Journal of Developmental and Physical Disabilities (2019) 31:171–188

https://doi.org/10.1007/s10882-018-9652-7
ORIGINAL ARTICLE

Developing and Implementing a Telehealth Enhanced

Interdisciplinary Pediatric Feeding Disorders Clinic:
a Program Description and Evaluation

Racheal R. Clark 1 & Aaron J. Fischer 1 & Erica L. Lehman 1 &

Bradley S. Bloomfield 2

Published online: 3 January 2019

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Pediatric feeding problems are highly prevalent in the general population and report-
edly higher in populations of youth with disabilities. A variety of treatment approaches
and settings have been explored yet challenges with generalization to home and
community settings continue to be experienced. Telehealth enhanced interdisciplinary
feeding services are one response to these challenges. This study described a model for
outpatient feeding services serving clients with intellectual and developmental disabil-
ities within a coordinated health care model through a telehealth enhanced clinic.
Further a cost savings analysis demonstrated a savings in travel time and travel costs
relevant to receiving services. Practical recommendations for practitioners who are
interested in using telehealth enhanced services for pediatric feeding problems were
discussed.

Keywords Telehealth; feeding problems . Behavioral interventions . Generalization

Although feeding behaviors and skills are critical components of child development,
problems with feeding are one of the most prevalent conditions affecting children ages
birth to 18 (Lukens and Silverman 2014). Within this age group, the prevalence rate of
feeding problems is estimated to be 25% to 45% of the general population (Bentovim
1970; Lukens and Silverman 2014). From a broad perspective, in the event that a child
displays a variety of eating behaviors that have an adverse effect on their health and/or
psychological functioning (e.g., excessive consumption, inadequate intake, refusal), the
child would then be classified as having feeding problems. When the adverse effect

* Aaron J. Fischer
aaron.fischer@utah.edu

1
University of Utah, 1721 Campus Center Drive SAEC 3220, Salt Lake City, UT 84112, USA
2
University of Alabama, Tuscaloosa, AL, USA
172 Journal of Developmental and Physical Disabilities (2019) 31:171–188

rises to a clinically significant impact, the child could meet diagnostic classification for
a pediatric feeding disorder.
Feeding disorders are estimated to occur in 3% to 5% of children (Satter 1990) and
may include a number of presenting concerns. These feeding-related problems can be
conceptualized as a continuum from mild food selectivity (e.g., brand, texture, type,
etc.) to total food refusal (Silbaugh et al. 2016). Food selectivity typically presents
when a child consumes a restrictive range of food preferences based on texture, taste,
and other sensory characteristics (Field et al. 2003). Children who engage in food
refusal behaviors often consume an insufficient volume or variety of food necessary to
maintain age appropriate weight and height benchmarks (Binnendyk and Lucyshyn
2008; Field et al. 2003).
There are a variety of etiologies for pediatric feeding disorders. As a result,
a comprehensive assessment of pediatric feeding disorders will include an
evaluation of organic or medical causes as a possible explanation for the
severity of the feeding problems (Binnendyk and Lucyshyn 2008). Additionally,
behavior assessment is necessary to identify the topography of mealtime prob-
lem behavior. Disruptive mealtime behaviors can range from minimally disrup-
tive actions to highly aggressive behaviors that negatively impact the child’s
ability to eat. Across the continuum of pediatric feeding disorders, there are a
heterogeneous group of behaviors that can include turning the head, crying,
pushing away the food, eloping from meals, aggression, packing or expelling
food (Addison et al. 2012).

Feeding Problems in Children with Intellectual and Developmental

Disabilities

Although feeding problems and disorders are observed in the general population,
prevalence rates in populations with disabilities are much higher. Research has dem-
onstrated that among a sample (n = 91) of children with intellectual disability (ID),
ranging from four to nine years old, 97% of the children had at least one feeding
problem (Gal et al. 2011). These problems included aspiration (e.g., regurgitation or
swallowing difficulties), food selectivity, feeding skill deficits, food refusal, and
nutrition-related behavior problems (e.g., overeating). Results further indicated that
95% of children with mild ID (n = 25), 100% of children with moderate ID (n = 32),
and 96% of children with severe/profound ID (n = 34) displayed at least one feeding
problem. Across the sample, more than 90% of the children were shown to have
problem behavior related to nutrition, including inappropriate volume consumption,
food stealing, and pica.
Limited research has evaluated the comorbidity of feeding problems and intellectual
disability; however, greater scholarly work has discussed the prevalence of feeding
concerns relevant to disabilities co-occurring with an intellectual disability, such as
Down syndrome, cerebral palsy and autism spectrum disorder (ASD). Prevalence rates
of up to 80% of children with Down Syndrome have feeding problems as well (Calvert
et al. 1976; Pipes and Holm 1980). Feeding problems and disorders are also common in
populations with cerebral palsy, with research and surveys documenting between 58%
and 89% of individuals with cerebral palsy having feeding problems (Fung et al. 2002).
Journal of Developmental and Physical Disabilities (2019) 31:171–188 173

Specifically, gastroesophageal reflux disease (GERD) is common among the cerebral

palsy population.
Investigations have revealed the rate of GERD between 70% to 90% in children
with cerebral palsy who also may present with failure to thrive (FTT), food refusal,
small volume feedings, or vomiting (Del Giudice et al. 1999; Gustafsson and
Tibbling 1994; Reves et al. 1993). In a study with over 12,000 children ages five
months to three and a half years, with moderate to severe cerebral palsy, the most
powerful prognostic factors for survival included feeding and mobility skills
(Strauss et al. 1998). Furthermore, nutritional status has a greater influence on linear
growth during the preschool years for children with cerebral palsy (Fung et al. 2002;
Stallings et al. 1993a, b; Sullivan et al. 2002).
Based on a literature review by Ledford and Gast (2006), over half of individuals
with ASD also have behavioral and nutritional concerns related to feeding. Of those
children with ASD referred to an interdisciplinary feeding clinic, 62% exhibited
selectivity by type, 31% by texture, 15% exhibited an oral-motor delay which resulted
in mechanical difficulties (e.g., chewing, moving the tongue, and closing the mouth),
12% had dysphagia (i.e., difficulty swallowing foods), 12% displayed food refusal and
were not meeting nutritional needs (Aponte and Romanczyk 2016). In addition to the
aforementioned feeding difficulties, individuals with ASD engage in more challenging
mealtime problem behaviors. According to Schreck and colleagues (Schreck et al.
2004), ratings by parents of children with ASD resulted in higher total problem scores
on the Children’s Eating Behavior Inventory than that of parents of children without
ASD. Of the total sample, the participants with ASD were also observed to consume a
more limited variety of fruits, vegetables, proteins, dairy products, and starches.

Adverse Consequences

As a result, there are long-term medical and social implications for children
affected by food selectivity and food refusal with regard to an individual’s
physical health, cognitive functioning, or social and adaptive skills. Children
who engage in food refusal or food selectivity may experience weight loss or
gain, low energy levels, or medical complications (Bolte et al. 2002; Bosaeus
2004; Matson et al. 2009). More specifically, these adverse outcomes may also
include developmental delays (i.e., cognitive and physical), nutritional deficits,
exacerbated behavior problems, and limit the child’s engagement in social settings
(Bandini et al. 2010; Matson et al. 2009; Sharp et al. 2013).
When there is a limited number of accepted foods, there has also been an increased
risk for nutritional inadequacy (Bandini et al. 2010; Zimmer et al. 2011). Children who
have limited food acceptance also may consume several micronutrients at levels below
the recommendations set forth by the U.S. Dietary References Intakes guidelines
(2015), and less than the levels of peers with typical feeding behaviors (Bandini
et al. 2010; Cornish 1999; 2002; Zimmer et al. 2011). Diets that include extremely
low volumes of fruits and vegetables typically result in low micronutrient intakes, and
contribute to obesity, gastrointestinal function impairments, and chronic disease
(American Diabetes Association 2017; American Heart Association 2017; American
Institute for Cancer Research 2017; Taylor et al. 2016;). With regard to these adverse
174 Journal of Developmental and Physical Disabilities (2019) 31:171–188

consequences, earlier identification and treatment of feeding difficulties is critical and

may prevent or attenuate these problems.
For the family of children with a feeding disorder, the implications are significant.
Feeding difficulties are associated with the erosion of subjective feelings of maternal
competence (Radford et al. 1997), the burden of excessive stress that may threaten
quality of daily life (Suarez et al. 2014), and the consistent disruption of family
routines. Caregivers of children with chronic feeding problems report high levels of
stress (Greer et al. 2008; Kerwin and Reider 1994) and may feel personally responsible
for the disorder. The perceived inability of a caregiver to fill the responsibility of
providing nourishment can have profound effects on a caregiver’s feelings of self-
efficacy, self-esteem, and overall confidence in parenting (Farrow and Blissett 2006;
Powers et al. 2002). Research has suggested that mothers specifically may have high
levels of depression, anxiety, eating disorders, mood or personality disorders (Chatoor
et al. 1998; Coulthard and Harris 2003; Duniz et al. 1996; Lindberg et al. 1996; Whelan
and Cooper 2000).
Further, compared to parents of healthy children, parents of children with FTT
display more negative interactions with their children and other family members as
well as parental dysfunction (Singer et al. 1990). In addition, a link has been demon-
strated between oral-motor dysfunction and problematic parent-child interactions in
families of children with Down’s syndrome and feeding difficulties (Spender et al.
1996). Overall, there has been a negative correlation demonstrated between high levels
of parental stress and positive parent-child interactions (Crist et al. 1994; Darke and
Goldberg 1994; McKay et al. 1996; Powers et al. 2002).

Treatment Approaches

A large body of empirical research suggests that feeding problems such as food refusal
and food selectivity can be treated using behaviorally-based intervention strategies
(Kerwin 1999; Silbaugh et al. 2016; Volkert and Piazza 2012). In a review of behav-
ioral interventions for food refusal, all 38 studies included reported improvements in
oral intake, and more than half of the participants who received supplemental tube
feedings were weaned from these feedings (Williams et al. 2007). This finding was
replicated in a systematic review by Sharp and colleagues (Sharp et al. 2010), which
found that behavioral interventions for feeding resulted in an overall large effect (d =
2.46). The literature on behavioral feeding interventions typically involves multiple
intervention strategies or treatment packages. These interventions may include ante-
cedent strategies, consequent strategies, or a combination of both. Antecedent inter-
ventions include behavioral momentum, noncontingent reinforcement (NCR), simulta-
neous presentation, sequential presentation, and fading (e.g., stimulus, texture, brand).
The consequent behavior strategies that are commonly used include escape extinction
(EE), positive reinforcement, shaping, and differential reinforcement.
Prior to treatment, the involvement of a multidisciplinary team in the assessment and
treatment of feeding problems is warranted in order to develop the most appropriate
treatment plan (Clawson and Elliott 2014; Sharp et al. 2017). A comprehensive
assessment provides health professionals and caregivers with more accurate informa-
tion regarding the cause of the feeding problem and what steps should be taken to
Journal of Developmental and Physical Disabilities (2019) 31:171–188 175

prevent further issues. When underlying medical conditions are the primary contributor,
these need to be managed accordingly. If the presenting problem also indicates a
behavioral aspect then appropriate behavioral feeding interventions should be
considered.
A majority of pediatric populations presenting with feeding problems respond well
to clinician developed and implemented management strategies. The most common
settings that provide feeding interventions include hospital outpatient departments and
feeding clinics (Sharp et al. 2014; Werle et al. 1993). However, when children present
with more severe and life-threatening feeding disorders such as failure to thrive or
limited progress to weaning from a feeding tube, more intensive treatment options are
typically explored and pursued (Silverman et al. 2013; Sharp et al. 2017). Many
children will receive intensive behavioral interventions provided through in-patient
and day treatment clinical services.
Admission to intensive programs can be beneficial for these high-risk populations.
These benefits include the capacity to rapidly wean children from feeding tubes, access
to medical and dietary professionals throughout, and a highly-controlled environment
to make behavior change (Silverman et al. 2013; Sharp et al. 2017). Intensive programs
also typically involve multiple feeding sessions per day and a treatment team approach
in which multiple providers (e.g., psychology, speech, occupational therapy, nutrition)
deliver services concurrently (Sharp et al. 2017). This high frequency of feeding
sessions can result in rapid improvement in behavior (e.g., volume, variety, mealtime
problem behavior) and offer greater monitoring of the child across multiple providers
(Milnes and Piazza 2014).
Although there are many benefits to intensive services, it may not be appropriate for
all referrals. Many individuals with feeding problems can benefit from outpatient
services on a less dense schedule. Less intensive clinic services can include individual
or group intervention, or outpatient services consisting of one-to-one sessions, once or
twice per week with a therapist. Many of these outpatient services may better serve
patients who present with less severe feeding difficulties including some with food
selectivity, texture aversion, and services following discharge from an intensive pro-
gram. These outpatient programs typically consist of a trained professional providing
intervention services for an established number of weeks and weekly hours and training
the client’s caregiver on the intervention protocol in order to facilitate generalization of
improved feeding outcomes.

Telehealth Approaches

Despite the advantages of these approaches, many families encounter barriers to

effective service provision. There are challenges with accessing experts in the assess-
ment and treatment of pediatric feeding disorders due to few providers with the
specialization, and fewer interdisciplinary clinics (Silverman 2010). In light of this
challenge, videoconferencing may be a desirable modality for the assessment and
treatment of feeding problems (Silverman 2010). A telehealth approach would allow
for natural observations to occur within the home environment during assessment and
treatment and alleviate the burden of travel to clinic appointments for families
(McGrath et al. 2006), allowing greater access to services for those living in rural
176 Journal of Developmental and Physical Disabilities (2019) 31:171–188

and underserved areas. Additionally, clinicians can identify aspects of the home
environment, including parent-child interactions, that might contribute to feeding
problems and promote generalization of more socially valid feeding skills and
behaviors (Silverman 2010).
Telehealth approaches are becoming more frequently used in a variety of fields such
as medicine (AACAP 2008), behavior analysis (e.g., Fischer et al. 2017), or school-
based consultation (e.g., Gibson et al. 2010; Fischer et al. 2016a, 2018). This telehealth
approach has recently been implemented to increase variety and volume of
nonpreferred foods in a child with avoidant/restrictive food intake disorder (ARFID;
Bloomfield et al. 2018). In this telehealth demonstration, a behavior consultant trained
the caregiver to implement a behavioral feeding intervention package through video-
conferencing. In addition to positive child outcomes, the caregiver demonstrated high
levels of procedural integrity and high levels of acceptability of the telehealth approach
to improving the child’s feeding behavior. In a different telehealth demonstration,
Peterson et al. (2015) evaluated differential reinforcement strategies to increase self-
drinking for two children with feeding disorders who resided in different states. The
telehealth application was effective and efficient in this study due to the great distance
between the clients and the clinic.

Purpose of Study

Pediatric feeding problems occur in the general population at a relatively high preva-
lence rate, with higher rates among children with disabilities. Feeding clinics through-
out the country provide crucial services to this population through various programs;
however, many clinics have difficulty reaching individuals in remote or underserved
areas. Additionally, positive feeding outcomes achieved in clinic may not generalize to
other ecological valid settings such as homes, schools, or day treatment facilities
without follow-up support. The purpose of this study is to describe a model of an
outpatient feeding program serving clients with intellectual and developmental disabil-
ities within a coordinated health care model through a telehealth enhanced clinic. This
study also presents a cost analysis and provides practical recommendations for practi-
tioners who are interested in using telehealth enhanced services for pediatric feeding
problems.

Program Model

The University of Utah Neuropsychiatric Institute (UNI) Neurobehavior Healthy

Outcomes Medical Excellence (HOME) program provides services to individuals
across the lifespan with various developmental disabilities (i.e., genetic disorders, birth
trauma, autism spectrum disorders, and brain injuries) through a coordinated health care
model. This model strives to meet the medical and mental health needs of the
individuals it serves, while acknowledging family and caregiver needs as well. At the
UNI Neurobehavior HOME program, clients may receive outpatient general medicine,
Journal of Developmental and Physical Disabilities (2019) 31:171–188 177

psychiatry, therapy, dietary, behavioral health, and case management services. In order
to be enrolled to receive care at the UNI Neurobehavior HOME program, clients must
receive Utah Medicaid funding, have a developmental disability, have mental health or
behavioral challenges, and be interested in receiving both primary medical care and
mental health treatment through the program.
In order to address the feeding problems many patients experienced, the Interdisci-
plinary Pediatric Feeding Disorders Clinic was established within the UNI
Neurobehavior HOME Clinic in 2015. The feeding clinic was designed to provide
services to individuals receiving care at the UNI Neurobehavior HOME program as
well as individuals in the community through research studies and grant funding. The
feeding clinic is directed by a Licensed Psychologist, coordinated by an advanced
school psychology doctoral student, and staffed by graduate students from the Univer-
sity of Utah’s Educational Psychology, Special Education, and Speech Language
Pathology Programs. UNI Neurobehavior HOME providers (i.e., treatment teams) refer
patients to the feeding clinic when a variety of feeding problems are indicated. Typical
referrals received may pertain to mealtime behaviors, inflexible brand preferences,
texture aversion, inadequate intake, or restrictive intake.
Upon receipt of referral, the feeding clinic coordinator schedules an intake visit with
the client’s caregiver. Prior to the visit, the UNI Neurobehavior HOME feeding clinic
procedures are outlined for the clients and caregivers over the phone, and an intake
packet (along with several other initial forms) is emailed to the family. The clients and
caregivers are asked to complete the intake packet along with a three-day food diary
detailing the client’s consumption of food and drink during those days, and record a
home-based mealtime video prior to the intake visit. The video is uploaded to a shared,
Health Insurance Portability and Accountability Act (HIPAA) compliant cloud storage
drive and viewed by the feeding team in order to see how feeding difficulties manifest
in the home setting. At the initial visit to the UNI Neurobehavior HOME feeding clinic,
the intake assessment is conducted by an interdisciplinary team including a speech and
language pathologist (SLP), occupational therapist (OT), nutritionist/dietitian, and
behavior specialist.
As part of the initial assessment, the SLP and OT meet with the child and caregiver
together to conduct an evaluation of relevant areas. The SLP assesses the child’s
anatomical structures and physiological functions that are related to speech and feeding
as well as the safety of the child’s swallow. They also inquire about any dental work the
child had that could interfere with oral consumption. During this time, the OT conducts
structural observations in order to evaluate the child’s range of motion, tone, and gross
and fine motor skills as they relate to mealtime. Once the SLP and OT have concluded,
the behavior specialist joins the family to conduct a semi-structured interview of
developmental and feeding history as well as current concerns including inappropriate
mealtime behavior.
Simultaneously, the nutrition/dietitian is present to gather information about the
current food profile along with historical and expected growth rates. Overall, the
comprehensive assessment determines if the individual’s current feeding difficulties
(e.g., food selectivity, food refusal, rumination, etc.) are due to chew/shallow issues,
behavior problems, and/or sensory sensitivities. Following the assessment, appropriate
178 Journal of Developmental and Physical Disabilities (2019) 31:171–188

referrals to other providers at the UNI HOME clinic may be made if additional
assessment services are warranted (e.g., a modified barium swallow study). Treatment
procedures will then be explained to the caregiver, and in the case the family is not
referred to another provider, they will be placed on the waiting list to receive behavioral
feeding treatment that may occur via telehealth or in the clinic.
Clients who go on to receive behavioral services are typically individuals who
present with mild to moderate food selectivity and/or inappropriate mealtime be-
havior including head turns, mouth covers, aggression, self-injurious behavior,
negative vocalization, elopement, and property destruction. For individuals who
received recommendations requiring involvement from other disciplines, a co-
treatment approach is organized in which two of the providers will simultaneously
work with the clients in order to target goals that affect both disciplines. For
example, the nutritionist and the behavior specialist might collaborate in order to
increase the client’s consumption and ensure they are meeting the appropriate
nutrition recommendations. Prior to initiating behavioral interventions, the compre-
hensive report is provided and discussed with the family in order to provide
clarification on next steps and answer any questions regarding results and
recommendations.
For clients referred to receive behavioral intervention for feeding problems, the
caregiver is contacted as soon as a student clinician becomes available to schedule
services. In clinic sessions are scheduled on the day of the week that the feeding clinic
operates, while telehealth sessions have greater flexibility with regard to scheduling.
All therapists conduct feeding interventions under the supervision of a behavior analyst
and licensed psychologist with expertise in the assessment and treatment of pediatric
feeding disorders. For sessions that are conducted via telehealth, clinicians are required
to obtain consent for filming from clients in order to record and upload their sessions to
the HIPAA compliant platform used by the university. All clinicians either have a
bachelor’s or master’s degree and many are currently receiving graduate training in
behavior analysis or psychology.
All feeding interventions are selected based on the presenting problems of the
participant (e.g., rumination, food-refusal, maladaptive mealtime behaviors including
difficulties with self-feeding or remaining seated at the table) and are based on
evidence-based practices. The intervention protocols are developed by combining
clinical expertise, scientific research, and patient/family care values. These interven-
tions include differential reinforcement, shaping, extinction, overcorrection, prompting,
fading and contingent access.
The treatment services are provided through an outpatient model with weekly or bi-
weekly visits that may occur at the UNI HOME clinic or via telehealth. At the outset of
treatment, caregivers sign a service agreement that outlines clinic policies and proce-
dures and explains the treatment process to children. Regardless of the modality
selected for service delivery, feeding intervention services are typically conducted over
the course of an 8- to 12-week period which is informed by progress, attendance, and
the parent implementation consistency and fidelity. Each session is generally scheduled
for a duration of 50 min, and the role of the interventionist is faded from the clinician to
the caregiver across sessions. By the end of the treatment period, the caregiver will be
expected to implement intervention procedures with limited to no support from the
clinician.
Journal of Developmental and Physical Disabilities (2019) 31:171–188 179

Telehealth Enhanced Services

Some clients are well-suited to receive intervention services remotely; either

initially or subsequent to receiving in-clinic services largely based on intensity
of behavior problems, the parent’s level of comfort and previous experience with
behavioral interventions, the extent to which different settings impact motivating
operations for various adaptive and maladaptive behaviors, and the client’s
distance from the clinic. Prior to treatment, all clients are required to attend
the in-person intake appointment in order to ensure the other providers are able
to collect the necessary assessment procedures (i.e., the SLP is able to thorough-
ly observe the client’s chewing and swallowing during consumption). After the
initial assessment session, observations of the client are conducted in the home
setting through remote observation technology (i.e., web-based camera and
videoconferencing). The observations target meals in the individual’s natural
environment, while limiting reactivity of an observer that tends to occur in
contrived clinic observations.
During telehealth sessions, the therapist conducts the sessions from a dedicated
telehealth office under the use of the secure network provided by the University of
Utah. The parent-child dyad join the sessions from their own homes via a device
with internet access, webcam, and microphone. Typically, parents use a tablet or
cell phone to access the secure telehealth platform. During the sessions, the parent
implements the behavioral feeding intervention under the therapist’s direction at a
dinner table. Sessions are remotely observed to monitor progress and monitor
treatment integrity. Performance feedback is provided to the interventionist (i.e.,
the caregiver) through videoconferencing, using a behavioral consultation frame-
work (Bergan and Kratochwill 1990). If the caregiver does not respond to the
behavior skills training to implement the feeding treatment, services will be
offered in the clinic with a trained therapist implementing the intervention. These
clinic-based services offer in-person modeling with the client, which is not an
option when using telehealth. Once feeding goals are achieved in the clinic
setting, the intervention is generalized to the caregiver, at home, using telehealth
technologies.
The clients who have benefitted from the telehealth services thus far have
been between the ages of 4 and 10, have had the intervention implemented by
a parent, and have been from families who have an annual income that falls
within the average to lower than average range. In total, 14 clients, which
included 10 males and 4 females, were served via telehealth. Clients had
previous diagnoses of autism spectrum disorder, developmental disability, or
intellectual disability. Each client received between 5 and 13 sessions through
this modality, with the majority of these clients receiving between 8 and 10
sessions. Parent training services have also been delivered through telehealth
without the client’s direct involvement. Clients served through telehealth have
made significant gains towards their individualized treatment goals. For exam-
ple, by the end of telehealth-based treatment, one family’s three children
engaged in reduced disruptive behavior during mealtimes, one client consumed
fruits and vegetables on a more consistent basis, and another client consumed a
larger variety of brands.
180 Journal of Developmental and Physical Disabilities (2019) 31:171–188

Cost Analysis of Telehealth Feeding Services

We conducted a cost analysis to determine the dollar amount families saved by

receiving feeding services via telehealth through the UNI HOME clinic. Although
reduced cost is typically considered a benefit of telehealth service provision, the
majority of current cost analysis literature in telehealth has been conducted in the
medical field (Armfield et al. 2012; Russo et al. 2016). Thus, we sought to provide
evidence of cost savings for behavior analytic service provision. To complete this
analysis, we calculated precise costs and considered the practical benefits this form
of service provision offers. Additionally, verifying substantial cost savings may also be
helpful as more providers consider offering services through this modality and must
estimate the anticipated benefit offered to patients in justifying any overhead costs.
We began the analysis by calculating the distance, in miles, from the home of the
clients who received services through telehealth to the clinic where they would have
received face to face services. The distance was multiplied by two to account for travel
to and from the clinic for each session, and that number was multiplied by the total
number of sessions that client received via telehealth. The cumulative number of miles
clients who received services via telehealth would have driven to receive services in the
clinic was calculated by adding the total number of miles for all clients served via
telehealth. In order to calculate costs for the total number of miles, the average price of
gasoline per mile was estimated at (Internal Revenue Service 2017) based on the
mileage rates for 2018.
Across eleven clients that were served via telehealth, each client received an average
of 10 sessions via telehealth and lived an average of 39 miles away from the clinic.
Considering the mileage both to and from the clinic, in total, the amount of money
these 10 clients saved in fuel costs was $3738, or about $375 per family. Additionally,
because the clinic was not required to provide technology infrastructure to provide
services via telehealth, and families simply received these services on a device they
already owned, the clinic did not need to consider how these cost savings related to the
money the clinic would need to invest in the acquisition of telehealth infrastructure.
While it was not possible to calculate the amount of time saved by circumventing
travel to the clinic due to variability in traffic and driving routes, it is also a reality that
families saved a significant proportion of time by eliminating travel time spent while
commuting to the feeding clinic. Future research should consider conducting further
analysis to evaluate the cost and time benefits of feeding services through telehealth.
Additionally, although many clients benefitted from services, it is difficult to compare
benefits to costs due to the wide variability in targeted goals and outcomes. However,
telehealth services were effective for clients in the sense that services did not need to be
transferred to the clinic for any clients, and all individuals were effectively served in the
home setting.

Case Example

To describe clinic procedures and highlight the social validity of providing services via
telehealth, the section below outlines the assessment and treatment services for a
hypothetical example that approximates clients UNI HOME clinic served in the past.
Journal of Developmental and Physical Disabilities (2019) 31:171–188 181

Muhammad was a nine-year-old client with an intellectual disability and several

symptoms associated with autism spectrum disorder who was referred to the feeding
clinic by his primary care physician in order to address his limited food consumption,
target his limited brand flexibility, and to increase food variety. Muhammad also
engaged in a variety of maladaptive mealtime behaviors including crying, spitting
foods out onto the table, and elopement. These behaviors, coupled with his limited
brand flexibility and the reduced variety of foods he consumed interfered with his
family’s ability to dine at most restaurants, go on vacation, or attend family gathering.
At Muhammad’s intake assessment, the interdisciplinary team concluded that his
feeding difficulties were a result of his learning history rather than attributable to any
deficits in his ability to chew or swallow. Thus, Muhammad was placed on the waiting
list to receive behavioral feeding services. Three weeks later, the graduate student
clinician assigned to the case scheduled an initial visit with Muhammad and his
caregiver for 5:00 pm on Wednesdays. This time was selected because it closely
approximated the family’s meal time, and it allowed enough time for Muhammad’s
father to prepare dinner for his older siblings. The first session was devoted to pairing
the clinician as a social reinforcer and building rapport, while the second and third
sessions were spent probing non-preferred foods and starting shaping procedures.1 The
graduate student therapist taught Muhammad’s father how to implement the procedures
and use the data sheet so that he would be able to continue targeting feeding goals
during home sessions. The first two shaping sessions progressed smoothly and Mu-
hammad met his feeding goals across those sessions. Muhammad complied with the
clinician’s instructions, demonstrated a positive affect throughout the sessions, and
expressed excitement to be engaging feeding behaviors to take a turn playing the card
game his father brought to the session. To ensure the potency of the reinforcer,
Muhammad’s father only let him play with the card game during feeding sessions
(both in clinic and at home).
By the fourth session, Muhammad’s father reported that each time he implemented
feeding sessions at home, his efforts were thwarted by Muhammad’s mother or older
siblings and Muhammad was not engaging in the behaviors he had mastered at the
clinic by the second session. His other family members did not appear to acknowledge
and respond appropriately to the more focused attention on Muhammad during meal-
times, and it was also becoming more challenging to drive the thirty minutes to and
from the clinic while balancing other family obligations. Muhammad’s father reported
that he was stressed and concerned; he thought it may no longer be feasible to continue
the services. However, he thought Muhammad was already benefiting from the services
a great deal, and expressed enthusiasm that he and his family may be able to take a
vacation or attend a family function in the near future.
To ameliorate these problems, the clinician recommended changing the format of
sessions to take place via telehealth so she could work with the family remotely during
mealtimes. That way, other family members could learn how feeding services worked,
and facilitate improved outcomes for Muhammad. The family had a tablet they were
able to use during telehealth sessions. The graduate student clinician instructed
Muhammad’s father to set the tablet up on the table so she could see him and Larry

1
See Bloomfield et al. (2018) and Fischer et al. (2015) for more information about shaping procedures for
feeding.
182 Journal of Developmental and Physical Disabilities (2019) 31:171–188

during sessions. The clinician also told Muhammad’s father he could use headphones to
communicate with her on the HIPAA compliant platform the clinic used for telehealth
services. Muhammad’s father was relieved there was a way to continue receiving
services without driving to the clinic and in the setting that continued to be the most
difficult for Muhammad. He expressed his gratitude for the clinic’s flexibility, and
informed Muhammad’s mother and older siblings about how services would proceed
and how everyone’s help would be critical to Larry’s success.
Once telehealth sessions began and Muhammad was able to see the clinician on
the tablet, his behaviors started to approximate the topography and frequency he
engaged in at the clinic. Having the tablet at the table reduced the likelihood other
family members would disrupt the session or inadvertently disrupt the contingencies
that operated on Muhammad’s behavior. By the eighth session, the initial goals had
been largely achieved–Muhammad was consuming several other brands of preferred
and non-preferred foods, and his family was able to attend a recent family dinner for
Muhammad’s grandmother’s birthday. While Muhammad’s father was satisfied with
the outcomes, he expressed concern that when the school year ended, the family
routine could be affected and Muhammad’s challenging behaviors could reemerge.
Empathizing with the concern, the clinic scheduled two follow-up sessions to take
place one month and three months after the final session.

Considerations

Practitioners and researchers who are interested in providing feeding services through
telehealth should be encouraged regarding the ease in setting up and using those
technologies for feeding assessment and treatment in populations that are remote and
underserved or that have complex healthcare needs and developmental disabilities.
Individuals who use telehealth for service provision can feasibly and efficiently develop
the practice infrastructure (i.e., hardware and software requisite to this modality of
service provision); however, they should be familiar with some practical and ethical
considerations prior to conducting feeding supports through telehealth.
First, practitioners and researchers should receive high-quality training on feeding
interventions and telehealth practice, which adheres to a competency-based training
model (Hatcher et al. 2013) that incorporates behavioral skills training (Parsons et al.
2013). Training for feeding interventions typically occur through workshops at pediat-
ric psychology, applied behavior analysis, and feeding specific conferences. Individuals
who are interested in providing feeding services should also consider contacting
institutions of higher education and regional training clinics that offer opportunities
to train and practice using feeding interventions with children and adolescents.
Telehealth training is available through most commercially available videoconferencing
platforms. These trainings include user manuals, frequently asked questions, and video
content. Further, individuals who want to use telehealth should refer to the literature
where a variety of books (Luiselli and Fischer 2016; Luxton et al. 2016), articles
(American Psychological Association 2013; Grady et al. 2011), and book chapters
(Fischer et al. 2017; Wangelin et al. 2016) present best practice considerations.
Individuals who provide feeding services through telehealth should be mindful they
Journal of Developmental and Physical Disabilities (2019) 31:171–188 183

practice within their competence and actively participate in training and professional
consultation with experts when necessary.
Second, when conducting feeding work, in general, teams must be comprised of
individuals from multiple disciplines working in an interdisciplinary fashion–
collaboratively and client driven (Sharp et al. 2017). If practitioners provide feeding
services without insight from related service providers, they run the risk of harming the
client. For example, if a child received a swallow study from a speech and language
pathologist, and the assessment indicated issues with aspiration with certain food
textures, the behavior health provider would delay or substantively modify treatment
to protect the welfare of the client. Typically, behavioral feeding services should not be
initiated until the client is medically cleared (i.e., there is no organic reason for the
feeding problems). Further, if the client has a medically complex circumstance, a more
intensive service delivery model may be necessary.
Third, when providing telehealth services, it is critical that practitioners are practic-
ing within the ethical guidelines set forth by their governing organizations. Since
feeding clinics typically include an interdisciplinary team, all members should refer
to their relevant ethical code(s) and ensure that services provided through telehealth
meet all standards. For example, when approaching feeding problem assessment and
treatment as a behavioral health provider, specifically as a licensed psychologist, the
individual would consult the APAs guidelines for ethical telepsychology practice (APA
2013). The APAs guidelines highlight the need to protect client confidentiality, ensure
privacy, and guarantee a consent process for telehealth services. Dart et al. (2016)
provide a comprehensive overview of legal, regulatory, and ethical issues during
telehealth practice and highlight key considerations for practitioners and researchers.
Fourth, and related to previous considerations regarding competency and
confidentiality and privacy, providers who use telehealth must be vigilant they
consider the type of software and hardware they use. When deciding which software
to conduct telehealth, practitioners should consider features that allow for robust
collaboration and interaction as was as being explicitly HIPAA compliant. Fischer
et al. (2016b) discuss features that should be included in telehealth software: on-screen
document sharing, group videoconferencing, instant messaging, recording capabilities,
integrated cloud storage, and legal compliance. Besides software, providers who use
telehealth need high quality hardware that maximizes screen size, picture and sounds
quality, and processing speed. Additionally, bandwidth (the rate at which data is
transferred across the internet) needs to be high enough (typically download and upload
speed at or above 50 Mbs) to facilitate videoconferences, avoid technical issues such as
dropped videoconferences, pixilated images, or sound/picture lag.
Fifth, despite the strong research support for behavioral feeding interventions, many
practical aspects such as maintenance and generalization, social validity, and applica-
tion are less apparent in the literature. As mentioned previously in this paper, mainte-
nance and generalization of skills, especially in a client’s home settings are not typically
targeted, which might have been due to the intrusiveness of observations. With the
advent of contemporary videoconferencing technologies practitioners have the ability
to virtually join families in their homes, providing services in the natural environment.
The ability to provide services in the home may promote generalization and reduce
recidivism for future feeding services. Practitioners and researchers must also consider
the social validity of their interventions, especially since parents or caregivers will be
184 Journal of Developmental and Physical Disabilities (2019) 31:171–188

facilitating services after telehealth sessions end. The ability to consult and provide
performance feedback to parents or caregivers through telehealth promotes generaliza-
tion of skills across behaviors (Bloomfield et al. 2018). While severe feeding problems
represent a large proportion of the feeding interventions literature, there is a need for
more research focusing on other less severe applications of feeding, especially food
selectivity.
Finally, a practical challenge clinicians face delivering services through telehealth is
billing. Telehealth services are not ubiquitously reimbursed through private and public
insurance. Currently there are state-by-state differences, inconsistencies in which
billing codes should be used, what services are covered, and what administrative steps
are needed to provide services. These barriers limit the ability of practitioners to
provide services to all individuals, regardless of their location. As telehealth continues
to become a mainstream part of service provision cross fields, it will be important for
policy makers and insurance providers to support the use of telehealth and fund those
services for a variety of evidence-based applications.

Conclusion

Considering the prevalence of pediatric feeding problems and the high prevalence rate
of these problems among children with intellectual and developmental disabilities,
feeding interventions are a crucial service that must be available, despite physical
distance from the point of clinical service provision. Telehealth feeding services
provide parents and caregivers with access to consultation and interventions for a less
acute, but prevalent population of individuals with feeding problems. The telehealth
application in a feeding clinic provides practitioners with the ability to support skills
generalization in the home by transitioning services into the home setting, or by
consulting with the family entirely through telehealth. Additionality, using telehealth
for outpatient feeding services saves families monetarily due to reduced or removed
travel costs, as well as their time traveling to and from clinics. Feeding clinics across
the country should consider developing similar telehealth infrastructure and provide
continuums of accessible feeding services to individuals in traditionally underserved
areas or as a way to promote generalization of skills in non-clinic settings.

Compliance with Ethical Standards

Funding The telehealth enhanced program described in this manuscript was funded in part by the Autism
Council of Utah.

Ethical Approval All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent was obtained in this study for all human subjects.

Conflict of Interest On behalf of all authors, the corresponding author states that there is no conflict of
interest.
Journal of Developmental and Physical Disabilities (2019) 31:171–188 185

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps
and institutional affiliations.

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