bfs@nu -world.com

Children who experience medical, developmental, and behavioral disabilities and their families often require intensive behavioral support to reduce the potential impact such events can have on the life of the family. One specific problem that can occur in children with chronic medical and developmental needs is potentially significant issues around food refusal and selectivity. 

It is also worth noting that food refusal and mealtime related problem behaviors can be all too common in younger children in general and very common in younger children experiencing a range of developmental disabilities. For this reason, effective management and intervention remains important regardless of the etiology, or cause, of this concern. 

Based on the potential complexity of issues related to food refusal in younger children, educators and other community-based providers must be knowledgeable of any relevant diagnosis, collaborative with medical professionals, and able to work within the family system in order to best address those social, functional, and adaptive skills needed by the child. Even when food refusal has a specific medical basis, it can be very hard for families, teachers, and other caregivers to remain objective and deliberate.  After all, few greater frustrations exist in child care then when a child is even refusing adequate nutrition.

At its worst, food refusal can become life threatening.  At the least, this behavior by a child can lead to enormous frustration for the family and other care givers.  Such behavior can also inadvertently shape interactive patterns around mealtime that actually reduce, rather than increase, the likelihood of success over time.  When this occurs, comprehensive behavioral support and intervention becomes even more important. 

For instance, extended mealtimes, punitive approaches, coercive cycles, attempts to provide a huge variety of food items (the smorgasbord approach to intervention!), reduced child independence, and family conflict can result. Coercive cycles reference the pattern between child and caregivers whereby the positive and the negative reinforcement cycles discussed earlier on this site can actually coexist. 

That is, the child is both negatively (gets out of meal expectation) and positively (is then able to gain access to a desirable alternative) reinforced while the parent/caregiver is more often negative reinforced when they finally give in to the problem behavior (the child discontinues their very aversive behavior towards the parent or caregiver!). As a result, chronic food refusal can very quickly leave the child at risk for impaired health and social functioning while pulling a caring family apart.  An unnecessary cycle of blame and guilt may become a part of the meal time routine.

Food refusal is more often related to context and other external variables then it is to issues solely in the child.  Intervention must consider the REASONS behind the problem combined with an awareness that the child is just ONE member of a complex social system.  Behavior rarely happens in a vacuum!  Besides evaluating meal opportunities, emphasis must also be on those interacting variables in the system that consistently compromise success.   Intervention, then, must target setting conditions rather than the focus person alone.

As with ANY challenging behavioral pattern, a specialized Mealtime Functional Behavioral Assessment (FBA) should be administered that examines environment, context, setting events, triggers, behavioral purpose (the outcome being received by the food refusing child) along with the concurrent needs of the child, setting, and primary persons in the setting. 

Such meal specific elements as eating history, preferred texture and pace, food temperature, preferred and non-preferred items, and family preferences are also considered. Specific behavioral skills as self-expression, waiting, protest, generalized compliance, sustained attention, choice making, & self-management should also be examined & targeted as needed. 

After all, if a child tends to be generally oppositional during the day, s/he should hardly be expected to suddenly start listening just because it is dinner time.  Similarly, children who have a very short attention span will require intervention and instruction which target this area BEFORE a more traditional meal routine should be expected.  Meal time intervention plans should not only target the meal routine, itself.  Environmental, interactive, and skill-based elements must also be actively intervened.      

The Mealtime FBA should also consider conditions and interactions that both increase and decrease the chance for mealtime success via the consideration of Setting Events (events that occur before an activity which increases or decreases the chance for other behaviors).  For instance, a child who engages in active play right before a meal may find it hard to suddenly sit down and eat.  Meals that occur with a large number of toys and other items within reach may keep the child overly focused on those items. 

Similarly, parents, caregivers, and/or teachers who spend a period of time before meals talking about the meal and trying to ’convince’ the child to eat may actually be socially reinforcing non-eating behavior patterns.  After all, if the child likes this time and contact with the parent, caregiver, or teacher, eating may actually reduce this pre-meal contact time!  A key here would be to rearrange the pre-meal time to sustain the positive contacts while changing the form or nature of those contacts. 

Food amounts and their overall presentation can also make a big difference.  As noted above, the stress of a child who consistently resists food can lead to interactive patterns with caregivers that actually reduces the chance for success over time.  To be effective, behavioral assessment must also examine for these transactional relationships.

Above all, interventions should be tailored to the needs of each child and family, be pro-active and, always, positive.

Childhood Food Refusal