Plate A Plate B

In a past blog I looked at Tiny Tastes as a way of increasing your child’s food repertoire. Tiny Tastes is a popular and fun method and I tend to use it with parents when there is some concern around the amounts and variety of foods their children are eating and where parents feel a child will enjoy the approach.

However as children get older the problem can become a chronic one. Their reluctance to eat different foods causes problems when they eat at friends' houses, restaurants, school. They become more aware of the need to change their eating and a quicker approach can be helpful.

Keith Williams and his team at the Penn State Hershey Medical Centre work with children with very severe eating restriction. In one case they reintroduced food with a sixteen year old with a diagnosis of Asperger’s Syndrome who had been fed by a gastrostomy tube for nine years because his food restriction was so severe. This young man increased the range of foods that he was happy to eat to seventy-eight different foods using this method by the time his treatment finished.

Recently they have outlined an intervention called Plate A, Plate B[1]. In the same way that Tiny Tastes dramatically reduces the demands placed on a child, in this approach the food to be tasted is reduced to a tiny amount, Food refusal is treated as a fear or phobia of that food and trying a food is made as easy, quick and underwhelming as possible.

Plate A/ Plate B the basics

1. Parents pick an initial twenty foods they would like the child to eat but which the child currently refuses.

2. The child is presented with two plates: Plate A and Plate B

3. On Plate A there are four ‘pea sized[2]’ pieces of food the child is not keen on or actively dislikes.

4. On Plate B there are four tablespoons of food the child likes.

5. In order to eat one portion of the food they like from Plate B, a child has to eat the ‘pea sized’ piece of food that they are concerned about from Plate A.

6. Meals are timed and last no longer than 10 minutes.

7. Parents take a very firm stance. Crying / arguing is ignored.

8. No other meals are offered and no snacks are given between meals.

9. When a child has eaten a ‘disliked’ food from Plate A on three consecutive occasions without gagging the portion size is increased (so from pea sized to half a teaspoon to a teaspoon to a spoonful etc).

10. Eating these two plates is considered a meal.

11. The child has six meals a day.

12. The process of six meals a day continues until a child is able to happily eat a tablespoon of a food without gagging of feeling repelled.

How I amend this for children with milder eating difficulties

1. I call trying food from Plate A / Plate B - ‘Taste Time’.

2. Rather than having six meals a day, parents do Taste Time just before a meal.

3. There is still a Plate A and Plate B with four tiny portions on Plate A and four tablespoon sized portions on Plate B

4. Children still get to eat a spoon of preferred foods from Plate B after each taste of food from Plate A. However once all four tastes are eaten the child then goes on to have the rest of a regular sized ‘accepted’ meal.

5. I let children decide which Plate A foods they will attempt first. The firm stance remains: Crying and arguing does not change the rules.

6. The basic rule is that a taste from Plate A is needed before a spoonful of food from Plate B can be had. If your child has not eaten anything after ten minutes then the meal is ended with no comment.

These amendments usually cut down on the focus and emphasis and allows the rest of the family to keep a relatively normal routine.

Common questions

• My child wants only treats on Plate B (so four unliked foods on Plate A but four snacky foods on Plate B)…

It is important that treats don’t get included in Taste Time (unless treats are all a child eats) as it can be hard to move to normal meals. Simply state that the foods on Plate B are not treat foods. Rather they are four regular mealtime foods. The foods on Plate B are a child’s regular, accepted foods. Hopefully they will be hungry for these and this will motivate them to try the very small amounts of food on Plate A. Not using treats also helps normalise mealtimes and prevents lots of negotiation.

• What if one of the twenty foods is a meal – for example pizza?

I break down a pizza into a pizza base taste with some tomato sauce on (this is more noticeable as the size increases but I try and make sure that the pea sized taste has sauce on!). I have a ‘melted cheese’ taste, a pepperoni taste etc. As the taste gets bigger I try and include all components. It takes a bit of juggling to ensure balance.

• I cannot prepare eight different foods before a meal. Are there any shortcuts?

Your list of twenty foods might include things like lasagne or simply things like courgettes. It is totally acceptable to buy a ready meal lasagne and divide it into twenty portions. Freeze each portion and defrost for a portion for Plate A. You will waste food but not excessively this way.

Further tips

• When you pick your twenty foods make sure they are foods your family regularly eats so that you can give your child a portion and let them see you eating it as well.

• If a child won’t eat cereal with milk, add teaspoon of milk to teaspoon of cereal and mix. Then put pea sized amount on Plate A.

• Use ready meals that you can split into small spoon portions and freeze in separate freeze bags.

• It can be easier to like some vegetables if they are shredded (so beetroot or carrot or courgette can be shredded raw when potion size increases).

[1] Sieverling, L., Kokitus, A and Williams, K. (2012). A clinical demonstration of a treatment package for food selectivity. Behavior Analyst Today, 13, 1-6.

[2] The portion size can be as small as a grain of rice if the child is very reluctant.

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