Feeding, Eating and Meal Time Behavior with Dena Kelly Part II

ABA on Tap is proud to present an interview with Dena Kelly. (Part II)

Dena Kelly, LPC, BCBA, LBS is a Licensed Professional Counselor and Board Certified Behavior Analyst with over 15 years of experience improving children’s eating behavior and quality of life through evidence-based interventions. Founder of Focused Approach, Dena develops ABA-based feeding programs and trains professionals and caregivers nationwide. She has presented at major conferences such as ABAI and FABA and continues to advance the field through education and advocacy. Dena has led feeding programs in both clinical and multi-state settings, designed diagnostic and therapy services for autism and feeding disorders, and trained teams to manage complex feeding challenges.

Focused Approach uses trusted, research-based techniques to address a wide scale of feeding challenges. Focused Approach delivers training and consultation to BCBA professionals, partners with existing clinics to add results-driven, full feeding programs into their offerings, and delivers direct feeding therapy support for families. Focused Approach goes above and beyond generalized services, tackling the most challenging and unique pediatric challenges. 

For more information, visit www.focusedapproach.com

In this episode. Dena discusses the scope of her work involving ABA professionals and how she educates them on feeding disorders, food refusal, providing insight into techniques, procedure, and protocol. She discusses the basics of setting events and stimulus cues, as well as more controversial applications like escape extinction, a procedure that can easily be applied incorrectly if not for the guidance and expertise of someone like Dena Kelly.

This brew is rich and dense, with a warming presence and complex, intense flavors. And we have two full pours for you, staring here with Part I. Enjoy the sense of fullness and satisfaction in this episode, and ALWAYS ANALYZE RESPONSIBLY.

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Transcript

SPEAKER_02: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_03: 0:51

All right, all right. And welcome yet again to ABA on Tap. I am your co-host, Mike Rubio. And this is part two of our interview with Dina Kelley. Enjoy.

SPEAKER_00: 1:04

And maybe it has to be pureed because that's going to be an easier way for them to be able to consume that in the beginning. And then we work our way back up to regular texture. Maybe he likes it to stab things with a fork. Maybe he'd rather scoop it with a spoon, right? We're going to find what the most, you know, interesting way for him to be able to get on to that food. But I usually start feeding therapy trials outside of mealtime for the same purpose you were talking about with trying to get out of the idea of we're restricting their actual eating. And so I will usually use it during like a snack time. So again, we want to be able to have a break between when they last ate those chicken nuggets and when they're going to eat again so that they're hungry. But you're going to start with maybe just that one piece of and something, depending on what that child was doing. and pair it with that high motivator so that they get that one bite in and then they move on. If they were to time out that session or not have that interest in being able to even access that motivator or do

SPEAKER_01: 2:08

that,

SPEAKER_00: 2:09

is that their feeding at that point is not directly impacted because then they would get down from that table, that session would be over, and in an hour they're coming back to eat their chicken nuggets that they're used to actually eating. But what I have found to be fascinating really is, you know, I think a lot of people, parents and professionals, are scared of their child crying. But I will say, I mean, I have two, my kids are older, they're nine and 12, and they still cry over some silly stuff, right? And so I feel like it's just a go-to response when the kid just doesn't want to do something, right? But what happens when that child starts crying because we want them to eat, and I think you were talking about this earlier with your daughter, right, is that if she wasn't eating is that you were finding yourself getting emotional and getting hype, right?

SPEAKER_03: 3:11

Start pushing and offering the extrinsic motivation and you start pandering.

SPEAKER_00: 3:15

But here's the thing. I take a most, but, but you don't do that when you're trying to have a task that's not eating related, right? Is you can stay a lot calmer. And so my like hashtags recently have been take the emotion out of mealtime because even though we may like love eating, right? We can't throw that onto the child. And I tell parents all the time too, because their first thing when a child takes a bite is, Oh, Do you like it? Is it good? Is it delicious? It doesn't matter, right? We want to say, how easy was that for you to chew? Nice work. You did a good job. Because at the end of the day, we need them to actually be consuming these foods as opposed to worrying about how much they love and enjoy, right? When they pick up their toys in the playroom, you don't say... Wasn't that so much fun picking up the toys? No, you go, Hey, you did a really great job. Nice work. Let's go do, you know, this other thing that we're going to go do now. And so with feeding, it, We get so heightened. And I say we because, you know, I've been guilty of that as well. But I see it so often with parents is that they get so nervous with the child not eating that they they run through. Right. They go through negotiation. Yeah. Then they get to anger. Then they get to, you know, sadness. Right. And then they get to that give up point. Right. So then they go, forget it. whatever, and just go, right? And now you're not getting

SPEAKER_03: 4:45

dessert.

SPEAKER_00: 4:46

And that's the other thing too, right? You start throwing in all these, well, now you're not going to have screens. Now you're not going to have dessert. Now you're not going to, how high can I up all of those answers? And so whenever I do a feeding program, whether a child's verbal or not, is that I have them very quickly learn what the contingencies are with mealtime. There's nothing that gets thrown in in the middle because we're frustrated. So at the beginning, it's, you know, you're going to be able to get this thing that you really want, whether, you know, for a lot of people, it's watching a show. For some kids, it's, you know, playing with mom or dad. For some kids, it's just being done eating, because again, eating may not necessarily be that enjoyable for them. They'd rather just go play by themselves. They don't even want somebody else to be playing with them. But that they know what's happening they're getting all of our attention and all of our you know focus when they're doing what it is that we want them to do and that when they're not we're staying in a space of calmness and so we're not getting into that anger and we're not getting into that over emotional like let me throw a bunch of other things at you because what that does is now you have a kid that's heightened because you're asking them to do something that might be hard for them and now you're heightened as the parent and so you both stay up here and everybody's in and everybody just leaves in tears. And so, a lot of our times, our kids are learning to regulate their emotions across life. And so our job as parents is to be able to stay in that calm space So that our kids can come down to that space to be able to be there with us. And so that is the really hard part. And that's why a lot of my programming is very heavy in the parent prep component. Because, you know, a lot of times they come and say, okay, so what are you going to do to get this kid to eat? And I say, it actually starts with you. And it's the same thing with the, with the therapist, you know, when you're working in a clinic setting, it starts with you. It starts with what is your reactions and responses to that child's heightened behavior. And if we can remain in a calm space, we get that child to be able to meet us in that calm space, which allows for that successful intervention.

SPEAKER_03: 7:06

And that means excitement too, or overexcitement. So people don't think about that as an If I'm happy and excited, that's also calm. No, it isn't. You're adding too much. Just be cool for a second.

SPEAKER_00: 7:18

I've had some kids over the years that have told me that I scared them because I actually got too excited. They put a bite in and I was

SPEAKER_01: 7:25

like, oh!

SPEAKER_00: 7:26

Could you not do that next time? So yes, you're absolutely right. It's all of those emotions. It's staying in a space of calm because what we want to be able to have them realize is that this isn't scary. Eating isn't scary. It's something that we have to be able to do for our health and safety. And it's something that we have to do for our social interactions and psychosocial functioning in life. And so it's a really important skill. It's very different for me than you know learning to match cards or learning to you know some of the different activities that the kids might do during the day even like sitting in circle time right like that's a great skill and we definitely have to learn that skill but to me food consumption right comes higher than some of those other activities and so you have to put more onus on that you have to be able to have more focus and seriousness around that intervention because we need to figure out how to get that to be successful.

SPEAKER_02: 8:31

Sure. I had one thing I wanted to follow up covering a lot of ground here. So I want to make sure nothing that you're saying gets lost because you're making so many good points. Something that you initially said in the beginning is that in the chicken nuggets example, you may present other foods, but not during mealtime. And I think historically in ABA, we would presented during mealtime because the motivating operations there, right? Like the motivation is hunger. So we would then extend that out and we'd say, okay, you know, first take a bite of whatever and then you can have whatever the reinforcer is. A lot of times it would be the preferred food. So my question to you is how do you kind of juxtapose that? Because somebody in more traditional ABA might say, well, they'll just wait you out until it's mealtime. Then they get their preferred food because their motivation is not as strong there. Now, historically in ABA when we've withheld that maybe we've created it probably hasn't been that successful because then we've created more food aversions because they're going longer and longer without eating because we're withholding that meal time so they're having more uncomfortable physiological side effects which now is just reinforcing their lack of desire to eat so how do you juxtapose the motivating operation there of hunger versus not really creating more and more and more of a food aversion

SPEAKER_00: 9:51

Sure. So first of all, right, when we talked about setting up specific meal times, we also include snack times within there. So there's always a break, right? And so I would be looking at like pulling it into one of those snack times first rather than like an actual full meal time. And I also would look at that meal time still being a chunk of time away from when the end of that feeding intervention was taking place so that if they weren't eating that, right, there's still an hour before we're going back to those chicken nuggets. The reason that I don't usually start with doing meals like that, right, like your example was, you know, if you just take this bite, then you get to eat that preferred food that you want to eat, is that for some kids, and why it's called a preferred food is just they prefer it over something else. But if you say you, if you eat this, you can have these nuggets. They'd rather have nothing. Then eat that food to get the nuggets. Right. And so, so to me, that's not a good motivator. And so when I look at like, how are we going to motivate them to do this? I try not to use food as a motivator at all. Because the reality is, especially with the children that have severe feeding disorders is that food is not motivating. They may have safe foods or foods that they gravitate towards more than others, but if given the choice between that or nothing, they're choosing nothing. That's a good point. I look at what are those things that are motivating them in regular life, like outside of mealtime. What are the things that they want those access to? What does that show that they absolutely love? We're going to save the the viewing of that show for the completion of, you know, that, that bite of food. And, and, and again, in the beginning, you're starting, I start so small. I have families that will sit there and say, really, this is all we're doing for the session today. And I'm like, yes, because they have to be able to, to get that success and feel that, that, you know, contingency in place, right? Like they took that one bite, they were able to swallow it here. Yeah. Let's watch Bluey. That was outstanding. And now we'll come back and try again tomorrow. And maybe we're going to do two bites tomorrow because you did awesome. And now you're starting to figure out that in order to, you know, see Bluey, you're going to be able to do those sorts of things. That would be what my low, like, like, younger kiddos that you're not able to include in the process of the treatment planning. I will always caveat to say that when a child is able to be a part of the treatment process, I include them in that as much as possible. I allow them to be able to pick some reinforcers. I allow them to be able to choose foods that they want to do. I have them actually group them into categories. And then we say like, all right, so out of these Which one might you be willing to try, right? And so a lot of times they are in that driver's seat and having that control component within their meals so that they're feeling better about the choices, right? They have a banana in front of them because they chose to try banana today. So, you know, it gives more of that motivation for them to want to be successful and want to be a part of that.

SPEAKER_02: 13:12

So starting small, using a non-food related reinforcer, and then if possible, allowing them control. Thank you very much, Mike. I know I've been asking a lot of the questions. I still have more, but let me pass it to you so it's not the tension. I'm thinking about a million

SPEAKER_03: 13:25

things. Me too. She's covered so much ground. I'm thinking about all the variables that go into this. And so whether we're talking about behavior or some incident that may be related to food trauma. So you've got me thinking about, I mean, way at the One of them had trouble latching on and feeding in the beginning. You're incredibly worried. They feed on one thing for six months. You introduce these purees. You're supposed to, well, a lot of recommendations is to try the same thing three days in a row so they can taste it. And you've got a lot of regeneration of taste receptors going on. So they're not going to remember it. And then at the very beginning, you finish those three days of those pureed pears and you go to something different and they spit it out and immediately you go back to those pears. So, I mean, this can start as early. It's blowing my mind how many things could go astray or awry in terms of some sort of picky toward restrictive eating, you know, from the very beginning

SPEAKER_02: 14:30

to your- Not even with an autism, just

SPEAKER_03: 14:32

in general.

SPEAKER_00: 14:32

Right, right. 100%, yep, just even in neurotypical kids. That's exactly where I was going.

SPEAKER_03: 14:37

Sorry. So no, that's exactly where I was going. No, thank you, because that's what I was trying to say. And then all of a sudden, I mean, back to something we discussed earlier, I don't know if I'm actually going to get to a question. I just have a lot of comments. I have a lot of comments. But yeah, no, the idea that, you know, then they start eating solids, same thing. They take to something you're so worried as a parent that they're having enough colitis intake that you'll do anything to make sure that you preserve that including giving them the same chicken nuggets every day and the same. So there's so many opportunities to develop these pretty vicious habitual cycles. And then maybe you get a diagnosis and a child that is experiencing heightened sensory concerns and that is only gonna impact that a little further. And then you get into adolescence and actually I do have a question. You mentioned this earlier. What is the correlation then, or maybe you know and you can speak to this, between picky toward restrictive eating toward now maybe the development of an eating disorder. Is that a possible progression or is that something separate?

SPEAKER_00: 15:48

When you say eating disorder, you're talking more about the anorexia

SPEAKER_03: 15:51

or bulimia. So I'll pitch it a different way. We're talking about caloric intake versus gustation versus satiety. And not that they're unrelated, but how do they all come together? Do they ever come together? Does a parent have to be concerned that if I don't take, what is a good level of concern to say, if I don't take care of this now, my adolescent autistic daughter is going to end up with bulimia, for example?

SPEAKER_00: 16:16

Yeah. So, so I'll flip it the other way is that oftentimes a lot of parents don't want to seek out feeding therapy because they have those fears of that child developing what we call, you know, that bad relationship with food and it's going to lead to that eating disorder. And the reality is there's not great data to support that that's actually the case at all. You know, the clinic that I worked at, I was there for over 10 years, but one of the men that was there he's a graduate assistant that was his actual his graduate project was that he went back over 10 years uh reached out to the families that had been you know through those feeding programs to be able to see where they were you know at this point and we weren't seeing um you know even within our own study development of any concerns with eating disorders um in that way at all. I would actually argue that the psychological component of them is different. They can present similarly. If you have a 16-year-old that has significant restriction, she's going to be really gaunt and really skinny. And potentially, one of my preteens, she was 12, she wasn't menstruating and she wasn't hitting puberty because she wasn't eating. And that is something that also is a characteristic of anorexia. Bulimia, you could run into those concerns as well from that restrictive eating. But again, from a psychological standpoint, is that they are too... Totally different things is that I have a 16 year old that is so restrictive in their eating. She's not worried about what her body looks like. She's worried about what she's putting inside of her mouth. And so, so I don't know this, the actual stats on, you know, how many people started out as, as a restrictive eater and then turned into, you know, one of the classic eating disorder situations. But from my experience and research and, and, you know, years of watching people do this is that, um, it's actually, uh, it, it, it doesn't seem to have a direct line. They seem to be very different psychological branches. Um, but, uh, but I, but I will say I have a lot of families that hold off on the intervention or fear that intervention because of that potential for an eating disorder. And because it's so different, it usually it, it's not, um, it's not a reason to hold off on treating the feeding issue if it's a feeding issue.

SPEAKER_03: 18:47

Thank you for that. That was a pressing question. And I think it's really important information, hopefully, for some parents that might be listening out there to be able to make that distinction. And I guess it does make sense in terms of understanding body image and caloric intake versus having some fear or some aversion to what might happen, whether it's from the moment you taste it or what might happen to your body once you ingest it. So, okay, that makes sense.

SPEAKER_00: 19:13

It is actually interesting. With my older kids, when we do have to look at the I actually will tell the parents I avoid the child counting the calories because I don't want that to, you know, become an issue or something that they end up looking at. You know, their focus is on calories. eating the food, finding foods that are feeling good for their body and the fruits and the vegetables. We're not thinking about the fact that, you know, this avocado has 300 calories in it. The mom is because she's trying to make sure that, you know, she's gaining the weight. But from the child standpoint, we're looking at it from what food choices are we making? We're not thinking about how many calories are in those foods.

SPEAKER_03: 19:56

And that makes sense what you say, too, because inevitably some parent might be hearkening back to their pediatrician and that growth chart or that weight gain trajectory, which is still an important variable, but to your point, maybe not the most pressing concern for us through this process. So, Mr. Dan, I know you've been sitting patiently.

SPEAKER_02: 20:15

Go ahead, sir. So I guess with that, let's say, because I remember a client that was basically on the verge of getting a G-tube because they were so concerned about his, I don't know if it's failure to thrive, but he was being so food adverse that he wasn't able to get enough calories that they were like hey if this doesn't change quickly we're going to have to take another measure medically what would be your thoughts and maybe this is hard to say because I'm sure there's a lot of different reasons that a lot of different individuals do a lot of different things do you have any thoughts that when it gets to that point of it's like hey we have to do something otherwise this individual is going to have to come in and get a g-tube to get calories any thoughts on any advice to parents at that point

SPEAKER_00: 20:59

so often if they're at the point of like within date, you know, if this child, this is one more meal, right. They're going to be in the hospital and having an issue. I actually, as, as opposite as it seems, I will say yes, get the tube for the short term. Because what that actually allows us to do is because again, we think about the parents and wanting them to get the calories. And if they're at the point where the pediatricians are asking them for a weight check every two days, and they are super high alert and high on anxiety, they're not going to be calm at that meal time like we were talking about because they're going to be like, just eat it. We don't want you to be on a tube. And this is so scary. So I will actually say, if they're at the severe point, right, is that I will actually say tube. Right now, maybe not even a G-tube. You can do like a less permanent. You could do the NG tube that, you know, a little more unpleasant because it goes up your nose and back down, but a little more in the temporary space. Because then we know at the end of the day that that child is getting in their calories, that family can sleep better at night, the pediatrician's not going to be so far on their back. And then it allows us to go at that child's pace for the introduction of new foods, right? Because if we're in the panic stage, it's going to be like, you need these foods and you need them now, right? We have to really like, you know, hightail it into this treatment, which and get them to shut down. That's not always the most pleasant. I want them before they get to that point because, because then you have, you have the need that they have this restriction, but they're not one meal away from being in the hospital. If they're at that point, I will say, get the tube so that we can use it as I ultimately, then what I do is use it as a supplement. So then it becomes, we're going to do our food. And if we only get in two bites in that meal today then you're doing the full eight ounce feed right for that child and then as we continue to go oh he actually had three ounces worth of food today awesome you only need to come back around with five ounces of that formula and then ultimately it fades out so that we get rid of that tube as that temporary kind of crutch to allow us to be in a calmer state as we work through that feeding and be able to get that child back on track

SPEAKER_02: 23:25

That makes a lot of sense.

SPEAKER_03: 23:27

Some people might say, and I hate to bring this up in a certain sense, but the urgency now necessitates or justifies escape extinction. We're going to hold a spoon in your mouth for 30 seconds. And I know that that's out there, right? Our old colleague. Yeah. I want to be cautious with this. I think the danger with that is how easily it could be misapplied. And then you're talking about that not being necessary in the gradual approach you're talking about. Could you speak to that a little bit?

SPEAKER_00: 24:01

Absolutely. So it is never my first go-to for escape extinction, but I do want to clarify, and I think you hit on both points, right? Is that in some cases, it is still needed, but it is needed from a person that is specialized in the training to be able to do it. So I think that's the important piece to highlight there is that just because you're a BCBA, right, does not mean that you have the training to utilize escape extinction in a feeding protocol in any capacity, right? But there are some kids in certain situations, whether it be they're age, whether it be their functioning level, whether it be the severity of the refusal that they have, that requires an intervention such as escape extinction, right? Because the need is impacting their overall functioning. I'll give you, I have my, my nephew is well, he's now two and a half, but he was, you know, my, my whole family has, I've been doing this for 20 years, right? So they know I do feeding land. She had this baby six months old. They were weaning him, you know, from breastfeeding a little bit more and, you know, starting to try some foods and he was eating a little bit and it really wasn't consistent. And most of the time he was putting it in and he was spitting it out and now he didn't even want to take his bottles anymore and he was really starting to struggle he was losing weight meal time was not fun for anyone and they were struggling as to decide what to do right and so obviously at 11 months old You're not going to say, okay, so which food would you want to choose to eat today, right? Because the 11-month-old's not going to make that choice. He's typically developing, right? So we weren't having necessarily concerns from a sensory perspective. We had him checked medically from, like, an issue of swallowing or any concerns that would be there. And I think that's an important component to note as well is that if there's any issue of– whether or not a child can eat or if there's certain textures that they can eat, I will always refer first medically to get cleared because I don't have a medical degree and so that's gonna be an important component, right? So he was cleared medically, he's typically developing, he's 11 months old and he is losing weight and not intaking any food and it's making his sleep struggle, it's making his overall functioning during the day, he's just miserable. And he was a perfect case to be able to utilize an escape extinction protocol. And for me, I think you said when you said escape extinction, that you hold it in their mouth for 30 seconds. Don't do that. No, no. That's something we had heard.

SPEAKER_03: 26:50

Something we had heard. And I was like, wait, we had an old colleague who had moved away and she called us and was like, yeah, can we run a situation by you guys? And I was like, yeah, no. And these, so these kids are about to get a G tube. No, they're just picky eaters. Oh my goodness. Get out of there. Run.

SPEAKER_00: 27:05

Yeah. So I would, Never recommend it for a picky eater. But when you have this sort of situation, right? But so he's 11 months old. So we utilize what I call non-removal of the spoon. So he sat in his high chair and we held the spoon up there. And again, he's going to cry because he's an 11 month old boy, right? And they cry all the time. And so he would put it in and his habit that he had developed was spit it back out, right? So we would scoop it up from his chair, right? And we would say, all right, try it again. Um, And then when he got that bite in and we go, yay! He would get like, and he loved that. He wanted more. He would, that was his favorite. More, more. Right. And so, all right, next bite. And then we can do it again. And now I will tell you, cause he's my own nephew, like at two and a half years old, the child will not stop eating. He loves eating. He eats all day. You know, my sister and brother-in-law are always like, can we send you our food bill now? Because you know, you fixed him too well. But, but there are those situations where when you have a child that is, quickly sliding down a path that would lead to more needed medical intervention and it is impacting them across the board. It's a quick and effective and ethical approach way to treat feeding when done by an appropriate feeding professional so again that that's my biggest red disclaimer is that it is never something that should be done willy-nilly um it should never be done by somebody that's not trained it should never be done for a child that's just in that picky you know you're not going to be like trying to broccoli um you know even if you're eating other things i want you to eat this broccoli and i'm going to hold it up to your mouth i would never. Because from an ethical standpoint, that's not appropriate. But again, when you check all of those other boxes, there are times where that intervention is the one that's warranted and the one that will come out with that most effective result for that child.

SPEAKER_03: 29:00

I like that. I think we can break it down to that that one phrase you keep saying, so that the notion that how do we get the child just to try it? Because until they try it, they have no chance of deriving any sort of reinforcement or otherwise from it. And just, and yet that simple premise can become a huge challenge. And yeah, you can, you know, you can drum up some really interesting strategies to try and get them to get that first taste. And then you have to consider the rest of the variables in terms of any sort of medical need. And, you

SPEAKER_00: 29:32

know, it can't just be Yeah,

SPEAKER_03: 29:34

that's all. I mean, think about so many layers that we've just gone through that, you know, as a parent, you're you're so stuck on the fact your child is not eating or they, you know, they're not gaining weight or they're losing weight. And that becomes your your driving force. It can be very challenging to then look at the rest of the landscape, I think, because we're covering so many variables that need to be considered here.

SPEAKER_00: 29:56

Right. But both from the parent and the BCBA, the best thing that we do, again, is remain calm in those intervention times. I think as a BCBA, we are so quick to go, that's not working, let's change it. As opposed to allowing us to sit kind of in that moment with that child of that, I don't want to do this. And they're sitting there and they're staring at, you know, that little strawberry on their plate. And we're so used to either like, over-talking, right? Oh, yeah. It's like, come on, you can do it. It's just one little bite. You've got this. Remember, we're going to do all these things. And the

SPEAKER_03: 30:32

parents doing it here and dads here doing the same thing.

SPEAKER_00: 30:33

You've got a whole crowd chattering at you. Right, it's all going on. And all that's doing is actually building that child's anxiety. And so I find if we all stay in this space, people are scared of silence, right? We've got to embrace that silence sometimes. And sometimes we just sit there and you see that child's like, you know, years going of, okay, this is scary, but I really do want to watch that show or this is good. You know, they're thinking about this out there and you're seeing, you know, the therapist or the parent, they're ready to go do whatever it is that we're doing, but we're sitting here and we're waiting and they're working their way through it. And when they get that bite, it cannot tell you the enjoyment I get as a therapist and watch both the parents and that child's face actually go, I did it. And it's that sense, it's not even always like, that was delicious. It's much more like that pride of they did something that was hard. And it was like, and you see that face of like, And then they want to tell everybody. I have little three-year-olds that are like, mom, dad, the cat, whoever else is over there. I just need to tell everybody that will listen to me, I took that bite of pizza. And so it really comes much more away from, wow, that food was so good. And more, I did this hard thing and I can do hard things. So now I'm not going to be as scared of that pizza because that wasn't so scary. And that's the... That's the satisfaction I want them to start getting. That's the more internal drive we can get more than we can get the necessary internal enjoyment of the actual food. But I can get them to actually enjoy the satisfaction that comes from doing those hard things and being able to eat those foods.

SPEAKER_03: 32:24

I like that stepwise progression because, again, we would want them to immediately enjoy that food. And what you're saying is, no, the first step is them just realizing I didn't die. And then now I'll take another bite. and hey, that's actually pretty good. So again, I think that's really important to highlight because as behavior analysts, we always have this perfectly envisioned three-part contingency where of course the child has to take a bite and if they don't, now we're facing failure, right? I didn't do this right. You're saying, no, if you've got the right, if you're pretty confident in your protocol, you're going to repeat. And this might result in no bite of food in their mouth, but you keep applying the protocol and analyzing what, what can we do next?

SPEAKER_00: 33:07

Give it time. Give it a chance. And again, I mean, there's certainly been times where I've had to adjust my protocols or change my plans based on how things go. But I think sometimes we are so quick, um, to say, I thought this was gonna work and this isn't working and quickly change to something else where if we had just given it one more day or given it another opportunity and readjusted really looking at what was our reaction or responses in those moments to be able to see what adjustments can be made, I think you'd actually have more success.

SPEAKER_02: 33:41

For sure. I think, Mike, you talked about, too, the fact of just if we can get it to happen, if we can find a way to reinforce. But like you mentioned, Dina, as well, that we have to be careful because I think sometimes that's where parents are trying to hide. They're trying to stick stuff in or hide it just to get them to have that bite. And then it actually makes it way worse. So we have to be very careful with that. I have a, so you kind of talked about it a little bit about the collaboration piece, but I wanted to highlight that because I think that's so important and pass it over to you. I'll share one small anecdote because I, historically, I wonder, and I think that maybe we've done more damage than good with feeding in ABA. And I'm interested to get kind of your suggestion moving forward, because I remember trying to get an individual to take a bite of a strawberry, and I've shared this example multiple times, but this was early, Dan. This was 15 years ago. It was just traditional ABA, Dan. We were going to sit there because you set the first thing contingency, and once you set it, then you can't do anything else, God forbid. Again, I've learned from this, but it was almost an hour and a half of this individual. He was strapped in his little high chair, tantruming to not take a strawberry, take a bite of a strawberry, and eventually did. And I left that session like, yes, I'm so proud that eventually followed through because literally it was five minutes before I was going to leave that session. I was like, oh, no. What am I going

SPEAKER_03: 35:10

to do?

SPEAKER_02: 35:10

And if this kid doesn't, you know, follow through on a contingency, I said the world's going to explode, followed through. And then, you know, later looking back of maybe that probably wasn't the best way of going about it. And maybe we've created more food aversion. So that's a story to ask the question of the importance of collaboration, because in ABA, we've done, you know, everything's on the three-part contingency and we are the experts in behavior, but that doesn't make us the experts in feeding or sleeping or motor skills or anything like that. It means we can work with individuals that maybe are more experts in these fields, but somehow a lot of this gets put on to us. And now maybe we've done more harm than good in saying, well, it's the antecedent behavior consequence. You just set that contingency and they need to eat. And if they don't, you don't give them anything they want. And maybe we've made it way worse. So that's kind of a long winded question to say, number one, do you think that historically maybe we've made it worse? And can you talk about the importance of collaboration with people that actually do know what they're doing in the feeding realm, not just the behavioral realm?

SPEAKER_00: 36:16

Sure. So I'm going to break that apart a little bit.

SPEAKER_01: 36:19

Please do.

SPEAKER_00: 36:20

So I think that the harm that happens to the point that we were just talking about is when people that aren't properly trained or supervised to implement feeding interventions are implementing feeding interventions, right? Like that's first and foremost is that I look at the BCBA as really like a general practitioner. They know a little bit of everything, but they're not necessarily a specialist, right? So when you go to your family doctor and you have a heart issue, the doctor might give you one initial recommendation. And if that doesn't work, they're going, we're sending you to the cardiologist, right? Because that's the specialist that specializes in that heart issue. It's a great analogy. That's great. And so I I do think that that's an important component. And I stress that every time I do a CEU or anything, I say, you know, the CEU does not lead you to being able to be a feeding expert and being able to do anything. So I think the only component that I would look at as harmful is when a BCBA is implementing feeding procedures without having training or appropriate supervision to be able to do so. I actually think when you look at the feeding research is that ABA has done a lot of great interventions and great help with children with feeding challenges across the board for years. And that, you know, I think over time, and I think as feeding has continued on in ABA land is that we figured out how to collaborate with other professionals. And I think when you say, you know, somebody that would be more specialized in feeding, I'm I'm guessing you're talking more in the realm of like the speech and OT, because that seems to be where they, you know, when somebody thinks about feeding, that's usually the first type of demographic that they're going to go to, right? Speech or OT. And I think for me, what I look at is there's components in which we can all work together in the areas in which we are most benefited, right? So from a speech perspective, I collaborate with speech a lot when I have kids that might not be having great oral motor skills. So, you know, I may have to work with the family on pureed food while the speech therapist is getting the child to actually have some solid jaw strength and moving their tongue around and being able to have the ability to manage the regular textured food, right? When I have an OT console, that's a lot of times, you know, go back to that idea of safety while you're eating. And I'm a huge advocate for kids sitting while they're eating and not standing and dancing and running around. But there's some kids that we know, right, that don't have good core strength and muscle strength. And so when they sit in a chair, they're kind of like, right, like they're hunched down and they're not really sitting up properly. And so I need, you know, that's the OT area. And so that's where a huge benefit is that they can, you know, work with that child to be able to develop that opportunity to sit them up straight so that when they're eating, it's successful. As well as that hand-eye coordination, you think about all the things that are involved with nutrition. with self-feeding, right? Scooping and stabbing bites are not easy, especially for kids that may have some fine motor difficulties. And so, you know, I love the opportunity to be able to say, this is a great thing that can be worked on during OT sessions that also can benefit within the feeding session. What I do see a lot of that in my experience, and I will say most of my experience is with pretty severe issues restrictive eater. So I don't work a lot with the younger kids in that early intervention land, which is where I think, you know, more education needs to go into to your point of like, let's kind of set the premise before it even becomes an issue. So it doesn't become an issue, right? I think that's a great part. So I will caveat with saying, you know, most of the individuals that I've seen over my whole career have been pretty severe and significant. They are not responsive often to food integration, food exposure, food interaction, right? So a lot of things that I hear about are like cook with your child or play– with the food, right? So let's put the broccoli here and let's play with, you know, moving the little dino nugget over to the tree and do all of that stuff. Let's squeeze the fruit and see how it feels. Let's lick it. Oftentimes, it does one of two things, right? The one thing it can do is that it can desensitize a highly sensitive child to those feelings and those textures. So now maybe a child that never wanted to be around even the look of food, right, can be there and hold it, play with it, but they seem to get the brick wall when it actually comes to like eating the food. So that's an area of concern that I see with a lot of families, but with some of them, it actually works counterproductive because it's not pleasant for some and for some foods. When I think about eating food, I love to eat food. We've all talked about this. We love to eat food. I don't want to stick my hand in the bowl of pudding or I don't necessarily want to squeeze a raspberry in my fingers. It doesn't feel as good to me. That's not going to get me to actually want to eat it more. That's going to make me go, it doesn't feel so good. And now I don't want to eat it. And so I look at those interventions as potentially helpful for some kids that fall in more of that picky eater category, where they're not in that severe case at this point, you know, they have the opportunity to be able to work through some of those things in a more like low key fun way. But at the end of the day, you know, for me, what used to be like the parents motto all the time, they always say don't play with your food. We're really not supposed to play with food, we're supposed to play with toys and other types of things. And so when I come in, for a feeding program. I'm looking at how do we set our mealtime expectations? And our mealtime expectations are that, you know, we're putting out the foods that we're going to eat today, whether that starts with just one little bite for a kiddo up to, you know, a full plate of food for a meal, depending on where they are in their treatment program. And we're going to scoop or stab or pick up our bites, depending on what would be appropriate for what that child's skill level is at. And we're going to just pop them in and eat it and be done. You don't need to be inspecting the food, looking at it. Sometimes when we expose our senses too much, it can actually work in the opposite direction and become aversive. And so when we have a child that has such significant restriction already, and again, it's impacting all of those things that we've talked about today, I find that those interventions aren't helpful in most cases. But I do find the huge benefit of collaboration and finding ways to be able to work with, like we were talking about the speech and the OT, with nutrition for some of the kids that are trying to get off of

SPEAKER_01: 43:44

tubes.

SPEAKER_00: 43:45

I have to know for this child's height and weight, what caloric intake do I need to get them to during a day? What variety of fruits and vegetables and proteins do they need to be able to warrant getting off of the tube? Sometimes it's connecting with GI. If we've got a child that is constipated, you're not going to feel like eating if you're constipated, right? But part of the reason you're constipated is because you're not eating. So there's like that vicious cycle. And so we have to be able to find that balance in, you know, how can we work with GI and say, can we clear out this constipation issue kind of so we can start fresh and give them that opportunity for success? Because you don't want to be able to work on feeding if they're not hungry or not feeling well physically with themselves. So I think that there's, but to me, there's

SPEAKER_01: 44:36

huge

SPEAKER_00: 44:36

benefit to ABA feeding. I think ABA feeding interventions have done wonders for families in a lot of ways. I could line up tens of hundreds of families that have had great success. But again, I think it really comes down to every individual child. We can look in the ABA land to things that we don't necessarily promote, right? We could think about like the hyperbaric chamber sort of situation, right? Where some people will say, oh, we take my child with autism. We heard about the hyperbaric chamber or we heard about a specific diet. We're going to cut out all of these things because it's going to cure their autism,

SPEAKER_01: 45:20

right?

SPEAKER_00: 45:22

We hear that stuff all the time. But what's funny is you're always going to find somebody that's going to say, That cured my child. That was helpful. That worked. And so my answer to professionals and to families all the time is when they say, should I keep doing X, Y, or Z? Should I keep doing this intervention? Should I keep doing that intervention? Whatever it might be. As I say, let's take some data. Look at the data. Are you seeing progress? What are the goals? What are you trying to get to? And if it's working for you, do it. I'm not going to say don't do that because that's not the approach that I would take. If you're having success with it and you're doing well, awesome. Keep doing that. If you're finding that you and your child are not having the success that you want or hitting the goals that you want, then you have to be able to look at what are the other options out there and what can you do. I think that's the best answer I can give from thinking about how to approach that from all those different angles.

SPEAKER_02: 46:30

Thank you for clarifying, too, because I probably should have worded it differently because, you know, I kind of live in my bubble of in-home ABA therapy. And I think you're 100 percent right that ABA probably has had a net positive, almost certainly has had a net positive impact on feeding. And when it's done with the multidisciplinary approach, like you've talked about, collaborating with specialists like yourselves, maybe even speech or occupational therapists. I was just thinking about, you know, the in-home therapy, how so often it maybe is miserable And everything is done by the BCBA without any collaboration. And then you run into potentially detrimental effects. So thank you for clarifying that.

SPEAKER_01: 47:10

Yeah,

SPEAKER_02: 47:10

I think that is an important piece.

SPEAKER_03: 47:13

Well, we we warned you that this would fly by. Give us the five minute warning here for any pressing questions. You mentioned special diets and then it clicked. GFCF. I've been doing this for a long time. That's probably a whole separate episode. But you alluded to it in terms of I remember way back in early practice and maybe gluten free foods weren't so attractive at that time. I think they've gotten incredibly good and better since then. But I remember, you know, not. ABA and those types of interventions not playing so well. And then I remember, you know, hitting the point in my career where I was going like, well, it got the whole family started doing it, got them all to sit around the table. And so, of course, the kid got I mean, yes, it makes sense. Like, even if they didn't have a gluten sensitivity, look at all these other behaviors that changed. And then it obviously it failed for some people, too, because they were expecting the child to eat it on their own. And it wasn't the most attractive food and nowhere close to what they were eating. And Anyway, so it didn't go very well. But I really like the way you kind of conceptualize that. Is it working for you? It's not harmful? Okay. Look at the data. Keep giving it a shot and do what you need there. So that's really good. We won't get too much further into the diets. Dina, I do want to give you a chance to tell our listeners where to find you and all the incredible things you do for people out in Pennsylvania. So if you could just tell us the name of your center. maybe a website address. And I don't know if you want people emailing you questions, but you're welcome to share that information as well before we close.

SPEAKER_00: 48:52

Absolutely. Yes. So all of my programs are actually completely virtual so my center is my dining room table most days but it has actually worked really well because it again puts it on a parent first focus and so it really gives that that onus to the family to make the change because when you're in a clinic setting a lot of times and I'm sure a lot of ABA clinics just feel this too is the family like drops off that child and says here you go you know and I'm gonna go do all of the other things that have to get done which is great but feeding is about that family time, that family connection. And ultimately, the family is the one that's going to be doing most of the meals. And so they need to be the most involved in that. And so all of my programs are virtual. They are very heavy in parent involvement and training and prep as far as that intervention goes. My website is focusedapproach.com. And people can absolutely email me directly. It's just dkelly at focusedapproach.com. And I do direct feeding intervention as well as a lot of professional development and CEUs for BCBAs and ABA clinics that are interested in how they can, you know, make some improvements on that feeding behavior for their children.

SPEAKER_03: 50:06

We'll make sure and include that information No trickery, meaning don't try to sneak new foods into their preferred foods. And like we like to say on ABA on Tab Dan, always analyze

SPEAKER_02: 50:46

responsibly.

SPEAKER_03: 50:46

Thank you, Dina.

SPEAKER_00: 50:48

Thank you guys so much.

SPEAKER_02: 50:51

Thank you so much, Dina. That was a

SPEAKER_00: 50:52

pleasure. Thank you guys so much. I love any opportunity to talk about feeding. Always, always excited to do that.

SPEAKER_03: 51:00

Thank you. We hope people find you through this and maybe we get more people going your way. And again, yeah, thank you so much. We learned a ton. Yeah. Anything that we can ever do for you, you ever want to come back on to promote something, please just let us know. We will send you as soon as we can if you want. So we do it out of courtesy. We send the Zoom audio to guests. Most of them don't want to take the time to listen to it. So they say it's OK. Yeah. So if you're OK with us just publishing. Yep. If at any point you were to listen to it or somebody tells you, hey, we heard you. And I don't know any concern arises from it. Just let us know. We're glad this. Yes, it's our content. We're not going to keep it up if you're not comfortable with it. That's only happened once out of almost 60 episodes. So I think people would feel pretty comfortable and they, you know, they say things they want to say and nobody nobody's worried about that. But yeah, anything we can ever do for you again, we can't thank you enough for your time and and for sharing all your knowledge today.

SPEAKER_00: 51:57

Great. Thank you so much. It was great to meet you guys. Have a good rest of your day.

SPEAKER_03: 52:00

Thanks a lot. You

SPEAKER_00: 52:01

too. Bye-bye.

SPEAKER_03: 52:02

ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.