Pediatric feeding problems: A behavior analytic approach to assessment and treatment.

Abstract

Although eating is considered an automatic physiologic process, many children experience feeding difficulties. The purpose of this article is to present a behavior analytic conceptualization of feeding problems and to summarize the empirically supported behavioral interventions for these problems. While negative reinforcement appears to maintain food refusal, classical conditioning may contribute to its initiation. Differential reinforcement of alternative behavior with escape extinction is an empirically supported intervention for feeding problems and has been successfully implemented by trained staff or parents, in multiple settings, with maintained gains over time and generalization to new foods for many children. While the efficacy of behavioral interventions has been established, future research should investigate the individual components of these interventions. Alex is a three-year old boy who eats a total of six foods as his entire diet: Burger King chicken nuggets, McDonald's French fries, macaroni and cheese, pudding, applesauce, and crackers. His parents are not sure whether to be worried about his eating or not; Alex is gaining weight and getting taller. His pediatrician tells them it is typical for children Alex's age to be picky eaters, and she advises them to continue to offer Alex healthier foods. They keep trying to offer him different, healthier foods, but he pushes the new food away and screams no. If his parents persist in offering the food and get a taste to his lips, Alex often gags uncontrollably for two to three seconds. During some of these gagging episodes, Alex has turned bright red alarming his parents. Does Alex have a feeding problem? This paper will address issues in defining what is a feeding problem, conceptualization of the origins and maintenance of feeding problems from principles of classical and operant conditioning, behavioral treatment, and future areas of research. What is a feeding problem? Severe and persistent feeding problems, which are experienced by 3-10% of children (Dahl & Sundelin, 1992; Jenkins, Owen, Bax, & Hart, 1984; Lindberg, Bohlin, & Hagekull, 1991; Reau, Senturia, Lebailly, & Christoffel, 1996), tend to persist and worsen over time (Lindberg et al., 1991; Marcontell, Laster, & Johnson, 2002; Nicholls, Christie, Randall, & Lask, 2001). Severe feeding problems are more prevalent in children with physical disabilities (26%-90%); mental retardation (23%-43%); medical illness, prematurity, and low birth weight (10%-49%) (Crist et al., 1994; Douglas & Bryon, 1996; Palmer, Thompson, & Linscheid, 1975; Reilly, Skuse, & Poblete, 1996; Thommessen, Heiberg, Kase, Larsen, & Riis, 1991). One way to determine if a behavior is a problem is to assess its impact on functioning. Some children experience severe feeding problems that place the child at risk for aspiration, malnutrition, invasive medical procedures (i.e., placement of a nasogastric or gastrostomy tube), admission to an inpatient unit for treatment of the feeding problem, and/or limitations in social, emotional, and educational functioning and development (Whitten, Pettit, & Fischhoff, 1969; Skuse, 1993). However, other children experience feeding difficulties that may not result in obvious functional limitations. So does Alex have a feeding problem? At first blush, the answer to this question may appear to be obvious; however, Alex's eating behavior poses an array of unanswered questions about the criteria for defining feeding problems. From a medical perspective, Alex is gain ing weight and growing so his eating is not a problem. From a nutrition perspective, Alex may not be getting all his vitamins and minerals; however, this might be addressed with a daily comprehensive mulitvitamin. From an educational perspective, Alex is able to attend school. He eats what his parents pack him for lunch. Although the teacher worries about his possible boredom with the same foods, she has not noticed any problems with his attention during academic tasks. …