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					    “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?

   The 2011 group is comprised of:
     9 speech pathologists from ADHC and
      Cerebral Palsy Alliance
     1 occupational therapist from ADHC
    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)
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.

   Method
      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 et al. 2010



Method (continued)
 The articles were then classified based on their:
       Treatment elements.
       Setting.
       Primary therapist.
       Generalisation.


   Statistical analysis
       Percentage of non-overlapping data (PND) and non-
        overlap of all pairs (NAP) used to evaluate the
        effectiveness of treatments.
                           …Sharp et al. 2010



   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
Strengths and Limitations of
   the Systematic Review
Strengths
 It is a systematic review.
 Good statistics, scientific principles
 Multidisciplinary


Limitations
 It does not compare behavioural interventions to non-
   behavioural interventions.
 It does not compare the effectiveness of each of the
   treatment elements (e.g. EE vs punishment, EE vs
   reinforcement schedules).
 It is only relevant for children with severe feeding
   disorders.
    Limitations and Strengths of the
     articles within the Systematic
                 Review
   Strengths
       Some follow up on effectiveness of parent
        training

   Limitations
       Long term follow up in the articles (5, 10 years
        later??)
       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

 We cross referenced initial articles we
  found against systematic literature
  review
 Developed selection criteria to refine
  list to articles to answer our question.
 No Clear comparison         Outcome measures used
 between EE vs other          inconsistent across our
methods in our available              articles.
       articles.
    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
 Behavioural interventions are
  effective in improving intake in
  children with severe feeding
  disorders. The most common
  interventions use a combination of
  behavioural strategies.
 Escape extinction in combination
  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 &
  choice
"Each person has the right to make
  their own decisions wherever possible
  and have choice “
 Nutrition & Swallowing Policy
              September 2010



“A prevention and risk management
  approach to individual nutritional
  health is required.” pp5

“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
         Package June 2010
Expanding Children’s Diets by Suzanne Evans
  Morris 2009
“Children need to learn about new foods in an
  unthreatening way…Mealtimes frequently are
  associated with expectations for eating and
  drinking. Many children are on guard and 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.”
                   Survey
   In following the E3BP model we collected
    data from therapists to review what
    interventions they were mostly likely to use
    for our paediatric feeding clients.

   115 responded to the survey however we
    could only view 100 responses due to
    account limits on survey monkey.
Participants and workplace

           11%


                       Speech
                       Pathologist

                       Occupational
                       Therapist
     29%
                       Psychologist
                 60%
                         70


                         60


                         50
Number of participants




                         40


                         30


                         20


                         10


                         0
                              NSW Health   Ageing Disability and Home   Non-Government   Private Practice   Other
                                                      Care               Organisations
                                                                          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 meal. Which of the following strategies are you MOST likely to
                                                   recommend?



                      60



                      50
Number of responses




                      40


                      30


                      20


                      10



                      0
                           Keep Ella at the table until       The whole family eat      Introduce non-preferred foods     Using a first, then chart to   Skipped question
                             she finishes her meal        together to provide modelling     to Ella in play activities    encourage her to eat non-
                                                                                                                         preferred foods followed by a
                                                                                                                                     reward
                                                                                           Intervention options
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.



                      2%   3%
                                                   For her to continue to use her
                                                   current strategies
            18%
                                      19%
                                                   Involve the student in mealtime
                                                   preparation

                                                   Offer the student more choices at
                                                   mealtime

                                                   Increase opportunities for the
                                                   student to engage in "messy play"
      10%                                          with real food
                                                   Encourage the student to engage
                                                   in pretend play with food items
                                            16%    (eg: feeding dolls)
                                                   Use a reward system (eg: after
                                                   each bite of food the student can
                                                   access a preferred activity)
                                                   Increase opportunities for the
            17%                                    student to observe other students
                                                   and the teacher eating
                                15%                Skipped question
    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
        desperate?
       Comparison to medications which are sometimes forced to
        be consumed?
       Is it ethical to withhold a treatment that has proven to be
        effective?
       Do we use some of the concepts within our daily lives?
Consulting the EBP triangle
 Escape extinction
combined with other          Current Best Evidence
therapy techniques
seem to achieve the
   ‘best’ results.




                                                     I just want my child
                                                         to eat so their
Are we comfortable
                                                       nutritional needs
         with
                                                     are met and I want
   recommending
                                                       this to happen in
 escape extinction
                                                           the easiest
  for children who
                                                         possible way!
  are regarded as
    fussy eaters?


        Clinical Expertise                           Client/Patient Values

                              (ASHA, 2004)
                In 2012…
Meetings will rotate between ADHC Metro
 South offices.

  Please contact:
   Emma Minchin
    emma.minchin@facs.nsw.gov.au
    8344 2700
   Tsen Levsen
    tsen-aie.levsen@facs.nsw.gov.au
    9701 6300
 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)
  References

Ahern et al (1996) An alternating treatments comparison of two intensive interventions for food refusal,
Journal of Applied Behavior Analysis 29 (3), pp 321-332

Burmucic K, Trabi T, Deutschmann A, Scheer PJ, Dunitz-Scheer M. (2006). Tube weaning according to the
Graz Model in two children with Alagille syndrome. Pediatric Transplantation, 10, 934–937.

Piazza.C.C, Patel. M.R, Santana. C.M, Goh. H.L, Delia. M.D & Lancaster. B.M (2002) An evaluation of
simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity.
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

				
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