STATISTICS REGARDING THE SOS APPROACH TO …sosapproach-conferences.com/wp-content/uploads/SOSstatistics6.pdfStudy 5 – Owen et.al. (2012) Documentation of the importance of the Parent

STATISTICS REGARDING THE SOS APPROACH TO FEEDING

PROGRAM

Copyright 2017 - Kay A. Toomey, Ph.D.

Study 1 – Creech (2006)

Documentation of changes in maladaptive and adaptive mealtime behaviors using the SOS Approach to Feeding program



Erin Creach, MA., CCC-SLP (2006) – unpublished dissertation study

• 10 children – ages 17-31 months• Each participant was presented with the same seven foods in a

pre-test and a post-test assessment session. Foods were presented by the parent in front of the child, in the same way as what they would typically do at home, for 1 minute.

• 7 sessions of structured SOS Therapy. • Video tape review of adaptive and maladaptive behaviors before

and after treatment• A behavioral coding scheme was developed to identify

categories of behavior including desired behaviors, non-desired behaviors, and neutral behaviors. Frequency counts of the observed behaviors were used for comparison and analyzed using a repeated-measures, one-tailed t-test.



Creech Study Results:

• Significant increase in positive mealtime behaviors (p<.006)

• = smiling, positive vocalizations, interaction with caregiver

• Significant increase in food interaction (p<.002).• = touch, stir, pick up

• No significant differences were seen in self-feeding (p<.079).



Creech Study Results:

• Significant decrease in negative mealtime behaviors (p<.001)

• = crying, trying to get out of chair

• Significant decrease in sensory responses (p<.003)

• = gagging, vomiting, finger splay, hand retraction

• Significant decrease in food rejection (p<.003)• = throwing, pushing away, turning head away


Study 2 - Boyd

• Documentation of significant increases in the range of foods children learn to eat using the SOS Approach to Feeding program.

• Identifies how long children take to graduate from treatment who only receive Group Therapy


Kim Boyd (2007) Doctoral Dissertation“The Effectiveness of the Sequential Oral Sensory

Approach Group Feeding Program”.

• Published in Dissertation Abstracts (2007)• Colorado School of Professional Psychology

• N = 37 children who had diet histories at the start and end of each round of Group therapy

• 12 sessions of Group therapy scheduled• Ages = 18-61 months; mean age = 37 months• Diagnoses = G-tubes (19%); GER (43%); Oral motor delays (97%),

low muscle tone (68%); sensory problems (84%); food sensitivities (38%); additional medical/learning diagnoses (41%) eg. Cardiac, autism, genetic disorder, pulmonary disease)


# of rounds of Group attended (Boyd) –3 rounds of 12 sessions of Group conducted per year

17 of 37 children graduated after one 12 week program = 46% (54% went on for additional therapy)

8 graduate after completing 2 - 12 week programs= 21%

5 graduate after three 12 week programs = 13.5%

4* graduate after four 12 week programs = 11% *these children had Gtubes

1* graduate after five 12 week programs = 3%

2* graduate after six 12 week programs = 5.5%


Boyd (2007) –Number of New foods

• Study reviewed 3 Day Diet Histories completed at approximately Sessions 1 and 12 of each round of Groups attended

• The number of new foods was counted from the Evaluation diet history to the end of the first round of Groups attended, and then between each additional Group attended and the previous round of Groups attended

• The number of DIFFERENT foods listed on the 3 Day Diet Histories was also compiled across ALL the diet histories completed


Boyd (2007) – Number of New foods

% Increase from Evaluation to end of Group #1 = 41%Mean # of foods at Evaluation = 19

Mean # of foods ON Diet History at end of Group 1 = 27

% Increase from end of Group 1 to end of Group 2 = an additional 17%

Mean # of foods ON Diet at end of Group 2 = 28

Mean # of foods ON Diet at end of Group 3 = 30


Boyd (2007) –Composite # of New foods

Time Point # of DIFFERENT Foods listed on Diet HxEvaluation 19End Grp 1 43 Cummulative # of End Grp 2 63 different foodsEnd Grp 3 82 consumed as listedEnd Grp 4 102 on 3 Day Diet Histories

*duplicated foods from one Diet History to the next were eliminated and not counted


Boyd (2007): Increases in Variety of different foods

• From Evaluation to end of Group 1 = 126%

• From end of Group 1 to end of Group 2 = 45%

• From end of Group 2 to end of Group 3 = 31%


Study 3 – Grey et.al. (2010)

• Documentation of improvements in maladaptive behaviors at mealtimes using the SOS Approach to Feeding program.

• Documentation of improvements in parental stress during mealtimes with the SOS Approach to Feeding program.


Grey, R., D’Andrea, T. & Westlake, K. (2010)

• Using the “S.O.S. Approach” at Trillium Health Centre, The Feeding News, 5(1), 1-3.

• SOS Approach to Feeding groups begun in 2008 – 8 sessions per group

• 3 groups per year for 2 years (= 6 groups)


Grey, R., D’Andrea, T. & Westlake, K. (2010)

• Demonstrated on a combined goals/progress data form, the SOS grid and the BPFA scale– Movement up the Steps to Eating Hierarchy– Decrease in parent reported stress– Increase in parent reported enjoyment of meals– Move scores on the Behavioral Pediatric Feeding

Assessment (BPFA) into the normal range (Crist and Napier-Phillips)


Study 4 – Toomey & Ross (2011)

• Documentation of improvements in growth using the SOS Approach to Feeding program

• Documentation of amount of time to transition off G-tubes onto an age appropriate diet (not just fluids or just fluids + purees) of textured table foods


Kay A. Toomey & Erin Sundreth RossSOS Approach to Feeding (2011)ASHA Perspectives on Swallowing and Swallowing Disorders (Dysphagia), Volume 20 (3), pp. 82-87.



SOS Approach Review of Group Therapy: n = 46 (non-GTube fed)

2000-2005 = time period of study• Children in Feeding Group = across 3 months

• Once per week sessions - 12 total sessions - 1.5 hours each

• Average weight gain = 1 pound• Average height gain = 1 inch

• Typically in children without weight or height gain for the previous 3 months.

– Data also presented at Society for Developmental and Behavioral Pediatrics (2005)



SOS Approach Review of Group Therapy: n = 19

(internal audit of Group children transitioned off their tubes – 2000 to 2005)

• Average for children transitioning off G-tubes, who entered Feeding therapy with some oral intake = 12 months from start of treatment; depending on age and step on Eating Hierarchy at which child started (n = 8)

Transition onto age appropriate table food diet. Treatment no longer needed once skills are achieved as G-tube can

be removed cost for 1x per week therapy for 12 months = approximately $9,500

for individual and $4500 for groups



SOS Approach Internal Audit

• Average for children transitioning off G-tubes who start at Step 1 on Hierarchy = 24 months (n=11)

• Transition off tube onto age appropriate foods– cost for 24 months of Group = approximately $9,000;

and 24 months of individual = about $19,000


Study 5 – Owen et.al. (2012)

Documentation of the importance of the Parent Education component of the SOS Approach to Feeding program


Owen, C., Ziebell, L., Lessard, C., Churcher, E., Bourget, V., Villenueve, H. (2012).

• Interprofessional group intervention for parents of children age 3 and younger with feeding difficulties: Pilot program evaluation

• Nutrition in Clinical Practice, 27 (1), pages 129-135.

• N = 30; 22 boys and 8 girls• Mean age = 26 + 8.2 months; range = 14 – 45

months• 4 session + 1 month follow up• Children with oral-facial malformations, severe

developmental disabilities, or medical problems directly affecting oral feeding were excluded



• Parent Education program based in part on the SOS program– Importance of mealtime environment– Understand predispositions to prefer or reject basic tastes– Steps to learn to eat– What are social contexts of eating

• 120 minutes initial parent education, then • 4 ninety minute “treatment” sessions across next 2

months• Sessions run by OT and Psychologist • Speech Pathologist and Dietitian also included in

some sessions



• Session #1: identify parental concerns re: their child, discuss impact of feeding problems on families, set goals, discuss feeding strategies

• Session #2: nutrition guidelines, how to introduce new tastes and textures, how to use strategic attention at mealtimes

• Session #3: group picnic • Session #4: communication and oral motor development

reviewed• One month break then • Follow up Session: discussion of status, progress and how to

prevent regression/relapse. Referral out if more therapy needed.



• Behavioral Pediatrics Feeding Scale –– 117 score before intervention; 106 after ; p = .001– Frequency of child problems = 9.7 before vs 7.4 after ; p = .05– Frequency of parent problems = 4.1 before vs 2.7 after ; p = .01

• Increased acceptance of food from each of 4 food groups• Parents reported –

– Initial difficulty implementing interventions, but ultimately achieved results

– Increased confidence – Decreased stress – Liked group support, but wanted more individualized attention

for their child


Study 6 – Benson et.al. (2013)• Documentation of the use of the SOS Approach to

Feeding program across 2 school years in a school for children with severe developmental delays

• Mixed results felt to be due to: – Incorrect inclusion of outliers in statistics– Lack of parent involvement– No treatment over the summer months

• Documents the importance of parent education component of the SOS Approach to Feeding (or rather the lack thereof)


Benson, J.D., Parke, C.S., Gannon, C., Munoz, D. (2013).

• A retrospective analysis of the Sequential Oral Sensory Feeding Approach in children with feeding difficulties. Journal of Occupational Therapy, Schools & Early Intervention, 6, 289-300.

• N = 34; very severely involved children treated in a school setting• Mean Age = 4.76 years; Range = 2.5 years to 7.67 years • Diagnoses: 38% ASD; 38% Neurological; 12% = Cerebal Palsy• Mean # of Sessions = 42; Range 3 sessions to 119 sessions

(outliers incorrectly included in data analysis)


Benson, J.D., Parke, C.S., Gannown, C., Munoz, D. (2013).

• 69% of children with neurological impairments demonstrated a consistent positive trend with regard to progressing up the Steps to Eating

• 39% of children with ASD showed a consistently positive trend upwards

• Totals: 47% no consistent positive trend; 53% with a positive trend

Problems with Study (beyond inclusion of outliers in stats):• No treatment over summer months; • Therapists changed from one school year to the next• Parent “education” incomplete at best; part of school

progress review


Study 6 – Menke & Pettit (2014)• Replication of growth outcomes reported by

Toomey & Ross 2011(in a different clinic not connected to the STAR Institute or Toomey & Associates, Inc.)

• Replication of increased food range as reported by Boyd 2007(in a different clinic not connected to the STAR Institute or Toomey & Associates, Inc.)

• Documentation of increases in adaptive mealtime behaviors AND skills (Goal Attainment Scaling)


Menke, C.E. & Pettit, K.L. (2014) • Effectiveness of Sequential Oral Sensory

Approach among Children with Food Selectivity

• University of South Dakota OT student project presented at the University of S.D. conference, April 2014

• N = 10; BUT project report is only on one child• 2 years of age to 3 years, 11 months• Have to have some oral feeding but can be on bottle,

breast or G-tube as primary calories • 10-12 sessions of therapy; 45 minute sessions; 1-2

sessions per week• Follow up at 6 months post treatment.


Menke, C.E. & Pettit, K.L. (2014)

One Child’s data presented as follows:• Weight gain = 1 pound; Height gain = 0.9 inches• Increased food repertoire by 20 new foods• Goal Attainment Scaling:

– Goal 1 = eats > 14 new foods (+2)– Goal 2 = touches mixed textured foods with whole

hand (+1)– Goal 3 = eats multiple bites of at least 2 new meat

items (+2)– Goal 4 = sits at table during family meal for at least 15

minutes (+2)Copyright 2017 - Kay A. Toomey, Ph.D.

Study 7 – Raja (2015) • Replication of importance of parent education

component of the SOS Approach to Feeding program reported by Owen et.al. (2012)

• Documentation of the effectiveness of the use of the General Treatment Strategies component of the SOS Approach to Feeding program

• Study conducted for National Health Initiative in the U.K.


Raja, Krupa (2015) University of London –caregiver workshop based on SOS

• Study is currently being written up for publication• 33 caregivers = teachers or support staff, parents/carers and other

education professionals participate in 6 hour workshop• Of 5-7 year-old children placed in a Special Needs School

environment with a diagnosis of Autism, Developmental Disabilities, Complex Needs

• Caregivers complete 3 questionnaires – #1 = 46 questions re: child’s Pre-Study environment/routines at

meals; level of independence/skills and food/drinks consumed; behaviors at meals; emotional well-being/quality of life; knowledge and confidence of caregivers re: feeding issues and managing feeding

– #2 = 11 questions re: caregivers’ new knowledge and confidence; effectiveness of workshop


Krupa (2015) University of London

• The third and final questionnaire consisted of 40 questions from questionnaire #1 + 20 questions re: Implementation and Caregivers’ Perception of Response to implemented guidelines. It was administered 6 weeks post training.

• Results:– Decreased use of distraction p = .001– Increased ability to participate in family style meals p

= .004– Increased independent finger feeding p = .003– Increased independent spoon use p = .000


Krupa (2015)• Increased independent straw use p = .02• Increased eating of balanced meals p = .02• Increased consumption of fruits (p = .000) and

vegetables p = .001• Increased sitting at meals (p = .01); decreased running

away (p = .006)• Decreased negative reactions to new foods p = .001• Decreased child emotionality and anxiousness at meals

p = .001• Decreased caregiver stress at meals p = .02• Increased caregiver confidence at meals p = .000


Study 8 – Marshall et.al. (2015) • Comparison of Systematic Desensitization and Operant

Conditioning for treating feeding problems– However, the Operant Conditioning protocol included a

component of allowing the child to move to a lower request level and a lower reward level (variant of Systematic Desensitization) versus being a true Flooding or Negative Reinforcement protocol

• SOS Approach to Feeding program chosen after one of the lead researchers conducted site visits and studied 22 feeding programs throughout the USA and Canada for a 9 month time period


COMPARING APPROACHES

Marshall, J., Hill, R., Ware, R.S., Ziviani, J. & Dodrill, P. (2015). Multidisciplinary intervention for childhood feeding difficulties. Journal of Pediatric Gastroenterology and Nutrition, 60(5), 680-687.

- The only randomized, well controlled study with professional therapists very proficient in each type of technique

- SOS training included attendance at a minimum of 2 SOS workshops, a week long visit to Denver and one year of clinical work using the program consistently


HELP study: Marshall, J. et.al. (2015)

• 10 therapy sessions• Graded sensory and oral motor tasks• Child intervention: Randomized to 1 of 2 therapy approaches

• Parent intervention:– Written information– Guided commentary (via CCTV)– Immersive practice (alternating sessions in room with child)

Systematic desensitization (SD)

Operant conditioning (OC)

Bottom-up Top-down

Model and play Prompt and reward

Internally driven Externally driven



• 3 groups of children (ages 2-6 years)– Medically complex (n = 26)– Autism Spectrum Disorder (n = 26)– Non-medically complex (n = 26)

• Parents chose Weekly (10 sessions, one per week) or Intensive (10 sessions in 1-2 weeks)

• 10 children from each subgroup (Systematic vs Operant) seen Intensively

• 16 children from each randomly assigned subgroup, seen weekly

• N = 68 children completed the studyCopyright 2017 - Kay A. Toomey, Ph.D.


Outcome measures

Assessments performed at baseline, end of treatment and 3 months post-treatmentFeeding assessmentParent-child interaction assessmentDiet historyFood frequency questionnaireAnthropometric assessmentBody composition assessment



– There were no significant differences in the 2 approaches in outcome, whether conducted intensively or weekly.

– When run to a protocol by an experienced multi-disciplinary team, in conjunction with parent training, both therapy approaches resulted in clinically significant improvements in: Dietary variety Mealtime behavior Parent confidence and perceived competence Parent stress


Study 9 – Suarez (2016)

• Documentation of the use of the SOS Approach to Feeding program combined with object reinforcement (positive reinforcement) and escape extinction (negative reinforcement)

• Direct documentation of generalization into the home setting.


COMBINING APPROACHES

• Suarez, M. (2015). Multicomponent treatment for food selectivity in children: Description and case report. Nutrition in Clinical Practice, 30(3), 425-431.

• 4 clients ages = 8, 7, 6 and 6 years old• # of foods at start = 12-14• All had sensory processing differences and/or sensory

sensitivity


Suarez, M. (2015)• Components of the treatment:

– Sensory integration (prep and as a positive reinforcement)

– Systematic desensitization (SOS Steps to Eating hierarchy)

– Positive reinforcement (sticker for achieving each step on the “Food Interaction Ladder”; which when completed earns a prize)

– Escape extinction (not allowed to get their “sensory break” unless achieved their pre-set goal for that food that week OR have to go on to the next food)


Suarez, M. (2015)

• Components of the treatment: – Parent education and home program (didactic

topics and goals to move up the Food Hierarchy ladder at home, with increasing challenges being set as each goal is met)

• Data Collected:– Food Inventory– Short Sensory Profile– Session data sheet (Food Interaction Ladder)


Suarez, M. 2015

• Graduation = 1 small bite of each family food presented at a meal, 90% of the time.

• Data:– Child 1 (ASD, ADHD) – 22 sessions to grad; went

from 12-19 foods in repetoire– Child 2 (premature) – 12 sessions to grad; went from

14 to 17 foods– Child 3 (no dx) – 10 sessions to grad; went from 14 to

15 foods– Child 4 (FAS) – 10 sessions to grad; went from 13 to

19 foods


COMPARISON SLIDES TO NEGATIVE REINFORCEMENT/FLOODING

PROGRAMS’ RESEARCH

– Beginning with early research into this type of feeding treatment, the language used to describe the approaches, the gradual inclusion of a multi-disciplinary team, and their outcomes



Data from Inpatient Programs: Negative Reinforcement

• Foy et al, (Infants and Young Children, 9, 26-35, 1997)

• 19 patients with NG and G-tubes• 3 weeks inpatient (at least 3 meals by

therapists/day) + 1x per week for 6-10 weeks• Results:

– 12 of 19 successful in transitioning off their G-tubes by last follow-up

– Range to transition off = 1-23 months– Mean = 7.6 months; median = 4 months


Force Feeding difference –pg. 33

• “ “Force feeding” suggests a strong emotional component, and an untrained feeder (or parent) may be angry, stressed, or anxious during the interaction. The program described here requires that the feeder be firm in behavior but calm emotionally.”

• “Feedings were done in the lap, with the child’s arms and legs restrained by the therapist if the child was struggling. … negative behaviors were ignored, and any positive behaviors…were praised” pg31



Foy et.al. (1997) • Children with G-tubes: mean = 10.8

months;• Failures = premature, developmentally

delayed, GER;

• Issue #1: Federal mandate for least restrictive environments (hospital, force feeding)

• Issue #2: All children placed on pureed foods (9-31 months = age of children) with no discussion of age transitions to age appropriate foods

Issues:• Issue #3: Cost (estimated cost for 3 weeks

inpatient stay + small amount of follow up= $15,600 at a minimum

– in 1997, a hospital day cost = $744.8 (Pfuntner et.al. 2012 )

• Willliams et.al. (2007) – indicated that the cost for an inpatient feeding program at their institution was $1,175/day– 12 children - $17,625 (15 days) to $51,700

(44 days) Copyright 2017 - Kay A. Toomey, Ph.D.

Copyright Copyright 2017 - Kay A. Toomey, Ph.D.2016 - Kay A. Toomey, Ph.D.

Flooding Procedures (Benoit & Coolbear, 1998)

• Study of 24 children; 17 weeks – 34 months of age• Food is placed on the lips or inside the child’s

mouth by adult• The adult actively helps calm the infant• 5-10 seconds later, more food is placed in the

child’s mouth if they swallowed the first bite. If they have not swallowed, an empty spoon is placed inside the mouth.

• This sequence is repeated every 5-10 seconds for 15-30 minutes; 3-4 times a day

Copyright 2016 -, Ph.D.

Benoit & Coolbear (1998)

• Protocol =1. placed on feeding schedule2. meals limited to 30 minutes3. no distractions allowed4. only water in between meals5. decrease tube feeds by 25%6. use flooding• 71 to 79% responded and achieved goals

pre-set before treatment (study does not document what these goals were)


Copyright 2016Copyright 2017 - Kay A. Toomey, Ph.D.- Kay A. Toomey, Ph.D.

Non-responders had significant scores for:

• Problems with chewing, sucking or moving the food placed in the mouth for more than 5 seconds

• Passively refusing to swallow the food placed in the mouth

• Lung or airway problems

Also had higher scores (although not significant) for:• Spitting out• Retching• Appearing to dislike eating

Benoit, D., Wang, E. & Zlotkin , S (2000)

• 64 children randomized into a nutrition advice treatment or a behavior treatment

• 32 children in each group• Ages 4 – 36 months; Mean = 17 months

• All tube feeds decreased by 25% before start• 7 sessions of intervention• All started on structured schedules and routines to

meals, no distractions, comfortable seating• All given same nutritional advice/week + if gained

weight => tube decreased by 25% more; if lost weight => tube increased by 25% more


Presenter

Presentation Notes

ADDED IN TUBE WEAN


• Behavior Treatment Group - received same nutrition advice and taught to use “flooding” = extinction => food was placed directly on the lips or inside of mouth, infant is calmed, new spoonful placed every 5-10 seconds despite distress. If infant did not swallow, an empty spoon was put into the mouth. Both completed regardless of gagging, although after gagging -> a dry spoon was put in mouth.

• In addition, 3-5 problem behaviors were targeted at meals and parents were taught techniques to eliminate these.


Presenter

Presentation Notes

Nutrition group – weighed and measured, given nutrition advice, if gained weight => tube further reduced by 25%, if lost weight => tube increased by 25%. Also, 47% were in Occupational Therapy


• Success = no tube use for 1 month by 8 or 14 week follow up visits

• 13% off tube by 2 weeks Follow up; 25% by 4 weeks, 47% in weeks 8 and 14.

• No data is released about children who did not transition off.

• No data was initially given as to what percentage of calories ingested were by oral versus tube feeding prior to start of the treatment.

• No follow up data is given.


Presenter

Presentation Notes

Drop out rate = 2 in behavioral group; 8 in nutrition Lack of attendance at 8 week follow-up by 6 of behavior group and 13 in nutrition group


• Parents had also completed a checklist of 30 Infant Feeding Behavior problems. There were no changes made in the Parents’ ratings of the presence of problem behaviors over the course of the program.

“it is possible that the behavioral intervention did not “cure” resistance to feeding…but rather gave the feeder tools to manage the problem” page 502


Operant Conditioning Techniques: (Williams et.al., 2007)

• N = 46• Median Age = 3 years 1 month; • Range = 16 months – 11 years• 24 days in a Day Treatment program on

average (x 3 meals/day = 72) @ a cost of $13,800 ($575/day)

• Range = 11 – 45 days (24 – 126 meals) @ a cost of $6,325 to $25,875


Williams et.al. (2007) – Operant techniques

• Contingency contacting = hold a bite/drink to mouth (escape prevention) until accepted, and then given a reward if accepted (positive reinforcement)

• Re-presentation = spit/vomited food is put back in the mouth (negative reinforcement)

• Swallow induction = a stimulus is applied if doesn’t swallow (positive punishment)

• Thermal stimulation = apply a cold stimulus to cause a swallow (positive punishment)

• Exit criterion = allow to exit once eat specified portion amount, and given a reward if “beat the clock”


Williams et.al. (2007) - techniques

• Texture Fading – start with purees/fluids and texture is increased

• Response cost for refusal – preferred activities removed for inappropriate feeding behaviors

• Differential reinforcement of other behaviors = given a reward if no vomiting occurs

• Token economy = earn tokens for appropriate mealtime behaviors

• Graduated guidance for self feeding = hand-over-hand then weaned

• Least to most prompts for self feeding = start with least prompts and increase


Williams et.al. (2007) - Results

• 67% weaned at end of Day Treatment program (11-45 days; 24-126 treatment meals)

• 30% had decreased tube feeds to 50% level• @ 1 year follow up – 63% weaned

– (6% relapsed to needing > 50% tube feeds• @ 2 year follow up – 74% weaned

– 6% still needing > 50% tube feeds


Inpatient Hunger Provocation(Kindermann et.al., 2008)

• N = 10 children• Ages = 9-21 months• 100% NG tube fed at start of program• Mean # days in hospital = 17.3; range = 9-33• All children’s tube feedings cut by 50% then stopped

after oral intake started (Day 4 to Day 24; mean = Day 9);

• Weight loss = 3.7% to 15.6% (mean = 9.2%) • All assessed by “multidisciplinary team” (no OT) and

SLP chooses foods appropriate for each child to be fed


Kindermann et.al. (2008)

• Fed 4-5 meals a day by a trained nurse. Only positive reinforcement was used and inappropriate behaviors were ignored.

– 1 of 10 children (10%) was dropped due to excessive weight loss

– 9 of 10 were discharged with no NG tube– 1 child immediately stopped orally feeding after

return to home and returned to tube feeding– 1 other children went back to partial tube

feedings within 4 months (22% relapse rate)


Multidisciplinary Inpatient Feeding Program(Cornwell, Kelly & Austin, 2010)

• N = 40; retrospective review (2001 to 2005)• Ages = 22 months to 7 years• # days inpatient = 46.43; range = 15 to 80 days• Average oral calories at start = 515; G-tube = 704 cals• G-tube calories decreased by 120 to 240ml’s (Hunger

Provocation)• RD oversees calorie additives and fluid supplements +

tube feedings only at night


Cornwell, Kelly & Austin (2010)

• Treatment included:– daily Speech Therapy (primarily oral stimulation)– 30 minutes of Sensory Therapy by an OTR 3-5 times

a week including Wilbarger protocol, tactile play and vestibular/proprioceptive exercises

• Feeding Treatment at 5 meals for 30 minutes by psychology or speech therapists (q 2 hours):– positive reinforcement = social praise, toy,video– extinction/negative reinforcement = non-removal of spoon,

planned ignoring• No caregiver in Phase 1; caregiver in other therapies in Phase 2;

caregiver in feedings in Phase 3; caregiver completes feeding in Phase 4


Cornwell, Kelly & Austin (2010)

• Oral calories after treatment = 898 (increased by approximately 383 calories on average)

• G-tube calories after treatment = 211 (decreased by 493 calories on average)

• 42.5% of the 40 children were fully weaned


REVIEW by Williams, Field & Seiverling (2010)

• Reviewed 38 Treatment studies of Food Refusal from 1979 to 2008

• 218 children across 38 studies (average = 5.7 children per study; range = 1 – 46; median = 3 children)

• 190 of 218 on supplemental tube feedings (87%)• 113 of 190 (59%) weaned from tube feedings by study

end = weeks to months depending on study

Copyright 2017 - Kay A. Toomey, Ph.D.Copyright 2017 - Kay A. Toomey, Ph.D.

Presenter

Presentation Notes

Treatment study

Published Studies to date primarily used “behavioral” techniques & small #’s

Williams et.al (2010)• 218 children across 38 studies (average = 5.7 children per study;

range = 1 – 46; median = 3 children)• Predominantly Single Case Study design• Of the 38 studies: 57% inpatient; 24% day treatment;

19% outpatient

“Behavioral” techniques used:• Positive reinforcement (97%)

– Food/drink reinforcers– Non-food reinforcers = objects, games/activity

Copyright 2017 - Kay A. Toomey, Ph.D.Copyright 2017 - Kay A. Toomey, Ph.D.

= Operant Conditioning techniques =

• Planned Ignoring (55%)• Escape prevention (60%)

– Return to chair– Force feeding– Physical guidance (therapist opens mouth)

– Non-removal of spoon– Re-presentation of food

• Stimulus fading (26%) = increase texture, texture fading, blending preferred + non-preferred


Inpatient “Behavioral Treatment” (Silverman et.al., 2013)

• 85 G-tube fed patients (2005-2009) started; 77 finished• 5 did not complete the program (1 left AMA or 4 -inability to complete protocol) =

6% and 3 discharged due to illness• Co-morbid disorders = 92% GI, 90% behavioral, 68% neurodevelopmental, 51%

cardiorespiratory, 22% upper airway anomaly, 17% allergic/immune, 16% sensory, 8% endocrine, 5% metabolic

• Average age = 4.5 years (range = 2.3 to 6.7 years)• Average duration of tube feeds = 3.7 years (range =

1.6 to 5.8 years)• Average oral intake at start = 28% (range = 0 to 113%) • Average oral intake at end of inpatient Therapy = 82%

(range = 12 to 167%)


Silverman et.al. (2013)

• Techniques = environmental manipulation, appetite manipulation (weight loss = 0-11% body weight; average = 4%), contingency contracting, re-presentation, texture fading, differential reinforcement of other behavior, positive reinforcement, gaze aversion

• 3 phases = 1. fed by therapists; 2. co-fed by therapists and parents; 3. fed by parents with therapists coaching via remote

• After 10 days intensive inpatient treatment, 51% were no longer using their G-tube. 12% more had transitioned off by a 1 year follow-up

• Parenting Stress Index showed improvement but not significant (p =0.086) from start of study to end


REVIEW by Lukens, C.T. & Silverman, A.H. (2014)

• Reviewed studies that were not single case design between 1998 and 2013.

• Only 13 studies met criteria for being randomized controlled trials (2 studies) or nonrandomized studies that examined aggregated outcome data

• 3 studies of children with ASD, 1 with children with CP and 9 of children with tube dependence


Lukens, C.T. & Silverman, A.H. (2014)

• 11 non-RCT studies: • Mean N = 54.5 (9 to 221)• Mean age = 3 years, 4.6 months• 82% used “behavioral” treatment • 54.5% used nutrition manipulation (e.g. cutting tube

feedings; scheduled meals)• 72.7% had some component of caregiver training• 45.5% involved oral motor therapy• 27.3% used “other” treatment strategies


SOS (2011): N = 19; 100% transitioned off(12 months to transition if some orals; 2 years to

transition if no orals). No relapses.

• Foy et.al (1997): N = 19; Inpatient - 63% transitioned off by 2 years (mean = 7.6 months) => flooding

• Williams et.al. (2007): N = 46; 67% weaned off by Day 45 of day treatment stay; 63% at one year; 74% at 2 years (6% relapse) => negative reinforcement

• Kindermann et.al. (2008): N = 10; Inpatient - 90% off NG tube by Day 33; 70% at 4 month follow-up (20% relapse) => positive reinforcement with objects

• Cornwell, Kelly & Austin (2010): N = 40; Inpatient – 42% of orals already at start; 42.5% weaned off by Day 47

• Williams, Field & Seiverling (2010): Review 38 studies; N = 218; 59% weaned on average from months to years

• Silverman et.al. (2013): N = 77; Inpatient – 28% of orals at start; 82% = average oral calories at end of 10 days + 51% weaned from G-tube; 12% more weaned at 1 year follow up Copyright 2017 - Kay A. Toomey, Ph.D.

Peterson et.al. (2016) - Study which “disproves” SOS

• SOS protocol not followed correctly. Legal involvement required to get researchers to correctly say they were using a “modified” version of SOS.

• Study incorrectly assumed that SOS treatment should be concluded after 12 sessions. There is no limit set on the number of sessions. Each child progresses up the Steps to Eating on their own timeline.

• Outcome measure used for study (= eating 5 bites of targeted foods) is not appropriate to draw the conclusion that SOS doesn’t work

• SOS doesn’t teach a child to eat a specific food. SOS teaches children to eat all foods.

• The correct outcome measure would have been movement up the Steps to Eating hierarchy within a set time frame OR to look at the number of sessions required to eat a new food.


Peterson, Piazza & Volkert (2016)

A Comparison Of A Modified Sequential Oral Sensory Approach To An Applied Behavior-analytic Approach In The Treatment Of Food Selectivity In Children With Autism Spectrum Disorders. Journal Of Applied Behavior Analysis.49, 1–27

• 6 children with severe ASD, 4-6 years old• Randomly assigned to ABA or Modified-SOS• Had to take 5 bites of 3 Target Foods 80% of the time to

be successful• Target foods chosen by the child’s parents (different for

each child)Copyright 2017 - Kay A. Toomey, Ph.D.


• 12 sessions of 90 minute modified SOS • Because the children were not progressing

adequately per the researchers, two children were arbitrarily given 3 SOS sessions more, and one child was given 7 additional SOS sessions.

• At this point, the researchers concluded that modified SOS was not effective because children didn’t 5 bites of the 3 target foods (80%) in the arbitrary timeframes they set


HOWEVER

• The data from the study actually proved that the modified SOS program was working beautifully.ӿ One child advanced to touching one target food on

his teeth (15 sessions) = Step 24 ӿ One child advanced to touching one target food to his

tongue (19 sessions) = Step 25ӿ One child advanced to placing bites of target food

inside his mouth, but spit each bite (15 sessions) = Step 28



• The ABA therapy was considered effective in 12 sessions for one child, 9 sessions for another child and 16 sessions for another child (16 min, 54 min, and 249 minutes) because they ate 5 bites of the target food 80% of the time.

• The 3 children who were “unsuccessful” in modified SOS, then underwent ABA intervention. They accepted the 5 bites of one of the target food in 64 minutes (1 child), 15 minutes (1 child) and 39 minutes (1 child) of ABA

• 2 of these 3 children also ate bites of the other 2 Target Foods without intervention from the ABA therapist.


“One potentially important finding was that we observed treatment generalization for two of the three children who participated in M-SOS (….) when we subsequently implemented ABA. When we implemented ABA for one target food, they began to accept the other two target foods in the absence of treatment.”

“We did not observe a similar pattern of treatment generalization for children who received only ABA.”

Page 24


ABA protocolFood was put in front of the child and they were told to “take a bite”• If the child did not accept the bite within 8 s of presentation • (a) touched the spoon to the child’s lips;• (b) followed the child’s head with the spoon and held the spoon

touching the child’s lips if the child engaged in inappropriate mealtime behavior;

• (c) left the spoon touching the child’s lips if the bite of food did not remain on the spoon and the therapist needed to obtain another bite;

• (d) deposited the bite when the child opened his mouth; and • (e) held the spoon to the side of the child’s lips if the child vomited,

coughed, or gagged while the therapist was holding the spoon at the child’s lips.


ABA protocolCorrect spoon presentation also included when the therapist• (a) returned the spoon or bowl within arm’s reach if the

child moved the items out of arm’s reach, • (b) scooped up expelled food within 3 seconds of

expulsion and placed the spoon with the bite back to the child’s lips, and

• (c) re-presented fresh bites after an episode of vomiting


Communications/Articles mentioning SOS

• Angell, A. (2010). Selective Eaters and Tactile Sensitivity: A Review of Classification and Treatment Methods That Address Anxiety and Support a Child’s Need for a Sense of Control. Infant, Child, & Adolescent Nutrition, 2, 299-303.


Communications/Articles mentioning SOS

• Banotai, A. (2010). Complex Feeding Disorders, ADVANCE for Speech-Language Pathologists & Audiologists, Vol. 20, No. 24, pp. 6-8.

• Vestrheim, K. (2010). Til Bords Meds Suksess. HELSE i vest, Nr. 4, pp. 12-15. (This is a Norwegian Publication).
