Interaction Management Interventions

 Positive Reinforcement

Reinforcement is one of the most powerful strategies to teach a child what to do. A reinforcer is anything that increases or strengthens a behavior.

Background Education for Providers

Positive reinforcement is defined as the delivery of a desired stimulus (e.g., praise, stickers, points toward a reward, preferred food [to be used only the case of undernutrition]), contingent on performance of a target behavior (e.g., taking a sip of milk, taking 3 bites of a new vegetable), that strengthens the probability that the target behavior will occur in the future. Typically, affectionate or approving forms of attention are used as positive reinforcement for children. For older 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. Thus, an integral component of most behavioral intervention programs is social approval contingent on desired feeding behavior.

Next to social attention, the most common consequence in behavioral feeding programs for undernutrition is preferred food. This technique is based on the Premack Principle, using a high-probability behavior (eating preferred food) to reinforce a low-probability behavior (eating new or non-preferred food). Contingent social attention is often combined with tangible forms of reinforcement, such as the opportunity to play with toys, the opportunity to watch television, the opportunity to gain tokens redeemable for items of value, or the opportunity to gain access to other preferred activities.

Instructions for Provider

Healthcare providers should discuss with parents their normal mealtime patterns, and the positive and negative behaviors that occur during mealtimes. Healthcare providers should provide information for parents on appropriate mealtime behaviors that should be reinforced, and the appropriate ways to provide positive reinforcement. Remind parents that attention is one of the most powerful reinforcers that they can use with their children. Handouts on positive reinforcement strategies and sticker charts (if age appropriate) should be given to parents to help them apply positive reinforcement strategies at home.

Supplemental Materials

 Extinction

Elimination of rewards paired with a behavior which decreases the likelihood of the behavior occurring in the future.

Background Education for Providers

The overall goal of extinction is to reduce or eliminate a behavioral response (e.g., a tantrum when a child is asked to eat a non preferred food). The most common example of extinction in feeding therapy is to ignore problem behaviors such as refusals or tantrums. Typically, differential social attention (paying attention to desirable behaviors while ignoring problem behaviors) maximizes the child’s opportunity to learn the behaviors that are desired by the feeder. Parent training in differential attention procedures often needs to include modeling and practice to refine caregivers’ skills and to provide emotional support during intervention.

Instructions for Provider

Healthcare providers should discuss with parents their normal mealtime patterns, and the positive and negative behaviors that occur during mealtimes. They should identify the inappropriate mealtime behaviors that should be extinguished and provide handouts on decreasing negative behaviors using differential reinforcement. Providers should be sure to discuss with parents the possibility for an extinction burst where the child’s inappropriate behavior may increase before it decreases (this is a normal phenomenon).

Supplemental Materials

 Mealtime Structure/Schedule

Providing a consistent environment and a fixed daily schedule of meals and snacks.

Background Education for Providers

Children, similar to adults, often benefit from a fixed schedule of activities across the day. When meals are set at fixed times each day, children become accustom to the routine and are comforted by the predictability of the similar characteristics of each meal. Further, children will develop a predictable pattern of hunger that coincides with the schedule of meals and snacks, which in turn motivates the child to feed.

Families should also have a feeding environment which is free from distractions, which has appropriate seating for the child, and allows the adult caregiver the ability to monitor feeding for the duration of the meal. Children typically feed best when eating at a table with food placed in front of them for the duration of the meal. At minimum, the child should be supervised one–to-one throughout the meal by a responsible adult. Ideally, the adult supervising the feeding is also eating so that they are able to model appropriate feeding behaviors for the child. The feeding environment should be free of distractions (e.g., no toys or TV at the table) as this will help the child to focus on the task of eating as well as focus their attention on the adult supervising the meal. The child should be seated so that they are comfortable and secure (with safety strap as appropriate).

Children should only be offered foods and beverages at specified meal or snack times. However, water should be offered and encouraged throughout the day. Children should learn that meal times are finite and that opportunities to feed in a given day are limited to the fixed schedule. Studies have shown that children who adopt a grazing meal pattern (e.g. frequent intake of small portions of food and caloric beverages through the day) take in fewer nutrients in a 24 hour period when compared to children that eat on a fixed schedule. Specifically, grazing reduces appetite and intake secondary to disruption of the hunger and satiation cycle. Without intervention, the grazing child will chronically under meet his/her nutrition needs to support appropriate growth and development.

Finally, unstructured feeding patterns can result in ambiguity as to who controls the food selections. If a child is granted even occasional control of menu selections, this may result in periods of great conflict when the adult caregiver attempts to introduce new or non-preferred foods. Children may erroneously conclude that they are in control of food choices and that they are entitled to select whatever foods they wish. Unfortunately, caregivers that encounter significant resistance when selecting new or non-preferred foods may defer their authority over the meal to ensure that their child eats something.

Ultimately, the parent may lose all ability to control the mealtime environment (food selections, meal schedule, meal duration).

Potential negatives: Tantrums, begging, sneaking snacks.

Not every family is able to follow the same feeding schedule due to logistics, culture, or regular family practices.

Instructions for Providers

The use of schedule and environmental factors to increase the positive effects of mealtime include: promoting appetite improving intake, providing a mealtime environment that minimizes distractions, promoting parental control, and improving overall nutrient intake.

Before Meals

  • Avoid eating between scheduled meals and snacks. Do not allow children to graze on snacks or juice throughout the day. This way your child can come to the table hungry.
  • Try to have meals and snacks around the same time every day. Keeping to a routine every day can be hard, but try to keep to routine on most days.
  • Make one meal for the family (with at least one item that your child enjoys) and expect that everyone eat what has been made (or they don’t eat at that meal). Do NOT act as a “short order cook!”

During Meals

  • Turn off the TV and put all toys and other distractions in a different area.
  • Eat all meals and snacks at a table with your child seated in a chair that fits him/her. Do not allow children to wander around the house with food/drink
  • Meals should last a maximum of 20 to 30 minutes. Younger children (under 5) may have 15 to 20 minute meals.
  • As often as possible, try to have family meals.
  • Offer solid food before liquids and oral feeding before tube feeding.

Ending Meals

  • Release your child from the table after the time is up (remember 20 to 30 minutes for kids over 5 and 15 to 20 minutes for kids under 5). Do not try to make a child sit at the table “until their plate is clean.”
  • Try to release your child from the table before he/she begins to whine, cry, or tantrum. It is best to end on a success!
  • Try to end meals on a positive note. An example could be your child taking one last bite or sip.

Supplemental Materials

 Behavioral Contracting

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.

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 measureable 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

 Stimulus Control Strategies

Stimulus control strategies are a type of behavioral interventions for weight management that are supported by research as being efficacious. Stimulus control strategies involve identification and modification of environmental factors that influence eating patterns. The goal of stimulus control strategies is to reduce environmental characteristics or situations that serve to trigger maladaptive eating behaviors.

Background Education for Providers

Setting Characteristics
The setting in which eating occurs, exerts an influence over intake. Relevant aspects include the immediate surroundings of the eating area and the child’s position and body support during meals. Activity-related characteristics include events preceding or follow meals. Setting characteristics may have a direct impact on the feeding environment, and/or they may affect feeding through a history of being paired with a child’s learning experiences. In behavioral terms, these paired settings events are described as exerting stimulus control over feeding behavior. Setting characteristics can exert facilitative or detrimental effects on children’s behavior. Research suggests important attributes of the feeding setting include physical surroundings, feeding position and body support, and activities preceding and following eating.

Physical Surroundings of Eating
A solitary location devoid of visual or auditory distractions (e.g., no television, computers and/or other screen time activities) may be most conductive to eating. Caregivers of finicky eaters typically are advised to serve meals in a consistent eating area, to restrict the people present to those who are eating, and to allow toys or activities only if they do not disrupt eating. In addition, it may be advisable to limit the number of feeders – especially early in intervention to one or two people who are trained in the feeding procedure. In the case of overnutrition, plating the food in the kitchen and offering the child only the portion sizes on his/her plate is recommended. Additionally, clearing the eating area of any excess food immediately after completion of the meal is recommended.

Feeding Position and Body Support
The goal of positioning is to provide postural control in a manner so that the child does not resort to abnormal postures to compensate for lack of control. A secure, well-balanced posture during meals enhances a child’s motor coordination and attention to feeding. The feeding position for infants is to be cradled in a caregiver’s arms or to be held securely on the caregiver’s lap. Older children typically are seated upright in a chair or high chair, which allows maximal use of the hands for self-feeding and reduces the likelihood of choking. As part of the intervention, parents are often told to seat children securely for meals. Muscle tone and posture are interrelated with a child’s state, physiological control, and oral-motor coordination. Children with physical disabilities often need modifications in feeding positions to provide for optimal alignment of head, neck, and trunk.

Instructions for Provider

The use of schedule and environmental factors to increase the positive effects of mealtime include: promoting appetite improving intake, providing a mealtime environment that minimizes distractions, promoting parental control, and improving overall nutrient intake.

Before Meals

  • Avoid eating between scheduled meals and snacks. Do not allow children to graze on snacks or juice throughout the day. This way your child can come to the table hungry.
  • Try to have meals and snacks around the same time every day. Keeping to a routine every day can be hard, but try to keep to routine on most days.
  • Make one meal for the family (with at least one item that your child enjoys) and expect that everyone eat what has been made (or they don’t eat at that meal). Do NOT act as a “short order cook!”

During Meals

  • Turn off the TV and put all toys and other distractions in a different area.
  • Eat all meals and snacks at a table with your child seated in a chair that fits him/her. Do not allow children to wander around the house with food/drink
  • Meals should last a maximum of 20 to 30 minutes. Younger children (under 5) may have 15 to 20 minute meals.
  • As often as possible, try to have family meals.
  • Offer solid food before liquids and oral feeding before tube feeding.

Ending Meals

  • Release your child from the table after the time is up (remember 20 to 30 minutes for kids over 5 and 15 to 20 minutes for kids under 5). Do not try to make a child sit at the table “until their plate is clean.”
  • Try to release your child from the table before he/she begins to whine, cry, or tantrum. It is best to end on a success!
  • Try to end meals on a positive note. An example could be your child taking one last bite or sip.

Supplemental Materials

Contact Us

E-mail 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.

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Milwaukee, WI 53226
(414) 955-8296
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Page Updated 03/11/2015
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