Nutrition Interventions for Children with Special Health Care Needs

Chapter 9 - Behavior Issues Related to Feeding
Parents and professionals routinely and inadvertently reward non-compliance and
food refusal with attention, and punish compliance and food acceptance through the
withdrawal of attention (1).
2. Escape: the avoidance of a non-preferred task
Almost all children treated for feeding dysfunction have already developed refusal
behaviors. Avoiding something unpleasant is a powerful reinforcer. In many
situations, this escape, also called negative reinforcement, will maintain the
avoidance behavior regardless of how well contingent attention is utilized (3,4).
(Negative reinforcement is defined as increasing a behavior by removing something
aversive, contingent upon the occurrence of the behavior.) An illustration follows:
• Sarah turns her head when a spoonful of food is presented (food refusal)
• Mom removes the spoon, and removes a little of the food (escape)
• Sarah looks at mom again (pre-skill for feeding)
• Mom presents the spoon (punishment for looking at mom)
• Sarah turns her head again (food refusal)
• Mom coaxes Sarah (attention for food refusal)
• Mom takes Sarah’s chin and forces the food into her mouth (aversive
conditioning)
• Sarah swallows the bite (food acceptance)
• Mom presents another bite (punishment for food acceptance)
It is difficult to avoid reinforcing food refusal with escape. Force-feeding merely
increases the aversive conditioning. Allowing the child to avoid the food gives the
child escape, thereby reinforcing food refusal. When we tell a child, “You may leave
time-out when you are quiet,” we are using negative reinforcement (escape from
time-out) contingent upon the occurrence of the target behavior (quiet behavior) (3).
3. Tangible reinforcement of food refusal: providing an item or activity
when the child engages in avoidance of a non-preferred feeding task (1)
During feeding, this type of reinforcement usually occurs in combination with escape
or attention. When a child refuses to eat, the parent allows her to leave the feeding
setting and then provides a comfort toy or a comfort food. For Ben, the tangible
reinforcer was a cloth diaper that he used as a security blanket. He had severe reflux
as an infant and the cloth diaper was used to clean his mouth. Every time the reflux
ended, the diaper was presented. He began to act as though the diaper caused
the reflux to end. During a reflux episode, he would reach for the diaper. Later, he
received a g-tube and a fundoplication. During any stress, including the presentation
of food, Ben reached for the diaper and covered his mouth with it. This diaper itself
106 Nutrition Interventions for Children With Special Health Care Needs