MaryLouise E. Kerwin, Ph.D., BCBA-D
Chair and Professor, Department of Psychology, Rowan University, Professor, Department of Biomedical Sciences at Cooper Medical School of Rowan University, Director, Center for Behavior Analysis
Why are behavioral treatment approaches used with pediatric feeding problems?
Answering this question requires an understanding of factors that cause and maintain feeding problems in children. In the past, research suggested that many feeding problems were caused by, or reflected, difficulties in the parent-child relationship, especially the mother-child relationship. More recent research suggests that some medical factors may have a larger role in contributing to feeding difficulties than previously recognized. While the medical basis for food refusal in a child with esophageal atresia seems obvious, the medical basis for some other feeding problems is less apparent. For example, what medical factors might explain the extremely limited diet of children with autism, or why a cognitively and developmentally typical three year old child will only eat pureed or smooth foods? Researchers are beginning to recognize the role of gastrointestinal function combined with muscle tone, movement and respiratory function on the developing child’s feeding.
But what does a growing appreciation of medical factors have to do with behavioral treatment? Children, like adults, use behavior to communicate. Adults who do not want to speak to someone at a party might ignore someone’s overtures to enter a conversation. Similarly, if children do not feel comfortable when they eat a certain texture of food, or a certain amount of food, they will likely refuse the food. Most parents, if not all parents, realize that refusal of the food communicates that the child is not interested in eating. In addition, parents know that children are often picky at one meal or another, but that children are supposed to be able to regulate calorie intake for growth if left to their own devices. Armed with this knowledge, most parents appropriately assume that the child is not hungry so they end the meal.
But what if the child’s food refusal is not simply a temporary or momentary blip in self-regulation of calories? What if the food refusal indicates something is wrong? How do parents differentiate between the temporary blip and a meaningful signal? Research suggests that most children are picky eaters between three and five years of age, but that they outgrow it. So parents, appropriately so, given their knowledge and understanding, wait it out and remove offending foods from diets and end meals early. But what if the child’s eating difficulty is a signal of an underlying medical problem? By the time the underlying problem is diagnosed and treated, the child has gotten into a pattern of refusal that often does not get better even after the underlying problem has been treated. At this point, the child (and parents) often need to relearn new ways of feeding through the use of behavioral treatments.
Many behavioral treatment programs for feeding problems are designed to increase food acceptance using positive reinforcement. In these programs, the child is presented with a bite of a non-preferred food. If the child accepts the bite of food, the child gets access to something positive for a brief period of time (e.g., a piece of preferred food or a favorite toy or activity). If the child does not accept the bite of non-preferred food, the bite of food is removed and time elapses (usually 20-30 seconds) before the presentation of the next bite. Occasionally, other components are added to the behavioral program to increase acceptance of non-preferred foods. If other components are added to the behavioral program, the program should be executed and monitored by a certified behavior analyst or similar professional with experience implementing behavioral treatment of feeding problems.
For a parent, following through on behavioral programs for feeding problems can be difficult because it seems so unnatural. However, by the time a behavioral program is implemented, feeding is not fun for the child nor the parents. One purpose of behavioral programs is to connect positive events with acceptance of non-preferred foods. Once this connection occurs, children often begin to spontaneously taste new foods and eat more at family meals. While I may have made it sound easy, the success of most behavioral treatment programs depends on effective and active management of any past or current impediments to eating. In fact, once a behavioral program has been successful, the child’s regression or lack of progress may indicate that the child’s original, underlying medical problem is no longer managed. In summary, most feeding problems originate from an underlying medical issue; however, once the medical difficulty is identified and treated, the feeding problem often remains, necessitating behavioral intervention.