Practical mealtime strategies to increase food variety in preschool children

The following stages of the study will generally take place during two to three weekly visits to the child's home, dependent on family availability. All participants will progress through the following phases. Procedures will be implemented by a Masters level behavior therapist, under the supervision of a Registered Psychologist and Board Certified Behavior Analyst (BCBA) Assessment - Interview with parents to gather more information regarding child's feeding habits, routines, mealtime problem behaviours and parent's feeding goals. An overall list of 12 target foods will be developed. - Caregiver will complete the Behavioural Pediatrics Feeding Assessment Scale (BPFAS) - Meal observation - the caregiver will be instructed to present foods to their child, one at a time, from an initial group of 4 target foods. They will otherwise be instructed to act as they usually would. This meal will continue for up to 15 min, or may end early if the caregiver requests to do so. - Intervention Intervention sessions will generally be conducted by the behavior therapist 2-3 times per week, depending on family availability. The length of each meal session will be limited to 20 minutes. Each meal session will generally involve a group of four foods, and all foods will initially be presented in pea-size bites. Caregivers will be requested to sit at the table and participate in each session. If a child leaves the table during any meal session, the experimenter will remove access to toys or other activities and state "it's our meal time now". If the child does not return to the table within 5-minutes, the session will be terminated for that day. The interventions will be introduced in the following order. If after at least three meals, the child is not consuming at least 80% of foods, we will proceed to the next listed intervention. Intervention A. Repeated Exposure During repeated exposure, four foods will be prepared and ready. The experimenter will use flashcards to randomly choose a different food to present to the child, one at a time. The experimenter will place the food on a small plate in front of the child, with the instruction "Try ___". The food may be presented on a spoon to the child where required (e.g., yoghurt). If the child approaches (e.g., tastes, licks) or accepts the food within 15-seconds, the experimenter and caregiver will provide praise specific to the child, for instance "well done [child's name], you are doing so great". If the child has placed the food in their mouth, after 15-s the experimenter will instruct the child to 'show me' and check that the child has swallowed the bite of food (praise provided). If the child has not swallowed the bite of food, they will be instructed again to do so. If the child does not approach or accept the food within 15-s of acceptance the experimenter will remove the food with no comment, and then present the next food with instruction. Procedural integrity (i.e., treatment fidelity) will be monitored by measuring experimenter behavior against a checklist that outlines the components of treatment. After an initial session, behavioural skills training (BST) will be used to teach parents to conduct repeated exposure sessions on days where the experimenter is not present. Behavioural skills training will involve reading written instructions together, the experimenter modelling the procedures, and the caregiver and experimenter (or child) role-playing the procedures. Caregiver adherence will be monitored by reminders (e.g., text message or email), as well as the caregiver completing a brief data sheet for each meal session. Intervention A+B: Repeated exposure + Modelling Repeated exposure will continue as above, though modelling will be involved as an additional component. Throughout the session, the experimenter and caregiver will now also have plate/s containing the target foods and will eat small pieces. At regular time they will express positive responses such as "oh this [name of food item] is delicious". As described above, parents will then be instructed to add modelling to sessions where the experimenter is not present. Intervention A+B+C: Repeated exposure+ Modelling + Reinforcement To identify reinforcement that is most relevant to the child, we will conduct an assessment known as a Functional Analysis. A functional analysis looks to identify potential reasons for food refusal, which are commonly a) caregiver attention, b) escape from eating (the meal ending or food removed), and/or c) access to preferred foods or activities (e.g., providing chips instead, turning TV on). Information used from the initial interview and prior meal sessions will be used to develop two conditions: • CONTROL condition: the reported consequences of food refusal are absent. If the caregiver highlighted that attention and preferred foods are often provided upon food refusal, this condition would involve providing attention and preferred foods continuously. • TEST condition: the reported consequences of food refusal are present in this condition. In comparison to the control condition example, the test condition would involve the caregiver providing attention and a preferred food upon every instance of food refusal. The assessment would involve 5-minute conditions, rotating between the control and test condition. If we see higher levels of problem behaviour in one condition over another, this indicates potential events that are motivating for the child (such as attention). If we do not see changes in the level of behaviour across conditions, we will conduct further interview with the caregiver and modify conditions. Once we have identified the relevant reinforcer, further intervention sessions will involve providing this reinforcer upon acceptance of bites of food. The session will continue to involve repeated exposure and modelling as described previously. However, the child will be instructed at the start of sessions that "taking a bite" will result in "________" (supported by a visual where required). During the session, if the child accepts the bite within 15-s, praise will be provided as previously described, as well as access to the reinforcer (e.g., attention and a bite of preferred food). If the child does not accept the bite within 15-s, it will be removed with no comment and the next food will be presented. If this intervention level is effective for the child, we will continue with caregiver training as described for the previous phases. As reinforcement is more detailed, training is likely to require more time than previous interventions. If this intervention level is not effective for the child, we will attempt further sessions with a higher level of reinforcement (e.g., larger bites of preferred food), or reduce the eating expectations (e.g., touching the food to the mouth results in reinforcement). If modified procedures do not result in improvements within three further meals, we will end the study for the child. If the caregiver consents, we will assist with referral to an appropriate provider (e.g, speech language therapy, child development team). End of the study The study will end for the child when they consume at least 80% of bites, during at least three meals which involve 12 target foods, or by November 15th 2019, whichever occurs earlier At the end of the study, The BPFAS will be provided to the caregiver to be completed again The caregiver will be asked to complete a brief satisfaction survey Follow-up The experimenter will visit the family 1 and 3 month(s) after intervention. The caregiver will be asked to conduct a meal during each visit, using foods that were previously used during the intervention, as well as new foods.