With food refusal being considered a normal part of typical development, how do you know if you have a fussy eater or a food refuser? If you have a child with a diagnosis of a neurodevelopmental disorder without any other medical conditions such as cleft palate, cerebral palsy, problems with their kidneys or intestines, the chances are that you are dealing with food refusal. Children with neurodevelopmental disorders such as Autism are 40-80% more likely to experience food related disorders such as food refusal than those without neurodevelopmental disorders (Chatoor, 2002).
Researchers have defined food refusal as the repetitive or constant pattern of accepting only a limited range of foods or in some extreme cases none at all leading to inappropriate weight gain (Field, Garland & Williams 2003). Food refusal can also lead to nutritional deficiencies and can increase the likelihood of cognitive and physical delays (Manikam and Perman, 2000)
Food refusal manifests in a range of behavioural problems around mealtimes that often leave families feeling very restricted or isolated from social events. Going to restaurants, holiday celebrations and even meal times at home can lead to disruptive behaviours. These behaviours include but are not limited to, crying, choking, vomiting, tantrums, closed mouth, spitting out food, gagging and eating on an inconsistent schedule.
What causes individuals to refuse food?
There three main factors that can cause and contribute to food refusal; medical, oral and behavioural (Piazza, 2008). Medical factors include, allergies, disorders of the gastrointestinal tracts (e.g. reflux) and neurological conditions. The second factors are oral motor difficulties, such as swallowing, chewing and weak oral muscles. The third factor is behavioural. Inappropriate behaviours as mentioned above often serve to avoid or delay intake of non-preferred food that are often related either the medical, oral conditions or a dislike of the texture, colour or taste of the food being presented. Increased attention during mealtimes as caregivers try to encourage food intake can also contribute to the negative cycle of food refusal.
What can I do about it?
Firstly if you are a caregiver and feel that the description above is relevant to you then please do seek professional help.
The first thing you should do is to explore medical and oral causes of food refusal. Your GP can help with this. Other professionals working in this field include, Speech and Language Therapists, Occupational Therapists, Nutritionists and Behaviour Analysts. In most cases a combination of these professionals would be most helpful. If you know that the problem is non medical or oral then as Behaviour Analysts we can help.
Research supports the use of behavioural interventions to decrease food selectivity and refusal in individuals with neurodevelopmental disabilities. At All Behaviour Consultancy our aim when addressing food refusal is to increase the amount of food intake, broaden the range food intake and to decrease behaviours and the time it takes to eat. The interventions that we use are grounded in the science of Applied Behaviour Analysis and have documented research evidence to support their efficacy:
–Appetite manipulation: Limit access to food and snacks between mealtimes. Try to avoid food intake for up to two hours before mealtimes. Meal times could be scheduled for 8a.m, 12pm, 3pm and 6pm. If you are struggling with food refusal the likelihood is that mealtimes last an average of an hour.
– Positive reinforcement: It sounds simple but provide positive social praise for acceptance of food. Providing rewards related to food or access to preferred items or activities after feeding has also been shown to be successful in decreasing/eliminating food refusal. Given the negative cycle often associated with eating, including positive reinforcement based strategies could help to break the negative associations of food and meal times by developing association with positive activities, objects and praise.
–Shaping/food chaining: Mixing and blending non-preferred with highly preferred food also works! Start of with a higher percentage of the preferred food to non preferred food. For example 95% preferred to 5% non-preferred and then work to systematically in increase the amount of non-preferred food whilst decreasing the amount of preferred food It should come to you as no surprise that there is research evidence to support that adding ketchup to vegetables led to an increase acceptance of vegetables without ketchup over time (Ahearn, 2003).
–Generalization: As soon as you are able to, explore eating in different areas of the house and out of the home setting. Introduce new foods early on.
-Extinction- You may be successful with a combination of all the above but in most cases extinction procedure will be required. Extinction basically means withholding access to everything but the food until they accept it. Extinction must be done in combination with the above strategies and under the supervision or advice from a professional such as a Behaviour Analyst.
We hope you have found this article helpful. If you want to learn more about food refusal and ABA, we’d be happy to help.
Below is a testimonial from a Learning Support Assistant (LSA) at a mainstream school whom we have provided extensive training in ABA to over the last few years. This LSA asked us for our support with a boy who was refusing food. We were able to provide her with a food refusal program and she was able to use what she has come to know as best practice strategies such as visuals, fading, shaping and reinforcement to support this young boy. Well done to this special LSA!
When we first started with this boy he would sit on the lunch table and not even face the plate of food that was put in front of him. If asked to turn around or even hold his fork he would grasp at his neck and show signs of anxiety. The only thing we could get him to eat was a banana, at home he would only eat McDonalds chips and bananas and a few other foods such as yoghurt.
After Georgiana set us up with the program we got to implementing it as soon as possible. I also made a picture resource with Velcro.
We started by just putting a small chunk of a new food on his plate and watching it take him 30 minutes to nibble at, but by the end of the term we saw so much progress to the point where he would eat a whole plate of foods that he had tried. An example of this would be; 2 Quarters of a ham sandwich, a box of raisins, a biscuit and a fruit. He would also take a fruit out every playtime on top of this! It’s genuinely so heart warming to see him eating with his friends and seeing the anxiety and fear slowly drop off him as he keeps trying!
We then sent the programme home with his mum for them to continue over the summer.
He still will not eat hot foods yet, but we are heading in the right direction!
Thanks Georgiana 🙂
Ahearn, W. H. (2003). Using Simultaneous presentation to increase vegetable consumption in a mildly selective child with Autism, Journal of Applied Behavior Analysis, 36, 361-365.
Chatoor Feeding disorders in infants and toddlers: diagnosis and treatment
Child Adolesc Psychiatr Clin N Am, 11 (2002), pp. 163-183
Field, D., Garland, M., & Williams, K. (2003). Correlates of speciﬁc childhood feeding problems. Journal of Pediatrics and Child Health, 39, 299–304.
Koegel, R. L., Bharoocha, A. A., Ribnick, C. B. Ribnick, R. C., Bucio, M. O., Fredeen, R. M., & Koegel, L. K. (2012). Using Individualized Reinforcer and Hierarchical Exposure Increase food flexibility in children with Autism Spectrum Disorders. Journal of Autism Developmental Disorder, 42(8), 1574-1581
Majdowski, A. C, Wallace, M. D., Doney, J. K., & Ghezzi, P. M. (2003) Parental Assessment and treatment of food selectivity in natural settings, Journal of Applied Behavior Analysis, 36, 383-386.
Piazza, C. (2008). Feeding disorders and behavior: What have we learned? Developmental Disabilities Research Reviews, 14, 174–181