Please visit their table during the break and after the lecture!

1. UHCL Autism Speaker Series Special thanks to underwriter CHRISTUS St. John Hospital and sponsors Hegwood & Associates, P.C., Johnson Space Center Federal Credit Union, and Spectrum of Hope Please visit their table during the break and after the lecture!

2. INCREASING APPROPRIATEMEALTIME BEHAVIORS Presented by: Nicole Stiefler Kyna Savage, M.Ed. University of Houston - Clear Lake

3. OVERVIEW OF THE PRESENTATION • Increasing food acceptance and decreasing food refusal • Importance • Assessments • Interventions • Increasing independent meal preparation behaviors • Importance • Assessments • Interventions

4. FEEDING DISORDERS • Between 33% and 80% of children with developmental delays have a feeding disorder (Bachmeyer, 2009) • Includes food selectivity, food or liquid refusal • Other inappropriate behaviors may occur

5. FOOD SELECTIVITY & FOOD REFUSAL • “Picky” eaters may be selective about: • Texture (e.g., crunchy, pureed, soft) • Food groups (e.g., grains, meat, sweets) • Taste (e.g., sweet, bland, spicy) • “Stubborn” eaters sometimes: • Refuse to eat enough food • Refuse to drink enough liquids • May not thrive without intervention

6. INAPPROPRIATE BEHAVIORS • Head turning • Closing the mouth • Spitting out food or liquids • Throwing up • Running away

7. OTHER INAPPROPRIATE BEHAVIORS • Hurting others (aggression) • Hurting themselves (self-injurious behavior) • Property destruction • Tantrums (screaming, crying, dropping to floor) • Arguing

9. IMPORTANCE OF INTERVENTION • Health Concerns • Weight loss • Malnutrition • Developmental Concerns • Impaired mental development • Impaired physical development • Social Concerns • Social isolation • Difficulty in public settings • Family Interaction Concerns • Stress • Mental health issues

10. GOLDEN RULE OF INTERVENTION • See a PHYSICIAN before starting intervention! • You MUST rule out potential medical causes • Dental issues • Swallowing disorders • Gastrointestinal disorders • Physical deformities • Oral motor deficiencies

11. CAUSES OF SOME FEEDING DISORDERS • Getting out of things they do not want: • Non-preferred foods • Non-preferred mealtime environments • Getting things they want: • Attention • Toys • Preferred foods

12. ADDRESSING FEEDING DISORDERS • What are the specific inappropriate behaviors? • What happens BEFORE the behavior? • What happens AFTER the behavior? • What should they eat? • Textures • Food groups • Specific foods • What might be an effective intervention?

13. ASSESSMENT: FINDING THE CAUSE • Interviews with caregivers • Food diary • Antecedent-Behavior-Consequence (ABC) recording • Functional analysis • Requires training and supervision, OR • Conducted by Board Certified Behavior Analyst

14. ABC RECORDING To get away from things they don’t want To get things they want

15. STRENGTHEN APPROPRIATE BEHAVIORS • Reward appropriate behaviors, such as: • Tolerating presence of non-preferred food • Trying new foods • Trying new liquids • Do not reward any inappropriate behavior • No removing the non-preferred food • No access to attention • No access to preferred toys, activities, or foods

17. WAYS TO REWARD EATING • Reward eating a non-preferred food with: • Preferred food • Preferred item or activity • Attention: Your praise and encouragement

18. SHAPING • Reward small steps toward trying new foods: • Tolerating the presence of a new food • Touching a new food • Licking a new food • Putting a new food in mouth • Taking a bite of a new food • Swallowing a new food

19. INCREASING INDEPENDENCE • Initially: One bite of a non-preferred food earns one bite of a preferred food Eat one carrot  Get one bite of a cookie Eat one carrot  Get 15 sec to play with Elmo • Eventually: A serving size of a non-preferred food earns one serving of a preferred food Eat serving of carrots  Get one cookie Eat serving of carrots  Watch a movie for 5 min

21. ESCAPE PREVENTION • Non-removal of the eating utensil

22. HOW TO PREVENT ESCAPE • Keep the spoon, fork, or food present • Even if inappropriate behavior occurs • Be prepared: • Plate with the food for entire meal • “Bite” plate for presenting one bite of food • Many forks or spoons • Reward eating with a preferred food, toy, attention, or a combination

23. GRADUATED GUIDANCE • Increase the amount of help provided

24. HOW TO USE GRADUATED ASSISTANCE • Use the least intrusive prompt possible: • Instruction • Gesture • Model • Partial Physical Guidance • Full Physical Guidance • Can use finger foods or foods on a utensil • Can use with escape prevention • Reinforce eating with a preferred food, toy, attention, or a combination

25. Throwing up or Spitting out Food • Once all medical problems have been ruled out: • Throwing up or spitting out food is a behavior • Treat it the same as any other problem behavior • If your child throws up or spits out food, present more food immediately • Reinforce eating with a preferred food, toy, attention, or a combination

26. PACKING (REFUSING TO SWALLOW) • Packing: Storing food in the cheeks and refusing to swallow • Use a spoon to redistribute food in the mouth • After allowing 10 s for chewing, give child a liquid to prompt swallowing • Reinforce swallowing with a preferred food, toy, attention, or a combination

28. Increasing Independent Meal Preparation

29. IMPORTANCE OF TEACHING • Promotes autonomy in young learners • Prepares older learners for independent living

30. PRE-TEACHING CONSIDERATIONS • What are the prerequisite skills necessary for the task? • Which kitchen tools and appliances do you want your learner to use? • Are the items needed accessible to the learner?

31. SELECTING FOOD FOR TEACHING • Choose highly preferred foods • Consider the number of steps to complete the task • Consider the amount of time and assistance that will be required

32. GENERAL APPROACH TO TEACHING • Identify a reinforcer (reward) for task completion • Create a task analysis • Use a teaching strategy • Select an appropriate teaching time

33. IDENTIFY THE REINFORCER (REWARD) TASKREINFORCER • Tying shoes  Play outside • Making bed  Make Mom happy & get praise • Brushing teeth  Praise & fun bedtime routine • Making a cake  Smells and tastes great!

34. TASK ANALYSIS • Breaking a complex skill into individual steps • Use to determine which behaviors to teach • Create one by performing the task & writing down each step

35. TASK ANALYSIS: CHOCOLATE MILK • Get a glass • Get a spoon • Get milk • Get chocolate syrup • Pour milk into glass • Pour syrup into spoon • Put spoon into glass • Stir syrup in glass • Put spoon in sink • Put syrup away

36. TEACHING STRATEGY • Behaviors taught from the end to the beginning • Called “backward chaining” • Trainer completes all but the last step for the learner • Learner eats each time the last step is completed • After the last step is mastered, learner completes the last 2 steps • Then the last 3 steps • Continue until the learner can complete all steps • Trainer provides assistance (prompts) as needed

37. PROMPTS USED DURING TEACHING • Visual: Pictures or written words of each step • Verbal: Tell the learner the step • Gesture/Model: Point to or demonstrate the step • Partial physical: Physically assist the learner to initiate the step • Full physical: Physically assist the learner through the entire step

38. How to Make Chocolate Milk

39. VISUAL PROMPTS

40. TASK ANALYSIS: CHOCOLATE MILK • Get a glass • Get a spoon • Get milk • Get chocolate syrup • Pour milk into glass • Pour syrup into spoon • Put spoon into glass • Stir syrup in glass • Put spoon in sink • Put syrup away

41. MODIFICATION OF TASKS • Have the learner pour from a smaller container • Modify the materials used • Use plastic cups, spoons, etc. • Make items reachable for the learner • Loosen lids

42. HANDS-ON ACTIVITY • Create a task analysis (TA) • Peanut butter & jelly sandwich • Bowl of cereal • Teach the task to a partner • Use backward chaining data sheet