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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:  speech pathologists from ADHC and Cerebral Palsy Alliance  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? What is the current best evidence? Engaging in EBP to learn more about EE What does our clinical expertise tell us? Look at our policies and procedures Survey current practice Where 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%) - nonremoval 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 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 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? 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 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 – 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 therapy techniques seem to achieve the ‘best’ results Current Best Evidence I just want my child to eat so their nutritional needs are met and I want this to happen in the easiest possible way! Are we comfortable with recommending escape extinction for children who 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