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Season 5: Episode 12 – Specialty Clinics at the University of Florida Health Center for Autism and Neurodevelopment

March 21, 2024

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Episode Description

The new episode of ABA Unfiltered is now live 🎙️🎉  In this episode, Dr. Vivian Ibanez from the Specialty Clinics at the University of Florida Health Center for Autism and Neurodevelopment (UFCAN) talks about ABA and Pediatric Feeding Disorders. Listen on Apple Podcasts, Spotify, YouTube, or Google Podcasts! https://bit.ly/ABAUnfiltered_Podcast

But that’s not all! We have something special in store for you. 💫 For those seeking professional development opportunities, head over to our CEU site using the Episode promo code. https://bcbaceu.bluesprigautism.com/

You can also access Dr. Ibanez’s “Behavior-Analytic Assessment and Treatment of Pediatric Feeding Disorders” course through our CEU site. With our special promotion, you can access this course completely free until the end of the year, 12/31/23, using the code podcast1023 at checkout. Plus, upon completion, you will earn 1 CEU, empowering you to enhance your expertise as a BCBA! 💙✨

Full transcript

0:14 Andrew Blomstrom: Hello everyone, this is Andrew Blomstrom, along with Amanda Fullbright, and you are listening to ABA Unfiltered, where each episode we interview guests from around the world of ABA. Whether you’re a BCBA, RBT, or just interested in ABA, you are sure to pick up some actionable advice you can utilize on your journey. Without further ado, we would like to welcome on our guest, Dr. Vivian Ibanez. Vivian, why don’t you go ahead and tell us a little bit about yourself?
0:42 Dr. Vivian Ibanez: Sure. So I am currently a research assistant professor here at the University of Florida in Gainesville, but I also am the clinical director of the Pediatric Feeding Disorders Program, which is a collaboration between Florida Autism Center and BlueSprig Pediatrics, along with the University of Florida Health Center for Autism and Neurodevelopment. Before I got here, though, I started out my work in behavior analysis at Kennedy Creeker Institute in Baltimore, Maryland. That’s kind of where I, so to speak, fell in love with the area of behavior analysis and really saw the change that it could make in families and children who were, you know, impacted by different types of behavioral health disorders. So after I started to specialize in feeding, I decided to go out to the Nebraska Medical Center to continue getting specialized work with Dr. Kathleen Piazza. And then I was fortunate enough to accept an offer extended by Dr. Tim Vollmer, who I’m sure many of us are aware of, just given his work in the field, but also his collaboration with Blue Sprick Pediatrics. And since then, our goal has been to basically expand services that are specialized for children both in and out of Florida. So that’s what I’ve been up to the last few years is just trying to kickstart these specialized services. And I’m excited to be here today to chat about those.
2:05 Andrew Blomstrom: Well, thank you. We’re excited to have you. So you kind of mentioned a little bit about your background and how you kind of got to your current position. But kind of curious, what led you to specialize in pediatric feeding disorders as a BCBA? And along with that, are there any like personal or professional experiences that kind of expired, inspired you for that to be your focus?
2:27 Dr. Vivian Ibanez: So truly, when it came to learning about feeding, I had no idea what I was getting myself into. Honestly, I was lucky in that when I graduated, there happened to only be an open position in feeding. So before I got into feeding, I actually had worked in severe problem behavior, so on the neurobehavioral unit. So working mainly on aggression, self-injury, and those types of behaviors. And when I graduated, they said, we’d love to have you back at Kennedy, but we only have an opening in feeding. And to be honest, I thought that it was eating disorders. And so right off the bat, you know, that sort of introduction to something about, you know, there are kids that won’t eat was really perplexing to me. So just the curiosity of wanting to understand why it would be that a child would not want to eat, given how much we all probably love food, um, you know, was very perplexing to me. So that really drew me. But to be honest, the social significance of eating was sort of the next layer. So once I learned what these difficulties looked like, I think seeing how it impacted the families, um, you know, I think we all take eating and drinking for granted, you know, not just uh parents who are able to successfully feed their children, but we all get together with friends to eat. You know, I was talking a little bit about before the show that we have a big football game coming up and we’re all planning football snacks, right? So just food also means a lot of social things. And so I think seeing the um impact that not being able to have that for families of these children had was really um powerful and drew me to that sort of field. And then the last thing I’ll say is for me, because I am originally from Guatemala, um, my parents used food a lot when we immigrated from the from Guatemala to the United States as reminders of the culture. And so again, I think just this like importance surrounding food, not only we eat to survive, but also just the cultural, you know, impact, the social impact. And seeing that that was not a situation that all families could have with these children really just made me want to keep learning more and more about it.
4:43 Andrew Blomstrom: Awesome. Thank you. Yeah, it is a huge impact. And like you said, we do take it for granted. It is such a big part of everyone’s life from the cultural aspect to holidays to events that you kind of overlook how much of an impact it has on our day-to-day lives.
4:58 Dr. Vivian Ibanez: Yeah, to be honest, I think my own parents and grandmother still don’t completely understand exactly what I do because I think they’re so um drawn to this idea of like, why would a child not want to eat? Or why would you have a child who only wants to eat the same thing over and over again? I mean, we all probably have experiences where it’s like, I’m so tired of, you know, eating cereal. I’ve been eating cereal too much this week. I’m not gonna keep eating cereal. I don’t want to look at it again or think about it. And so I think just um even explaining that situation to my own family sometimes has been an interesting sort of process.
5:31 Amanda Fullbright: Yeah, I bet.
5:33 Dr. Vivian Ibanez: I bet. Yeah.
5:34 Amanda Fullbright: So, Vivian, there’s there’s multiple approaches to to feeding and pediatric feeding disorders. Talk to us about the role of ABA in the treatment of pediatric feeding disorders and and how it might be the same or different from other approaches.
5:50 Dr. Vivian Ibanez: So you’re really right, Amanda. There are lots of different approaches and for very good reasons. Um, I always say to everyone that I have yet to see a feeding case, whether it’s total food refusal where the kid isn’t eating anything at all, or you have a child who’s food selective where maybe they’re they might be referred to as what we call a picky eater, where there’s only one reason contributing to the feeding difficulty. So, because for most of these kids, there’s usually more than one reason going on, um, that uh requires a lot of different providers to be in touch with the family. So, from a pediatric standpoint, you know, they’re gonna take a medical approach. They’re gonna ask questions related to is there anything internally going on that could be making feeding uncomfortable for this child? So in the case of a lot of kids who have, you know, who are not eating anything at all, they may be having really severe food allergies that no one really knows about. Um, in the case of a picky eater, their diet might be contributing to severe constipation. And if they’re very constipated, they feel very full very fast. So they’re not going to be very motivated to eat. Um, so that’s sort of the medical approach. But we also have to really take into account skills. So again, um, we don’t think about just even the skills required to take a drink or to eat or to chew. And so speech and occupational therapy have a really good lens to be able to take a look at the child from that standpoint. So is there perhaps low muscle tone concerns that are contributing to fatigue in the mouth? Um, if the child has only been exposed to liquids most of their life, we’re probably not going to expect that they know how to chew. And so there’s going to be concerns there. Um, so right off the bat, you already look at three different approaches there that are really critical to helping these children. Um, and but then you know, when it comes to behavior analysts in their role, what we see is that once kids have tried one of those approaches, in other words, we know the kid is allergic to eggs, so the medical answer is don’t give the kid eggs anymore. We know the child can’t chew. So the answer is we need to drop the texture and give them something easier. We find that for some kids, that’s just not enough. Meaning, even after they’ve exhausted all of these approaches, they’re still engaging in behavior that becomes really difficult for parents to manage. So a lot of our parents really describe meals as anxiety-provoking, where, you know, if you think about just the number of times we have to feed kids, you know, usually it’s, you know, three main meals, two snacks. Five times a day, a parent is becoming really stressed because they either have to, you know, work through tantrums or they have to prepare entirely separate meals and do very specific things and follow a very specific routine to get their kid to eat. That’s where we come in. Um, when kids have those ongoing behaviors despite having tried other approaches, our role is to basically figure out what exactly is going on in terms of the consequences or responses of that child’s behavior is contacting. Um, and you know, for most of the kids, research in ABA has shown that that tends to be a combination of escape and attention or breaks and attention. Um, so that’s really where we come in is once that child has kind of exhausted all these other approaches, we go in and we try to figure out what else we can do to change those consequences and motivate the child to engage in more adaptive or appropriate behavior.
9:24 Amanda Fullbright: So would you stop?
9:27 Amanda Fullbright: So would you say that every case um that you work with is a multidisciplinary approach?
9:34 Dr. Vivian Ibanez: I do think that, you know, years, if you had asked me, you know, maybe eight to ten years ago when I first when I first was kind of starting in this sort of area, if you had asked me whether that would be the case for all kids, I probably would have said no, because I used to have this perception that, you know, food selectivity was a little bit less severe and didn’t require as many kind of, you know, hands-on or input. But now, fast forward 10 years, not only have we published more studies that have focused on food selectivity, particularly in children with autism, but just the fact that eating is a complex process. No matter how you spin it, you know, you at minimum should always be getting medical clearance. Even if it’s going to be a child who it’s like, we think they can eat, you know, they eat 10 different foods, they don’t have any chewing problems. Um, I think it’s still good practice to kind of cross that off the list and just ensure that we haven’t missed anything. So I would say that at minimum, you know, you’re always at least involving a medical provider, but to the extent that you need specialized, you know, specialists like a pulmonologist, an allergist, and all that, that’s when you start to get into more maybe complex cases. Um I think there is a spectrum, but I also think that no matter what, if you’re going to approach feeding, it’s still really good practice to um involve at minimum a medical provider to clear the child.
1:06 Amanda Fullbright: So, how do you have any advice for how you’ve been able to successfully collaborate with all different kinds of other disciplines? I know that that it’s not always a strength of behavior analysts. It’s not something that we, you know, really go into in school and things like that, depending on our supervision. Maybe, maybe we didn’t get great models for that. Any advice?
1:29 Dr. Vivian Ibanez: It is hard. And I empathize with a lot of behavior analysts and other clinicians because I think I often take for granted the sort of setting that we have established here through our collaboration with Blue Sprig and the university system. So for me, it’s very simple on any given day to send a message to a dietitian and ask, hey, can you do a quick calorie count for this child? Their current weight is this. Do you think that they’re growing too fast? Do you think we need to back off a little bit or go up? And I realize that that is not a luxury that a lot of community-based providers have. So that being said, I’ve always encouraged clinicians that sometimes it just takes a lot of front work to get to know who in your community you can connect with. Because I have found that once you find a good medical provider, um, like a PCP that, you know, understands feeding difficulties, which may require getting training on how to explain sort of that approach and what we’re talking about when we mean that, um, it can lead to, I think, better collaborations in the community. But that’s not easy. And I recognize that. That’s gonna take work of, you know, calling, maybe visiting PCP offices and trying to educate them perhaps on what you’re asking for when you mean medical clearance. Because I have been in the situation where someone says, well, the doctor’s just gonna clear any kid. They’re gonna say, yep, the kid’s fine, it’s the autism, you know, that’s why they’re having the feeding difficulty. And sometimes we find out that it’s not just related to that situation. So um, along with having and taking time to kind of get to know providers in the community, I would also suggest that um collaborating or trying to get some sort of supervision or access to an expert where they can help you make paperwork. Because um, we’ve been fortunate in our collaboration here with Blue Sprig, where we’ve developed some really nice sort of models and decision-making tools that I think are excellent. Um, and what I have found is if you sort of put specific questions that are more prompted, you might get more answers. Back in the day, we used to say, okay, just get a letter that says they’re medically cleared. Well, that’s not going to tell you a lot of information. But if you change your form to have very targeted questions, now you’re putting the provider in a position where they have to respond more than just, sure, I’m medically clearing this child. Um, and like I said, in our collaboration internally here, we’ve been able to develop some of those forms. So I would encourage people who are maybe not necessarily working for Blue Spring and working for other companies to do the same thing where maybe they reach out to specialists and try to get some assistance on how to make appropriate forms that prompt people a little bit more specifically. That’s great advice. Thank you for that.
4:15 Andrew Blomstrom: So, in that past, uh and in that last question, you kind of hinted at this, but I was wondering if you could tell us a little bit more about um the pediatric feeding disorder program at the Florida Autism Center Specialty Clinic, uh, located at the University of Florida um in the Center for Autism and Neurodevelopment, otherwise referred to as UFCAN.
4:35 Amanda Fullbright: That is the longest name.
4:36 Andrew Blomstrom: Yeah, I know. It’s a mouthful. Ever.
4:40 Dr. Vivian Ibanez: Um, sure. So our program um started just a few years ago. I always say two because that first year was COVID year, and I feel like that’s kind of a you know, off year where there was a lot of other things kind of going on. But we’re really fortunate because we have a long history of a collaboration with Florida Autism Center that has kind of evolved over the years. And we were able to kind of take the support of the university system, which really wanted to provide and add specialized services to the state of Florida. So before we added this service, a lot of our families were having to basically make the decision to travel out of state. So that need, in combination with sort of the support of the infrastructure of Blue Sprig and Florida Autism Center, really allowed us to design a program that would be able to help families who had basically tried other approaches and still felt like, you know, my kid just isn’t eating the way that other kids are. Or I am so stressed out because, you know, I’ve tried speech, I’ve tried OT, I’ve tried nutritional interventions, and I’m still kind of feeling a little stuck. Um and so our services are intensive and short-term in nature, meaning when we enroll children into our program, we see them for 12 weeks with the goal of after 12 weeks being able to step them down to a one-to-one or community-based, like more traditional uh therapy. Um, so the goal is really to jumpstart. So to set a nice foundation, kickstart some of the feeding, and then basically follow them up until they become what we call an age typical feeder, meaning if they’re six, we want them to be able to eventually leave the program eating like any other six-year-old would. And that takes time, right? So I always tell families, I’m like, when you come in, it doesn’t mean that in 12 weeks your kid’s gonna be eating a steak or eating maybe in the way that you want them to, but the intensive program and the mission is to make a big start, kickstart everything, and be able to successfully transfer the care to the parent so that the parent can be an active participant in follow-up therapy. Um so while they’re in the intensive program, we’re working on skills like increasing their calories, reducing tube feedings, weaning them off of the tube. If they’re a more food selective, then we’re trying to increase to at least 16 different foods. Um then we’re also working on drinks separately because a lot of times we have kids who um have more challenges in one area than the other. And so we really have to take time to target those separately. Um, and then by the end, we really want to be the parent that’s driving the bus on this, that they’re the ones that are feeding the meals so that when we do follow-up, it’s the parents coming and continuing to serve as the feeder. Um, so it is it is a big commitment. You know, it’s 12 weeks, Monday through Friday, 9 a.m. to 4 p.m., five meals a day. A lot of parents refer to it as feeding boot camp a little bit. Um, but it really matches the need of these kids. We’re talking about kids who have very severe feeding challenges to the point where if they don’t get in for our services, they’re either going to continue to lose weight and need a tube placed, or they’re going to be at further risk of other nutritional complications. So we had a kid who came in and was having really severe uh bleeding in the gums because they were having a lot of dental problems from their severe oral aversion. And we don’t think about this, but the risk is if any of that blood goes into the bloodstream, like you’re talking about infections and then there are other sort of larger later consequences. So, you know, we’re really, I think, targeting kids who, you know, time is not in their favor, where they really need these services fast and they’re medically necessary at that point.
8:32 Andrew Blomstrom: You talked a lot about caregivers and parents and kind of their involvement. What are some of the strategies that you employ to involve the caregivers in the treatment process? And, you know, why is their participation? And you kind of hinted at this in the last question or answer, but why is their participation so important in this program?
8:53 Dr. Vivian Ibanez: Yeah, I always say I give a lot of credit, obviously to the kids. The kids do a lot of hard work in the program, but I really credit the parents. You know, the I always say that the role of a parent really cannot be overstated in terms of what our program requires. Um, so to begin, we do work with every single family to try to figure out their readiness for the program. So, you know, we we recommend that at minimum caregivers attend two hours a week, at the very least, of family guidance, um, starting right about from week two. That first week, we’re still kind of getting to know the child, developing rapport between the therapist and the child. Um, and of course, if there’s any barriers to that, we work with the families because we recognize that even two hours a week might be really challenging for some parents. But I always have to say that by the time they get to us, parents know what they’re looking for and they’re kind of at a point where they’re ready to do basically anything to get their kids to get better. And so we really, I always say kind of look out, but I think it matches the need of the medical necessity for these kids that are coming to us. Um, we also involve them at the start and ask a lot of questions about what their meals look like at home. So we really try to take sort of that um approach in terms of being sensitive to different, you know, cultural variations and food practices to really make them feel like they’re getting um goals met that are actually meaningful for their family. So, you know, I wouldn’t recommend, you know, an arbitrarily pick a bunch of foods when that’s not what the family eats. You know, we really want the kid to go home and participate in family meals. So right at the start, we make them feel involved by really allowing them to have a lot of input on what the goals are going to look like for their child. Um, and then like I said, they attend weekly. So they’re there observing through a one-way mirror, looking at what the process looks like. And then once we have identified an effective treatment, we’re also starting to do some research in our clinic to ask what types of feedback and training methods they prefer. So a lot of the literature says, you know, BST, and we know BST works, but are there specific parts that could make BST feel more or less acceptable to families? And so that’s something we’re starting to do as well, to be able to have parents come in and feel like they’re active participants and even picking the training method methodology that we use. Um, and then, you know, once they’re in there, it’s always really fun to see sort of that first moment where the parents, like, oh my gosh, like I can actually feed my kid and they’re not, you know, fighting me, you know. And so um they contact that reinforcer. And then I, you know, it what always happens, and we laugh about this, is that, you know, they say, all I want is for my kid to just leave eating like three foods. If you can just get them to eat three foods, I will call this a win. Well, once we’re at 16, then they want more and more eating steak by the end. And so we kind of sometimes have to remind them, you know, your kid just started doing this. We don’t want to push too much too fast. Um, but we really, I think, luck out because our parents are really great and, you know, our staff are also really great. At you know, developing rapport with them and keeping them really involved in the process.
2:05 Andrew Blomstrom: Awesome.
2:06 Dr. Vivian Ibanez: Yeah.
2:08 Amanda Fullbright: You said that there are 16 foods. And I’m just curious, how do you guys, in addition to some of the family dynamics and cultural considerations, which is awesome? Um, what other things do you, you know, use as variables to help you decide what are those foods? Like, do you work with a dietitian? Are you trying to make it well, you know, well-balanced meals and things like that? Like talk to us about it.
2:32 Dr. Vivian Ibanez: Yeah, that’s a great question. So when we say the 16 foods, at minimum we target all four food groups. So proteins, fruits, vegetables, and then grains or starches. Um, and not only like I said, do we get parent input, but sometimes you, you know, you hit the nail on the head right there, Amanda, where we really need a dietitian because we are not, as behavior analysts, experts in really knowing, you know, if a child has a severe protein deficiency, what are the ones that are gonna get us, you know, up to the goal faster? Or if the child has severe constipation, we don’t want to assume and just say, okay, we’re gonna, you know, load them with all these high fiber foods. Well, sometimes if you do too much, now you’re putting the kid in a position where they’re gonna have the opposite problem. And we don’t want that either. Um, so at minimum, we always involve the parent to start, and then we take that list and we get it cleared by a dietitian who we collaborate with through University Florida Health System. Um, they’re both, they’re really wonderful. We have a nice set of a nice collaboration going on there. And then, you know, for some of the more trickier cases, we may have to have more ongoing involvement. So it may not be as simple as here’s our list, do you think the list is good? Um, we sometimes get kids who can’t have a lot of sugar and we may not realize how much sugar is in fruits. And so that child has to be on a very low number of fruits. So maybe there’s six of the 16 foods, they may have more in other groups and the least number in in the fruit category. So we do often, you know, collaborate with a dietitian. And then as far as how much we’re giving them, you know, we don’t want to be in a position where we’re, you know, giving the child too much and they’re growing too fast. And so we also monitor all of our kids get weighed weekly. Um, for the kids who are coming in with a failure to thrive diagnosis, they’re getting weighed twice a week. And then we also track height. So we send that at the end of the week, we review all of those records. All of our RBTs are taking weights of everything that they serve, weights of everything that comes out to spill. We monitor all that, and then we report it in a weekly spreadsheet that goes to the dietitian. So a lot of work on that end. But they everything gets weighed here. There’s not a single gram that goes unnoticed. We even like if the child spills stuff on the shirt, we’ve even gotten like weights of another shirt to try to calculate the difference. So we really try to pretty we’re pretty meticulous about that.
4:56 Amanda Fullbright: Very precise. I mean, that’s awesome. Yeah, um, I’m just curious, is there a food group that you find is easier or or harder with most of the clients you’ve treated?
5:10 Dr. Vivian Ibanez: Honestly, the vegetables are always the hardest, right? But look, we’re not always it’s always vegetables. But then, and then if the child doesn’t have any restrictions in terms of fruits, I do think fruits tend to be a little bit easier because they are sweeter. Um, one of our graduate students in Dr. Tim Vollmer’s lab is actually looking at whether children have an easier time accepting foods that look more similar to their previous diet. So if the child is coming in and eating mostly white foods, like crunchy foods and things like that, um, are they more likely to experience sort of generalization where we don’t need to treat all of the foods if the foods look similar? Um, and you know, I think that we probably all can think about sometimes when we look at a food, if it looks like something we’ve tried, we we might be more likely to do that. So that’s kind of what he’s asking is do children um with feeding disorders also sort of gravitate more towards things that look familiar? Um, so we’ve started to do some of that work as well.
6:06 Amanda Fullbright: Yeah, that makes sense. Yeah. What’s the youngest child you’ve ever treated?
6:13 Dr. Vivian Ibanez: That I’ve so in my experience, I’ve I have treated kids as young as um eight weeks old when I had the experience at the Nebraska Medical Center where we had a collaboration with the NICU. Um here, Fastboard in our clinic, as we’ve started to set up services, we’ve had the youngest client around 15 months of age. Um, but I believe we’re currently evaluating a couple of kids because now we’re starting to develop collaborations with the NICU here as well. So we may start to see some infants on the younger side, which our staff get excited about babies.
6:47 Amanda Fullbright: So the little ones, yeah. That’s my my experience on a personal note. I I worked with uh a feeding specialist when my son was in the NICU, uh, was a pre-meat, and and that’s my experience, but he has not had a problem since eating.
7:02 Dr. Vivian Ibanez: No. We’re hoping to strengthen that collaboration because when you talk about like prevention and that sort of angle, you know, it does make you wonder how many of those kids, given that we know that if they are born a little bit on the earlier side, they might have early feeding difficulties. Well, if you get a behavior analyst in there, you know, earlier to coordinate with speech and lactation specialists and all of those, could we basically mitigate or prevent kids who go on who are going to have severe feeding difficulties? So we’re excited about that. Um, and you know, we really want to be able, I think, to expand the ages we serve. Although I’ll say that most of the time we’re getting three to six year olds is kind of more, I think, uh, the average in terms of the kids we see here. So yeah.
7:48 Amanda Fullbright: Are there any misconceptions or or myths about the treatment of pediatric feeding disorders in relation or in the context of ABA that you you come across? And anything you want to maybe clarify for our listeners?
8:02 Dr. Vivian Ibanez: You probably can already think of some of them, just because, you know, we are, you know, it goes without saying I think we all can, all three of us can acknowledge that I think right now, the field of behavior analysis, there are a lot of, you know, what someone might refer to as public relation concerns, right? There’s a lot of opinions out there and, you know, some sort of mixed um uh perceptions of what behavior analysts do. But when we narrow in on feeding, you know, I think that um unfortunately, you know, this is kind of like a sort of um, you know, I guess I’ll start by saying I want to acknowledge it’s hard to get training in feeding. There are very few places to go, right? And we have a lot of behavior analysts working in many areas where they don’t have a lot of access to sort of a place that can teach them what to do with feeding and what not to do. And so I think a lot of times without sort of intending to, there may be behavior analysts who might be, you may be practicing a little bit outside of their scope. And so um I think unfortunately, sometimes there’s situations where perhaps someone might take an article and read it and, you know, think that, okay, if I just, you know, keep the bite at the lips and I use this procedure, I should get these effects. And they may not realize that they’re sort of nuances or they may not think about the medical clearance process. And so I empathize with these clinicians because they’re tasked with serving the children that come in. And we know a lot of kids have feeding difficulties. And then when they go to the literature, most of the literature involves escape extinction. So now you’re kind of in this sort of difficult situation. What do you do when you don’t have a lot of places to refer the child? And the literature tells you that you should use escape extinction. Um, so I think uh that is often a scenario where I think it leads to sort of some misperceptions of what escape escape extinction looks like. You know, I’ve heard a lot of people say, you know, it’s force feeding, or you’re just, you know, shoving food into the kid’s mouth, right? And so I do want to clarify and say that in an appropriate setting with the appropriate sort of medical clearances and appropriate training, um, you know, the child always has a choice to refuse, right? So I always describe escape extinction to our families as we’re gonna place structure in place and we’re gonna keep the bite there for a predetermined amount of time. But at the end of the day, if your kid wants to sit there and hold out, we give them that choice, right? And our job then is to say, what else can we do to make this more effective? So I would say that I would just want to clarify that um when done in an appropriate setting by qualified behavior analysts, um, the child really always has a choice. And in our clinic, our practices, if in three days something isn’t getting better with that procedure, we usually make a pretty quick change. So we’re also not in a situation where we’re trying this and exhausting and you know, waiting the child out for days. I think sometimes people have this image where it’s like, you’re just sitting there for days waiting this kid out and hours and hours on end. But you know, we have quick meals. It’s 45 minutes, 10 minutes at a time. We take a break. Um, and in three days, if we’re not getting anywhere, we usually, at least in our clinical practice um under my supervision, we make a change after three days. So we’re not sitting there forever trying to wait the kid out. Um so one that I think I would want to clarify.
1:19 Amanda Fullbright: Thank you for that. Yes, yes, everyone has those um, you know, sometimes misconceptions. Sometimes, you know, like you said, that that is what might be happening, but perhaps it’s not what should be happening.
1:32 Dr. Vivian Ibanez: And I don’t blame a lot of people. I will say that I’ve done a lot of self-reflection of my own work. I there have been scenarios where I read articles and I understand the technological sort of description of what I’m talking about, but I can see now reflecting on um having had the experience here in Florida where we would travel to a lot of centers. You know, I used to always say, before I came to University of Florida, I basically lived in bubbles, the Kennedy Krieger bubble and then the Nebraska Medical Center bubble. And those are great bubbles, wonderful training, lots of resources there, but they’re not very representative of the most of most settings that BCDAs are working in. So when I got here, that was really the first time where I got to travel to different centers and actually see what BCBAs were up against in terms of the clients that they were serving and the needs and sort of how they would navigate. Like you said, it’s not easy to even do, you know, core care coordination in terms of a community-based provider. And there’s nuances to that procedure and that process. So I think I just I think I’ve learned to have more sort of self-reflection on making sure that when I’m writing a procedure and describing it, would someone in that setting actually understand what we mean when we say, you know, that we’re implementing this part of the procedure? Or would someone really understand what that setting looks like? And in our own self-reflection, to be honest, if you look a lot of the feeding articles, I would say that probably the answer is no, especially for a lot of the early work. I don’t think that people have been as clear about sort of all the medical clearances or all the setting. We kind of take for granted when you’re in those bubbles, you take for granted what you have and you don’t think about the things that other people don’t have to probably place more clarity. So in our work, we are really trying to be better about writing um more clearly so that behavior analysts and community-based settings can really have a good perception of what’s going on. And then two, we really are trying to dedicate research to interventions without escape extinction, not because it’s a bad thing or anything like that. And I want to clarify it truly, I’ve seen it be a life-saving procedure, but because clinicians need other things that they can do, right? And sometimes extinction is not possible. Dr. Vollmer has done a lot of talks on that where he says, you know, it’s a great tool and it, you know, we know it’s done a lot of great work, but it’s not possible. Sometimes it’s not appropriate. And then if you’re in that situation, then you need to have other options. So we’ve been trying to explore antecedent-based interventions to be able to increase the evidence for that so that clinicians can go to the literature and have a choice. And right now, I would say there’s not a lot of choice because most of it is weighted towards escape extinction. So I really hope that with self-reflection on how we’re describing these things, along with expanding research in these other areas, that hopefully within time we’ll be able to have a situation where clinicians do feel like they have a choice.
4:32 Amanda Fullbright: Yeah, I’ve really appreciated the work that’s been coming out of UF around, you know, alternatives to escape extinction. I know Dr. Vellmer has talked to the Bluesburg um staff and has done trainings with us on that. Um, I just I really appreciate it very much. As someone who has a little bit of a trauma history with implementing escape extinction myself, right? Um I really appreciate that.
4:57 Amanda Fullbright: Yeah, definitely.
4:59 Amanda Fullbright: So are there any other innovations in in your field of treating feeding disorders that you’re excited about or believe that are going to make a significant impact on the field?
5:11 Dr. Vivian Ibanez: I am really excited about the work that’s coming out in terms of focusing on autism and food selectivity for a few reasons. One, you know, we know with a lot of the data that’s coming out of the BACB, most behavior analysts are working in the autism, you know, industry or sort of with that population. And so we know that because most people are working with kids with autism and we know that food selectivity is quite prevalent, I think there’s been this push to better understand what do we mean when we say food selectivity? Because we’re not talking about picky eaters, you know, we’re really talking about a very different sort of um situation. And so where we’ve advanced is I think we’ve started to conceptualize food selectivity as another symptom or a core symptom of resistance to change or insistence on sameness. So I think back in the day, many years ago, when you thought about, you know, the core symptoms of autism and so to speak, we would think about, you know, rigidity with schedules or lining things up in a certain way. But now, fast forward, we’re really thinking, well, food selectivity falls right into that same category. You know, for a lot of these kids, they insist on wearing the same clothes, right? I had a patient in Nebraska, and if I don’t know if any of you have been to Nebraska, but the winters are brutal. It’s very, very cold, very, very windy. And this child would insist on only wearing the same shorts. And that’s, you know, counterproductive when you’re trying to take your child out in the cold and not, you know, prevent them from getting sick and all those things. So um, just like we think about that insistence on sameness, it’s no different when we get a child who eats the same food in the same way, the same color, shape, texture, and so space, so forth. And so because we’re now conceptualizing food selectivity in that way, I think now we’re starting to do more interventions to better understand how to reduce that resistance to change. And so in our lab, um, which in a few weeks, if anyone is in Florida and attending FABA, we will be presenting on sort of this choice-based intervention to treat food selectivity. And it was all in the absence of escape extinction. So we used sort of this matching law conceptualization to try to um stack the cards in the favor of the child choosing a healthier food over a what we called change-resistant food. So, you know, we have kids who sometimes come in, they’ll only eat goldfish in a certain way, or they’ll only eat yogurt over and over again. So, how can we take the um sort of matching law uh perspective to be able to motivate the child to choose away from something they’re familiar with? Um, and so I think that excites me. And then I think we’re also starting to really ask novel questions about why is it that these kids gravitate towards certain foods? Like, why does one kid want yogurt that’s only, you know, pink and another kid just wants orange foods? Is it the color for this kid? Is it the texture for this kid? Is it that it’s creamy? Is it that it’s soft? Is it that it’s sweet? So now we’re also asking things about stimulus properties. So I always tell my staff, you know, make a list of everything the kid, uh, of everything that describes that food. Is it sweet, salty? What about the temperature? What about the size, shape, visual, you know, all these properties? Because if we can start to understand which of those properties motivates the child, now we can develop better fading interventions that aren’t just arbitrary or based on, well, we think the kid probably likes the crunchy aspect. Well, what if we ask the kid and really try to do those assessments? Um, so I’m I’m really excited about a lot of the stuff that’s focusing on food selectivity because I think that that is probably the thing that most BCBAs tend to be up against when they’re taking clients in and trying to make decisions about what feeding programs to offer.
8:57 Amanda Fullbright: Could you just I know we’re running a little long, but I have another curiosity question. What is the difference? Where’s the line between picky eater and food selectivity?
9:08 Dr. Vivian Ibanez: Yeah, that’s a good question. So picky eating is typical right around the time that the child is two, when you know they become more independent. You know, they’re walking, they’re self-feeding, they know where the good snacks are in the pantry. Like my niece does this all the time. She knows exactly where the fruit snacks are stored, and she now is tall enough to reach for them. And so that’s right around the time where you start to see that happen and food preferences develop, right? So we all, I mean, we all love the sweet, you know, salty, maybe foods that aren’t as good for us. Um, and so what where we draw the line is if the child is approaching, you know, four years and over where they’re still not gravitating or eating other foods, like, and they don’t need to do it perfectly. You know, you always see the situation at dinner where it’s like finished, you know, they leave the broccoli for last on their and the parent has to be like, just take one more bite and then you can be done dinner. That’s typical. But what’s not typical is if that parent is exhausting a lot of different options just to get the kid to try one bite of a new food, now you’re talking about maybe a more challenging problem from a psychosocial perspective where the parent is feeling really stressed out. And then where we also draw the line is is it having medical um implications? So, you know, is the child having severe constipation because they’re only eating, you know, two to three foods and they’re not really meeting their daily needs. And that one gets tricky, Amanda, because I think those kids get missed because they’re growing fine. They look great on the outside. You know, sometimes they’re growing just like other kids. The problems are more internal, where that would require like blood work or other things. So I always say, you know, if they’re four and over and that parent still feels like my, you know, they can’t name the last time the kid ate in a vegetable, or they say, my child has eliminated an entire food group along with other health conditions. That’s where I think we’re starting to talk more about food selectivity, selectivity rather than picky eating.
1:09 Amanda Fullbright: Thank you for that clarification. That that that helps a lot. Yeah. Yeah.
1:17 Andrew Blomstrom: Thank you so much for all of the stuff that you have shared so far. I do have a question. So during this conversation, you shared lots of useful information on feeding. If our listeners wanted to find out more information like about your work or access additional resources related to pediatric feeding disorders or ABA, is there anywhere that you would suggest them kind of going to start to learn more about pediatric feeding disorders and/or ABA?
1:46 Dr. Vivian Ibanez: Yeah, so we, you know, obviously a lot of our work is published in probably most of the journals that BCBAs are contacting. So a lot of our work is in Journal of Applied Behavior Analysis, behavioral interventions. Um, we have some in behavior analysis and practice. So I would certainly start by looking there. And then we are in the middle right now of kind of revamping the website through Blue Sprig, and we hope to add sort of a frequently asked questions sort of section on there. So I would tell listeners to kind of keep an eye out for the developments on that website because that’s going to be very parent-friendly, but also clinician friendly, so that people kind of can learn a little bit about what we do, um, what services and trainings we offer. And then if they’re maybe thinking about whether a child should be referred, we’re hoping to have that information available soon. So that’s a little bit all in development right now, but hopefully that’ll be available um relatively soon.
2:38 Andrew Blomstrom: Awesome. Thank you very much. Are you ready to play question of the week?
2:46 Dr. Vivian Ibanez: I think so.
2:47 Andrew Blomstrom: Awesome. We have uh three questions we’d like to ask you. Two of the questions are the same questions that we asked all guests on the ABA unfiltered podcast. And then uh we’ll go ahead and do the third wildcard question.
2:59 Dr. Vivian Ibanez: But we’ll I’m a little nervous about the wild card.
3:01 Andrew Blomstrom: Yeah. We’ll go ahead and start with um some of the common questions. Okay. Um, you know, Amanda and I are both in the learning and performance development department, so we’re always, you know, trying to learn new things ourselves to kind of improve the learning process for our learners. And so we always like to learn about our guests and see what they’re learning. So I was wondering if you could tell us something new that you have learned recently. And this can be work or non-work related.
3:27 Dr. Vivian Ibanez: I’m gonna take advantage of it being non-work related because it is an exciting week here in Gainesville, Florida, because we are playing a rival or uh a team this weekend, Tennessee. And I recently just learned that we have not the UF uh gators have not lost a single home game since 2003. So it is a big weekend. I didn’t realize how long of a stretch we had. And I also realized that some people listening may be saying, Don’t say that because it’s you’re gonna change.
3:55 Amanda Fullbright: Not that one.
3:56 Dr. Vivian Ibanez: But we are rooting for the gators here this weekend. So So um that is a fact that I recently learned.
4:02 Andrew Blomstrom: Very nice.
4:04 Dr. Vivian Ibanez: So let’s hope that streak continues.
4:06 Andrew Blomstrom: Yeah. People might be uh sending you some emails if uh if not. So the next question, let’s imagine today, instead of 24 hours in a day, you’ve got 25 hours. How would you spend that extra hour?
4:25 Dr. Vivian Ibanez: Um honestly, I feel like I don’t get enough time to explore new recipes. So I often enjoy like finding a new recipe. Like I just got Chrissy Teagan’s baking book. So I probably, if I had an extra hour, I would find something new to try to bake or cook if I had the time. Usually it’s crushing to do the same thing for dinner because you feel like you don’t have enough time.
4:48 Andrew Blomstrom: Yeah, I don’t have time.
4:49 Dr. Vivian Ibanez: So I probably take time to do something a little bit um that I haven’t tried making. Awesome.
4:57 Andrew Blomstrom: We are also always trying to experiment.
5:00 Amanda Fullbright: Yeah. I made a new recipe yesterday, and my son so kindly told me it was garbage.
5:07 Andrew Blomstrom: So they’re so kind, aren’t they?
5:10 Dr. Vivian Ibanez: Honest with you. unknown 45:12 Yeah.
5:12 Andrew Blomstrom: My oldest will give us the thumbs up or thumbs down at meals. Sometimes it’ll go in there, but you’re always hoping for the thumbs up.
5:23 Dr. Vivian Ibanez: Yeah, my siblings always say that it’s like you never know what you’re gonna get. Like they’ll ask the kids, they’ll ask for a certain thing, and then they serve it, and it’s like, no, I actually want this. And then you just feel like you’re like, I don’t even know what you want anymore.
5:36 Andrew Blomstrom: Correct. Or, you know, they’ll like one thing uh today. This is my favorite thing ever. It’s like, okay, I’ll make it again. And then next time it’s like, why did you make this? I hate this.
5:44 Dr. Vivian Ibanez: It’s like which again, I mean, still, I mean, obviously, on the topic of feeding, like that’s why I think sometimes it’s hard to know when you should become concerned because like a lot of times it is a lot of these things are typical, right? So I often remind people and parents, I’m like, we actually might not be the program for you. Like what you’re doing is actually pretty typical. Yeah.
6:06 Andrew Blomstrom: Are you ready for question of the week?
6:10 Dr. Vivian Ibanez: I think so. Wild card.
6:13 Andrew Blomstrom: All right. The wild card question. Let me go ahead and start sharing my screen.
6:19 Dr. Vivian Ibanez: Okay. So I’ll tell you when to stop. Is that how the game works?
6:24 Andrew Blomstrom: Yes. So I just want to confirm, are you able to um see my screen?
6:28 Dr. Vivian Ibanez: Yeah, I can see it.
6:29 Andrew Blomstrom: Awesome. In a second, here I’m gonna go ahead and hit this play button, which is going to go ahead and start this uh wheel to spin. Whenever you’re ready, just go ahead and tell me to stop. Each one of these numbers is corresponding with a question in front of me. Um, and so we will see what our final question for you is. Are you ready?
6:49 Amanda Fullbright: I’m ready.
6:50 Andrew Blomstrom: All right, so I’m gonna go ahead and play. And whenever you’re ready, just tell me to stop.
6:59 Amanda Fullbright: Stop.
7:02 Andrew Blomstrom: Okay, question number three. If you could tell us the best advice you have ever received.
7:09 Dr. Vivian Ibanez: This is a this is an easy one. I’m glad we got this one. Um, so most recently, obviously, I said I’ve been working with Dr. Tim Vulmer, and the best advice I have received from him is surround yourself with good people. Because he always says that, you know, a lot of people um talk about the great work that we’re doing here, and they’ve admired and acknowledged, acknowledged his work. And he’s always said, you know, it really is representative of the fact that I just have such a good community. So I think I’ll say the same thing. Surround yourself with good people, have a good community, and you know, good things happen.
7:45 Amanda Fullbright: Awesome. I love that. Thank you for sharing that. Yeah. I also do want to point out that on our um our website with our CEU courses that we have a course that you did. It’s a recorded webinar um from a couple of years ago, but uh behavior analytic assessment and treatment of pediatric feeding disorders. So um if any of our listeners want to go there, um check that out and we’ll we’ll put a link.
8:10 Amanda Fullbright: Um, I know, I know. Here we are.
8:15 Amanda Fullbright: Well, thank you so much for taking time. I know you are very, very busy. Um, but you know, taking the time to talk to us and um disseminate this information to our listeners is is incredible. So thank you so much for your time. And I hope your gators win uh this weekend, even though this will be uh uh published after the game. Well, you know, uh I do hope to send you the good vibes this weekend.
8:42 Dr. Vivian Ibanez: Thank you, Andrew and Amanda. I do appreciate you. I know a lot of work goes into putting this on. So I also appreciate the invitation and all the work that you guys do to make this available.
8:51 Amanda Fullbright: Oh, well, thank you.
8:52 Amanda Fullbright: Thank you very much. Well, have a great weekend and thank you to our listeners, and we’ll see you next time.
8:58 Andrew Blomstrom: Bye.
8:59 Amanda Fullbright: Bye.
9:00 Andrew Blomstrom: If you or someone you know is looking for some CEUs, head over to https://bcbaceu.bluesprigautism.com/ and use the promo code podcast to get five dollars off any CEU in the catalog. A link to the site can be found below in the description. Thanks again for tuning in, and we’ll see you next time.

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