May 4, 2025 • 50 mins
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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dan Lowery (00:11):
Welcome to ABA on Tap, where our goal is to find
the best recipe to brew thesmoothest, 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 ingredientsto form the best concoction of
ABA on tap.
In this podcast, we will talkabout the history of the ABA
(00:35):
brew, how much to consume toachieve the optimum buzz while
not getting too drunk, and therecommended pairings to bring to
the table.
So without further ado, sitback, relax, and always analyze
responsibly.
Mike Rubio (00:54):
All right, all right.
Welcome back to yet anotherinstallment of ABA on Tap.
I am your ever gratefulco-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 anotherincredible guest, really excited
about the content expertisethat we are going to glean from
(01:15):
today.
It's going to give us a lot tochew 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 isdone with me.
But yes, we've got a veryspecial guest, Dina Kelly, who's
going to talk to us aboutfeeding and eating and mealtimes
and all those things that canbe very, very challenging for
(01:38):
parents who are facing any givenchallenge.
Parents of young children areoftentimes going to find
themselves with some level offrustration.
Also
Dan Lowery (01:48):
a need and a weakness in ABA, at least in my
experience.
One
Mike Rubio (01:51):
of those areas that we can employ our task analyses
and maybe it doesn't go veryfar, maybe ends up a little bit
authoritarian or doing thingsthat are a little bit forceful
at times.
I know that I can think back inmy past and go, oh yeah, we
probably got that way wrong.
And the outcomes usually tellyou pretty quickly.
But without further ado, ourspecial guest today, Dina Kelly,
(02:14):
you're going to talk to usabout a lot of important things
that I think any parent of ayoung child, especially can
glean from very easily.
Thank you for your time today.
How are you?
Dena Kelly (02:25):
Hi, good.
Thank you guys so much forhaving me on the show today.
I'll start by giving somebackground so that everybody
understands where I'm comingfrom with the knowledge that I'm
talking about today.
I am an LPC, which is alicensed professional counselor,
a clinical psych background, aswell as a BCBA.
So I come into this with twodifferent backgrounds.
(02:48):
backgrounds coming into bothpsychology, but ultimately from
the clinical side and thebehavioral side.
I initially had no idea whatfeeding therapy was or anything
about it.
I was finishing my master's inclinical psych and thought that
I was just going to be doingsome sort of therapy children
with autism.
(03:08):
You know, behavior analysis wasstill somewhat newer when I was
doing that, and landed at aninternship that was an autism
clinic, but had an intensivefeeding clinic, and got put in
there for my first semester, andnever turned back.
So one semester in an intensivefeeding clinic, being able to
see how these children's liveswere impacted by their lack of
(03:31):
eating, and how quickly thistherapeutic interventions were
actually able to improve theirlife and the life of the family
around them and, and all ofthat, it was just so reinforcing
for me, that I really enjoyedit and ended up saying, this is
what I want to continue to do.
So stayed within that program.
And grew professionally withinthere, ultimately directing and
(03:56):
leading that program and all ofthe staff at that clinic and got
the opportunity to leave there,which was a very, Intensive
feeding program.
So kids would just come to thatclinic to get their feeding
services and then they wouldleave.
And so a lot of those children,especially ones with autism,
were getting ABA services fromother places or they were going
(04:19):
to get OT or they were going toget speech in other locations
throughout the rest of theirday.
And I had the chance about fouryears ago to be able to join an
ABA clinic to do some feedingthere.
And that was a very differentexperience for me because now
I'm right in the center of beingaround all of these children
(04:41):
that are coming in for ABAtherapy, intensive ABA therapy.
They're there, you know,usually four to eight hours in a
day.
I'm around a bunch of BCBAs andRBTs and able to see firsthand
how throughout the day, childrenthat were having a lack of good
eating, um, were beingimpacted, right?
(05:02):
And so it was a lot of, um,programming to, um, reduce
tantrums, right?
Or, um, RBTs were constantlystruggling with kids laying in
the middle of the floor and notable to get out.
Right.
How are we going to be able tomake that work?
Or they're constantly runningback to the room because the
(05:24):
child wants a snack.
And, you know, they just werestarting to set up and work.
And now they have to go back tothis other room because that's
where the snack is.
Right.
There was a lot of of chaos andand trying to do some
interventions around this foodrefusal without actually
addressing the issue of that.
food refusal.
And so what started to happenis I would be able to work with
(05:46):
these children individually.
They would be in my program.
The BCBAs and the RBTs werelearning how to implement these
interventions.
and seeing such a greatimprovement in these children in
not only their eating, but thentheir corollary behavior.
So you start to see that thetantrums are decreasing, that
they're able to focus on anycertain activity for a longer
(06:08):
period of time, that sometimestoilet training, depending on
the age of the child becomeseasier because now they're
actually having those foods gothrough them so that they can
actually go to the bathroom andthey're not so constipated or
dehydrated.
And so that was a really niceexperience, but it also
highlighted for me how many, Ithink you guys said it at the
(06:30):
beginning that, you know,feeding is kind of a topic that
not too many people know toomuch about.
It is a specialty.
You kind of have to fall into,you know, a structured feeding
program and get that supervisionto be able to ultimately go out
and do it on your own.
So I was having BCBAs and RVTsconstantly at my door saying, I
(06:52):
have an off hour.
Can I just sit in on yourfeeding session?
Or can we just talk aboutfeeding for a little bit?
And I have so much informationor so many questions.
And so ultimately- A BCPA had
Dan Lowery (07:02):
questions and didn't have all the answers?
Dena Kelly (07:04):
Oh, what is this?
Yes.
Yeah.
That's a
Dan Lowery (07:09):
joke, Dan.
Go ahead, Dina.
Sorry.
Dena Kelly (07:13):
Yeah, no, you know what, they were super humble in
those situations of being ableto say, I want to learn more
about feeding, you know, and soabout two years ago, I ended up
saying I need to start my ownpractice because it would allow
me the opportunity to continuesome direct intervention, but
also continue to be able toeducate people.
(07:34):
ABA professionals on thingsthey can be doing to start that
process to improve not only thatchild's mealtime, but again,
all of those other behaviorsthat then they're dealing with
outside of mealtime.
Mike Rubio (07:48):
eating and then maybe more fundamentally
something like sleeping and thenotion that either of those
things are disrupted and theymight be now precursors or
antecedents, if you will, tochallenging behavior.
You cut right through that fora lot of these professionals who
might have otherwise beenattributing these challenging
behaviors to a slew of otherthings that maybe had nothing to
(08:11):
do with it.
And during that time, you'relooking for all these motivators
and you're looking for allthese other extrinsic pieces.
Speaker 01 (08:16):
And
Mike Rubio (08:17):
really, you've got this basic fundamental internal
drive that isn't being takencare of.
I'm going to ask a quickquestion.
And Dan, I know you probablyhave this question too.
And I'm sure we'll spend a lotof time on this premise.
But the idea that I've set upmy activity I think I'm
establishing my instructionalcontrol.
And then now this kid runs outto grab some food and they're
(08:39):
not sitting to eat the food, butthey need that food.
That's a lot of behavioralstuff to work through.
Tell us about that journey foryou and for those BCBAs in tow.
Dena Kelly (08:50):
Yeah.
So, so it's really a lot of thework happens before that direct
intervention piece, right?
So I, you know, you could neverjust say, well, here's, here's
the quick answer to make thatstop happening.
Just like any otherintervention, right?
There's kind of things you haveto put in place ahead of time
and kind of behind the scenes tobe able to make those changes
(09:10):
and make that effective.
And one of the biggest thingsthat we see a lot is that,
especially in ABA land, is thatwe attribute a lot of
characteristics to children withautism and we give it as a, an
out or an excuse, right?
So we'll say, oh, they haveautism.
So, you know, we were, it'sokay that they only eat yogurt
(09:36):
all day because whatever, right?
Like fill in the blank with anyone 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 pastthat a lot for a lot of people
and say they have autism, butthey can still learn to do all
(09:58):
of these other things and theycan do them really well.
And so it's fascinating to beable to watch these kids where
they've been given the out for awhile and saying that they
can't.
I have a lot of families,individual families that will
come to me and they will startthe sessions by saying, You
know, my child will never eatyogurt because they do not like
(10:19):
that pureed type of consistency.
And ultimately, by the end oftreatment, that ends up being
their highly preferred food andthe one that they often
gravitate to.
And a lot of times it's justone of those things that they
were never really exposed to itbecause maybe one time they
threw it on the floor when theyhad it.
And so they were, you know,expected that they didn't like
(10:40):
it and they really neverpresented it again, to really be
able to have that opportunityto try it and realize that it is
actually good and somethingthat they can like.
But to get back to yourquestion, thinking about these
kids, especially in the clinicand ones that are going back and
forth a lot for food, when wehave kids that have food
refusal, oftentimes our goal orthe parent's goal that then gets
(11:04):
rubbed off onto the staffbecomes, If they're going to eat
something, let them eatwhenever they want to eat,
whatever they want to eat,because we just know we need to
get calories in, even if thatmeans every 10 minutes they're
running for Doritos, right?
But what happens is then we getinto this act of grazing.
And when we graze as humans,right?
(11:25):
we lose our ability to feelhunger.
So if you're sitting here,right, working on a bunch of
podcasts all day and you're justsitting around and not really
doing much and you're eatingsome 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 thisreservation at this really
awesome steak restaurant andwe're going out to dinner.
You're going to be like, Idon't really feel like it
(11:46):
because I'm not that hungry,right?
Because you've actually beengrazing all day.
And so that's one of the thingsthat happens with a lot of
these kids is that when they'reconstantly given access to food
throughout the day without thosestructured break times, it
doesn't allow our body toactually feel hunger.
And so the problem with thatis, one, we're going to
(12:07):
constantly need to just keepfueling that need to eat.
It becomes a habit, especiallyfor a lot of our routine kids
with autism, right?
And without that feeling ofhunger, we're less motivated to
want to eat or try moreinteresting type foods, right?
If you were really hungry andyou had a food, somebody showed
(12:32):
up with a platter of even let'ssay cookies, and it's not
usually a flavor of cookie thatyou're super interested in or
would typically pick, but you'rehungry, you're more likely to
at least give that cookie a trybecause you're motivated.
You have that need right now.
You're hungry.
If you had been popping popcornin your mouth for the past
(12:53):
three hours, And those cookiesshowed up that weren't really
your favorite flavor.
You go, I'm good.
I don't really feel like I needto eat that.
And so that impacts our abilityto do feeding therapy, because
if a kid's been eating Doritosall day and now we sit them in a
chair, we say we're going totry, you know, this chicken
nugget.
Right.
They're going to say, I'm nothungry.
(13:13):
Like, I don't there's there's.
no reason or motivation orinterest in being able to do
that.
And so one of the first thingsthat I look at, which really
doesn't even directly work onthe feeding intervention is
being able to set structuredmeal time.
So I say like, even if you'retalking about a kid that just
eats the dino nuggets, right?
Or just eats Doritos or justeats yogurt or whatever it might
(13:36):
be is take those foods thatthey're familiar with.
So you're not even messing withit.
You're not even in nointroduction of new food, no
change to anything.
All you are doing are settingsome meal and snack time
intervals.
And so that you're giving themthat stretch of time to go
without the food and thenthey're coming back and end the
(13:58):
kind of Part two to that is whenthey come, they sit at the
table or wherever their seatedsituation would be because we
always want them to be seatedwhen they're eating from a
safety perspective.
If they're grabbing food andrunning, that's not great
either.
But they come, they sit down,they eat whatever it is that
they want to eat, those foodsthat they're already familiar
(14:19):
with and they're comfortablewith, and then they go back out
to play.
And then they wait until thattimer beeps or whenever somebody
says like, okay, it's time forour snack time now or it's time
for our meal time.
And we try to break that habitof the constant grazing so that
we can allow for our body'snatural digestion to start
working, which allows us more ofthat motivational opportunity
(14:41):
to work on introducing newfoods.
Dan Lowery (14:45):
That's it.
gonna have to let my girlfriendlisten to this because she's a
constant grazer and then wheni'm like hey i got dinner
reservation she's never hungrythat 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 anddiscrete trial with almost the
exclusive M and M reinforcementand how contrary, I mean, and
I've known that for yearsalready and I've changed my
practice, but now thinking backinto how contrary it is to what
(15:26):
you were just discussing.
And then yes, to your pointearlier, the attributions very
easily going to othercharacteristics or related
symptoms of autism that, that,may in fact be true, but now
we've really muddied the waters.
How do you extricate thesevariables from what should, man,
(15:47):
this is fascinating.
And what you're talking aboutis extremely parsimonious, but
very challenging for youngparent of a young child.
I mean, your kids get you onthat when they don't eat right.
I'm sure this happens to younow on a more personal front.
Like you're looking at how manybites or the idea that just
four more bites and then I'lllet you, that'll be the negative
(16:07):
reinforcement.
Talk to us a little bit aboutsome of those direct strategies
that you use or that you teachBCBAs.
And I'm sure there's a slew ofthem.
I think one of the things we'vebeen very guilty of is trying
to find these individualrecipes.
Like it's going to have to bedifferent in everybody's
kitchen.
Again, pun intended.
Everybody's home is going to bea little bit of a different
situation that you're going toapply these concepts to.
(16:29):
And then your three-partcontingency is going to look a
little different for each childor each household.
Cultural pieces probably comein.
I threw a lot at you there.
Give us some of yourexperiences with that.
Dena Kelly (16:41):
Yeah, absolutely.
And you hit the nail on thehead for sure that there's a
very individualized concept tofeeding.
And I think that's why itreally is such a specialty and
why I harp on that idea of evenif you feel like you've mastered
one kid with feeding, itdoesn't mean that you're now
great to be able to work withany child with feeding because
(17:04):
there's a lot of different–reasons as to how that feeding
issue came about, right?
So there can be more of what Ilook at as these kids with what
they call pediatric feedingdifficulties or feeding
disorders, where it's more ofthese early on skill deficits.
So that toddler age, they'rerefusing food, they're figuring
(17:25):
out developmentallyappropriately the cause and
effect of life, right?
And they go, oh, if I throw thebroccoli on the floor,
raspberries come on my plate.
So that's really cool, right?
And so sometimes that can justspiral into being a kiddo that
now only eats, you know, ahandful of foods where they
might have been a really greateater up until about that
(17:47):
two-ish year old mark, becausenow appropriately they're
figuring out, again, some ofthat cause and effect component.
It could be some skilldeficits.
So again, we have children withautism.
that are in a variety ofdifferent therapies.
And I say, oftentimes, you'rediagnosed with autism around the
age of two to three years old.
So up until that point, parentsare extremely overwhelmed.
(18:10):
Then they get this diagnosis,and they're even more
overwhelmed, right?
And they're thrown all thesethings, right?
Start ABA, start speech, startOT, start like meet with a
nutritionist, right?
And you've got all of thesethings.
And so you're throwing your kidfrom 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 maybeyou're giving them a pouch or
(18:32):
you're doing one of thosethings.
And now you have a three orfour year old that doesn't
really know how to use a spoonor fork correctly because they
haven't really had to do thatbecause it hasn't been the focus
of what they were expected todo at that point.
And so we have some of thosekids that that can have those
sorts of things.
We have kids that have justhigher sensory sensitivities,
(18:55):
whether it be to the texture ofthe food.
the smells of the other foodsthat are around them, that idea
of just being able to sit at thetable and take bites of food,
there's a lot of things that canimpact that.
The other half of feedingchallenges come from more what
would fall under the DSMdiagnosis of ARFID, which stands
(19:19):
for avoided and restrictivefood intake disorder.
It is an actual diagnosis atthis point.
It's under the mental healthcodes.
And when we're looking at anARFID diagnosis, although
technically the definition saysthat it can start in infancy, I
don't see it so much from infantlevel, right?
(19:42):
What I see a lot more of in theARFID diagnosis land is
children that either had asignificant...
food trauma.
So in some capacity, maybe theyhad a choking incident and are
now terrified to eat.
Um, they had, um, some, maybethey took a bite of food and it
was really, really hot and theyspit it out and now they, you
(20:04):
know, don't want to eat anymore.
I actually had a client for along period of time, um, before
the mom finally connected withme he was carrying around a
Dixie cup and he would spit hisspit into the Dixie cup because
he was so scared to swallow thatwe had to ultimately work him
back up to eating so we can havesome of that food trauma and we
(20:25):
also it comes with kids thathave high levels of more of that
generalized anxiety in generaland so we have these kids that
that Everything in life isanxiety producing, right?
And food is just one of thosethat has so many different
properties to that, right?
It can be crunchy, it can bechewy, it can be hot, it can be
(20:48):
cold, it can smell like this, itcan smell like that, it can be
squishy, right?
Like there's all of thesethings.
And so add that to the list ofanxieties, right?
That I can have with a child.
The other thing that happens isthat sometimes kids that had
more of those pediatric feedingdifficulties and were allowed to
avoid foods for years at a timehave now developed anxiety for
(21:10):
those foods because they'veavoided them for so long.
And when we equate it to otherthings in our lives that we
avoid, phobias that we mighthave in ourselves because we
just have not experienced themin a really long time or just
have never wanted to, whichmight not actually be that bad,
If we tried it, we just don'tknow, right?
(21:33):
And so that's where we get alot 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 isrestricting more and more of his
food.
And now he's down to a fewbites of food.
So we have a bunch of differentpresentations.
We also, what's been actuallyhappening more recently and more
(21:56):
of my client load has becomemore, middle teenagers, so 14 to
16, 17 girls that go to more ofthe like, hospital type
settings because they're havingthis food restriction and they
get put into an eating disordersclinic.
And now technically in the DSM,right, the ARF diagnosis falls
(22:21):
in the eating disorders section.
But it is so different fromanorexia and bulimia because
anorexia and bulimia are morerooted in body dysmorphia.
So they are engaging in thosefood behaviors to impact what
their body is looking like orfeeling like.
Whereas ARFID, they'rerestricting that food because
(22:46):
they're scared of that food.
It has nothing to do with theiractual body image.
And so what ends up happeningin a lot of these clinic
settings is that the goal is toget them up to a higher weight.
And so they will tried toshovel these children with food.
I've had one of the teenagers,they ended up putting a tube, an
(23:08):
NG tube up her nose just to beable to pump calories in.
She was vomiting because theywere putting so many calories
into her on a day just to beable to get the weight gain up.
But it wasn't addressing theissue of food and it wasn't
actually getting to the rootcause of their restriction of
eating and it was actually justmaking the whole experience way
(23:31):
more unpleasant and andimmersive to them to begin with
so that's been an interestingyou know uptick for sure in my
clientele of kids that I've beenseeing 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 ofinformation.
And Dan, I want to pass it overto you because I know you've
got questions.
I certainly do.
I kind of want to framesomething for us.
So we're talking about, youknow, we're BCBAs.
We deal with autism treatment.
So we kind of have thatgeneral, you know, concept
(24:09):
looming over us.
But then you're talking aboutkids in general and ARFID and
autism might have a correlationI don't know what that is so
we're kind of covering a lot ofground here developmentally and
I appreciate that and I kind ofwant to encourage us to try and
separate it as well ascorrelated as well as we can
moving forward because there isyou know I'm the father of a
(24:29):
four-year-old and I can saypretty wholeheartedly she's a
great eater and eats things thatleave people stunned well she's
eating that yes and then Oncein a while, she'll choose to not
eat enough for my parentalperception for three, four days.
And it's miserable.
And I have to, you know, I canpreach my BCBA stuff all day,
(24:50):
but I have to practice it athome.
And in those moments, I lose mybetter wits about me.
And I do dumb things and endup, you know, with behavior that
then in a differentcircumstance, you know, back to
our previous discussion might beattributed to the diagnostic or
a slew of other things thatreally might not be related.
I created the issue thatbecause it is a fundamental
(25:11):
concern of eating.
And so she might be pickysometimes.
And then you're talking aboutrestrictive eating.
modes of eating behavior.
So I want to kind of put thatout there.
I'm going to pass it over toDan.
We've got a lot of ground tocover.
I think we'll be talking for awhile.
So,
Dan Lowery (25:26):
okay.
So much ground to cover that.
So I made some notes so I cancompartmentalize it.
But my first question to you isjust back on the RFID piece.
So we've ran some, we've runand previously we ran parent
groups at our previous company.
And there was a client thatMike and I had that was very,
very knowledgeable, veryintelligent lady and very well
read.
And she was running into issueswith her son who eventually got
(25:52):
this ARFID diagnosis and therewas another parent who later on
was having even more issues withher son and she suggested
looking into this ARFID pieceand I never heard of ARFID and
this was maybe a year or twoago.
That was literally the firsttime I'd ever heard of ARFID and
then this kind of came about.
(26:13):
I was like, huh, what is thisARFID?
What does this diagnosis mean?
Does it get you access toresort?
Like what is, this ARFID pieceand why is it important to get
this diagnosis?
So I know you've talked aboutARFID and being different than
some of the body dysmorphicdiagnoses, but anything in
addition that you'd like to sayabout what it entails, why it
might be important, who might beappropriate for this diagnosis?
Dena Kelly (26:38):
Yeah, sure.
So yeah, so when you're lookingat an ARFID diagnosis, so let
me rewind that actually.
An anorexic and a bulimicactually ultimately...
love food, but they have areally poor relationship with
that food, right?
So the anorexic that might berestricting because they want to
(27:00):
lose all of that weight,they're dreaming about the cake
and the candies and the foodthat they want to be eating.
They're drooling over it andthinking about it, and they're
just putting up that barrierfrom eating it, right?
An ARFID diagnosis is thateating disturbance that that is
(27:21):
more specific to the food.
So it is the sensorycharacteristics of that food or
that fear.
Like we were talking about thefeeding trauma, right?
Kids like that are afraid ofchoking that fear that if they
put this in their mouth, they'regoing to have a scary
experience.
They're going to choke.
They're going to throw up.
They're going to have, I had achild that had a horrific fear
(27:43):
of vomiting.
And so she would never eat morethan a couple bites of food
because she never wanted herbelly to even get to the point
of feeling anywhere near fullfor that fear of throwing up.
And so the other component withARFID is that weight is not an
(28:06):
alone factor to look at an ARFIDdiagnosis.
And this is the one that Iscream from the rooftops
constantly because I havefamilies that come to me with
school-aged kids that have beendealing with food refusal since
that child was two But becausethey are rowing and gaining
weight and they go to thepediatrician and the
(28:26):
pediatrician just keeps going,they're fine.
They're going to grow out ofit.
Don't worry.
And the mom's going, but he'sonly eating one cup of mac and
cheese a day.
And he's fine or throw a pediashort in there and he'll be
fine.
Don't worry about it.
And the years go on.
And for whatever reason, somekids bodies can survive on
McDonald's French fries.
I don't know how.
I wish I could figure it out.
(28:47):
But there are some kids thateat only McDonald's French fries
and grow to be appropriatelysized people.
But the problem is when we seethat is that we would say, oh,
well, then they should be fineand they don't necessarily have
a feeding issue.
But the point of this RFIDdiagnosis is really the impact
(29:07):
on psychosocial functioning.
And that's the key component ofthis diagnostic criteria that I
always looked at is that markedinterference with psychosocial
functioning is when this childis refusing to eat this food,
Growth is huge, right?
That's a major importantcomponent.
But so is how is their bodyfeeling?
(29:28):
We're talking about sleep.
We're talking about tantrums.
We think about that idea ofhangriness, right?
We've all experiencedhangriness 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 yourrelationship with your parents
and your siblings and yourfriends because of how snippy
you might be because you'reactually hungry and you don't
know it, right?
It can also impact from asocial perspective, going to a
birthday party, going to hangout with friends, eating lunch
(30:00):
at school, I have some kids thatsit in the nurse's office,
because they don't want to be inthe cafeteria with all of their
friends eating because theydon't want to eat.
And so those, those are theparts that for me, you know,
when somebody says, if thatchild with autism is comfortable
just eating yogurt, let's justlet them eat the yogurt.
(30:21):
is that that's what's the partfor me where I will always say,
but can we think about thebigger picture of all of this
and the potential for whatopportunities they may want to
be a part of that they'remissing out on because the
yogurt isn't fulfilling all ofthose things for them.
And when we're so restricted inthat capacity is that it
(30:44):
impacts, we have brands changetheir packaging all the time
right and so you have a childthat's very brand specific and
loves the paw patrol on thefront of the cheese stick right
or the dino nugget that has thespecific dinosaur on the front
and now they decided to do arebrand and they changed what
that looked like even though therecipe might be exactly the
(31:07):
same is that now they don't wantto eat that food anymore and so
now that parent that wasstocking all of you know that
one food now they don't want toeat any of it anymore and that's
just cut back on what theiractual intent And so that's the
part for me that really discernsthe difference and what we have
to be able to look at and thinkabout when a child is having
(31:29):
that food refusal is how is itimpacting their overall
lifestyle?
life I've had families thatcan't travel I had a girl that
was her whole thing when shefinished my program she was five
years old and all she said wasdo we get to go on vacation now
you know because the parents theparents would keep saying we
can't travel anywhere becauseyou don't eat anything and you
(31:52):
know really it made it difficultfor the family to be able to go
anywhere because that child waseating such limited food and it
really didn't travel easily.
And so so that was like a biggoal for them is that they could
actually travel because now shewas 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 mentionedabout a general fear of food.
How is that differentiatedbetween just picky eating?
So like, especially since a lotof our individuals are
non-vocal, how does a parentknow whether it's RFID?
How does a clinician knowwhether it's RFID versus just
somebody who wants to eatchicken nuggets and cookies all
(32:32):
day?
Dena Kelly (32:33):
Perfect.
Well, so if they're eatingchicken nuggets and cookies all
day, right, I'm arguing thatthat goes beyond picky eating.
So when I think about a pickyeater, I'm thinking about the
child that prefers strawberriesover blueberries and only wants
the crunchy carrots.
She doesn't want the softcarrots, right?
But like, but they have foodswithin each food group that
(32:54):
they're eating.
Maybe their proteins are onlychicken nuggets and hot dogs and
bacon and kind of like all theprocessed stuff, but they have
proteins within there.
You know, maybe their fruitsare more things like applesauce
and banana.
And, you know, they're nothaving mangoes and kiwis and
like fancy stuff, but they'reeating kind of that kid friendly
(33:16):
diet, right?
We look at like from a pizzaand mac and cheese and those
sorts of things.
But for me, again, it goes backto that psychosocial
functioning piece.
A picky eater will still beable to pick something off of
the kid's menu at a restaurant.
A picky eater will usually beable to find something at the
(33:36):
birthday party set of food to beable to eat, right?
A picky eater is, you know,able to go to Thanksgiving
dinner and eat more than theroll.
You know, that's always likethe joke is that the kid only
wants to eat the roll.
Is that, you know, maybe theydon't want the turkey without.
the gravy and the seasoning andall of the stuff on top, but
they'll have a couple pieces ofthat turkey or they'll have a
(33:56):
little bit of potato with whatthey're eating, right?
And they're trying some ofthose different things.
That's the picky eater is thatit's not necessarily impacting
their overall functioning.
They're able to get, they cansit at school lunch.
They're not in that hangryphase.
They're not having meltdownsand tantrums over their food
intake or lack of food intake.
(34:18):
When we think about thatrestrictive eater or that ARFID
eater is that they've gone anextended period of time Yeah,
absolutely.
activities that everybody is apart of, right?
(34:58):
I have families that don't wantto go to the zoo for the day,
because they're worried that thechild's not going to find
anything to eat.
And the mac and cheese thatthey make has to be, you know,
right from the microwave at acertain temperature for that
child to be able to eat it.
And so they can't pack it withthem, right?
When you start thinking aboutall of the rules that go in
place with what that child iswilling to eat, that's where
(35:21):
it's that flag of concern forme.
So, you know, I don't expectall of our kids to have a great
lovely palette a variety of youknow you willing to eat anything
at all the time but they shouldbe able to you should feel
comfortable that you canaccommodate their eating needs
kind of wherever you are orwherever they're going and if
(35:44):
that's an area of struggle foryou or for you know that child
that that that's that's the bigred flag that there's a concern
and probably warrant someintervention.
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, maybetoward 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 hugeexpanse of...
behaviors and circumstances andfoods and maybe the parent
(36:18):
isn't even willing to modelthese new healthier foods again
really good intent but man it'sa huge it's a huge amount of
ground to cover so what i hearyou saying is even to what to to
to a certain extent uh evenjust having your if your child
is a yogurt child and that'swhat they eat even just having
(36:39):
them take different flavors ofyogurt, yogurt in different
packagings.
all of those things.
So you might be on the yogurtfor a little while still.
And as a parent orprofessional, you may not see
the progress in that from theeating piece, but you're talking
about the other variables thatare also impactful on that are
(36:59):
also significant on thatjourney.
This is pretty gradual stuff iswhat I'm saying.
Encouraging people to bepatient about it.
Dena Kelly (37:07):
Well, absolutely.
So that's another one of thetips that I have, right?
Is that idea of taking whatthey're already eating and
expanding off of that becauseyou're right, you can't go, I
tell families all the time, myfirst goal in a feeding therapy
program is to actually make yourrestrictive kid a picky eater,
right?
Is to be able to have them havea few foods within each
category that allows them toexpand their experiences and to
(37:29):
be able to teach them especiallywhen you have a kid that likes
dino nuggets, is we need tolearn that a nugget is a nugget
is a nugget.
So whether you're having a dinonugget, whether it's a
Chick-fil-A nugget, whether it'sa chicken finger at the
restaurant, at the kid's meal.
So it's all within the samecategory, but we start to be
able to generalize out to someof those other things.
(37:50):
So it can be a gradual process,and it is a gradual process for
most kids.
kids in most situations I willsay you know when some of them
are are really restrictive andit's actually impacting their
their health and theirfunctioning is that that's where
you want that really intensiveprogram to be able to say we got
to jump into this and work onit quickly but but But still,
(38:15):
you're not going from a kidthat's only eating yogurt and
saying, here's your steak andbroccoli, because you're getting
nowhere with that.
You're getting nowhere fast.
But yeah, depending on how thatfood restriction is impacting
that child's health and theiroverall functioning kind of
allows you to guide what thepace speed is going to look like
(38:39):
for that child, for sure.
because it will be differentfor every child.
But that is always my start isyou 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'regoing to actually introduce
goldfish.
And they're like, wait aminute, no, like we have to do a
fruit.
I'm like, right, but we have tofirst show them, right, that
(39:00):
something that looks verydifferent from a Cheez-It is
pretty comparable, right?
And so that starts to build thetrust of like, okay, so this
was different, but it's going totaste the same, right?
And so once they start to tastethat, okay, so now that was a a
Dorito, right?
Or maybe we can then try apiece of toast with melted
(39:22):
cheese on it.
So it's still getting thecrunchy, but now we're getting
into more of the real food,right?
Which lends us to a grilledcheese and maybe into a cheese
sandwich, right?
And it allows that trajectoryof building trust and being able
to see what some of thoseinterests 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 Iunderstand it correctly.
So you mentioned that it a lotof times comes from a genuine
fear of not wanting to try otherfoods.
I remember and you brought upchicken nuggets.
There was one client that I hadthat would only eat Carl's Jr.
chicken nuggets.
That's all that this individualwould 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 foodrestaurants.
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 prioritizethat.
The parent didn't want to fightthe battle so that it just
became habitual over time.
So I guess my question to youis, can ARFID also just, is it
just the outcome of thisindividual is at this point, so
this is what they're eating?
Or is it, Is there a way todifferentiate whether it's being
(40:37):
scared versus being justbehavioral and being routine
based?
Because a lot of theindividuals that we work with,
especially on the spectrum, cantend to be routine based.
And then it just became chickennuggets all the time.
I'm not sure if that makessense of what I'm asking.
Dena Kelly (40:50):
It does.
And to me, I think my answerwould be.
we'd still work through itregardless similarly, because
usually it doesn't matterbecause the longer, the longer
that you're in a specific habitor routine and you avoid other
things is that you ultimatelyare developing, right?
(41:11):
Like our minds just regularlyin life, right?
Like the longer you don't dosomething, the more potential
angst you have to do that thingagain.
And so, so I look at that with,with these kids with ARFID a
lot is that sometimes it canhappen, again, from an issue or
(41:32):
an incident or stemming fromjust some generalized anxiety.
And sometimes it comes fromyears of avoidance of certain
foods or food groups or texturesor 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 wherethey're at now.
It doesn't really matter whatthe 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 workingwith a child that had a choking
incident, right, and is comingback to the table to try to work
their way through food, I'mprobably going to approach that
a little bit differently than Iwould, you know, a young kid
that's just had some avoidanceof food for for years at a time.
(42:15):
Because again, we talk aboutthat trauma-informed component,
right?
Of course.
We have to be able to look atsome of that.
But I would say at the end ofthe day, the interventions are
similar.
And what's been fascinating forthe clients that I work with is
that when they actually getexposure to these foods is that
(42:41):
they realize they're not thatscary and that they are okay.
I had a kid for a while thatwould come on my Zoom screen and
on the back, he made a littlebanner for himself and it would
say, but I didn't die with anexclamation
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 remindinghimself of that throughout the
treatment.
And so for a lot of my kids,especially ones that are verbal
(43:18):
and are gonna have thatinteraction is that I have them
hierarchy foods, rate them, giveme feedback on the foods that
they're thinking.
And what's cool is that overtreatment time, you see that
even if they rated a food maybea one or a two in the beginning
is that after continued practiceis that now that food's up to a
three or a four out of five,you know, instead of staying
(43:41):
down there, but even cooler.
And I just did a poster on thisfor the Pennsylvania ABA
presentation was I had a girlwho's once she put the food in
the first, almost all of herfirst ratings of food were at
least a three, if not higher.
And she was like, why was I soscared of this stuff?
(44:03):
You know, but, but it wasgetting over that hump.
She was a child that was, shewas so restricted.
She was on a tube and shewasn't eating.
And now she eats tons of stuff.
And it was really about findingthe opportunity to be able to
give her some motivation to wantto do it because that's one of
the biggest things in bothARFID, you know, and, and, just
(44:27):
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 afear 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 youa thousand bucks if you climb
(44:50):
up the ladder, yeah, I might bethinking 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 actuallywasn't that bad, but I would
have never gotten up there had Inot been having that external
(45:11):
motivator or drive because Idon't have an internal interest
in heights.
I always use heights because Idon't have an internal interest
or drive in heights.
But there's a lot of peoplethat do.
There's a lot of people thatlove being up high and standing
on rooftops and that's their cupof tea.
It's not mine.
But certainly with the rightexternal motivator, I might be
willing to try that.
(45:31):
And if I continue to try that,Would I become more accustomed
to what that felt like and beable to reduce some of that
anxiety around that experience?
And so that's what happens witha lot of our kids with feeding
challenges is that they're notgetting necessarily the same
enjoyment from eating that I sayyou and I will.
(45:51):
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 adelicious dessert, I'm finding
room, right?
(46:18):
How can I be able to make morespace for that?
parents, we say, clean up theplayroom and we can go outside
and play at the playground,right?
(46:38):
Or we've got to brush our teethso that we have time to read
books before bed, right?
So it's not, we're not sayingbrush your teeth because, you
know, you want good dentalhygiene and it's going to feel
good for your mouth.
The kid's going to look at youand say, well, that's
ridiculous.
They're going to brush theirteeth because they want the
book, right?
And over time, throughout theyears is that they start
(47:02):
realizing, right, as a childgets older, they ultimately
realize like they don't want tohave bad breath so they're going
to wear they don't want likethe way their mouth feels if
they don't brush their teeth andso they do start getting more
of that internal motivationafter years of practice with the
external motivators because nowthey see how much better their
you know mouth is or they don'thave the bad breath around their
(47:22):
friends or that sort of a thing
Dan Lowery (47:24):
classic reinforcement fading um i have
so going back to the the chickennuggets example um with like
the the individual that wouldonly eat carl's junior chicken
nuggets What would be yourspecific suggestion in a
situation like that?
Because what the parents woulddo is sometimes try other
chicken nuggets, but then assoon as the kid would take a
(47:44):
bite, he would realize that itwas not a Carl's Jr.
chicken nugget.
He would immediately shut down.
Historically in ABA, we woulddo a lot of, well, first try a
bite of this, and then you canhave your Carl's Jr.
chicken nuggets and then...
Sometimes the kid would outlastthe therapist and then you run
into either ethical issues or Idon't know if there's health
(48:05):
issues where then the parentjust gives in because they don't
want to have their kid be indistress.
And then you run into some ofthe other maybe GI or sleeping
issues because the kid's holdingout longer.
The kid now doesn't want to tryany other chicken nugget and
maybe not even the Carl's Jr.
chicken nuggets anymore becausehe's worried that it's not
going to be that long.
What would be yourrecommendation in a situation
(48:27):
like that of how you would kindof address that situation?
Dena Kelly (48:30):
Sure.
So usually I would start withnot...
the exact same type of foodbecause I don't want to get into
trickery.
I don't want it to be, let meset this up to look exactly the
same, but then when you take abite, it's going to look
different.
It's going to taste different.
I don't like trickery orsecretness at all.
(48:56):
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 andnow the kid doesn't trust
anything.
That makes
Dena Kelly (49:10):
a lot of sense.
Go ahead.
So I want to build trust versusthey could get their trust to
go away, right?
And so you have to be able tostart really small and depending
on the age of the child, thecommunication ability of that
child, what it would reallychange that, right?
If a child's going to talk tome, the first thing I'm going to
say is you're going to havesome choices and which one do
(49:33):
you want to try?
In your case, I'm guessing wasyour child talking at that
point?
No, he was non-vocal.
Right.
So potentially putting out somepictures of some choice options
and trying to be able to havesome communication in that
capacity.
If not, is that you're lookingat what are the things that are
highly motivating?
And so how can you start withsome introduction of a food that
(49:55):
might have a similar...
taste palette line right likemaybe like a fish stick as
opposed to a chicken finger orsometimes when you have a kid
that might like drink strawberrymilk or something i can pull
like a strawberry yogurt or trya piece of strawberry and you
might need to start really smalllike you know you can't start
(50:17):
with a whole strawberry is thatit 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 ofour interview with Dina Kelly.
Please do return for part twoand...
Speaker 01 (50:32):
Always analyze responsibly.
Speaker 04 (50:36):
Thank
Mike Rubio (50:37):
you.
ABA on Tap is recorded live andunfiltered.
We're done for today.
You don't have to go home, butyou can't stay here.
See you next time.
Welcome to ABA on Tap, where our goal is to find
the best recipe to brew thesmoothest, 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 ingredientsto form the best concoction of
ABA on tap.
In this podcast, we will talkabout the history of the ABA
(00:35):
brew, how much to consume toachieve the optimum buzz while
not getting too drunk, and therecommended pairings to bring to
the table.
So without further ado, sitback, relax, and always analyze
responsibly.
Mike Rubio (00:54):
All right, all right.
Welcome back to yet anotherinstallment of ABA on Tap.
I am your ever gratefulco-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 anotherincredible guest, really excited
about the content expertisethat we are going to glean from
(01:15):
today.
It's going to give us a lot tochew 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 isdone with me.
But yes, we've got a veryspecial guest, Dina Kelly, who's
going to talk to us aboutfeeding and eating and mealtimes
and all those things that canbe very, very challenging for
(01:38):
parents who are facing any givenchallenge.
Parents of young children areoftentimes going to find
themselves with some level offrustration.
Also
Dan Lowery (01:48):
a need and a weakness in ABA, at least in my
experience.
One
Mike Rubio (01:51):
of those areas that we can employ our task analyses
and maybe it doesn't go veryfar, maybe ends up a little bit
authoritarian or doing thingsthat are a little bit forceful
at times.
I know that I can think back inmy past and go, oh yeah, we
probably got that way wrong.
And the outcomes usually tellyou pretty quickly.
But without further ado, ourspecial guest today, Dina Kelly,
(02:14):
you're going to talk to usabout a lot of important things
that I think any parent of ayoung child, especially can
glean from very easily.
Thank you for your time today.
How are you?
Dena Kelly (02:25):
Hi, good.
Thank you guys so much forhaving me on the show today.
I'll start by giving somebackground so that everybody
understands where I'm comingfrom with the knowledge that I'm
talking about today.
I am an LPC, which is alicensed professional counselor,
a clinical psych background, aswell as a BCBA.
So I come into this with twodifferent backgrounds.
(02:48):
backgrounds coming into bothpsychology, but ultimately from
the clinical side and thebehavioral side.
I initially had no idea whatfeeding therapy was or anything
about it.
I was finishing my master's inclinical psych and thought that
I was just going to be doingsome sort of therapy children
with autism.
(03:08):
You know, behavior analysis wasstill somewhat newer when I was
doing that, and landed at aninternship that was an autism
clinic, but had an intensivefeeding clinic, and got put in
there for my first semester, andnever turned back.
So one semester in an intensivefeeding clinic, being able to
see how these children's liveswere impacted by their lack of
(03:31):
eating, and how quickly thistherapeutic interventions were
actually able to improve theirlife and the life of the family
around them and, and all ofthat, it was just so reinforcing
for me, that I really enjoyedit and ended up saying, this is
what I want to continue to do.
So stayed within that program.
And grew professionally withinthere, ultimately directing and
(03:56):
leading that program and all ofthe staff at that clinic and got
the opportunity to leave there,which was a very, Intensive
feeding program.
So kids would just come to thatclinic to get their feeding
services and then they wouldleave.
And so a lot of those children,especially ones with autism,
were getting ABA services fromother places or they were going
(04:19):
to get OT or they were going toget speech in other locations
throughout the rest of theirday.
And I had the chance about fouryears ago to be able to join an
ABA clinic to do some feedingthere.
And that was a very differentexperience for me because now
I'm right in the center of beingaround all of these children
(04:41):
that are coming in for ABAtherapy, intensive ABA therapy.
They're there, you know,usually four to eight hours in a
day.
I'm around a bunch of BCBAs andRBTs and able to see firsthand
how throughout the day, childrenthat were having a lack of good
eating, um, were beingimpacted, right?
(05:02):
And so it was a lot of, um,programming to, um, reduce
tantrums, right?
Or, um, RBTs were constantlystruggling with kids laying in
the middle of the floor and notable to get out.
Right.
How are we going to be able tomake that work?
Or they're constantly runningback to the room because the
(05:24):
child wants a snack.
And, you know, they just werestarting to set up and work.
And now they have to go back tothis other room because that's
where the snack is.
Right.
There was a lot of of chaos andand trying to do some
interventions around this foodrefusal without actually
addressing the issue of that.
food refusal.
And so what started to happenis I would be able to work with
(05:46):
these children individually.
They would be in my program.
The BCBAs and the RBTs werelearning how to implement these
interventions.
and seeing such a greatimprovement in these children in
not only their eating, but thentheir corollary behavior.
So you start to see that thetantrums are decreasing, that
they're able to focus on anycertain activity for a longer
(06:08):
period of time, that sometimestoilet training, depending on
the age of the child becomeseasier because now they're
actually having those foods gothrough them so that they can
actually go to the bathroom andthey're not so constipated or
dehydrated.
And so that was a really niceexperience, but it also
highlighted for me how many, Ithink you guys said it at the
(06:30):
beginning that, you know,feeding is kind of a topic that
not too many people know toomuch about.
It is a specialty.
You kind of have to fall into,you know, a structured feeding
program and get that supervisionto be able to ultimately go out
and do it on your own.
So I was having BCBAs and RVTsconstantly at my door saying, I
(06:52):
have an off hour.
Can I just sit in on yourfeeding session?
Or can we just talk aboutfeeding for a little bit?
And I have so much informationor so many questions.
And so ultimately- A BCPA had
Dan Lowery (07:02):
questions and didn't have all the answers?
Dena Kelly (07:04):
Oh, what is this?
Yes.
Yeah.
That's a
Dan Lowery (07:09):
joke, Dan.
Go ahead, Dina.
Sorry.
Dena Kelly (07:13):
Yeah, no, you know what, they were super humble in
those situations of being ableto say, I want to learn more
about feeding, you know, and soabout two years ago, I ended up
saying I need to start my ownpractice because it would allow
me the opportunity to continuesome direct intervention, but
also continue to be able toeducate people.
(07:34):
ABA professionals on thingsthey can be doing to start that
process to improve not only thatchild's mealtime, but again,
all of those other behaviorsthat then they're dealing with
outside of mealtime.
Mike Rubio (07:48):
eating and then maybe more fundamentally
something like sleeping and thenotion that either of those
things are disrupted and theymight be now precursors or
antecedents, if you will, tochallenging behavior.
You cut right through that fora lot of these professionals who
might have otherwise beenattributing these challenging
behaviors to a slew of otherthings that maybe had nothing to
(08:11):
do with it.
And during that time, you'relooking for all these motivators
and you're looking for allthese other extrinsic pieces.
Speaker 01 (08:16):
And
Mike Rubio (08:17):
really, you've got this basic fundamental internal
drive that isn't being takencare of.
I'm going to ask a quickquestion.
And Dan, I know you probablyhave this question too.
And I'm sure we'll spend a lotof time on this premise.
But the idea that I've set upmy activity I think I'm
establishing my instructionalcontrol.
And then now this kid runs outto grab some food and they're
(08:39):
not sitting to eat the food, butthey need that food.
That's a lot of behavioralstuff to work through.
Tell us about that journey foryou and for those BCBAs in tow.
Dena Kelly (08:50):
Yeah.
So, so it's really a lot of thework happens before that direct
intervention piece, right?
So I, you know, you could neverjust say, well, here's, here's
the quick answer to make thatstop happening.
Just like any otherintervention, right?
There's kind of things you haveto put in place ahead of time
and kind of behind the scenes tobe able to make those changes
(09:10):
and make that effective.
And one of the biggest thingsthat we see a lot is that,
especially in ABA land, is thatwe attribute a lot of
characteristics to children withautism and we give it as a, an
out or an excuse, right?
So we'll say, oh, they haveautism.
So, you know, we were, it'sokay that they only eat yogurt
(09:36):
all day because whatever, right?
Like fill in the blank with anyone 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 pastthat a lot for a lot of people
and say they have autism, butthey can still learn to do all
(09:58):
of these other things and theycan do them really well.
And so it's fascinating to beable to watch these kids where
they've been given the out for awhile and saying that they
can't.
I have a lot of families,individual families that will
come to me and they will startthe sessions by saying, You
know, my child will never eatyogurt because they do not like
(10:19):
that pureed type of consistency.
And ultimately, by the end oftreatment, that ends up being
their highly preferred food andthe one that they often
gravitate to.
And a lot of times it's justone of those things that they
were never really exposed to itbecause maybe one time they
threw it on the floor when theyhad it.
And so they were, you know,expected that they didn't like
(10:40):
it and they really neverpresented it again, to really be
able to have that opportunityto try it and realize that it is
actually good and somethingthat they can like.
But to get back to yourquestion, thinking about these
kids, especially in the clinicand ones that are going back and
forth a lot for food, when wehave kids that have food
refusal, oftentimes our goal orthe parent's goal that then gets
(11:04):
rubbed off onto the staffbecomes, If they're going to eat
something, let them eatwhenever they want to eat,
whatever they want to eat,because we just know we need to
get calories in, even if thatmeans every 10 minutes they're
running for Doritos, right?
But what happens is then we getinto this act of grazing.
And when we graze as humans,right?
(11:25):
we lose our ability to feelhunger.
So if you're sitting here,right, working on a bunch of
podcasts all day and you're justsitting around and not really
doing much and you're eatingsome 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 thisreservation at this really
awesome steak restaurant andwe're going out to dinner.
You're going to be like, Idon't really feel like it
(11:46):
because I'm not that hungry,right?
Because you've actually beengrazing all day.
And so that's one of the thingsthat happens with a lot of
these kids is that when they'reconstantly given access to food
throughout the day without thosestructured break times, it
doesn't allow our body toactually feel hunger.
And so the problem with thatis, one, we're going to
(12:07):
constantly need to just keepfueling that need to eat.
It becomes a habit, especiallyfor a lot of our routine kids
with autism, right?
And without that feeling ofhunger, we're less motivated to
want to eat or try moreinteresting type foods, right?
If you were really hungry andyou had a food, somebody showed
(12:32):
up with a platter of even let'ssay cookies, and it's not
usually a flavor of cookie thatyou're super interested in or
would typically pick, but you'rehungry, you're more likely to
at least give that cookie a trybecause you're motivated.
You have that need right now.
You're hungry.
If you had been popping popcornin your mouth for the past
(12:53):
three hours, And those cookiesshowed up that weren't really
your favorite flavor.
You go, I'm good.
I don't really feel like I needto eat that.
And so that impacts our abilityto do feeding therapy, because
if a kid's been eating Doritosall day and now we sit them in a
chair, we say we're going totry, you know, this chicken
nugget.
Right.
They're going to say, I'm nothungry.
(13:13):
Like, I don't there's there's.
no reason or motivation orinterest in being able to do
that.
And so one of the first thingsthat I look at, which really
doesn't even directly work onthe feeding intervention is
being able to set structuredmeal time.
So I say like, even if you'retalking about a kid that just
eats the dino nuggets, right?
Or just eats Doritos or justeats yogurt or whatever it might
(13:36):
be is take those foods thatthey're familiar with.
So you're not even messing withit.
You're not even in nointroduction of new food, no
change to anything.
All you are doing are settingsome meal and snack time
intervals.
And so that you're giving themthat stretch of time to go
without the food and thenthey're coming back and end the
(13:58):
kind of Part two to that is whenthey come, they sit at the
table or wherever their seatedsituation would be because we
always want them to be seatedwhen they're eating from a
safety perspective.
If they're grabbing food andrunning, that's not great
either.
But they come, they sit down,they eat whatever it is that
they want to eat, those foodsthat they're already familiar
(14:19):
with and they're comfortablewith, and then they go back out
to play.
And then they wait until thattimer beeps or whenever somebody
says like, okay, it's time forour snack time now or it's time
for our meal time.
And we try to break that habitof the constant grazing so that
we can allow for our body'snatural digestion to start
working, which allows us more ofthat motivational opportunity
(14:41):
to work on introducing newfoods.
Dan Lowery (14:45):
That's it.
gonna have to let my girlfriendlisten to this because she's a
constant grazer and then wheni'm like hey i got dinner
reservation she's never hungrythat 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 anddiscrete trial with almost the
exclusive M and M reinforcementand how contrary, I mean, and
I've known that for yearsalready and I've changed my
practice, but now thinking backinto how contrary it is to what
(15:26):
you were just discussing.
And then yes, to your pointearlier, the attributions very
easily going to othercharacteristics or related
symptoms of autism that, that,may in fact be true, but now
we've really muddied the waters.
How do you extricate thesevariables from what should, man,
(15:47):
this is fascinating.
And what you're talking aboutis extremely parsimonious, but
very challenging for youngparent of a young child.
I mean, your kids get you onthat when they don't eat right.
I'm sure this happens to younow on a more personal front.
Like you're looking at how manybites or the idea that just
four more bites and then I'lllet you, that'll be the negative
(16:07):
reinforcement.
Talk to us a little bit aboutsome of those direct strategies
that you use or that you teachBCBAs.
And I'm sure there's a slew ofthem.
I think one of the things we'vebeen very guilty of is trying
to find these individualrecipes.
Like it's going to have to bedifferent in everybody's
kitchen.
Again, pun intended.
Everybody's home is going to bea little bit of a different
situation that you're going toapply these concepts to.
(16:29):
And then your three-partcontingency is going to look a
little different for each childor each household.
Cultural pieces probably comein.
I threw a lot at you there.
Give us some of yourexperiences with that.
Dena Kelly (16:41):
Yeah, absolutely.
And you hit the nail on thehead for sure that there's a
very individualized concept tofeeding.
And I think that's why itreally is such a specialty and
why I harp on that idea of evenif you feel like you've mastered
one kid with feeding, itdoesn't mean that you're now
great to be able to work withany child with feeding because
(17:04):
there's a lot of different–reasons as to how that feeding
issue came about, right?
So there can be more of what Ilook at as these kids with what
they call pediatric feedingdifficulties or feeding
disorders, where it's more ofthese early on skill deficits.
So that toddler age, they'rerefusing food, they're figuring
(17:25):
out developmentallyappropriately the cause and
effect of life, right?
And they go, oh, if I throw thebroccoli on the floor,
raspberries come on my plate.
So that's really cool, right?
And so sometimes that can justspiral into being a kiddo that
now only eats, you know, ahandful of foods where they
might have been a really greateater up until about that
(17:47):
two-ish year old mark, becausenow appropriately they're
figuring out, again, some ofthat cause and effect component.
It could be some skilldeficits.
So again, we have children withautism.
that are in a variety ofdifferent therapies.
And I say, oftentimes, you'rediagnosed with autism around the
age of two to three years old.
So up until that point, parentsare extremely overwhelmed.
(18:10):
Then they get this diagnosis,and they're even more
overwhelmed, right?
And they're thrown all thesethings, right?
Start ABA, start speech, startOT, start like meet with a
nutritionist, right?
And you've got all of thesethings.
And so you're throwing your kidfrom 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 maybeyou're giving them a pouch or
(18:32):
you're doing one of thosethings.
And now you have a three orfour year old that doesn't
really know how to use a spoonor fork correctly because they
haven't really had to do thatbecause it hasn't been the focus
of what they were expected todo at that point.
And so we have some of thosekids that that can have those
sorts of things.
We have kids that have justhigher sensory sensitivities,
(18:55):
whether it be to the texture ofthe food.
the smells of the other foodsthat are around them, that idea
of just being able to sit at thetable and take bites of food,
there's a lot of things that canimpact that.
The other half of feedingchallenges come from more what
would fall under the DSMdiagnosis of ARFID, which stands
(19:19):
for avoided and restrictivefood intake disorder.
It is an actual diagnosis atthis point.
It's under the mental healthcodes.
And when we're looking at anARFID diagnosis, although
technically the definition saysthat it can start in infancy, I
don't see it so much from infantlevel, right?
(19:42):
What I see a lot more of in theARFID diagnosis land is
children that either had asignificant...
food trauma.
So in some capacity, maybe theyhad a choking incident and are
now terrified to eat.
Um, they had, um, some, maybethey took a bite of food and it
was really, really hot and theyspit it out and now they, you
(20:04):
know, don't want to eat anymore.
I actually had a client for along period of time, um, before
the mom finally connected withme he was carrying around a
Dixie cup and he would spit hisspit into the Dixie cup because
he was so scared to swallow thatwe had to ultimately work him
back up to eating so we can havesome of that food trauma and we
(20:25):
also it comes with kids thathave high levels of more of that
generalized anxiety in generaland so we have these kids that
that Everything in life isanxiety producing, right?
And food is just one of thosethat has so many different
properties to that, right?
It can be crunchy, it can bechewy, it can be hot, it can be
(20:48):
cold, it can smell like this, itcan smell like that, it can be
squishy, right?
Like there's all of thesethings.
And so add that to the list ofanxieties, right?
That I can have with a child.
The other thing that happens isthat sometimes kids that had
more of those pediatric feedingdifficulties and were allowed to
avoid foods for years at a timehave now developed anxiety for
(21:10):
those foods because they'veavoided them for so long.
And when we equate it to otherthings in our lives that we
avoid, phobias that we mighthave in ourselves because we
just have not experienced themin a really long time or just
have never wanted to, whichmight not actually be that bad,
If we tried it, we just don'tknow, right?
(21:33):
And so that's where we get alot 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 isrestricting more and more of his
food.
And now he's down to a fewbites of food.
So we have a bunch of differentpresentations.
We also, what's been actuallyhappening more recently and more
(21:56):
of my client load has becomemore, middle teenagers, so 14 to
16, 17 girls that go to more ofthe like, hospital type
settings because they're havingthis food restriction and they
get put into an eating disordersclinic.
And now technically in the DSM,right, the ARF diagnosis falls
(22:21):
in the eating disorders section.
But it is so different fromanorexia and bulimia because
anorexia and bulimia are morerooted in body dysmorphia.
So they are engaging in thosefood behaviors to impact what
their body is looking like orfeeling like.
Whereas ARFID, they'rerestricting that food because
(22:46):
they're scared of that food.
It has nothing to do with theiractual body image.
And so what ends up happeningin a lot of these clinic
settings is that the goal is toget them up to a higher weight.
And so they will tried toshovel these children with food.
I've had one of the teenagers,they ended up putting a tube, an
(23:08):
NG tube up her nose just to beable to pump calories in.
She was vomiting because theywere putting so many calories
into her on a day just to beable to get the weight gain up.
But it wasn't addressing theissue of food and it wasn't
actually getting to the rootcause of their restriction of
eating and it was actually justmaking the whole experience way
(23:31):
more unpleasant and andimmersive to them to begin with
so that's been an interestingyou know uptick for sure in my
clientele of kids that I've beenseeing 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 ofinformation.
And Dan, I want to pass it overto you because I know you've
got questions.
I certainly do.
I kind of want to framesomething for us.
So we're talking about, youknow, we're BCBAs.
We deal with autism treatment.
So we kind of have thatgeneral, you know, concept
(24:09):
looming over us.
But then you're talking aboutkids in general and ARFID and
autism might have a correlationI don't know what that is so
we're kind of covering a lot ofground here developmentally and
I appreciate that and I kind ofwant to encourage us to try and
separate it as well ascorrelated as well as we can
moving forward because there isyou know I'm the father of a
(24:29):
four-year-old and I can saypretty wholeheartedly she's a
great eater and eats things thatleave people stunned well she's
eating that yes and then Oncein a while, she'll choose to not
eat enough for my parentalperception for three, four days.
And it's miserable.
And I have to, you know, I canpreach my BCBA stuff all day,
(24:50):
but I have to practice it athome.
And in those moments, I lose mybetter wits about me.
And I do dumb things and endup, you know, with behavior that
then in a differentcircumstance, you know, back to
our previous discussion might beattributed to the diagnostic or
a slew of other things thatreally might not be related.
I created the issue thatbecause it is a fundamental
(25:11):
concern of eating.
And so she might be pickysometimes.
And then you're talking aboutrestrictive eating.
modes of eating behavior.
So I want to kind of put thatout there.
I'm going to pass it over toDan.
We've got a lot of ground tocover.
I think we'll be talking for awhile.
So,
Dan Lowery (25:26):
okay.
So much ground to cover that.
So I made some notes so I cancompartmentalize it.
But my first question to you isjust back on the RFID piece.
So we've ran some, we've runand previously we ran parent
groups at our previous company.
And there was a client thatMike and I had that was very,
very knowledgeable, veryintelligent lady and very well
read.
And she was running into issueswith her son who eventually got
(25:52):
this ARFID diagnosis and therewas another parent who later on
was having even more issues withher son and she suggested
looking into this ARFID pieceand I never heard of ARFID and
this was maybe a year or twoago.
That was literally the firsttime I'd ever heard of ARFID and
then this kind of came about.
(26:13):
I was like, huh, what is thisARFID?
What does this diagnosis mean?
Does it get you access toresort?
Like what is, this ARFID pieceand why is it important to get
this diagnosis?
So I know you've talked aboutARFID and being different than
some of the body dysmorphicdiagnoses, but anything in
addition that you'd like to sayabout what it entails, why it
might be important, who might beappropriate for this diagnosis?
Dena Kelly (26:38):
Yeah, sure.
So yeah, so when you're lookingat an ARFID diagnosis, so let
me rewind that actually.
An anorexic and a bulimicactually ultimately...
love food, but they have areally poor relationship with
that food, right?
So the anorexic that might berestricting because they want to
(27:00):
lose all of that weight,they're dreaming about the cake
and the candies and the foodthat they want to be eating.
They're drooling over it andthinking about it, and they're
just putting up that barrierfrom eating it, right?
An ARFID diagnosis is thateating disturbance that that is
(27:21):
more specific to the food.
So it is the sensorycharacteristics of that food or
that fear.
Like we were talking about thefeeding trauma, right?
Kids like that are afraid ofchoking that fear that if they
put this in their mouth, they'regoing to have a scary
experience.
They're going to choke.
They're going to throw up.
They're going to have, I had achild that had a horrific fear
(27:43):
of vomiting.
And so she would never eat morethan a couple bites of food
because she never wanted herbelly to even get to the point
of feeling anywhere near fullfor that fear of throwing up.
And so the other component withARFID is that weight is not an
(28:06):
alone factor to look at an ARFIDdiagnosis.
And this is the one that Iscream from the rooftops
constantly because I havefamilies that come to me with
school-aged kids that have beendealing with food refusal since
that child was two But becausethey are rowing and gaining
weight and they go to thepediatrician and the
(28:26):
pediatrician just keeps going,they're fine.
They're going to grow out ofit.
Don't worry.
And the mom's going, but he'sonly eating one cup of mac and
cheese a day.
And he's fine or throw a pediashort in there and he'll be
fine.
Don't worry about it.
And the years go on.
And for whatever reason, somekids bodies can survive on
McDonald's French fries.
I don't know how.
I wish I could figure it out.
(28:47):
But there are some kids thateat only McDonald's French fries
and grow to be appropriatelysized people.
But the problem is when we seethat is that we would say, oh,
well, then they should be fineand they don't necessarily have
a feeding issue.
But the point of this RFIDdiagnosis is really the impact
(29:07):
on psychosocial functioning.
And that's the key component ofthis diagnostic criteria that I
always looked at is that markedinterference with psychosocial
functioning is when this childis refusing to eat this food,
Growth is huge, right?
That's a major importantcomponent.
But so is how is their bodyfeeling?
(29:28):
We're talking about sleep.
We're talking about tantrums.
We think about that idea ofhangriness, right?
We've all experiencedhangriness 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 yourrelationship with your parents
and your siblings and yourfriends because of how snippy
you might be because you'reactually hungry and you don't
know it, right?
It can also impact from asocial perspective, going to a
birthday party, going to hangout with friends, eating lunch
(30:00):
at school, I have some kids thatsit in the nurse's office,
because they don't want to be inthe cafeteria with all of their
friends eating because theydon't want to eat.
And so those, those are theparts that for me, you know,
when somebody says, if thatchild with autism is comfortable
just eating yogurt, let's justlet them eat the yogurt.
(30:21):
is that that's what's the partfor me where I will always say,
but can we think about thebigger picture of all of this
and the potential for whatopportunities they may want to
be a part of that they'remissing out on because the
yogurt isn't fulfilling all ofthose things for them.
And when we're so restricted inthat capacity is that it
(30:44):
impacts, we have brands changetheir packaging all the time
right and so you have a childthat's very brand specific and
loves the paw patrol on thefront of the cheese stick right
or the dino nugget that has thespecific dinosaur on the front
and now they decided to do arebrand and they changed what
that looked like even though therecipe might be exactly the
(31:07):
same is that now they don't wantto eat that food anymore and so
now that parent that wasstocking all of you know that
one food now they don't want toeat any of it anymore and that's
just cut back on what theiractual intent And so that's the
part for me that really discernsthe difference and what we have
to be able to look at and thinkabout when a child is having
(31:29):
that food refusal is how is itimpacting their overall
lifestyle?
life I've had families thatcan't travel I had a girl that
was her whole thing when shefinished my program she was five
years old and all she said wasdo we get to go on vacation now
you know because the parents theparents would keep saying we
can't travel anywhere becauseyou don't eat anything and you
(31:52):
know really it made it difficultfor the family to be able to go
anywhere because that child waseating such limited food and it
really didn't travel easily.
And so so that was like a biggoal for them is that they could
actually travel because now shewas 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 mentionedabout a general fear of food.
How is that differentiatedbetween just picky eating?
So like, especially since a lotof our individuals are
non-vocal, how does a parentknow whether it's RFID?
How does a clinician knowwhether it's RFID versus just
somebody who wants to eatchicken nuggets and cookies all
(32:32):
day?
Dena Kelly (32:33):
Perfect.
Well, so if they're eatingchicken nuggets and cookies all
day, right, I'm arguing thatthat goes beyond picky eating.
So when I think about a pickyeater, I'm thinking about the
child that prefers strawberriesover blueberries and only wants
the crunchy carrots.
She doesn't want the softcarrots, right?
But like, but they have foodswithin each food group that
(32:54):
they're eating.
Maybe their proteins are onlychicken nuggets and hot dogs and
bacon and kind of like all theprocessed stuff, but they have
proteins within there.
You know, maybe their fruitsare more things like applesauce
and banana.
And, you know, they're nothaving mangoes and kiwis and
like fancy stuff, but they'reeating kind of that kid friendly
(33:16):
diet, right?
We look at like from a pizzaand mac and cheese and those
sorts of things.
But for me, again, it goes backto that psychosocial
functioning piece.
A picky eater will still beable to pick something off of
the kid's menu at a restaurant.
A picky eater will usually beable to find something at the
(33:36):
birthday party set of food to beable to eat, right?
A picky eater is, you know,able to go to Thanksgiving
dinner and eat more than theroll.
You know, that's always likethe joke is that the kid only
wants to eat the roll.
Is that, you know, maybe theydon't want the turkey without.
the gravy and the seasoning andall of the stuff on top, but
they'll have a couple pieces ofthat turkey or they'll have a
(33:56):
little bit of potato with whatthey're eating, right?
And they're trying some ofthose different things.
That's the picky eater is thatit's not necessarily impacting
their overall functioning.
They're able to get, they cansit at school lunch.
They're not in that hangryphase.
They're not having meltdownsand tantrums over their food
intake or lack of food intake.
(34:18):
When we think about thatrestrictive eater or that ARFID
eater is that they've gone anextended period of time Yeah,
absolutely.
activities that everybody is apart of, right?
(34:58):
I have families that don't wantto go to the zoo for the day,
because they're worried that thechild's not going to find
anything to eat.
And the mac and cheese thatthey make has to be, you know,
right from the microwave at acertain temperature for that
child to be able to eat it.
And so they can't pack it withthem, right?
When you start thinking aboutall of the rules that go in
place with what that child iswilling to eat, that's where
(35:21):
it's that flag of concern forme.
So, you know, I don't expectall of our kids to have a great
lovely palette a variety of youknow you willing to eat anything
at all the time but they shouldbe able to you should feel
comfortable that you canaccommodate their eating needs
kind of wherever you are orwherever they're going and if
(35:44):
that's an area of struggle foryou or for you know that child
that that that's that's the bigred flag that there's a concern
and probably warrant someintervention.
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, maybetoward 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 hugeexpanse of...
behaviors and circumstances andfoods and maybe the parent
(36:18):
isn't even willing to modelthese new healthier foods again
really good intent but man it'sa huge it's a huge amount of
ground to cover so what i hearyou saying is even to what to to
to a certain extent uh evenjust having your if your child
is a yogurt child and that'swhat they eat even just having
(36:39):
them take different flavors ofyogurt, yogurt in different
packagings.
all of those things.
So you might be on the yogurtfor a little while still.
And as a parent orprofessional, you may not see
the progress in that from theeating piece, but you're talking
about the other variables thatare also impactful on that are
(36:59):
also significant on thatjourney.
This is pretty gradual stuff iswhat I'm saying.
Encouraging people to bepatient about it.
Dena Kelly (37:07):
Well, absolutely.
So that's another one of thetips that I have, right?
Is that idea of taking whatthey're already eating and
expanding off of that becauseyou're right, you can't go, I
tell families all the time, myfirst goal in a feeding therapy
program is to actually make yourrestrictive kid a picky eater,
right?
Is to be able to have them havea few foods within each
category that allows them toexpand their experiences and to
(37:29):
be able to teach them especiallywhen you have a kid that likes
dino nuggets, is we need tolearn that a nugget is a nugget
is a nugget.
So whether you're having a dinonugget, whether it's a
Chick-fil-A nugget, whether it'sa chicken finger at the
restaurant, at the kid's meal.
So it's all within the samecategory, but we start to be
able to generalize out to someof those other things.
(37:50):
So it can be a gradual process,and it is a gradual process for
most kids.
kids in most situations I willsay you know when some of them
are are really restrictive andit's actually impacting their
their health and theirfunctioning is that that's where
you want that really intensiveprogram to be able to say we got
to jump into this and work onit quickly but but But still,
(38:15):
you're not going from a kidthat's only eating yogurt and
saying, here's your steak andbroccoli, because you're getting
nowhere with that.
You're getting nowhere fast.
But yeah, depending on how thatfood restriction is impacting
that child's health and theiroverall functioning kind of
allows you to guide what thepace speed is going to look like
(38:39):
for that child, for sure.
because it will be differentfor every child.
But that is always my start isyou 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'regoing to actually introduce
goldfish.
And they're like, wait aminute, no, like we have to do a
fruit.
I'm like, right, but we have tofirst show them, right, that
(39:00):
something that looks verydifferent from a Cheez-It is
pretty comparable, right?
And so that starts to build thetrust of like, okay, so this
was different, but it's going totaste the same, right?
And so once they start to tastethat, okay, so now that was a a
Dorito, right?
Or maybe we can then try apiece of toast with melted
(39:22):
cheese on it.
So it's still getting thecrunchy, but now we're getting
into more of the real food,right?
Which lends us to a grilledcheese and maybe into a cheese
sandwich, right?
And it allows that trajectoryof building trust and being able
to see what some of thoseinterests 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 Iunderstand it correctly.
So you mentioned that it a lotof times comes from a genuine
fear of not wanting to try otherfoods.
I remember and you brought upchicken nuggets.
There was one client that I hadthat would only eat Carl's Jr.
chicken nuggets.
That's all that this individualwould 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 foodrestaurants.
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 prioritizethat.
The parent didn't want to fightthe battle so that it just
became habitual over time.
So I guess my question to youis, can ARFID also just, is it
just the outcome of thisindividual is at this point, so
this is what they're eating?
Or is it, Is there a way todifferentiate whether it's being
(40:37):
scared versus being justbehavioral and being routine
based?
Because a lot of theindividuals that we work with,
especially on the spectrum, cantend to be routine based.
And then it just became chickennuggets all the time.
I'm not sure if that makessense of what I'm asking.
Dena Kelly (40:50):
It does.
And to me, I think my answerwould be.
we'd still work through itregardless similarly, because
usually it doesn't matterbecause the longer, the longer
that you're in a specific habitor routine and you avoid other
things is that you ultimatelyare developing, right?
(41:11):
Like our minds just regularlyin life, right?
Like the longer you don't dosomething, the more potential
angst you have to do that thingagain.
And so, so I look at that with,with these kids with ARFID a
lot is that sometimes it canhappen, again, from an issue or
(41:32):
an incident or stemming fromjust some generalized anxiety.
And sometimes it comes fromyears of avoidance of certain
foods or food groups or texturesor 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 wherethey're at now.
It doesn't really matter whatthe 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 workingwith a child that had a choking
incident, right, and is comingback to the table to try to work
their way through food, I'mprobably going to approach that
a little bit differently than Iwould, you know, a young kid
that's just had some avoidanceof food for for years at a time.
(42:15):
Because again, we talk aboutthat trauma-informed component,
right?
Of course.
We have to be able to look atsome of that.
But I would say at the end ofthe day, the interventions are
similar.
And what's been fascinating forthe clients that I work with is
that when they actually getexposure to these foods is that
(42:41):
they realize they're not thatscary and that they are okay.
I had a kid for a while thatwould come on my Zoom screen and
on the back, he made a littlebanner for himself and it would
say, but I didn't die with anexclamation
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 remindinghimself of that throughout the
treatment.
And so for a lot of my kids,especially ones that are verbal
(43:18):
and are gonna have thatinteraction is that I have them
hierarchy foods, rate them, giveme feedback on the foods that
they're thinking.
And what's cool is that overtreatment time, you see that
even if they rated a food maybea one or a two in the beginning
is that after continued practiceis that now that food's up to a
three or a four out of five,you know, instead of staying
(43:41):
down there, but even cooler.
And I just did a poster on thisfor the Pennsylvania ABA
presentation was I had a girlwho's once she put the food in
the first, almost all of herfirst ratings of food were at
least a three, if not higher.
And she was like, why was I soscared of this stuff?
(44:03):
You know, but, but it wasgetting over that hump.
She was a child that was, shewas so restricted.
She was on a tube and shewasn't eating.
And now she eats tons of stuff.
And it was really about findingthe opportunity to be able to
give her some motivation to wantto do it because that's one of
the biggest things in bothARFID, you know, and, and, just
(44:27):
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 afear 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 youa thousand bucks if you climb
(44:50):
up the ladder, yeah, I might bethinking 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 actuallywasn't that bad, but I would
have never gotten up there had Inot been having that external
(45:11):
motivator or drive because Idon't have an internal interest
in heights.
I always use heights because Idon't have an internal interest
or drive in heights.
But there's a lot of peoplethat do.
There's a lot of people thatlove being up high and standing
on rooftops and that's their cupof tea.
It's not mine.
But certainly with the rightexternal motivator, I might be
willing to try that.
(45:31):
And if I continue to try that,Would I become more accustomed
to what that felt like and beable to reduce some of that
anxiety around that experience?
And so that's what happens witha lot of our kids with feeding
challenges is that they're notgetting necessarily the same
enjoyment from eating that I sayyou and I will.
(45:51):
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 adelicious dessert, I'm finding
room, right?
(46:18):
How can I be able to make morespace for that?
parents, we say, clean up theplayroom and we can go outside
and play at the playground,right?
(46:38):
Or we've got to brush our teethso that we have time to read
books before bed, right?
So it's not, we're not sayingbrush your teeth because, you
know, you want good dentalhygiene and it's going to feel
good for your mouth.
The kid's going to look at youand say, well, that's
ridiculous.
They're going to brush theirteeth because they want the
book, right?
And over time, throughout theyears is that they start
(47:02):
realizing, right, as a childgets older, they ultimately
realize like they don't want tohave bad breath so they're going
to wear they don't want likethe way their mouth feels if
they don't brush their teeth andso they do start getting more
of that internal motivationafter years of practice with the
external motivators because nowthey see how much better their
you know mouth is or they don'thave the bad breath around their
(47:22):
friends or that sort of a thing
Dan Lowery (47:24):
classic reinforcement fading um i have
so going back to the the chickennuggets example um with like
the the individual that wouldonly eat carl's junior chicken
nuggets What would be yourspecific suggestion in a
situation like that?
Because what the parents woulddo is sometimes try other
chicken nuggets, but then assoon as the kid would take a
(47:44):
bite, he would realize that itwas not a Carl's Jr.
chicken nugget.
He would immediately shut down.
Historically in ABA, we woulddo a lot of, well, first try a
bite of this, and then you canhave your Carl's Jr.
chicken nuggets and then...
Sometimes the kid would outlastthe therapist and then you run
into either ethical issues or Idon't know if there's health
(48:05):
issues where then the parentjust gives in because they don't
want to have their kid be indistress.
And then you run into some ofthe other maybe GI or sleeping
issues because the kid's holdingout longer.
The kid now doesn't want to tryany other chicken nugget and
maybe not even the Carl's Jr.
chicken nuggets anymore becausehe's worried that it's not
going to be that long.
What would be yourrecommendation in a situation
(48:27):
like that of how you would kindof address that situation?
Dena Kelly (48:30):
Sure.
So usually I would start withnot...
the exact same type of foodbecause I don't want to get into
trickery.
I don't want it to be, let meset this up to look exactly the
same, but then when you take abite, it's going to look
different.
It's going to taste different.
I don't like trickery orsecretness at all.
(48:56):
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 andnow the kid doesn't trust
anything.
That makes
Dena Kelly (49:10):
a lot of sense.
Go ahead.
So I want to build trust versusthey could get their trust to
go away, right?
And so you have to be able tostart really small and depending
on the age of the child, thecommunication ability of that
child, what it would reallychange that, right?
If a child's going to talk tome, the first thing I'm going to
say is you're going to havesome choices and which one do
(49:33):
you want to try?
In your case, I'm guessing wasyour child talking at that
point?
No, he was non-vocal.
Right.
So potentially putting out somepictures of some choice options
and trying to be able to havesome communication in that
capacity.
If not, is that you're lookingat what are the things that are
highly motivating?
And so how can you start withsome introduction of a food that
(49:55):
might have a similar...
taste palette line right likemaybe like a fish stick as
opposed to a chicken finger orsometimes when you have a kid
that might like drink strawberrymilk or something i can pull
like a strawberry yogurt or trya piece of strawberry and you
might need to start really smalllike you know you can't start
(50:17):
with a whole strawberry is thatit 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 ofour interview with Dina Kelly.
Please do return for part twoand...
Speaker 01 (50:32):
Always analyze responsibly.
Speaker 04 (50:36):
Thank
Mike Rubio (50:37):
you.
ABA on Tap is recorded live andunfiltered.
We're done for today.
You don't have to go home, butyou can't stay here.
See you next time.
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