Picky Eaters Facts and Interventions Part 1
A Picky eater is a broad term covering many food issues. Common feeding difficulties include mechanics of eating (holding utensils, etc.), swallowing, restricted food preference (types, texture, & presentation), eating too much, and eating too little. Ethical and legal issues regarding the implementation of feeding interventions in schools may vary across training, location, and experience and consulting with a team of experienced professionals (i.e. SLP, OT, dietician, medical doctor, psychologist, BCBA, etc.) is a critical component of the treatment plan. Research has shown that applied behavior analysis procedures such as antecedent interventions and escape extinction have been effective in treating feeding issues with students with Autism. This webinar will review types of eating issues, ethical issues related to treating feeding issues in schools, assessment procedures, and a review of evidence based practice to help with specific issues.
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[00:00:02.281]Hello, and welcome to our webinar today.
[00:00:05.606]This training is brought to you
[00:00:07.408]by the Tri-State Webinar Series,
[00:00:10.075]which is made available through collaboration
[00:00:12.769]with the Colorado Department of Education,
[00:00:15.627]the Kansas TASN Autism and Tertiary Behavior Supports,
[00:00:20.286]and the Nebraska Autism Spectrum Disorders Network.
[00:00:24.057]We are so glad to have you join us today.
[00:00:29.473]Polling questions will be used throughout the webinar.
[00:00:32.970]Follow the directions when each question is presented.
[00:00:38.699]This lesson consists of a webinar
[00:00:40.592]by Melinda Henson, BCBA, behavior analyst
[00:00:43.961]for the Nebraska Autism Spectrum Disorders Network.
[00:00:47.428]I received my board certified behavior analyst credential
[00:00:50.498]in 2009, following the completion of a master's degree
[00:00:54.072]in special education with an emphasis on autism education
[00:00:57.487]through the University of Missouri.
[00:00:59.801]I completed my behavior analyst coursework
[00:01:02.017]through Florida Institute of Technology.
[00:01:04.401]My career has included positions within University,
[00:01:07.349]State Agency, home and school settings,
[00:01:10.262]supporting the individuals with autism across the lifespan.
[00:01:13.966]My primary clinical interests are in the areas
[00:01:16.372]of early childhood education,
[00:01:18.460]functional behavior assessment and supports,
[00:01:21.069]building collaborative teams and school settings,
[00:01:23.726]and delivering effective staff development
[00:01:25.711]and training procedures.
[00:01:30.539]Learner objectives for part one of the Picky Eaters
[00:01:33.623]Facts and Interventions webinar series
[00:01:35.988]will include the ability to identify
[00:01:38.233]estimated prevalence of feeding problems
[00:01:40.502]in children with an ASD,
[00:01:42.472]understand different examples
[00:01:43.927]of feeding and eating challenges,
[00:01:46.395]recognize ethical considerations
[00:01:48.270]in treating feeding issues within school settings,
[00:01:51.285]and identify behavioral assessment factors
[00:01:53.708]to emphasize or adapt for children with autism.
[00:02:01.913]Learner objectives for part one of this series
[00:02:04.382]will be met by reviewing the following topics,
[00:02:07.409]current identified prevalence
[00:02:08.889]of feeding concerns in children with an ASD,
[00:02:12.109]types of eating challenges to rule in or out,
[00:02:15.168]including mechanics, physiological concerns,
[00:02:18.038]swallowing, restricted food interests,
[00:02:20.455]and nutritional concerns,
[00:02:22.388]ethical considerations related to treating
[00:02:24.696]feeding issues in schools, including scope of practice,
[00:02:28.129]use of multidisciplinary teams,
[00:02:30.314]and IDEA and related services,
[00:02:32.827]and finally, a brief introduction to behavioral assessment.
[00:02:38.368]Let's begin with an overview of the estimated prevalence
[00:02:41.252]and impact of feeding and eating challenges
[00:02:43.637]in children with an autism spectrum disorder.
[00:02:48.097]Autism is characterized by impairments
[00:02:50.146]in social interaction, communication deficits,
[00:02:53.128]and repetitive or stereotyped behavior.
[00:02:56.033]A number of reasons have been suggested
[00:02:58.084]for the prevalence of feeding problems
[00:02:59.784]in children with an ASD,
[00:03:01.673]including a concentration on detail,
[00:03:06.296]fear of novelty, sensory impairments,
[00:03:08.772]deficits in social compliance,
[00:03:10.775]and biological food intolerance.
[00:03:14.636]reinforcement of negative feeding patterns,
[00:03:16.793]and communication difficulties
[00:03:18.592]have been suggested as additional social reinforcers
[00:03:21.469]that contribute to the maintenance
[00:03:23.006]of maladaptive feeding behaviors in this population.
[00:03:26.719]Ahearn, Castine, Nault, and Green in 2001,
[00:03:30.352]suggested that selective feeding in children with ASD
[00:03:33.628]was a manifestation of their restricted interests
[00:03:40.086]The estimated prevalence of feeding problems
[00:03:42.120]in children with autism has been reported
[00:03:44.405]to be as high as 90% by Kodak & Piazza in 2008,
[00:03:49.251]with close to 70% of children
[00:03:51.034]with an autism spectrum disorder
[00:03:52.761]described as selective eaters
[00:03:54.854]by Twachtman-Reilly et al in 2008.
[00:04:03.835]For example, up to 89% of children
[00:04:06.729]with autism spectrum disorders
[00:04:08.954]display strong preferences for certain foods
[00:04:11.458]by type, texture, color, or packaging,
[00:04:14.558]consume a narrower range and quantity of food
[00:04:17.230]when compared with peers,
[00:04:19.009]and or display elevated rates of disruptive behavior
[00:04:22.157]when presented with a non-preferred food.
[00:04:26.801]In 2003, Schwarz concluded that most of these problems
[00:04:30.804]in children with ASD can be categorized
[00:04:33.447]as behavior feeding disorders,
[00:04:35.610]including aversive eating behaviors,
[00:04:38.007]such as food refusal, choking, gagging,
[00:04:40.477]and expulsion with no medical basis,
[00:04:42.984]and sensory-based feeding problems,
[00:04:45.206]textural aversions to specific kinds of foods,
[00:04:48.051]usually involving the refusal of foods with greater texture.
[00:04:51.839]Schwarz explained that feeding difficulties
[00:04:53.836]in children without ASD on the other hand,
[00:04:56.805]are usually due to a medical condition,
[00:04:59.152]such as esophageal problems,
[00:05:01.048]swallowing disorders, and motor delays.
[00:05:05.688]For the purpose of this webinar,
[00:05:07.567]we will use a definition provided by Ledford & Gast,
[00:05:10.620]2006, for feeding problems,
[00:05:13.124]but we'll use the term picky eating
[00:05:15.190]to mean children with ASD with selective acceptance of food
[00:05:18.853]or refusal to eat many or most foods
[00:05:21.122]with no known medical explanation.
[00:05:23.723]This will eliminate the need to discriminate
[00:05:25.832]between the terms aberrant feeding behaviors,
[00:05:28.619]maladaptive feeding behavior,
[00:05:30.335]problem feeding behavior, and problem feeders.
[00:05:37.639]Picky eaters are considered to have a feeding problem
[00:05:40.255]when they eat less than 20 foods,
[00:05:43.166]they eat fewer and fewer foods over time
[00:05:45.869]until they are limited to about five
[00:05:47.440]to 10 foods they will eat,
[00:05:49.658]they refuse foods of certain textures altogether,
[00:05:52.662]they will eat one food over and over,
[00:05:55.062]but unlike mildly picky eaters, they will eventually
[00:05:57.550]burn out and not go back to eating that food again,
[00:06:00.931]they will not accept new foods on their plate
[00:06:02.994]and will not tolerate even touching or tasting a new food.
[00:06:06.417]They might cry, scream, and tantrum
[00:06:08.425]when new foods are placed on their plate.
[00:06:11.057]They are unwilling to try a new food
[00:06:12.745]even after 10 exposures.
[00:06:14.984]They have a rigidity and need for routine
[00:06:17.180]or sameness during meals,
[00:06:19.051]and they are inflexible about certain foods.
[00:06:24.946]The emergence and maintenance of severe feeding problems
[00:06:27.801]in ASD often has no identifiable organic factors
[00:06:31.701]or gastrointestinal etiology,
[00:06:34.460]leading to the hypothesis that aberrant feeding habits
[00:06:37.215]among those with ASD may be a manifestation
[00:06:40.410]of restricted interests, behavioral rigidity,
[00:06:43.425]and or perseveration.
[00:06:47.918]Please take a moment to answer the following question.
[00:06:51.062]In 2008, Kodak & Piazza reported the prevalence
[00:06:54.195]of feeding problems in children with autism
[00:06:56.830]as high as what percent?
[00:07:13.660]The correct ans is D,
[00:07:15.558]the estimated prevalence in children with autism
[00:07:18.832]reported by Kodak & Piazza is as high as 90%.
[00:07:25.834]Unlike typical picky eating seen in childhood,
[00:07:28.954]more significant feeding problems
[00:07:30.602]are not a normal part of child development.
[00:07:33.505]Children who are problem feeders often have
[00:07:35.656]inadequate caloric intake, poor weight gain and growth,
[00:07:39.131]as well as vitamin and mineral deficiencies.
[00:07:41.995]If left untreated, children who are problem feeders
[00:07:44.662]can suffer from malnutrition, dehydration,
[00:07:47.460]and impaired intellectual, emotional,
[00:07:49.435]and academic development.
[00:07:51.593]Problem feeders, or extreme picky eaters,
[00:07:54.519]will often need extensive therapy
[00:07:56.176]from a multidisciplinary feeding team.
[00:07:58.930]This might include occupational therapists,
[00:08:01.472]speech therapists, nutritionists,
[00:08:04.079]a psychologist or a behaviorist, and physician,
[00:08:06.961]of which the parents are an integral part
[00:08:09.154]in order to overcome their eating problems.
[00:08:14.303]Let's begin by discussing common types of feeding issues,
[00:08:17.292]including organic factors such as mechanical delays
[00:08:20.349]and physiological issues
[00:08:22.026]before discussing restricted food preferences
[00:08:24.366]and nutritional concerns.
[00:08:26.512]We will suggest a hierarchy of assessment
[00:08:28.515]which considers any underlying physical
[00:08:30.774]or medical barriers prior to implementing
[00:08:33.001]behaviorally-based eating interventions.
[00:08:38.758]The first step in evaluating feeding and eating concerns
[00:08:41.614]is to consider any relevant mechanics of eating barriers.
[00:08:45.680]This would include consulting with an occupational therapist
[00:08:48.513]to assess any issues related to motor ability,
[00:08:52.037]positioning, bite size, and chewing.
[00:08:54.848]Typical consumption involves a number of successive steps.
[00:08:58.389]Bringing a bite to the lips,
[00:08:59.848]accepting food into the mouth,
[00:09:01.784]chewing and forming a bolus,
[00:09:03.575]swallowing and clearing the mouth.
[00:09:05.724]Problems may arise at different points
[00:09:07.362]along this chain of consumption.
[00:09:09.794]To improve mechanics of feeding,
[00:09:11.546]occupational therapists often work directly with children
[00:09:14.224]on the following goals.
[00:09:16.125]Establishing a developmental sequence
[00:09:17.939]of self-feeding skills.
[00:09:19.669]For example, teaching a child to hold a spoon,
[00:09:22.369]scoop food, or bring a spoon to mouth
[00:09:24.423]as prerequisite feeding skills.
[00:09:26.990]Improving oral motor skills, such as sucking,
[00:09:29.500]chewing, propelling, and swallowing food
[00:09:31.690]effectively, efficiently, and safely.
[00:09:34.668]For children with feeding-related problems,
[00:09:36.936]occupational therapists often focus on enhancing
[00:09:39.515]feeding performance by applying techniques
[00:09:41.829]to improve the mechanics of feeding,
[00:09:43.995]or by suggesting strategies to their primary caregivers
[00:09:47.116]to promote feeding interaction
[00:09:48.695]and improve mealtime behaviors.
[00:09:54.202]Physiological feeding and eating issues
[00:09:56.276]refers to a variety of organic factors
[00:09:58.908]that lead to difficult or painful eating
[00:10:01.064]that may precipitate or play a role
[00:10:02.952]in the development of feeding concerns.
[00:10:05.796]These include metabolic abnormalities
[00:10:08.385]or defects in absorption that accompany conditions
[00:10:11.087]such as cystic fibrosis, mitochondrial disease,
[00:10:14.323]short bowel syndrome, or lactose intolerance,
[00:10:17.453]gastrointestinal issues involving persistence emesis
[00:10:20.563]and or diarrhea, e.g. gastroesophageal reflex,
[00:10:26.765]Children with ASD that present with any type of GI issue
[00:10:30.044]often have difficulty expressing their discomfort
[00:10:33.155]and or correctly identifying its source.
[00:10:36.014]This affects the child's ability to obtain relief
[00:10:38.563]or prevent the discomfort from recurring.
[00:10:41.081]In some cases, the children's effort to prevent discomfort
[00:10:43.947]may lead to the refusal of larger categories of food
[00:10:47.324]rather than just the particular one causing discomfort.
[00:10:51.427]Structural or anatomical deficits,
[00:10:54.129]for example, bronchial pulmonary dysplasia,
[00:10:56.755]malrotated intestines, micrognathia,
[00:11:02.751]such as irritable bowl syndrome or reflux,
[00:11:05.422]can also make eating unpleasant for a child.
[00:11:08.195]Diarrhea and constipation can signal GI inflammation.
[00:11:12.143]Children who exhibit frequent head banging,
[00:11:14.563]tantrums for discernible reason,
[00:11:16.596]hanging upside down, and putting pressure
[00:11:18.382]on the abdomen all the time may have GI inflammation.
[00:11:22.460]Have your pediatrician or a pediatric gastroenterologist
[00:11:26.061]examine your child and give you an opinion
[00:11:28.199]about whether more testing is needed.
[00:11:30.861]Food sensitivities or allergies may go undetected
[00:11:33.732]in young children.
[00:11:35.471]It's often hard to identify the food culprits,
[00:11:38.037]so as a result, many children respond
[00:11:39.917]with global food refusals.
[00:11:42.059]It's worthwhile to have food sensitivities
[00:11:44.121]checked out medically, and or work with a nutritionist
[00:11:47.460]or dietician who understands food sensitivities
[00:11:50.213]and how to resolve them.
[00:11:51.979]Medical professionals and their input should be sought
[00:11:54.559]in order to address any underlying health issues
[00:11:56.978]that may be a causal factor in feeding and eating concerns.
[00:12:03.522]Another type of a physiological basis
[00:12:05.748]to feeding and eating concerns that should be ruled out
[00:12:08.728]includes oral motor deficits or dysphagia.
[00:12:11.869]Dysphagia is a severe and relatively rare
[00:12:14.471]swallowing deficit that is diagnosed via a swallow study
[00:12:17.799]conducted by a qualified speech language pathologist.
[00:12:21.683]Problems with coordination of breathing and swallowing
[00:12:24.273]can also lead to cautious food exploration.
[00:12:27.287]Most new eaters take a while to get these rhythms down,
[00:12:30.167]so babies and toddlers often gag, choke,
[00:12:32.425]and even vomit in their beginning explorations
[00:12:34.788]of solid foods.
[00:12:36.843]While it's okay for these experiences to happen,
[00:12:40.343]if they persist or a child begins more global food refusals,
[00:12:43.983]get a pediatrician to recommend a swallow study.
[00:12:47.458]More severe dysphagia involving aspiration
[00:12:50.007]has not been reported in the autism literature,
[00:12:52.814]suggesting that it is only seen in those children with ASD
[00:12:56.391]who also experience additional medical issues,
[00:12:59.474]such as a seizure disorder,
[00:13:01.222]chromosomal syndrome, or other neurological impairment.
[00:13:04.928]Field et al in 2003 had a case audit
[00:13:08.291]that suggested that this may also be true
[00:13:10.407]regarding oral motor difficulties that impact feeding.
[00:13:14.228]Page and Boucher reported that when the study population
[00:13:16.886]includes children with ASD and more complex needs,
[00:13:20.362]the incidence of oral motor difficulties
[00:13:22.460]as assessed by both imitation and automatic production
[00:13:25.484]of tongue and lip movements rises dramatically.
[00:13:28.851]They also assessed chewing and drooling,
[00:13:31.194]finding that difficulties in these areas were less prevalent
[00:13:34.030]than the production of lip and tongue movements.
[00:13:37.150]Speech language pathologists should be sought
[00:13:39.004]for their input in order to assess any underlying
[00:13:41.658]swallowing or dysphagia issues that may be
[00:13:43.847]a causal factor in feeding and eating concerns.
[00:13:49.204]Finally, hypersensitivity to food tastes,
[00:13:51.840]smells. and textures may be considered
[00:13:54.086]a physiological eating issue.
[00:13:56.678]Behavioral research using standardized questionnaires
[00:13:59.354]such as the sensory profile by Dunn, 1999,
[00:14:03.101]has identified sensory-processing difficulties
[00:14:05.588]that both directly and indirectly impact eating processes.
[00:14:09.448]I.E. abnormal response to taste and smell,
[00:14:12.357]heightened sensitivity to tactile input,
[00:14:14.699]and auditory filtering problems.
[00:14:17.237]Tomchek and Dunn, in 2007,
[00:14:19.690]found that items that were directly related to eating,
[00:14:22.644]e.g. will only eat certain tastes, picky eater,
[00:14:25.876]especially regarding food textures,
[00:14:28.013]were significantly elevated in children with ASD
[00:14:30.786]in comparison to their typically developing peers.
[00:14:34.234]Kushner et al in 2005, directly examined
[00:14:37.572]the relationship between taste processing
[00:14:39.953]and food preferences in children with ASD.
[00:14:42.715]These researchers found that the participants with ASD
[00:14:45.745]demonstrated more restricted food preferences
[00:14:48.036]than did controls, with preferences being based
[00:14:50.835]on both the texture and flavor of the food.
[00:14:53.900]Sensory processing disorders make it hard for children
[00:14:56.242]to explore foods because they have extreme reactions
[00:14:59.577]to texture, smells, tastes,
[00:15:01.595]and the sounds of foods being chewed,
[00:15:03.821]by themselves or others.
[00:15:05.914]Occupational therapists can help to assess
[00:15:07.997]sensory processing deficits
[00:15:10.167]and identify specific types of input
[00:15:12.144]that may help remediate some of these concerns.
[00:15:18.064]Restricted food choices and selective eating
[00:15:20.278]based on type, texture, and familiarity in presentation
[00:15:24.270]are common among children with autism spectrum disorders.
[00:15:27.825]Usually associated with preferences for carbohydrates,
[00:15:30.808]snacks, and processed foods,
[00:15:32.506]while rejecting fruits and vegetables.
[00:15:35.019]In a literature review of studies published
[00:15:37.057]between 1994 and 2000, Ledford and Gast, in 2006,
[00:15:41.753]identified food selectivity by type and texture
[00:15:44.649]in 46 to 89% of children with ASD who had feeding problems.
[00:15:49.719]Cermak, Curtin, and Bandini, in 2010,
[00:15:52.839]also found a high prevalence of food selectivity
[00:15:55.613]in children with ASD,
[00:15:57.513]as well as nutritional deficiencies in some cases.
[00:16:00.822]In a recent meta-analysis, Sharp et al, in 2013,
[00:16:04.853]reported that children with asd
[00:16:06.641]had significantly more feeding problems than peers.
[00:16:09.822]Food selectivity was the most frequent concern,
[00:16:12.572]and there was a lower intake of calcium and protein.
[00:16:18.831]Children with asd often have
[00:16:20.549]significantly higher instances of food selectivity by type,
[00:16:24.427]and lower instances of total food refusal
[00:16:26.897]and oral motor problems than did children
[00:16:29.028]in other developmental disability populations.
[00:16:32.688]Selectivity by type or presentation has been defined
[00:16:35.517]as eating a narrow range of food
[00:16:38.018]that was nutritionally inappropriate,
[00:16:40.236]eating only a few different foods,
[00:16:42.105]and often refusing to eat entire food groups.
[00:16:45.687]A defining feature of this category
[00:16:47.505]was the consistency with which the children ate
[00:16:50.326]a restricted range of foods.
[00:16:54.697]Cornish, in 1998, and Emend et al in 2010,
[00:16:58.778]indicated that children who demonstrate selective eating
[00:17:01.703]have restricted diets that can cause malnutrition,
[00:17:04.451]dehydration, and some more health concerns.
[00:17:07.345]For example, a child with food selectivity
[00:17:09.777]may consume crunchy-textured items like chips,
[00:17:12.697]crackers, and dry cereal,
[00:17:14.774]but avoid softer-textured foods like yogurt and fruits.
[00:17:18.714]Over-consumption of foods with limited nutritional value
[00:17:21.764]may lead to future health problems such as obesity,
[00:17:24.776]diabetes, and high blood pressure, among others.
[00:17:28.452]Conversely, the under-consumption of a variety
[00:17:31.194]of nutritionally-dense foods as the result
[00:17:33.569]of food selectivity may result in children
[00:17:36.195]that suffer physical consequences,
[00:17:38.130]such as low body weight and dehydration,
[00:17:40.652]and are considered developmentally at risk.
[00:17:43.463]Furthermore, children who eat selectively
[00:17:45.523]usually demonstrate disruptive behaviors
[00:17:48.165]when parents and care providers try to encourage them
[00:17:50.746]to consume non-preferred foods.
[00:17:55.600]Please take a moment to answer the following question.
[00:17:58.717]A study by Twachtman-Reilly et al, in 2008,
[00:18:02.336]described close to what percent of children with ASD
[00:18:05.092]as selective eaters, defined as a limited consumption
[00:18:08.389]of foods based on texture, taste, and familiarity?
[00:18:15.936]The correct answer is 70% of children with ASD
[00:18:20.014]were defined as selective eaters by Twachtman-Reilly et al.
[00:18:29.776]The next section will discuss basic ethical considerations
[00:18:33.197]when implementing feeding and eating interventions
[00:18:35.691]in school settings.
[00:18:42.087]Ethical considerations include the impact
[00:18:44.427]of identifying and respecting
[00:18:46.232]professional scope of practice,
[00:18:48.371]the successful use of multidisciplinary teams,
[00:18:51.504]and information from IDEA and related services.
[00:18:59.929]Scope of practice is a core component
[00:19:02.250]of ethical guidelines for a wide variety
[00:19:04.506]of professionals within school settings.
[00:19:07.237]For example, the behavior analyst certification board
[00:19:10.402]includes scope of practice
[00:19:11.826]under ethics code 1.02 as follows,
[00:19:15.242]A, all behavior analysts provide services,
[00:19:18.031]teach, and conduct research only within the boundaries
[00:19:20.769]of their competence, defined as being commensurate
[00:19:23.673]with their education, training,
[00:19:25.144]and supervised experience.
[00:19:27.349]And B, behavior analysts provide services,
[00:19:30.007]teach, or conduct research in new areas,
[00:19:32.452]e.g. populations, techniques, and behaviors,
[00:19:35.511]only after first undertaking appropriate study,
[00:19:38.879]training, supervision, and or consultation
[00:19:41.643]from persons who are competent in those areas.
[00:19:45.226]Other professions, such as speech language pathologists,
[00:19:47.971]psychologists, occupational therapists,
[00:19:50.290]physical therapists, and more,
[00:19:52.114]are ruled by similar ethical boundaries
[00:19:54.371]which directs them to consider their experience
[00:19:57.304]and ability to recommend, implement, and train
[00:20:00.247]on any type of proposed intervention model,
[00:20:03.265]and or to consider their access
[00:20:05.177]to a competent source if indicated.
[00:20:11.331]Twachtman-Reilly et al, in 2008,
[00:20:14.021]created a graphic representation
[00:20:15.974]for a multidisciplinary team approach
[00:20:18.631]when working with children with autism spectrum disorders
[00:20:21.284]and feeding difficulties.
[00:20:23.341]The authors contend that the feeding issues
[00:20:25.464]of students with asd can be addressed successfully
[00:20:28.663]in the naturalistic environment of the school-based setting
[00:20:32.090]with the involvement of multiple professionals
[00:20:34.062]and remediation efforts.
[00:20:36.333]Team collaboration is conceptualized in figure one.
[00:20:39.850]Within the school team, the degree of involvement
[00:20:42.260]by each team member is dependent on both his
[00:20:44.906]or her level of specialized training
[00:20:46.940]in feeding disorders in general,
[00:20:49.147]as well as the extent to which he or she has been trained
[00:20:51.738]to implement specific therapeutic techniques.
[00:20:55.181]At the consultation level,
[00:20:56.780]individuals with specific expertise in asd
[00:21:00.145]may be called in to address issues
[00:21:02.202]such as disruptive behavior
[00:21:03.753]and the need for specific educational supports.
[00:21:07.006]These supports may also benefit the child at mealtime.
[00:21:10.039]The final circle of collaboration
[00:21:12.051]involves professionals outside of the school environment,
[00:21:15.123]such as experts from a swallowing and feeding clinic,
[00:21:17.945]physician, and nutritionist.
[00:21:20.014]As in all multidisciplinary team efforts,
[00:21:22.793]professionals function as interdependent
[00:21:24.843]with sincere respect for scope of practice
[00:21:27.099]and professional ethical guidelines of their colleagues.
[00:21:33.773]FAPE, or free and appreciate public education,
[00:21:36.893]is based on the provision of special education
[00:21:39.341]and related services to eligible students
[00:21:42.032]in conformance with the student's
[00:21:43.644]individualized education plan, or IEP.
[00:21:47.004]The statue provides that students with disabilities
[00:21:49.788]who are found eligible for special education
[00:21:52.000]under IDEA may receive related services
[00:21:55.445]and supplementary aids and services.
[00:21:58.297]Specifically, related services include speech
[00:22:01.064]language pathology, physical and occupational therapy,
[00:22:04.448]medical services, and school health services,
[00:22:06.999]along with other identified supports.
[00:22:09.550]Feeding may be considered a learning opportunity
[00:22:11.840]as defined within a student's IEP,
[00:22:14.461]providing team consideration of the impact
[00:22:16.748]of withholding food or restricting access to reinforcement,
[00:22:19.982]as well as ensuring thorough training for staff
[00:22:22.683]in any identified intervention procedures.
[00:22:28.676]The inclusion of feeding skills in an IEP
[00:22:31.182]can produce a variety of learning outcomes
[00:22:33.386]that go beyond oral intake and food preparation,
[00:22:36.507]including greater independence during mealtimes
[00:22:38.948]and increased opportunities
[00:22:40.369]for social interactions with others.
[00:22:42.910]Meaningful and functional outcomes
[00:22:44.623]come from integrating feeding goals
[00:22:46.312]and short-term objectives
[00:22:47.736]into daily routines and activities.
[00:22:52.655]It is important to take into account
[00:22:54.367]the reason for including feeding goals in an IEP.
[00:22:57.891]As with targeting academic, social,
[00:23:00.035]and behavior goals, there must be a rationale.
[00:23:03.226]Feeding goals should include a brief explanation
[00:23:05.365]of its importance, such as Max will increase
[00:23:08.356]self-feeding skills to prepare for kindergarten,
[00:23:11.089]or Sophie will improve food preparation skills
[00:23:13.983]to be more independent.
[00:23:15.947]Addressing feeding skills in an IEP also reinforces
[00:23:19.283]contextual learning and linkages to real world outcomes.
[00:23:26.160]Please answer the following question.
[00:23:28.766]Many school-based professionals are governed
[00:23:30.852]by ethical guidelines which direct them
[00:23:33.085]to first consider their experience and ability
[00:23:35.593]to recommend, implement, and train
[00:23:38.142]on any proposed intervention model.
[00:23:45.447]The correct answer is A, true.
[00:23:48.337]Ethical guidelines govern a wide variety
[00:23:50.954]of school-based professionals.
[00:23:55.567]Part two of this webinar series,
[00:23:57.802]presented by Dr. Janine Kesterson,
[00:24:00.342]will cover behavioral assessment
[00:24:01.928]of feeding and eating issues in depth.
[00:24:04.338]Rather than reviewing the basic components
[00:24:06.266]of the assessment process, this section will highlight
[00:24:09.186]those factors that require emphasis for children with asd.
[00:24:13.037]We will cover a brief overview now.
[00:24:17.155]Assessment factors to emphasize for children with an asd
[00:24:20.742]include the direct assessment of food selectively,
[00:24:23.660]and or food refusal, including functional assessment
[00:24:26.576]and behavior rating scales for eating and mealtime behavior,
[00:24:30.163]the assessment of unsafe eating behaviors
[00:24:32.513]that put the child at risk for choking,
[00:24:34.511]even in absence of a physiologically-based
[00:24:38.169]and the assessment of patterns of consistency
[00:24:40.311]or inconsistency in eating performance.
[00:24:46.422]Functional analysis or descriptive analyses
[00:24:49.101]of inappropriate mealtime behavior
[00:24:51.135]should be used to prescribe treatment for children
[00:24:53.568]with autism and feeding problems.
[00:24:55.974]Research has shown that functional analysis
[00:24:58.189]identified behavior function for most children,
[00:25:01.362]with results indicating that food refusal
[00:25:03.462]was frequently maintained by escape,
[00:25:05.817]such as meal termination, and attention, or coaxing.
[00:25:13.221]Many longstanding feeding problems
[00:25:15.093]involve learned behaviors whose function
[00:25:17.243]is to escape unpleasant feeding experiences
[00:25:19.949]and or to gain attention from caregivers.
[00:25:25.174]Behavioral mismanagement in the form
[00:25:26.901]of positive reinforcement,
[00:25:28.750]e.g. caregiver attention for inappropriate behavior,
[00:25:32.096]and negative reinforcement, e.g. removing food
[00:25:35.012]and or ending meals due to problem behaviors,
[00:25:37.881]may inadvertently shape and strengthen problem behavior.
[00:25:41.329]When these behaviors are reinforced,
[00:25:43.103]they tend to become more frequent or intense.
[00:25:48.483]Please take a moment to answer the following question.
[00:25:52.152]Recent research on the functional analysis
[00:25:54.440]of inappropriate mealtime behavior in children with asd
[00:25:58.115]identified the following behavioral functions
[00:26:00.449]as most common.
[00:26:02.188]A, access to tangible and escape.
[00:26:05.241]B, escape and attention.
[00:26:07.401]Or C, automatic sensory and attention.
[00:26:23.096]The correct answer is B, escape and attention
[00:26:26.275]were most frequently identified
[00:26:27.893]as the maintaining variables
[00:26:29.406]of inappropriate mealtime behavior.
[00:26:35.417]Eating is an essential human activity,
[00:26:37.980]necessary to sustain life and ensure growth,
[00:26:41.039]but it is also a common challenge for children
[00:26:43.351]and a source of stress for caregivers.
[00:26:46.008]The estimated prevalence of feeding problems
[00:26:48.101]in children with autism has been reported to be
[00:26:51.035]as high as 90%, with close to 70% of children
[00:26:54.441]with an asd described as a selective eater.
[00:27:02.055]Applied behavior analysis, or ABA,
[00:27:04.702]has been effective in overcoming food selectivity.
[00:27:08.060]Consequence-based procedures such as positive reinforcement
[00:27:11.134]and access to preferred stimuli
[00:27:13.377]have been used to increase appropriate eating
[00:27:15.634]and escape extinction has been implemented
[00:27:17.618]to decrease mealtime problem behavior.
[00:27:22.774]Antecedent-based procedures are implemented
[00:27:25.134]to promote acceptance of novel foods
[00:27:27.678]using such strategies as food blending,
[00:27:30.201]sequential and simultaneous presentation of foods,
[00:27:33.315]paced prompting, demand fading,
[00:27:35.146]and behavioral momentum.
[00:27:39.975]Recent research has emerged in which teachers
[00:27:42.274]and paraprofessionals have been successfully trained
[00:27:44.909]by professionals with expertise in ABA procedures
[00:27:48.439]to implement interventions for food selectivity,
[00:27:51.387]even with no prior experience.
[00:27:53.656]It is suggested that similar ABA procedures
[00:27:55.967]for students who do not exhibit extreme problem behavior
[00:27:59.459]could be replicated to receive intervention at school
[00:28:02.429]as a component of their educational program.
[00:28:07.544]Because children spend significant time attending school,
[00:28:10.798]teachers can play a vital role intervening with a problem
[00:28:13.793]such as food selectivity.
[00:28:15.780]Similarly, there is need to expand effective treatment
[00:28:18.548]beyond intensive clinical and inpatient programs
[00:28:21.367]to alternative settings, such as public schools.
[00:28:24.562]Please join Dr. Janine Kesterson, BCBA-D,
[00:28:27.881]for part two of this webinar series,
[00:28:30.226]in which she will cover behavioral assessment procedures
[00:28:32.851]and intervention strategies for picky eaters with autism.
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