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

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

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.

Transcript

Dan Lowery: 0:11

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.

Mike Rubio: 0:54

All right, all right. Welcome back to yet another installment of ABA on Tap. I am your ever grateful co-host, Mike Rubio, along with Mr. Dan Lowry. Mr. Dan, always good to see you, sir. Great to see you as well. We've got yet another incredible guest, really excited about the content expertise that we are going to glean from today. It's going to give us a lot to chew on, pun intended. Pun completely intended. I'm doing that in the new year. If I say something, I mean it. This pun not intended thing is done with me. But yes, we've got a very special guest, Dina Kelly, who's going to talk to us about feeding and eating and mealtimes and all those things that can be very, very challenging for parents who are facing any given challenge. Parents of young children are oftentimes going to find themselves with some level of frustration. Also

Dan Lowery: 1:48

a need and a weakness in ABA, at least in my experience. One

Mike Rubio: 1:51

of those areas that we can employ our task analyses and maybe it doesn't go very far, maybe ends up a little bit authoritarian or doing things that are a little bit forceful at times. I know that I can think back in my past and go, oh yeah, we probably got that way wrong. And the outcomes usually tell you pretty quickly. But without further ado, our special guest today, Dina Kelly, you're going to talk to us about a lot of important things that I think any parent of a young child, especially can glean from very easily. Thank you for your time today. How are you?

Dena Kelly: 2:25

Hi, good. Thank you guys so much for having me on the show today. I'll start by giving some background so that everybody understands where I'm coming from with the knowledge that I'm talking about today. I am an LPC, which is a licensed professional counselor, a clinical psych background, as well as a BCBA. So I come into this with two different backgrounds. backgrounds coming into both psychology, but ultimately from the clinical side and the behavioral side. I initially had no idea what feeding therapy was or anything about it. I was finishing my master's in clinical psych and thought that I was just going to be doing some sort of therapy children with autism. You know, behavior analysis was still somewhat newer when I was doing that, and landed at an internship that was an autism clinic, but had an intensive feeding clinic, and got put in there for my first semester, and never turned back. So one semester in an intensive feeding clinic, being able to see how these children's lives were impacted by their lack of eating, and how quickly this therapeutic interventions were actually able to improve their life and the life of the family around them and, and all of that, it was just so reinforcing for me, that I really enjoyed it and ended up saying, this is what I want to continue to do. So stayed within that program. And grew professionally within there, ultimately directing and leading that program and all of the staff at that clinic and got the opportunity to leave there, which was a very, Intensive feeding program. So kids would just come to that clinic to get their feeding services and then they would leave. And so a lot of those children, especially ones with autism, were getting ABA services from other places or they were going to get OT or they were going to get speech in other locations throughout the rest of their day. And I had the chance about four years ago to be able to join an ABA clinic to do some feeding there. And that was a very different experience for me because now I'm right in the center of being around all of these children that are coming in for ABA therapy, intensive ABA therapy. They're there, you know, usually four to eight hours in a day. I'm around a bunch of BCBAs and RBTs and able to see firsthand how throughout the day, children that were having a lack of good eating, um, were being impacted, right? And so it was a lot of, um, programming to, um, reduce tantrums, right? Or, um, RBTs were constantly struggling with kids laying in the middle of the floor and not able to get out. Right. How are we going to be able to make that work? Or they're constantly running back to the room because the child wants a snack. And, you know, they just were starting to set up and work. And now they have to go back to this other room because that's where the snack is. Right. There was a lot of of chaos and and trying to do some interventions around this food refusal without actually addressing the issue of that. food refusal. And so what started to happen is I would be able to work with these children individually. They would be in my program. The BCBAs and the RBTs were learning how to implement these interventions. and seeing such a great improvement in these children in not only their eating, but then their corollary behavior. So you start to see that the tantrums are decreasing, that they're able to focus on any certain activity for a longer period of time, that sometimes toilet training, depending on the age of the child becomes easier because now they're actually having those foods go through them so that they can actually go to the bathroom and they're not so constipated or dehydrated. And so that was a really nice experience, but it also highlighted for me how many, I think you guys said it at the beginning that, you know, feeding is kind of a topic that not too many people know too much about. It is a specialty. You kind of have to fall into, you know, a structured feeding program and get that supervision to be able to ultimately go out and do it on your own. So I was having BCBAs and RVTs constantly at my door saying, I have an off hour. Can I just sit in on your feeding session? Or can we just talk about feeding for a little bit? And I have so much information or so many questions. And so ultimately- A BCPA had

Dan Lowery: 7:02

questions and didn't have all the answers?

Dena Kelly: 7:04

Oh, what is this? Yes. Yeah. That's a

Dan Lowery: 7:09

joke, Dan. Go ahead, Dina. Sorry.

Dena Kelly: 7:13

Yeah, no, you know what, they were super humble in those situations of being able to say, I want to learn more about feeding, you know, and so about two years ago, I ended up saying I need to start my own practice because it would allow me the opportunity to continue some direct intervention, but also continue to be able to educate people. ABA professionals on things they can be doing to start that process to improve not only that child's mealtime, but again, all of those other behaviors that then they're dealing with outside of mealtime.

Mike Rubio: 7:48

eating and then maybe more fundamentally something like sleeping and the notion that either of those things are disrupted and they might be now precursors or antecedents, if you will, to challenging behavior. You cut right through that for a lot of these professionals who might have otherwise been attributing these challenging behaviors to a slew of other things that maybe had nothing to do with it. And during that time, you're looking for all these motivators and you're looking for all these other extrinsic pieces.

Speaker 01: 8:16

And

Mike Rubio: 8:17

really, you've got this basic fundamental internal drive that isn't being taken care of. I'm going to ask a quick question. And Dan, I know you probably have this question too. And I'm sure we'll spend a lot of time on this premise. But the idea that I've set up my activity I think I'm establishing my instructional control. And then now this kid runs out to grab some food and they're not sitting to eat the food, but they need that food. That's a lot of behavioral stuff to work through. Tell us about that journey for you and for those BCBAs in tow.

Dena Kelly: 8:50

Yeah. So, so it's really a lot of the work happens before that direct intervention piece, right? So I, you know, you could never just say, well, here's, here's the quick answer to make that stop happening. Just like any other intervention, right? There's kind of things you have to put in place ahead of time and kind of behind the scenes to be able to make those changes and make that effective. And one of the biggest things that we see a lot is that, especially in ABA land, is that we attribute a lot of characteristics to children with autism and we give it as a, an out or an excuse, right? So we'll say, oh, they have autism. So, you know, we were, it's okay that they only eat yogurt all day because whatever, right? Like fill in the blank with any one random food, you know, that, that, They have, you know, and it always gets caveated, they have autism, so, right, fill in the blank. And so, you know, I push past that a lot for a lot of people and say they have autism, but they can still learn to do all of these other things and they can do them really well. And so it's fascinating to be able to watch these kids where they've been given the out for a while and saying that they can't. I have a lot of families, individual families that will come to me and they will start the sessions by saying, You know, my child will never eat yogurt because they do not like that pureed type of consistency. And ultimately, by the end of treatment, that ends up being their highly preferred food and the one that they often gravitate to. And a lot of times it's just one of those things that they were never really exposed to it because maybe one time they threw it on the floor when they had it. And so they were, you know, expected that they didn't like it and they really never presented it again, to really be able to have that opportunity to try it and realize that it is actually good and something that they can like. But to get back to your question, thinking about these kids, especially in the clinic and ones that are going back and forth a lot for food, when we have kids that have food refusal, oftentimes our goal or the parent's goal that then gets rubbed off onto the staff becomes, If they're going to eat something, let them eat whenever they want to eat, whatever they want to eat, because we just know we need to get calories in, even if that means every 10 minutes they're running for Doritos, right? But what happens is then we get into this act of grazing. And when we graze as humans, right? we lose our ability to feel hunger. So if you're sitting here, right, working on a bunch of podcasts all day and you're just sitting around and not really doing much and you're eating some popcorn and you're eating some chips. And then at the end of the day, you get called from your spouse and they say, oh, I got us this reservation at this really awesome steak restaurant and we're going out to dinner. You're going to be like, I don't really feel like it because I'm not that hungry, right? Because you've actually been grazing all day. And so that's one of the things that happens with a lot of these kids is that when they're constantly given access to food throughout the day without those structured break times, it doesn't allow our body to actually feel hunger. And so the problem with that is, one, we're going to constantly need to just keep fueling that need to eat. It becomes a habit, especially for a lot of our routine kids with autism, right? And without that feeling of hunger, we're less motivated to want to eat or try more interesting type foods, right? If you were really hungry and you had a food, somebody showed up with a platter of even let's say cookies, and it's not usually a flavor of cookie that you're super interested in or would typically pick, but you're hungry, you're more likely to at least give that cookie a try because you're motivated. You have that need right now. You're hungry. If you had been popping popcorn in your mouth for the past three hours, And those cookies showed up that weren't really your favorite flavor. You go, I'm good. I don't really feel like I need to eat that. And so that impacts our ability to do feeding therapy, because if a kid's been eating Doritos all day and now we sit them in a chair, we say we're going to try, you know, this chicken nugget. Right. They're going to say, I'm not hungry. Like, I don't there's there's. no reason or motivation or interest in being able to do that. And so one of the first things that I look at, which really doesn't even directly work on the feeding intervention is being able to set structured meal time. So I say like, even if you're talking about a kid that just eats the dino nuggets, right? Or just eats Doritos or just eats yogurt or whatever it might be is take those foods that they're familiar with. So you're not even messing with it. You're not even in no introduction of new food, no change to anything. All you are doing are setting some meal and snack time intervals. And so that you're giving them that stretch of time to go without the food and then they're coming back and end the kind of Part two to that is when they come, they sit at the table or wherever their seated situation would be because we always want them to be seated when they're eating from a safety perspective. If they're grabbing food and running, that's not great either. But they come, they sit down, they eat whatever it is that they want to eat, those foods that they're already familiar with and they're comfortable with, and then they go back out to play. And then they wait until that timer beeps or whenever somebody says like, okay, it's time for our snack time now or it's time for our meal time. And we try to break that habit of the constant grazing so that we can allow for our body's natural digestion to start working, which allows us more of that motivational opportunity to work on introducing new foods.

Dan Lowery: 14:45

That's it. gonna have to let my girlfriend listen to this because she's a constant grazer and then when i'm like hey i got dinner reservation she's never hungry that hit home you have no idea i'm

Dena Kelly: 14:57

really sorry to your girlfriend that just hit home i

Dan Lowery: 15:00

was it i was yeah i was thinking about how much i related to that that piece

Dena Kelly: 15:04

yeah yeah

Mike Rubio: 15:06

this is uh so i i hearkened back to the early days of of uh my career in ABA and discrete trial with almost the exclusive M and M reinforcement and how contrary, I mean, and I've known that for years already and I've changed my practice, but now thinking back into how contrary it is to what you were just discussing. And then yes, to your point earlier, the attributions very easily going to other characteristics or related symptoms of autism that, that, may in fact be true, but now we've really muddied the waters. How do you extricate these variables from what should, man, this is fascinating. And what you're talking about is extremely parsimonious, but very challenging for young parent of a young child. I mean, your kids get you on that when they don't eat right. I'm sure this happens to you now on a more personal front. Like you're looking at how many bites or the idea that just four more bites and then I'll let you, that'll be the negative reinforcement. Talk to us a little bit about some of those direct strategies that you use or that you teach BCBAs. And I'm sure there's a slew of them. I think one of the things we've been very guilty of is trying to find these individual recipes. Like it's going to have to be different in everybody's kitchen. Again, pun intended. Everybody's home is going to be a little bit of a different situation that you're going to apply these concepts to. And then your three-part contingency is going to look a little different for each child or each household. Cultural pieces probably come in. I threw a lot at you there. Give us some of your experiences with that.

Dena Kelly: 16:41

Yeah, absolutely. And you hit the nail on the head for sure that there's a very individualized concept to feeding. And I think that's why it really is such a specialty and why I harp on that idea of even if you feel like you've mastered one kid with feeding, it doesn't mean that you're now great to be able to work with any child with feeding because there's a lot of different– reasons as to how that feeding issue came about, right? So there can be more of what I look at as these kids with what they call pediatric feeding difficulties or feeding disorders, where it's more of these early on skill deficits. So that toddler age, they're refusing food, they're figuring out developmentally appropriately the cause and effect of life, right? And they go, oh, if I throw the broccoli on the floor, raspberries come on my plate. So that's really cool, right? And so sometimes that can just spiral into being a kiddo that now only eats, you know, a handful of foods where they might have been a really great eater up until about that two-ish year old mark, because now appropriately they're figuring out, again, some of that cause and effect component. It could be some skill deficits. So again, we have children with autism. that are in a variety of different therapies. And I say, oftentimes, you're diagnosed with autism around the age of two to three years old. So up until that point, parents are extremely overwhelmed. Then they get this diagnosis, and they're even more overwhelmed, right? And they're thrown all these things, right? Start ABA, start speech, start OT, start like meet with a nutritionist, right? And you've got all of these things. And so you're throwing your kid from service to service to service. And now at the end of the day, you just want them to So maybe you're feeding them or maybe you're giving them a pouch or you're doing one of those things. And now you have a three or four year old that doesn't really know how to use a spoon or fork correctly because they haven't really had to do that because it hasn't been the focus of what they were expected to do at that point. And so we have some of those kids that that can have those sorts of things. We have kids that have just higher sensory sensitivities, whether it be to the texture of the food. the smells of the other foods that are around them, that idea of just being able to sit at the table and take bites of food, there's a lot of things that can impact that. The other half of feeding challenges come from more what would fall under the DSM diagnosis of ARFID, which stands for avoided and restrictive food intake disorder. It is an actual diagnosis at this point. It's under the mental health codes. And when we're looking at an ARFID diagnosis, although technically the definition says that it can start in infancy, I don't see it so much from infant level, right? What I see a lot more of in the ARFID diagnosis land is children that either had a significant... food trauma. So in some capacity, maybe they had a choking incident and are now terrified to eat. Um, they had, um, some, maybe they took a bite of food and it was really, really hot and they spit it out and now they, you know, don't want to eat anymore. I actually had a client for a long period of time, um, before the mom finally connected with me he was carrying around a Dixie cup and he would spit his spit into the Dixie cup because he was so scared to swallow that we had to ultimately work him back up to eating so we can have some of that food trauma and we also it comes with kids that have high levels of more of that generalized anxiety in general and so we have these kids that that Everything in life is anxiety producing, right? And food is just one of those that has so many different properties to that, right? It can be crunchy, it can be chewy, it can be hot, it can be cold, it can smell like this, it can smell like that, it can be squishy, right? Like there's all of these things. And so add that to the list of anxieties, right? That I can have with a child. The other thing that happens is that sometimes kids that had more of those pediatric feeding difficulties and were allowed to avoid foods for years at a time have now developed anxiety for those foods because they've avoided them for so long. And when we equate it to other things in our lives that we avoid, phobias that we might have in ourselves because we just have not experienced them in a really long time or just have never wanted to, which might not actually be that bad, If we tried it, we just don't know, right? And so that's where we get a lot of those more school-aged kids that have had, you know, they've been known to be like the anxious boy. And now this anxious boy is restricting more and more of his food. And now he's down to a few bites of food. So we have a bunch of different presentations. We also, what's been actually happening more recently and more of my client load has become more, middle teenagers, so 14 to 16, 17 girls that go to more of the like, hospital type settings because they're having this food restriction and they get put into an eating disorders clinic. And now technically in the DSM, right, the ARF diagnosis falls in the eating disorders section. But it is so different from anorexia and bulimia because anorexia and bulimia are more rooted in body dysmorphia. So they are engaging in those food behaviors to impact what their body is looking like or feeling like. Whereas ARFID, they're restricting that food because they're scared of that food. It has nothing to do with their actual body image. And so what ends up happening in a lot of these clinic settings is that the goal is to get them up to a higher weight. And so they will tried to shovel these children with food. I've had one of the teenagers, they ended up putting a tube, an NG tube up her nose just to be able to pump calories in. She was vomiting because they were putting so many calories into her on a day just to be able to get the weight gain up. But it wasn't addressing the issue of food and it wasn't actually getting to the root cause of their restriction of eating and it was actually just making the whole experience way more unpleasant and and immersive to them to begin with so that's been an interesting you know uptick for sure in my clientele of kids that I've been seeing but did You know, that was a long-winded answer. I

Mike Rubio: 23:47

feel like to circle back. We let you loose. That was an amazing amount of information. And Dan, I want to pass it over to you because I know you've got questions. I certainly do. I kind of want to frame something for us. So we're talking about, you know, we're BCBAs. We deal with autism treatment. So we kind of have that general, you know, concept looming over us. But then you're talking about kids in general and ARFID and autism might have a correlation I don't know what that is so we're kind of covering a lot of ground here developmentally and I appreciate that and I kind of want to encourage us to try and separate it as well as correlated as well as we can moving forward because there is you know I'm the father of a four-year-old and I can say pretty wholeheartedly she's a great eater and eats things that leave people stunned well she's eating that yes and then Once in a while, she'll choose to not eat enough for my parental perception for three, four days. And it's miserable. And I have to, you know, I can preach my BCBA stuff all day, but I have to practice it at home. And in those moments, I lose my better wits about me. And I do dumb things and end up, you know, with behavior that then in a different circumstance, you know, back to our previous discussion might be attributed to the diagnostic or a slew of other things that really might not be related. I created the issue that because it is a fundamental concern of eating. And so she might be picky sometimes. And then you're talking about restrictive eating. modes of eating behavior. So I want to kind of put that out there. I'm going to pass it over to Dan. We've got a lot of ground to cover. I think we'll be talking for a while. So,

Dan Lowery: 25:26

okay. So much ground to cover that. So I made some notes so I can compartmentalize it. But my first question to you is just back on the RFID piece. So we've ran some, we've run and previously we ran parent groups at our previous company. And there was a client that Mike and I had that was very, very knowledgeable, very intelligent lady and very well read. And she was running into issues with her son who eventually got this ARFID diagnosis and there was another parent who later on was having even more issues with her son and she suggested looking into this ARFID piece and I never heard of ARFID and this was maybe a year or two ago. That was literally the first time I'd ever heard of ARFID and then this kind of came about. I was like, huh, what is this ARFID? What does this diagnosis mean? Does it get you access to resort? Like what is, this ARFID piece and why is it important to get this diagnosis? So I know you've talked about ARFID and being different than some of the body dysmorphic diagnoses, but anything in addition that you'd like to say about what it entails, why it might be important, who might be appropriate for this diagnosis?

Dena Kelly: 26:38

Yeah, sure. So yeah, so when you're looking at an ARFID diagnosis, so let me rewind that actually. An anorexic and a bulimic actually ultimately... love food, but they have a really poor relationship with that food, right? So the anorexic that might be restricting because they want to lose all of that weight, they're dreaming about the cake and the candies and the food that they want to be eating. They're drooling over it and thinking about it, and they're just putting up that barrier from eating it, right? An ARFID diagnosis is that eating disturbance that that is more specific to the food. So it is the sensory characteristics of that food or that fear. Like we were talking about the feeding trauma, right? Kids like that are afraid of choking that fear that if they put this in their mouth, they're going to have a scary experience. They're going to choke. They're going to throw up. They're going to have, I had a child that had a horrific fear of vomiting. And so she would never eat more than a couple bites of food because she never wanted her belly to even get to the point of feeling anywhere near full for that fear of throwing up. And so the other component with ARFID is that weight is not an alone factor to look at an ARFID diagnosis. And this is the one that I scream from the rooftops constantly because I have families that come to me with school-aged kids that have been dealing with food refusal since that child was two But because they are rowing and gaining weight and they go to the pediatrician and the pediatrician just keeps going, they're fine. They're going to grow out of it. Don't worry. And the mom's going, but he's only eating one cup of mac and cheese a day. And he's fine or throw a pedia short in there and he'll be fine. Don't worry about it. And the years go on. And for whatever reason, some kids bodies can survive on McDonald's French fries. I don't know how. I wish I could figure it out. But there are some kids that eat only McDonald's French fries and grow to be appropriately sized people. But the problem is when we see that is that we would say, oh, well, then they should be fine and they don't necessarily have a feeding issue. But the point of this RFID diagnosis is really the impact on psychosocial functioning. And that's the key component of this diagnostic criteria that I always looked at is that marked interference with psychosocial functioning is when this child is refusing to eat this food, Growth is huge, right? That's a major important component. But so is how is their body feeling? We're talking about sleep. We're talking about tantrums. We think about that idea of hangriness, right? We've all experienced hangriness in our life. That's why my

Dan Lowery: 29:35

girlfriend really needs to listen to this, but go ahead.

Dena Kelly: 29:38

We've all had that, right? But that can seriously impact. That's going to impact your relationship with your parents and your siblings and your friends because of how snippy you might be because you're actually hungry and you don't know it, right? It can also impact from a social perspective, going to a birthday party, going to hang out with friends, eating lunch at school, I have some kids that sit in the nurse's office, because they don't want to be in the cafeteria with all of their friends eating because they don't want to eat. And so those, those are the parts that for me, you know, when somebody says, if that child with autism is comfortable just eating yogurt, let's just let them eat the yogurt. is that that's what's the part for me where I will always say, but can we think about the bigger picture of all of this and the potential for what opportunities they may want to be a part of that they're missing out on because the yogurt isn't fulfilling all of those things for them. And when we're so restricted in that capacity is that it impacts, we have brands change their packaging all the time right and so you have a child that's very brand specific and loves the paw patrol on the front of the cheese stick right or the dino nugget that has the specific dinosaur on the front and now they decided to do a rebrand and they changed what that looked like even though the recipe might be exactly the same is that now they don't want to eat that food anymore and so now that parent that was stocking all of you know that one food now they don't want to eat any of it anymore and that's just cut back on what their actual intent And so that's the part for me that really discerns the difference and what we have to be able to look at and think about when a child is having that food refusal is how is it impacting their overall lifestyle? life I've had families that can't travel I had a girl that was her whole thing when she finished my program she was five years old and all she said was do we get to go on vacation now you know because the parents the parents would keep saying we can't travel anywhere because you don't eat anything and you know really it made it difficult for the family to be able to go anywhere because that child was eating such limited food and it really didn't travel easily. And so so that was like a big goal for them is that they could actually travel because now she was more open to trying and eating other foods.

Dan Lowery: 32:10

So with the I want to follow up on that ARFID piece, though. So the diagnosis you mentioned about a general fear of food. How is that differentiated between just picky eating? So like, especially since a lot of our individuals are non-vocal, how does a parent know whether it's RFID? How does a clinician know whether it's RFID versus just somebody who wants to eat chicken nuggets and cookies all day?

Dena Kelly: 32:33

Perfect. Well, so if they're eating chicken nuggets and cookies all day, right, I'm arguing that that goes beyond picky eating. So when I think about a picky eater, I'm thinking about the child that prefers strawberries over blueberries and only wants the crunchy carrots. She doesn't want the soft carrots, right? But like, but they have foods within each food group that they're eating. Maybe their proteins are only chicken nuggets and hot dogs and bacon and kind of like all the processed stuff, but they have proteins within there. You know, maybe their fruits are more things like applesauce and banana. And, you know, they're not having mangoes and kiwis and like fancy stuff, but they're eating kind of that kid friendly diet, right? We look at like from a pizza and mac and cheese and those sorts of things. But for me, again, it goes back to that psychosocial functioning piece. A picky eater will still be able to pick something off of the kid's menu at a restaurant. A picky eater will usually be able to find something at the birthday party set of food to be able to eat, right? A picky eater is, you know, able to go to Thanksgiving dinner and eat more than the roll. You know, that's always like the joke is that the kid only wants to eat the roll. Is that, you know, maybe they don't want the turkey without. the gravy and the seasoning and all of the stuff on top, but they'll have a couple pieces of that turkey or they'll have a little bit of potato with what they're eating, right? And they're trying some of those different things. That's the picky eater is that it's not necessarily impacting their overall functioning. They're able to get, they can sit at school lunch. They're not in that hangry phase. They're not having meltdowns and tantrums over their food intake or lack of food intake. When we think about that restrictive eater or that ARFID eater is that they've gone an extended period of time Yeah, absolutely. activities that everybody is a part of, right? I have families that don't want to go to the zoo for the day, because they're worried that the child's not going to find anything to eat. And the mac and cheese that they make has to be, you know, right from the microwave at a certain temperature for that child to be able to eat it. And so they can't pack it with them, right? When you start thinking about all of the rules that go in place with what that child is willing to eat, that's where it's that flag of concern for me. So, you know, I don't expect all of our kids to have a great lovely palette a variety of you know you willing to eat anything at all the time but they should be able to you should feel comfortable that you can accommodate their eating needs kind of wherever you are or wherever they're going and if that's an area of struggle for you or for you know that child that that that's that's the big red flag that there's a concern and probably warrant some intervention.

Speaker 04: 35:55

There's some really good intent that comes in here with people that are parents, for example. My child's a picky eater, maybe toward the restrictive end, and I'm going to make some changes, and I'm going to go 180 degrees to this healthy stuff. And now you've got this huge expanse of... behaviors and circumstances and foods and maybe the parent isn't even willing to model these new healthier foods again really good intent but man it's a huge it's a huge amount of ground to cover so what i hear you saying is even to what to to to a certain extent uh even just having your if your child is a yogurt child and that's what they eat even just having them take different flavors of yogurt, yogurt in different packagings. all of those things. So you might be on the yogurt for a little while still. And as a parent or professional, you may not see the progress in that from the eating piece, but you're talking about the other variables that are also impactful on that are also significant on that journey. This is pretty gradual stuff is what I'm saying. Encouraging people to be patient about it.

Dena Kelly: 37:07

Well, absolutely. So that's another one of the tips that I have, right? Is that idea of taking what they're already eating and expanding off of that because you're right, you can't go, I tell families all the time, my first goal in a feeding therapy program is to actually make your restrictive kid a picky eater, right? Is to be able to have them have a few foods within each category that allows them to expand their experiences and to be able to teach them especially when you have a kid that likes dino nuggets, is we need to learn that a nugget is a nugget is a nugget. So whether you're having a dino nugget, whether it's a Chick-fil-A nugget, whether it's a chicken finger at the restaurant, at the kid's meal. So it's all within the same category, but we start to be able to generalize out to some of those other things. So it can be a gradual process, and it is a gradual process for most kids. kids in most situations I will say you know when some of them are are really restrictive and it's actually impacting their their health and their functioning is that that's where you want that really intensive program to be able to say we got to jump into this and work on it quickly but but But still, you're not going from a kid that's only eating yogurt and saying, here's your steak and broccoli, because you're getting nowhere with that. You're getting nowhere fast. But yeah, depending on how that food restriction is impacting that child's health and their overall functioning kind of allows you to guide what the pace speed is going to look like for that child, for sure. because it will be different for every child. But that is always my start is you have to gain trust with them. And so I will tell families, you know, a kid that's eating only Cheez-Its is I say, we're going to actually introduce goldfish. And they're like, wait a minute, no, like we have to do a fruit. I'm like, right, but we have to first show them, right, that something that looks very different from a Cheez-It is pretty comparable, right? And so that starts to build the trust of like, okay, so this was different, but it's going to taste the same, right? And so once they start to taste that, okay, so now that was a a Dorito, right? Or maybe we can then try a piece of toast with melted cheese on it. So it's still getting the crunchy, but now we're getting into more of the real food, right? Which lends us to a grilled cheese and maybe into a cheese sandwich, right? And it allows that trajectory of building trust and being able to see what some of those interests are for that child.

Dan Lowery: 39:41

So I want to go back to the ARFID piece, though, just so I can make sure that I understand it correctly. So you mentioned that it a lot of times comes from a genuine fear of not wanting to try other foods. I remember and you brought up chicken nuggets. There was one client that I had that would only eat Carl's Jr. chicken nuggets. That's all that this individual would eat.

Dena Kelly: 39:59

What is Carl's Jr.?

Dan Lowery: 40:01

Oh, it's like Hardee's.

Dena Kelly: 40:03

Oh, you guys, you guys have to... Different fast food restaurants. Yes, yes.

Dan Lowery: 40:09

I like this. Think about McDonald's. One fast food restaurant, chicken nuggets. It has to be one,

Speaker 04: 40:14

yeah.

Dan Lowery: 40:15

I'm not sure if it was behavioral in that this individual seemed to prioritize that. The parent didn't want to fight the battle so that it just became habitual over time. So I guess my question to you is, can ARFID also just, is it just the outcome of this individual is at this point, so this is what they're eating? Or is it, Is there a way to differentiate whether it's being scared versus being just behavioral and being routine based? Because a lot of the individuals that we work with, especially on the spectrum, can tend to be routine based. And then it just became chicken nuggets all the time. I'm not sure if that makes sense of what I'm asking.

Dena Kelly: 40:50

It does. And to me, I think my answer would be. we'd still work through it regardless similarly, because usually it doesn't matter because the longer, the longer that you're in a specific habit or routine and you avoid other things is that you ultimately are developing, right? Like our minds just regularly in life, right? Like the longer you don't do something, the more potential angst you have to do that thing again. And so, so I look at that with, with these kids with ARFID a lot is that sometimes it can happen, again, from an issue or an incident or stemming from just some generalized anxiety. And sometimes it comes from years of avoidance of certain foods or food groups or textures or smells or those sorts of things.

Dan Lowery: 41:45

So it doesn't matter. Okay, that's perfect. So it's kind of just where they're at now. It doesn't really matter what the reason they got there is. It's where they're at now.

Dena Kelly: 41:52

mean, now, again, you certainly can address it. Like, obviously, if I'm working with a child that had a choking incident, right, and is coming back to the table to try to work their way through food, I'm probably going to approach that a little bit differently than I would, you know, a young kid that's just had some avoidance of food for for years at a time. Because again, we talk about that trauma-informed component, right? Of course. We have to be able to look at some of that. But I would say at the end of the day, the interventions are similar. And what's been fascinating for the clients that I work with is that when they actually get exposure to these foods is that they realize they're not that scary and that they are okay. I had a kid for a while that would come on my Zoom screen and on the back, he made a little banner for himself and it would say, but I didn't die with an exclamation

Speaker 01: 42:57

point.

Dena Kelly: 42:58

And he would keep reminding himself of this fear that he had of, and he was like, why did I think that I was gonna die eating a blueberry? He was like, that was weird. And so he would keep reminding himself of that throughout the treatment. And so for a lot of my kids, especially ones that are verbal and are gonna have that interaction is that I have them hierarchy foods, rate them, give me feedback on the foods that they're thinking. And what's cool is that over treatment time, you see that even if they rated a food maybe a one or a two in the beginning is that after continued practice is that now that food's up to a three or a four out of five, you know, instead of staying down there, but even cooler. And I just did a poster on this for the Pennsylvania ABA presentation was I had a girl who's once she put the food in the first, almost all of her first ratings of food were at least a three, if not higher. And she was like, why was I so scared of this stuff? You know, but, but it was getting over that hump. She was a child that was, she was so restricted. She was on a tube and she wasn't eating. And now she eats tons of stuff. And it was really about finding the opportunity to be able to give her some motivation to want to do it because that's one of the biggest things in both ARFID, you know, and, and, just pediatric feeding challenges, kids with autism, is that if eating isn't enjoyable for them, why are they going to do it, right? So, you know, if you have a fear of heights and somebody said, climb up the ladder, you're going to go, no thanks, dude, right? I don't want to do that. But if they said, I'll give you a thousand bucks if you climb up the ladder, yeah, I might be thinking I might try to climb up that ladder, right? If they gave you 10,000 bucks, you're probably up the ladder, right? For the most part. And when you get to the top, what could actually happen is you could go, that actually wasn't that bad, but I would have never gotten up there had I not been having that external motivator or drive because I don't have an internal interest in heights. I always use heights because I don't have an internal interest or drive in heights. But there's a lot of people that do. There's a lot of people that love being up high and standing on rooftops and that's their cup of tea. It's not mine. But certainly with the right external motivator, I might be willing to try that. And if I continue to try that, Would I become more accustomed to what that felt like and be able to reduce some of that anxiety around that experience? And so that's what happens with a lot of our kids with feeding challenges is that they're not getting necessarily the same enjoyment from eating that I say you and I will. I imagine you guys like eating. I love eating.

Speaker 01: 45:55

For sure.

Dena Kelly: 45:56

I don't need anybody to do anything for me when it comes to eating. I could be full as can be. And if somebody pulls out a delicious dessert, I'm finding room, right? How can I be able to make more space for that? parents, we say, clean up the playroom and we can go outside and play at the playground, right? Or we've got to brush our teeth so that we have time to read books before bed, right? So it's not, we're not saying brush your teeth because, you know, you want good dental hygiene and it's going to feel good for your mouth. The kid's going to look at you and say, well, that's ridiculous. They're going to brush their teeth because they want the book, right? And over time, throughout the years is that they start realizing, right, as a child gets older, they ultimately realize like they don't want to have bad breath so they're going to wear they don't want like the way their mouth feels if they don't brush their teeth and so they do start getting more of that internal motivation after years of practice with the external motivators because now they see how much better their you know mouth is or they don't have the bad breath around their friends or that sort of a thing

Dan Lowery: 47:24

classic reinforcement fading um i have so going back to the the chicken nuggets example um with like the the individual that would only eat carl's junior chicken nuggets What would be your specific suggestion in a situation like that? Because what the parents would do is sometimes try other chicken nuggets, but then as soon as the kid would take a bite, he would realize that it was not a Carl's Jr. chicken nugget. He would immediately shut down. Historically in ABA, we would do a lot of, well, first try a bite of this, and then you can have your Carl's Jr. chicken nuggets and then... Sometimes the kid would outlast the therapist and then you run into either ethical issues or I don't know if there's health issues where then the parent just gives in because they don't want to have their kid be in distress. And then you run into some of the other maybe GI or sleeping issues because the kid's holding out longer. The kid now doesn't want to try any other chicken nugget and maybe not even the Carl's Jr. chicken nuggets anymore because he's worried that it's not going to be that long. What would be your recommendation in a situation like that of how you would kind of address that situation?

Dena Kelly: 48:30

Sure. So usually I would start with not... the exact same type of food because I don't want to get into trickery. I don't want it to be, let me set this up to look exactly the same, but then when you take a bite, it's going to look different. It's going to taste different. I don't like trickery or secretness at all. When people call pink salmon, they say, this is just pink chicken. Don't you love pink chicken? Those sorts of things. I don't get sneaky.

Dan Lowery: 49:04

That makes a lot of sense because then you run the risk of it being way worse and now the kid doesn't trust anything. That makes

Dena Kelly: 49:10

a lot of sense. Go ahead. So I want to build trust versus they could get their trust to go away, right? And so you have to be able to start really small and depending on the age of the child, the communication ability of that child, what it would really change that, right? If a child's going to talk to me, the first thing I'm going to say is you're going to have some choices and which one do you want to try? In your case, I'm guessing was your child talking at that point? No, he was non-vocal. Right. So potentially putting out some pictures of some choice options and trying to be able to have some communication in that capacity. If not, is that you're looking at what are the things that are highly motivating? And so how can you start with some introduction of a food that might have a similar... taste palette line right like maybe like a fish stick as opposed to a chicken finger or sometimes when you have a kid that might like drink strawberry milk or something i can pull like a strawberry yogurt or try a piece of strawberry and you might need to start really small like you know you can't start with a whole strawberry is that it would be here's this small piece of strawberry

Speaker 04: 50:23

Oh, and sorry for that abrupt stop there. This does conclude part one of our interview with Dina Kelly. Please do return for part two and...

Speaker 01: 50:32

Always analyze responsibly.

Speaker 04: 50:36

Thank

Mike Rubio: 50:37

you. 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.