Food selectivity is a common problem in many children with Autism Spectrum Disorder (ASD). While research into this area is beginning to develop, there are currently few studies investigating the use of parent-implemented interventions within this population. The present study aimed to teach parents to implement multi-component behavioural interventions at home to ameliorate the food selectivity of their children. The study also aimed to show that these interventions could increase children’s preference for previously nonpreferred foods. Five children and their parents participated. The interventions delivered to the children were tailored to meet their needs and to fit within the context of their families. Each of these interventions was composed of antecedent, positive reinforcement and escape extinction strategies. Parents recorded their children’s food acceptance and disruptive behaviours during each intervention session. In addition, preference assessments were conducted in order to track changes in the children’s preferences for the target foods. The results showed that all of the parents were able to introduce at least one new food to their children’s diets during the intervention. Further, four of the five children showed an improvement in their preference for the targeted foods. These results were maintained at follow-up, although two of the children had only maintained some of the foods that had been introduced. All of the parents reported that their children consumed more foods at follow-up than they had during baseline and indicated that they thought the interventions had been effective. These results indicate that parents are able to implement multi-component behavioural interventions to increase the range of foods in their children’s diets and improve their children’s preference for these foods.

Feeding disorders are psychological conditions that occur during infancy and early childhood, and result in insufficient intake of foods. Existing feeding disorder research identifies a raft of factors associated with predisposition, development and maintenance of feeding disorders, as well as a multitude of potential outcomes for the child and the system around them. However, neither feeding disorders nor their aetiological bases are well defined or uniformly applied in general, academic or clinical domains. Furthermore, the relationships and differences between observable characteristics, diagnostic criteria, and problem perceptions, and the bearing of these on disorder identification and treatment, are under-researched. The numerous definitions and profiles for feeding disorders make comprehension and knowledge gathering very difficult for caregivers and researchers, and thus hinder research and clinical progression in the field. The overarching aim of this thesis was to examine and characterise paediatric feeding disorders. The objective was to characterise and triangulate what feeding disorders are in terms of observable appearance, external perception, and psychometric properties, and better understand what constitutes a feeding disorder from multiple relevant perspectives. A mixed methods approach was taken to the collection and analysis of data, to obtain both depth and breadth of information. The results of the current thesis suggest that feeding disorders are characterised by a variety of behaviours and features within a biopsychosocial model. While physical models of feeding disorders are outdated, the potential for underlying physical contributing factors and resultant physical outcomes was highlighted throughout the current research and should not be ignored. However, overreliance on physicality, under-recognition of psychological processes, and consequent deficits to disorder identification within clinical settings, was also illustrated within the research. Furthermore, significant issues were raised regarding the lack of a consistent and inclusive model of feeding problems and disorders within healthcare systems. Though most clinicians saw feeding on a scale from normal to abnormal and frequently emphasised the value of early identification and treatment, the referral and treatment pathways that were discussed whereby only the most severe or physically affected children were treated, were not consistent with these models. Interviews with mothers highlighted the role of intrinsic child factors within the development of disordered feeding, including challenging behavioural characteristics, sensory sensitivities, difficult temperament, and lack of feeding motivation or avoidance of new foods. The importance of these child factors was supported by psychometric assessment, which identified distinct patterns of child characteristics associated with different types of problematic or disordered feeding, and a strong association between disordered feeding and the parent perception of having a difficult child. Furthermore, video observations of child mealtimes highlighted not only disparity in the amount of food eaten between disordered and non-disordered children, but a considerable deficit in the level of interest, motivation, and engagement with feeding shown by disordered children. Deficits to child feeding motivation pose a problem for parents that is less obvious than extreme emotional reactions, but which can be equally distressing for the parent who views nourishing their child as one of their major responsibilities. This point was reinforced across parent interviews and mealtime observations, and should be a key factor in the identification of families in need of support and intervention. Parent interviews, healthcare professional interviews, and psychometric assessment, all highlighted the considerable presence and role of parent anxiety within feeding disorder development. Parent anxiety was discussed as a potential cause and an outcome of challenging feeding behaviour, exacerbated by the perceived extent of the child s feeding condition and the dearth of support and information about dealing with significant feeding issues. Anxiety was seen by parents and healthcare professionals to influence the feeding strategies used by parents, and without intervention to contribute to a downward spiral of negative feeding interactions. Disordered feeding was also seen to interfere with social interactions, which would otherwise play an important role in the child s feeding and dietary development, and provide social support and guidance for parents. These patterns of problem and disorder perpetuation are liable to persist while general and clinical understanding of feeding disorders is minimal and inconsistent. The findings of the current thesis pose a great variety of potential influences and risk factors for feeding disorder development, supporting an individualistic approach to disorder identification and intervention, and the need for a significant change in the current systems for dealing with feeding disorders. It is essential to take each of the different components into consideration to understand the specific mechanisms underpinning the maintenance of the feeding disorder and aid selection of the most suitable and efficient approach to intervention. The pattern of factors implicated in each individual feeding disorder case will be differentiated according to the child, the parent and the child s general environment. Identification of the full range of children in need of support and intervention is reliant on recognition of the diversity in disorder type, severity and presentation.

Previous research on the assessment of pediatric feeding disorders has shown that negative reinforcement (escape) plays a major role in the maintenance of food refusal and that escape extinction (EE) may be necessary in the treatment of severe food refusal. The current study examined the influence of two potential motivating operations (MOs) on escape from bite presentations for 3 children with severe food refusal: (a) noncontingent positive reinforcement (NCR) and (b) food satiation (as a result of enteral nutritional support). The abolishing effects of NCR on negative reinforcement for refusal behaviors were demonstrated in Experiment 1 when escape was allowed for food refusal and in Experiment 2 during demand fading across a hierarchy of bite placements. The interactive effects of NCR and food satiation on negative reinforcement for escaping bite presentations (within a hierarchy of bite placements) were demonstrated in Experiment 3. NCR abolished escape as a reinforcer and food satiation established escape as a reinforcer. The combined MO effects of NCR and food deprivation resulted in decreased refusal behaviors and increased acceptance across all bite placements in Experiment 3 even though escape was allowed. Results extend the existing bodies of literature on the competition between positive and negative reinforcement and the effects of specific biological conditions on escape-maintained behavior. Implications for treatment and future research are discussed.

The purpose of this study was to evaluate the effectiveness of video modeling of contingencies alone and/or combined with direct exposure to the contingencies in the treatment of food selectivity. Treatment procedures included sequentially introducing videos in which models consumed nonpreferred food, were exposed to differential reinforcement, or exposed to escape extinction and differential reinforcement. In addition, participants were exposed to differential reinforcement. Results indicated video modeling of differential reinforcement plus differential reinforcement may be effective at increasing consumption of some nonpreferred foods, but the results were not replicated across all foods. For one participant, consumption of one food increased with video modeling alone.

Ätproblem hos barn är relativt vanliga och existerar både hos i övrigt friska barn och hos barn med andra sjukdomar och diagnoser. I vissa fall är ätproblemen så allvarliga att de leder till malnutrition. Ofta delas ätproblem in i kategorier beroende på om man tycker sig se en medicinsk orsak eller inte, man skiljer därmed på organiska och icke-organiska problem. Detta arbete fokuserar främst på det som i litteraturen brukar kallas matvägran. Syftet var att belysa området i stort genom att presentera och diskutera aktuell litteratur och forskning om matvägran samt att kritiskt granska olika förklarings-modeller och begrepp. Tre fall av barn med matvägran beskrivs också. Beskrivningarna är baserade på information som lämnats av barnens mödrar i intervjuer och syftar till att beskriva hur naturalförloppet vid matvägran kan se ut samt att undersöka föräldrarnas attityder och känslor kring problemet i sig och kring vårdkontakter. Gemensamma drag var bland andra att barnen haft problem med att äta redan från början och att de alla kräkts frekvent. Mödrarna i de tre fallen beskriver också att de är besvikna över vården av deras barn. Genomgången av etiologi och orsaksteorier pekar mot att matvägran sannolikt är en komplex samverkan mellan en rad olika fysiologiska, psykologiska och miljömässiga faktorer. Att kalla besvären antingen organiska eller icke-organiska kan vara missvisande. Huruvida barnet uppvisar en ovilja eller aversion mot att äta borde vara avgörande för val av behandling och behandlingen bör utformas så att barnets integritet respekteras. / Feeding problems in children are common and exist both in otherwise healthy children and in children with medical conditions. In some cases the feeding problems are severe enough to cause malnutrition. A distinction is often made between organic feeding problems, which are thought to be caused by a medical condition and non-organic problems, where no obvious medical reason can be found. This study was primarily focused on what is referred to as food refusal. The aim of the study was to illuminate the area by presenting and discussing current research as well as critically view common terminology and theories. Three case studies of children with food refusal are also posed. The descriptions are based on information extracted from interviews of their mothers and aim to describe how the natural course of food refusal can present itself as well as to explore parental attitudes and feelings around the problem itself and around contacts with the health care system. Some of the common denominators were that the children all exhibited feeding problems from the beginning and that they have suffered frequent vomiting. The mothers have been disappointed with the care that their children have received. The review of etiology and theories points towards food refusal being a complex interplay between physiological, psychological and environmental factors. To label the problem as being either organic or non-organic can be misleading. Weather the child exhibits an aversion or unwillingness to eat should be an important aspect in choosing treatment form and respecting the child´s integrity should be a priority in treatment.

Bakgrund: Mat- och dryckesvägran i livets slutskede är ett fenomen som sjuksköterskor inom palliativ omvårdad ofta stöter på. När en patient vägrar äta och dricka, uppstår frågor om hur symtomlindring och lindrat lidande bäst ska gå till, samtidigt som patientens autonomi och självbestämmande hedras. Syfte: Syftet var att belysa sjuksköterskors upplevelser och attityder kring att vårda patienter inom palliativ omvårdnad som frivilligt slutar äta och dricka. Metod: En allmän litteraturstudie med induktiv ansats utfördes. Datainsamlingen genomfördes i databaserna CINAHL, Pubmed och PsycINFO och resulterade i sju resultatartiklar. Resultat: Genom dataanalysen framträdde tre huvudkategorier: 1) Ett växande fenomen där sjuksköterskor upplever många brister 2) Sjuksköterskors attityder till patientens beslut 3) Sjuksköterskors upplevelser av att möta anhöriga. Den första kategorin lyfter sjuksköterskors upplevelser av de brister som försvårar deras möjlighet att vårda patienterna. Den andra kategorin belyser sjuksköterskors acceptans kring fenomenet. Den tredje kategorin belyser sjuksköterskors kontakt med anhöriga. Konklusion: Resultatet tyder på att sjuksköterskors upplevelser och attityder till frivillig mat- och dryckesvägran är mestadels positiva, men att sjuksköterskor efterfrågar mer information, utbildning, lagar och riktlinjer kring ämnet. / Background: Food and drink refusal at the end-of-life is a phenomenon that nurses in palliative care often encounter. When a patient refuses to eat and drink, questions arise about how symptom relief and alleviated suffering should best be done, while simultaneously respecting the patient's autonomy and self-determination. Purpose: The purpose was to illuminate the nurses' experiences and attitudes about caring for patients in palliative care who voluntary stop eating and drinking. Method: A general literature review with an inductive approach was conducted. The data collection was carried out in the databases CINAHL, PubMed and PsycINFO, which resulted in seven articles. Results: Through the data analysis, three categories emerged: 1) A growing phenomenon where nurses experience many deficiencies 2) Nurses' attitudes to the patient's decision 3) Nurses' experiences of meeting relatives. The first category highlights nurses' experiences of the deficiencies that make it difficult for them to care for the patients. The second category highlights nurses' acceptance of the phenomenon. The third category highlights nurses' contact with relatives. Conclusion: The results indicate that nurses' experiences and attitudes towards voluntary stopping of eating and drinking are mostly positive, but that nurses request more information, education, laws, and guidelines on the subject.

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