Extensions of Assessment and Treatment of Food Selectivity

Extensions of Assessment and
Treatment of Food Selectivity

Presented by:
Holly C. Gover, PhD, BCBA-D
Vanderbilt University Medical Center - TRIAD
o I was a picky eater with the palette of a
toddler until my 20s
o Incompetence in ability to help families
with picky eating
o Life Skills Clinic at Western New
England University
o Since 2016… clinics, schools, homes,
telehealth, ages 3-22, varied
communication skills, etc.
o Each client continues to improve the
process
Rapid Fire Intro
o Food selectivity is pervasive
o Eating a variety of foods is important
…and a willingness to try a variety of foods may be of equal importance
o More research is needed on procedures that promote autonomy and inspire
behavior change through positive reinforcement contingencies
Objectives (2020)
o Identify ways to ensure safety and minimize risk
o Articulate the steps of a comprehensive assessment model
o Describe how to promote consumption of nonpreferred foods using
synthesized reinforcers, shaping, and embedded choice-making
opportunities
o Describe how to increase consumption of the amount and variety of
foods in a meal
Objectives
o Identify ways to ensure safety and minimize risk
o Quickly articulate the steps of a comprehensive assessment model
o Describe how to promote consumption of nonpreferred foods using
synthesized reinforcers, shaping, and embedded choice-making
opportunities with children with and without strong
communication skills, and in schools and in homes
o Describe how to incorporate trauma-informed care strategies to
increase safety and feasibility
Assessment
Open-Ended Interview
Food Preference Survey
Selecting target foods
Foods to target for consumption:
o Caregiver/client preference
o Child does not have adverse history with the food
o Family also eats the food
o Convenient to prepare every day and cut into pieces
o Taste remains consistent across time*
Foods to be used as reinforcers:

o Child always eats the food
o Convenient to prepare every day and cut into small pieces
Preference Analysis
Food preparation
• Select between ~5-8 nonpreferred foods and ~3-5 preferred foods
• Cut into small pieces (~1”x1”)
Food presentation
• Preferred/nonpreferred foods randomized and presented twice
• Place on plate with spoon/fork
• No differential reaction if the child eats the food or not
• Food removed contingent on any bid
• Instruct through language or contingencies, depending on child’s skills
Video 1
Video 2
Functional Analysis
Dad’s Attention
Escape
Snacks
Avoidance TV
Toys
Control Mom’s Attention
Functional Analysis
Purpose
o Safely demonstrate control over mealtime problem behavior
o Develop a baseline of tolerable problem behavior in the presence of food-
related establishing operations
o Identify a motivating context in which to subsequently increase
consumption during treatment
Performance-based Functional Analysis
PB in SR
Robert
1
In SR
PB in EO
In EO
0
0 4 8 2 6 0 4 8 2 6 0 4 8 2 6 0 4 8 2 6 0 4 8 2 6 0 4 8 2 6 0 4 8 2 6 0
:0 :1 :2 :4 :5 :1 :2 :3 :5 :0 :2 :3 :4 :0 :1 :3 :4 :5 :1 :2 :4 :5 :0 :2 :3 :5 :0 :1 :3 :4 :0 :1 :2 :4 :5 :1
00 00 00 00 00 01 01 01 01 02 02 02 02 03 03 03 03 03 04 04 04 04 05 05 05 05 06 06 06 06 07 07 07 07 07 08
Minutes
Video 3
Video 4
By the end of the assessment….
o Identified preferred and non-preferred foods to target for treatment

o Identified the events that safely evoke and abate mealtime problem
behavior
o Established baseline of consumption and mealtime problem behavior
Treatment
Phase 1: Bite Shaping
1 meal = 3-6 trials (depending on # target

foods)
Each trial the child selects:

• A food
• And what to do with that food
Corresponding consequence
delivered
delivered
delivered
delivered
delivered
delivered
Meal Complete
delivered
Luke
Age: 6
Language Level: Age appropriate
Diagnosis: Autism; ADHD
Referred for: Food selectivity, mealtime problem behavior
Swallow x 4 Functional Analysis Baseline Shaping with partial extinction
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Touch (plate) Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Video 5
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Swallow x 3
Swallow x 2
Swallow
Chew 5 s
Chew 3 s
Tongue 3 s
Tongue Full
Full SR
SR
Lips Full SR
Partial
Partial SR
SR
Smell Partial SR
Nose No
No SR+
SR+
No SR+
Hold Burrito
Burrito
Burrito
Noodle
Touch Noodle
Noodle
Lasagna
Lasagna
Pasta
1 ft away Pasta
Pasta
2 ft away
5 ft away Luke
5 ft (covered)
IMB
SPB
Pack
Gag
Vomit
Cry
5 10 15 20 25 30 35 40 45
Trials
4 5 6 7 8
Visits
4/28 5/5 Date 5/12 5/17 5/19
Treatment components
• Choice-board
• Shaping
• Varying levels of
• Differential
differential reinforcement
reinforcement with
• Choice of food
synthesized reinforcers
• Choice of what to do with
• Choice to participate
food
• Hang-out corner
Shaping without escape extinction
Chew food for 5 s
Chew food for 3 s
Balance food on tongue
Lick the food
Smell the food
Touch the food
Look at food across the table

Levels for Luke – 6 yo Levels for Derek – 4 yo
1. Look at food, uncovered, food is within arm’s reach
1. Look at food, uncovered, 2.
3.
Touch plate
Touch food with utensil or hand
food is within arm’s 4. Analyst hands food to hold
5. Hold food
reach 6. Bring to chin
7. Bring to nose
2. Touch plate 8. Bring to nose and smell
3. Touch food with utensil 9.
10.
Touch piece of food to lips
Touch piece of food to tongue 1 s
or hand 11. Food to tongue 2 s
12. Food to tongue 3 s
4. Hold food in spoon or 13. Balance on tongue, 3 s
14. Balance on tongue, close mouth, 1 piece
hand 15. Balance on tongue, close mouth, 2 pieces
5. Bring to nose 16.
17.
Balance on tongue, close mouth, 3 pieces
Balance on tongue close mouth, 4 pieces
6. Bring to nose and smell 18. Hold on tongue, move back and forth
19. Move back and forth, 2 pieces
7. Touch piece of food to 20. Move back and forth, 3 pieces
21. Move back and forth, 4 pieces
lips 22. Hold food with front teeth
8. Touch piece of food to 23.
24.
Bite food in 2 pieces with front teeth
Bite in 2, hold 3 s
tongue 25. Bite in 2, hold 5 s
26. Hold food with side teeth
9. Balance on tongue 3 s 27. Bite in 2, side teeth
28. Bite in 2, hold 3 s
10. Chew food 3x, spit out 29. Bite in 2, hold 5 s
11. Chew food 5x, spit out 30.
31.
Put on back teeth
Chew food 1x (back teeth), spit out
12. Swallow 1 bite of food 32. Chew food 2x, spit out
33. Chew food 3x, spit out
37. Chew food 20s, spit out
38. Swallow 1 bite of food

Gradually increase expectations.
Task analyze if client is struggling.
Differential Reinforcement
Leave the table, eat fruit snacks, watch YouTube

videos of kids unwrapping toys, analyst watches
with you and makes positive comments
Chat with the analyst at table
Sit quietly at table for ~30s until

next trial
Full SR
Partial SR
No SR+
Burrito
Noodle
Lasagna
Pasta

Chat with the analyst at table

next trial


next trial


next trial

with you and makes positive comments for 2
min

with you and makes positive comments for 30 s
Access to computer, attention,

mand compliance, twizzlers
Access to computer, attention,

mand compliance
Use differential reinforcement;
ensure it is meaningful.
Choice
Choice
What to do
with it
Nonpreferred
Food
Choice
What to do Preferred
with it Food
Nonpreferred Preferred
Food Toys
Choice
• Strip down materials and procedural components until
the child understands the contingency
What sized array can they select from?
Choice
• Strip down materials and procedural components until
the child understands the contingency
What sized array can they select from?
Pictures vs actual food items
Consider taking the time to teach choice-making
Choice
Participation
What to do Preferred
with it Food
Nonpreferred Preferred
Food Toys
Hang out Space
Treatment table
Reinforcement
space
Choice
o The Enhanced Choice Model (Rajaraman et al. 2021)
Potentially more appropriate for a controlled settled and kids
with strong communication skills
o Open-door policy
Potentially more appropriate for children with less language
Be attuned to behavior suggesting withdrawal of assent
o Full-assent based procedures
Potentially more appropriate for children with strong
communication skills and less controlled settings
Video 7 and 8
Choice
Do not force participation. Give

clients the opportunity to opt in and
out.
Treatment components
• Shaping using modeling

• Differential reinforcement with synthesized reinforcers
• Open-door/full-assent model
Trauma-informed care
 “to use that understanding to design service systems that accommodate the
vulnerabilities of trauma survivors and allow services to be delivered in a
way that will facilitate consumer participation”
 “The concept of consumer participation implies not only that the person is an
active, willing participant in the therapeutic or research process, but that
their participation is critical to success.”
“Trauma-assumed care”
“…..it is both possible and probable that there are clients who
arrive at the doorstep of ABA services with a history of trauma that
will remain unknown to the service provider.”
Guiding conscience
Key Components of TIC
Acknowledge Trauma and its Potential Impact
Ensure Safety and Trust
Promote Choice and Shared Governance
Emphasize Skill Building

Skyler
 12 years old, autism spectrum disorder

 Encyclopedic mind for movie/tv characters
 Loves giving his teachers homework and quizzes
 Highly selective eater, big on candy and snacks
 Specific rules about what he eats where
Trauma-informed care
 “to use that understanding to design service systems that accommodate the
vulnerabilities of trauma survivors and allow services to be delivered in a way
that will facilitate consumer participation”
 The concept of consumer participation implies not only that the person is an
active, willing participant in the therapeutic or research process, but that
their participation is critical to success.
Assessment
• Open-ended interview with caregivers (Hanley, 2012)

• Preference assessment
Ensure Safety and Trust
Assessment
• Open-ended interview with caregivers (Hanley, 2012)

• Preference assessment
• Open-ended interview with client
Promote Choice and
Shared Governance
Baseline – Noncontingent Reinforcement
Treatment – Shaping
Video 9
Sweet Potato
Cheese
Apple
Shaping
Baseline Baseline
Sweet Potato
Cheese
Apple
Shaping
Baseline Baseline
Sweet Potato
Cheese
Apple
Shaping
Baseline Baseline
Sweet Potato
Cheese
Apple
Baseline Shaping
Sweet Potato
Cheese
Apple
Additional TIC Components
o Collaborated when he had difficulties at a given step
o Never attempted to “strong-arm” him through a step
o Participation was up to him, including schedule and “make up

sessions”
Promote Choice and

Shared Governance

sessions”
Ensure Safety
and Trust
Emphasize Skill
Building

sessions”
Promote Choice and

Shared Governance

sessions”
Emphasize Skill
Building
Thank you!
Presented by:
Holly C. Gover, PhD, BCBA-D
holly.gover@vumc.com
Initial Screening
Which clients to work with?

o Food selectivity vs. food refusal
o Receptive and expressive communication
• Strong imitation skills needed, at minimum
o Special considerations for “client zero”
Logistics
o Who?
• Whoever is comfortable/trained/knows the client well
• Keep consistent, if possible
o Where?
• Separate or different from typical environment
o When?
o Not during snack/lunch/mealtimes
o Space out from meals, less important in beginning
o How often will sessions be run?
• Minimally ~3 hours per week
Safety
o Anyone running sessions
• CPR/First Aid Certified
• Trainings available for identifying choking:
(https://opwdd.ny.gov/providers/choking)
o Recruit professional advice from SLPs/OTs
• Specializing in feeding/swallowing, if needed
o Do not practice on an island
o Allergy and medical history informed
o Ensure emotional safety
• History with feeding interventions
• History with certain foods
Beyond bite shaping
1. Meal-building
2. Generalization to mealtimes
3. Generalization to caregivers and the home
4. Assess need to repeat treatment with new foods

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Extensions of Assessment and Treatment of Food Selectivity

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Extensions of Assessment and

Treatment of Food Selectivity

Foods to be used as reinforcers:

o Identified preferred and non-preferred foods to target for treatment

1 meal = 3-6 trials (depending on # target

Each trial the child selects:

Chew food for 5 s

Chew food for 3 s

Balance food on tongue

Lick the food

Smell the food

Touch the food

Look at food across the table

Leave the table, eat fruit snacks, watch YouTube

Chat with the analyst at table

Sit quietly at table for ~30s until

Leave the table, eat fruit snacks, watch YouTube

Chat with the analyst at table

Sit quietly at table for ~30s until

Leave the table, eat fruit snacks, watch YouTube

Sit quietly at table for ~30s until

Leave the table, eat fruit snacks, watch YouTube

Sit quietly at table for ~30s until

Leave the table, eat fruit snacks, watch YouTube

Leave the table, eat fruit snacks, watch YouTube

Access to computer, attention,

Access to computer, attention,

Do not force participation. Give

• Shaping using modeling

Acknowledge Trauma and its Potential Impact

Ensure Safety and Trust

Promote Choice and Shared Governance

Emphasize Skill Building

 12 years old, autism spectrum disorder

• Open-ended interview with caregivers (Hanley, 2012)

• Open-ended interview with caregivers (Hanley, 2012)

o Never attempted to “strong-arm” him through a step

o Participation was up to him, including schedule and “make up

Promote Choice and

o Never attempted to “strong-arm” him through a step

o Participation was up to him, including schedule and “make up

o Never attempted to “strong-arm” him through a step

o Participation was up to him, including schedule and “make up

Promote Choice and

o Never attempted to “strong-arm” him through a step

o Participation was up to him, including schedule and “make up

Which clients to work with?

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