Marcus Autism Center€¦ · Pediatric Feeding Disorders: A Multidisciplinary Approach to...

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Pediatric Feeding Disorders: A Multidisciplinary Approach to Assessment and Treatment

Rashelle Berry MPH, MS, RD, CSP Michele Cole Clark MED CCC-SLPRoseanne Lesack, PhD, BCBA-D, ABPPPediatric Feeding Disorders Program, Marcus Autism CenterChildren’s Healthcare of AtlantaDepartment of PediatricsEmory University School of Medicine

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Marcus Autism Center

Disclosure Statement

Rashelle Berry, Michele Cole Clark, and Roseanne Lesack have no relevant financial or nonfinancial relationships to disclose other than each is employed by the Marcus Autism Center in Atlanta, Ga.

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Rashelle Berry, MPH, MS, RD, CSP

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NutritionistPediatric Feeding Disorders ProgramMarcus Autism Center |Children’s Healthcare of Atlanta

• BA, Emory University, Psychology• MPH, Emory University, Epidemiology• MS, Georgia State University, Health Sciences/Nutrition

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Michele Cole Clark MEd CCC-SLP

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Speech Pathologist Pediatric Feeding Disorders ProgramMarcus Autism Center |Children’s Healthcare of Atlanta

• B.S.Ed., University of Georgia, Speech Pathology• M.Ed., University of Georgia, Speech Pathology• ASHA certification in SLP

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Marcus Autism Center 5

Roseanne Lesack, PhD, BCBA-D, ABPP

Senior Psychologist, Pediatric Feeding Disorders ProgramThe Marcus Autism Center | Children's Healthcare of AtlantaAssistant Professor, Division of Autism and Related DisordersDepartment of Pediatrics, Emory University School of Medicine

• BA, UCLA, Psychology• PhD, Fordham University, School Psychology• BCBA-D, Board Certified Behavior Analyst-Doctoral Level• ABPP, Boarded in Clinical Child and Adolescent Psychology

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Marcus Feeding Disorder Program

Clinical Outcomes:• 74% increase in oral intake

• > 50% successfully weaned from feeding tube in 8 weeks

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Who Are You?

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MADDIE

• HX: 38 week gestation, IUGR, Failure to Thrive, Liquid dependent

• 20 months at admission to day treatment and accepted all foods at puree texture, but unable to tolerate higher textures or changes in textures

• Frequent gagging and frequent emesis

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Nutrition and Health

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Insert key fact connected with photo

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Socialization

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Most Children Enjoy Eating

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Childhood ObesityWhat Happens When this Isn’t The Case?

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Slide 13 Newborn Well-Child Visits

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Prevalence

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Up to 40% of all children evidence some type of picky eating

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Mild Feeding Difficulties

• Typically resolve spontaneously or with low intensity interventions such as:– Caregiver education about meal structure – Modifications to food presentation/preparation– Nutrition Guidance

• Not associated with significant concerns regarding:– Growth– Nutrient deficiencies– Child’s relationship with food and social involvement

during meals

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Prevalence

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3-10% of children evidence severe and persistent feeding

problems -Kerwin, 1999

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Prevalence

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26-90% of children with physical

disabilities evidence severe and persistent

feeding problems -Kerwin, 1999

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Prevalence

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23-43% of children with intellectual

disability evidence severe and persistent


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Prevalence

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10-49% of children with medical illness, prematurity, and low birth weight evidence severe and persistent


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Prevalence

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Children with autism are five times more likely to evidence

feeding concerns than their peers-Sharp et al., 2013

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Pediatric Feeding Disorders

Pediatric Feeding Disorder (Avoidant/Restrictive Food Intake Disorder):Eating/feeding disturbance leading to a failure to meet appropriate nutritional and/or energy needs associated with: • Significant weight loss (or lack of appropriate weight gain)• Significant nutritional deficiency• Dependence on enteral feeding or oral nutritional supplements• Interference with psychosocial functioning• Cannot better be attributed to anorexia, bulimia, other organic concern

-(American Psychiatric Association, 2013)

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Feeding Disorder Categorization

Food Refusal

• PARTIAL/TOTAL• Feeding tube dependence• Formula dependence• Failure to thrive/under

weight

Food Selectivity

• TYPE• Lack of dietary variety

• TEXTURE• Skill deficit• Lack of experience• Lack of generalization

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Slide 25 Pediatric feeding disorders - Volume

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Slide 26 Pediatric feeding disorders - Volume

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Severe problem behaviors during meals:– Crying– Disruptions– Elopement– Aggression– Spitting– Expulsion

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Volume: DetectionVolume: Medical Solution

Feeding Tube Formula/Liquid Dependence

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Escape and Avoidance

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Slide 30 Pediatric feeding disorders - Variety

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Slide 31 Pediatric feeding disorders - Variety

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Slide 32 VS

• 380 calories• 2 grams of saturated fat• 10 grams of dietary fiber• Key micronutrients:

Vitamin AThiaminRiboflavinNiacinVitamin B12Vitamin CVitamin DVitamin EFolateCalciumIronMagnesiumZinc


ThiaminRiboflavinNiacinVitamin CCalcium IronMagnesium

•No quantities of: Vitamin AVitamin B12Vitamin DVitamin EFolateZinc

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Slide 33 Variety : Medical SolutionVariety: Detection

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Easy Solution = Give Them What They Want

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Escape and Avoidance

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Learning Process: Parent-Child Dyad

Child: Displays refusal behaviors

during bite presentation

Parent: Removes the

feeding demand

Child’s Refusal Behavior

Reinforced

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Learning Process: Parent-Child Dyad

Child: Displays refusal behaviors

during bite presentation

Parent: Removes the

feeding demand

Child’s Refusal Behavior

Reinforced

Child: Stops crying, screaming, aggression

etc.

Food removal is reinforced

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Your Role

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Videos of 3 kids crying/refusing bite

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• Is this child crying because of behavioral factors, oral motor factors, medical factors?

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Multidisciplinary Team

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Behavioral Psychology

Medicine: Gastroenterology

Care Coordination: Social Work

Nutrition

Oral Motor: SLP/OT

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Scope of Practice

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SLP: Oral Motor

Nutrition


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SLP: Oral Motor

• Assess baseline oral sensorimotor function • Non-nutritive oral motor skill • Nutritive oral motor skill

• Meal observation• Oral hypersensitivity

• Swallow safety: oral phase/oropharyngeal phase• (safety of pharyngeal/ esophageal phase of the swallow

determined by OPMS )• Determine best seating/ positioning for safe feeding• Determine target textures of foods fed in day treatment and

outpatient behavioral feeding sessions• Advance nutritive oral sensorimotor skill • Advance food texture

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SLP Scope of Practice ASHA Position Statement:

The speech-language pathologist is a primary professional involved in assessment and management of individuals with swallowing and feeding disorders. ■ Performing clinical swallowing and feeding evaluation; Performing instrumental assessment of swallowing function with medical professionals as appropriate; ■ Identifying normal and abnormal swallowing anatomy and physiology; ■ Identifying signs of possible or potential disorders in upper aerodigestive tract swallowing and making referrals to appropriate medical personnel; ■ Making decisions about management of swallowing and feeding disorders;■ Developing treatment plans; Providing treatment for swallowing and feeding disorders, documenting progress, and determining appropriate dismissal criteria;■ Providing teaching and counseling to individuals and their families;■ Educating other professionals on the needs of individuals with swallowing and feeding disorders and the speech-language pathologists' role in the diagnosis and management of swallowing and feeding disorders;■ Serving as an integral part of a team as appropriate;■ Advocating for services for individuals with swallowing and feeding disorders;■ Advancing the knowledge base through research activities.

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•Assess the underlying function of food refusal behavior•Define target behaviors to be addressed in treatment•Create data collection system and format for analysis•Implement protocols that address the function of problem behavior to decrease refusal behaviors including fading and shaping procedures

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Nutrition

• Assess and monitor growth: weight, height, body mass index

• Determine caloric and nutritional needs

• Evaluate for gastrointestinal and allergy concerns

• Adjust tube feedings• Determine food list

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• Nutrition

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Healthy Eating Patterns

• Updated Dietary Guidelines for Americans released in 2010 by the USDA (www.dietaryguidelines.gov)• Based on the most up-to-date scientific evidence

• Focus on:• Nutrient-dense foods/beverages

• Maintaining a healthy weight

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Source: Position of the American Dietetic Association: The roles of registered dietitians and dietetic technicians, registered in health promotion and disease prevention

Barriers to Consuming a Healthy Diet

• Individual

• Interpersonal

• Organization

• Community

• Society

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Nutrition Concerns: Food Refusal

• Food refusal– Feeding tube dependence

• Appropriate weight• Tube feeding schedule, amounts, tolerance

– Bottle dependence • Nutritionally complete supplement?

• Partial food refusal– ↑ caloric needs– Failure to thrive

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Nutrition Concerns: Food selectivity

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Dietary Restriction

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Parent Mediated

ChildMediated

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Dietary Restriction

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Parent Mediated

ChildMediated

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Dietary Restriction

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Vitamin AThiaminRiboflavinNiacinVitamin B12Vitamin CVitamin DVitamin EFolateCalciumIronMagnesiumZinc

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ThiaminRiboflavinNiacinVitamin CCalcium IronMagnesium

•No quantities of: Vitamin AVitamin B12Vitamin DVitamin EFolateZinc

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Higher Risk Pediatric Populations

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• Children on medical prescribed diets– Gluten-free– Allergen-free– Ketogenic

• Children with developmental/behavioral disabilities– Child mediated refusal behaviors– Parent mediated dietary restriction

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Slide on GFCF

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Food and their nutrients

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Nutrient Primary Food Sources

Short term impact of deficiency

Long term impact of deficiency

Vitamin A Vegetables Impaired vision Blindness, increased infection susceptibility, poor growth

Folic Acid Fortified grains Megoblastic, macrocyticanemia

Weakness, depression, and neuropathy

Vitamin B12 Fish, meat, and poultry

Megoblastic anemia Neuropathy, neurologic disorders

Vitamin C Fruit, vegetables Scurvy Lesions, weaknessVitamin D Fortified milk Poor bone growth Rickets, Osteomalacia,

OsteoporosisVitamin E Vegetable oils, nuts Neuromuscular disturbances

Calcium Dairy products Poor bone growth Osteoporosis

Iron Fish, meat, and poultry; fortified products

Poor growth, impaired muscle function

Iron deficiency anemia

Zinc Fish, meat, poultry, eggs, dairy products

Loss of sense of taste and smell; poor immune function; poor growth

Acrodermatitis enteropathica

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Scurvy

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– “the patient had a very limited diet, eating only hamburgers, Wheat Chex®, Pop Tarts®, oyster crackers, and pancakes” (Cole et al. Scurvy in a 10-year-old boy. Pediatr Derm (2011) 28: 444–446.)

– “the child subsisted nearly exclusively on chocolate milk and that the parents did not supplement the child’s diet with multivitamins” (Gongidi et al. Scurvy in an autistic child: MRI findings. Pediatr Radiol(2013) 43:1396–1399.)

– “He was subsisting on Honeycomb cereal and one type of Goldfish crackers. Although vitamin supplementation had been tried, [the] patient had either refused or vomited.” (Harrington et al. Limping in a child with autism. Contemporary Pediatrics. April 1. 2007.)

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Rickets

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– “his current nutritional intake derived mainly from chips and gravy with a complete refusal of dairy products” (Stewart et al. Symptomatic nutritional rickets in a teenager with autistic spectrum disorder. Child: care, health and development (2008), 34(2): 276–278.)

– “Dietary history revealed a markedly altered intake consisting of only French fried potatoes and water for several years.” (Clark et al. J Parenter Enteral Nutr (1993) 17: 284-286.)

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Iron Deficiency and Anemia

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• Increased risk of iron deficiency in children with ASD shown by measuring serum ferritin levels– Latif et al. Iron Deficiency in Autism and Asperger

Syndrome. Autism. (2002) 6: 103-114.– Herguner et al. Ferritin and iron levels in children with

autistic disorder. Eur J Pediatr. (2012) 171(1):143-6.

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Nutrition Assessment62

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Nutrition Assessment: History

• Feeding practices in infancy– Milk feedings

• Breast or bottle + response to both• Maternal elimination diets or frequent formula changes• Reflux – controlled or not?

– Solid feedings• Time of introduction• Initial response and subsequent pattern

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Nutrition Assessment: History

• Growth history– Underweight? Overweight? Up and down? WNL?– Age in which growth trajectory changed– Use of supplements to maintain growth

• PO• Feeding tube

– Parents concerned? Health professionals concerned?

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Nutrition Assessment – Growth

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Weight Classification

BMI-for-Age Percentile

Underweight <5th percentile

Normal Weight 5th - <85th percentile

Overweight 85th - <95th percentile

Obesity ≥95th percentile

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Nutrition Assessment - Intake

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• Consistently accepted foods

Food Group Foods Accepted

Fruits

Vegetables

Meats/Beans

Grains

Dairy

Drinks

Snacks/Sweets

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Nutrition Assessment: Intake

• Preferred Food List– What food groups are included?– What food groups are excluded?– What foods CAN be part of the diet?

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Nutrition Assessment – Intake

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• Meal/Snack Patterns

Meal Time Place Foods and Amounts

Breakfast

AM Snack

Lunch

PM Snack

Dinner

Evening Snack

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• Feeding Schedule– How does school differ from home?– How do weekdays differ from weekends?– Does the child have the same schedule as the rest of the

family?– Does the child graze throughout the day?

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Nutrition Assessment – Intake

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Three-Day Food Intake Record (Food Diary)

Instructions: please record all food/fluid consumed during the next three days. Please be as specific as possible to ensure accuracy of the analysis. Record the amount eaten in either volume (tbsp, cup) or weight (g, oz) measurements. Include brand names and methods of preparation when appropriate.

Date Food/Drink Item Yield Amount Eaten

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• Diet recall is an imprecise science BUT– We know that parents overestimate intake– Kids with ASD and food selectivity do not vary much day to

day

• Best way to detect deficiencies in the diet• Preferred list might be 15 foods; in actuality, 4 foods

are being consumed in large quantities

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Nutrition Intervention in Tube Dependence

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• Work towards daytime bolus feedings• Offer the child foods before tube feedings• Give the child “credit” for oral intake

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Daytime Bolus Feedings

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CurrentTime Amount (mL) Rate9:00 PM 350 50 mL/hour7:30 AM 240 200 mL/hour11:00 AM 240 200 mL/hour2:30 PM 240 200 mL/hour6:00 PM 150 150 mL/hourTOTAL 1220

Step 1Time Amount (mL) Rate9:00 PM 340 50 mL/hour7:30 AM 240 205 mL/hour11:00 AM 240 205 mL/hour2:30 PM 240 205 mL/hour6:00 PM 160 205 mL/hourTOTAL 1220

Step 2Time Amount (mL) Rate9:00 PM 330 50 mL/hour7:30 AM 240 210 mL/hour11:00 AM 240 210 mL/hour2:30 PM 240 210 mL/hour6:00 PM 170 210 mL/hourTOTAL 1220

Instructions: Move to each step after 5 days of tolerance. Tolerance means no increase in vomiting, gagging, or other gastrointestinal symptoms.

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Meal Planning

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Meal/ Food Amount to feed approx. calories

Breakfast (8:00 am)Pureed food PO 180 180.0Tube feeding 80 80.0

Lunch (12:00 pm)Pureed food PO 180 180.0Tube feeding 80 80.0

Afternoon Snack (3:00 pm)Pureed food PO 180 180.0Snack foods 50

Dinner (6:00 pm)Pureed food PO 180 180.0Tube feeding 80 80.0

Food total 960 1010

Daily Needs 1000

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“Credit” for Oral Intake

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Pediasure : pureed food

Grams consumed in meal Amount tube feed can be decreased (in cc)

Amount tube feed to give (in cc)

0 to 14 no decrease 24015 to 29 15 22530 to 43 30 21044 to 58 45 19559 to 72 60 18073 to 87 75 16588 to 101 90 150102 to 115 105 135116 to 130 120 120131 to 144 135 105145 to 159 150 90160 to 173 165 75174 to 188 180 60189 to 202 195 45203 to 216 210 30217 to 231 225 15

above 231 remove 8 ounces tube feedingClinic food conversion 1.04

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Nutrition Intervention in ASD

• Balanced Diet– Nutrient deficiencies– Weight management

• Dietary Manipulation• Medical Intervention

– Gastrointestinal– Allergy

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Balancing the Diet

• Balance the plate– Ideally, a meal contains foods from 3 food groups; a snack

contains foods from 2 food groups– Work with preferred food list, mixing most preferred with

“will accept”– If possible, each meal or snack should have a fruit and/or

vegetable

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Reducing Volume

• Eliminate grazing– Appropriate for all children; especially overweight and

underweight– Time with restricted access to food should be increased

gradually

• CAUTION– Child might excessively tantrum, aggress, have self

injurious behavior

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Vitamin Supplementation

• Add multivitamin– Appropriate for:

• Children with a medium level of rigidity• Children who chew• Children who will eat candy• Children who are selective only by texture NOT by type• Children who do not hoard food

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Vitamin Supplementation

• CAUTION– Many children diagnosed with food selectivity will not take

a multivitamin since it is not a preferred food– If the child is overweight due to hoarding, risk of overdose– Diet might be excessive in some nutrients; multivitamin

could put some nutrients above TUL

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Additives to food

• Add _____ to preferred food– Add… butter, instant breakfast, fiber, water, pureed

vegetables, vitamins…• Add a very small amount at a time, starting as small as 1/8

teaspoon

• CAUTION– Run the risk of contaminating the food and further

decreasing the number of foods accepted– Need to have a good idea of degree of selectivity

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Parent Consultation

• Regulate meal pattern– 3 meals + 2 snacks– Eat every 2 ½ to 3 hours

• Offer foods from at least 2 food groups at each meal and snack (if possible)– Ideal is 3 food groups for meals, 2 for snacks

• Slowly reduce or increase portions as appropriate• Eliminate grazing

– Start with 15 minutes no grazing, increase by 15 minutes every 3 days if no tantrums, work up to 2 ½ hours

• Eliminate juice or other sugary drinks– If juice is only drink accepted, dilute with water slowly, over time

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Summary: Scope of Practice

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Behavioral intervention is the ONLY empirically supported treatment for individuals diagnosed

with pediatric feeding disorders

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What is…

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B. F. Skinner

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What is ABA: APPLIED

(NOT Rats!)

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What is ABA: BEHAVIOR

Behavior must be MEASURABLE

and OBSERVABLE

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Defining Behavior

• Dead man test (Ogden Lindsley,1965)

If a dead person can do it, it ain't behavior.

And if a dead person can't do it, then it is behavior.

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Dead Person Examples

• Is this behavior, yes or no?– Reading a book– Sitting still and being quiet– Tying a shoe– Not using profanity– Speaking with appropriate words– Breathing– Not complying with a task

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Target Behaviors to Increase

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Target Behaviors to Decrease

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What is ABA: ANALYSIS

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Slide 100


What happens AFTER the

behavior occursThe TARGET

behaviorWhat happens BEFORE the

behavior occurs

Behavioral ABC’s: Four-Term Contingency

100

Motivational Operations

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Slide 101


Analyzing Behavior

What is the antecedent?

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Slide 102



behavior occursThe TARGET

behavior

What happens BEFORE the

behavior occurs


102


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Slide 103


Analyzing Behavior

What is the behavior?

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Slide 104



behavior occurs

The TARGET behavior

What happens BEFORE the

behavior occurs


104


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Slide 105


Analyzing Behavior

What is the consequence?

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Slide 106



106

Motivational OperationsImpacts effectiveness of a consequence

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Slide 107


Analyzing Behavior

What is the motivational operation?

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Slide 108


Analyzing Behavior


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Slide 109


Analyzing Behavior


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Slide 110


Analyzing Behavior


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Slide 111


Analyzing Behavior


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Slide 112


Analyzing Behavior


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Slide 113


Analyzing Behavior


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Slide 114


Analyzing Behavior


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Slide 115


Analyzing Behavior


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Slide 116


Consequences: Reinforcement and Consequences

116

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Slide 117 Reinforcement and Punishment

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Slide 118 Reinforcement and Punishment

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Slide 119


What Does the Child Learn…

…if the child cries and the food is removed?

Target behavior• Crying• Food acceptance

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Slide 120


What Does the Child Learn…

…if the spoon is kept at the lips and doesn’t move until the bite is taken?

Target behavior• Crying• Food acceptance

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Slide 121


Extinction

121

• Reduction in behavior after reinforcement is removed

• Behavior stops or occurs much less frequently because it is no longer reinforced

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Slide 122


Extinction in Everyday Life

122

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Slide 123


Extinction

• This is also a form of escape extinction– What is the behavior that was previously reinforced?– What is the behavior that is no longer reinforced?

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Slide 124


Extinction Burst

124

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Slide 125

125

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Slide 126

126

Behavioral intervention is the ONLY empirically supported treatment for individuals diagnosed

with pediatric feeding disorders

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Slide 127


Why Does it Matter?

127

Ethical Use of Resources

Time

EnergyMoney

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Slide 128

128

Clinical Decision Making Process

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Slide 129

129


Formalized Data Collection

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Slide 130

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Form

aliz

ed D

ata

Col

lect

ion

Structured Decision Rules

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Slide 131

131


Form

aliz

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ata

Col

lect

ion

Stru

ctur

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ecis

ion

Rul

es

Standardized Treatment Elements

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Slide 132

132


Form

aliz

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ata

Col

lect

ion

Stru

ctur

ed D

ecis

ion

Rul

es

Sta

ndar

dize

d Tr

eatm

ent

Ele

men

ts

Individualized Treatment Approach

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Slide 133

133


Form

aliz

ed D

ata

Col

lect

ion

Stru

ctur

ed D

ecis

ion

Rul

es

Sta

ndar

dize

d Tr

eatm

ent

Ele

men

ts

Indi

vidu

aliz

ed T

reat

men

t A

ppro

ach

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Slide 134

134


Formalized Data Collection

• Operational Definitions• Types of Data to Collect• Summarizing Data

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Slide 135


Importance of Operational Definitions

Why do we have them?

135

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Slide 136


Formalized Data Collection: Operational Definitions

136

• Must be specific to assure the definition is so narrow in scope that others would observe only what you had in mind

• Allows 2 or more people to collect data on the same set of target behaviors

• “What do you mean by that?”• Remember, behaviors should be observable and

measurable

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Slide 137


“Does not like new food”

vs.

“Pushes away the plate and leaves the table when new food presented”


vs.

“Throws self on floor, sticks finger in mouth to make himself throw-up and begins to bang head on floor when presented with new foods”

Formalized Data Collection:Importance of Specificity


vs.

“Every time he takes a bite of a new food says, ‘It’s not my taste’”

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Slide 138


“Can chew …”

vs.

“Can chew crunchy dissolvable solids, soft chewable solids, and firm chewable solids ”


vs.

“Pushes away the plate and leaves the table when new food is presented”

Formalized Data Collection:Importance of Specificity

“Is sensitive to sensory input”

vs.

“Covers her ears and screams when she hears noises above a conversational tone”

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Slide 139


Variable Examples

• What do you track in your clinical practice?

• How do you define that so that it is observable and measurable?

139

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Slide 140


Formalized Data Collection:Operational Definition Examples

140

• Acceptance• Mouth clean• Combined inappropriate behaviors• Expulsion• Packing

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Slide 141


Types of Data Collected

• Occurrence Data– Did the behavior occur during the trial? Yes or No

• Check or no check

• Frequency Data– How many times did the behavior occur? #

• Example: 5 times

• Duration Data– How long did the behavior occur? Seconds, minutes

• Example: 30 seconds,

141

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Slide 142



• Occurrence Data– Did the behavior occur during the trial? Yes or No

• Check or no check

142

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Slide 143



• Frequency Data– How many times did the behavior occur? #

• Example: 5 times

143

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Slide 144



• Duration Data– How long did the behavior occur? Seconds, minutes

• Example: 30 seconds,

144

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Slide 145


POP QUIZ!

145

1. How do you take frequency data?

2. How do you take occurrence data?

3. How do you take latency data?

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Slide 146


Formalized Data Collection:Data Sheet

146

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Slide 147 Summarizing Data•Graphs•Tables •Narrative

For 3, 5-bite sessions, there was an average of 10 chews per bite presentation (9, 10, 11), with low rates of refusal behaviors (average 20%; 10%, 20%, 30%) and no instances of crying.

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Slide 148


Why is This Important?

148

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Slide 149


Persisting with a Reasonable Request

• Identifying where the child can be most successful and then expecting the child to attain that goal

149

BUT AT SOME POINT, THE REQUEST SHOULD BE FOOD CONSUMPTION!

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Slide 150


Meet the child where she is…

AGE APPROPRIATE FOODS DEVELOPMENTALLY APPROPRIATE FOODS

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Slide 151


Fading

151

Definition • Identify where the child can be successful with regards to completing task and low problem behavior

• Antecedent side of the behavioral ABC’s-clinician decides prior to behavior occurring

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Slide 152


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Slide 153


1 chew

Fading

153

3 chews

8 chews

5 chews

8 chews + swallow

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