Improving Feeding Skills and Mealtime Behaviors in Children and Youth with Disabilities

A single-subject multiple treatment design counterbalanced across nine participants with moderate to severe and multiple disabilities was used to determine the efficacy of a school-based multi-treatment package (a combined dysphagia treatment and positive reinforcement behavior management program) for children and youth (ages 4-17) with feeding problems as compared to use of a dysphagia treatment program or a positive reinforcement behavior management program alone. While results found improvement in development of feeding skills and positive mealtime behaviors with all intervention programs, the combined intervention package was the most effective intervention strategy. These results may help professionals establish best practices for treatment of feeding problems in schools. Problematic mealtime behaviors are a common finding in children diagnosed with feeding and/or swallowing problems collectively known as dysphagia (Arvedson, 1997; Kerwin, 1999; Logemann, 2000; Munk & Repp, 1994). These behaviors may develop for a variety of reasons and range from those that are socially inappropriate to those that have a detrimental effect on nutrition and health. These challenges often make mealtimes unpleasant. Many problems that children experience in the areas of feeding, growth, and food acceptance have been attributed to a combination of the medical or physical condition of the child, inappropriate food selection, and/or inappropriate dynamics during feeding (Satter, 1990). Inappropriate caregiver-child interactions that have been found to precipitate problems may include attention for negative behaviors, responses to attempts at forced feeding, and reduction of feeding choices due to food selectivity preferences in children (Christophersen & Hall, 1978). Children with dysphagia may find mealtimes stressful and unpleasant. If children have experienced airway compromise such as occurs with aspiration and choking, they may associate these negative experiences with the act of eating. Medically fragile children are often subjected to medically necessary but intrusive and aversive oral/facial sensory inputs. Suctioning, oral and nasal gastric tube placement, and the use of facial tape to secure tubes may lead to tactile defensiveness and oral hypersensitivity (Comrie & Helm, 1997). Early experiences with oral sensory stimuli are often limited for children with neurological and/or physical impairments, especially for those who experience extensive episodes of hospitalization. This may limit new and repeated exposure to foods. This lack of oral sensory experiences may lead to food aversions and refusals, a common finding in children with eating disturbances (Pelchat & Pliner, 1986). Early experience and repeated exposure to new foods contributes to development of food acceptance patterns and control of food intake. In fact, most children are likely to reject new foods initially, but they learn to like them with time and repeated neutral exposure (Birch, Johnson, & Fisher, 1995; Birch & Marlin, 1982). It is clear that eating does not exist in isolation from the context in which it takes place. Caregiver influences, physical conditions, social, psychological factors, and the feeding environment impact the development of feeding. Statement of the Problem Children with combined dysphagia and problematic mealtime behaviors present a particuCorrespondence concerning this article should be addressed to Rita L. Bailey, Department of Special Education, Illinois State University, Campus Box 5910, Normal, IL 61790-5910. Education and Training in Developmental Disabilities, 2005, 40(1), 80–96 © Division on Developmental Disabilities 80 / Education and Training in Developmental Disabilities-March 2005 lar challenge for school personnel involved in supervision and feeding of children and youth with disabilities. Several authors have described programs for increasing oral-motor skills and oral-sensory awareness in children (e.g., Alexander, 1987; Bahr, 2001; Gaebler & Hanzlik, 1996; Hall, 2001; Morris & Klein, 1987), direct and compensatory therapies for improving feeding and swallowing skills (e.g. Arvedson, 1998; Hall; Kovar, 1997; Larnert & Ekberg, 1995; Logemann, 2000) and behavior management programs to improve behavior at mealtimes (Kerwin, 1999; Munk & Repp, 1994; Rasnake & Linscheid, 1987; Sisson & Dixon, 1986). Unfortunately, these have not been widely used in educational settings. In fact, dysphagia treatment by speech-language pathologists (SLPs) has historically occurred predominately in medical settings (Silliman, 2000). Management of feeding and swallowing disorders has become an issue for school-based SLPs. The American Speech Language and Hearing Association addressed this issue in their Technical Report Executive Summary (2002) stating, The area of pediatric swallowing and feeding disorders is one of the most rapidly evolving patient care areas for medically-based SLPs and other professionals serving children. In addition, as an increasing number of highrisk infants survive and enter educational programs, SLPs must acquire medical knowledge and skills to manage swallowing and feeding disorders (p. 76). Additionally, while behavior management programs and dysphagia treatment for management of feeding problems have been described, there are relatively few studies that have investigated combined treatments for dysphagia co-existing with behavioral feeding problems. The comparative use and efficacy of dysphagia treatment programs, behavior management programs, and combined treatment programs is unknown. This information is necessary to establish best practices for treatment of feeding problems in children and youth. Dysphagia Treatment Methods Therapies for pediatric dysphagia include direct intervention strategies such as oral-motor exercises and swallowing maneuvers (Logemann, 2000). Compensatory strategies include positioning for optimal safety and airway protection, specialized feeding techniques to change the feeding pattern (i.e., therapeutic feeding methods), sensory enhancement procedures, nutritional enhancement, and the use of adaptive feeding equipment to encourage heightened awareness, maximization of skills, and improved independence in feeding (Alexander, 1987; Arvedson, 1997; Arvedson & Brodsky, 1993; Gaebler & Hanzlik, 1996; Hall, 2001; Logemann; Morris & Klein, 1987). Methods chosen vary according to the specific needs and cognitive abilities