Child Constitution Interventions – Overweight

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  Referral Worksheet to Address Behavioral/Psychiatric Issues
  Behavioral Management

Behavioral methods are useful in increasing food variety in youth who are overweight or obese. Behavioral methods include the use of repeated exposure to new foods and varied textures, positive reinforcement for trying new foods or textures, and use of ignoring (extinction procedures) or punishment for reducing unwanted behaviors related to trying new foods and textures. The goal of these methods is to increase the child’s acceptance of a variety of foods, thereby improving the quality of their oral intake.

Background Education for Providers

Suboptimal nutritional intake in children who are overweight or obese may result, in part, from consuming a restricted range of foods and refusal to eat a variety of foods or textures. It is common for children to exhibit neophobia, a preference of familiar foods over novel foods. Temporary neophobia is considered an adaptive response, in that unfamiliar foods may be dangerous and should be approached with caution. Parents often respond by removing the item from the child’s diet, thereby failing to broaden the variety of foods that the child will accept. Unfortunately, this may cause parents to stop offering previously rejected foods, and many parents will often fail to experiment with new foods, assuming that new foods would only result in food battles.

A number of strategies can be helpful in increasing the diversity of foods that a child will eat including repeated exposure to the new food, positive reinforcement for trying the food, and use of ignoring or punishment for reducing unwanted behaviors related to trying new foods.

One simple but fundamental technique for countering a child’s resistance to new or unfamiliar foods is to repeatedly offer the foods by placing them on the child’s plate, even though the child may not be required to eat them. Previous research has shown that preferences for novel foods increase markedly after approximately 10 exposures, regardless of the taste of the food, but that children must actually taste the new foods to change preference judgments, rather than simply seeing or smelling the foods.

Positive reinforcement involves the delivery of a desired stimulus (e.g., praise, stickers, points toward a reward), contingent on performance of a target behavior (e.g., taking 3 bites of a new vegetable). This reinforcement strengthens the probability that the desired behavior (trying the vegetable) will occur in the future. Typically, affectionate or approving forms of attention are used as positive reinforcement for young children. For school age children, the use of a sticker chart or point system in which points can be accumulated to earn prizes or privileges may be of value. For positive reinforcement to be effective, the child must have a strong desire for the reinforcement and must only get the reinforcement if he/she satisfies the goal.

Systematically discontinuing a reward following a response decreases the future probability of the response occurring. The most common example of extinction in behavioral feeding programs is to ignore undesired child behaviors such as refusals or tantrums related to trying new foods. Differential social attention involves combining the techniques of providing positive social attention contingent on cooperative behavior and ignoring the child briefly contingent on misbehavior, which presumably maximizes the child’s opportunity to learn the behaviors that are desired by the feeder.

Punishment involves delivering an unwanted stimulus (e.g., giving a time out) or removing a rewarding stimulus (e.g., losing a point, loss of parent attention) contingent on undesired behavior (spitting out food, tantruming about trying new food). Punishment weakens the probability that the undesirable response will occur. Punishment procedures involving highly aversive stimuli are recommended only when less intrusive procedures are not successful, the target behavior is damaging to the child or others, and when carefully monitored by trained personnel.

Instructions for Provider

For children who present with eating a limited variety of foods, it is recommended that the primary care provider talk with the family about implementing the following things at home (in the following order):

  1. Encouraging the child to smell, touch, and taste a variety of different foods and tracking their experiences on the Taste Challenge handout.
  2. Beginning to place one new food on a child’s plate with each meal.
  3. Encouraging the child to try 5 bites of a new food on their plate. A caregiver may offer a developmentally appropriate reward (stickers, points, etc.) for each time the child takes 5 bites.
  4. The caregiver should also praise the child for taking the bites and ignore any arguing, tantrums, or gagging responses.
  5. The above steps should be repeated up to 10 times (on consecutive days) until the child accepts the new food.

If after 10 trials, the child still refuses the food, the following steps could be implemented:

  1. The child could be informed in advance that a failure to take 5 bites will result in a developmentally appropriate consequence such as a time out (for preschool children) or loss of a point/token/sticker/privilege for older children.

Parents should be instructed that the reward for trying a new food should be paired with significant verbal praise.

Parents should be instructed that the reward should be given immediately after the goal is met (i.e., the child has taken 5 bites).

Parents should be instructed that only one new food should be tried at a time.

Supplemental Materials

  Behavioral Contracting/Goal Setting

A behavioral contract is a written agreement between a caregiver and a child to help them to achieve a specified goal. In a medical context this tool is generally used to help with adherence to a medical plan. Typically, the goal is stated in clear terms that the caregiver and the child understand, the behavior is defined, and a reward is agreed upon which is available upon completing the conditions of the contract.

Background Education for Providers

Using behavioral contracts to treat nutrition problems is a common practice. Previous studies support the use of this technique, especially when a clearly defined behavior is identified which can be easily modified and monitored.

Typically a behavioral contract includes (1) who the caregivers and child are, (2) the targeted problem to change, (3) the goal or objective, (4) method of monitoring, and (5) consequences, which may include both positive and negative consequences dependent upon the child’s progress.&

When developing a contract make sure that each participant is aware of their role. Typically, the caregiver is responsible for monitoring progress and giving rewards/consequences as appropriate. The child must follow the behavioral objective guidelines (engaging in a specified behavior or refraining from a specified behavior) to earn the reward. The most effective contracts have only 1 or 2 target behaviors which are clearly defined and which are easily monitored. Monitoring should be done daily and rewards and/or consequences should be given at the appropriate interval. Rewards and/or consequences should match the difficulty of the task. In other words, do not over reward believing this will improve the likelihood a child will comply. Past studies show that children who are over compensated actually decrease the frequency of the target behavior! Likewise, rewards and consequences should be in close proximity to the behavior otherwise the reward/consequence loses its effectiveness to change behavior.

Instructions for Provider

A behavioral contract is a written agreement that allows a child to earn a small reward or privilege by demonstrating a desirable behavior. Effective contracts are negotiated between adult caregivers and a child. In negotiation, the caregivers and child decide on a clearly defined target or goal, choose measurable short term objectives, establish methods for tracking progress, arrange for frequent positive consequences for meeting the terms of the contract, and specify dates and times for evaluation and renegotiation of the contract.

Goals should be likened to specific behavioral changes as opposed to clinical outcomes. For example, eating 3 servings of vegetables a day is a better goal than reaching a weight goal. Once the desired behavior has changed for a sustained period the contract should be renegotiated to promote continued progress on nutrition goals.

Supplemental Materials

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