Help Your Child With Feeding Problems – For Individuals With Autism Spectrum Disorders

Intro: This podcast is brought to you by the LeafWing Center. Helping children and families since 1999. Brought to you by the Clinical Treatment team at the LeafWing Center, this is the Autism Parent Helper Podcast.

Rei Reyes: Hello listeners! Welcome to Leafwing Center’s very first podcast. My name is Rei Reyes.

Mari Oganisyan: I’m Mari Oganisyan.

Manjit Sidhu: Manjit Sidhu here.

Lloyd Gilbert: Lloyd Gilbert.

John Lubbers: I’m John Lubbers.

Sevan Celikian: Hi everyone, I’m Sevan Celikian.

John Lubbers: What we want to talk about today is kind of an interesting issue. I think we’ve all encountered this quite a few times in our clinical practice is this idea of feeding problems. We know that when we work with our children or our individuals that oftentimes there’s some concern about this individual does or does not eat this or there would be some area for change in terms of eating. I’ve seen it in my clinical practice over the years and we’re talking about quite a few years, I’d say maybe 20, 30, 40% of the time. So it’s pretty, pretty prevalent. And so why don’t we spend some time talking about that today.

Sevan Celikian: Sounds like a plan, John. So like you said, John, it’s about 20, 30, 40% of children experience feeding problems on some level. We know that feeding problems are common amongst typically developing children, but they’re even more prevalent amongst children living with autism.

John Lubbers: So, even like a typically developing kids have these issues, right? You were talking about your neurotypical boys and girls have some feeding issues. Is that what we’re hearing?

Sevan Celikian: Yeah. Like you said earlier, we might be dealing with, with picky eating or not eating enough or not eating enough of the right things or eating too much of things that we don’t want some of the kids to be eating and so on. So they present in many different forms.

John Lubbers: And I might not understand, right, guys, is it like our kids with special needs or individuals with special needs? There’s maybe even a higher prevalence. Are we seeing that?

Sevan Celikian: Yeah. In fact, there was a research done in 2009 by Nicholls and Bryant-Waugh showed us that feeding problems affect approximately as high as 40-80% of children with disabilities including autism.

John Lubbers: Wow. 40-80%. That’s a big number. Again, pretty high. Yeah, that’s really a significant number there. And those kinds of things. What are we talking about? What are those things?

Sevan Celikian: So feeding problem is a loose definition as it relates to the field of autism. There’s a number of definitions out there, but it consists of a variety of factors, some combination of the following, let’s say the inability or refusal to eat certain foods because of a variety of factors. Now those factors can include skill deficit, food selectivity, challenging behaviors, medical issues, lack of effective and consistent caregiver feeding practices, even Pica or the eating or attempting to eat non-food items.

John Lubbers: So now that you said that’s kind of an interesting thing. I never really thought about a skills deficit when it comes to eating. I guess I have no deficits with respect to eating, but I guess maybe if you look at it, it is a skill. You have to, to put something, you have to cut a food and you have to put it in your mouth, you have to chew it and then you have to swallow it. Right? So there’s like three, four different sub skills that you need to have some fluency with.

Sevan Celikian: That’s true. At the most basic, the most fundamental level, skill deficits should be considered when we’re talking about feeding problems, like you mentioned, chewing and swallowing. Some children with autism may present difficulties with oral and motor skills, even handling utensils, forks, knives, spoons, things of that nature. So these deficits can make eating and feeding more difficult, for sure.

Rei Reyes: I agree with that. Cause I mean, we all work with the younger children and more of a common thing about children, children living with autism is that their fine motor skills aren’t as developed. So we’re talking about using utensils for eating, then, they are at a disadvantage there.

John Lubbers: Yeah, definitely. And maybe, we spent a lot of time teaching those fine motor skills too as well. With respect to food selectivity, which is an interesting other a whole other direction. It seems like that’s quite a broad definition of things. There is those of us, like me, I personally, I don’t really dig oysters so that I guess you could say I have some level of food selectivity because and then, but I eat pretty much most everything else. I stay more to our western foods, here that I was accustomed to growing up in the United States. When we get into things that are not so common in our U.S. culture, I tend to be a little bit more hesitant to approach those kinds of things. But I guess, to some degree, we all have some level of food selectivity, but I guess maybe becomes a problem when it becomes a little extreme.

Sevan Celikian: It affects nutritional intake, limits your diet, cuts into family life, that sort of thing. So yeah, you made a good point, John. All of us probably have some level of food selectivity. It just doesn’t affect us to the level where it’s harmful nutritionally and it affects family lifestyle and that sort of a thing. We know that food selectivity is very common in the field of autism. There was one study done by Provost in 2010. He used parent self-report questionnaires and found that 95% of children with autism were reported by parents to have a range of specific food preferences. And this was done using a sample of 23 children living with autism. So interestingly, the types of food preference included preference based on food color, food packaging, food texture, and certain food temperatures.

John Lubbers: That’s fantastic. That is so interesting. So we’re talking about 23 kids, so it’s not a massive number of kids, but I’m sure this doesn’t seem to be inconsistent with maybe what we’ve experienced clinically. But yeah, it doesn’t sound too far off of it, but it seems kind of interesting food colors. Okay. So, you could imagine like a kid who was like, oh, I only eat orange foods or I only eat green foods. We would love that I’m sure. Cause green foods would be vegetables. Yeah. Kind of goes into the rigidity to yes it does. Yeah. And it could be part of that rigidity kind of thing. Food packaging, that’s not one that I would have expected.

Sevan Celikian: Yeah. So in that particular study, the same food presented in different packages. Some of the kids would refuse to eat the same food if it was presented in a different package simply because of the packaging, packaging were talking about and plastic bags and what not. Yeah. Plastic bags, wrappers, and things of that nature.

John Lubbers: Interesting. Depending on what its marketed towards or what’s on it could make a big factor as well. And packaging, that raises the question of what specifically they were talking about.

Sevan Celikian: Packages could work as a conditioned reinforcer cause you already know what’s inside and you’ve kind of associated with the package with what you’re going to get inside. So when that’s changed around it could have an impact, but food texture now that’s, that was a big one. Yeah. Out of that sample, 71% of the kids or 17 of them, had a range of specific food preference just based on food texture alone. I’m sure we’ve all seen this a lot in our practice. Some kids just will not eat anything or will prefer not to eat anything mushy or.

John Lubbers: Slimy.

Manjit Sidhu: Anything wet.

John Lubbers: Yes, that didn’t surprise me at all. That’s kind of when we were talking about selectivity. That’s kind of what I immediately my brain went to is textures and stuff like that. I think in my experience, that’s what I see most often with our kids is they act like, oh, I don’t like slimy things or creamy things or what have you. And in fact, I’ve even talked to some adults that are, like that, just in the coffee shop. Yeah. Ooh, no, that’s kind of kind of slimy. And…like mayonnaise.

Manjit Sidhu: I can’t eat yogurt, yogurt. Because it’s lumpy. It’s a texture.

Lloyd Gilbert: Yeah. Like you mentioned the oysters. I’m the same way with octopus or anything along those lines. Yes. That’s something that even touching it just bothers me.

John Lubbers: I used to really be resistant to it when I was a kid, like octopus and Calamari and that kind of stuff. As I’ve grown older, I’ve become more open to it now. So now I’ll eat it without too much problem. My kids are still really like, whoa, what are you eating dad?

Manjit Sidhu: Yeah. Desensitized huh?

John Lubbers: Yeah I guess I got desensitized over time yeah.

Lloyd Gilbert: That also has another dual effect to it also cause if you’ve had it raw it’s a lot chewier, chewier than than the outside of it, which is slimy.

John Lubbers: What is this? What is this food temperatures thing? That’s another surprise to me in there, I’m guessing hot versus cold.

Rei Reyes: I remember it’s not as common. I can only remember one child that I worked years ago that had a preference for piping hot food. Really? Yes. So the food is always placed in the microwave. But out of all the clients I’ve worked with, that’s the only one I can remember.

Manjit Sidhu: I’ve had one. Now it comes to my mind. It had to be super hot. And that’s how he ate it.

Rei Reyes: Mostly hot, not cold right?

Sevan Celikian: There could be a sensory issue going on there too, right? Because children with autism, there are sensory impairments and sensory sensitivities. So the way one child living with autism experiences, cold or hot or soft or hard could be totally different from another individual. So that may play a role as well with the temperature factor.

John Lubbers: Yeah. I just, it’s just so interesting. 95% of the kids with ASD manifested or showed some form of food issue. Some issue with feeding that. So yeah, that’s pretty darn prevalent.

Sevan Celikian: Another interesting thing about the food textures we spoke about. Maybe you guys have had the same experience but in my practice and then the reading that I’ve done, there’s been situations where a child will, will not eat, let’s say an apple or a strawberry when presented in sliced form or whole form. But when the texture or form is modified let’s say into a juice or smoothie and things of that nature, they may be more willing to try the same food. So that’s just something for us to keep in mind when we play around with textures and forms gives us some more options to work with. So that’s something that might be helpful.

Lloyd Gilbert: Can be really good for parents. Yeah. Because I think a lot of time we all kind of get in that fixed mentality needs to be this way or that way, but changing things up a little bit, that would be a good thing for them to look at as well.

John Lubbers: Yeah. I think even we even as neurotypical grownups may do that kind of stuff as well where, those juice bars, Jamba juice and Robek’s and all those places, they become quite popular because a lot of us, it’s a good way to get our fruits and vegetables and so I’ve heard people actually say that they prefer to drink their fruit, their vegetables rather than to eat them.

Mari Oganisyan: Because they don’t have to do the chewing.

John Lubbers: And the tasting! Yeah, maybe it goes right down your throat, gets in your tummy, and yeah.

John Lubbers: That’s a good point. Yeah. Really interesting.

Sevan Celikian: Challenging behaviors – that plays a role with feeding problems, it definitely as parents out there know, makes mealtime a lot more difficult that those behaviors might include throwing or ear/eye pressuring, resistance to sit at the table, that sort of thing.

John Lubbers: Yeah, it seems to me, and I mean not to do a functional assessment without doing a functional assessment, but it seems to me a little bit like those just a lot of behaviors that are sort of escape avoidance behaviors. The tantrum, the throwing the food away. They are escaping the eating location, the table or the chair or whatever it is. So it’s a lot of behaviors we see serving the function of escape, which is interesting as well.

Manjit Sidhu: Yeah. Those behaviors are just another way of saying, I don’t want it.

John Lubbers: Exactly.

Sevan Celikian: Those sensory issues. Yeah. Like we, we kinda touched on that earlier too. I mean, that’s something that, we should be aware of because impairments in sensory processing are common in children living with autism. So that may affect their eating habits, a child living with autism, biting into something crunchy like an apple or a chip. It could be aversive, a lot of pressure on the teeth, the jaw. So it might be helpful to consider those sensory issues.

John Lubbers: And those are things like, obviously the taste of the food, but also the smell of it too. What it smells like. Some foods have stronger smells than others. We’ve heard, in offices where there’s shared kitchens, the people in this office cook this food and it’s really garlicky and the people in this office cook this food and it’s really this or that or what have you. And that those smells can even affect us. We’re, we’re pretty well aware of that. That, that’s really interesting to me.

Sevan Celikian: Yeah, definitely. And it’s always good to keep in mind medical and gastrointestinal issues. Those are some other factors associated with feeding problems. Things like acid reflux or difficulty with bowel movements. These are factors associated with feeding problems and it could affect the nutritional intake of children living with autism. So, identification of these at an early age, it’s likely to benefit children’s nutritional and overall health. In the long run.

John Lubbers: Yeah that’s real common sense to me, if we don’t, when we’re sick, when we have the flu, we don’t, sometimes we don’t want to eat food is not appetizing to us. And so if our kids or individuals on the spectrum are in some sort of distress in terms of their GI tract or what have you. It makes sense to me it seems real common sense. They wouldn’t be that interested in eating

Sevan Celikian: Totally. Some children living with autism exhibit Pica behaviors and what we mean by Pica is the eating or attempting to eat non food substances. So that’s another one of the factors that’s been recognized amongst feeding problems.

John Lubbers: And clinically I’ve seen that, put a percentage on all the individuals. It’s not low, but I guess maybe it stands out to me when I see it when I come across it. I might’ve seen it 5% of the kids or the individuals that I worked with and oftentimes too, I usually see it in adults more so than kids. And I’ve seen things from like eating rocks, picking up a rock off the ground and eating it to eating cigarette butts or cigarette filters and uh, leaves and all kinds of things like that. And I know a lot of times there’s been a little bit of a medical theory on this that, that Pica is in fact, maybe the, the body’s internal way of getting minerals and vitamins that it’s deficient in, without the person being aware of it.

John Lubbers: So it’s kind of like a subconscious way of, I’m deficient in magnesium so we’re going to go find something that gives me magnesium, so I’m gonna go eat dirt that kind of thing. I know that was a hypothesis people had. And so a lot of times what we do when we get that is first thing we do is refer to a pediatrician or a physician or somebody to, to do an assessment in terms of the individuals, their overall nutritional status, whether they’re missing anything mineral or vitamin wise. So it was pretty interesting to me when we’ve worked with people with pica in the past.

Sevan Celikian: That is good practice John, thanks for sharing that. And the research also shows that there’s usually a relationship between Pica, aggressive behavior and gastrointestinal problems, which is not surprising because if we’re attempting to eat or eating non food items then gastrointestinal problems is, usually, something that’s expected after that. So, yeah, whenever we’re considering feeding problems in children with autism, Pica should be included whenever relevant. Like you said, John, it probably doesn’t affect, a huge portion of the population, but some individuals do exhibit Pica behaviors.

John Lubbers: Absolutely. What do you guys think about the kind of where we are in the new millennium and in the, what we’ll just kind of have this discussion as the Western world and our practices and our daily lives now where what meal time is for us, when we have school age kids, it’s like, okay, let’s eat fast so we can get to school. So we’re trying to eat whatever it is. Lunch is usually consumed at school by the, is sort of a school responsibility. Often times or sometimes we’ll send our children to school with lunches, but then dinner kind of circles back around to the family. And a lot of times our families are juggling things. There’s babies involved and there’s teenagers involved and we’ve got to figure out how to make a meal time or, or feed a few mouths.

John Lubbers: And so what I kind of am wondering is, is our more traditional meal time, in quotes, is that something more of the past or is that, is that something, the present construct?

Sevan Celikian: It’s a really good question, John. In my experience, I’ve found that mealtime and meals and eating habits vary widely from individual to individual and family to family based on their lifestyles, their schedules, work, school, what their motivation is. Do we want to sit down and do we all want to eat together. Do we just want to eat and move on to the next thing.

John Lubbers: And where to eat. And where to have dinner, in front of TV?

Sevan Celikian: Yeah. At the dinner table with everyone there. Siblings, parents. So lots of variability.

John Lubbers: Yeah, it’s really, it’s a complex issue. Are we aware of any like assessments that we can, that can kind of help us take a look at this from a more standardized practice?

Rei Reyes: Yes, I mean, we want an assessment, one thing in our field is that we really want to operationally define like, so we’re all sure what exactly we’re looking at. And one way to do that is to use some kind of an assessment. There are assessments out there, there’s this children’s eating behavior inventory, screening tool for feeding problems, or step, and behavioral pediatrics feeding assessment scale or BPFAS. But John, these were not really developed for children living with autism. And again, we want to make sure that we are using some kind of a tool there that is specific to the population we’re working with, but it’s not there at least until the BAMBI. It stands for brief autism mealtime behaviors inventory. It was developed by Lukens and Linscheid back in 2008.

Rei Reyes: And in a nutshell, it is the first standardized questionnaire that we can use with families of there with children living with autism. It’s a pretty straightforward questionnaire. Much like the other questionnaires that we have used, some direct measurement measurement that we have used with our clients’ families. So it’s not difficult at all. And from my understanding, they, they have grouped the questionnaire into three, like the first group taps into something like what variety of food a child may or may not be into. Okay. Ask about their willingness to try new items. Speaks a little bit to that idea of selectivity. Exactly. Like what’s Sevan had gone over earlier, it asked something about preparation of food textures and type. A second group is about food refusals. Basically it looks into the behavioral aspects of things that we observe from a childlike tantrums, crying, closing mouths.

Rei Reyes: And all that. And the third feature is what really separates the BAMBI from other assessments because it does tap into autistic or autism specific behaviors such as inattention to self injurious behaviors and repetitive behaviors to name a few. And and again, like I said, it’s a very straight forward questionnaire. You rate a question between one and five. One, I believe is never or rarely and a five is at least every meal. And you answered this question for all 18 questions. Okay. So it’s not too long. It’s not too long. And again, from what I’ve read, the tally a score is, is figured out in the end from a behavioral perspective and us here in this field, it’s best to do this like in the beginning. So you have a baseline–how bad the behavior is in the beginning. And we have the intervention, we run scores and a few weeks later or a few months, we run the assessment again and see how the scores may have changed over time. Obviously we want the score to be lower than baseline, which will suggest that the intervention we’ve used is somewhat working.

Sevan Celikian: That’s pretty cool. Right? Yeah. Thanks for pointing that out. It’s great that the BAMBI’s out there and it can be used by parents, practitioners. It’s effective, it’s straightforward. It could be filled out by parents and anyone that’s really familiar with, with the child’s, eating habits really. So that’s a really cool tool to be used.

John Lubbers: Now, I’ve never had the chance of using the BAMBI, but knowing what I know a little bit about assessment, specifically what I’m talking about when we administer the questions about Behavioral Function or the Motivation Assessment Scale one of the critical factors in there is do the, does the respondent understand the question so that when they answer it, they give you a good answer that you can then take that information and use it. I’m sure none of us have had the chance to use the BAMBI, but I’m wondering if I’m going to try to use it now and wondering if it’s pretty user-friendly if it gives us good information pretty easily.

Sevan Celikian: Oh, that’s a really good point, John. Yeah, we walked through answers were all the questions and the answers to produce valid results. And like you said, Rei, those questions are pretty straight, standardize. They’re pretty straightforward. And yeah, so with that, the BAMBI, has a pretty good amount of validity overall.

John Lubbers: So we have a tool to assess now. Okay. We have something, which is great because with what we want to do, like you said, Rei, we want to assess and then look for progress over time. Do we have an intervention? Is there any sort of intervention that we’re aware of?

Manjit Sidhu: We do. we found something called Eat-Up and let’s just start with what Eat-Up stands for, it’s Easing Anxiety Together with Understanding and Perseverance. Basically it’s just an intervention that parents can use at meal times. It uses evidence-based practices and training of parents as the primary interventionists because they’re the ones that are going to be there for the meal time. So it’s important that they learn the skills and the interventions that they can apply.

John Lubbers: So really consistent with our philosophy in applied behavior analysis. Right. Yeah. So that’s a nice sort of consistency with what we do already.

Manjit Sidhu: Right. so for Eat-Up, it was applied into a research article that we found, published in November, 2016 by Cosby and Muldoon. I’ll tell you the name of the article. It’s a “Eat-Up-Family-centered feeding intervention to promote food acceptance and decreased challenging behaviors. A single case experimental design replicated across three families of children with autism spectrum disorder.” It was really interesting article. Like I just said, it was, focused on three different individual families and it was to promote food acceptance and decreased challenging behaviors that occurred at mealtime and it was effective. These interventions that will hopefully go through, we’re all effective in yeah, well goes there.

John Lubbers: It’s great too because it was in 2016 so it’s a reasonably recent study. Yeah. Which is really great. I don’t know if we recall, I don’t have any notes here about where it was published. We can obviously try to look that up and put it in some show notes or something like that or on the website. For anybody who wanted to look that up.

Mari Oganisyan: Yeah. And the training procedures that they use, they were two phases to the training components, that intervention coaching phase where the parent was trained to implement the intervention with coaching. And then parents were given feedback after the training session was over so that they know, what are some of the things that they can work on, and going forward. And then there was also a second component, which was, and I’ll also keep in mind, once the parent was able to do 90% of the intervention strategies over three consecutive sessions, they would go into a phase two.

John Lubbers: So Mari, if I understand right, the coaching phase, the goal was for the experts to teach the parents to be able to implement the intervention at 90% accuracy. And they had to do that over three different feeding sessions before they moved on to phase two.

Mari Oganisyan: Exactly. Cool. And once they got to phase two, which was the intervention independent phase, like I mentioned during that Phase, the coaching was eliminated. But the after, session feedback continued because of course the parent should be aware of what are some things that could continue to work on and improve. And then in phase two, if the child demonstrated 85% of the food acceptance based on each child’s individual goal, that was completed.

John Lubbers: Oh. So phase two continued on with the parents implementing the intervention all by themselves for whatever period of time it took for them to achieve 85% of the goals

Mari Oganisyan: that they had set up at the beginning.

John Lubbers: Yeah. And those goals are things like increasing the number of vegetables eaten or decreasing? Challenging behaviors. Exactly. Yeah.

Mari Oganisyan: For example. There was Blake, there was three participants. For Blake’s goal, the family’s goal was to increase participation in meal time, increase vegetables in their diet. And then of course they wanted to decrease the challenging behaviors, which this, participant exhibited, like leaving the table, banging their head. While when they were trying to communicate refusal.

John Lubbers: So again, the goals were to increase participation in family meal times. So I guess if we were to read between the lines here, this particular participant, the family had a meal time and this particular individual would maybe not participate in that. They might eat on the sofa, the TV or outside of those times

Manjit Sidhu: or not stay at the table for a consistent period of time. Got it. They couldn’t keep them at the table for a consistent amount of time.

John Lubbers: Got It. And then I see incorporate vegetables into the diet and that’s pretty much all parents sort of goals, right? Yeah, absolutely. I could see that being pretty consistent. And then I think what we’re seeing a lot of is the decrease in challenging behaviors and those were leaving the table and then some self-injurious behavior, a behavior banging head with hands to communicate. Like, “I don’t want to eat this,” “so I’m going to hit my head?”

Manjit Sidhu: Interesting. Yeah, there are two participants had similar goals as well. But they’re, they’re eating style was a little bit different where these other two kids would eat in the living room, in front of the TV or one of them would eat in the car to and from therapy sessions or after-school activities and whatnot, but the parental goals were the same basically to increase food acceptance, have their child eat healthier foods and like we said, decrease all the challenging behaviors that make these mealtimes difficult for parents causing a lot of frustration and anxiety. And then you just kind of ended up saying, okay, eat whatever because I can’t deal with this. Yeah. Is that, to work through that?

Sevan Celikian: I think it’s really cool how this particular study that Eat-Up approach focuses on parents and caregivers as trainers or implementers of an intervention. Because we know from our experiences and the research that young children with autism typically rely on their parents (exactly) or caregivers to prepare and provide their food. As adults, maybe not so much for us, but as a young child. Yeah. And especially young child living with autism, they really do rely on the caregivers and parents to do that.

John Lubbers: And one particular thing that struck me about this was one of the second participant here had, what would be the way to say this be…, eating behavior that was more atypical or less typical of what we would expect? So specifically what I’m talking about is it was described in the article that this particular participant would chew the food without swallowing it, spit the chewed food into the participant’s palm, shape that food into a ball, and then would put it back in the mouth and repeat that multiple times before swallowing it. So that was a little bit more atypical kind of eating behavior and then of course something that if this was a school-aged kid and they were doing this at school among peers would be something they’d probably, his or her peers would, would maybe notice and, or perhaps react to standout. So that was interesting to me. And then the third boy, the third participant, and again, are eating vegetables and fruits that sort of, always present goal and desire by parents is to have those, to have our kids eat more of that stuff, but also had sort of that textural thing. They disliked wet foods like apple slices, which was interesting.

Manjit Sidhu: Exactly. Any preferred eating crunchy and sweet foods.

John Lubbers: Sweet. So, yeah. Yeah, it doesn’t ever away.

Manjit Sidhu: So he was eating a lot of dry cereal and cookies. Got It. And chips.

John Lubbers: So with respect to the goals, did the parents choose those or did the researchers, or do we know that?

Manjit Sidhu: All these goals are individualized to fit each family and their daily routine. So yes, it was the parents, they worked with their team and they, worked on goals that were important to them.

John Lubbers: Okay. All right. And so they went about pursuing those goals by some intervention plan, right? There was a like some sort of component intervention.

Mari Oganisyan: Yeah. They had four strategies, so four different areas. So there was the food characteristics, which, include increasing variety of foods presented to the child. So increasing how often less preferred foods are presented. And they did this by offering foods from three different groups. They also selected food that the child is likely to learn to eat, such as the texture you’ve talked about the color, the shape or the definitely make the strategy, the goals more successful. So we want to pick foods that are going to be more desirable and they presented both the preferred and the less preferred foods at each meal time. Interesting. Yeah. and then the second strategy was, it’s called dyadic communication. This pretty much promotes the conversation, the communication between the parent and the child. This approach is to give the child a voice so that the child can communicate their wants and needs. I want to eat, I don’t want to eat that food. I do want to eat that food. And with visual aids for example, showing both a carrot if you’re trying to have the child eat the carrot and the cookie and say first eat your carrot and then you can have your cookie.

John Lubbers: Do you recall, Mari, did the article say anything and you probably don’t, but did the article say anything to the effect of — where I’m going with this. I’m being devil’s advocate a little bit and I’m sure our parents out there are thinking about this as well, is that if we’re training functional communication training and we’re teaching our kids to say no thanks, I don’t want that. And they’re saying, no thanks, I don’t want that to the vegetables and fruits. Did they say it all in the article about how they responded to that? Did they ultimately say, well, okay, that’s great. You’re doing a great job telling me you don’t want that. But no, this has been, it’s just green for you.

Mari Oganisyan: I guess in both, they didn’t mention anything specifically, but yes, of course you want to have a variety of foods. Maybe something like we talked about, less desirable to motor desirable, maybe something that’s a more of a secondary food that’s going to be similar to what they’re trying to have the child eat. So that they’ll be more successful in having them consume that food. So that’s why I think the texture, the color, things like that a little bit more important. I think if the parent knows the child, the best so they know what are some favorite things that they like so they try to figure out some foods that are going to be close to what he likes and then move to go from there.

Rei Reyes: That was a good question, John, because it’s true. I mean cause there are teaching two things. So tolerance for food and a good way a replacement behavior to avoid a food they may not want. I’m guessing if you think about this, and we probably apply this in our practice by just offering the child of something obviously they will not eat like onion. Yeah. I mean they will never eat onion so then that’s when they probably reinforce, “I don’t want that.” Okay. But they did give a secondary favorite food or something then. That’s interesting. You haven’t used onion in your practice, John?

John Lubbers: I’ve used more like if-then, so you can, using Premack principle, you can get this contingent on this, if you want this, here’s the extreme example of that. If you want this ice cream, then have a bite of this broccoli, That’s usually what I utilize where I, where I was thinking about this is the thing about teaching, a lot of times it’s both the wonderful, thing, but it’s also, there’s the downside to it is if we teach, functional communication training, advocacy and empowerment, and we teach our kids to say I don’t want to eat that, I don’t like that, then we ultimately have to kind of respect that. It’s like, okay, yes, that’s true. You don’t want that salad. All right, okay. you’re telling me just the way you should, you’re not know of no challenging behaviors. We kind of have to roll with that sometimes. And so it’s a delicate balance.

Rei Reyes: it is not just for feedings, it is for, “in general.” Yeah. No, like “using their words to ask for something.” “Can I have my iPad?” If you say “please,” you will. “Can I have iPad, please?” No, you can’t. Right, exactly. Yeah.

Mari Oganisyan: So I guess in that scenario of course they want to continue to introduce different foods so that I guess yeah, to try to get, yeah. My goal is to have them consume.

John Lubbers: Yeah. So yeah, they talked a little bit about if-then too, which we use a lot or Premack principle, reinforcing a lesser problem behavior with a higher problem behavior. That’s great fundamental behavior analysis

Sevan Celikian: Always a solid go-to intervention. And I’ve noticed that sometimes it even helps having a visual reminder of the, the reinforcer. Like, like “first we have to eat our carrots and broccoli” and then showing a visual of what’s to come after instead of just saying it that way. It’s more tangible, more immediate kind of within reach. Maybe not within reach but within eye-shots so that way…

Manjit Sidhu: ..they know what they know what they’re working for. They know exactly what they were… so there’s a constant reminder. It’s right there. Yeah. Increasing motivation a little bit.

Mari Oganisyan: They also use a technique called visual food acceptance hierarchy. So it’s a strategy unique to Eat-Up. It’s basically systematic desensitization. Non-preferred food. Okay. For example, if the goal is to eat a carrot, the strategy, the starting point for the child, would it be a, touch the carrot and then then next to tap the carrot to the lips and then taking a bite of the carrot. And then each as each step was successful an arrow was moved up as a visual reminder of that target behavior. And then the reinforcer was given.

John Lubbers: Okay. Interesting. There is a great deal of systematic cognitive behavior therapy in systematic desensitization, using systematic desensitization to treat everything from phobias to things that we refuse so that makes sense that that’s something as one of the components that they put in there.

Manjit Sidhu: Another strategy that the article mentions is the physical environment of meal times. So really, basically this is how mealtime should look. Each and every day they talk about eating at a specific table. So having a designated area where dinner or lunch is going to be eaten, staying with your child. So don’t just a set a plate out and walk away and leave it to them to finish but be there with them. if the child has siblings or you even as an adult, you want to sit there and eat with your child. So you can be role models. you also want to remove any distractions. So, turning off the TV, having no toys in the room, those kinds of things. You want to also increase the expectation of the time at the table. So, we mentioned earlier, some kids, I think it was one of the participants that wouldn’t stay at the table long enough to finish meals. So therefore, family meal times become difficult. so basically with this here, you want to teach them to learn to stay at the table and you want to increase the time periodically. Day One would look, you’re going to try to have them stay at the table successfully for five minutes. So, and then the next time increase it.

John Lubbers: So just to revisit something that you mentioned, eating at a specific table. So they’re actually, implementing or I don’t want to say imposing, that’s kind of the wrong word, but they’re prescribing some structure to the environment. Just a, just a quick survey, there’s two, four, six of us here. of the six of us, how many of us have a dining table?

Manjit Sidhu: Okay. Yes.

John Lubbers: Okay. So all six of us have a dining table. Okay. Do all six of us eat our meals at the dining table? All of our meals?

Manjit Sidhu: No, not at all. That’s where most. Okay. All right. The majority of lunch. Yeah, but that’s if I’m at home maybe. But I’ve got kids so we eat breakfast together at the table and we definitely eat dinner at our dinner table. Got It together.

John Lubbers: So you have a pretty structured meal time system.

Manjit Sidhu: We do get together for breakfast and dinner.

John Lubbers: Okay that was my next question. And if we eat at the dining table. How many of us eat together at the same time?

Lloyd Gilbert: With us, what we try and do is this is eat together. Okay. And then we have that.

John Lubbers: So that’s you. Us, we, cause we have school age kids, and the adults versus the kids. The adults have slightly different meal times as the kids. So we kind of on a daily basis, we probably don’t eat our meals together. Maybe on weekends when there is not that school structure and all that is more when we do it, the majority of us are, we like, does that sound like the majority of us or?

Mari Oganisyan: I have infants so they have a little bit of a different eating schedule than we do but I try to, as far as dinner time, try to wait so that I’m having dinner with my husband. Okay.

John Lubbers: Yeah. So you guys can have that.

John Lubbers: For my family, this rather hard. I mean it’s very inconsistent. Like what John said between Monday and Friday. It’s like whenever, wherever, whomever but on the weekend, that’s when you want some structured meal time. Yeah. But I can understand how difficult this may be for participants, your families out there who really want to direct this. And then I think this is probably the hardest part of the intervention because we have to change the family’s perspective too on how they have your mealtimes. Yeah. And that’s a lot of behavioral change with schedules involved.

John Lubbers: Yes. Yeah. And we’re so busy nowadays, they also prescribed staying with the child, which I thought was kind of interesting in the sense that a lot of us will end, like, I’m, I’m guilty of this. Well, okay, here’s your lunch or here’s your dinner and then I’ll go and do something that I need to do since especially since I’m not always eating at the same time. So, I, I probably have, when I probably eat about 40 or 50% of my meals with or that we all eat them together or stay, I stayed with them. So it’s not that often, which is kind of interesting. That would be a little bit hard for our family to do or be an adjustment for our family.

Manjit Sidhu: Well, I think for me, the reason that we eat together, and my daughter was a picky eater as a baby, as in, a child. and I used to have to sit with her at the table to make sure she was eating. She was one of those kids who, an hour to eat a small little meal. So it would constant reminders. K let’s eat you gotta take your next bite. So it just be kind of became a habit and fell into it like that where now we’re all at the table together so it works out. Right.

John Lubbers: That’s really cool. Yeah, we’re set up for you guys.

Sevan Celikian: And I know it’s interesting because some of the approaches that the Eat Up study is advocating, like eating at a specific table designating a specific place for the behavior to occur. It reminds me of of some of BF Skinner’s teachings. And if I remember correctly, he was an advocate of establishing a particular setting for a specific behavior to occur or to evoke, then everything in that environment over time becomes a cue or an SD or yeah, a a habit. And then it strengthens over time. And we do this as adults, during other times they too, besides meal time getting work done at the office, getting exercises done at the gym. So it’s like each of these environments almost kind of evoke the behavior that is desirable.

John Lubbers: Yeah. It interesting. Cultivating stimulus control. Yeah. That’s really interesting as well and then of course, the other more common sense things, remove distraction from the environment. If you have a TV or an iPad or some, some virtual reality game, it becomes a little difficult, It probably get much focused on your eating. and then what about this increase your expectations for time at the table, Was that basically a sort of a statement saying, okay, meal time you used to take, you child used to take five or 10 minutes to eat, but now we’re going to slow down and take 20 minutes to eat and we’re going to eat all the food on her plate. Was that, do we, do you guys recall at all? Was that essentially what they were speaking there?

Manjit Sidhu: I think this was more, there was a participant who wouldn’t stay at the table. That was a way of, of his food refusal. Got It. Okay. so this was working up a longer period of time at the table so he could sit and eat.shaping procedures.

John Lubbers: Got It. That makes sense. All right. Yeah. okay. That’s great.

Manjit Sidhu: The article also mentions the last strategy was that social environment. So, this was intended to support the positive parent child interactions, to avoid power struggles and to be able to communicate effectively. Basically they tell you, maintaining a positive tone, you need to be calm. Nobody needs to be yelling or be angry, although that is pretty likely to happen when your, when your child is, tantruming, engaging in a lot of challenging behaviors. they mentioned using positive reinforcement. If your child did a bite of the carrot or the Broccoli, you want to let them know that they did a good job. I know a good job for taking a bite of that carrot, encouraging, exploring last preferred foods. So if you’ve got something on your plate or on their plate and if they happen to take a stab at it, good for you, good job. You took a bite of that, let them know that you saw that and you were happy, following through with the expectations that you’ve set. So if you’re going to is tell your child you’re going to eat three bites of that vegetable, then you want to make sure that you kind of follow through with that and then

Sevan Celikian: that’s actually a pretty important point Manjit because we want to be aware of following through with expectations and, and also not inadvertently reinforce escape behaviors. So that’s exactly, we want our kiddo to eat A, B and C foods, but they engage in some behaviors, some challenging behaviors and then we say, all right, whatever, like go take a break, or okay, here’s a sweet item instead then whether we realize it or not, we’re,

Manjit Sidhu: and that’s learned behavior again, they learn, they can do that and be able to get away with stuff. Yeah. So you definitely want to follow through with what you’ve said. They also mentioned focusing or staying focused on the goal of food consumption. So this kind of ties in with what Mari was talking about earlier with the visual hierarchy, each child will have a different goal. They’ll move up the hierarchy as their successful within each step. And this can be within or across meal times. You might not get them to be able to eat the Broccoli or the carrot, the very first meal time that you’re trying this, it might take a couple of days or even weeks before you can get them to be successful. But, so that’s different for each child and you want to set that up that way.

John Lubbers: And I don’t recall, was this where we were talking about like our systematic desensitization process here? Okay. Yes. So like for discussion’s sake, like where you’re saying could take multiple sessions, multiple feeding times, day one might be like touching the carrot. Okay. And then day two might be touching the carrot to your lips or something. In between those lines. Got It. So I’ve done that several times to get to the second step. Got It. And just being aware of where you are in that process. Yeah. Okay.

Manjit Sidhu: Sometimes they can’t even tolerate having that on their plate. Even that could be just, and they don’t have to eat it, but they have to be able to tolerate it being on the plate. Yeah. It’s different for each child.

John Lubbers: We’ve seen that, I’ve seen that clinically where even the sight of a food will evoke tantrum behavior and escape behavior and big tantrums, 20, 30, 40, hour long tantrums, just the sight of some carrot or peas or something like that. Right.

Manjit Sidhu: The last strategy that was mentioned in the article was to use token based systems. So we’re, I mean, we’re all familiar with that. If your child eats his vegetables, he’ll get a sticker. And at the end of the week, if he’s had a good week with eating vegetables, and he’s earned five stickers might get a trip to the arcade or something along those lines.

John Lubbers: Did the article, talk about, is the token system one that’s built into the intervention, do they have like you use these tokens and this is your token board and etc. Etc. And this is what you exchange your tokens for or did they have you kind of develop your own token system in your own household? Like one household may have one set of tokens and then another household may have another

Manjit Sidhu: it was individualized for each family, each participant. Okay. Out of all the three participants of maybe only one was interested, going to the arcade or it might be a different reward for each child. Yeah. Yeah. Okay. And it could be, for one, it might be to be able to eat all of your vegetables, get a token or for another, it might just, like we said earlier, to just tolerate the vegetable being on the plate might earn a token. Got It. Okay. So it’s individualized for each participant.

John Lubbers: So there’s some skill and some fluency with, setting up and administering a token system is kind of necessary here. It would be helpful. So it almost might be good to have these, these coaches with you. It’s good that the coaches start you off on that. So they can give you those basic fundamentals a little bit before the parents I’m talking about get the basic fundamentals of how to use a token system, how to set up before they really jumped too far into it. Interesting. Again, more more sound behavior analysis there.

Manjit Sidhu: So these were all the interventions that were mentioned in the article. They really worked with the three families that were involved. all three children demonstrated an increase in their food acceptance and a decrease in challenging behaviors during meal time and the parents also reported that they had fewer feelings of frustration and anxiety that related to meal times after the intervention was over.

Mari Oganisyan: So that absolutely makes sense. Having your parents actively involved increase their willingness to be involved and continue with these strategies and having the strategies implemented at the family home versus the clinical setting, decrease the need for generalization from clinic to home because it was already occurring in a natural setting, which is ideal. That’s what we want. Right. And having the parents implement these strategies also decreased the need for transferring these skills from across different people because their parents already started. The parent is the one that’s involved at meal time. and they’re the ones learned how to implement these. So that’s amazing.

John Lubbers: So what another thing that I thought was really interesting was sort of this social validity component of this and where are the parents reported that they had a fewer feelings of frustration and anxiety regarding meal time. And feeding and I did started to me to think, and I don’t recall from the article whether there was, they formally assessed anxiety and frustration or whether those were more anecdotal comments. I can’t recall that, from the article, I’m going to assume they were probably.

Rei Reyes: I think they did. They used another measure there to assess something along the lines of that frustration anxiety or something like that.

Rei Reyes: I think there was but I’m not sure what it was called, there was, I believe, my memory serves me correctly. It was more towards the end. It was a self report, the self report. Yes.

Sevan Celikian: Very positive results using those ideas.

John Lubbers: Yeah, that’s great. So it sounds like all around this is a successful intervention. One, it changed the child’s behavior and there was some change there and two, there was an additional benefit to the families. The parents felt less stress and less anxiety. So that’s a, that’s a good thing too. That social component is social validity component. Very cool. Right on. So, this is really an interesting topic, tonight that we talked about. And I think, like we said at the beginning of this, this is one that a lot of our families and parents encounter. I think too, like, one thing that it kind of goes without being said, but we should say it anyways because sometimes it’s worth doing so is that if this meal times if your son or daughter’s food, their diet is not a problem for you and your family and it’s not a problem for the child in terms of their nutrition and their health and their weight, then it’s probably not a problem.

John Lubbers: So, even if four or five, six foods, if they’re getting the adequate nutrition they need and it fits within your family practices and it fits within that individual in their school, the child in their school, in that, it’s probably not a problem. So this really, unless this is a problem for you, unless this is something that’s resulting in some, some deficit in nutritional value for the individual to child or, it’s limiting your functioning as a family, you can’t go to only, you can only go to one fast food restaurant, which we’ve seen before. If you want to go out as a family for dinner and individuals, only will eat one particular food, that can be kind of restricting as family practices. If it’s not those situations.

John Lubbers: And maybe this not a problem for you and you don’t need to do it, but if it is, then it can spark a conversation with behavior analyst or with an occupational therapist, to kind of say, is this something worth exploring? I know we’ve got some is some level of food pickiness or food refusal or something like that or maybe something more severe like PICA or what have you. and it could definitely suggest, do you think professional, is there some area for intervention or change or is there something we could do? I don’t know, just some, just throwing out some ideas there.

Lloyd Gilbert: I’d seen some of the other issues too for parents looking into this more deeply is between just simple searching, feeding verse eating disorders.

John Lubbers: Good point.

Lloyd Gilbert: Cause I know when we were looking it up, we had a hard time differentiating between the two. So yes, when we specify at each one we’re able to come up with at least promote our impression was eating disorders is more specifically dealing with your Bulimia or your Anorexia whereas feeding is dealing more within the realm of something potentially they would be dealing with something that they can look up to help them a little bit more.

John Lubbers: Yeah. And that’s, that’s pretty key too because when we were just using key terms and we were popping things into Google or even into the scientific, search engines, Eric, and that sort of stuff. if you chose, eating disorder, you got results on bulimia or Anorexia. If you chose and even Google, if you chose feeding disorders, you might be more likely to get this stuff on pickiness and refusal and that sort of stuff.

John Lubbers: So that’s kind of an important takeaway is if you’re going to go do some more research on this, use the correct terms or it might set you down the wrong path and frustrate you.

Lloyd Gilbert: Yeah. I think it also goes to show too, that there’s needs to be more information, more experiments done to increase this because if we’re just doing a general search and we’re more familiar with it, and I can only imagine the frustration that parents are going through as well, looking at it from perspective of I have a newborn or I have a two, three year old who has these potential issues, I don’t know where to go, where am I going to search? So more of that would help.

John Lubbers: Especially with our kids on the spectrum.

Sevan Celikian: Well, we definitely explored some, some really important, a really important topic here. We covered some of the factors associated with feeding problems. We covered some of the interventions that are being used out there and how this affects families and what some families can do to research and to bring this up to to their providers. So, yeah, I think we covered some good ground here.

John Lubbers: Yeah, it was great. And listener, feel free to reach out to us to ask questions, suggest topics and seek information and we thank you for listening and we’ll see you next time.

Outro: For more insight from the Leafwing Center, please visit the Leafwing Center website and blog page at leafwingcenter.org. Email us at [email protected] or visit us at your favorite social media outlet. Feel free to submit questions or comments about this or future podcasts and we will put links to information discussed in today’s show on the website. We look forward to next time. Thank you.