Nutrition Interventions for Children with Special Health Care Needs

Section 2 - Problem-Based Nutrition Interventions
Reinforcement is most powerful when it is delivered instantly. If escape is provided
quickly when the child exhibits the targeted behavior, the behavior following the
target behavior (which may be an avoidance response such as crying, head turning,
or gagging) is not reinforced.
As a general rule, reinforcement should be five times more powerful than the
targeted behavior. Implementing this can be somewhat subjective. The reinforcer
can be made to last five times longer, or it can be delivered with a great deal of
enthusiasm, or the quality of the reinforcer can be increased. However, a child should
not struggle for three minutes to swallow a new taste or texture and then be given
only a five second interval of reinforcement in the form of social praise.
Once the child exhibits the first targeted behavior without hesitation, on eight out of
ten trials, for three consecutive sessions, it is time to change the targeted behavior.
A trial may last only seconds or the entire length of a session. A session may last
from 3 to 30 minutes depending on the targeted behavior. Perhaps the first targeted
behavior was to accept touch from the therapist’s finger to the lips for five seconds.
The second targeted behavior may be to increase the duration of the touch, or it may
be to move the touch from the lips to the teeth, or it may be to have the child accept
the same touch from the parent (1).
The protocol above is a simplified explanation of what an effective intervention
might look like. Developing such a program should be done with the collaboration
of a behaviorist experienced in treating feeding dysfunction. A quick behavior plan
checklist is included in Table 7-3 to help evaluate whether or not the most obvious
needs are included in an intervention plan.
It is important to note that, for some families, carefully designed intervention
strategies and adequate training in their implementation are not sufficient.
Sometimes there are significant family dynamic issues that prevent the parent from
having the ability or motivation to follow through with recommendations. Other
times, a parent is motivated to maintain the current situation for reasons outside
the feeding arena. In these situations there are usually multiple difficult behaviors
present in the environment and multiple providers frustrated with an inability to
make progress in any area of concern. With these circumstances, we have found
it most effective to refer the family to a counselor or a social worker with a family
therapy approach to deal with other underlying issues. Most family counselors and
social workers utilize a family systems or cognitive-behavioral approach which is
different from the applied behavior analysis and functional assessment approach.
Once the family is more stable, a highly focused behavior approach can be used
to address the specific behaviors causing feeding dysfunction. A skilled pediatric
psychologist with expertise in feeding may be able to provide intervention that
Nutrition Interventions for Children With Special Health Care Needs 113