Summer 2010

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Q&A: Food Tolerance and Feeding Difficulties

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.

Initial Question

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?

Response 1

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:

1. Choose a food that is similar to one the child likes.
2. The child touches food on the table (imitation).
3. Child picks food up (imitates instructor picking up identical piece of food).
4. Child imitates touching food to forehead.
5. Child imitates touching food to closed lips.
6. Child imitates touching food to teeth.
7. Child imitates touching food to tongue.
8. Child imitates putting in mouth.
9. Child imitates swallowing.
10. Start expanding foods.

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.

Response 2

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:

• First we established a highly desired reinforcer that the child would earn after responding correctly. This reinforcer was limited to the "food" program only.
• For the first step, the child was required to only touch the food that was presented on the plate. The instructor modeled the response for the child. One food was introduced at a time. The child was only given access to the reinforcer and was required to remain at the teaching table until he touched the food. Once the child consistently and quickly (within 3-5 seconds) touched the first food, a second food was introduced. We introduced approximately 30 foods in this phase. At this point the child had learned to touch any novel food presented quickly, as he consistently received the reinforcer and was excused to take a break each time.
• Next the response requirement was increased so that the child was required to pick up a bite-sized piece of the food. The same procedure outlined above was implemented for this step. The child picked up about 30 foods before moving on.
• Next the child was required to lick about 30 foods using the same procedure as above.
• Then the child was required to eat a bite-sized portion of the food. The bite-sized piece was presented on the plate. The instructors had extra pieces on hand in case the child, spit the food out, smeared it on their clothing, etc. The same rules applied from the above steps. For this step, the team picked about 15 foods from the list of about 30 to systematically introduce.
• After the child had successfully eaten 15 new foods (one bite), the amount required was systematically increased, and then generalized to parents, restaurants, brands, etc. At first, the sittings were very long (could take an hour); however, from my data, the length of time decreased and the gains were maintained and generalized over time.

Response 3

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?

1. maybe the child has a history of texture issues related to feeding; perhaps he got over the chewing stage but couldn't really bring himself to swallow it
2. maybe he has reflux and his throat is somewhat inflamed/irritated; it might be more uncomfortable for him to swallow solids than liquids and purees
3. maybe his oral motor skills aren't where they need to be. To efficiently transfer food around or clear his mouth, he would need to be able to lateralize his tongue to clear certain areas off to the side. How does oral motor imitation look, especially the tongue movements?

Treatment ideas:

1. get a complete feeding history on him (i.e., how his feeding and drinking skills developed, what kinds of foods he accepted/accepts, what kinds he refused/refuses, whether there is any history of oral motor or feeding difficulty that was diagnosed or treated)
2. the parents should consult with the pediatrician to see if he/she would recommend anything
3. assuming there doesn't appear to be medical causes, implement a feeding program in which you systematically move from smooth to lumpy to chewy solids; at each level, reinforce for swallowing after each bite (only permit mild residue); it would be nice to visually check after each bite, but that may create a chain of behaviors in which he opens his mouth every time (not socially appropriate); begin with foods that don't have a history of strong refusal
4. make an "empty mouth" a criterion for leaving the meal or snack table; it may help to have him drink something, too

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.

Response 4

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.

Response 5

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.

Response 6

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.

Response 7

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.

• Explain to the child that if he eats all of the (cracker), then he can have the (candy). This can be stated simply, "First cracker, then candy."
• Set the timer for one minute.
• If he does not eat the food before the timer goes off, remove the tray.
• Provide two opportunities in a session.
• Gradually increase how much the child has to eat to access the reinforcer.
• As you increase the portion size, increase the time period.
  The food should always be completely consumed by the time the timer sounds. (You can include "swallowing" the food as part of the response requirement.)
• Begin with food items that are similar to food he already eats or used to eat, but no longer eats.
• You can target more than one food at a time. However, do not target too many items at once, as you want to ensure that the child gets enough exposure to each food.
• Carry out this plan both during and outside of structured therapy sessions, for a total of three times per day, if possible.

Response 8

I have a few general guidelines to add to the procedure described in the last response.

1. Begin with one food item until the child eats a small portion (a small handful).
2. Once the child eats a small handful of one food, begin to target at least one other food.
3. Up to three foods can be targeted at one time, depending on the parents' desires. If they wish to expose him to a variety of tastes, target foods only until he eats a small portion. If they wish to make a particular food part of his diet, target a food longer, until he eats a larger portion.
4. It is important that parents generalize into the natural environment once he eats a small portion in therapy. For example, once he eats 5 bites of cracker, they might try having him eat 5 bites of cracker at the dinner table and then allow him to eat the rest of his meal (foods he likes to eat).
5. Finally, place the crackers on the same plate as his other food and continue to increase the amount on his plate.

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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