The purpose of this article is to offer a practical guide for professionals and parents who implement behavioural interventions to treat feeding disorders in children.
Feeding problems appear more frequently among children with developmental disorders (33-88%) but are also common in typically developing children, 2% to 35% of whom also exhibit them (percentages vary depending on the severity of the feeding disorder under study). Feeding disorders can be classified in two broad categories: selective eating of certain food types, food groups or flavours and insufficient oral food intake.
Involuntary reinforcement of inappropriate feeding behaviours very often contributes in the onset and maintenance of feeding problems. Specifically, when an inappropriate behaviour exhibited by the child (e.g., crying) results in the food removal and/or meal termination (e.g., parents remove vegetables from the table), in the presentation of a preferred food (e.g., fried eggs appear) or the presentation of another preferred stimulus (e.g., cartoons are turned on after the onset of problem behaviour, the parent pays attention to the child’s crying), then this inappropriate behaviour will tend to appear more frequently in the future.
Behavioural interventions that have been successfully used for the treatment of feeding disorders include a combination of strategies based on positive reinforcement and on escape extinction. More in detail, they include providing access to preferred stimuli (e.g., toys) when the child engages in desirable feeding behaviours and not accepting non-desirable behaviours (e.g., crying) as a means to escaping from food (i.e., the child does not manage to escape food through engaging in the non-desirable behaviour).
Although it is an evidence-based effective procedure, escape extinction has been associated with a number of undesirable side effects, including an initial burst in the inappropriate behaviour, extinction-induced aggression and emotional responding (such as crying). In addition, extinction might be difficult to implement and treatment fidelity might be compromised as a result of the child’s size or strength. As a result of its use, meals might become aversive for children as well as caregivers. For these reasons, treatments based on escape extinction might not be the best option, especially since a number of studies have shown that behavioural procedures can be effective without the use of escape extinction and that the omission of escape extinction facilitates implementation by parents. The two main effective strategies used instead of escape extinction are based on reinforcement and antecedent manipulation.
Reinforcement-based strategies involve providing the child with access to preferred stimuli contingent on desired behaviours (e.g., access to a favourite toy after the child swallowed bites of food or showing favourite videos during meal times). Preferred foods or drinks are always used as positive reinforcers, either alone or in combination with social praise. At the same time, it is crucial that we ignore problem behaviours so that positive results can be achieved for children whose problem behaviour is maintained by attention.
Antecedent-based procedures include the simultaneous presentation of desirable and undesirable foods, either by placing them together in a spoon or by mixing them or putting one inside the other or covering each other. The simultaneous presentation of food stimuli (e.g., non-preferred vegetables with preferred fried potatoes) is sufficient for turning non-desirable food into reinforcing. Pairing both flavours could boost the reinforcing power of the less desirable one. Nevertheless, this pairing can potentially work in an inverse fashion, especially in the case of children with a very restricted food repertoire, restricting even further the variety of preferred foods (e.g., the child could stop eating fried potatoes as a result of pairing them with non-desirable vegetables). This risk can be overcome by gradually increasing the non-desirable food (e.g., presenting a very small quantity of vegetables at the beginning and gradually increasing this). As far as the availability of desirable foods is concerned, access to these should be restricted, so that deprivation can increase their reinforcing power. In simple words, if the desired food is fried potatoes, it is suggested that the child can only have fries during meal times and as the treatment plan for feeding disorders dictates, so that there is strong motivation to obtain them. Research has shown that the simultaneous presentation of foods is effective mostly with solid foods, while mixing and fading foods is more effective with liquids. Finally, another method for increasing the variety of foods the child eats is to provide verbal rules that the child is likely to follow in combination with rules that the child is less likely to follow with the aim to increase the likelihood of following the latter.
In any case, in the selection of the best strategy, children’s individual history, their nutritional needs for maintaining a healthy development as well as their family’s needs should be taken into account. It is also important that the treatment is supervised by a behaviour analyst with extensive experience in feeding disorders.
Bachmeyer, M. H. (2009). Treatment of Selective and Inadequate Food Intake in Children: A Review and Practical Guide.Behavior Analysis in Practice, 2(1), 43-50. Article summarised with the editor’s permission.
Summary & Translation in Greek: Elena Marinopoulou & Vasilis Vlachodimos
Editor: Katerina Dounavi, PhD, BCBA-D