© Borgis - Postępy Nauk Medycznych 1/2013, s. 28-34
*Giovambattista Presti, Silvia Cau, Paolo Moderato
Zmiana nawyków żywieniowych u dzieci: podejście behawioralne
Changing the way our children eat: a behavior analytic approach
Istituto G.P. Fabris, Università IULM, Milan, Italy
Head of Department: Paolo Moderato, PhD
Mimo iż jedzenie jest zachowaniem potrzebnym do przetrwania, nie jest ono łatwo kontrolowane przez ludzi. Już we wczesnym dzieciństwie mogą pojawić się trudności związane z karmieniem i przyjmowaniem pokarmu, które polegają na niemożności lub odmowie spożywania wystarczającej ilości i jakości jedzenia, aby dziecko otrzymało odpowiednie składniki odżywcze. Problemy te można opisać jako nieprawidłowości w formie (częstość, czas trwania, szybkość, czas dnia) i zawartości (rodzaj jedzenia) łańcuchów zachowania związanych z jedzeniem. Do niepoprawnych zachowań związanych z karmieniem należą: odmowa jedzenia, ataki złości związane z jedzeniem, wybiórczość jedzenia, zbyt wolne lub zbyt szybkie jedzenie, wymioty, ataki kaszlu, sprawcze trzymanie zamkniętych ust w celu uniknięcia jedzenia. Trudności związane z jedzeniem można przypisywać wielu powodom, ale większość z nich wynika z interakcji elementów biologicznych i środowiskowych.
W obecnej pracy, omawiamy, w ramach podejścia behawioralnego, różnorodne strategie modyfikacji zachowań związanych z karmieniem i przyjmowaniem pokarmu przez dzieci. Krótko opisujemy jak analitycy zachowania konceptualizują problemy z jedzeniem, podajemy kilka przykładów interwencji ukierunkowanych na różne trudności związane z jedzeniem, a także nakreślamy główne założenia programu behawioralnego mającego na celu zwiększenie konsumpcji owoców i warzyw przez dzieci w wieku 2-11 lat, i – w związku z tym – zmniejszenie problemu otyłości dziecięcej.
Though related to contingencies of survival, eating is not an easily self-maintained behavior. A number of feeding and eating problems may arise early in a child life and are defined by his/her inability or refusal to eat or drink a sufficient quantity or variety of food to maintain proper nutrition. They appear as alterations in the form (frequency, duration, speed, time of the day) and in the content (type of food) of feeding/eating behavioral chains. Dysfunctional mealtime behaviors include food refusal, tantrums, food selectivity, rapid or slow eating, vomiting, coughing, or keeping mouth voluntary closed. Problematic feeding is ascribed to many causes, and it mainly arises from the interaction of biological and environmental factors.
In this paper we will discuss a wide range of strategies elaborated within a behavior analytic framework to show how feeding and eating in children can be effectively modified. We will briefly focus on how behavior analysts conceptualize problematic feeding, then examine some examples of intervention strategies for different feeding problems, and finally sketch how a behavioral based intervention on a large scale may increase fruit and vegetables consumption in children between 2 and 11 years old and ultimately help in preventing child’s obesity.
Eating is the way in which chemical and biochemical constituents and energy in form of food are swallowed, metabolized and delivered to the body cells. The mother starts to feed a baby right after birth and some components of the child behavior, the suction reflex for example, are genetically embedded, others, such as orienteering the head towards the nipple, in the case of breast feeding, are quickly learned. A little later in life we learn how to feed ourselves with chains of behavior of increasing complexity.
Though related to contingencies of survival, eating is not an easily self-maintained behavior and it is commonly taken for granted as a simple and automatic activity. A number of feeding and eating problems may arise early in a child life and are defined by the child inability or refusal to eat or drink a sufficient quantity or variety of food to maintain proper nutrition. They appear as alterations in the form (frequency, duration, speed, time of the day) and in the content (type of food) of feeding/eating behavioral chains. Dysfunctional mealtime behaviors include food refusal, tantrums, food selectivity, rapid or slow eating, vomiting, coughing, or keeping mouth voluntary closed. Commonly a distinction is made between mild and severe problematic feeding (1). The mild ones are temporary and easily solvable, while the severe ones are linked to an inadequate amount of food intake and may lead to life-threatening conditions in the long run.
It is estimated that between 20 to 40% of children show some form of feeding problems and the prevalence can increase up to 80% among children with mild to severe mental cognitive impairment (1). Problematic feeding is ascribed to many causes, and it mainly arises from the interaction of biological and environmental factors. Medical conditions like gastroesophageal reflux, anatomical abnormalities (e.g., cleft-lip and palate), cerebral palsy or dysphagia are associated with feeding problems (2). Problematic feeding may occur as a function of combining both child anatomical and physical (fine and gross motor skills) problems, if present, with environmental contingencies. In cases when the cause of food refusal is a painful medical condition, caregiver responses to children during meals may maintain or exacerbate the problem. Once problematic behavior is established environmental contingencies are enough to produce and maintain the behavior itself even when medical conditions are removed (see following section).
When biological conditions are lacking still problematic feeding may develop because of the same set of environmental events. However if the child is growing adequately, many medical professionals may not agree on whether or not problems related to eating resulting from parent-child interaction constitutes a feeding problem. Therefore, feeding problems are often defined in medical literature as a function of clinical judgment, and they are diagnosed on the basis of the topography of the behavior rather than of the environmental events they are a function of (3).
In this paper we will discuss the clinical behavior analytic framework of problematic feeding ranging from food refusal to low preference for fruit and vegetables during infancy. We will briefly focus on how behavior analysts conceptualize it, then examine some examples of intervention strategies for different problems. Since healthy eating habits may contrast the rise of obesity in children, which is reaching epidemic dimensions (4) we will end sketching how a behavioral based intervention on a large scale may increase fruit and vegetables consumption in kids between 2 and 11 years old and hopefully contribute in preventing child obesity.
PROBLEMATIC FEEDING: PRODUCTION AND MAINTENANCE
Behavior analysis is a natural science of behavior (5, 6) that has been now developed for 75 years (7). It aims to identify the manipulable (independent) variables of which a behavior (dependent variable) is a function. Antecedent events signal to an organism that the emission of a specific behavior may produce reinforcing or punishing consequences. While consequent events that follow a specific behavior may increase (reinforce) or reduce (punish) the probability of occurrence of that specific behavior in the future.
Likewise behavior analysts conceptualize functionally or disfunctionally eating and feeding as related to a set of antecedents and consequences. Feeding problems may arise from learned behaviors that develop as a result of a child’s interactions with the environment (e.g., through negative reinforcement, such as escape from eating, or through positive reinforcement, such as attention or access to tangible items) (8). According to LaRue, Stewart, Piazza, et al. (9) they represent one class of behavior in children that is mainly maintained by negative reinforcement. In a typical negative reinforcement experimental paradigm a response produce the removal, reduction or prevention of aversive stimulation, and as a consequence the probability of the same response to occur again in the future in the same conditions is increased. Children who suffer from gastro-esophageal reflux, for example, might exhibit refusal of food when retrosternal pyrosis makes eating painful. In these cases parents show a tendency to respond by removing food, postponing or terminating feeding (8, 10). Usually the refusal is accompanied by other behaviors like tantrums, crying, head turning or batting at the spoon on the table. In the long run parent’s behavior of removing food and halting the meal becomes more frequent and food refusal too.
What parents notice and appreciate is that all the strategies they apply produce a stop in the problematic behavior. Woods et al. (11) observed inappropriate and appropriate attention given by parents of 25 children, including tube dependent children, liquid dependent children and food selective children enrolled in an intensive feeding program. They showed that the forms of parental attention resulted in a temporary decrease (probability and frequency) of inappropriate behaviors. The decrease was temporary and eventually the feeding problem emerged again.
When the effects produce by parent’s are temporarily on child’s behaviors they worsen mealtime problems in the long term and a vicious cycle is created. Both attention to problematic behavior (positive reinforcement) and removal of food (negative reinforcement) increase the probability of that eating problem followed by those classes of consequences will occure more frequently in the future. On the other hand the cessation of the child behavior following parents actions will increase (negative reinforcement) the parent’s behavior (e.g. attention to problematic behavior or removal of food).
In these conditions medical interventions may fail not because they are not effective, but just because the child neglect to test their effectiveness. Thus, another vicious cycle may add up to the previous one. Food refusal under negative reinforcement conditions provided by parents leads to a failure to appreciate that eating may no longer be painful in the presence of an appropriate medical intervention, and the child, by refusing to eat, misses the opportunities to practice all the behaviors that are related to feeding and eating and does not develop the repertoire of oral motor skills or strengths to become capable eater, further worsening the clinical picture.
For example Piazza, Fisher, Brown et al. (8) applied a functional analysis to identify and quantify consequences of inappropriate mealtime behaviors of 15 children who had been referred to a treatment program for severe feeding disorders. The procedure of functional analysis described by Iwata, Dorsey, Slifer, et al. (12) manipulates systematically the conditions (antecedents and consequences) under which a problematic behavior may occur, thus helping identifying the environmental context that leads to problematic feeding. The Authors first identified a wide range of consequences used by parents for inappropriate mealtime behaviors: coaxing and reprimanding, allowing the child to periodically take a break from or avoid eating, and giving the child preferred food or toys following inappropriate behavior. Then systematically tested the effects of these consequences on children mealtime behavior, alternating conditions where inappropriate mealtime behavior was or was not followed by one of the consequences typically used by parents. Results indicated that those consequences actually worsened behavior for 10 of the 15 participants (67%) who displayed high levels of problematic feeding behaviors during one or more of the test conditions relative to the baseline condition, suggesting that consequences played a role in the child’s feeding problem.
Even when food ingestion is not related with heartburn or other medical conditions, parents use a variety of strategies to motivate their children to eat. Faced with problematic behaviors they may put a stop to the meal and wait for the child to “calm down” before continuing. Or the may give more attention to the child, only when exhibiting the problematic mealtime behavior. For example, a mother may turn the head and attend to other duties in the kitchen waiting for the child to finish eating and provide attention to the child’s behavior only when food refusal occurs. Some parents may offer to their child a more preferred food, when the child refuses to eat a less preferred one. The shared vision in these and other examples is that it is better for the child to eat something rather than nothing. Parents may also provide toys during the meal or use the food like an airplane to calm or distract the child from behaving inappropriately.
PROBLEMATIC FEEDING: INTERVENTION STRATEGIES
There is no “one fits all” intervention strategy to treat problematic feeding. Tailored solutions based on a functional analysis of the behavior and the context in which it occurs are generally suggested from an Applied Behavior Analysis point of view. ABA is and applied science “in which tactics derived from the principles of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change” (13 p. 20). A basic assumption of any ABA based intervention is that the child does his/her best given the conditions under which he/she is functioning. These conditions are usually assessed by descriptive analysis and direct observation to identify target behaviors and functionally related antecedents and consequences (13). Some studies, like the one by Fisher et al. above mentioned have attempted to apply more formal functional analysis methodology to problematic feeding. Thus by identifying and manipulating antecedents or consequences dysfunctional feeding can be decreased or healthier choices in eating can be taught and maintained in the long term.
Using a functional analysis in the treatment of food refusal is important to identify the variety of consequences that follow children feeding behavior to maintain it. This brings to more effective treatment because different strategies may be empirically based based on the function of the target behavior. In addition different strategies can be compared to identify the most effective, Plummer et al. (14) for example, evaluated how appropriate and inappropriate eating behavior of two 5-years-old boy and girl, both being diagnosed in the autistic spectrum, and the first one with comorbidity of brain damages, varied as a function of three independent variables: reinforcement, a typical time out procedure, and regularly paced teacher instructions. They were also assessed for other problematic play behaviors. No response decrement was observed during timeout, and response increment was recorded for reinforcement conditions. In the condition where timeout was ineffective paced instructions, coupled with reinforcement, resulted to be effective in increasing appropriate and reducing inappropriate eating behaviors close to zero levels.
Another study implemented time out procedures to decrease inappropriate noon and evening mealtime behaviors of sixteen retarded children, adolescence and young adults. Inappropriate feeding behaviors treated were timed out in a fixed order for all participants, for example by removing the person from the meal-room until he/she finished or with a 15-seconds removal of the plate. The choice of one or another procedure was depending on the health status of the subject or of the initial behaviors rates. Both procedures were successful in decreasing the percentage of occurrence of problematic mealtime behaviors (15).
Reinforcement based procedure were also used to treat four handicapped children with a history of food refusal and nutritionally at risk (16). During baseline a number of problematic behaviors were identified, namely: children accepted very little or no food, expelled it frequently, and showed a number of disruptive behaviors. The treatment consisted of social praising, giving access to preferred foods, brief moment to play, and forced feeding. All treatment plans were tailored on child’s needs and one or more of the above procedures were used for each child. A marked behavioral improvement was seen along with an increase of food consumption and further improvements were observed up to 30 months follow-ups.
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1. Laud RB, Girolami PA, Boscoe JH, Gulotta CS: Treatment outcomes for severe feeding problems in children with autism spectrum disorder. Behavior Modification 2009; 33: 520-536.
2. Piazza CC, Carroll-Hernandez TA: Assessment and treatment of pediatric feeding disorders. Encyclopedia on Early Childhood Development 2004. http://www.child-encyclopedia.com/(last accessed 24 august 2012)
3. Kerwin MLE: Pediatric Feeding Problems: A Behavior Analytic Approach to Assessment and Treatment. The Behavior Analyst Today 2003; 4(2): 162-176.
4. James PT, Leach R, Kalamara E, Shayeghi M: The Worldwide Obesity Epidemic, Obesity Research 2001; 9(Suppl. 4): 228S-33S.
5. Skinner BF: Science and Human Behavior. New York: Macmillan 1953.
6. Catania AC: Learning. Englewood Cliffs NJ. Prentice-Hall 1992.
7. Skinner BF: The Behavior of Organisms: An Experimental Analysis. Cambridge, MA 1938.
8. Piazza CC, Fisher WW, Brown KA et al.: Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis 2003; 36: 187-204.
9. La Rue RH, Stewart V, Piazza CC et al.: Escape as reinforcement and escape extinction in the treatment of feeding problems. Journal of Applied Behavior Analysis 2011; 44: 719-735.
10. Borrero CSW, Woods JN, Borrero JC et al.: Descriptive analyses of pediatric food refusal and acceptance. Journal of Applied Behavior Analysis 2010; 43: 71-88.
11. Woods IN, Borrero JC, Laud RB et al.: Descriptive Analyses of Pediatric Food Refusal: The Structure of Parental Attention. Behavior Modification 2010; 34(1): 35-56.
12. Iwata BA, Dorsey MF, Slifer KJ et al.: Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis 1994; 27: 197-209. Reprinted from: Analysis and Intervention in Developmental Disabilities 1982; 2: 3-20.
13. Cooper JO, Heron TE, Heward WL: Applied behavior analysis (2nd ed.). Upper Saddle River, NJ, Pearson 2007.
14. Plummer S, Baer DM, LeBlanc JM: Functional considerations in the use of procedural timeout and an effective alternative. Journal of Applied Behavior Analysis 1977; 10: 689-705.
15. Splinder BE, Guess D, Garcia E, Baer D: Improvement of retardates’ mealtime behaviors by timeout procedures using multiple baseline techniques. Journal of Applied Behavior Analysis 1970; 3: 77-84.
16. Riordan MM, Iwata BA, Finney JW et al.: Behavioral assessment and treatment of chronic food refusal in handicapped children. Journal of Applied Behavior Analysis 1984; 17: 327-341.
17. Tiger JH, Hanley GP: Using reinforcer pairing and fading to increase the milk consumption of a preschool child. Journal of Applied Behavior Analysis 2006; 39: 399-403.
18. Shore BA, LeBlanc D, Simmons J: Reduction of unsafe eating in a patient with esophageal stricture. Journal of Applied Behavior Analysis 1999; 32: 225-228.
19. Benton D: Role of parents in the determination of the food preferences of children and the development of obesity. International Journal of Obesity 2004; 28: 858-869.
20. Fischer R, Birch JL: Fat preferences and fat consumption of 3- to 5-year-old children are related to parent adiposity. Journal of the American Dietetic Association 1995; 95: 759-764.
21. Nguyen VT, Larson DE, Johnson RK, Goran MI: Fat intake and adiposity in children of lean and obese parents. American Journal of Clinical Nutrition 1996; 63: 507-513.
22. WHO Consultation on Obesity. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Geneva, Switzerland 2000.
23. Institute of Medicine’s (IOM) Standing Committee on Childhood Obesity Prevention. Early Childhood Obesity Prevention Policies. Washington, National Academy of Sciences 2011.
24. Ebbeling CB, Pawlak DB, Ludwig DS: Childhood obesity: public-health crisis, common sense cure. Lancet 2002; 360: 473-482.
25. Horne PJ, Lowe CF, Fleming PFJ, Dowey AJ: An effective procedure for changing food preferences in 5-7 year-old children. Proceedings of the Nutrition Society 1995; 54: 441-452.
26. Lowe CF, Dowey AJ, Horne PJ: Changing what children eat. [In:] Murcott A (ed.): The Nation’s Diet: The Social Science of Food Choice. London, Longman 1998; p. 57-80.
27. Hendy H, Raudenbush B: Effectiveness of teacher modeling to encourage food acceptance in preschool children. Appetite 2000; 34: 61-76.
28. Wardle J, Cooke L, Gibson EL et al.: Increasing children’s accteptance of vegetables: A randomized trial of guidance to parents. Appetite 2003; 40, 155-162.
29. Baer DM, Deguchi H: Generalized imitation from a radical behavioural viewpoint. [In:] Reiss S, Bootzin RR (ed.): Theoretical Issues in Behaviour Therapy. Orlando, FL, Academic Press 1985; p. 179-217.
30. Bandura A: Social Learning Theory. Englewood Cliffs, NJ, Prentice-Hall 1977.
31. Bandura A: Social cognitive theory. Annals of Child Development 1989; 6: 1-60.
32. Gewirtz JL, Stingle KG: Learning of generalized imitation as the basis for indentification. Psychological Review 1968; 75: 374-397.
33. Skinner BF: Contingencies of Reinforcement. Englewood Cliffs, NJ, Prentice-Hall 1969.
34. Lowe CF, Horne PJ, Tapper K et al.: Effects of a peer modelling and rewards-based intervention to increase fruit and vegetable consumption in children. European Journal of Clinical Nutrition 2004; 58(3): 510-522.
35. Horne PJ, Tapper K, Lowe CF et al.: Increasing children’s fruit and vegetable consumption: a peer-modelling and rewards-based intervention. European Journal of Clinical Nutrition 2004; 58: 1649-1660.
36. Horne PJ, Hardman CA, Lowe CF et al.: Increasing parental provision and children’s consumption of lunchbox fruit and vegetables in Ireland: the Food Dudes intervention. European Journal of Clinical Nutrition 2009; 63: 613-618.
37. Presti G, Cau S, Moderato P: Changing the diet of our kids: The Italian Food Dudes program. Paper presented at the ABAI Sixth International Conference: Granada, Spain 2011, November 24-6.
38. Horne PJ, Greenhalgh J, Erjavec M et al.: Increasing pre-school children’s consumption of fruit and vegetables. A modelling and rewards intervention. Appetite 2011; 56: 375-385.