““Just take a bite!”Just take a bite!”Is keeping a child at the Is keeping a child at the table during mealtimes table during mealtimes

REALLY the best way to get REALLY the best way to get them to eat?them to eat?

Evidence Based Practice, Feeding Disability

Who are we?Who are we?

The 2011 group is comprised of:9 speech pathologists from ADHC and

Cerebral Palsy Alliance1 occupational therapist from ADHC

Why did we include an OTWhy did we include an OT

This is the first year a professional outside of speech pathology has been involved in the EBP network.

The purpose was to: Widen our access to resources Widen the field of experience to those who have

trained experience in people with sensory processing disorders

A genuine interest by the occupational therapist to support her professional development and use of EBP.

Our Clinical questionOur Clinical question

Began with searching for the best intervention strategies for supporting fussy feeders.

20 articles

Our initial search, developed our interest in the strategy of Escape Extinction/ new direction for our EBP

Our clinical questionOur clinical question

To increase feeding outcomes for children with fussy eating, is escape extinction more effective

than other interventions?

To increase feeding outcomes for children with fussy eating, is

escape extinction more effective than other interventions?

1. What is the current best evidence?

Engaging in EBP to learn more about EE.

2. What does our clinical expertise tell us? Look at our policies and procedures Survey current practice

3. Where do client values fit in with this topic?

Discussing and considering how families may view EE.

Escape Extinction Escape Extinction

‘Escape extinction is a term that has been used to describe procedures that prevent the child from escaping the feeding situation’ (Piazza et al, 2003). Goal is for the child to no longer be able to use inappropriate behaviours to escape the mealtime. It is Often used in combination with reinforcement procedures.

IncludesPhysical guidance When a bite is not accepted, gentle pressure may be applied to the mandibular

joint, physically guiding a child to open their mouth so food can be deposited inside (Ahern et al, 1996)

Non removal of the spoon ‘Consists of a feeder presenting a bite of food on a spoon in that position until

the child consumes the food.’ (Tarbox et. al 2010 pg. 223)

Method A Systematic review of the literature for treatment

of paediatric feeding disorders.

Inclusion criteria: An experimental design with a control group. Published in an English language peer-reviewed journal

between Jan 1970 and June 2010. Evaluated intervention for children with a severe feeding

disorder. Intervention aimed at improving solid food intake. The dependent variable was a measure of food intake

(e.g. acceptance, grams). The children did not meet the DSM-IV criteria of an eating

disorder.

Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Paediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-365.

……Sharp et al. 2010Sharp et al. 2010

Method (continued) The articles were then classified based on their:

Treatment elements. Setting. Primary therapist. Generalisation.

Statistical analysis Percentage of non-overlapping data (PND) and non-

overlap of all pairs (NAP) used to evaluate the effectiveness of treatments.

Out of 124 possible studies, 48 met the criteria.

All of the studies emphasised behavioural interventions: Escape extinction was the most widely used (83%) - non-removal of the

spoon was used in 48%, a prompt to open the mouth if the bite was not initially accepted was used in 21% and non-removal of the food was used in 25%.

Differential reinforcement (reinforcement of acceptance) was the second most-common intervention strategy implemented (77%).

10% of studies involved punishment-based procedures. 90% of studies involved more than one element in a “treatment

package”.

Acceptance of food into the mouth was the most frequent measure of food intake (72.9%). Swallowing the bite was used as an outcome measure in 27% of studies.

PND and NAP scores (M=88%) put the behavioural interventions as a whole into the effective treatment range

……Sharp et al. 2010 Sharp et al. 2010

Strengths It is a systematic review. Good statistics, scientific principles Multidisciplinary

Limitations It does not compare behavioural interventions to non-

behavioural interventions. It does not compare the effectiveness of each of the

treatment elements (e.g. EE vs punishment, EE vs reinforcement schedules).

It is only relevant for children with severe feeding disorders.

Strengths and Limitations of Strengths and Limitations of the Systematic Reviewthe Systematic Review

Limitations and Strengths of the Limitations and Strengths of the articles within the Systematic articles within the Systematic

ReviewReview Strengths

Some follow up on effectiveness of parent training

Limitations Long term follow up in the articles (5, 10 years

later??) Some articles did not appear to look at

generalisation – training of the parents, follow up at home, family views/perspectives, qualitative data

……back to our question back to our question

We cross referenced initial articles we found against systematic literature review

Developed selection criteria to refine list to articles to answer our question.

No Clear comparison between EE vs other

methods in our available articles.

Outcome measures used inconsistent across our

articles.

What other interventions are there?What other interventions are there?What is the evidence for these?What is the evidence for these?

No published studies to compare the clinical efficacy or cost effectiveness of interventions for assisting children with feeding difficulties and/or a limited dietary intake.

Other interventions for children with feeding difficulties include:

- Graz Model (EAT and No-tube program)

- Sequential Oral Sensory (SOS) Approach to Feeding

Graz Model Graz Model (EAT and No-tube program)(EAT and No-tube program)

Developed by Professor Marguerite Dunitz-Scheer and Professor Peter Scheer from University of Graz

Psychosomatic approach that aims to remove the tube and for the child to sustain themselves in a nutritionally sufficient way

Three week intensive course with three different ways of participating (NET coaching, Outpatient or Inpatient)

Fast reduction of tube feeds under medical supervision

Interdisciplinary therapy sessions with specific therapy around food

Daily play picnic, a specialized eating therapy based on psychoanalytical nondirective play therapy with various kinds of food.

Graz Model - EvidenceGraz Model - Evidence

Level IV Evidence, Case Series

tube feeding with sufficient oral feeding after treatment (defined as the child’s ability to sustain stable body weight by self motivated oral feeding).

92% were completely and sufficiently fed orally after treatment. Tube feeding was discontinued completely within a mean of 8 days, the

mean time of treatment was 21.6 days. 6-8% could not be weaned and remained fully or partially tube fed. These children deemed “not weanable” (i.e. children with tube primarily for

intake, most children with severe disabilities, hx aspiration, lack of mobility and independence)

Limited long term data.

Sequential Oral Sensory (SOS) Sequential Oral Sensory (SOS) Approach to FeedingApproach to Feeding

Designed to ax and address all factors involved in feeding difficulties 4 Major Tenets:

1. Myths about eating interfere with understanding and treating feeding2. Systematic desensitisation is the best first approach to feeding rx3. Typical feeding development gives the best blueprint for rx4. Food choices play an important role in feeding treatment

General Treatment Strategies: 1. Social Modeling2. Structuring Meal/Snack Times3. Reinforcement4. Accessing the Cognitive

No published research available but is currently being conducted by Children’s Nutrition Research Centre, QLD.

Clinical Bottom LineClinical Bottom Line

Behavioural interventions are effective in improving intake in children with severe feeding disorders. The most common interventions use a combination of behavioural strategies.

Escape extinction in combination with other behavioural techniques was the most widely used and successful approach.

EE and Workplace Policies & EE and Workplace Policies & ProceduresProcedures

ADHC Policies Disability Service Standards (NSW Disability

Services Act 1993) Nutrition and Swallowing Policy (Amended Sept 2010)

Nutrition and Swallowing Decisions about Nutrition- attachment (Sept 2010) Nutrition in Practice Manual (Oct 2003)

Behaviour Support Policy (Jan 2009) Behaviour Support Policy and Practice Manual (Jan 2009)

Speech Pathology Practice Package (June 2010)

What do your policies and procedures reflect?

Disability Service Standards Disability Service Standards (NSW Disability Services Act 1993)(NSW Disability Services Act 1993)

Standard 3  - Decision making & choice

"Each person has the right to make their own decisions wherever possible and have choice “

Nutrition & Swallowing PolicyNutrition & Swallowing PolicySeptember 2010September 2010

“A prevention and risk management approach to individual nutritional health is required.” pp5

“Balancing tensions between individual choice and duty of care” pp6-7

Behaviour Support Policy Behaviour Support Policy (Jan 2009)(Jan 2009)

“The Department promotes a positive approach to behaviour support, based on comprehensive assessment and analysis of the meaning and function of behaviour in a whole-of-life context. The aim of positive approaches to behaviour support is to provide a respectful and sensitive environment in which the Service User is empowered to achieve and maintain their individual lifestyle goals.” pp7

Speech Pathology Practice Speech Pathology Practice Package Package June 2010June 2010

Eating Behaviour Problems: Practice Manual from the Centre for Child Community Health 2006 “Appropriate and successful eating in children also

demands a division of responsibility. Parents choose food that is safe and appropriate for the child, offer it in a positive and supportive fashion and allow the child to determine how much and even if he or she will eat at all.” pp12

“Encouraging children to experience new foods is assisted by familiarity and lack of pressure to eat.” pp16

“Bribery is counterproductive.” pp16

“Allowing the child to maintain control of intake may have important long-term positive health implications.” pp16

Speech Pathology Practice Speech Pathology Practice Package Package June 2010June 2010

Eating Behaviour Problems: Practice Manual from the Centre for Child Community Health 2006

“Interventions that have been most successful in promoting healthy eating behaviours in children include:

Repeating the exposure of a new or novel food to improve acceptance through increased familiarity

Modelling behaviours, that is, parental and peer consumption of a food increases consumption and preference of it by the child

Allowing the child to determine (control) how much food is eaten from a selected menu, which results in consistent and adequate energy intake despite meal-to-meal variation in intake

Ensuring that the social context in which food is offered is one that is likely to increase preferences for a variety of foods, including new foods

Making positive statements to encourage the child to taste novel or new foods.” pp28

Speech Pathology Practice Speech Pathology Practice Package Package June 2010June 2010

Expanding Children’s Diets by Suzanne Evans Morris 2009

“Children need to learn about new foods in an unthreatening way…Mealtimes frequently are associated with expectations for eating and drinking. Many children are on guard and spend a great deal of energy protecting themselves from new sensory experiences that feel dangerous. Comfort and safety are the most important aspects of the mealtime. When children feel safe and comfortable, they are more willing to risk and participate in new experiences.”

SurveySurvey

In following the E3BP model we collected data from therapists to review what interventions they were mostly likely to use for our paediatric feeding clients.

115 responded to the survey however we could only view 100 responses due to account limits on survey monkey.

Participants and workplaceParticipants and workplace

60%

29%

11%

SpeechPathologist

OccupationalTherapist

Psychologist

0

10

20

30

40

50

60

70

NSW Health Ageing Disability and HomeCare

Non-GovernmentOrganisations

Private Practice Other

Workplace

Nu

mb

er o

f p

arti

cip

ants

Ella is a six year old girl with autism. She is a fussy eater and will only eat white Ella is a six year old girl with autism. She is a fussy eater and will only eat white food. Her mother would like for Ella to eat all the food presented to her at each food. Her mother would like for Ella to eat all the food presented to her at each

meal. Which of the following strategies are you meal. Which of the following strategies are you MOSTMOST likely to recommend? likely to recommend?

0

10

20

30

40

50

60

Keep Ella at the table untilshe finishes her meal

The whole family eattogether to provide modelling

Introduce non-preferred foodsto Ella in play activities

Using a first, then chart toencourage her to eat non-

preferred foods followed by areward

Skipped question

Intervention options

Nu

mb

er o

f re

spo

nse

s

Case Study 1: Case Study 1: Mrs Mack (teacher) reports that the only way she can Mrs Mack (teacher) reports that the only way she can get one of her students to eat, is by holding a spoon in front of them get one of her students to eat, is by holding a spoon in front of them

until they take a bite. What other strategies would you suggest to Mrs until they take a bite. What other strategies would you suggest to Mrs Mack? You could select more than one answer.Mack? You could select more than one answer.

3%

19%

16%

15%

17%

10%

18%

2%For her to continue to use hercurrent strategies

Involve the student in mealtimepreparation

Offer the student more choices atmealtime

Increase opportunities for thestudent to engage in "messy play"with real food

Encourage the student to engagein pretend play with food items(eg: feeding dolls)

Use a reward system (eg: aftereach bite of food the student canaccess a preferred activity)

Increase opportunities for thestudent to observe other studentsand the teacher eating

Skipped question

What about What about Client/Patient Values?

Possible that escape extinction has already been trialled by parents prior to intervention from trained therapists

Possible that that clients have already associated “negative” feelings around mealtimes/food intake.

Parents sharing their own experiences and learning from other parents who may have a typically developing child.

For our own children/grandchildren, it is possible we have implemented escape extinction techniques and observed some success without even realising it.

What about What about Client/Patient Values?

Does the ADHC practice package allow therapists implement escape extinction?

Does the Disability Services Act (1993) support the use of escape extinction?

Restrictive practice guidelines Ethics – do we feel comfortable making

recommendations using escape extinction? What if the child is malnourished and the family is

desperate? Comparison to medications which are sometimes forced to

be consumed? Is it ethical to withhold a treatment that has proven to be

effective? Do we use some of the concepts within our daily lives?

Consulting the EBP triangle Consulting the EBP triangle

Current Best Evidence

Clinical Expertise Client/Patient Values

(ASHA, 2004)

Escape extinction combined with other therapy techniques seem to achieve the

‘best’ results.

Are we comfortable with recommending escape extinction for children who are regarded as fussy eaters?

I just want my child to eat so their

nutritional needs are met and I want this to happen in

the easiest possible way!

In 2012…In 2012…

Meetings will rotate between ADHC Metro South offices.

Please contact: Emma Minchin

emma.minchin@facs.nsw.gov.au8344 2700

Tsen Levsentsen-aie.levsen@facs.nsw.gov.au9701 6300

Next year for paed feeding Next year for paed feeding (disability)(disability)

•Transitioning from a gastrostomy to oral feeds

•Efficacy of specific therapy approaches (e.g. SOS)

•Group therapy for problem feeders

•Laura Mobbs (ADHC, Penrith)

•Tsen Levsen (ADHC, Burwood)

•Emma Minchin (ADHC, Rosebery)

•Rachel Cummins (ADHC, Rosebery)

•Kylie Ryan (ADHC, Hurstville)

•Jean Chan (ADHC, Rosebery)

•Katharine White (ADHC OT, Rosebery)

•Maria Andreadis (ADHC, Fairfield)

•Amanda Khamis (Cerebral Palsy Alliance, Kingswood)

•Jill Rosen (former member from ADHC)

ReferencesReferences

Ahern et al (1996) An alternating treatments comparison of two intensive interventions for food refusal, Journal of Applied Behavior Analysis 29 (3), pp 321-332

Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M. (2006). Tube weaning according to the Graz Model in two children with Alagille syndrome. Pediatric Transplantation, 10, 934–937.

Piazza.C.C, Patel. M.R, Santana. C.M, Goh. H.L, Delia. M.D & Lancaster. B.M (2002) An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavioural Analysis, 35(3), 259-270.

Sharp, W.G., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010). Paediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348-365.

Tarbox J., Schiff A., Najdowski A. C. Parent-Implemented Procedural Modification of Escape Extinction in the Treatment of Food Selectivity in a Young Child with Autism. Education and Treatment of Children, 33.2 (2010): 223-234.

Thomas T, Dunitz-Scheer M, Kratky E, Beckenback H and Scheer P (2010). Inpatient tube weaning in children with long-term feeding tube dependency: A retrospective analysis. Infant Mental Health Journal, 31(6), 664–681.

Any questions?

By Lauren Child