occupational therapists – The primary treatment is sensory integrative therapy, which targets underlying sensory deficits by identifying and developing an individualized sensory diet. Exposure to new foods may also occur via play based therapy. Oral motor skill development may be the goal of occupational therapy as well, as well as self-feeding behavior such as using utensils.
Speech therapists – These practitioners specialize in diagnosing and treating physiological difficulties associated with eating including assessing and treating poor oral muscle tone and swallowing disorders (known as dysphagia). Other popular treatments include pre-chaining and food chaining programs.
Psychologists – Use of cognitive therapy, relaxation and imaging techniques are generally used to treat both feeding and eating disorders.
Behavior Analysts – Evaluate environment factors maintaining maladaptive behaviors that occur at mealtime, such as the caregivers’ response to the child. Using this information, treatments that employ the core principles of applied behavior analysis (ABA) are developed specific to the child. Reinforcement for engaging in desired behaviors (taking bites, chewing, swallowing, using utensils, etcetera) is incorporated.
An (2010) article published in Clinical Child and Family Psychology Review evaluated treatment outcomes of feeding disorders within the published scientific literature. The authors specified 8 criteria in order for articles to be included in this review. Of note, inclusion criteria specified studies: 1) listing food intake as the goal of the intervention, 2) examining the effects of treatment of what is now known as ARFID, 3) meeting the criteria for rigorous scientific research (e.g. reliability data and graphically displayed, clearly identifiable baseline and treatment phases). Of the 48 studies that met these criteria, all emphasized the use of behavioral interventions with more than half of the studies included coming from the Journal of Applied Behavior Analysis. The authors note that the few articles that described approaches using sensory, psychodynamic, family and oral motor therapy were excluded since no outcomes of treatment effectiveness were described in these studies, making the behavioral treatment of feeding disorders the only treatment model currently proven to be effective.
Behavioral Feeding Therapy Treatments of Pediatric Feeding Disorders
It is important to note that the treatment of feeding disorders is a specialty field within applied behavior analysis. Therefore, when seeking treatment of a feeding disorder for your child, only those with experience and extensive training in this area are qualified to carry out these interventions. Really, not just any BCBA can do this and those that do have received years of supervised experience before practicing independently.
Three factors are examined before a behavioral intervention is designed and implemented.
- The first are medical factors. These are assessed by a physician and determine if there is an underlying medical condition that is causing or contributing to the problem. These can include structural abnormalities (such as short gut syndrome or palate malformation) or factors such as reflux and allergies. This is a critical step that must be completed and treated (if necessary) before considering a behavioral intervention.
- The second are skill factors associated with eating such as chewing, swallowing and oral motor weakness. These are assessed by speech language pathologists and some occupational therapists who have received training in this area. A child who presents with signs of these deficits must be evaluated before considering a behavioral intervention. Often times, oral motor therapists will work collaboratively with a BCBA in order to develop a treatment approach that is safe and effective for the child.
- The third are behavioral factors, which are assessed by a behavior analyst who examines parent/child interactions to determine the function of the child’s food refusal. These interventions can only address feeding behaviors that are maintained by the environment – not the physiological issues that may have resulted in the maladaptive mealtime behavior.
With feeding disorders, behavior analysts are concerned with the volume of food consumed, the variety of foods accepted (i.e. does the child eat foods from all food groups?), the rate of eating (are meals too long?) as well as behavioral issues that may impede feeding or impact family/social mealtimes. Common behavioral concerns faced by parents include: solid or liquid refusal, physical and verbal protest, refusal to self-feed, throwing food, expelling food, gagging or coughing, selectivity by texture, type or color, as well as vomiting. Research on this subject has determined that there are three common consequences that maintain the problematic behaviors surrounding feeding disorders. They include providing escape (e.g. ending the meal, or removing the non-preferred food), attention (can be in the form of coaxing, comforting, or reprimands) or access to preferred items or food, with escape being the most common consequence following problematic mealtime behavior. Of note, it was determined that all of these consequences (i.e. the reinforcing consequences) were more likely to follow refusal/problem behavior rather than food acceptance. It is this link between the behavior and the consequences it produces that can turn a behavior that may have had a sensory or medical etiology to develop into a chronic pattern of food refusal. Therefore, what makes ABA based interventions so successful is that the specific consequences identified to maintain the problem are used to correct the problem, with the terminal goal being food acceptance. The result is a process that: 1) breaks the link between the problem behavior and the variable(s) that maintain it, 2) teaching an appropriate response and 3) providing a powerful reward for that response.
Recommendations for Caregivers
There is a range of treatment options available for ARFID with varying levels of treatment intensity. Several hospitals offer day treatment or outpatient services and some feature a multidisciplinary team. There are also clinic-based feeding services available that can be offered for varying levels of intensity, as well as home based services for less intensive feeding needs or to generalize feeding programs into the home and to help provide ongoing support to the caregivers.
The first step to any intervention is identifying the problem. It is important to note that scientists are still searching for the cause of feeding disorders, especially for chronic food selectivity and refusal. What is more, the body of research in this subject is surprisingly sparse. To date, the only treatment modality that has demonstrated repeated effectiveness, is that based on the principles of behavior analysis.
Like other areas of development, early intervention to address maladaptive mealtime behavior is important. In most cases, a better prognosis is associated with developing desired mealtime behaviors before bad habits become the norm. That being said, there are plenty of school age children that have participated in behaviorally based feeding programs and have been successful in reshaping years of inappropriate mealtime behavior.
Ultimately it is the child’s caregivers who will be responsible for ensuring that the new rules for mealtime are carried out. A child may make incredible progress with a therapist, but that child has no reason to change their behavior outside of the treatment setting, which is why caregiver training is the most important component of any program to address challenging mealtime behavior. And while there is effort involved, many caregivers have reported that putting the effort in to develop appropriate eating behaviors is far more worthwhile than the ongoing frustration of a child that engages in problematic mealtime behavior.
Addison, L., Piazza, C., Patel, M., Bachmeyer, M., Rivas, K., Milnes, S., and Oddo, J. (2012) A Comparison of Sensory Integrative and Behavioral Therapies as Treatment for Pediatric Feeding Disorders. Journal of Applied Behavior Analysis, 45 (3), 455 – 471.
Borrero, C., Woods, J., Borrero, J., Masler, E., Lesser, A. (2010). Descriptive Analyses of Pediatric Food Refusal and Acceptance. Journal of Applied Behavior Analysis, 43 (1) 71 – 88.
“Feeding and Swallowing Disorders (Dysphagia) in Children”. Asha.org. N.p., 2016. Web. 22 Mar. 2016.
Kelly, N. Shank, L., Bakalar, J., Tanofsky-Kraff, M. (2014) Pediatric Feeding and Eating Disorders: Current State of Diagnosis and Treatment. Current Psychiatry Report, 16 (5), 1 – 12.
Kreipe, R., Palomaki, A. (2012). Beyond Picky Eating: Avoidant/Restrictive Food Intake Disorder. Current Psychiatry Reports, 14, 421 – 431.
Ledford, J & Gast, D. (2006) Feeding Problems in Children with Autism Spectrum Disorders: A Review. Focus on Autism and Other Developmental Disabilities 21 (3), 153 – 166.
Sharp, W. Jaquess, D., Morton, J. and Herzinger, C. (2010). Pediatric Feeding Disorders: A Quantitative Synthesis of Treatment Outcomes. Clinical Child and Family Psychology Review 13 348 – 365.
Shore, B., & Piazza, C., (1997). Pediatric Feeding Disorders. In Knoarski, Favell, J.E. & Favell, J.E. (eds.), Manual for the Assessment and Treatment of the Behavior Disorder of People with Mental Retardation (pp. 65 – 89). New York: Guildford.