Treatment of Pediatric Feeding Disorder in Children with Autism

1. Treatment of Pediatric Feeding Disorder in Children with Autism Meghan Dehring, B.S. Umbreen Iqbal, M.S. Carmen Reisener, Ph.D. Mississippi State UniversitySchool Psychology

2. Overview • Introduction • Definition of Pediatric Feeding Disorder • Causes • Background Literature • Methods • Results • Conclusion/Discussion • Questions

3. Feeding • No human activity has greater biological and social significance than feeding.

4. PFD Definition • When a child is unable to maintain proper nutrition due to refusal or failure to eat and drink in adequate amounts (Piazza & Carroll-Hernandez, 2004). • According to DSM-IV: “feeding disorder of infancy or early childhood is defined as a persistent failure to eat adequately, as reflected in significant weight loss over at least 1 month” (APA, 1994, p. 99).

5. PFD • Feeding disorders may be characterized by one or more of the following: • Symptoms associated with nutritional status (e.g., Failure to Thrive) • Symptoms related to oral motor aspects of eating (e.g., oral motor dysfunction) • Inappropriate behavior during meals (e.g., tantrums)

6. PFD • Feeding disorders including food refusal are considered a common problem in children with developmental disabilities (Palmer & Horn, 1978). • 25% of the typically developing children are diagnosed with feeding disorder • 33% of children with developmental disabilities are diagnosed with displaying similar problems (Patel & Piazza, 2001). • Diagnostic-specific treatments for feeding disorders could significantly improve their energy consumption and nutritional status (Schwarz et al., 2001).

7. PFD • Patient Demographics: • Mean Age: 3 years (39 months) • Gender: 64% male, 36% female • Developmental Level: • 53% Developmental Delays • 47% Typical Cognitive Development

8. Causes of PFD • Medical or genetic conditions that interfere with eating or development of feeding behaviors • Neuro-motor delays or dysfunction • Oral-motor problems • Mechanical obstruction • Feeding tube • Behavioral mismanagement • Failure to teach appropriate eating habits

9. Etiologies • Medical: Mom feeds me = I get sick • Oral Motor: No practice eating = Poor eating skills • Behavioral: I Fight/Refuse = Food goes away • Physiological: Decreased intake = Increased tolerance

10. Mississippi • In 2009 estimated population of 2,951,996 people – with 1,640,270 people living in rural Mississippi • Over 1,212 children in the state verified with an Autism Spectrum Disorder (e.g., meeting IDEA criteria) • Not many mental health services available specifically in the rural areas • Rarely any services available to families when it comes to dealing with developmental disorders (like autism, feeding disorders, etc.) (USDS-ERS, 2009)

11. Background Literature Availability of Services in Rural areas • Lock & Finstein, 2009 • Autism Spectrum Disorders • Studied sibling support, group involvement in rural west Texas • Really hard to find support groups • Also difficult to find family support system in rural areas

12. Background Literature Kerwin, 1999 • Examined peer-reviewed articles (1970-1997) evaluating empirically based interventions for feeding disorders • most promising interventions for the feeding disorders • contingency management treatment involving positive reinforcement for appropriate feeding behaviors • ignoring of inappropriate feeding behavior • non-removal of the spoon for refusal (escape extinction)

13. Background Literature Piazza and colleagues (2003) • Three treatment plans, for children with PFD • 1. escape extinction, 2. differential positive reinforcement, and 3. escape extinction and positive reinforcement • Acceptance, mouth clean, inappropriate behaviors, negative vocalizations were recorded • Escape extinction: increased Food intake • Positive reinforcement with escape extinction: decreased inappropriate behavior, smaller extinction bursts.

14. Background Research Bachmeyer and colleagues (2009) • Functional analysis indicated escape and adult attention as function of behavior. • A treatment combining escape and attention extinction yielded desired results: increase in food acceptance and decrease in inappropriate mealtime behavior

15. In Summary • Several treatment packages have been studied within the literature of feeding disorders • Escape extinction (EE) has been found to be a necessary component of treatment for PFD (although, may not be effective when used alone) • Additional components which include differential positive reinforcement based techniques have worked as well • It is always important to perform functional analyses to match treatment components for every client’s needs

16. Our Research • The purpose of our study was to systematically examine the relative effects of various function-based treatment packages consisting of extinction and reinforcement components.

17. Method Participants: • Two, 7-year-old, African-American females diagnosed with autism were referred to a university-based psychology service center due to feeding concerns and inappropriate mealtime behaviors. • Currently working with a 6-year-old Caucasian male diagnosed with PDD-NOS. • Bottle dependency • Severe food selectivity • Inappropriate mealtime behaviors • Goals: increase liquid intake (i.e., orange juice, milk, water) and decrease bottle dependency

18. Method Setting and Materials • All clinic-based sessions were conducted in a 4 x 6 room in the service center using age-appropriate seating arrangements (i.e., booster chair), drinking utensils (pink cut out cup with 6 cc of liquid), and other relevant objects for feeding. General Procedures • 5-drink sessions • Non-self feeder format; a trained feeding therapist served as the feeder for all sessions • Drinks were presented at midline • Praise was delivered for 5-s acceptance and mouth cleans

19. Functional Analysis • Data indicated that inappropriate mealtime behaviors, low acceptances, and mouth cleans were maintained by escape from drinking and adult attention for both the female participants and for our current client.

20. Functional Analysis : 6-year-old Caucasian male with PDD-NOS Escape vs. Control Attention vs. Control Combined inappropriate mealtime behaviors per minute sessions

21. Dependent Variables • Frequency of inappropriate mealtime behaviors • Turned head 45° from presentation of cup • Batted at the cup • Blocked access to the mouth • Hit the feeder from the elbow to hand during presentation • Acceptance of drink presented • Liquid actively accepted within 5 s of presentation • Mouth cleans • Swallowing within 30 s of acceptance

22. Interobserver Agreement • A second observer simultaneously but independently scored 42% of all sessions for one female participant and 33% of sessions for the other. • The total interobserver agreement for the first and second participant’s acceptance was 93% (range, 73% to 100%) and 89% (range, 77% to 100%) respectively. • For the first female, the total interobserver agreement for mouth clean was 91% (range, 60% to 100%), and the total interobserver agreement for inappropriate mealtime behaviors was 88% (range, 58% to 100%). • For the second, the total interobserver agreement for mouth clean was 87% (range, 62% to 100%), and the total interobserver agreement for inappropriate mealtime behaviors was 89% (range, 60% to 100%).

23. Experimental Design • A multielement design was used to evaluate levels of the dependent variables of three treatment packages. • The conditions were randomly selected.

24. Experimental Design Matched Treatment Comparison Assessment (Drinking) Phase A:Baseline • Escape + Attention Phase B: • Escape Extinction+ Attention Extinction+ Differential Reinforcement of Alternative Behaviors+ Differential Negative Reinforcement of Alternative Behaviors (EE+AE+DRA+DNRA) Phase C: • AE+Esc+DRA Phase D: • EE+Attn+DNRA

25. Demonstration

28. Results • For both female participants the most effective treatment was one in which the extinction and reinforcement components were matched to all maintaining variables (i.e., escape and attention).

29. Results: Current Clinic Case

30. A + E EE+AE+DRA+DNRA A+E

32. Conclusion • The current study supports previous research and demonstrates that the matched treatments were successful for two of the three participants - - we cannot conclude that the success of our current clinic case is due to our treatment.

33. Discussion • 6-year-old male • Higher functioning than the other two female participants • Had received previous feeding therapy for orange juice and foods (i.e., apple sauce, carrots) – carry over effects • very rule governed • Most reinforced by praise and overall positive social attention • His parents reinforce good clinic days with an opportunity to eat and play at McDonald’s • Possibility of skewed FA data due to environmental/parental variables

34. Future Research • Service provision for children with Autism and PFD in rural areas • Re-examine reinforcement alone conditions to increase liquid consumption because there is a possibility that positive reinforcement is effective when the child exhibits some level of appropriate feeding behaviors.

35. Special Thanks • Susan Beveridge • Kelsey Nurnberg • Tia Daniels • Sam Woods for their help and support in conducting this study

36. Questions?

37. References American Psychiatric Association. (1992). Diagnostic and statistical manual of mental disorders (4th ed., rev). Washington, DC: Author. Bachmeyer, H. M., Piazza, C. C., Fredrick, D. L., Reed, K. G., Rivas, D. K., & Kadey, J. H. (2009). Functional analysis and treatment of multiply controlled in-appropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658. Kerwin, E. M. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Journal of Pediatric Psychology, 24, 193-214. Lock, R. H., & Finstein, R. (2009). Examining the Need for Autism Sibling Support Groups in Rural Areas.Rural Special education Quarterly, 28(4), 21-30.

38. References Palmer, S., & Horn, S. Feeding problems in children. (1978). In: Palmer S, Ekvall S, eds. Pediatric Nutrition in Developmental Disorders. Springfield, IL: CC Thomas; 1978:107-29. Patel, R. M., Piazza, C. C., Kelly, L. M., Ochsner, A. C., & Santana, M. C. (2001). Using a fading procedure to increase fluid consumption in a child with feeding problems. Journal of Applied Behavior Analysis, 34, 357-360. Piazza, C. C., Patel, R. M., Gulotta, S. C., Sevin, M. B., & Layer, A. S. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.

39. References Piazza, C. C., & Carroll-Hernandez, T. A. (2004). Assessment and treatment of pediatric feeding disorders. In R. E. Trembly, R. G. Barr, R. DeV. Peters (Eds.), Centre of Excellence for Early Childhood Development (on line). Available at http://www.child-encyclopedia.com/pages/PDF/Piazza-Carroll- HernandezANGxp.pdf. Schwarz, M. Steven., Corredor, J., Fisher-Medina, J., Cohen, J., & Rabinowitz, S. (2001). Diagnosis and treatment of feeding disorders in Children with developmental disabilities. Pediatrics, 108(3), 671-676. United States Department of Agriculture, Economic research Service. (2009). Retrieved from: http://www.raconline.org/states/mississippi.php

40. Contact Information Meghan Dehring • Phone: (586) 255-5154 • Email: mad279@msstate.edu • Address: 175 President’s Circle Allen Hall, 508 Mississippi State, MS 39762