Developing and Implementing a Telehealth Enhanced Interdisciplinary Pediatric Feeding Disorders Clinic: a Program Description and Evaluation

  • Racheal R. Clark
  • Aaron J. FischerEmail author
  • Erica L. Lehman
  • Bradley S. Bloomfield


Pediatric feeding problems are highly prevalent in the general population and reportedly 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 disabilities 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.


Telehealth; feeding problems Behavioral interventions Generalization 


Compliance with Ethical Standards


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.


  1. Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45(3), 455–471.Google Scholar
  2. American Academy of Child and Adolescent Psychiatry (AACAP). (2008). Practice parameter for telepsychiatry with children and adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 47(12), 1468–1483.Google Scholar
  3. American Diabetes Association. Healthy eating. Accessed January 15, 2017.
  4. American Heart Association. The American Heart Association’s Diet and Lifestyle Recommendations. Recommendations_UCM_305855_Article.jsp#.WJvkqIgrLnA. Published March 15, 2017. Accessed March 17, 2017.
  5. American Institute for Cancer Research. Diet - What to Eat for Lower Cancer Risk. Accessed January 25, 2017.
  6. American Psychological Association. (2013). Guidelines for the practice of telepsychology. The American Psychologist, 68, 791–800.Google Scholar
  7. Aponte, C. A., & Romanczyk, R. G. (2016). Assessment of feeding problems in children with autism spectrum disorder. Research in Autism Spectrum Disorder, 21, 61–72.Google Scholar
  8. Armfield, N. R., Donovan, T., Bensink, M. E., & Smith, A. C. (2012). The costs and potential savings of telemedicine for acute care neonatal consultation: Preliminary findings. Journal of Telemedicine and Telecare, 18(8), 429–433. Scholar
  9. Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., Maslin, M., & Must, A. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. Journal of Pediatrics, 157(2), 259–264.Google Scholar
  10. Bentovim, A. (1970). The clinical approach to feeding disorders of childhood. Journal of Psychosomatic Research, 14(3), 267–276.Google Scholar
  11. Bergan, J. R., & Kratochwill, T. R. (1990). Behavioral consultation in applied settings. New York: Plenum.Google Scholar
  12. Binnendyk, L., & Lucyshyn, J. M. (2008). A family-centered positive behavior support approach to the amelioration of food refusal behavior: An empirical case study. Journal of Positive Behavior Interventions, 11(1), 47–62.Google Scholar
  13. Bloomfield, B. S., Fischer, A. J., Clark, R. R., & Dove, M. B. (2018). Treatment of food selectivity in a child with avoidant/restrictive food intake disorder through parent teleconsultation. Behavior Analysis in Practice.
  14. Bolte, S., Ozkara, N., & Poustka, F. (2002). Autism spectrum disorders and low body weight: Is there really a systematic association? International Journal of Eating Disorders, 31(3), 349–351.Google Scholar
  15. Bosaeus, I. (2004). Fibre effects on intenstinal functions (diarrhea, constipation, and irritable bowel syndrome). Clinical Nutrition Supplements, 1, 33–38. Scholar
  16. Calvert, S. D., Vivian, V. M., & Calvert, G. P. (1976). Dietary adequacy, feeding practices, and eating behavior of children with Down’s syndrome. Journal of American Dietetic Association, 69, 152–156.Google Scholar
  17. Chatoor, I., Hirsch, R., Ganiban, J., Persinger, M., & Hamburger, E. (1998). Diagnosing infantile anorexia nervosa. The observation of mother–infant interactions. Journal of the American Academy of Child Adolescent Psychiatry, 37, 959–967.Google Scholar
  18. Clawson, E. P., & Elliott, C. A. (2014). Integrating evidence-based treatment of pediatrics feeding disorders into clinical practice: Challenges to implementation. Clinical Practice in Pediatric Psychology, 2(3), 312–321.Google Scholar
  19. Cornish, E. (1999). A balanced approach towards healthy eating in autism. Top Clinical Nutrition, 14(4), 85.Google Scholar
  20. Cornish, E. (2002). Gluten and casein free diets in autism: A study of the effects on food choice and nutrition. Journal of Human Nutrition and Diet, 15(4), 261–269.Google Scholar
  21. Coulthard, H., & Harris, G. (2003). Early food refusal. The role of maternal mood. Journal of Reproductive and Infant Psychology, 21, 335–345.Google Scholar
  22. Crist, W., McDonnell, P., Beck, M., Gillespie, C. T., Carrett, P., & Mathews, J. (1994). Behaviour at mealtimes and the young child with cystic fibrosis. Journal of Developmental and Behavioural Pediatrics, 15, 157–161.Google Scholar
  23. Darke, P., & Goldberg, S. (1994). Father-infant interaction and parent stress with healthy and medically compromised infants. Infant Behavior and Development, 17, 3–14.Google Scholar
  24. Dart, E. H., Whipple, H. M., Pasqua, J. L., & Furlow, C. M. (2016). Legal, regulatory, and ethical issues in telehealth technology. In J. K. Luiselli, A. J. Fischer, J. K. Luiselli, & A. J. Fischer (Eds.), Computer-assisted and web-based innovations in psychology, special education, and health (pp. 339–363). San Diego: Elsevier Academic Press.Google Scholar
  25. Del Giudice, D., Staiano, A., Capano, G., Romano, A., Florimonte, L., & Miele, E. (1999). Gastrointestinal manifestations in children with cerebral palsy. Brain Dev, 21, 307–311.Google Scholar
  26. Dietary Guidelines for Americans 2015–2020. Office of Disease Prevention and Health Promotion. Published December 2015. Accessed 20 June 2018.
  27. Duniz, M., Scheer, P., Trojovsky, A., Kaschnitz, W., Kvas, E., & Macari, S. (1996). Changes in psychopathology of parents of NOFT (non-organic failure to thrive) infants during treatment. European Child & Adolescent Psychiatry, 5(2), 93–100.Google Scholar
  28. Farrow, C., & Blissett, J. (2006). Maternal cognitions, psychopathologic symptoms and infant temperament as predictors of early infant feeding problems. A longitudinal study. International Journal of Eating Disorders, 39, 128–134.Google Scholar
  29. Field, D., Garland, M., & Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Paediatrics and Child Health, 39(4), 299–304.Google Scholar
  30. Fischer, A. J., Luiselli, J. K., & Dove, M. (2015). Effects of clinic and in-home treatment on consumption and feeding-associated anxiety in an adolescent with avoidant/restrictive food intake disorder. Clinical Practice in Pediatric Psychology, 3, 154–166.Google Scholar
  31. Fischer, A. J., Dart, E. H., Radley, K. C., Richardson, D., Clark, R., & Wimberly, J. (2016a). Evaluating the effectiveness of videoconferencing as a behavioral consultation medium. Journal of Educational and Psychological Consultation, online first, 1–22. doi:
  32. Fischer, A. J., Schultz, B. K., Collier-Meek, M. A., Zoder-Martell, K., & Erchul, W. P. (2016b). A critical review of videoconferencing software to support school consultation. International Journal of School & Educational Psychology, 6, 12–22. Scholar
  33. Fischer, A. J., Clark, R., Askings, D., & Lehman, E. (2017). Technology and telehealth applications. In J. K. Luiselli (Ed.), Applied behavior analysis advanced guidebook. New York: Academic Press/Elsevier.Google Scholar
  34. Fischer, A. J., Bloomfield, B. S., Clark, R. R., McClelland, A., & Erchul, W. P. (2018). Increasing student compliance with teacher instructions using telepresence robot problem-solving teleconsultation. International Journal of School & Educational Psychology, 1–15.
  35. Fung, E. B., Samson-Fang, L., Stallings, V. A., Conaway, M., Liptak, G., Henderson, R. C., Worley, G., et al. (2002). Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy. Journal of American Dietetic Association, 102, 368–373.Google Scholar
  36. Gal, E., Hardal-Nasser, R., & Engel-Yeger, B. (2011). The relationship between the severity of eating problems and intellectual developmental deficit level. Research in Developmental Disabilities, 32(5), 1464–1469.Google Scholar
  37. Gibson, J. L., Pennington, R. C., Stenhoff, D. M., & Hopper, J. S. (2010). Using desktop videoconferencing to deliver interventions to a preschool student with autism. Topics in Early Childhood Special Education, 29(4), 214–225.Google Scholar
  38. Grady, B., Myers, K., Nelson, E., Belz, N., Bennett, L., Carnahan, L., et al. (2011). Evidence-based practice for telemental health. Telemedicine and E-Health, 17, 131–148.Google Scholar
  39. Greer, A. J., Gulotta, C. S., Masler, E. A., & Laud, R. B. (2008). Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. Journal of Pediatric Psychology, 33, 612–620.Google Scholar
  40. Gustafsson, P. M., & Tibbling, L. (1994). Gastro-esophageal reflux and orsophageal dysfunction in children and adolescents with brain damage. Acta Paediatric, 83, 1081–1085.Google Scholar
  41. Hatcher, R. L., Fouad, N. A., Campbell, L. F., McCutcheon, S. R., Grus, C. L., & Leahy, K. L. (2013). Competency-based education for professional psychology: Moving from concept to practice. Training and Education In Professional Psychology, 7(4), 225–234. Scholar
  42. Internal Revenue Service. (2017). Standard Mileage Rates for 2018 Up from rates for 2017. Retrieved from: Accessed March 2018.
  43. Kerwin, M. (1999). Empirically supported treatments in pediatric psychology. Severe feeding problems. Journal of Pediatric Psychology, 24, 193–214.Google Scholar
  44. Kerwin, M. L., & Reider, E. (1994). Oral feeding problems of infants and toddlers and parenting stress of their mothers and fathers. Paper presented at the Kansas Conference in Clinical Child Psychology. Lawrence, KS.Google Scholar
  45. Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental Disabilities, 21, 153–166.Google Scholar
  46. Lindberg, L., Bohlin, G., Hagekull, B., & Palmerus, K. (1996). Interactions between mothers and infants showing food refusal. Infant Mental Health Journal, 17, 334–337.Google Scholar
  47. Luiselli, J. K., & Fischer, A. J. (Eds.). (2016). Computer-assisted and web-based innovations in psychology, special education, and health. New York: Academic Press/Elsevier.Google Scholar
  48. Lukens, C. T., & Silverman, A. H. (2014). Systematic review of psychological interventions for pediatric feeding problems. Journal of Pediatric Psychology, 39(8), 903–917. Scholar
  49. Luxton, D. D., Nelson, E., & Maheu, M. M. (2016). A practitioner's guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. Washington, DC: American Psychological Association. Scholar
  50. Matson, J. L., Fodstad, J. C., & Dempsey, T. (2009). The relationship of children’s feeding problems to core symptoms of autism and PDD-NOS. Research in Autism Spectrum Disorders, 3, 759–766.Google Scholar
  51. McGrath, P. J., Watters, C., & Moon, E. (2006). Technology in pediatric pain management. In G. A. Finley, P. J. McGrath, & C. T. Chambers (Eds.), Bringing pain relief to children: Treatment approaches (pp. 159–176). Totowa: Humana Press.Google Scholar
  52. McKay, J. M., Pickens, J., & Stewart, A. L. (1996). Inventoried and observed stress in parent-child interactions. Current Psychology: Developmental, Learning, Personality, Social, 15, 223–234.Google Scholar
  53. Milnes, S. M., & Piazza, C. C. (2014). Intensive treatment of pediatric feeding disorders. In D. D. Reed, F. D. DiGennaro Reed, & J. K. Luiselli (Eds.), Handbook of crisis intervention and developmental disabilities (pp. 393–408). New York: Springer.Google Scholar
  54. Parsons, M. B., Rollyson, J. H., & Reid, D. H. (2013). Teaching practitioners to conduct behavioral skills training: A pyramidal approach for training multiple human service staff. Behavior Analysis in Practice, 6(2), 4–16. Scholar
  55. Peterson, K. M., Volkert, V. M., & Zeleny, J. R. (2015). Increasing self-drinking for children with feeding disorders. Journal of Applied Behavior Analysis, 48(2), 436–441.Google Scholar
  56. Pipes, P. L., & Holm, V. A. (1980). Feeding children with Down's syndrome. Journal of the American Dietetic Association, 77, 277–282.Google Scholar
  57. Powers, S. W., Byars, K. C., Mitchell, M. J., Patton, S. R., Standiford, D. A., & Dolan, L. M. (2002). Parent report of mealtime behavior and parenting stress in young children with type 1 diabetes and in healthy control subjects. Diabetes Care, 25, 313–318.Google Scholar
  58. Radford, J., Thorne, S., & Bassingthwaighte, C. (1997). Long-term gastrostomy in children: insights from expert nurses. Issues in Comprehensive Pediatric Nursing, 20(1), 35–50.Google Scholar
  59. Reves, A. L., Cash, A. J., Green, S. H., & Booth, L. W. (1993). Gastroesophageal reflux in children with celrebral palsy. Child: Care, Health and Development, 19, 109–118.Google Scholar
  60. Russo, J. E., McCool, R. R., & Davies, L. (2016). VA telemedicine: An analysis of cost and time savings. Telemedicine Journal And E-Health: The Official Journal Of The American Telemedicine Association, 22(3), 209–215. Scholar
  61. Satter, E. (1990). The feeding relationship: problems and interventions. The Journal of Pediatrics, 117(2), S181–S189.Google Scholar
  62. Schreck, K., Williams, K., & Smith, A. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34(4), 433–438.Google Scholar
  63. Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348–365. Scholar
  64. Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., Klin, A., Jones, W., & Jaquess, D. L. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: a meta-analysis and comprehensive review of the literature. Journal of Autism and Developmental Disorders, 43(9), 2159–2173.Google Scholar
  65. Sharp, W. G., Burrell, T. L., & Jaquess, D. L. (2014). The autism MEAL plan: A parent-training curriculum to manage eating aversions and low intake among children with autism. Psychology Review, 13, 348–365.Google Scholar
  66. Sharp, W. G., Volkert, V. M., Scahill, L., McCracken, C. E., & McElhanon, B. (2017). A systematic review and meta-analysis of intensive multidisciplinary intervention for pediatric feeding disorders: How standard is the standard of care? The Journal of Pediatrics, 181, 116–124.Google Scholar
  67. Silbaugh, B. C., Penrod, B., Whelan, C. M., Hernandez, D. A., Wingate, H. V., Falcomata, T. S., et al. (2016). A systematic synthesis of behavioral interventions for food selectivity in children with autism spectrum disorders. Review Journal of Autism and Developmental Disorders, 3, 345–347. Scholar
  68. Silverman, A. H. (2010). Telehealth interventions for feeding problems. In A. Southall & C. Martin (Eds.), Feeding problems in children: A practical guide for health professionals (2nd ed., pp. 261–276). Oxon: Radcliffe Medical Press.Google Scholar
  69. Silverman, A. H., Kirby, M., Clifford, L. M., Fischer, E., Berlin, K. S., Rudolph, C. D., & Noel, R. J. (2013). Nutritional and psychosocial outcomes of gastrostomy tube-dependent children completing an intensive inpatient behavioral treatment program. Journal of Pediatric Gastroenterology and Nutrition, 57(5), 668–672.Google Scholar
  70. Singer, L. T., Song, L. Y., Hill, B. P., & Jaffe, A. C. (1990). Stress and depression in mothers of failure to thrive children. Journal of Pediatric Psychology, 15, 711–720.Google Scholar
  71. Spender, Q., Stein, A., Dennis, J., Reilly, S., Percy, E., & Cave, D. (1996). An exploration of feeding difficulties in children with Down’s syndrome. Developmental Medicine and Child Neurology, 38, 681–694.Google Scholar
  72. Stallings, V. A., Charney, E. B., Davies, J. C., & Cronk, C. E. (1993a). Nutritional status and growth of children with diplegic or hemiplegic cerebral palsy. Developmental Medicine and Child Neurology, 35, 997–1006.Google Scholar
  73. Stallings, V. A., Charney, E. B., Davies, J. C., & Cronk, C. E. (1993b). Nutrition-related growth failure of children with quadriplegic cerebral palsy. Developmental Medicine and Child Neurology, 35, 126–138.Google Scholar
  74. Strauss, D. J., Shavelle, R. M., & Anderson, T. W. (1998). Life expectancy of children with cerebral palsy. Pediatric Neurology, 18, 143–149.Google Scholar
  75. Suarez, M. A., Atchison, B. J., & Lagerwey, M. (2014). Phenomenological examination of the mealtime experience for mothers of children with autism and food selectivity. American Journal of Occupational Therapy, 68(1), 102–107.Google Scholar
  76. Sullivan, P. B., Juszezak, E., Lambert, B. R., Rose, M., Ford-Adams, M. E., & Johnson, A. (2002). Impact of feeding problems on nutritional intake and growth: Oxford feeding study II. Developmental Medicine and Child Neurology, 44, 461–467.Google Scholar
  77. Taylor, C. M., Northstone, K., Wernimont, S. M., & Emmett, P. M. (2016). Picky eating in preschool children: Associations with dietary fiber intakes and stool hardness. Appetite, 100, 263–271.Google Scholar
  78. Volkert, V. M., & Piazza, C. C. (2012). Empirically supported treatments for pediatric feeding disorders. In P. Sturmey & M. Herson (Eds.), Handbook of evidence based practice in clinical psychology (Vol. 1, pp. 456–481).Google Scholar
  79. Wangelin, B. C., Szafranski, D. D., & Gros, D. F. (2016). Telehealth technologies in evidence-based psychotherapy. In J. K. Luiselli, A. J. Fischer, J. K. Luiselli, & A. J. Fischer (Eds.), Computer-assisted and web-based innovations in psychology, special education, and health (pp. 119–140). San Diego: Elsevier Academic Press.Google Scholar
  80. Werle, M. A., Murphy, T. B., & Budd, K. S. (1993). Treating chronic food refusal in young children: Home based parent training. Journal of Applied Behavior Analysis, 26, 421–433.Google Scholar
  81. Whelan, E., & Cooper, P. J. (2000). The association between childhood feeding problems and maternal eating disorder: A community study. Psychological Medicine, 30, 69–77.Google Scholar
  82. Williams, K. E., Riegel, K., Gibbons, B., & Field, D. G. (2007). Intensive behavioral treatment for severe feeding problems: A cost-effective alternative to tube feeding? Journal of Developmental and Physical Disabilities, 19, 227–235.Google Scholar
  83. Zimmer, M. H., Hart, L. C., Manning-Courtney, P., Murray, D. S., Bing, N. M., & Summer, S. (2011). Food variety as a predictor of nutritional status among children with autism. Journal of Autism and Developmental Disorders, 42(4), 549–556.Google Scholar

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

Authors and Affiliations

  1. 1.University of UtahSalt Lake CityUSA
  2. 2.University of AlabamaTuscaloosaUSA

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