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Ethical Considerations of Behavioral Feeding Interventions

Children with autism spectrum disorder (ASD) often have feeding issues. Behavior analysts must follow the Professional and Ethical Compliance Code during feeding assessments and interventions.

Feeding Problems in Children with ASD

Restricted behaviors in food selections are common in ASD. Feeding problems include:

  1. Food selectivity: Aversion or liking for specific foods.

    • Extreme selectivity: Consuming 10–15 foods.

    • Moderate selectivity: Consuming more than 15 foods but less variety than usual.

  2. Food/liquid refusal: Refusing all, possibly needing tube feeds.

  3. Refusal to self-feed: Allowing others to feed but not self-feeding.
    Comorbid diagnoses like ADHD and anxiety can complicate feeding problems.

Importance of Interdisciplinary Collaboration

Collaboration is crucial due to the complexity of ASD and feeding issues. Problems can cause nutritional deficiencies and caregiver stress. Behavior analysts need to make ethical, collaborative decisions during assessments and treatment.

Need for Interdisciplinary Collaboration

Behavior analysts must practice within their competence, seeking training or consultation when needed. Feeding requires expertise from various fields. Section 4.02 requires behavior-change programs to be client-specific. Section 2.03 requires collaboration with other professions. The collaborative process ensures treatment doesn't cause harm and promotes positive outcomes.

Medical Collaboration

Medical professionals provide evaluations before behavioral interventions. Section 3.02 requires medical consultation if a behavior is influenced by medical variables. Collaboration can identify medical symptoms or allergies. Professionals include gastroenterologists, nurses, and nutritionists. Ongoing collaboration is important.

Allied Health

Allied health professionals (non-physicians or nurses) use evidence-based practices. They include speech-language pathologists, nutritionists, and occupational therapists. Speech-language pathologists assess oral motor skills. Occupational therapists address seating and self-feeding. Nutritionists identify foods to target. The behavior analyst collaborates to ensure individualization and data-based evaluation.

Parents and Caregivers

Informed consent is required before assessments, specifying procedures and collaboration. Section 3.03 requires a description of assessments, and Section 3.04 requires reviewing results in understandable language. Parents should be included in treatment. Collaboration with parents and nutritionists determines foods and targets interfering behaviors. Parent involvement is critical for generalizing outcomes.

The Role of the Behavior Analyst

After assessments, a behavior analyst assesses feeding problems with a functional assessment. Section 3.01 requires an updated assessment before a behavior-change program. Piazza et al. (2003) showed functional analysis leads to successful treatment. The behavior analyst modifies environmental contingencies to increase feeding behavior. Section 4.09 emphasizes the least restrictive procedure.

Navigating Non-Evidence-Based Practices

It's essential to acknowledge differing philosophies. Section 2.09 includes clients’ right to effective treatment. The behavior analyst shares literature to assist the client. Sensory integration is often recommended but has limited data. The SOS approach uses desensitization but has limited empirical support. Behavioral intervention components are necessary to treat feeding disorders effectively. Section 1.01 requires behavior analysts to use their knowledge of science. Brodhead (2015) discussed having a systematic strategy when faced with a non-behavioral treatment recommendation.

Navigating Evidence-Based Practices

Evidence-based practices have demonstrated success. Common procedures are differential reinforcement, physical guidance, and escape extinction. A behavior analyst needs to refer to the Professional and Ethical Compliance Code for Behavior Analysts to determine appropriate implementation.

Positive Reinforcement Strategies

Differential reinforcement can increase appropriate mealtime behavior. Ledford et al. (2018) found contingent rewards were common. Section 4.01 requires interventions to align with behavior analysis. Some studies compared noncontingent reinforcement with escape extinction. The behavior analyst should be aware of the least restrictive procedure. Other positive reinforcement procedures include modeling, shaping, fading, and visual supports. Section 4.03 requires adapting interventions to ensure individualization.

Physical Prompting

Physical prompts, like hand-over-hand prompting, can be effective. The interdisciplinary team should agree on termination conditions. Section 4.08 highlights using reinforcement-based procedures first. Consultation with professionals assists in deciding if physical prompting is necessary. Ahearn et al. (1996) found caregivers preferred physical prompting. This supports Section 4.02, which emphasizes including the client in treatment development.

Escape Extinction

Feeding problems are often maintained by negative reinforcement. Escape extinction reduces feeding problems maintained by escape. It involves continuing food presentation until acceptance. Caution is needed due to negative side effects. Consistent implementation is essential. Section 3.02 requires medical consultation before implementation. Combining positive reinforcement with escape extinction may reduce inappropriate behaviors. Section 4.07b requires identifying environmental variables. Section 4.11 emphasizes identifying measurable termination criteria. Informed consent must be gathered. The behavior analyst must also review other available interventions. The client and caregiver have the right to choose among interventions.

Conclusion and Recommendations

Treating selective feeding involves ethical analysis and specialized skills. Behavior analysts must assess their skills and seek supervision if needed. This requires informed consent. Assessment is crucial, requiring collaboration with professionals. A coordinated effort ensures a multidisciplinary approach. A functional assessment by the behavior analyst informs treatment. Tools can assist clinicians to ensure ethical practices. The clinician must evaluate which approach is best suited to the client.