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<strong>Education</strong> <strong>and</strong> <strong>Tra<strong>in</strong><strong>in</strong>g</strong> <strong>in</strong> <strong>Developmental</strong> <strong>Disabilities</strong>, 2005, 40(1), 80–96 © <strong>Division</strong> on <strong>Developmental</strong> <strong>Disabilities</strong> Improv<strong>in</strong>g Feed<strong>in</strong>g Skills <strong>and</strong> Mealtime Behaviors <strong>in</strong> Children <strong>and</strong> Youth with <strong>Disabilities</strong> Rita L. Bailey <strong>and</strong> Maureen E. Angell Ill<strong>in</strong>ois State University Abstract: A s<strong>in</strong>gle-subject multiple treatment design counterbalanced across n<strong>in</strong>e participants with moderate to severe <strong>and</strong> multiple disabilities was used to determ<strong>in</strong>e the efficacy of a school-based multi-treatment package (a comb<strong>in</strong>ed dysphagia treatment <strong>and</strong> positive re<strong>in</strong>forcement behavior management program) for children <strong>and</strong> youth (ages 4-17) with feed<strong>in</strong>g problems as compared to use of a dysphagia treatment program or a positive re<strong>in</strong>forcement behavior management program alone. While results found improvement <strong>in</strong> development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors with all <strong>in</strong>tervention programs, the comb<strong>in</strong>ed <strong>in</strong>tervention package was the most effective <strong>in</strong>tervention strategy. These results may help professionals establish best practices for treatment of feed<strong>in</strong>g problems <strong>in</strong> schools. Problematic mealtime behaviors are a common f<strong>in</strong>d<strong>in</strong>g <strong>in</strong> children diagnosed with feed<strong>in</strong>g <strong>and</strong>/or swallow<strong>in</strong>g problems collectively known as dysphagia (Arvedson, 1997; Kerw<strong>in</strong>, 1999; Logemann, 2000; Munk & Repp, 1994). These behaviors may develop for a variety of reasons <strong>and</strong> range from those that are socially <strong>in</strong>appropriate to those that have a detrimental effect on nutrition <strong>and</strong> health. These challenges often make mealtimes unpleasant. Many problems that children experience <strong>in</strong> the areas of feed<strong>in</strong>g, growth, <strong>and</strong> food acceptance have been attributed to a comb<strong>in</strong>ation of the medical or physical condition of the child, <strong>in</strong>appropriate food selection, <strong>and</strong>/or <strong>in</strong>appropriate dynamics dur<strong>in</strong>g feed<strong>in</strong>g (Satter, 1990). Inappropriate caregiver-child <strong>in</strong>teractions that have been found to precipitate problems may <strong>in</strong>clude attention for negative behaviors, responses to attempts at forced feed<strong>in</strong>g, <strong>and</strong> reduction of feed<strong>in</strong>g choices due to food selectivity preferences <strong>in</strong> children (Christophersen & Hall, 1978). Children with dysphagia may f<strong>in</strong>d mealtimes stressful <strong>and</strong> unpleasant. If children have experienced airway compromise such as occurs with aspiration <strong>and</strong> chok<strong>in</strong>g, they may associate these negative experiences with the Correspondence concern<strong>in</strong>g this article should be addressed to Rita L. Bailey, Department of Special <strong>Education</strong>, Ill<strong>in</strong>ois State University, Campus Box 5910, Normal, IL 61790-5910. act of eat<strong>in</strong>g. Medically fragile children are often subjected to medically necessary but <strong>in</strong>trusive <strong>and</strong> aversive oral/facial sensory <strong>in</strong>puts. Suction<strong>in</strong>g, oral <strong>and</strong> nasal gastric tube placement, <strong>and</strong> the use of facial tape to secure tubes may lead to tactile defensiveness <strong>and</strong> oral hypersensitivity (Comrie & Helm, 1997). Early experiences with oral sensory stimuli are often limited for children with neurological <strong>and</strong>/or physical impairments, especially for those who experience extensive episodes of hospitalization. This may limit new <strong>and</strong> repeated exposure to foods. This lack of oral sensory experiences may lead to food aversions <strong>and</strong> refusals, a common f<strong>in</strong>d<strong>in</strong>g <strong>in</strong> children with eat<strong>in</strong>g disturbances (Pelchat & Pl<strong>in</strong>er, 1986). Early experience <strong>and</strong> repeated exposure to new foods contributes to development of food acceptance patterns <strong>and</strong> control of food <strong>in</strong>take. In fact, most children are likely to reject new foods <strong>in</strong>itially, but they learn to like them with time <strong>and</strong> repeated neutral exposure (Birch, Johnson, & Fisher, 1995; Birch & Marl<strong>in</strong>, 1982). It is clear that eat<strong>in</strong>g does not exist <strong>in</strong> isolation from the context <strong>in</strong> which it takes place. Caregiver <strong>in</strong>fluences, physical conditions, social, psychological factors, <strong>and</strong> the feed<strong>in</strong>g environment impact the development of feed<strong>in</strong>g. Statement of the Problem 80 / <strong>Education</strong> <strong>and</strong> <strong>Tra<strong>in</strong><strong>in</strong>g</strong> <strong>in</strong> <strong>Developmental</strong> <strong>Disabilities</strong>-March 2005 Children with comb<strong>in</strong>ed dysphagia <strong>and</strong> problematic mealtime behaviors present a particu-
lar challenge for school personnel <strong>in</strong>volved <strong>in</strong> supervision <strong>and</strong> feed<strong>in</strong>g of children <strong>and</strong> youth with disabilities. Several authors have described programs for <strong>in</strong>creas<strong>in</strong>g oral-motor skills <strong>and</strong> oral-sensory awareness <strong>in</strong> children (e.g., Alex<strong>and</strong>er, 1987; Bahr, 2001; Gaebler & Hanzlik, 1996; Hall, 2001; Morris & Kle<strong>in</strong>, 1987), direct <strong>and</strong> compensatory therapies for improv<strong>in</strong>g feed<strong>in</strong>g <strong>and</strong> swallow<strong>in</strong>g skills (e.g. Arvedson, 1998; Hall; Kovar, 1997; Larnert & Ekberg, 1995; Logemann, 2000) <strong>and</strong> behavior management programs to improve behavior at mealtimes (Kerw<strong>in</strong>, 1999; Munk & Repp, 1994; Rasnake & L<strong>in</strong>scheid, 1987; Sisson & Dixon, 1986). Unfortunately, these have not been widely used <strong>in</strong> educational sett<strong>in</strong>gs. In fact, dysphagia treatment by speech-language pathologists (SLPs) has historically occurred predom<strong>in</strong>ately <strong>in</strong> medical sett<strong>in</strong>gs (Silliman, 2000). Management of feed<strong>in</strong>g <strong>and</strong> swallow<strong>in</strong>g disorders has become an issue for school-based SLPs. The American Speech Language <strong>and</strong> Hear<strong>in</strong>g Association addressed this issue <strong>in</strong> their Technical Report Executive Summary (2002) stat<strong>in</strong>g, The area of pediatric swallow<strong>in</strong>g <strong>and</strong> feed<strong>in</strong>g disorders is one of the most rapidly evolv<strong>in</strong>g patient care areas for medically-based SLPs <strong>and</strong> other professionals serv<strong>in</strong>g children. In addition, as an <strong>in</strong>creas<strong>in</strong>g number of highrisk <strong>in</strong>fants survive <strong>and</strong> enter educational programs, SLPs must acquire medical knowledge <strong>and</strong> skills to manage swallow<strong>in</strong>g <strong>and</strong> feed<strong>in</strong>g disorders (p. 76). Additionally, while behavior management programs <strong>and</strong> dysphagia treatment for management of feed<strong>in</strong>g problems have been described, there are relatively few studies that have <strong>in</strong>vestigated comb<strong>in</strong>ed treatments for dysphagia co-exist<strong>in</strong>g with behavioral feed<strong>in</strong>g problems. The comparative use <strong>and</strong> efficacy of dysphagia treatment programs, behavior management programs, <strong>and</strong> comb<strong>in</strong>ed treatment programs is unknown. This <strong>in</strong>formation is necessary to establish best practices for treatment of feed<strong>in</strong>g problems <strong>in</strong> children <strong>and</strong> youth. Dysphagia Treatment Methods Therapies for pediatric dysphagia <strong>in</strong>clude direct <strong>in</strong>tervention strategies such as oral-motor exercises <strong>and</strong> swallow<strong>in</strong>g maneuvers (Loge- mann, 2000). Compensatory strategies <strong>in</strong>clude position<strong>in</strong>g for optimal safety <strong>and</strong> airway protection, specialized feed<strong>in</strong>g techniques to change the feed<strong>in</strong>g pattern (i.e., therapeutic feed<strong>in</strong>g methods), sensory enhancement procedures, nutritional enhancement, <strong>and</strong> the use of adaptive feed<strong>in</strong>g equipment to encourage heightened awareness, maximization of skills, <strong>and</strong> improved <strong>in</strong>dependence <strong>in</strong> feed<strong>in</strong>g (Alex<strong>and</strong>er, 1987; Arvedson, 1997; Arvedson & Brodsky, 1993; Gaebler & Hanzlik, 1996; Hall, 2001; Logemann; Morris & Kle<strong>in</strong>, 1987). Methods chosen vary accord<strong>in</strong>g to the specific needs <strong>and</strong> cognitive abilities of the child. Behavior Management Methods While a variety of behavior management programs are available, this study employed positive re<strong>in</strong>forcement procedures. Positive re<strong>in</strong>forcement protocols use social praise, attention <strong>and</strong> encouragement, together with the selective presentation of preferred re<strong>in</strong>forcers as social <strong>and</strong>/or tangible rewards. A pre-session assessment of re<strong>in</strong>forcer preference protocol (Gast et al., 2000) was the method used to determ<strong>in</strong>e re<strong>in</strong>forcement preferences <strong>in</strong> this study. The purpose of this study was to determ<strong>in</strong>e the efficacy of a multi-treatment feed<strong>in</strong>g skill <strong>and</strong> mealtime behavior <strong>in</strong>tervention package <strong>and</strong> evaluate: (a) effects of a dysphagia treatment program on development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors, (b) effects of a positive re<strong>in</strong>forcement behavior management program (PRBMP) on development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors, (c) effects of a comb<strong>in</strong>ed dysphagia <strong>and</strong> PRBMP program package on development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors, (d) comparative effectiveness of each <strong>in</strong>tervention or <strong>in</strong>tervention package on development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors <strong>in</strong> children <strong>and</strong> youth with disabilities, <strong>and</strong> (e) whether improvements <strong>in</strong> development of feed<strong>in</strong>g skills <strong>and</strong> positive mealtime behaviors will be ma<strong>in</strong>ta<strong>in</strong>ed when <strong>in</strong>terventions are provided by tra<strong>in</strong>ed school staff members. Feed<strong>in</strong>g Skills <strong>and</strong> Mealtime Behaviors / 81
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