Using “The Food Game” to overcome hurdles of Eating Issues in Children

By Emaley McCulloch, M.Ed., BCBA

Do you know a picky eater?  The odds are, you do, since 25% of children are reported to present some form of feeding issues and the number increases to 80% in children with developmental delays (Manikam & Perman, 2000). The nature of feeding issues in children can be a combination of behavioral and organic. That is why it is important to consult with a multidisciplinary team when creating a comprehensive treatment plan. The team can include a nutritionist, an occupational therapist, speech therapist and behavior analyst. When organic causes are ruled out, many of these feeding issues can be resolved with low intensity behavioral interventions (Sharp, Jaquess, Mortin & Herzinger, 2010).  Dinnertime will no longer feel like a hostage negotiation, and you might even get to eat at restaurants again!

Types of Behavioral Feeding Issues

Some types of feeding issues seen in typically developing and children with disabilities include:

• Extremely limited diet—may limit foods of certain texture, color, type etc.
• Will only eat at certain places
• Will only eat from certain dishes or drink containers
• Over- or under-consumption of food and/or liquids
• Refuses to participate in meal time routines

Common Behavioral Interventions for Feeding Issues

There are a number of evidence-based strategies that can be used to combat feeding issues.  These strategies are based on principles of behavioral science.

Shaping – Breaking down a target response into steps or approximations and presenting and rewarding one step at a time. For example, if your child only consumes fruit in the form of yogurt, you can start by systematically increasing the size of the fruit pieces in the yogurt.

Differential Reinforcement of Alternate Behavior – Includes rewarding approximations of desired feeding responses while ignoring inappropriate responses. For example, reward small steps towards accepting new foods (tolerating them on table/plate, smelling or touching, licking) and provide preferred foods contingently on these “accepting behaviors”.

Other techniques that are effective can come with possible negative side effects if not done incorrectly or not systematically enough. For example, using physical guidance to resisting the child’s attempts to escape can blow up in your face (literally, if the child has a handful of spaghetti and decent aim). If the procedure is not set up with enough motivation, or if the response effort is too much for the child, you may end up in a power struggle and create a negative meal time experience which can only exacerbate the problem.

The Food Game

To overcome some of the hurdles of these strategies, The Food Game provides a fun and choice-based approach to teaching a child to accept new foods. Played with a teacher/caregiver only or with a group of siblings or peers, it turns sampling foods into a fun game that can be used as a supplement to structured feeding sessions. Having peers and siblings participate provides an opportunity for the child to be presented with peer models of appropriate “accepting behaviors”.

The Food Game is a board game with markers/pieces that move across the board when each player completes certain actions with different items of food. To set up the game, you must have the board with spaces of different “eating actions” that are arranged in systematic approximations of eating (e.g. Look at the food, smell it, touch it, hold it, bring to mouth, lick it, hold in mouth, chew and swallow small bite, chew and swallow big bite). You can download  a board here or you can make your own. You can paste it on cardboard or laminate it.

What you need

• Board
• Small markers/pieces with picture or word of the target food item (key tags or small pieces of card stock paper)
• Large marker to mark goal (e.g. pom-pom, action figure)
• Small containers with bite size food
• Prize/reward for reaching goal

Choosing food to target

In the beginning sessions, you will target samples of food that the child can already easily eat. Subsequent sessions will slowly introduce foods that are more and more difficult. The success of the game is determined by how well you systematically introduce and reward approximations of desired responses. Through the game the child/children move across spaces that require them to complete approximations of eating (Step 1: Look at the food, 2: smell it, 3: touch it, hold it, bring to mouth, lick it, hold in mouth of __ seconds, chew and swallow small bite, chew and swallow big bite). The final target response is different for each food item used in the game and the target response gets harder across game sessions. For example, a child may only be able to touch a banana but chew and swallow a cashew. 

How to Play

1. Determine items or rewards that motivate your child to meet a feeding goal. For some children, just achieving the goal/space on the board could be rewarding enough. Also use a lot of praise and energy during the game to keep things fun and positive!

2. Choose Foods to Target. Make a list of foods the individual already eats. Start The Food Game with foods that the individual already likes.  This will help get them used to the game. Once they learn the rules of the game, systematically and strategically add new targets and foods. Take small steps by using the list of foods that is already tolerated and then choose foods that are most similar. For example if the individual will eat one kind of corn chip, then maybe introduce a different kind of corn chip or try a tortilla chip. This will increase the likelihood of success. If you move too quickly, the game becomes too difficult and the individual might resist playing. For example, if you have an individual who usually resists eating fruits, it would not be recommended to move from eating chips to a piece of banana.

3. Have child choose a marker with food item written or picture on it to start moving across the steps on the board. You can use key-tags to put a picture of the food item on them or simply use a small piece of cardstock with a picture of food item or word written on it. On their turn, use the “marker” to indicate what step/space they are on in the game board.

4. Select goal for each food item. Use a bigger marker (big pom-pom or action figure the person likes) to mark the goal to achieve the final reward. For example, in this game session, Abby’s final goal is to put a blueberry up to her mouth, so there is a Littlest Pet Shop figurine sitting on that square of the game board and she is moving her marker through the steps until she reaches the target step.

5. Take Turns and Use Peer Modeling. Have peers or family members play together. This allows the individuals to encourage each other and observe models going through the steps and getting reinforced. During a person’s turn, they select a marker/food (having choices also increases success with the game) then the facilitator/teacher puts the big marker on the final step they must reach to win that round. That person goes up the steps until 1) they reach the final target and get a reward or 2) they decide to stop at a step and give someone else a turn. If they stop before reaching the marker, they do not get a reward and can pick up where they left off on their next turn.

6. End the game on a positive note. Try to end the game after a short enough duration (ex. 20 minutes) before they lose interest or it gets too difficult. Provide praise for their effort. Write good notes so you can remember where to pick up on the next game.

7. Generalize. Once foods have been sampled and practiced in the game multiple times, introduce those foods during meals systematically.

Additional Tips

• When first introducing The Food Game, use highly preferred rewards. This will help to compete with escape-motivated behavior. Eating non-preferred foods can be a very difficult task for some people. To put yourself in their shoes, just imagine this: what kind of reward would you need if someone told you to eat a caterpillar?
• The goal is to pair food with reinforcement, not to teach children to tolerate distressing situations. If the child displays avoidance or distress and wants to escape from the situation you may want to go back to a step that was easier for the child to gain success.
• Predetermined target steps can change and will depend on your learner. For some, the steps might need to be very small and require more time at each step. Others might be able to take bigger steps.

You might be surprised how fast your child decides to move forward in the game. I’ve seen very resistant children try several new foods in one game that they would never have tried during feeding sessions or during meals (though we have never actually tried it with caterpillars). It’s amazing what choice and gaming can do!

References

Manikam, R., & Perman, J.A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology. Jan;30(1):34-46.

Sharp, W., Jaquess, D.L., Morton, J.F., & Herzinger, C.V. (2010) Pediatric Feeding Disorders: A Qualitative Synthesis of Treatment Outcomes. Clinical Child Family Psychological Review. 13:248-365

Emaley McCulloch, M.Ed, BCBA co-founded Autism Training Solutions, LLC in  2008, and is currently the Vice President of Relias Institute at Relias Learning. Relias Learning is the premier provider of online health care training for Health and Human Services, Senior Care and Public Safety. Emaley is a Board Certified Behavior Analyst and holds an MA in Special Education. She has served in the field of ABA for over 18 years and has provided and overseen services to individuals between the ages of 18 months to 24 years in homes, schools and clinical settings. For eight years she served as a consultant and supervisor at agencies based in Hawaii and Japan where she trained groups of professionals and parents. Emaley’s passion is elearning, staff training, dissemination of evidenced-based interventions, research, film and videography and using technology in the field of behavior analysis and special education.  You can contact her at [email protected].