Nutrition Interventions for Children with Special Health Care Needs

Chapter 9 - Behavior Issues Related to Feeding
Understanding contingent attention is simple. Using it correctly, however, is more
difficult than it first appears. It goes against the typical parenting response, which is
to instruct, explain, remind, and encourage. Few parents or professionals are able to
master the subtleties of delivering contingent attention accurately without hands-on
training.
Escape-Maintained Behavior: quantifying the task, breaking the task down
into manageable steps, building behavioral momentum, reinforcing with
escape, adding attention and/or tangible reinforcers, extinguishing escape.
Escape must be extinguished. This entails ensuring that avoidance behaviors do not
result in a delay or removal of the task demand. If touch to the lips is the targeted
behavior, the therapist’s finger must remain on or near the lips even during head
turning. If a bite of food is presented, it is not removed until a bite is taken. This
is only possible when the target behavior is a very small step up from a previously
mastered behavior. The child should find that compliance with the task demand
is easier than waiting, and that the reinforcer is powerful enough to override the
conditioned aversion.
Using escape extinction in isolation can trigger intense anxiety and a fight or flight
response on the part of the child. Escape extinction should only be implemented
within the context of a complete intervention package which includes a functional
assessment, task analysis, targeted replacement behavior, an intense reinforcement
plan and behavioral momentum paradigm (9).
Since escape is a likely reinforcer for many children who engage in food refusal, it
is important to demonstrate to the child in a concrete way, exactly what is required
to gain escape. This is called quantifying the task. If the child is cooperative,
therapists tend to try to get “just a little more” progress. This punishes the child
for cooperating. A more effective approach is to make the goal very small and
attainable, and then indicate to the child how long, or how often she must exhibit
the behavior to gain escape. Singing a phrase from a song while providing oral
stimulation indicates that the task is over when the song phrase is over. Stopping
at the end of the song builds confidence in the child that escape can be attained
through cooperation fairly easily. Using a timer, singing, and counting are all methods
of quantifying the duration of a single task. Always stopping a trial at the expected
interval builds predictability and therefore, cooperation in the child.
If the goal is to have the child touch a food item, the therapist can have a plate
clearly visible to the child, with a small number of pieces of food. The food item is
removed as soon as the child touches it.
112 Nutrition Interventions for Children With Special Health Care Needs