Escape Extinction for Fussy Eaters: Effective Intervention Strategy?

1. “Just take a bite!”Is keeping a child at the table during mealtimes REALLY the best way to get them to eat? Evidence Based Practice, Feeding Disability

2. Who are we? • The 2011 group is comprised of: • 9 speech pathologists from ADHC and Cerebral Palsy Alliance • 1 occupational therapist from ADHC

3. Why did we include an OT • This is the first year a professional outside of speech pathology has been involved in the EBP network. • The purpose was to: • Widen our access to resources • Widen the field of experience to those who have trained experience in people with sensory processing disorders • A genuine interest by the occupational therapist to support her professional development and use of EBP.

4. Our Clinical question • Began with searching for the best intervention strategies for supporting fussy feeders. • 20 articles • Our initial search, developed our interest in the strategy of Escape Extinction/ new direction for our EBP

5. Our clinical question To increase feeding outcomes for children with fussy eating, is escape extinction more effective than other interventions?

6. To increase feeding outcomes for children with fussy eating, is escape extinction more effective than other interventions? • What is the current best evidence? • Engaging in EBP to learn more about EE. • What does our clinical expertise tell us? • Look at our policies and procedures • Survey current practice • 3. Where do client values fit in with this topic? • Discussing and considering how families may view EE.

7. Escape Extinction ‘Escape extinction is a term that has been used to describe procedures that prevent the child from escaping the feeding situation’ (Piazza et al, 2003). Goal is for the child to no longer be able to use inappropriate behaviours to escape the mealtime. It is Often used in combination with reinforcement procedures. Includes Physical guidance When a bite is not accepted, gentle pressure may be applied to the mandibular joint, physically guiding a child to open their mouth so food can be deposited inside(Ahern et al, 1996) Non removal of the spoon ‘Consists of a feeder presenting a bite of food on a spoon in that position until the child consumes the food.’ (Tarbox et. al 2010 pg. 223)

8. Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Paediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-365. Method • A Systematic review of the literature for treatment of paediatric feeding disorders. • Inclusion criteria: • An experimental design with a control group. • Published in an English language peer-reviewed journal between Jan 1970 and June 2010. • Evaluated intervention for children with a severe feeding disorder. • Intervention aimed at improving solid food intake. • The dependent variable was a measure of food intake (e.g. acceptance, grams). • The children did not meet the DSM-IV criteria of an eating disorder.

9. …Sharp et al. 2010 Method (continued) • The articles were then classified based on their: • Treatment elements. • Setting. • Primary therapist. • Generalisation. • Statistical analysis • Percentage of non-overlapping data (PND) and non-overlap of all pairs (NAP) used to evaluate the effectiveness of treatments.

10. …Sharp et al. 2010 • Out of 124 possible studies, 48 met the criteria. • All of the studies emphasised behavioural interventions: • Escape extinction was the most widely used (83%) - non-removal of the spoon was used in 48%, a prompt to open the mouth if the bite was not initially accepted was used in 21% and non-removal of the food was used in 25%. • Differential reinforcement (reinforcement of acceptance) was the second most-common intervention strategy implemented (77%). • 10% of studies involved punishment-based procedures. • 90% of studies involved more than one element in a “treatment package”. • Acceptance of food into the mouth was the most frequent measure of food intake (72.9%). Swallowing the bite was used as an outcome measure in 27% of studies. • PND and NAP scores (M=88%) put the behavioural interventions as a whole into the effective treatment range

11. Strengths and Limitations of the Systematic Review Strengths • It is a systematic review. • Good statistics, scientific principles • Multidisciplinary Limitations • It does not compare behavioural interventions to non-behavioural interventions. • It does not compare the effectiveness of each of the treatment elements (e.g. EE vs punishment, EE vs reinforcement schedules). • It is only relevant for children with severe feeding disorders.

12. Limitations and Strengths of the articles within the Systematic Review • Strengths • Some follow up on effectiveness of parent training • Limitations • Long term follow up in the articles (5, 10 years later??) • Some articles did not appear to look at generalisation – training of the parents, follow up at home, family views/perspectives, qualitative data

13. …back to our question • We cross referenced initial articles we found against systematic literature review • Developed selection criteria to refine list to articles to answer our question. No Clear comparison between EE vs other methods in our available articles. Outcome measures used inconsistent across our articles.

14. What other interventions are there?What is the evidence for these? • No published studies to compare the clinical efficacy or cost effectiveness of interventions for assisting children with feeding difficulties and/or a limited dietary intake. • Other interventions for children with feeding difficulties include: • Graz Model (EAT and No-tube program) • Sequential Oral Sensory (SOS) Approach to Feeding

15. Graz Model (EAT and No-tube program) • Developed by Professor Marguerite Dunitz-Scheer and Professor Peter Scheer from University of Graz • Psychosomatic approach that aims to remove the tube and for the child to sustain themselves in a nutritionally sufficient way • Three week intensive course with three different ways of participating (NET coaching, Outpatient or Inpatient) • Fast reduction of tube feeds under medical supervision • Interdisciplinary therapy sessions with specific therapy around food • Daily play picnic, a specialized eating therapy based on psychoanalytical nondirective play therapy with various kinds of food.

16. Graz Model - Evidence • Level IV Evidence, Case Series • tube feeding with sufficient oral feeding after treatment (defined as the child’s ability to sustain stable body weight by self motivated oral feeding). • 92% were completely and sufficiently fed orally after treatment. • Tube feeding was discontinued completely within a mean of 8 days, the mean time of treatment was 21.6 days. • 6-8% could not be weaned and remained fully or partially tube fed. • These children deemed “not weanable” (i.e. children with tube primarily for intake, most children with severe disabilities, hx aspiration, lack of mobility and independence) • Limited long term data.

17. Sequential Oral Sensory (SOS) Approach to Feeding • Designed to ax and address all factors involved in feeding difficulties • 4 Major Tenets: • Myths about eating interfere with understanding and treating feeding • Systematic desensitisation is the best first approach to feeding rx • Typical feeding development gives the best blueprint for rx • Food choices play an important role in feeding treatment • General Treatment Strategies: • Social Modeling • Structuring Meal/Snack Times • Reinforcement • Accessing the Cognitive • No published research available but is currently being conducted by Children’s Nutrition Research Centre, QLD.

18. Clinical Bottom Line • Behavioural interventions are effective in improving intake in children with severe feeding disorders. The most common interventions use a combination of behavioural strategies. • Escape extinction in combination with other behavioural techniques was the most widely used and successful approach.

19. EE and Workplace Policies & Procedures ADHC Policies • Disability Service Standards (NSW Disability Services Act 1993) • Nutrition and Swallowing Policy (Amended Sept 2010) • Nutrition and Swallowing Decisions about Nutrition- attachment (Sept 2010) • Nutrition in Practice Manual (Oct 2003) • Behaviour Support Policy (Jan 2009) • Behaviour Support Policy and Practice Manual (Jan 2009) • Speech Pathology Practice Package (June 2010) What do your policies and procedures reflect?

20. Disability Service Standards (NSW Disability Services Act 1993) Standard 3  - Decision making & choice "Each person has the right to make their own decisions wherever possible and have choice “

21. Nutrition & Swallowing PolicySeptember 2010 “A prevention and risk management approach to individual nutritional health is required.” pp5 “Balancing tensions between individual choice and duty of care” pp6-7

22. Behaviour Support Policy (Jan 2009) “The Department promotes a positive approach to behaviour support, based on comprehensive assessment and analysis of the meaning and function of behaviour in a whole-of-life context. The aim of positive approaches to behaviour support is to provide a respectful and sensitive environment in which the Service User is empowered to achieve and maintain their individual lifestyle goals.” pp7

23. Speech Pathology Practice Package June 2010 Eating Behaviour Problems: Practice Manual from the Centre for Child Community Health 2006 • “Appropriate and successful eating in children also demands a division of responsibility. Parents choose food that is safe and appropriate for the child, offer it in a positive and supportive fashion and allow the child to determine how much and even if he or she will eat at all.” pp12 • “Encouraging children to experience new foods is assisted by familiarity and lack of pressure to eat.”pp16 • “Bribery is counterproductive.” pp16 • “Allowing the child to maintain control of intake may have important long-term positive health implications.” pp16

24. Speech Pathology Practice Package June 2010 Eating Behaviour Problems: Practice Manual from the Centre for Child Community Health 2006 “Interventions that have been most successful in promoting healthy eating behaviours in children include: • Repeating the exposure of a new or novel food to improve acceptance through increased familiarity • Modelling behaviours, that is, parental and peer consumption of a food increases consumption and preference of it by the child • Allowing the child to determine (control) how much food is eaten from a selected menu, which results in consistent and adequate energy intake despite meal-to-meal variation in intake • Ensuring that the social context in which food is offered is one that is likely to increase preferences for a variety of foods, including new foods • Making positive statements to encourage the child to taste novel or new foods.” pp28

25. Speech Pathology Practice Package June 2010 Expanding Children’s Diets by Suzanne Evans Morris 2009 “Children need to learn about new foods in an unthreatening way…Mealtimes frequently are associated with expectations for eating and drinking. Many children are on guard and spend a great deal of energy protecting themselves from new sensory experiences that feel dangerous. Comfort and safety are the most important aspects of the mealtime. When children feel safe and comfortable, they are more willing to risk and participate in new experiences.”

26. Survey • In following the E3BP model we collected data from therapists to review what interventions they were mostly likely to use for our paediatric feeding clients. • 115 responded to the survey however we could only view 100 responses due to account limits on survey monkey.

27. Participants and workplace

29. Ella is a six year old girl with autism. She is a fussy eater and will only eat white food. Her mother would like for Ella to eat all the food presented to her at each meal. Which of the following strategies are you MOST likely to recommend?

30. Case Study 1: Mrs Mack (teacher) reports that the only way she can get one of her students to eat, is by holding a spoon in front of them until they take a bite. What other strategies would you suggest to Mrs Mack? You could select more than one answer.

31. What about Client/Patient Values? • Possible that escape extinction has already been trialled by parents prior to intervention from trained therapists • Possible that that clients have already associated “negative” feelings around mealtimes/food intake. • Parents sharing their own experiences and learning from other parents who may have a typically developing child. • For our own children/grandchildren, it is possible we have implemented escape extinction techniques and observed some success without even realising it.

32. What about Client/Patient Values? • Does the ADHC practice package allow therapists implement escape extinction? • Does the Disability Services Act (1993) support the use of escape extinction? • Restrictive practice guidelines • Ethics – do we feel comfortable making recommendations using escape extinction? • What if the child is malnourished and the family is desperate? • Comparison to medications which are sometimes forced to be consumed? • Is it ethical to withhold a treatment that has proven to be effective? • Do we use some of the concepts within our daily lives?

33. Consulting the EBP triangle Escape extinction combined with other therapy techniques seem to achieve the ‘best’ results. Current Best Evidence I just want my child to eat so their nutritional needs are met and I want this to happen in the easiest possible way! Are we comfortable with recommending escape extinction for children who are regarded as fussy eaters? Clinical Expertise Client/Patient Values (ASHA, 2004)

34. In 2012… Meetings will rotate between ADHC Metro South offices. Please contact: • Emma Minchin emma.minchin@facs.nsw.gov.au 8344 2700 • Tsen Levsen tsen-aie.levsen@facs.nsw.gov.au 9701 6300

35. Next year for paed feeding (disability) • Transitioning from a gastrostomy to oral feeds • Efficacy of specific therapy approaches (e.g. SOS) • Group therapy for problem feeders

36. Laura Mobbs (ADHC, Penrith) • Tsen Levsen (ADHC, Burwood) • Emma Minchin (ADHC, Rosebery) • Rachel Cummins (ADHC, Rosebery) • Kylie Ryan (ADHC, Hurstville) • Jean Chan (ADHC, Rosebery) • Katharine White (ADHC OT, Rosebery) • Maria Andreadis (ADHC, Fairfield) • Amanda Khamis (Cerebral Palsy Alliance, Kingswood) • Jill Rosen (former member from ADHC)

37. References Ahern et al (1996) An alternating treatments comparison of two intensive interventions for food refusal, Journal of Applied Behavior Analysis 29 (3), pp 321-332 Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M. (2006). Tube weaning according to the Graz Model in two children with Alagille syndrome. Pediatric Transplantation, 10, 934–937. Piazza.C.C, Patel. M.R, Santana. C.M, Goh. H.L, Delia. M.D & Lancaster. B.M (2002) An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavioural Analysis, 35(3), 259-270. Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Paediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-365. Tarbox J., Schiff A., Najdowski A. C. Parent-Implemented Procedural Modification of Escape Extinction in the Treatment of Food Selectivity in a Young Child with Autism. Education and Treatment of Children, 33.2 (2010): 223-234. Thomas T, Dunitz-Scheer M, Kratky E, Beckenback H and Scheer P (2010). Inpatient tube weaning in children with long-term feeding tube dependency: A retrospective analysis. Infant Mental Health Journal, 31(6), 664–681.

38. Any questions? By Lauren Child