Nutrition Interventions for Children with Special Health Care Needs

Chapter 9 - Behavior Issues Related to Feeding
The operant conditioning was still in place. When food refusal was well established
and the child was formally diagnosed with failure to thrive, he was referred to
a feeding team with a behaviorist. At this point a long and arduous process of
systematic desensitization, reinforcement, escape extinction, and careful pain
management was needed to progress his oral feeding.
Case: Aversive conditioning as a result of sensory and motor concerns
Charlotte was a young child with sensory, physical, and environmental factors
that conditioned her to avoid eating. Charlotte came from a poor socioeconomic
background. She was never evaluated for developmental concerns.
Because she was significantly underweight, she was referred for a behavioral
feeding evaluation. The physician saw no need for a developmental or sensory
evaluation because there were many foods that “she ate when she felt like it.”
A comprehensive evaluation was conducted according to the policy of the
feeding team. During the evaluation, Charlotte initially refused to eat. She
turned her head and tried to get out of her chair. Her mother talked to her,
gently encouraging her to eat and trying to play games to amuse and distract
her during the feeding trial. She eventually ate several very large bites of
soft foods, and then began to refuse all food again. She avoided hard and
crunchy foods and smooth foods, like whipped cream and ranch dressing.
She sat very straight in her chair and her fingers splayed when smooth foods
were introduced. She didn’t chew very effectively and “pocketed” foods in
her cheeks. Several very subtle gags were noted, as was a hypoactive gag
response during an inter-oral examination.
Observation during play suggested poor quality of movement. A sensory
history was taken and a developmental observation was completed which
revealed significant sensory processing difficulties, inability to move in
flexion, and poor oral motor skills. A diagram of Charlotte’s feeding behaviors
includes:
food textures = discomfort
swallowing = gag/panic
eating = gag/panic/discomfort
refusal behaviors=attention/toys/escape
For Charlotte, as with many children, there were sensory and physical reasons for
her food refusal. At the same time, her caregivers had adapted to her behavior in a
way that provided for environmental reinforcement for her food refusal. Once again,
104 Nutrition Interventions for Children With Special Health Care Needs