Nutrition Interventions for Children with Special Health Care Needs

Section 2 - Problem-Based Nutrition Interventions
both classical and operant conditioning were well established by the time the referral
was received. The next section will explore how Charlotte’s environment served to
strengthen her refusal behaviors, although it did not cause them.
Environmental Reinforcement
While there are often physical, medical, or sensory causes for a child’s initial food
selectivity and refusal, what happens in the environment as a result of that food
refusal is equally important. There are four environmental variables that tend to
maintain both positive and negative behaviors (1). By observing what happens
immediately before and after food refusal and food acceptance, we can begin to get
an idea of how these variables might be influencing behavior.
1. Attention as a reinforcer for food refusal
Although Charlotte had developmental and sensory reasons for avoiding food, other
variables were operating. Charlotte received more attention for food refusal than
for food acceptance. In the research literature, attention has been proven to be a
powerful reinforcer of both desirable and undesirable behaviors across many settings
and populations. Attention, for these purposes, is defined as eye contact, touch,
speech, or increased proximity. When Charlotte was being fed by her mother, the
following pattern occurred repeatedly:
• Mom puts the food on Charlotte’s tray (neutral)
• Charlotte turns her head (food refusal)
• Mom holds up the spoon and says, “Take a bite honey” (attention: eyes, speech)
• Charlotte turns her head (food refusal)
• Mom leans forward (attention: increased proximity)
• Mom looks, turns Charlotte’s chin back (attention: touch)
• Mom looks Charlotte in the eye (attention: eye contact)
• Mom says, “Take a bite honey” (attention: speech)
• This pattern is repeated several times (attention for food refusal)
• Charlotte takes a bite (food acceptance)
• Mom turns from Charlotte to reload the spoon (removal of attention)
Charlotte’s story is very common. The unintended misuse of attention contributes to
the maintenance of many feeding difficulties. Attempts at encouraging, coaxing and
reminding can all result in behavior that is maintained by high levels of attention.
Once the child takes a bite, parents tend to give themselves and the child a “break,”
thereby reducing attention for the very behavior they would like to see increased.
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