BEHAVIOR

10.1177/0145445503259833
Kuhn, MatsonMODIFICATION
/ ASSESSMENT /OF
September
FEEDING 2004

Assessment of Feeding and Mealtime

Behavior Problems in Persons With
Mental Retardation
DAVID E. KUHN
JOHNNY L. MATSON
Louisiana State University

Feeding and mealtime behavior problems are commonly observed among individuals with
developmental disabilities. These problems include, but are not limited to, food refusal, food
selectivity, mealtime aggression, rumination, pica, and insufficient feeding skills. Difficulties of
this type can be associated with life-threatening consequences of other serious health-related
problems. Because of the nature of these problems and the lack or accurate client self-reporting,
an interdisciplinary assessment in addition to a thorough behavioral assessment is recommended
to ensure the best quality of care. This article discusses the role of the various disciplines, and the
types of behavioral assessments that are currently being utilized by clinicians and researchers.

Keywords: feeding; mealtime; behavior problems; mental retardation

Individuals diagnosed with mental retardation have a higher prev-

alence of comorbid disorders and behavior problems than do the gen-
eral population (Borthwick-Duffy, 1994; Matson & Barrett, 1993).
One area of concern among this population includes feeding and
mealtime behavior problems. Although problems such as food refusal
and rumination are often associated with infants and children
(Johnston, 1993; Parry, 1994; Riordan, Iwata, Finney, Wohl, & Stan-
ley, 1984), these problems are also prevalent among older individuals
with mental retardation. Rogers, Stratton, Victor, Kennedy, and
Andres (1992) estimated that 6-10% of individuals diagnosed with
mental retardation living in institutional settings engage in rumina-
tion, and on a larger scale as many as 80% of individuals diagnosed
with severe and profound mental retardation have a serious problem
related to feeding (Perske, Clifton, McClean, & Stein, 1977).
BEHAVIOR MODIFICATION, Vol. 28 No. 5, September 2004 638-648
DOI: 10.1177/0145445503259833
© 2004 Sage Publications

638
 Kuhn, Matson / ASSESSMENT OF FEEDING 639

Feeding problems such as rumination, vomiting, pica, food refusal,

and inadequate feeding skills are all behaviors that can contribute to
severe health problems, both among the general population and the
developmentally disabled. These problems can include, but are not
limited to, aspiration, esophagitis, and dehydration due to vomiting or
rumination, poisoning resulting from pica, and malnutrition due to
inadequate food intake (Kern & Marder, 1996; Pueschel, Cullen,
Howard, & Cullinane, 1977-1978; Rogers, Stratton, Msall, & Andres,
1994). Furthermore, individuals who fail to take in a sufficient amount
of food may be placed on feeding tubes such as nasogastic or gastron-
omy tubes (Riordan et al., 1984; Shore & Piazza, 1997). These inter-
ventions can be associated with other health risks, and fail to aid in the
development of appropriate and effective eating behavior.
Feeding problems are often confounded by other deficits common
in this population in areas such as communication (Poulton &
Algozzine, 1980), motor skills/abilities (Newell, 1997), physical
abnormalities (Pulsifer, 1996), and nutritional imbalances common in
this population (Lofts, Schroeder, & Maier, 1979; Pace & Toyer,
2000). For example, individuals may refuse food because they do not
like that particular type of food, but are unable to appropriately com-
municate this dislike. Or, individuals may ruminate because they are
physically unable to recruit other sources of stimulation because of
physical limitations (e.g., confined to a wheelchair). A nutritional or
chemical imbalance/deficit may precipitate the occurrence of pica
(e.g., dirt to compensate for an iron deficiency). Finally, an individual
may eat only small amounts of food or only eat foods of a specific
texture because of an esophageal stricture.
Certain conditions where mental retardation is typically present are
associated with an increased risk of feeding problems. For example,
Spender et al. (1996) found that oral motor functions of individuals
with Down’s syndrome, specifically jaw and tongue function, were
often impaired, resulting in feeding difficulties. Similarly, Frazier and
Friedman (1996) found a high prevalence of aspiration among indi-
viduals with Down’s syndrome. Riordan et al. (1984) suggested that
developmentally disabled individuals are more likely to have oral
motor dysfunction.
Some medical problems may be mistaken for behavior problems,
such as rumination resulting from gastroesophageal reflux disease
640 BEHAVIOR MODIFICATION / September 2004

(GERD). Medication side effects may also present similar to a behav-

ior problem such as a misdiagnosis of rumination due to neuroleptics,
which have been shown to interfere with swallowing (Bohmer et al.,
1999; Rogers et al., 1992). To identify the problem, its etiology and/or
function, and determine an appropriate course of treatment, it is nec-
essary to effectively and comprehensively identify and assess the
problem.

ASSESSMENT OF FEEDING AND MEALTIME PROBLEMS

BEHAVIOR RATING SCALES

Prior to assessing the function or etiology of feeding and mealtime

problems, the individual problems must be identified. The identifica-
tion of feeding problems among adults with mental retardation has not
historically been formalized or systematic. In state institutions, the
responsibility of identifying and treating these problems has fallen on
a nutritional management committee including, among those from
other disciplines, an occupational therapist, a nutritionist, and a physi-
cian. Identification of the problem has also resulted from staff or care-
givers informally alerting health personnel when the problem has
resulted in severe health problems or has been difficult to manage.
Although several problems may be appropriately identified and
addressed by these disciplines (e.g., rumination due to GERD, or food
refusal due to esophagitis), many problems may be more
appropriately evaluated by mental health professionals (i.e.,
psychologists).
Some measures have proven useful for identifying the presence of
feeding difficulties in individuals with mental retardation. The Reiss
Screen (Reiss, 1987) is a 38-item questionnaire used to screen for
symptoms of psychopathology and other maladaptive behaviors dis-
played by individuals with mental retardation. The psychometric
properties for this instrument range from modest to good, .75 includ-
ing test-retest reliability, .67 interrater reliability, and an internal reli-
ability (Cronbach’s alpha) at .85 (Sturmey, Burcham, & Perkins,
1995). Although this questionnaire does target a wide range of disor-
ders and problem behaviors, very little attention is given to problems
 Kuhn, Matson / ASSESSMENT OF FEEDING 641

related to feeding and mealtime behavior (Item 12). This item

addresses problems related to weight gain or loss resulting from either
overeating or insufficient eating.
The Diagnostic Assessment for the Severely Handicapped–II
(DASH-II) (Matson, 1995) is a more comprehensive 84-item instru-
ment that screens for symptoms of psychopathology among individu-
als diagnosed with severe and profound mental retardation. The
symptoms are subdivided into 13 diagnostic categories. The
psychometric properties of this instrument are good, with reliability
coefficients for interrater and test-retest at .86 and .84, respectively
(Matson, 1995). The DASH-II includes six items that address feeding
problems common among individuals with severe and profound men-
tal retardation including food stealing, vomiting, choking, pica, eating
too fast, and eating an insufficient amount. Although feeding prob-
lems may also be symptoms of forms of psychopathology (e.g.,
depression), many of the problems identified by the DASH-II are
problematic in and of themselves.
The Assessment of Dual Diagnosis (ADD) (Matson & Bamburg,
1998) is another screening instrument used to identify symptoms of
psychopathology among individuals diagnosed with mild and moder-
ate mental retardation. Similar to other screening measures of
psychopathology, it is essential that this instrument be used in con-
junction with other assessments, including behavioral observation.
The ADD is a 79-item scale that groups items into 13 subscales that
correspond to disorders in the Diagnostic and Statistical Manual of
Mental Disorders (4th ed.). Six items related to eating comprise one of
the subscales, targeting food refusal, eating too quickly, pica, rumina-
tion, vomiting, and a fear of weight gain. Three of the items (food
refusal, vomiting, and a fear of weight gain) target symptoms associ-
ated with Anorexia Nervosa and/or Bulimia Nervosa. The
psychometric properties of this instrument are very good, with reli-
ability coefficients for internal consistency, interrater, and test-retest
at .93, .98, and .93, respectively (Matson & Bamburg, 1998). None of
these scales provide a detailed evaluation of common feeding
problems in persons with mental retardation.
The Screening Tool of fEeding Problems (STEP) (Matson & Kuhn,
2001) is a behavior rating scale designed for the express purpose of
642 BEHAVIOR MODIFICATION / September 2004

identifying feeding problems displayed by individuals diagnosed

with mental retardation. The STEP consists of 23 items each of which
targets a specific feeding problem, or problem/deficit that interferes
with feeding, for example, food-type selectivity, food texture selectiv-
ity, pushing food away, vomiting, and eating too quickly. For catego-
rizing purposes, these problems are organized into five categories of
problems including aspiration risk, feeding skills, selectivity, behav-
ior problems, and nutrition. The psychometric properties for this mea-
sure are modest, with test-retest reliability (.72), and cross-rater reli-
ability (.71) (Matson & Kuhn, 2001). Once the problem(s) has been
identified, an interdisciplinary evaluation and behavioral assessment
is essential.

INTERDISCIPLINARY ASSESSMENT

Medical evaluation. Depending on the problem and/or topography

of the feeding problem a comprehensive workup is recommended.
The identification of a medical or motor problem can assist in the
treatment or approach to treatment of the problem. For example,
determining that an individual refuses to eat certain foods (e.g., toma-
toes) because it exacerbates his or her GERD would suggest a medical
intervention (e.g., acid-suppressing medication) to suppress the
reflux. A medical assessment may include the following assessment
components. To assess the integrity of the hypopharynx and other
upper gastrointestinal anatomy, and to ensure that the individual can
protect his or her airway during swallowing, a Barium Swallow Study
would be indicated (Babbitt et al., 1994; Hyman, 1994). This proce-
dure also provides information regarding the movement of the food/
bolus through the upper gastrointestinal tract, which may demonstrate
that the individual is bringing food up from the stomach or esophagus
back into the mouth (i.e., rumination). It is also useful in diagnosing
severe grades of GERD (Ott, 1994).
An upper gastrointestinal tract (GI) endoscopy provides informa-
tion about whether medical conditions exist (e.g., esophagitis), and
about the mucosal lining of the esophagus, stomach, and duodenum
(Babbitt et al., 1994; Bohmer et al., 1999). The presence of esopha-
geal reflux can also be ascertained using this technique (Kuruvilla &
 Kuhn, Matson / ASSESSMENT OF FEEDING 643

Trewby, 1989). A gastric emptying scan is useful in evaluating motil-

ity in the upper gastrointestinal tract (Babbitt et al., 1994). Aberrant
results may be associated with a poor appetite. Esophageal
manometry is a relatively new technique that measures
intraesophageal pressure that provides information about peristalsis
and thus the esophageal motility (Patti, Diener, Tamburini, Molena,
and Way, 2001).

Nutrition evaluation. Nutritionists can also provide valuable infor-

mation pertaining to feeding problems (O’Brien, Repp, Williams, &
Christophersen, 1991). An evaluation of the individual’s weight indi-
cates whether he or she is overweight or underweight. An evaluation
of an individual’s diet ensures that all necessary nutrients are con-
sumed. A nutritionist can assess food allergies that contribute to the
presenting problem, or identify syndromes that are the basis for prob-
lems such as the inability to digest or metabolize certain proteins.

Occupational therapy evaluation. Instrumental in the evaluation of

behavioral feeding problems is an evaluation by an occupational ther-
apist (O’Brien et al., 1991). This evaluation is comprehensive in
examining the individual’s coordination and physical ability to per-
form various tasks. The skills evaluated that are necessary for self-
feeding include gross reflexive movements, hand-eye-coordination,
and motor development. The skills evaluated for oral feeding include
oral pharyngeal reflexes, and oral-motor skills including sucking,
swallowing, chewing, and tongue control.

OBSERVATIONAL ASSESSMENT

Parameters. As will be discussed below, the majority of the behav-

ioral assessment methodology for feeding problems among persons
diagnosed with mental retardation is individually tailored to the indi-
vidual and the presenting problem. Similar to the assessment of other
severe behavior problems (e.g., self-injurious behavior and aggres-
sion), the dependent variables are typically measured using a fre-
quency count, duration, occurrence/nonoccurrence data, or perma-
nent products. For example, a clinician would use a frequency
644 BEHAVIOR MODIFICATION / September 2004

measure when recording the number of times a food was presented,

and/or the number of times the food was accepted or expelled, or the
number of times the individual engaged in physical aggression during
the meal. A duration measure may be useful when examining how
long the individual remains in his or her seat during the meal, and
occurrence data may be used when recording an individual engaging
in rumination, because the behavior often does not have a discrete
beginning and end. A measure of permanent products may be useful
when measuring the amount of food consumed/not consumed. These
measures provide quantifiable information regarding the occurrence
of the target behavior, though accurate data collection is dependent on
trained observers.

Assessment. Assessments of feeding problems have predominantly

involved manipulating the consequence following the problem behav-
ior. For example, following the behavior of pushing food away, the
effects of various consequences, such as delivering or withholding
attention, permitting a break from the meal, or access to more pre-
ferred foods, are evaluated. Munk and Repp (1994) recognized that
this type of assessment only identified possible functional relations
between the problem behavior and a consequence. Therefore, they
designed an assessment to evaluate the effects of the antecedent con-
dition, or in this case the type and texture of the food being presented,
on the occurrence of problem behavior. In 1994, Munk and Repp eval-
uated the stimulus variables that may occasion food refusal behavior
by systematically manipulating the types of foods (e.g., fruits, vegeta-
bles, meats, starches) and the food textures within each food type
(e.g., junior, ground, chopped), and recorded the participants’ accep-
tance and expulsion of food. This methodology provided information
about whether the participants refused food because of selectivity by
type of food, selectivity by the texture of the food, or selectivity by
both type and texture.
Functional assessment techniques have been applied to numerous
behavior problems (e.g., self-injurious behavior, physical aggres-
sion); however, its application with feeding problems has not been as
well researched. Sprague, Flannery, and Szidon (1998) conducted
analyses to identify the behavioral function(s) of mealtime spitting
 Kuhn, Matson / ASSESSMENT OF FEEDING 645

and whining. Following interviews with family and staff, and meal
observations, the authors generated hypotheses regarding the function
of the mealtime behavior and tested the hypotheses across two experi-
mental conditions. Providing differential consequences following
problem behavior, Sprague and colleagues demonstrated that the
mealtime problem behavior was maintained by positive reinforce-
ment in the form of access to the next bite of food. Interobserver agree-
ment averaged 97% for 30% of sessions conducted. No data were
reported regarding the initial mealtime observation or caregiver inter-
views and how the hypotheses were generated, thus questions remain
whether other reinforcement contingencies should have been
evaluated.
Girolami and Scotti (2001) conducted analog functional analyses
of food refusal and related mealtime behavior displayed by 3 partici-
pants. Using experimental conditions similar to those described by
Iwata, Dorsey, Slifer, Bauman, and Richman (1982), the authors
tested five hypotheses regarding the function of the problem behavior:
(a) positive reinforcement in the form of access to attention, (b) nega-
tive reinforcement in the form of escape from bite/meal, (c) positive
reinforcement in the form of access to tangibles, (d) positive rein-
forcement in the form of access to preferred edibles, and (e) automatic
reinforcement. Interobserver agreement averages were maintained at
or above 90% across all participants and dependent measures for at
least 30% of intervals observed. Moderate to high levels of consis-
tency (W = .64, .92, .96, using Kendall’s Coefficient of Concordance)
were obtained between the results of the analog analyses and those
obtained from other functional assessment data, using the Motivation
Assessment Scale (MAS) (Durand & Crimmins, 1988), the Func-
tional Analysis Interview Form (FAIF) (O’Neill, Horner, Albin,
Storey, & Sprague, 1990), and observational descriptive data (Bijou,
Peterson, & Ault, 1968).
Informal observations and/or descriptive assessments (Bijou et al.,
1968) provide information about events surrounding the target behav-
ior that can aid in assessment and the identification of functional rela-
tions. When evaluating mealtime behavior, the variables assessed may
include the characteristics of the feeder (if applicable), interactions
between the feeder and client, and the behavior of the feeder (e.g., the
646 BEHAVIOR MODIFICATION / September 2004

rate at which they present food, or the type of attention they deliver
during the meal) (Babbitt et al., 1994).

SUMMARY

The assessment of feeding and mealtime behavior problems exhib-

ited by persons with mental retardation is a process that ideally
requires a multidisciplinary approach, including assessments from
occupational therapists, physicians, dieticians, and psychologists.
Assessment procedures utilized by mental health professionals (i.e.,
psychologists) targeting feeding and mealtime behavior problems
have not been as standardized or methodologically sound as other dis-
ciplines, or compared to assessment procedures applied to other
behavior problems. Recent developments in assessment methodology
are encouraging, including the functional analysis of food refusal
described by Girolami and Scotti (2001) and the STEP developed by
Matson and Kuhn (2001). Research on treatments for feeding and
mealtime behavior problems has been growing; however, the need
remains for standardized assessment methods. Though many feeding
related problems are best treated by disciplines other than psychology,
many problems can and should be assessed and treated using
behavioral techniques.

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David E. Kuhn, M.A., is currently a fourth-year graduate student in clinical psychology

at Louisiana State University. He will be completing his pre-doctoral internship at the
Kennedy Krieger Institute in Baltimore, MD. His current research interests include the
assessment and treatment of mealtime problem behavior and other destructive behaviors
displayed by individuals with developmental disabilities.

Johnny L. Matson received his Ph.D. in psychology from Indiana State University. He is
currently a full professor and director of clinical training at the Louisiana State Univer-
sity. He has published extensively in the field of mental retardation. His current research
interests include the assessment of psychopathology among persons with developmental
disabilities and the evaluation of side effects of psychotropic medication use in persons
with developmental disabilities.