Behavioural Assessment and Treatment to Transition Children from Tube Feeding to Oral Nutrition

Part 1. Caregiver interviews and brief mealtime observation Pediatric Feeding Assessment Interview. The structured interview will be completed with caregivers. The survey is designed to elicit information about potential antecedents and consequences that influence the child’s feeding behaviour. Consent will be gained to access relevant paediatric reports to identify previous and current medical diagnoses and oral motor skill. Specific details will be collected with regards to liquids/foods (oral stimuli) previously or currently accepted (antecedent dimensions), as well as caregiver responses to the child’s inappropriate mealtime behaviour (consequence dimensions). Pediatric Inventory for Parents. This self-report questionnaire has been considered well established at assessing family functioning in the context of chronic childhood medical problems. The questionnaire will also be administered following treatment. Preference assessment. An interview, The Reinforcement Assessment for Individuals with Severe Disabilities (RAISD) will be used to determine the preferences of a participant. This interview tool will be completed by a caregiver, or child where able. This interview provides information on useful reinforcers for the individual. We will then conduct a paired-stimulus preference assessment where we will record the participant’s frequency of approach to items when presented in varied pairs. The most preferred items and activities will be used during the assessment and treatment, and to develop rapport with the participant Brief mealtime observation: A brief mealtime will be observed where the caregiver initially feeds the child under normal conditions, followed by structured conditions (e.g., presenting food every 30 sec) Part 2. Experimental Assessment Assessment to occur in a regularly scheduled mealtime. The researcher will present the child with food or drink under a range of conditions (i.e., feeding method, volume of food). Assessment sessions will last for up to 30 min, and up to 6 sessions spread over a few mealtimes (e.g., 3 hours) may be required. Data will be collected with respect to acceptance of oral stimuli, as well as rates of mealtime problem behaviour. We will examine these assessment results to develop an initial treatment plan based on the conditions that resulted in consumption of food or drink, or lowered rates of problem behaviour (e.g., less screaming observed when a bottle is used instead of spoon). Part 3. Experimental treatment evaluation Intervention will initially be conducted by the researcher. Intervention will involve progressively altering properties of food, liquid, feeding method, or instructions, based on assessment results. Treatment examples could include one or a combination of the following progressions: - Volume (e.g., empty teaspoon to full teaspoon) - Texture (e.g., puree to chopped fine food) - Feeding method (e.g., baby bottle to a spoon) - Food preference (e.g., blending non-preferred food with preferred food) - Feeding-related instructions (e.g., instructions with high compliance to instructions with low compliance) Progression of treatment (e.g., increasing volume or texture) will be determined based on directly observed behavioural criteria. Progression will occur following three consecutive sessions where a child's consumption (acceptance and mouth clean) is at or above 80%, and problem behaviour is at or below 20%. Behavioural data, the child's weight, and volume of oral stimuli consumed will be shared with the child's Health Team to determine enteral nutrition reductions. If initial treatments do not demonstrate clinically significant results (over three consecutive sessions - maximum one week), additional treatment components will be added the following week (provided consent is provided from caregiver and Health Team is consulted). These additional components could include: (a) Reinforcement. We will use differential reinforcement procedures whereby we will provide reinforcement for consumption of the oral stimuli, whilst providing no reinforcement for any inappropriate behaviours. The items used as reinforcers for each child will be based on initial assessment. Following the consumption of the oral stimulus, we will provide access to the preferred food or item (for a period up to 15 s). (b) Escape Extinction. The escape extinction method will be determined with caregiver and health team input, but will take either of the following forms if the oral stimulus is not accepted within 5-s. - Nonremoval of the spoon – the oral stimulus will be held near the child’s mouth - Physical guidance – gentle pressure will be applied the child’s jaw to allow the oral stimulus to be placed in the mouth Intervention sessions will take place within regular mealtimes, for up to 30 min. The author will initially conduct intervention during at least 2 mealtimes per week. The author will continue to conduct the intervention at this frequency until stable treatment progress is achieved (e.g., the child progresses through at least two treatment levels). The timeframe to achieve stable treatment progress will vary by participant. Part 4. Caregiver training and implementation of procedures Caregivers will participate in training sessions, involving (a) review of written protocols, (b) observation of researcher led meals and data recording, (c) Role play of procedures, (d) Caregiver implementation under supervision. Data will be collected on the accuracy to which caregivers implement procedures. After meeting criterion, caregivers will be able to implement procedures with their child. At this stage it would be expected that the caregiver implements procedures during every oral feeding meal (e.g., 3 x 30 min meals per day). This would continue until the child meets their initial treatment goal (e.g., to eat an age-appropriate portion of pureed food), or up to 12 months. Adherance to the intervention will be monitored by collecting 'Procedural Integrity' data. An independent observer will record whether each treatment component is implemented correctly or incorrectly for the researcher. The researcher would collect this data when the caregiver is implementing procedures (either in vivo or from video recording). Treatment sessions will be continued in the manner above (e.g., either researcher- or caregiver-implemented) until the child reaches their treatment goal, or 12 months