The Effects of a Brief Behavioral Intervention on Food Refusal in a Child With a Fear of Choking

1 Theoretical and Research Basis for Treatment

The fear of choking is characterized by a fear and avoidance of swallowing foods, liquids, pills, or a combination of these in the absence of a true organic medical problem affecting swallowing and feeding (Burklow & Linscheid, 2004). Most choking phobias develop following a choking incident; however, having a sore throat or a negative experience with distasteful food or medicine may also lead to a fear of choking. A person with a choking phobia typically exhibits intense anxiety and emotional distress in the presence of the feared stimulus (e.g., food, liquid, medication), which results in restricted eating patterns or complete avoidance of eating. Although prevalence of choking phobias is unknown, it seems to occur more often in females with age of onset ranging from young childhood to adults (McNally, 1994).

Treatments for choking phobias in both children and adults vary and include the use of selective serotonin reuptake inhibitors (SSRIs; Banerjee, Bhandari, & Rosenberg, 2005), hypnosis (Culbert, Kajander, Kohen, & Reaney, 1996), eye movement desensitization and reprocessing (EMDR; Roos & Jongh, 2008), SSRIs combined with cognitive-behavioral therapy (CBT; Lopes, Melo, Curral, Coelho, & Roma-Torres, 2014), CBT in the absence of antidepressants (Davis, Reuther, & Rudy, 2013; Suraweera, Hanwella, & De Silva, 2014), and behavioral treatment using various forms of in vivo exposure and contingency management in both inpatient and outpatient settings (Chatoor, Conley, & Dickson, 1988; Chorpita, Vitali, & Barlow, 1997; Evans & Pechtel, 2011). Burklow and Linscheid (2004) rapidly eliminated choking phobias in six children by combining both contingency management and in vivo exposure with appetite manipulation by allowing only water between meals and providing hospital privileges (e.g., watching TV, visits, phone calls) contingent on eating foods.

Recently, Williams, Field, Riegel, and Paul (2011) successfully treated a child with a fear of vomiting, emetaphobia, using a brief, exposure-based behavioral treatment that was originally used to treat children with food selectivity (Paul, Williams, Riegel, & Gibbons, 2007). The behavioral intervention consisted of implementing taste sessions during which the participant was required to taste a single bite of food before earning a short break. In addition, probe meals during which the participant was not required to take bites of foods were implemented to assess her progress across treatment. After 7 days of treatment, the child was discharged consuming all foods and liquids by mouth, with gastrostomy tube feeds completely eliminated. The current study examined the effects of the same intervention on food refusal in a child with a fear of choking.

2 Case Introduction

The participant was a typically developing 4.5-year-old Caucasian female who presented with total food refusal and complete dependence on 3 to 4 bottles of a chocolate-flavored pediatric formula per day. She lived with her biological parents and her 10-year-old brother. Beyond her current presenting problem, the participant’s family reported no significant stressors or conflicts between family members. The participant was enrolled in a pre-K education program and was reported to be very outgoing and social.

3 Presenting Complaints

The participant stopped eating almost all foods by mouth for approximately 3 months prior to treatment following an acute choking incident during which she was eating a peanut butter and jelly sandwich. She required a “forceful pat on the back” until the bolus dislodged. Following the incident, the participant’s diet gradually declined and resulted in her mother presenting a pediatric formula. Two weeks following the incident, an X-ray was performed to rule out foreign body aspiration as the participant continued to refuse solid foods. Parents reported that there were no constrictions noted on the X-ray. Parents also reported a gastroenterologist recommended a barium swallow study and an endoscopy but the primary care provider did not believe these tests were indicated. She received a proton-pump inhibitor for 9 days and it was discontinued because no changes were observed.

The participant was seen for an initial interdisciplinary feeding clinic evaluation 3 months after the acute choking episode. Her body mass index (BMI) was 15.5, which was the 50th percentile for females of her age. At the time of the clinic evaluation, the participant was consuming three to four 8-oz chocolate-flavored pediatric formula per day in addition to drinking water, juice, crumbles of a chocolate bar, and small amounts (i.e., up to 5 tablespoons) of chocolate pudding. The participant’s mother reported that her daughter complained that there was “sand or glass” in her food as she continued to refuse to eat solids. Parents consulted with a psychologist for several weeks prior to the clinic evaluation but no progress was reported. The participant had no reported issues with vomiting and was reported to tolerate 8 oz of formula at a time. Parents reported that their daughter did not have any issues with constipation and that she had bowel movements two to three times per day. While parents reported that their daughter did not have any problems brushing her teeth, they reported that she had previously developed what resembled an obsessive compulsive behavior of brushing her teeth every time she drank for 3 weeks before the pattern eventually resolved.

During the evaluation, a feeding observation was conducted and the participant was presented with her preferred pediatric formula and crumbles of a chocolate bar, which she was reported to eat on occasion. She asked to hold her mother’s hand during the feeding observation and while she was able to consume 8 oz of pediatric formula in 4 min, the participant exhibited signs of anxiety and distress (i.e., crying and clinging to her mother) when presented with the chocolate bar. She asked if she could just smell it and after doing so, the clinicians terminated the feeding observation.

Following the initial clinic evaluation, intensive treatment was recommended based on the participant’s dependence on pediatric formula and almost complete absence of solid food intake. In addition to having trained staff implement a behavioral intervention, intensive treatment would be able to include both medical and nutritional monitoring as the participant began to accept and increase the volume of solid foods consumed during treatment and as her dependency on pediatric formula decreased.

4 History

The participant’s family reported that prior to the choking episode, the participant had no history of mental health problems and her medical history was significant only for acute illnesses typical in childhood. The participant had no history of delays in development and her parents reported that their daughter was a very good eater and ate a wide variety of foods prior to the incident. No family history of anxiety or psychosocial stressors was reported by the parents.

5 Assessment

Information gathered from a diagnostic interview with the participant and her parents indicated that the participant’s food refusal was associated with her fear of choking. Medical evaluations of the food refusal did not identify any biological conditions responsible for the participant’s food refusal. The child did not exhibit any anxiety in situations outside of mealtimes. While food refusal associated with a fear of choking was previously conceptualized as a specific phobia (American Psychiatric Association, 2000), using the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American Psychiatric Association, 2013), the participant met criteria for avoidant/restrictive intake disorder represented by her dependence on pediatric formula and conditioned negative experience associated with food intake following, or in anticipation of, an aversive experience (i.e., choking). Furthermore, her avoidance to eat was not attributable to a medical condition, mental disorder, anorexia nervosa or bulimia nervosa, or associated with a cultural practice.

6 Case Conceptualization

Unlike most of those with food refusal, the participant in this study did not have any known medical conditions (e.g., gastroesophageal reflux, chronic constipation, etc.) that may have been related to her refusal (Field, Garland, & Williams, 2003). Instead, her conditioned aversion to eating appeared to be related to her acute choking episode. It was likely that her refusal was maintained by three factors—negative reinforcement, positive reinforcement in the form of attention, and lack of appetite. Negative reinforcement occurred in the form of escape from feeding demands placed on her by those in her environment as they tended to remove demands when she exhibited refusal. In addition, she received various forms of attention (e.g., emotional reactions, continued encouragement to eat) from her parents and others contingent on the refusal. Furthermore, because the participant was drinking three to four bottles of pediatric formula per day and her nutritional needs were met, hunger did not motivate her to eat.

Based on this conceptualization of the case, it was decided that the brief exposure-based intervention that has previously been used to treat food selectivity by both therapists (Paul et al., 2007; Pizzo, Williams, Paul, & Riegel, 2009) and caregivers (Seiverling, Williams, Sturmey, & Hart, 2012) and has also successfully treated a child with food refusal secondary to emetaphobia (Williams et al., 2011) would be used to treat the participant in this study.

7 Course of Treatment and Assessment of Progress

The participant attended an intensive day treatment feeding clinic from 8:15 a.m. until 2:15 p.m. Monday through Friday for 9 days. Across treatment, probe meals and taste sessions were implemented by two feeding therapists, one with a master’s degree in speech language pathology and one with a bachelor’s degree. In addition, a doctoral-level behavior analyst, who supervised the case and the participant’s mother, implemented both meals and taste sessions.

Two 10-min baseline meals were conducted to assess the participant’s level of intake prior to treatment. During baseline meals, the participant was presented with teaspoon-size bites of three foods (i.e., cheezits, pancake, and apple sauce) and juice by the therapist and then again by her mother with the same foods and water. The feeder presented the bite up to the participant’s mouth and said “take a bite.” After 15 s, the feeder presented the next bite and again provided verbal instructions. The feeder rotated through the target foods following this procedure until a timer beeped at the end of the 10 min. The participant was not required to eat any bites during baseline but was given verbal praise if she accepted any bites or drinks. The feeder ignored all refusal behavior (i.e., pushing the food away, covering her mouth, crying, shaking or turning her head, saying “no,” and screaming). Bite acceptance was defined as the participant accepting the entire portion of presented food without any visible remnants of the food on the spoon and swallowing without spitting the food out. She did not accept any of the foods presented in both baseline sessions but drank 72 g of juice and 83 g of water respectively. Treatment began following the two baseline sessions as the participant did not accept any bites of foods presented within baseline.

Treatment involved both taste sessions and probe meals. Single-bite taste sessions involved presenting a single bite of food and the session was terminated as soon as she consumed the bite. The participant was given 30 s to self-feed the bite and if she did not self-feed, the feeder presented the bite up to her mouth and provided the verbal instruction “take your bite” every 30 s until she consumed the bite. If the participant expelled the bite or a portion of the bite, the feeder re-presented the size of the piece expelled until the participant consumed the entire bite presented. As in baseline, the feeder ignored all refusal behavior. As soon as the participant consumed the bite, she was given a 2-min break outside of the treatment room where she had access to preferred toys and activities. During the first 4 days of treatment, the participant was exposed to a variety of foods in single-bite taste sessions. After approximately 10 taste sessions, she was then given a 10-min probe meal with the foods she had been given during the previous taste sessions. Probe meals resembled baseline meals in that the participant was presented with several foods and a drink and she was not required to take any bites by mouth and all inappropriate behaviors were ignored. Probe meals allowed therapists to assess the participant’s progress during treatment and to determine when to discontinue single-bite taste sessions. If the participant did not consume bites of a particular food during a probe meal, that food was then presented in subsequent taste sessions. Foods that the participant did accept during probe meals were presented during probe meals with the participant’s mother and then during meals at home with the child. Following 4 days of presenting taste sessions followed by probe meals, taste sessions were discontinued and the participant was presented with both foods previously presented in taste sessions as well as novel foods in probe meals.

Figure 1 shows the percentage of single-bite taste sessions accepted under 30 s across the first four days of treatment. During the first day, the participant only accepted 54% of bites presented during taste sessions under 30 s; however, the percentage of bites increased across treatment sessions until she accepted 90% of bites under 30 s on the fourth day of treatment before single-bite taste sessions were discontinued and new foods began to be presented during probe meals. The longest latency for the participant to accept a bite during taste sessions was 21 min during which a pea-size bite of an animal cracker was presented during the fourth taste session on the first day of treatment.

OPEN IN VIEWER

Figure 1.

The percentage of bites eaten under 30 s during single-bite taste session across the first four treatment days.

Figure 2 shows the number of bites eaten during probe meals across baseline and treatment. The participant did not accept any bites during baseline. Across treatment, her acceptance of bites during probe meals was variable and ranged from 2 to 42 bites with a slightly lower level of bites accepted after taste sessions were discontinued. It is important to note that the participant was not required to take any bites during probe meals and that the focus of these meals was to determine if the participant would start to accept foods in a more typical meal format. Across treatment, the participant demonstrated a pattern of eating fewer bites in morning sessions and reported not being hungry during many of the 8:15 a.m. sessions. Her mother reported that her daughter did not have a large appetite in the morning even prior to the choking incident. The participant’s limited appetite in the morning may explain some of the variability in her acceptance of bites across treatment probe meals. Each treatment day, the participant tended to accept fewer bites in the first probe meal followed by an increase in bites accepted during subsequent probe meals.

OPEN IN VIEWER

Figure 2.

The number of bites eaten during 10-min probe meals across baseline and treatment.

8 Complicating Factors

Although the participant exhibited anxiety and distress during initial taste sessions on the first day of treatment, she was very cooperative during treatment. The participant’s family also closely followed therapist recommendations during treatment. During a postdischarge follow-up conversation, the participant’s mother reported that the participant continued to eat a wide variety of foods during the first several weeks following discharge without a structured meal plan in place. She was reported to try new foods, eat meals at a table with family and friends, and request food. Approximately 1 month following discharge, the participant’s mother reported that her daughter showed some resistance to eating at a large family party. She then was reported to request macaroni and cheese and refuse other foods for several days. It was recommended that the family reinstate 10-min structured probe meals as they had done in treatment. The family reported that the participant exhibited less refusal behavior and continued to eat a wide variety of foods presented when the structured meals were reinstated.

9 Access and Barriers to Care

The participant’s treatment took place at an intensive pediatric day treatment feeding program. Whereas the family was able to attend the program, many families do not live in close proximity to a pediatric feeding program. Furthermore, many caregivers are not able to attend a full-day program with their child for an extended period of time. It is important for clinicians and researchers to continue examining the effects of this type of behavioral feeding intervention in less intensive outpatient settings as well as in the home.

10 Follow-Up

After 9 days of treatment, the participant was discharged with a probe meal protocol in place during which the participant selected two foods and her mother selected one or two foods at each meal to ensure variety. Several postdischarge phone calls were completed with the family during which the family reported progress and the therapist answered any questions and provided recommendations. Sixteen months following discharge, the participant’s mother filled out a posttreatment food preference inventory of 86 commonly eaten foods and reported that her daughter ate 47 of the foods (see Figure 3). At 16-month follow-up, the participant’s BMI was reported to be 14.9, which was the 42nd percentile for females her age. Her mother reported that her daughter had no problems with eating and no longer reported a fear of choking.

OPEN IN VIEWER

Figure 3.

Number of foods reported eaten by the child before treatment, at the end of treatment, and at 16 months following treatment.

11 Treatment Implications of the Case

The intervention in this study has been demonstrated to be successful at treating food selectivity in children (Paul et al., 2007; Pizzo et al., 2009; Seiverling et al., 2012) as well as a child with food refusal secondary to emetaphobia (Williams et al., 2011). While food refusal linked to a fear of choking is similar in many aspects to refusal associated with emetaphobia, this study further demonstrates the effectiveness of this brief intervention to treat a wide variety of feeding problems in children. While one study reported rapid and sustained improvement in three children with choking phobias following low dose SSRI treatment (Banerjee et al., 2005), there is an increased risk of suicide and other side effects associated with the use of SSRIs in children and adolescents (Food and Drug Administration, 2007). This study adds to the growing literature of successful behavioral interventions at treating choking phobias (Burklow & Linscheid, 2004; Chatoor et al., 1988; Chorpita et al., 1997) without the use of antidepressants.

12 Recommendations to Clinicians and Students

It is important to note that although the participant in this study was consuming over 30 foods at the end of treatment, her mother reported that 1 month following discharge, her daughter began to exhibit some refusal behavior and insisted on eating a highly preferred food for several days before the family reinstated the discharge treatment meal plan that resembled a probe meal during which the child was able to select two foods and a caregiver selected one food to ensure variety. During the meal, verbal praise was provided contingent on the participant’s acceptance of bites and inappropriate behaviors were ignored. Although the participant’s acceptance of a variety of foods increased after her parents reinstated the structured probe meal at home, her slight regression 1 month following treatment exemplifies the importance of caregiver training and carryover of a discharge meal protocol into the home following a brief behavioral intervention.

Rapid behavioral interventions have been shown to effectively treat choking phobias in as little as three treatment days (Burklow & Linscheid, 2004); however, if caregivers do not follow discharge recommendations regarding how to respond to the child’s refusal behavior or if they do not implement the discharge mealtime protocol, treatment gains may not be maintained. Clinicians should work closely with families to develop a discharge mealtime protocol and train all caregivers who are likely to implement meals on discharge. Several studies have demonstrated the effectiveness of behavioral skills training (BST) packages involving the use of instructions, rehearsal, modeling, and feedback to train caregivers how to implement feeding interventions (Mueller et al., 2003; Seiverling et al., 2012). It is recommended that clinicians refrain from providing written or verbal instructions alone when training caregivers and to instead provide the additional components of modeling, rehearsal, and feedback to ensure caregivers are adequately trained in the developed feeding intervention.