Picky Eaters: Facts and Interventions: Part 2
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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[00:00:02.332]Hello, and welcome to our webinar today.
[00:00:05.824]This training is brought to you by the Tri-State
[00:00:08.810]Webinar Series, which is made available through
[00:00:11.631]collaboration with the Colorado Department of Education,
[00:00:15.588]the Kansas TASN Autism and Tertiary Behavior Supports,
[00:00:20.609]and the Nebraska Autism Spectrum Disorders Network.
[00:00:24.419]We are so glad to have you join us today.
[00:00:29.662]Polling questions will be used throughout the webinar.
[00:00:33.221]Follow the directions when each question is presented.
[00:00:38.581]Hi everyone, my name is Janine Kesterson,
[00:00:41.289]a licensed psychologist, school psychologist,
[00:00:43.738]and board certified behavior analyst.
[00:00:46.239]I have experience in many different states
[00:00:48.431]in a variety of settings.
[00:00:50.299]I've worked in public schools and two residential schools
[00:00:53.506]for children with autism, developmental delays,
[00:00:56.391]traumatic brain injury, and neurological disorders.
[00:00:59.985]My specialties include feeding, toileting,
[00:01:03.066]treatment integrity, and interventions for severe aggression
[00:01:06.551]and self-injurious behavior.
[00:01:08.632]I am currently a state trainer for TASN,
[00:01:11.084]Autism and Tertiary Behavior Supports.
[00:01:14.382]In my current role, I provide training,
[00:01:16.720]coaching, and technical assistance to schools in Kansas.
[00:01:20.257]Today I'm excited to bring you part two of Picky Eaters,
[00:01:24.156]facts and interventions.
[00:01:26.585]This webinar will address understanding assessment
[00:01:29.473]and the team approach for picky eating.
[00:01:31.720]It will also identify evidence based procedures
[00:01:34.396]to help with restricted food preference and/or textures.
[00:01:39.117]Typically when you think of feeding intervention,
[00:01:41.347]you think this happens in a hospital or clinical setting.
[00:01:44.709]There has been research that students with milder forms
[00:01:47.324]of eating problems receiving intervention in the schools
[00:01:50.829]as part of their educational program.
[00:01:53.619]But there are many factors to consider.
[00:01:56.260]The first thing you want to rule out
[00:01:58.568]is any major health factors.
[00:02:00.752]You do not want to put the student in any risk for
[00:02:03.155]a health emergency situation, such as severe weight loss,
[00:02:07.171]metabolic issues, or aspiration.
[00:02:10.256]Next, you should use a multidisciplinary team.
[00:02:14.111]This ensures that physiological factors are ruled out.
[00:02:17.665]A number of professionals with different expertise
[00:02:20.419]can look at all aspects of the child
[00:02:22.754]and the severity may be determined.
[00:02:25.721]For example, making sure the student can swallow food,
[00:02:29.542]there is no motor issues with chewing, et cetera.
[00:02:33.134]The third thing to consider,
[00:02:34.487]if staff will need extra training.
[00:02:37.072]For a food intervention to be in place,
[00:02:39.340]staff will need to run the plan exactly as written
[00:02:42.292]and need to read through it, have it modeled,
[00:02:45.090]have it practiced through role-playing the intervention
[00:02:48.771]and asking questions before the intervention begins.
[00:02:52.302]In addition, professionals need to be observing
[00:02:54.928]and doing treatment integrity checks to insure
[00:02:57.719]the intervention is being implemented correctly and if not,
[00:03:01.575]stepping in and retraining staff.
[00:03:04.244]Lastly, any factors mentioned in part one of the webinar
[00:03:07.866]not mentioned here should also be considered.
[00:03:11.612]Take a minute to complete poll question one
[00:03:14.033]by checking all answers that apply.
[00:03:17.237]That is correct.
[00:03:18.450]Using a team approach gets different knowledge
[00:03:20.400]and expertise from professionals, it helps rule out
[00:03:23.426]physiological factors, also helps determine the severity
[00:03:27.223]of the problem, and if this is something that can be
[00:03:30.793]targeted in the school.
[00:03:32.578]A student may hit you during a feeding intervention,
[00:03:35.523]but that is not specifically why you need a team approach.
[00:03:39.408]Research has shown that completing assessments
[00:03:41.895]before starting an intervention help lead to less problem
[00:03:45.088]behavior and more effective treatments.
[00:03:47.820]The assessments that have shown some success are
[00:03:50.346]functional behavior assessments, preference assessments
[00:03:54.188]for preferred and non-preferred food, and the presentation
[00:03:57.497]of how the food is displayed, or the size of the bite.
[00:04:02.269]The first assessment we will talk about
[00:04:04.278]is the functional behavior assessment.
[00:04:06.504]This determines why the student is not eating
[00:04:08.888]and what is maintaining this behavior.
[00:04:11.586]An example for the attention function
[00:04:13.861]is when the individual engages in food-throwing,
[00:04:16.752]spitting food out, gagging, et cetera, for attention.
[00:04:21.340]For escape, the student tries to get out of eating.
[00:04:24.772]The student may do this by acting out, refusing to eat
[00:04:28.246]so they can get another food they want,
[00:04:30.571]or by avoiding eating something they don't want to try.
[00:04:34.534]The next function of the behavior is escape to tangible.
[00:04:38.166]The student engages in a behavior to remove the food item
[00:04:41.257]and get access to an item they have been
[00:04:43.484]wanting to play with or have.
[00:04:45.756]The last function is sensory.
[00:04:47.943]This is where the types of textures are an issue
[00:04:51.205]and may also be the bite size.
[00:04:53.980]Once you've determined what the function is,
[00:04:56.278]this will guide you to an intervention.
[00:05:00.198]Next is a preference assessments.
[00:05:02.518]Preference assessments are important for preferred,
[00:05:05.611]non-preferred foods, or condiments that you may use
[00:05:08.962]for reinforcement or an antecedent intervention.
[00:05:12.808]For preferred foods, it gives the student
[00:05:15.103]a motivator to work for and earn
[00:05:17.771]once they have swallowed the non-preferred food.
[00:05:20.481]The reason you would do a preference assessment
[00:05:22.909]with a non-preferred food is to make sure that food
[00:05:25.710]is really not preferred.
[00:05:27.802]The last preference assessment with condiments
[00:05:30.087]may be used to put on a non-preferred food
[00:05:32.706]to help the student swallow the item.
[00:05:35.140]The presentation assessment refers to the size of the bite
[00:05:38.845]on the spoon and/or plate.
[00:05:41.611]For example, having all items on the plate or one at a time,
[00:05:45.906]having a large portion on the spoon,
[00:05:48.327]or a smaller portion size.
[00:05:50.370]Lastly, you would want to make sure that
[00:05:52.384]the speech pathologist and the OT have evaluated the student
[00:05:56.208]for oral motor skills, swallowing issues,
[00:05:59.349]and other issues that may occur.
[00:06:04.744]Take some time to write out your answer.
[00:06:18.119]Great job, you are correct.
[00:06:20.007]You should complete assessments
[00:06:21.446]before a feeding intervention to decrease problem behavior
[00:06:24.449]and make treatments more effective.
[00:06:26.633]For example, once you know the function of the behavior
[00:06:29.570]you can target that behavior with interventions
[00:06:32.379]that fit that function to make treatment more effective.
[00:06:36.079]Also, completing a preference assessment
[00:06:38.453]will help you know what is reinforcing enough
[00:06:40.771]to help decrease the behavior.
[00:06:43.504]The following have been found effective
[00:06:45.272]and have the most research for feeding interventions.
[00:06:48.295]Antecedent procedures, escape extinction,
[00:06:51.096]and differential reinforcement of alternative behaviors.
[00:06:56.096]Sharp et al. reviewed treatments of feeding issues
[00:06:59.220]and found that escape extinction were used in 83% of studies
[00:07:04.381]and differential reinforcement of alternative behaviors
[00:07:07.744]were used in 77% of the studies.
[00:07:11.036]Common treatment packages were escape extinction
[00:07:14.689]plus differential reinforcement, and escape extinction,
[00:07:18.651]differential reinforcement of alternative behaviors,
[00:07:21.509]and antecedent procedures combined.
[00:07:24.365]Most treatments had five to 10 bite sessions.
[00:07:27.603]Escape extinction was the most-used treatment.
[00:07:31.057]Interventions that were successful without escape extinction
[00:07:34.012]were differential reinforcement of alternative behaviors
[00:07:38.231]and the following antecedent procedures:
[00:07:41.269]non-contingent reinforcement, simultaneous presentation,
[00:07:44.738]and stimulus fading.
[00:07:47.165]These interventions will be described
[00:07:48.761]in the following slides and then examples of research
[00:07:52.888]and these procedures used will be discussed.
[00:07:56.577]Antecedent procedures are implemented before the acceptance
[00:07:59.757]of a bite of a drink, or immediately after acceptance
[00:08:02.929]of a bite or drink to promote swallowing.
[00:08:06.454]This procedure can be used in isolation
[00:08:08.767]or with consequence-based procedures such as
[00:08:10.971]differential reinforcement of alternative behavior,
[00:08:14.607]also known as DRA, or escape extinction.
[00:08:18.342]Few studies just focus on antecedent-based strategies.
[00:08:22.108]Most studies usually include an extinction component,
[00:08:25.115]such as ignoring behaviors, verbally redirecting,
[00:08:28.639]or keeping food constant and not removing.
[00:08:31.921]The advantages of multi-component strategies
[00:08:34.292]allows the student to tolerate
[00:08:36.170]and gradually increase without behavior.
[00:08:38.721]Simultaneous presentation is the presentation
[00:08:41.557]of preferred food at the same time as a non-preferred food.
[00:08:45.674]So this could be a condiment or cracker with food on it.
[00:08:49.599]Sequential presentation is a highly preferred food
[00:08:52.692]that is delivered as a consequence for acceptance
[00:08:55.176]and consumption of a non-preferred food.
[00:08:58.350]Stimulus fading is a systematic gradual removal
[00:09:01.913]of usually artificial or intrusive prompts,
[00:09:04.748]or discriminative stimuli prompts such as directions,
[00:09:08.810]imitative prompts, physical guidance, and other cues.
[00:09:13.488]Bite size is exactly how it sounds, the size of the bite.
[00:09:17.413]The chaser procedure is having the student
[00:09:19.452]take a bite and then use a drink to wash it down
[00:09:22.658]and help swallow.
[00:09:24.710]Blending food is mixing it together with a condiment
[00:09:27.386]or another preferred food item.
[00:09:30.034]Modeling has been done with peers and siblings
[00:09:32.866]and has shown some positive outcomes.
[00:09:35.248]For modeling, a peer or sibling will go first
[00:09:38.105]and follow the same procedure
[00:09:39.826]expected of the target student.
[00:09:42.001]The target student watches the model,
[00:09:43.859]and then is asked to perform the same procedure.
[00:09:46.829]Please take a minute to decide
[00:09:48.233]if the answer is true or false.
[00:10:01.401]Great job! The answer is true.
[00:10:04.041]Simultaneous presentation is an antecedent procedure
[00:10:07.118]that has been shown to be consistently effective.
[00:10:10.602]Escape extinction is a behavioral procedure
[00:10:13.289]that is generally used to treat
[00:10:15.089]escape or avoidance maintained behaviors.
[00:10:18.315]Utilization of escape extinction procedures includes
[00:10:21.707]discontinuing the escape contingency
[00:10:24.006]upon the occurrence of the behavior,
[00:10:26.560]escape extinction as restrictive,
[00:10:28.930]usually used for difficult behaviors that occur,
[00:10:31.870]such as expelling or packing food,
[00:10:34.831]resisting food presentation, and disrupting meals.
[00:10:38.622]This procedure is not easily implemented,
[00:10:41.482]may be perceived poorly, and can increase problem behavior.
[00:10:46.072]Escape extinction has been found effective alone,
[00:10:48.984]or when combined with DRA, non-contingent reinforcement,
[00:10:53.370]high probability sequence,
[00:10:55.467]and preferred and non-preferred goods.
[00:10:58.219]There are many challenges with escape extinction.
[00:11:01.068]These challenges are:
[00:11:02.978]temporary increase in problem behavior,
[00:11:05.599]not always necessary, emotional responding,
[00:11:09.808]and extinction-induced aggression is caused.
[00:11:13.516]Escape extinction is especially used
[00:11:16.082]during serious health risk situations.
[00:11:20.075]The first intervention is non-removal of a spoon or plate.
[00:11:24.358]For non-removal of spoon, the spoon is lifted
[00:11:27.115]to the student's mouth and not removed until a bite is taken
[00:11:30.761]and/or swallowed while ignoring problem behavior.
[00:11:34.699]For the plate, it is placed in front of the student
[00:11:37.161]and not removed until the bite or all the food on the plate
[00:11:40.253]is completed, while ignoring the problem behavior.
[00:11:44.730]Physical guidance can look many different ways.
[00:11:47.667]One is bringing the spoon hand over hand
[00:11:49.791]to the student's mouth.
[00:11:51.591]Another could be using a light touch on the chin,
[00:11:54.358]prompting the student to open their mouth,
[00:11:56.415]or applying pressure to the mandibular joint.
[00:12:00.499]Please take a minute to write out your answer.
[00:12:12.414]Escape extinction is a behavioral procedure
[00:12:14.739]that is generally used to treat escape
[00:12:16.966]or avoidance maintained behaviors.
[00:12:19.248]Utilization of escape extinction procedures
[00:12:21.970]includes discontinuing the escape contingency
[00:12:24.839]upon the occurrence of the behavior.
[00:12:28.410]Differential reinforcement of alternative behaviors,
[00:12:31.411]also known as DRA.
[00:12:33.864]DRA is a reinforcement of one form of behavior
[00:12:37.338]and not another, or the reinforcement of a response
[00:12:40.835]under one condition but not another.
[00:12:43.410]Differential reinforcement uses positive reinforcement
[00:12:46.695]to differentiate or separate appropriate student behavior
[00:12:50.608]from inappropriate behavior by increasing one
[00:12:54.151]while decreasing the other.
[00:12:56.355]DRA is effective,
[00:12:58.038]contingent upon appropriate eating behaviors.
[00:13:01.682]For example, for a feeding intervention,
[00:13:04.059]if a student is eating their food,
[00:13:06.248]there will be lots of praise, lots of attention,
[00:13:08.624]and talking to the student.
[00:13:10.561]If the student is not eating and is screaming,
[00:13:12.864]staff would not give any attention to the student.
[00:13:15.800]DRA has also been effective in combination
[00:13:18.513]of antecedent and escape extinction interventions.
[00:13:22.706]Now we are going to review some research studies
[00:13:24.936]using DRA, antecedent procedures, and/or escape extinction.
[00:13:29.860]These studies have been completed in a variety of settings,
[00:13:32.740]with a few that have been completed in the school.
[00:13:36.143]Levin and Carr 2001 article looked at four students
[00:13:39.501]with autism, ages five to seven.
[00:13:42.344]All the students had significant cognitive impairment.
[00:13:45.662]All students exhibited aggression, self-injurious behavior,
[00:13:48.813]and/or throwing food during mealtimes.
[00:13:51.728]The students were evaluated by a nutritionist
[00:13:54.099]for dietary needs before the study.
[00:13:56.977]A preference assessment was completed
[00:13:58.990]with 20 foods for each student.
[00:14:01.780]10 of the foods were known and 10 unknown.
[00:14:04.749]These foods were presented four at a time
[00:14:07.389]for five times, in random order, for 20 trials per session.
[00:14:11.664]During the assessment, bite-sized items were presented
[00:14:14.551]with the prompt, "Try this."
[00:14:16.634]The interventionist then waited five seconds
[00:14:19.040]to see if the student ate, and if not,
[00:14:21.365]it was modeled and another five seconds was given.
[00:14:24.297]Data was recorded if the student ate or not.
[00:14:27.984]These are the results of the preference assessment.
[00:14:30.537]100% met criteria to use as a preferred item.
[00:14:34.242]Manny was unable to continue participation
[00:14:36.829]in the intervention phase due to health problems.
[00:14:40.496]This graph shows the grams consumed for non-preferred
[00:14:43.466]and preferred foods during the preference assessment.
[00:14:51.553]Food used for the interventions were chicken,
[00:14:53.691]and orange, and raw carrots.
[00:14:55.806]This graph shows the grams of the non-preferred food
[00:14:58.428]consumed across the four conditions.
[00:15:01.279]The first condition had access to preferred food items
[00:15:04.073]prior to intervention meal,
[00:15:05.894]no positive reinforcement-based intervention implemented.
[00:15:09.948]Next, no access to preferred food items
[00:15:13.441]prior to intervention meal,
[00:15:16.574]positive reinforcement-based interventions
[00:15:18.392]were not implemented.
[00:15:20.561]The third phase, there was access to preferred food items
[00:15:23.337]prior to intervention meal,
[00:15:25.604]and positive reinforcement was implemented.
[00:15:28.609]The last phase was no access
[00:15:30.417]to preferred food items to the meal,
[00:15:33.095]and positive reinforcement intervention was implemented.
[00:15:36.530]As you can see, the last phase where no preferred food
[00:15:39.317]was available before intervention
[00:15:41.316]and reinforcement occurred,
[00:15:43.481]for consumption had significant results.
[00:15:47.697]For intervention two, new target foods were added
[00:15:50.749]to Jack, Luis, and Bess.
[00:15:52.666]These foods were roasted chicken breast and banana
[00:15:55.525]for Bess and Jack, and Honey Nut Cheerios
[00:15:57.786]and 2% milk for Luis.
[00:16:00.374]This graph shows the grams of the second target
[00:16:02.820]of non-preferred food consumed
[00:16:04.960]and the frequency of problem behavior.
[00:16:08.005]First the interventions implemented baseline where
[00:16:10.455]no intervention occurred, and then the treatment used
[00:16:13.068]the last successful intervention, the no access
[00:16:16.196]to preferred food before the meal
[00:16:18.959]and positive reinforcement for consumption.
[00:16:22.126]For the new food, behavior did increase
[00:16:24.711]but decreased over time,
[00:16:26.219]and the intervention did increase food consumption.
[00:16:30.483]This study used an escape and token DRA
[00:16:33.528]to increase food acceptance
[00:16:35.251]with a four year old with speech delays
[00:16:37.285]and possible Pervasive Developmental Disorder.
[00:16:40.344]This study was completed in an inpatient setting.
[00:16:44.261]The phases of the treatment were DRA positive reinforcement,
[00:16:47.846]and DRA negative reinforcement.
[00:16:50.167]The procedure for the DRA positive reinforcement
[00:16:53.020]was the spoon was held two to three inches
[00:16:55.393]in front of the mouth,
[00:16:56.977]child was prompted to take a bite of food,
[00:16:59.629]and praise was offered contingent on eating the bite.
[00:17:02.986]The DRA plus physical guidance phase
[00:17:05.482]was when the child refused a bite,
[00:17:07.892]gentle pressure was applied to the mandibular junction
[00:17:11.097]with the simultaneous deposit of food in the child's mouth.
[00:17:14.831]The last phase, and most successful,
[00:17:17.082]was DRA negative reinforcement.
[00:17:19.859]The child earned tokens with bites of food
[00:17:22.311]and the meal was terminated when pre-specified
[00:17:24.673]number of tokens were turned in.
[00:17:27.057]The number of tokens earned was specified
[00:17:29.059]on the difficulty of the food.
[00:17:31.039]Example, one token for a bite of applesauce,
[00:17:33.781]two for other foods.
[00:17:37.069]Kern and Marder 1996 study looked at the comparison
[00:17:40.479]of simultaneous and delayed reinforcement.
[00:17:43.715]The study used a seven year old boy
[00:17:45.616]with Pervasive Developmental Disorder.
[00:17:48.381]The intervention took place during breakfast,
[00:17:50.654]lunch, and dinner using four different items.
[00:17:54.288]When the study began,
[00:17:55.582]he was only eating five different foods
[00:17:58.077]items, and if other foods were presented,
[00:18:00.620]he would exhibit self-injurious behavior and tantrums.
[00:18:05.368]During baseline, a spoonful of food was held
[00:18:07.780]in front of the child for 30 seconds.
[00:18:10.321]If nothing occurred, the next food was presented.
[00:18:13.347]For the intervention, a multi-element design
[00:18:16.121]was implemented to compare escape extinction
[00:18:18.887]with simultaneous reinforcement for fruit,
[00:18:21.593]and escape extinction
[00:18:23.240]with delayed reinforcement for vegetables.
[00:18:26.345]Escape extinction was holding the food in front of the child
[00:18:29.201]until he accepted the bite.
[00:18:31.560]If the bite was accepted then expelled,
[00:18:34.531]it was re-presented.
[00:18:36.231]If self-injurious behavior occurred, it was ignored.
[00:18:39.537]During simultaneous condition, a chip and the fruit
[00:18:42.653]was presented at the same time.
[00:18:45.277]During delayed, the chip was provided
[00:18:47.583]after vegetable was accepted.
[00:18:50.099]As you can see in the graph,
[00:18:51.384]results indicated both were effective,
[00:18:53.575]but simultaneous reinforcement with escape extinction
[00:18:56.571]had a faster change.
[00:18:59.358]Ahearn 2003 study looked at the antecedent procedures,
[00:19:03.218]simultaneous presentation to increase vegetable consumption.
[00:19:07.784]The participant was a 14 year old boy with autism
[00:19:10.786]and profound intellectual disability.
[00:19:14.534]The student liked condiments, so they were used
[00:19:17.132]as a part of the simultaneous presentation.
[00:19:20.247]The vegetables were carrots, broccoli, and corn.
[00:19:24.265]This graph shows the results of the study.
[00:19:26.717]As you can see, simultaneous presentation
[00:19:28.827]was very effective.
[00:19:30.536]Four baseline vegetables were presented in 1/4 pieces
[00:19:33.710]on a spoon and presented on a plate for five trials.
[00:19:37.610]Each trial a prompt was given, "Take a bite,"
[00:19:40.075]and data was taken if eaten or not.
[00:19:42.750]During the simultaneous condition,
[00:19:44.843]the vegetable was paired with a condiment.
[00:19:48.306]VanDalen and Penrod, 2010, looked at the difference
[00:19:51.838]between antecedent procedures, simultaneous,
[00:19:55.066]and sequential presentation.
[00:19:57.225]First, a preference assessment was completed
[00:20:00.176]for preferred and non-preferred foods.
[00:20:02.604]Next, for the simultaneous presentation,
[00:20:05.679]the highly preferred item was placed on top
[00:20:07.946]of the non-preferred food.
[00:20:10.228]Verbal praise was then given initially for accepting
[00:20:12.825]and then for swallowing.
[00:20:14.999]When inappropriate mealtime behavior occurred,
[00:20:17.799]a 30 second escape from demands was allowed,
[00:20:20.887]and the bite of the food was removed from the plate.
[00:20:24.163]Contingent on consumption of the entire plate
[00:20:26.505]of non-preferred foods, the child was allowed
[00:20:28.607]access to preferred foods upon request.
[00:20:32.724]If the meal was not finished, the child was delayed
[00:20:36.120]alternate meal or snack for one to two hours.
[00:20:40.562]For the sequential procedure,
[00:20:42.322]all the same procedures were used,
[00:20:44.411]except once the child accepted the non-preferred food
[00:20:47.955]and swallowed, the preferred food was given.
[00:20:51.418]For the phase using escape extinction,
[00:20:53.749]the bite remained in position until the child
[00:20:56.174]opened the mouth naturally, such as yawning,
[00:20:58.975]speaking, et cetera, and then food was inserted.
[00:21:03.103]Any food that was spit out
[00:21:04.609]was re-presented until swallowing.
[00:21:07.449]If 30 minutes passed without consumption,
[00:21:09.800]the meal was terminated.
[00:21:11.662]Results in this figure show that sequential
[00:21:14.260]and simultaneous presentation was not successful
[00:21:17.368]without escape extinction procedures added.
[00:21:20.909]Results show with extinction, simultaneous presentation,
[00:21:24.138]and sequential presentation was successful
[00:21:27.454]in consuming non-preferred foods.
[00:21:30.201]For Emilio, during the simultaneous condition
[00:21:33.100]he began taking the preferred food off
[00:21:35.293]and eating the non-preferred,
[00:21:37.345]and then eating the preferred in a sequential pattern.
[00:21:40.806]Overall results indicate sequential presentation
[00:21:43.651]plus escape extinction was the most successful procedure.
[00:21:48.129]For Sira and Fryling 2012 article,
[00:21:51.031]peer modeling and differential reinforcement
[00:21:54.126]was used with a nine year old with autism.
[00:21:57.231]The study looked at adding spaghetti, sauce,
[00:21:59.779]eggs, and hamburgers, defined as patty and ketchup.
[00:22:04.130]First, a preference assessment was completed
[00:22:06.607]to find highly preferred foods.
[00:22:08.936]For the procedures, the student observed a peer eat
[00:22:12.117]one bite at a time.
[00:22:13.871]The peer took the bite and then received praise and reward.
[00:22:17.165]Then it was the target student's turn.
[00:22:19.675]If the student did not take a bite after 30 seconds,
[00:22:22.702]the plate was removed and the student ignored.
[00:22:25.557]Then the trial would go back to the peer model.
[00:22:28.808]Items earned were food, a drink, or a tangible item
[00:22:32.374]for five minutes, plus praise.
[00:22:35.310]This figure shows bites eaten across all phases.
[00:22:38.786]The results indicated that a treatment package
[00:22:41.475]of DRA and peer modeling may be effective
[00:22:44.748]in treating feeding issues.
[00:22:46.901]Escape extinction is not always needed.
[00:22:50.339]Knox et al. 2012 article looked at a teacher-implemented
[00:22:54.442]paced prompting, demand fading, and DRA
[00:22:57.389]to increase food consumption for an adolescent girl
[00:23:01.035]with autism and disruptive mealtime behaviors.
[00:23:05.077]The student only ate crackers,
[00:23:06.647]cereal, and drank apple juice.
[00:23:09.221]The foods chosen to add to her diet were
[00:23:11.787]mac and cheese, chicken nuggets, turkey sandwich,
[00:23:15.564]cheese sticks, vegetable chips, apples,
[00:23:19.186]mandarin orange, and fruit cups.
[00:23:22.235]The teacher and assistants were trained
[00:23:24.295]before the intervention started.
[00:23:26.802]Staff were required to read protocols, have it modeled,
[00:23:30.910]and then role-played before they could implement.
[00:23:33.943]For the intervention, three bowls
[00:23:35.981]were on three different plates.
[00:23:38.777]The teacher or the assistant told the student,
[00:23:41.554]"If you eat what is in the bowls, you earn your reinforcer."
[00:23:45.671]The student received praise
[00:23:47.179]when she picked the new foods to eat.
[00:23:49.834]Once she ate the food in the bowls,
[00:23:51.764]she received a sticker for her sticker chart.
[00:23:55.305]If the student did not take a bite within 30 seconds,
[00:23:58.556]she was prompted to eat her lunch.
[00:24:01.617]80% of the sessions were checked to ensure staff
[00:24:04.411]were following the protocol.
[00:24:07.447]The figure shows the total volume
[00:24:09.459]of each lunch the student ate.
[00:24:11.786]Overall, this intervention was successful
[00:24:14.067]in increasing the foods the student ate.
[00:24:18.009]Barahona et al. 2013 study was a follow-up
[00:24:21.753]from the Knox et al. 2012 study with the same student.
[00:24:26.806]The nutritionist said the student
[00:24:28.334]needed more variety in her foods.
[00:24:30.788]Again for this study, all staff were trained
[00:24:33.284]with written instruction, role-play rehearsal,
[00:24:35.961]and performance feedback before implementing.
[00:24:39.335]The foods from the first phase to be added were
[00:24:42.699]pasta marinara, meatballs, broccoli and cheese,
[00:24:46.757]pudding, and raisins.
[00:24:48.713]For the intervention, the student had her home-packed lunch
[00:24:51.459]consisting of foods from the first study
[00:24:54.846]and only had to eat one novel food a day.
[00:24:57.824]The foods were drawn at the beginning of the week.
[00:25:00.440]For example, raisins were drawn for Monday,
[00:25:03.271]pudding on Tuesday, et cetera.
[00:25:06.353]Praise was given every 60 seconds when the student
[00:25:09.505]was eating novel food and home-packed food.
[00:25:12.687]If the student ate the novel food each day,
[00:25:15.171]she earned a sticker.
[00:25:16.706]If she earned all five stickers at the end of the week,
[00:25:19.599]she was able to cash in for a tangible item
[00:25:22.521]and earned a lunch superstar badge
[00:25:25.223]she got to wear and socialize with her favorite staff
[00:25:28.147]outside of the classroom.
[00:25:30.370]The second intervention used three items
[00:25:33.046]from her home-packed lunch
[00:25:34.982]and a full portion of novel food from the cafeteria.
[00:25:39.333]The five novel foods were selected randomly
[00:25:41.776]at the beginning of the week from the cafeteria menu.
[00:25:45.616]This eventually grew to all of the cafeteria meal.
[00:25:49.302]A lunch visual was added so the student knew
[00:25:51.755]what food she would be eating that day.
[00:25:56.192]This figure represents the percentage of home-packed
[00:25:59.366]and novel food the student ate.
[00:26:01.627]As you can see, the student was successful
[00:26:04.029]at increasing novel foods, and eventually eating
[00:26:07.140]all of the cafeteria foods offered
[00:26:09.518]with antecedent intervention and positive reinforcement.
[00:26:13.833]In conclusion, it is important to remember
[00:26:16.329]to use a team approach.
[00:26:18.109]This will help you rule out health and other problems.
[00:26:21.099]Next, make sure you complete your proper assessments
[00:26:24.404]for the most effective intervention.
[00:26:26.842]Base your intervention on your student needs.
[00:26:29.906]Don't use escape extinction unless it is necessary
[00:26:33.046]due to possible adverse effects.
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