“Just take a bite!”Just take a bite!” Is keeping a child at theIs keeping a child at the table during mealtimestable during mealtimes REALLY the best way to getREALLY the best way to get them to eat?them to eat?

Our clinical questionTo increase feeding outcomes for children with fussy eating, is escape extinction more effective than other interventions?... To increase feeding outcomes for child

“Just take a bite!”

Is keeping a child at the

table during mealtimes

REALLY the best way to get

them to eat?

Evidence Based Practice, Feeding Disability

Who are we?

Why 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 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 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 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.

Includes

Physical 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)

 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.

 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

 It does not compare the effectiveness of each of

the treatment elements (e.g EE vs punishment,

Limitations and Strengths of the articles within the Systematic

 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

articles we found against

systematic literature review

to refine list to articles to

answer our question.

What other interventions are there? 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 (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 - 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)

Approach 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 feeding

2. Systematic desensitisation is the best first approach to feeding rx

3. Typical feeding development gives the best blueprint for rx

4. Food choices play an important role in feeding treatment

 General Treatment Strategies:

1. Social Modeling

2. Structuring Meal/Snack Times

3. Reinforcement

4. Accessing the Cognitive

 No published research available but is currently being conducted by Children’s

Nutrition Research Centre, QLD

Clinical Bottom Line

effective in improving intake in

children with severe feeding

disorders The most common

interventions use a combination

of behavioural strategies.

with other behavioural

techniques was the most widely used and successful approach.

EE and Workplace Policies &

Procedures

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 (NSW Disability Services Act 1993)

Standard 3  - Decision making

Nutrition & Swallowing Policy

“Balancing tensions between

individual choice and duty of care” pp6-7

Behaviour Support Policy

(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

Package June 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

Package June 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

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.”

collected data from therapists to

review what interventions they were mostly likely to use for our paediatric feeding clients

we could only view 100 responses due

to account limits on survey monkey.

Participants and workplace

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

Case Study 1: 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 until they take a bite What other strategies would you suggest to Mrs

Mack? You could select more than one answer.

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 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

Consulting the EBP triangle

Current Best Evidence

Clinical Expertise Client/Patient Values

Next year for paed feeding

(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)

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