Applied Behavior Analysis in the Treatment of Pediatric Feeding Disorders

ABA and the Treatment of Pediatric Feeding Disorders

According to one 2008 study in the Journal of Child and Adolescent Psychiatric Clinics of North America, as many as 90% of children with autism experience a feeding disorder. Another 2008 study published in the Journal of Language, Speech, and Hearing Services in Schools found that 70% of autistic children had co-occurring feeding disorders. Applied behavior analysis has been shown to increase appropriate behavior in children with autism, and also to decrease undesirable or inappropriate behavior. Although research is limited on the efficacy of using applied behavior analysis to improve pediatric feeding disorders, the research that has been conducted shows that ABA techniques are effective.

Applied Behavior Analysts Should Know These Pediatric Feeding Disorder Criteria

Pediatric feeding disorders may also be referred to as avoidant or restrictive food intake disorders. The simple definition for the disorder involves repeated instances of refusal to eat at all, or only eating restricted types of and quantities of food.

A diagnosis of the disorder is made at the point when the child’s health and nutritional intake is impacted by what many parents are familiar with as “picky eating.” Additional diagnostic criteria include an impact on social functioning, mealtime disruption, and an impact on family relationships.

Children who exhibit feeding disorders may be on the autism spectrum. Other children who are at risk of feeding disorders include children with developmental delays, anxiety and depression, and ADHD. Physical causes may also play a role in feeding problems, including dysphagia (poor oral motor skills/difficulty in chewing or swallowing), pain due to food sensitivities or reflex, and low muscle tone. Some children develop a fear of eating following an episode of choking: an understandable natural response.

Pediatric Feeding Disorder Behaviors Can Have Behavioral Solutions

Working as part of a treatment team, an applied behavior analyst (ABA) will develop interventions that can help the child to improve feeding problems.

In one 2008 study, caregivers of 6 autistic children with feeding disorders performed a functional analysis of each child’s mealtime behavior. ABAs worked with the caregivers to implement the analysis and improve their child’s behavior and achieved a high level of integrity and response. Another study in 2010 calculated the probability of effectiveness for parent consequences offered to a group of 25 children with severe food selectivity or refusal problems. Consequences included offering the ability to escape the meal, receive attention, or receive a tangible reward for ceasing to refuse food or for trying different foods. The most effective intervention turned out to be paying attention (coaxing) and offering the means to escape the meal after eating appropriately.

Rapid eating is another frequently-observed feeding problem, particularly among children with autism or other developmental needs. One effective behavioral intervention for rapid eating used a pager prompt to help time bites of food. Intensive day treatment and periodic therapy sessions with children and caregivers have each shown some positive results in improving feeding disorders and problems among autistic children.

Specific Behaviors in Pediatric Feeding Disorders That Impact Applied Behavior Analysis

“Picky eating” may cross the boundary with a feeding disorder when a child does any of the following at mealtime:

  • Eating only one type of food (hot dogs, white bread).
  • Eating only foods that meet a certain taste or appearance criterion (a specific color such as brown, or a specific texture such as gelatin).
  • Declining foods that are not offered in the way the child desires (bread crusts not cut off, food cut in uniform pieces).
  • Refusing to eat nutritious food groups (all fruits, all vegetables, all protein).

Children on the autism spectrum may refuse to chew food, limiting their intake to soft foods only. The child may also refuse to use utensils although they can use a fork, knife, or spoon. Some children may also chew food then spit it out at other family members at mealtime. Each of these situations has a potential for moderation or mediation through applied behavior analysis.

Behavioral Solutions Can Reduce Impacts of Feeding Disorders on Children

Children with feeding disorders can become debilitated due to a lack of nutrition. Young children with feeding disorders may receive a diagnosis of “failure to thrive.” Older children can experience worsening of cognitive deficits or physical health when they fail to consume sufficient nutritious food.

About 1 million children under the age of 5 in the U.S. are diagnosed with a feeding disorder, according to Feeding Matters. If these children are required to use a feeding tube, the cost averages $32,000 a year, Feeding Matters reports.

Applied Behavior Analysts can play a role in reducing the incidence of feeding disorder diagnosis and use of feeding tubes. Studies conducted in 2012 reported that children who received enteral feeding also experienced undesirable side effects including reflux, swallowing problems, gagging, and vomiting.

Applied Behavior Analysis and its Role in Pediatric Feeding Disorder Treatment Teams

Applied behavior analysis can help in the diagnosis and treatment of complex child feeding disorders. A 1998 study which remains useful classified pediatric feeding problems according to five criteria: neurological conditions, cardiorespiratory problems, metabolic dysfunction, structural/physical abnormalities, and behavioral issues. Of the children who were studied, behavioral causes for the feeding disorder were present in 85% of patients.

A child who experiences a physical or structural difficulty in swallowing and who also exhibits a behavioral problem with eating will receive treatment from a pediatrician for physical problems. An ABA may step in and assist the child and caregiver to improve behavioral problems at mealtimes.

Another child may experience neurological problems which make it difficult for them to coordinate the movement of a fork or spoon to their mouth. A physical therapist and neurologist may work to design a treatment plan to improve the physical and neurological barriers to self-feeding. Understandably, a child who struggles with the act of eating may feel frustrated and act out at mealtime. An ABA can assist the caregiver and child to have more positive eating experiences and improve their pediatric feeding disorder.

Further Reading on Applied Behavior Analysis in the Treatment of Pediatric Feeding Disorders

Classifying Complex Pediatric Feeding Disorders – Article from the Journal of Pediatric Gastroenterology and Nutrition.

Feeding Matters – Resources for providers and caregivers on pediatric feeding disorders.

Recent Studies on Feeding Problems in Children With AutismNational Institutes of Health‘s Literature review of studies of the impact of applied behavior analysis on pediatric feeding disorders.

Another helpful resource:

Top 25 Online Master’s in Autism Spectrum Disorder (ASD)

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