Parents Promoting Mealtimes using
Evidence Based Strategies in ASD:
Cognitive, Behavioral, and Social Strategies
NJSHA, First Interprofessional Autism Conference
Deirdre Muldoon, Ph.D., CCC-SLP, BCBA &
Joanna Cosbey, PhD, OTR/L
June 10, 2017
Our Mealtime Team
Deirdre
Parents &
Child
Joanna
Other
Professionals
Importance of Positive
Mealtime Experiences
• Maintain nutrition
• Support learning and behavior
• Ease caregiver stress
• Promote positive family interactions
• Empower caregivers
What Works?
• Environmental changes
• Food manipulation
• Cognitive and behavioral interventions
• Caregiver education
• Caregivers as interventionists
Environmental Modifications
• Minimizing distractions
• Appropriate seating
• Vibrating timers for pacing
• Use of colored bowls
Food Manipulation
• Food chaining
• Attention to food characteristics
• Changing bite size/number
Cognitive & Behavioral
Strategies
• ABC of behavior
• Individualized reinforcement (positive, non-contingent,
differential)
• Escape extinction
• Systematic desensitization / Hierarchical food exposure
ABC of Behavior
• Setting Events: change the value of reinforcers
• Antecedents: trigger behaviors
• Consequences: reinforce behaviors
Reinforcement
• Consequence that makes a behavior stronger
• Positive
• Non-contingent
• Differential
Escape Extinction
• Extinction: withholding of reinforcement for behavior in
order to decrease the behavior
• What do we know?
• The research
• The practical considerations
• Our approach
Hierarchical Food Exposure,
aka, Systematic Desensitization
• Can pair it with reinforcement strategies
• Individualize it for the client
Caregivers as
Interventionists
• More opportunities for learning
• Greater rate of progress
• Decreased caregiver stress
• Maintains regularity of routines
• Supports co-occupations
•
Keen, Couzens, Muspratt, & Rodger, 2010; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010;
Simpson, 2001
Sam
An EAT-UPTM Case Study
Case Example: Sam
• Three year old boy with autism
• Significant communication impairment
• Cultural considerations - vegetarians
• Mother was concerned about
• Need to force feed him (headlock!) and
• Limited variety of food in his diet
• Family had previous exposure to ABA and so were familiar
with behavior principles
• Mealtime plan (EAT-UPTM) ran for 6 months (October to
April)
EAT-UPTM
•
Integration of
evidence-based behavioral strategies,
environmental supports,
dyadic communication supports, and
parent as primary interventionist.
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Tracked acceptance of less-preferred foods and presence of challenging behaviors
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Data collection methods and tools include
Direct observation
Fidelity measures
Pre- and post-intervention questionnaires
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Sam’s mealtime team included
Deirdre as coach
Joanna as consultant (via Skype, email, and phone)
Registered behavior technician as trainer
Parent as interventionist
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EAT-UPTM Domains: The Basics
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1. Manipulation of Food
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At least one preferred and one less preferred food present
Select foods that child is likely to learn to eat
2. Communication of Parent and Child
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Prompts repeated less than three times
Functional communication opportunities
Elements of choice
3. Physical Environment
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Able to reach the food and have good foot support
Use of physical prompts (like hand-over-hand help) if needed
Minimize distractions
4. Social Environment
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Behaviors encouraged (reinforced) good behavior
Model expected behavior
Try to prevent inappropriate behaviors
Be positive
Other Examples of
EBPs Used
• Behavioral momentum
• Visual hierarchy
• Fading
• Parent training
• Prompting
• Reinforcement
Sam:
Assessment Procedures
• Brief Autism Mealtime Behavior Inventory (Lukens, 2005)
• Behavioural Pediatrics Feeding Assessment Scale (BPFAS) (Crist
& Napier-Phillips, 2001)
• Food Frequency Questionnaire (adapted from Harvard School of
Public Health, 2012)
• 24-hour food recall (adapted from Lukens, 2005)
• Family Quality of Life survey (Hoffman, Marquis, Poston, Summers,
& Turnbull, 2006)
• Goodness of fit survey (adapted from Albin, Lucyshyn, Horner, &
Fannery, 1996)
• Functional assessment interview and observation
Acceptance of Less
Preferred Food in Clinic
Baseline
Intervention phases
Maintenance
Coaching
Independent
Offered LP food but
force fed by mother
Percentage of mealtime strategies
implemented accurately by parent
Parent Implementation of
Mealtime Plan
Intervention phase:
Coaching
Intervention phase:
Independent
Maintenance
24 Hour Food Recall
Pre: 10/22/2015
Post: 4/8/2016
• white bread & margarine
• wheat bread
• wheat bread with spinach
• lentil bread stuffed with lentils
• cookie wafers
• chapati with mango and
• mac and cheese
• 1 slice Kraft cheese
• frozen yogurt
• whole milk – 16 ounces
• fruit punch – 4 ounces
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Number of foods
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cabbage
oatmeal chewy bar/chocolate
covered
pasta & red sauce with cheese
pizza
water
pineapple, orange, carrot and
apple juice/whole juice
Implications
• Collaboration and interprofessional practice is essential
• Cross over of traditional roles
• Collaboration with parents for best possible outcomes
• Need for broader training for SLP, OT with regard to
behavioral feeding disorders