Intensive ABA Services
The following question was posted on the Lovaas Institute consultant email list. Below are some of the responses offered, to illustrate the variety of potential solutions available.
I have been helping a family develop and increase food tolerance with their four-year-old son for approximately six months. While he now demonstrates tolerance of placing non-preferred food in his mouth, he has yet to achieve eating the food. He stores the food in his cheeks for hours at a time and/or takes a significant amount of time to swallow the food he doesn't store. I am looking for any resources or ideas that you have to address both food tolerance programming as well as storing the food in cheeks?
When I am preparing to begin food tolerance programming, I sit with the parents and make a detailed list of the foods the child currently does and does not eat. Sometimes the distinction is a color issue (only beige foods), sometimes a textural issue (only crunchy foods/no purees or liquids), a flavor issue (only salty foods), a variety issue (only 3 foods total), a temperature issue, etc. This gives me a basis for starting to expand the child's food repertoire. What I typically do is expand one feature of a food at a time and reinforce for increasing amounts of acceptance. For example, if the child will eat raw/crunchy vegetables but no cooked vegetables, I might steam a raw carrot slice for less than a minute and reinforce for one tiny bite (he accesses his preferred foods item only upon taking that bite- that's why I often have to start out with teeny-tiny goals so the child can be successful). Eventually, you steam it for longer periods of time. Or if the child won't eat sauce on pasta, maybe the first piece of pasta will have sauce and the rest can be plain. Or if the child will each Cheetos and Cheerios, I might pick another crunchy snack food so I'm not changing too much at once. You get the idea. You usually don't have to do this gradual desensitization for every item. Once the child accepts a few new items, he might generalize the rest. Keep in mind, too, that the instructors will be pairing themselves with a procedure that may likely be unpleasant. They will need to make up for this 100-fold during all other therapy time.
An example of a systematic desensitization follows:
The steps outlined above can take place over days or weeks. Systematic desensitization can be time-consuming, but I have also found it to be effective.
I have worked with two children with very limited diets and used the desensitization approach mentioned above with great success. The two children had very different learning profiles, however the approach worked very well for both. The method of implementation that I used varied slightly:
I haven't observed a child demonstrate this storing behavior, but here are some hypotheses and ideas you could consider. I'm assuming he stores the food in his cheeks with solid foods only, not liquids or purees such as applesauce?
You can refer to the following feeding manual if you would like: Pre-Feeding Skills, by Suzanne Evans Morris, Ph.D., C.C.C. and Marsha Dunn Klein, M.Ed., O.T.R. It has normative information for feeding, as well as treatment strategies. It is an SLP manual, not an ABA manual.
If there doesn't seem to be any oral motor issues with this child, you may want to try a picture schedule that would include: bite, chew, swallow, then drink (with a preferred drink). I put this in place for a 5-year-old-boy who had similar eating behaviors, no medical feeding issues, some minimal oral motor issues, and stored food in his cheeks. He also took an exceptionally lengthy amount of time to eat. We now use a token board with the above schedule on it so that he must engage in the sequence (bite, chew, etc.) several times before he receives access to the drink reinforcer.
I wanted to add that much of the research I have read uses escape as the reinforcer, rather than delivering a preferred food, or in addition to a preferred food. In essence, if the child is engaging in refusal behaviors to end the meal, escape the feeding situation, etc. (which may come up during the desensitization process), using escape as the reinforcer for accepting a bite (e.g. a 15 minute break from any feeding demands) may shorten the length of time at the table, decrease the refusal behaviors and increase intake of the target food. In some cases, as the child began to accept the food, he/she would approach the table for another bite before the break time was completed.
Similar to one of the other suggestions, you could reserve a special beverage or other highly preferred primary reinforcement that he can only have access to upon swallowing the non-preferred food. If he is a visual learner, perhaps you could try a "meals chart." It could include pictures of the non-preferred food, as well as a picture of something preferred. Maybe have 2-3 pictures of the non-preferred, then after he chews and swallows it, you could remove one of the three pictures of non-preferred, and continue until he has finished chewing/swallowing all the non-preferred, and the only picture left is his preferred food/drink.
Here is an outline I have used to develop food tolerance:
SD: Present a small amount of food for the child to eat.
Goal Response: The child eats the entire portion of the food presented.
Setup: Place two small plates on a tray. On the left-hand plate, put a small amount of food you want the child to try (e.g., a new kind of cracker). On the right-hand plate, put something the child really enjoys (e.g., candy). Place a timer between the two plates and set it for one minute.
I have a few general guidelines to add to the procedure described in the last response.
In my experience, I have learned to continually target three foods at one time in therapy and then generalize whichever ones the child seems to prefer to the natural environment. Targeting more than one food seems to set up a hierarchy of least to most preferred foods that can be used to your advantage. In one of my experiences, the child was making steady but very slow progress with his first food (noodles). We introduced a second food (cucumbers). He did not like the cucumbers at all, and would wait as long as possible before eating even a tiny bite. However, when we presented the noodles, he immediately ate them, and within a week was eating a regular portion for lunch. The opposite case works just as well. If you introduce carrots as your second food, and the child likes the taste of carrots more than the first food, steak, he may rapidly increase how many carrots he eats because he prefers the carrots over the steak.
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The names of all children in this newsletter have been changed in respect for family confidentiality.
Where's My Hand! Say, "give me five" but lose your hand in your sleeve – have child help you find it and then lose the other hand.
Keep It Up! Cooperate keeping one balloon floating in the air.
Bubble Gum Bubble! Blow a big bubble of bubble gum and pop it with a big pop.
Macarena! Dance the Macarena. Learn all the moves in gross-motor imitation and build it together.
Kick the Can! Play kick the can by racing to be the first one to kick the can over. The child doesn't know which trial you'll let him go on, so you've got a head start. The anticipation of trying to race you keeps his attention at a peak. (But don't cheat by going when he's not attending!)