Behavioral Feeding Therapy

What is Behavior Analysis?

Behavior analysis is the study of the relationship between environmental conditions, behaviors, and consequences. Here’s an example of behavior analysis in a pediatric feeding case:

When seated at a table with food (environmental condition), a child chews and swallows food from a plate (behavior). As a result, the child is satiated (consequence).

When changes to mealtime behaviors are needed, a behavior therapist alters the relationship between eating behaviors and environmental conditions, as well as the relationship between eating behaviors and their consequences.

What is a Reinforcer?

reinforcers-feeding-therapyA reinforcer is a stimulus or event that occurs following a behavior and that alters the probability of that particular behavior occurring in the future. For example:

A bite of food is presented to a child, who opens their mouth and accepts the food. After the bite is taken, the feeder says, “Good job!”

If saying “Good job!” leads to more mouth openings in the future, saying this phrase to the child would be considered to be a reinforcer.

Misconceptions of Behavior Analysis

A common misconception is that using behavior analysis in feeding signifies that a child is misbehaving in some way.

However, it is more accurate to state that the behavior therapist alters the rates of various mealtime behaviors until the distributions of these behaviors result in an optimal amount of intake—whether measured by volume, time, or age appropriateness.

Another misconception is that behavior analysis is too simplistic to deal with feeding.

The reality is that behavior analysis is a complex study. There is a multitude of different variables that can be adjusted to speed up behavior acquisition as well as strengthen newly established behaviors.

What Behaviors Are Targeted?

Bite Acceptance

This refers to when a child, who doesn’t self-feed, opens their mouth within a few seconds of a spoonful of food being presented to them.

Packing

packing-pocketing-squirreling-foodThis is sometimes also referred to as pocketing or squirreling. Packing occurs when a bite is deposited into the mouth (self-fed or not), and the food is not swallowed within a normal amount of time. Packing can fall into two categories:

  1. Packing can be selective according to food type. For example, a picky eater might not pack bites of an apple or another fruit, but does pack broccoli. This type of packing is more likely to be attributed to food refusal.
  2. Packing can also be selective according to texture. For example, if a child does not pack purees, but does pack the same food in its non-pureed form, then this type of packing is more likely to be attributed to a skill deficit in chewing or in being able to manipulate certain textures in the mouth.

The consistency of foods also plays an important role in packing. A child who has been on a feeding tube for a long time might often pack bites of puree. Such children are not used to swallowing food that is thicker than their saliva. In this case, there is a skill deficit in swallowing thicker consistencies.

Eliminating either category of packing inversely increases the rate of swallowing.

Coughing/ Gagging

This only pertains to a feeding disorder if there are no medical reason for this to occur.

Vomiting

Vomiting refers to foods that are ingested and then expelled from the mouth. There are many factors that may cause vomiting issues, including reflux, motility issues, allergies, feeding tube placement, habit arising from a previously resolved medical issue, consistency of food, texture of food, and time since last feeding. There are many behavior- based procedures that can lessen the frequency of vomiting, if not eliminate it completely.

Combined Inappropriate Behaviors (CI):

These include head turns, turning the torso more than 180°, hitting the spoon, and kicking. Typically, a behavior-based approach includes decreasing the rates of these behaviors.

Expel

This refers to a bite being deposited into the mouth and then spat out without being ingested. This can occur with or without the skill deficits mentioned above under “Packing.” In order to apply the proper treatment, it is important that the behavior therapist makes a good assessment to determine the reason of the expulsion. Expulsions also occur with liquids.

Pica

This occurs when a child aTempts to ingest non-edible items such as toys or hairbrushes. Pica does not refer to the mouthing of non-food items that toddlers typically engage in.

Rumination

This refers to the reingestion of food that has been previously vomited. This can occur without the vomit leaving the mouth. This cycle of vomiting and reswallowing can occur for hours at a time.

Treating Feeding Disorders with Behavior Analytic Methodology

behavioral feeding therapyThere are an infinite number of distributions of behaviors that can exist at mealtimes. If there are low volumes of intake or a limited variety of foods consumed, an analysis of mealtime behaviors should be conducted:

  1. Some behaviors interfere with intake, such as vomiting, head turns, crying, expelling, or batting at the spoon.
  2. Desired behaviors—such as mouth openings, swallowing, or chewing—do occur, but at lower than optimal rates.
  3. There are times when a behavior that needs to occur does not exist. Such a behavior needs to be conditioned from scratch.

Once the analysis is completed, a treatment plan can be devised to address each of the behaviors that should be targeted to improve the level of intake. There are multiple treatments that can be used to address a particular behavior. The key is to find the right combination of treatments that addresses all of the mealtime behaviors.

The focus of this approach is on behaviors and not diagnoses. Whether a child has autism, Down syndrome, cerebral palsy, or is developmentally normal is irrelevant. What matters most is:

  1. What the child is doing
  2. Which behaviors need to be improved upon
  3. Which behaviors need to occur less frequently

The treatment process can become complex because:

  1. Many behaviors need to be targeted within a given trial.
  2. Some of the different targeted behaviors also need to be conditioned to occur sequentially.
  3. Some behaviors such as chewing can be complex to treat because, for example, chewing itself consists of more than one behavior. The same goes for swallowing.

Advantages of Using Behavioristic Approach to Pediatric Feeding Disorders

There are a number of advantages in using this approach.

  1. Using behavior analysis makes therapy highly individualized. Because the focus is on behavioral distributions, this method allows for the complete customization of feeding therapy.
  2. Sometimes the changes needed in feeding behaviors are critical to the health and well being of a child. If implemented correctly, desired changes in mealtime behaviors are produced quickly.
  3. The effects of behavior based feeding therapy are long lasting.