08/24/2015  |  By Jennifer Croner, Kim Duhanyan, Silva Orchanian, and Mary Jane Weiss

What do families and teachers of children with developmental disabilities think of when people discuss health and wellness? More often than not, issues of nutrition and fitness top the list. The behavioral resistance to change common in people with disabilities sometimes makes it difficult to limit or alter foods as well as to insert fitness regimes into a daily routine. In this article, we explore the need for intervention in these areas and suggest effective strategies toward improving health status in individuals with developmental disabilities.

Focus on Nutrition

A recent review found children with autism are five times more likely to have a feeding problem as compared to typically developing children.  These feeding problems may include medical conditions such as: difficulty swallowing, food selectivity, ritualistic eating behaviors and meal-related tantrums or disruptions, among other difficulties.

A common worry among parents of individuals with intellectual and developmental disabilities who have food selectivity is that their child is not receiving proper nutrition from their diet. Often, children with disabilities have a narrow range of preferred foods. They also may reject foods of certain textures, colors or other characteristics.  Caregivers might be able to address the narrow range issue with some creativity. For example, it may be helpful to focus on fruits, as they are sweet and still provide many vitamins and nutrients. Vary the vegetables you offer, and whenever possible, provide an alternative choice.

Another tip is to utilize whole grains whenever possible. For example, replacing your white bread with whole grain bread, using brown rice, and adding other heartier grains will provide more fiber and nutrients. Offer lean proteins including chicken, turkey, beans, low-fat dairy and tofu.  Additionally, try to limit access to saturated or trans fats, salt and sugar. When serving meals or snacks, always provide a drink. Encourage your child to pace during the meal and completely chew or swallow before taking the next bite. It is often helpful to teach that taking a drink and wiping one’s mouth should follow each bite. This helps to ensure that all food is thoroughly chewed and swallowed and increases the amount of time between bites.

Decreasing Challenging Behaviors During Meals

Another common problem that might lead to nutritional deficits is challenging behavior during the meal that can include food refusal and disruptive actions. One way to reduce these challenges is to make the snack or meal fun by using positive reinforcement. Positive reinforcement occurs when a behavior is followed by the addition of a preferred consequence. This can lead to that behavior occurring more often in the future. Providing some of your child’s favorite toys or activities such as watching TV or listening to music while they are eating might increase the amount of food they consume. While positive reinforcement has often been shown to increase consumption of foods that the child is already eating, it is often important to also increase the variety of foods they are eating. 

One way to do this is to provide a preferred food after your child consumes something new or non-preferred. Think of Grandma’s Rule: “Eat your peas, and then you can have ice cream.”  We are building on the same principle here. If your child takes a bite of broccoli, he or she then can have a bite of chicken nuggets. Another useful strategy is to start small and slowly increase the amount of food you are offering. At first, only require that your child take one bite of broccoli. After this is completed successfully, they get an entire chicken nugget. As they continue to eat the broccoli, slowly raise the bar. Now they have to eat two bites of broccoli for the chicken nugget, then three, and so on until they are eating an entire portion of vegetables. It is often helpful to continually re-present the bite if your child throws the food on the floor or spits it out. This can be achieved by holding the spoon in front of their mouth until they consume it. These various strategies can be used to increase both the amount and variety of foods consumed. At times, food refusal is extreme. It is important to have the support and expertise of professionals who know how to advise you. Be sure to be in close touch with your child’s team about any changes you plan to make, and keep everyone informed of the progress and challenges.

Final Thoughts on Eating Issues

Every parent worries at some time about his or her child’s nutritional status. This is much more common and much more intense when a child has a disability. Furthermore, children with disabilities are at higher risk for feeding issues, given their behavioral, motoric and sensory challenges. Creative meal planning can lead to added nutritional content. Developing appropriate pacing of eating can lead to better habits. Using preferred activities during and after the meal might reduce resistance. Using some strategies to slowly build tolerance for new or less preferred foods is also helpful. Caregivers working on feeding need the knowledge and involvement of experts in this area. While it can be a daunting challenge, real changes are possible with the right planning and with the use of effective procedures.

What About Exercise?

The importance of incorporating physical activities on a daily basis into all of our lives is a key piece to promoting overall health and wellness. Inactivity is a widespread issue for all Americans and for children in particular. The rates of overweight and obesity for both adults and children are increasing, and activity levels are low across all ages. For children with disabilities, it is even more problematic. It has been found that more than half of all children with autism spectrum disorders are either overweight or at risk for being overweight. Studies have shown this weight gain most often is due to inadequate levels of physical activity. To compound this, the medications commonly prescribed to those with developmental disabilities can also contribute to weight gain. In addition, careful attention should be given to the excessive use of edible reinforcement for clinical and academic programming, since this can be another contributing factor to weight gain.

Adhering to a healthy lifestyle is clearly essential for individuals with developmental disabilities, but how do we best incorporate it into the day-to-day routine for the individuals we serve? Often, caregivers share this goal and attempt to increase physical activity for the individuals with autism in their care. Most of the time, they fail.  Individuals with developmental disabilities may resist the exercise routine, may not have stamina to tolerate the exercise, and may engage in aberrant behavior that interferes with the activity.

There are many ways to successfully engage individuals with disabilities in recreational and exercise related activities, utilizing their preferred activities to motivate them. Within residential and school programs, activities such as playing basketball, using the treadmill, boot camp activities, fitness programs through the Wii and races can be included in daily schedules and routines. Systematically introducing these routines into our clients’ lives produces long-term outcomes and lifelong habits that impact overall health and wellness. Shaping procedures are very effective to increase individuals’ duration of participation in those activities that require more effort. For example, clinical experience shows that slowly introducing cardio equipment for one-minute increments and increasing that duration on a measured schedule has been effective.

Another successful method can be having individuals do five sit-ups and five jumping jacks to begin, and increasing the number of repetitions completed. Utilizing visual schedules and terminal reinforcers allows the individual to have a clear understanding of what they are expected to complete and what they can access upon completion. Many of these strategies are used by typically developing exercisers as well. Many of us need to work slowly to increase our stamina. Who wants to exercise without knowing when it is going to end?  This is especially true for learners with developmental disabilities.

Another strategy is to combine the other preferred experiences with the exercise routine. When introducing exercise, for example, one can pair these routines with access to watching a preferred movie or listening to a preferred musical artist. Again, most typical learners do not enjoy being on the treadmill with no music or television to entertain them! It is also a good idea to have staff members, family and friends participate in the routine next to the individual. This not only promotes the individual completing the routine with the right form and technique, but also allows them to feel like they do not have to complete the activity alone.

There are other activities that can be incorporated into daily routines that also increase movement and motion. Gardening, for an example, is a great way to get an individual moving, squatting, bending, carrying items and getting some exercise without even knowing it! Other examples might include cleaning the house, taking out the trash, biking to a park, or walking to a store to get needed items.  It is helpful to find opportunities for additional exercise that can be embedded into daily routines.

Individuals with developmental disabilities do not have all of the same opportunities to engage in social and competitive activities with peers within their same age group. However, such opportunities can be contrived. Exercise and sporting events provide these opportunities along with teaching individuals with developmental disabilities so many important and life changing skills that cannot be learned in a structured classroom setting. Recently, a couple of individuals within our agency ran and/or walked two charitable 5k races with their teachers. Their entire community was present to demonstrate their support, cheer for them and capture action shots as they crossed the finish line. Their peers, other staff members, and their families were extremely proud of their accomplishment. Many people enjoy participating in group-gym or boot camp style classes as an opportunity to have fun with a group of people while still exercising.

Carryover to Other Areas of Life

The benefits of exercise and good nutrition carry over into other areas of life as well. It has been noted that people that exercise consistently tend to sleep better. Exercise also helps students with disabilities exert their physical energy in an adaptive and positive manner. Nutrition influences global health and reduces obesity. Those with healthy, active lifestyles may not get ill as frequently. Exercise raises serotonin levels, increasing overall happiness, enjoyment and social interactions. As previously stated, these healthy and movement-based activities also provide additional opportunities for peer and group interactions, a skill set that we are consistently working to strengthen in individuals with developmental disabilities.  

Jennifer Croner, M.S.Ed.,  is the Research and Training Coordinator for Melmark. Kim Duhanyan, BCBA, is the Director of Residential Services, Melmark New England. Silva Orchanian, is the BCBA, Director of School Services, Melmark New England. Mary Jane Weiss, Ph.D., BCBA-D, is the Executive Director of Research, Melmark. Melmark is a comprehensive multi-service agency, providing residential, educational and therapeutic services for children and adults with autism, intellectual disabilities, brain injuries and other neurological and genetic diagnoses.
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