Nutrition Interventions for Children with Special Health Care Needs

Chapter 9 - Behavior Issues Related to Feeding
• Understanding what the child is trying to achieve with the challenging behavior
• Understanding how difficult behaviors are developed in the first place
• Understanding how the current situation is maintaining those behaviors
• Developing strategies to prevent the development of food refusal behaviors
• Implementing effective and technically accurate interventions that change the
current structure to reinforce desired behaviors and eliminate the reinforcement
that is currently in place for the behaviors to be decreased
• Developing behaviorally sound instructional goals and strategies for replacement
behaviors that will facilitate progression of oral-motor skills, food acceptance, and
other therapy goals
How Food Refusal Behaviors Develop
Understanding the variables involved in the development and maintenance of difficult
behaviors always precedes developing an effective intervention. Behaviorists, social
workers, or counselors are often consulted on a feeding team when a child actively,
vocally, and consistently refuses food. Tantrums and aggression may accompany this
behavior. While this is an excellent situation for utilizing the skills of a behaviorist, it
is very late in the development of the behavioral sequence. By understanding how
food refusal develops, other professionals can make a referral earlier in the aversive
conditioning phase, preferably before the behavior has a chance to develop at all.
Classical Conditioning
Behaviors can be developed (learned) by what occurs before or during the behavior.
This is called classical conditioning (2). Classical conditioning occurs when a neutral
stimulus is paired with another stimulus. In feeding, such conditioning occurs when
food presented to the mouth is paired with pain or satiation. The neutral stimulus
becomes a discriminative stimulus that a punisher or reinforcer will occur. For
example, a nipple in the mouth becomes a signal or warning that pain or satiation is
about to occur.
Operant Conditioning
Behaviors can also be conditioned by what occurs after the behavior. This is called
operant conditioning. Operant conditioning occurs when a behavior (eg, sucking) is
followed by a response (eg, pain/satiation) that punishes or reinforces the behavior
(3). A behavior results in a predictable response that reinforces or punishes the
occurrence of that behavior. For example, sucking results predictably in pain/satiation
that increases or decreases sucking in the future. A behavior has been reinforced if
102 Nutrition Interventions for Children With Special Health Care Needs