How to Treat Picky Eating and Associated Behavior Through Noncontingent Reinforcement

Picky Eating Can Lead To Long-Term Problems; Treating It Is Crucial. How You Treat It Matters.

Picky eating, also known as food selectivity, is a common issue among persons with developmental disabilities, particularly among those diagnosed with autism spectrum disorder (ASD). Picky eating carries a greater risk of nutrient deficiencies and social inadequacy. This selectivity across food textures, colors, tastes, temperature, and smells can develop into chronic food selectivity known as food refusal. Food refusal, a severe restricted pattern of eating, often involves some type of intensive medical treatment, whether behavioral outpatient services or hospitalization. Long-term, food refusal can result in malnutrition and impaired mental and physical development. 

What not to do 

Typically, when one member of the family is a picky eater, parents report limited food choices for other members in the family, lack of meaningful interactions during mealtimes, and an increase in spousal stress. Treatment usually involves some form of reprimands, repeated food presentations, or “waiting out” the refusal until the child gives in through hunger. 

These methods may come out of desperation but have been shown to increase avoidance of food when implemented outside of professional help. Even then, professionals have steered away from using these methods due to the several issues it may cause such as associated aggression and self-injurious behavior. 

A better alternative 

What experts in the field of applied behavior analysis (ABA) have learned is that certain techniques can be as effective as the interventions above without the use of coercion or punishment. One technique known as Noncontingent Reinforcement (NCR) confirms the theory of parsimony – sometimes the solution to a problem is the simplest one. Its ease of implementation and treatment effects can be pretty powerful. 

It is a preventative treatment, which means it stops the selectivity before it happens rather than treating the food selectivity after it happens. NCR uses well-known reinforcers (i.e., motivators) to compete with certain patterns of behavior. Essentially, providing reinforcers on a very strict time schedule reduces the need to act (e.g., fight or flight) on an aversive situation and additionally associates the surrounding environment with those reinforcers. 

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When applied to mealtimes, NCR increases attempts to try new or non-preferred foods and creates a positive atmosphere. Examples of reinforcers include favorite snacks, toys, and music. 

Studies have confirmed NCR increases food acceptance, healthy habits, and family bonding (Wilder et al., 2005, Ingvarsson, et al. 2008, Berth et al., 2019, Luis et al. 2021). Prior to attempting NCR, caregivers should start by consulting with their pediatrician, then a Board Certified Behavior Analyst (BCBA). 

To implement, caregivers should choose a neutral setting, neutral plates and utensils, and identify a highly preferred item that can be delivered easily and either dissipates or ends on its own. Examples include brief videos on an iPad (i.e., no longer than 2-3 minutes) or bite-sized foods (no bigger than a tablespoon). A timer helps to keep the timing consistent if using a duration-based reinforcer. 

Caregivers must also choose 1-3 foods to initially target. Food should somewhat resemble preferred foods in texture, color, smell, or temperature. Once materials are accessible, you can begin implementing NCR. 

Start by presenting the highly preferred item or edible (e.g., video on an iPad or favorite snack) at the same time as the novel or non-preferred tablespoon of food. Duration-based reinforcers such as videos and music should be provided continuously through the entire NCR procedure. 

If the bite is accepted, provide lots of praise (e.g., “You did it!”). If they turn away or engage in destructive behavior, immediately remove the non-preferred or novel food. If there is no response, the caregiver should remove the non-preferred or novel bite of food within 30 seconds. 

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Continue providing the highly-preferred item or preferred food no matter what. The procedure should last no longer than 10-15 minutes per day as this presents sufficient learning opportunities while maintaining treatment fidelity. 

Eventually, over numerous attempts, research has demonstrated that food acceptance will increase. Once this happens, different foods can be introduced, and caregivers can begin to play around with how often the highly-preferred item or food is presented (this should be done gradually over time). There are hardly any aversive effects, but as mentioned before, a pediatrician or nutritionist should be consulted beforehand to provide dietary guidelines. 

NCR can lead to positive, long-term effects such as increases in family meal frequency and decreases in malnutrition, aggressiveness, and self-injury in individuals with autism.

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