Intensive Multidisciplinary Feeding Day Programs in the United States: A Report Regarding the Treatment Landscape.

Intensive multidisciplinary intervention is increasingly recognized as the standard of care for children with complex feeding problems. Much, however, remains unknown about this treatment model. This current qualitative, prospective study sought to identify intensive multidisciplinary day hospital programs operating in the US, describe the treatment approach, and summarize current capacity.

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder.

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.

A Retrospective Consecutive Controlled Case Series of Underspoon: A Modified-Bolus Placement to Address Behavior That Interfere With Swallowing.

Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

Treatment of Feeding Concerns in Children With Autism Spectrum Disorder: A Systematic Review of Behavioral Interventions With Caregiver Training.

Successful feeding intervention ultimately requires generalization and adoption of treatment into the home. Treatment models, however, differ regarding how and when caregivers are integrated into care delivery process. Some treatments involve a primary model of parent training with caregivers serving as co-therapist at the onset of intervention, while others involve a complimentary model where a therapist delivers the intervention and caregiver training occurs once the child's behavior is stable. This review systematically evaluates the evidence-base regarding behavioral feeding intervention for children with autism spectrum disorder (ASD), with a specific focus on interventions involving parent training. Results provide further evidence regarding the potential benefits of behavioral intervention to improve feeding concerns in ASD, while also highlighting growing attention to documenting and/or evaluating parent training within the treatment literature. Important questions remain regarding factors guiding the use of a primary or complimentary model of parent training.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization.

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Evaluating Characteristics Associated with Success with Tube Weaning After Intensive Multidisciplinary Intervention.

OBJECTIVE: Evidence suggests intensive multidisciplinary intervention holds benefit for children with feeding tube dependence complicated by comorbid medical, behavioral, and/or developmental conditions; however, much remains unknown regarding factors affecting a patient achieving full oral feeding after intervention. METHODS: This retrospective review involved consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-2019) for feeding tube dependence and food refusal. This study compared the clinical presentation and treatment outcomes for patients who successfully transitioned to full oral feeding versus patients experiencing a partial wean at the last follow-up. RESULTS: Eighty-one patients completed intervention and provided outcome data (46 male patients and 35 female patients; age range 10-230 mo). Fifty-eight patients (72%) weaned from tube feeding at the last follow-up; 23 patients (28%) experienced a partial wean. The full wean group experienced greater progress by discharge (e.g., oral intake and goals achieved) and participated in longer follow-up compared with the partial wean group. Clinical characteristics associated with lack of full wean included a history of congenital heart disease requiring surgery and a history of developmental disabilities. CONCLUSION: Improving response to intensive multidisciplinary intervention likely necessitates the development of treatment adjuncts for patients whose medical and/or developmental conditions complicate wean from tube feeding, tailoring treatment for at-risk populations. Future iterations of this model of care should also adjust the quantity and/or quality of follow-up support for patients who discharge from intervention below certain clinical benchmarks.

Intensive multidisciplinary feeding intervention for patients with avoidant/restrictive food intake disorder associated with severe food selectivity: An electronic health record review.

OBJECTIVE: Expert consensus increasingly recognizes intensive multidisciplinary intervention (IMI) as the standard of care to address chronic and severe feeding problems in pediatric populations. In this study, we examined the clinical presentation, intervention characteristics, and treatment outcomes for young children receiving IMI for avoidant restrictive rood intake disorder (ARFID) involving nutritional insufficiencies associated with severe food selectivity. METHOD: We followed the Strengthening the Reporting of Observational Studies in Epidemiology statement to conduct this retrospective chart review. The review focused on consecutive patients (birth to age 21 years) admitted to the IMI program over a 5-year period (June 2014 to June 2019). Inclusion criteria required micronutrient insufficiencies (vitamins A, B12, C, D, E; folic acid; calcium; iron; and zinc) and chronic mealtime refusal behavior (e.g., turning head away from food/spoon, pushing or throwing spoon, crying, screaming, and leaving the table) associated with severe food selectivity. RESULTS: Over the 5-year period, 63 of the patients met study entry requirements. Of these, 60 patients (50 boys and 10 girls; mean age = 72 ± 39 months; range = 23-181) completed intervention (95% treatment completion rate). At discharge, dietary diversity improved by 16 new therapeutic foods (range: 8-22), rapid acceptance and swallowing of new foods exceeded clinical benchmarks (80% or > bites), and risk for nutritional inadequacies declined for this patient cohort. DISCUSSION: Results of the current study support the benefits of IMI to increase dietary variety, improve mealtime behaviors, and enhance nutritional intake for children with ARFID presenting with severe food selectivity.

A systematic review of physical guidance procedures as an open-mouth prompt to increase acceptance for children with pediatric feeding disorders.

This article reviews behavioral treatments of pediatric feeding disorders using physical guidance procedures as an open-mouth prompt (i.e., jaw prompt, finger prompt, Nuk prompt, side deposit) to increase food acceptance. We identified 9 articles containing 35 systematic evaluations. We coded participant and study characteristics and assessed the experimental rigor, quality, and outcomes of each evaluation. Of the high-quality research present, the finger prompt variation and side deposit reliably increased acceptance. We found mixed results on the efficacy of the jaw prompt, although it was the most widely researched procedure. Further, authors reported interobserver agreement for 100% of the participants, procedural integrity for 60%, social validity for 80%, fading for 5%, and follow-up for 55%. Based on the invasive nature of physical guidance, we provide recommendations for researchers and clinicians to increase the quality of their treatment evaluations. We discuss limitations, implications for practice, and future research.

Using telehealth to provide outpatient follow-up to children with avoidant/restrictive food intake disorder.

The COVID-19 global health crisis compelled behavior analysts to consider alternatives to face-to-face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day-treatment program; and transitioned to an outpatient follow-up program. In Experiment 1, we analyzed the data of participants who received follow-up both in-clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow-up either in-clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in-clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.

Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review.

OBJECTIVE: To assess characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence. STUDY DESIGN: We conducted a retrospective study of consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding. RESULTS: Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230 months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33 months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39 ± 1 kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up. CONCLUSIONS: Our findings support the effectiveness of our intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. Further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders.

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.

Food preferences before and during treatment for a pediatric feeding disorder.

Little is known about the food preferences of children with a feeding disorder and medical diagnoses. Therefore, we conducted repeated paired-stimulus-preference assessments with foods to which we either exposed or did not expose 3 children with a feeding disorder and medical diagnoses during clinical treatment. Responding was relatively equivalent for exposure and nonexposure foods throughout the preference assessments, suggesting that preferences for foods did not change due to exposure during treatment.

Modified-Bolus Placement as a Therapeutic Tool in the Treatment of Pediatric Feeding Disorders: Analysis From a Retrospective Chart Review.

Purpose Recognizing the need to advance the treatment of pediatric feeding disorders, an emerging area of inquiry focuses on therapeutic techniques that address expulsion and packing possibly associated with oral-motor dysfunction. In the current study, we documented the use of modified-bolus placement in the treatment of pediatric feeding disorders at an intensive, multidisciplinary day-treatment center over a 26-month period. Method The retrospective observational cohort study involved patients admitted for the assessment and treatment of chronic food refusal from August 2013 to October 2015. Results Patients (n = 23) who received modified bolus placement displayed moderate-to-severe oral-motor deficits. Use of modified-bolus placement was associated with reduced expulsion and packing of bites during meals, and treatment gains coincided with a threefold increase in grams consumed per meal. Conclusion Results provide additional support for the potential therapeutic benefits of enhancing bolus placement onto the tongue as a means to improve mealtime performance in children with pediatric feeding disorders when included as an adjunct to more traditional behavioral approaches.

An experimental demonstration of AAB renewal in children with autism spectrum disorder.

Operant renewal is a return of extinguished behavior due to changes in contextual stimuli that control the occurrence or nonoccurrence of a response. Well-established in classical conditioning and operant research, renewal presents itself in three forms-ABA, ABC, and AAB-and poses threats to treatment maintenance where extinction procedures are utilized. As AAB renewal may be less likely to occur than ABA or ABC renewal, the current study sought to determine if AAB renewal would occur with three participants with Autism Spectrum Disorder who were taught a simple lever pull response. Results showed that lever pulls increased for two of three participants when we introduced novel stimuli (i.e., a light and a buzzer) to alter the contextual environment after extinction. These findings suggest that AAB renewal may account for some instances of response recovery after extinction and that the procedure of this study may be beneficial to the further study of renewal and the variables that affect its occurrence within a translational model.

Evaluation of Practice Trials to Increase Self-Drinking in a Child with a Feeding Disorder.

Self-drinking is an important skill for children to acquire as they transition from infancy to early childhood; however, the literature is limited (e.g., Collins, Gast, Wolery, Holcombe, & Leatherby, 1991; Peterson, Volkert, & Zeleny, 2015). We manipulated the consequences associated with self-drinking relative to those associated with being fed along the dimension of response effort. Results demonstrated that self-drinking increased when the child could either choose to self-feed one drink or be fed one drink and 5 practice trials with an empty cup.

A Systematic Review and Meta-Analysis of Intensive Multidisciplinary Intervention for Pediatric Feeding Disorders: How Standard Is the Standard of Care?

OBJECTIVE: To assess models of care and conduct a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders. STUDY DESIGN: We searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. Effect size estimates were calculated based on a meta-analysis of proportions. RESULTS: The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from tube feeding was 71% (95% CI 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress. CONCLUSIONS: Results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. Future research must address key methodological limitations to the extant literature, including improved measurement, more comprehensive case definitions, and standardization/examination of treatment approach.

The Munroe-Meyer Approach: Continuous Integration of Didactic Instruction, Research, and Clinical Practice.

Increased demand for applied behavior analysis (ABA) services has increased the need for additional masters-level practitioners and doctoral-level academicians and clinical directors. Based on these needs, the University of Nebraska Medical Center's (UNMC) Munroe-Meyer Institute has developed a PhD program. The academic structure at UNMC allowed us to create our PhD program in a relatively quick and efficient manner. Our PhD program has many unique features, including (a) close integration of didactic instruction with clinical and research training provided by leading experts in ABA in which students immediately apply concepts introduced in the classroom during coordinated clinical and research practica; (b) structured grant writing training in which students learn to write and submit an NIH-level grant;

Further Manipulations in Response Effort or Magnitude of an Aversive Consequence to Increase Self-Feeding in Children with Feeding Disorders.

Although some children with feeding disorders may have the necessary skills to feed themselves, they may lack motivation to self-feed solids and liquids. Rivas, Piazza, Roane, Volkert, Stewart, Kadey, and Groff (Journal of Applied Behavior Analysis, 47, 1-14, 2014) and Vaz, Volkert, and Piazza (Journal of Applied Behavior Analysis, 44, 915-920, 2011) successfully increased self-feeding for children who lacked motivation to self-feed by manipulating either the quantity or the quantity and quality of bites that the therapist fed the child if he or she did not self-feed. In the current investigation, we present three case examples to illustrate some challenges we faced when using these procedures outlined in the aforementioned studies and how we addressed these challenges.

A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder.

Treatments of pediatric feeding disorders based on applied behavior analysis (ABA) have the most empirical support in the research literature (Volkert & Piazza, 2012); however, professionals often recommend, and caregivers often use, treatments that have limited empirical support. In the current investigation, we compared a modified sequential oral sensory approach (M-SOS; Benson, Parke, Gannon, & Muñoz, 2013) to an ABA approach for the treatment of the food selectivity of 6 children with autism. We randomly assigned 3 children to ABA and 3 children to M-SOS and compared the effects of treatment in a multiple baseline design across novel, healthy target foods. We used a multielement design to assess treatment generalization. Consumption of target foods increased for children who received ABA, but not for children who received M-SOS. We subsequently implemented ABA with the children for whom M-SOS was not effective and observed a potential treatment generalization effect during ABA when M-SOS preceded ABA.