RESUMO
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.
RESUMO
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.
Assuntos
Transtornos da Alimentação e da Ingestão de Alimentos , Criança , Consenso , Transtornos da Alimentação e da Ingestão de Alimentos/diagnóstico , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Humanos , Estado NutricionalRESUMO
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.
Assuntos
Transtorno Alimentar Restritivo Evitativo , Transtornos da Alimentação e da Ingestão de Alimentos , Adulto , Criança , Pré-Escolar , Ingestão de Alimentos , Registros Eletrônicos de Saúde , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Feminino , Preferências Alimentares , Humanos , Masculino , Estudos Retrospectivos , Adulto JovemRESUMO
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.
Assuntos
Terapia Comportamental/métodos , Nutrição Enteral/efeitos adversos , Comportamento Alimentar/psicologia , Transtornos de Alimentação na Infância/terapia , Criança , Pré-Escolar , Nutrição Enteral/psicologia , Transtornos de Alimentação na Infância/psicologia , Feminino , Humanos , Masculino , Pais/psicologia , Estudos RetrospectivosAssuntos
Transtorno do Espectro Autista , Transtorno Alimentar Restritivo Evitativo , Hipersensibilidade Alimentar , Humanos , Transtorno do Espectro Autista/complicações , Hipersensibilidade Alimentar/complicações , Hipersensibilidade Alimentar/diagnóstico , Masculino , Criança , Pré-Escolar , FemininoRESUMO
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.
Assuntos
Transtornos da Alimentação e da Ingestão de Alimentos/diagnóstico , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Necessidades Nutricionais , Estado Nutricional , Criança , Pré-Escolar , Feminino , Humanos , Comunicação Interdisciplinar , Masculino , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Padrão de CuidadoRESUMO
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;
RESUMO
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.
Assuntos
Transtornos de Alimentação na Infância , Transtornos da Alimentação e da Ingestão de Alimentos , Criança , Humanos , Extinção Psicológica , Transtornos de Alimentação na Infância/terapia , Reforço Psicológico , Terapia Comportamental/métodos , Comportamento AlimentarRESUMO
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.
Assuntos
Transtorno do Espectro Autista , Criança , Humanos , Transtorno do Espectro Autista/terapia , Cuidadores , Pais/educação , Terapia ComportamentalRESUMO
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.
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Deglutição , Transtornos da Alimentação e da Ingestão de Alimentos , Criança , Humanos , Estudos Retrospectivos , Terapia Comportamental/métodos , Comportamento AlimentarRESUMO
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.
Assuntos
Nutrição Enteral , Transtornos da Alimentação e da Ingestão de Alimentos , Adulto , Terapia Comportamental , Criança , Nutrição Enteral/efeitos adversos , Transtornos da Alimentação e da Ingestão de Alimentos/etiologia , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Desmame , Adulto JovemRESUMO
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.
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Transtornos de Alimentação na Infância , Transtornos da Alimentação e da Ingestão de Alimentos , Terapia Comportamental , Criança , Comportamento Alimentar , Transtornos de Alimentação na Infância/terapia , Humanos , BocaRESUMO
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.
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Transtorno Alimentar Restritivo Evitativo , Telemedicina , Assistência ao Convalescente/métodos , Assistência Ambulatorial/métodos , COVID-19/epidemiologia , COVID-19/prevenção & controle , Criança , Pré-Escolar , Humanos , Telemedicina/métodosRESUMO
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.
Assuntos
Transtornos do Comportamento Infantil , Transtornos de Alimentação na Infância , Transtornos da Alimentação e da Ingestão de Alimentos , Terapia Comportamental , Criança , Pré-Escolar , Extinção Psicológica , Comportamento Alimentar , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Transtornos de Alimentação na Infância/terapia , Humanos , Lactente , Estudos ProspectivosRESUMO
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.
Assuntos
Transtornos do Comportamento Infantil , Transtornos da Alimentação e da Ingestão de Alimentos , Preferências Alimentares , Criança , Comportamento Alimentar , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , HumanosRESUMO
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.
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Métodos de Alimentação , Transtornos de Alimentação na Infância/terapia , Transtornos das Habilidades Motoras/terapia , Criança , Pré-Escolar , Estudos de Coortes , Estudos Transversais , Transtornos de Alimentação na Infância/complicações , Feminino , Humanos , Lactente , Masculino , Transtornos das Habilidades Motoras/complicações , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Research has demonstrated that interspersing mastered tasks with new tasks facilitates learning under certain conditions; however, little is known about factors that influence the effectiveness of this treatment strategy. The initial purpose of the current investigation was to evaluate the effects of similar versus dissimilar interspersed tasks while teaching object labels to children diagnosed with autism or developmental delays. We then conducted a series of exploratory analyses involving the type of reinforcer delivered for correct responses on trials with unknown or known object labels. Performance was enhanced under the interspersal condition only when either brief praise was delivered for all correct responses or presumably more preferred reinforcers were provided for performance on known trials rather than on unknown trials.
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Transtorno Autístico , Ensino/métodos , Criança , Comportamento Infantil/psicologia , Pré-Escolar , Preferências Alimentares , Humanos , Reforço Psicológico , PesquisaRESUMO
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.
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Transtorno do Espectro Autista/psicologia , Condicionamento Operante , Criança , Pré-Escolar , Extinção Psicológica , Humanos , Masculino , Esquema de Reforço , Reforço PsicológicoRESUMO
Factors that influence choice between qualitatively different reinforcers (e.g., a food item or a break from work) are important to consider when arranging treatments for problem behavior. Previous findings indicate that children who engage in problem behavior maintained by escape from demands may choose a food item over the functional reinforcer during treatment (DeLeon, Neidert, Anders, & Rodriguez-Catter, 2001; Lalli et al., 1999). However, a number of variables may influence choice between concurrently available forms of reinforcement. An analogue for treatment situations in which positive reinforcement for compliance is in direct competition with negative reinforcement for problem behavior was used in the current study to evaluate several variables that may influence choice. Participants were 5 children who had been diagnosed with developmental disabilities and who engaged in problem behavior maintained by escape from demands. In the first phase, the effects of task preference and schedule of reinforcement on choice between a 30-s break and a high-preference food item were evaluated. The food item was preferred over the break, regardless of the preference level of the task or the reinforcement schedule, for all but 1 participant. In the second phase, the quality of the break was manipulated by combining escape with toys, attention, or both. Only 1 participant showed preference for the enriched break. In the third phase, choice of a medium- or low-preference food item versus the enriched break was evaluated. Three of 4 participants showed preference for the break over the less preferred food item. Results extend previous research by identifying some of the conditions under which individuals who engage in escape-maintained behavior will prefer a food reinforcer over the functional one.
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Transtorno Autístico/terapia , Terapia Comportamental/métodos , Transtornos do Comportamento Infantil/terapia , Comportamento de Escolha , Deficiências do Desenvolvimento/terapia , Deficiência Intelectual/terapia , Reforço Psicológico , Agressão/psicologia , Transtorno Autístico/psicologia , Criança , Transtornos do Comportamento Infantil/psicologia , Pré-Escolar , Deficiências do Desenvolvimento/psicologia , Reação de Fuga , Feminino , Preferências Alimentares , Humanos , Individualidade , Deficiência Intelectual/psicologia , Masculino , Motivação , Esquema de Reforço , Comportamento Autodestrutivo/prevenção & controle , Comportamento Autodestrutivo/psicologia , Reforço por RecompensaRESUMO
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.