Child Constitution Interventions

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  Referral to Address Behavioral/Psychiatric Issues
  Behavioral Management

Behavioral management procedures systematically apply positive and negative consequences contingent on specific child behaviors. Behavior management procedures consist of techniques based on learning principles that can be applied to problems to strengthen adaptive behaviors and weaken maladaptive behaviors. Of particular interest in clinical feeding interventions are 1) aspects of the feeder’s responses that have an inadvertent affects on feeding patterns and 2) planned techniques for “unlearning” or modifying maladaptive feeding patterns by rearranging social and environmental consequences for feeding. Behavior management techniques have been particularly recommended for problems related to food selectivity, mealtime conduct problems, and delays in self-feeding, as opposed to problems with quantity of intake which may be more affected by appetitive variables.

Background Education for Providers

Considerable evidence supports the use of behavioral approaches in the treatment of feeding disorders. Behavioral treatment goals generally consist of (1) decreasing behavioral problems at meals; (2) decreasing parent stress at meals; (3) increasing pleasurable parent-child interactions at meals; (4) increasing oral intake or variety of oral foods; (4) advancing texture (e.g. moving from purees and smooth foods to chewable solids); and (5) increasing the structure and routine of meals. Behavioral treatment strategies include implementation of mealtime structure and a feeding schedule, appetite manipulation, behavior management, and parent training. Ongoing consultation with other specialists, especially a dietician and speech pathologist, is frequently necessary to monitor the safety of the therapeutic plan that can result in transient weight loss, or that may unmask oral motor or swallowing deficits as behavioral resistance to feeding begins to resolve.

The essential elements of behavior management are (1) to identify the targeted behavior for change; (2) select techniques to increase or decrease behaviors congruent with feeding goals; and (3) develop a treatment plan that consistently pairs a contingency (positive or negative) with the targeted behavior. Strategies to increase positive behaviors include use of positive and negative reinforcement and discrimination training. To reduce negative behaviors, treatments typically include extinction, satiation, punishment, and desensitization. Typically, behavioral strategies are used in combination to create the strongest treatment effects in the shortest period of time.

Overview of behavior management principles and strategies (PDF)

Instructions for Provider

Principles to INCREASE behavior

Underlying Principle Description of Application Example Supplemental Materials for at Home Behavioral Management
Positive Reinforcement (PDF) Positive consequences for desired behavior Give praise, physical affection, or tangible rewards Behavioral Parent Training-Increasing Positive Behavior (PDF)
Positive Reinforcement Strategies (PDF)
Feeding Sticker Chart (PDF)
Token System Placemat (PDF)
Negative Reinforcement (PDF) Terminate aversive stimulus contingent on desired behavior Release physical restraint when child accepts food Referral Form for Behavioral Psychology (PDF
Discrimination (PDF) Reinforce target behavior in presence of defined stimulus Praise modeled behavior of eating Tips for Modeling (PDF)
Shaping (PDF) Reinforce successive approximations toward desired response Praise 1) looking at food, then 2) allowing food to touch lips, then 3) opening mouth, then 4) accepting food The 5-Senses Challenge (PDF)
Sample Behavioral Contract (PDF)
Behavioral Contract Template (PDF)
Shaping Placemat (PDF)
Fading (PDF) Gradually remove assistance and reinforcement needed to maintain behavior Decrease extent of guidance and rewards as child gains self-feeding skills Tips for Weaning Off Rewards (PDF)

Principles to DECREASE Behavior

Underlying Principle Description of Application Example Supplemental Materials for at Home Behavioral Management
Extinction (PDF) Withholding rewarding stimulus contingent on target response Ignore mild inappropriate behavior; Continue prompts during escape behavior Tips to Extinguish Unwanted Behaviors (PDF))
Punishment (PDF) Present aversive stimulus or remove rewarding stimulus contingent on undesired behavior Use timeout; Give verbal reprimand; Restrict toys; Use overcorrection Timeout (PDF)
Referral (PDF)
Desensitization (PDF) Pair conditioned aversive stimulus with absence of aversive events or with presence of positive events Distract child during fearful procedure; Use gentle massage to promote acceptance of touch< The 5-Senses Challenge (PDF) Desensitization Tips (PDF)
  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

Contact Us

Email the Nutritional Disorders Telehealth Network Project Team

Please contact us if you are interested in using any of the project materials or if you would like more information regarding the project.