By Erica Bushnell
MA, BCBA, RN
Questions and concerns regarding eating habits are common for a BCBA to encounter when serving clients diagnosed with autism. Approximately 45% to 90% of children with autism have difficulty with eating, specifically food selectivity (Bandini et. al, 2017). Food selectivity consists of three different domains which include food refusal, limited food repertoire, and high-frequency single food intake (Bandini et. al, 2017). Food selectivity may occur with a variety of foods depending on their texture, color, smell, and taste. It is not uncommon for children with food selectivity to eat the same foods for every meal. Appropriate nutrition is important for the overall development and well-being of a child. Therefore, a food program may be utilized to achieve a more appropriate and well-balanced diet.
If a food program is deemed necessary by the child’s family and clinical team, the first step is typically to complete a food intake assessment. A food intake assessment is done to evaluate highly preferred foods and non-preferred foods. The assessment contains a variety of foods across all classes to determine a baseline level of a child’s food intake, preferences, and aversions. The food intake assessment will also gather a history of feeding issues, behaviors that occur during mealtimes, or any special diets the child may currently be on or was on previously. The intake form will then allow the child’s clinical team and family to create appropriate goals for the child.
After the food intake is completed, a food will need to be selected to introduce into the child’s repertoire. Choosing food can be done in a variety of ways. For example, the child’s family may want to introduce fruits or vegetables into the child’s diet. The family may also want to incorporate a family favorite meal to increase the likelihood that the client will eat the food at mealtimes. The food intake assessment can also be used during this step to determine if a food should be chosen based on other factors such as texture, taste, or smell.
When implementing a food program, there are a few basic Applied Behavior Analytic (ABA) principles that are used to help achieve mastery of food items. One ABA principle that may be used is called shaping. Shaping is when reinforcement of small steps towards an end goal is provided to the child. When using shaping procedures with food programs, the child may be required to initially touch the food to their lips. After that step is mastered, they may then be required to lick the food and then eventually place the food item into their mouth. Reinforcement is provided when each of these steps occurs to shape the terminal behavior of eating the new food.
A second ABA principle used when implementing food programs is called the Premack Principle. The Premack Principle means that engagement with a desired activity, such as eating a preferred food, is only possible when completing a non-desired activity, such as eating a non-preferred food. It is also known as Grandma’s Law or a first, then contingency. When using this principle in food programs, providing the child with a highly preferred food or reinforcer after they eat the non-preferred food will likely increase the behavior of eating the non-preferred food. For example, a highly preferred reinforcing edible for a child may be a potato chip. If a food program is being used to increase the child’s intake of carrots, he or she would be provided with a potato chip after consuming a piece of a carrot. To receive the desired item of the potato chip, the child must engage in the less desirable behavior of eating the carrot.
Fading procedures are also used during food programs. Initially, when being introduced to a new food item, a child may receive reinforcement for each bite of non-preferred food that is eaten. As the child progresses and continues to eat the non-preferred food item, the frequency of reinforcement may change. For example, the child may be required to eat two or three bites of the non-preferred food before he or she is provided with reinforcement. The fading criteria will be set by the child’s clinical team and will continue to be used until the child successfully masters eating the non-preferred food item.
Parental or caregiver involvement and commitment are extremely important for the success of a food program. It may be required for the parent to send in non-preferred food items and reinforcement items or activities consistently. Parents or caregivers must also be willing to continue with the implementation of the food program outside of therapy. Like many mastered skills, mastered food items will require frequent introduction to maintain mastery. It is also important for the parent or caregiver to understand the possibility of a spike in maladaptive behaviors. The child may display these behaviors to escape the food program. Over time, these behaviors should decrease but communication should remain open between the caregiver or parent and the child’s clinical team to determine if a change in the protocol is necessary. Patience is also key when food programs are implemented at home or in the clinic setting. It may take some time for the child to master a certain food and increase their food repertoire.
Feeding concerns are usually a top priority for families of children diagnosed with autism. Ensuring the child is getting proper nutrients and calories is important for their growth and development. With collaboration, patience, and consistency, food programs can be successful at increasing a child’s food repertoire and exposure to novel foods.
Bandini, L. G., Curtin, C., Phillips, S., Anderson, S. E., Maslin, M., & Must, A. (2017). Changes in food selectivity in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(2), 439–446.
July 29, 2021, Erica Bushnell