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Learning to choose food and drink

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VOL: 98, ISSUE: 10, PAGE NO: 58

This paper is the product of collaborative work between Patricia Hall, MSc, psychology research assistant, Adult Psychological Therapies Service, Cherry Trees, Pontefract; Dr Pete Coia, Dr Julia Maskrey, Debbie Turner and Louise Raper, DipSW. All were employed at Wakefield and Pontefract Community Health NHS Trust at the time of the research

We make many choices every day. Some are extremely important and, accordingly, we put a lot of effort into making them. Most choices, however, are less important and involve little conscious effort. For example, choosing what to have for breakfast is a quick, often impulsive, process. As the outcome is relatively unimportant, the choice is also relatively unimportant. We make these smaller choices so often that we may not even realise we are actually making decisions. It is these trivial choices that we take most for granted.

We make many choices every day. Some are extremely important and, accordingly, we put a lot of effort into making them. Most choices, however, are less important and involve little conscious effort. For example, choosing what to have for breakfast is a quick, often impulsive, process. As the outcome is relatively unimportant, the choice is also relatively unimportant. We make these smaller choices so often that we may not even realise we are actually making decisions. It is these trivial choices that we take most for granted.

Most adults with severe learning disabilities do not make even the most trivial of choices. For instance, most do not choose the food and drinks they have at mealtimes (Wilson et al, 1984). What is 'normal' for these adults could be considered by adults without learning disabilities to be unpleasant, even punitive.

Jackson and Jackson (1998) suggest that increasing choices for people with learning disabilities is closely related to their development of personal autonomy. They also point out that they are less likely to behave in an antisocial manner in order to obtain a degree of control in their lives if they have more opportunities to make choices.

People with severe learning disabilities are dependent on their carers to provide opportunities for them to make choices. However, in many cases, carers make the choices on behalf of their clients, making assumptions about their tastes and preferences. Unfortunately, the opinions of carers do not necessarily predict the food choices of people with learning disabilities (Parsons and Reid, 1990; Windsor, 1994). Therefore, it would seem appropriate to use systematic procedures, rather than subjective opinion, to identify the preferences of an individual with a learning disability (Green et al, 1988).

This case study illustrates a method of giving an adult with a severe learning disability the opportunity to make a choice and establish his food preferences. We attempted to determine what his preference(s) were by presenting and recording choices enough times for a valid and reliable pattern to be seen. The results show that the participant was able to make choices and demonstrate consistent preferences about food. Additionally, the opportunity to practise picking up food items led to improvements in his motor skills. This experimental approach has wider applications in enhancing the quality of life for individuals who may initially appear to be incapable of making choices for themselves.

Patient profile
Daniel Wright is 38 years old and has a severe learning disability. His vision and hearing are also impaired, he has poor mobility and motor coordination and appears underweight. He lives in a long-stay hospital for adults with learning disabilities. His daily routine is made up of direct care tasks - being dressed, fed, toileted. Because resources in the hospital are limited, Mr Wright spends large amounts of time with little to do and has few, if any, opportunities to make choices.

Food items
The food items used in this study were selected because of their substantial calorific content and the likelihood that Mr Wright would be able to distinguish between them. They are also readily available in shops and need little preparation. Four different items were presented in small portions - cheese biscuits, cubes of Cheddar cheese, chunks of chocolate biscuit bar and pieces of chocolate sponge roll.

Assessment procedure
Mr Wright was presented with a choice of two different items of food presented on a tray in each session. This procedure has been used successfully in several other studies (Windsor, 1994). When one item of food was eaten, or knocked off the tray, it was replaced. The session ended when all portions of one of the food items had either been eaten or knocked off the tray.

Each food item was paired with all the other food items at least once and appeared in four out of the eight sessions. Within each session each food item was presented on both Mr Wright's right and left hand sides an equal number of times. (The side on which food items were presented made no statistically significant difference to any of the results. Therefore, the side of presentation was ignored in all subsequent analysis.)

Behavioural definitions
A choice was considered to have been made when Mr Wright attempted to pick up a food item, whether or not he got it into his mouth. The trial ended once he had made a choice.

Sometimes Mr Wright would pick up and eat one food item and then take the remaining item before the first had been replaced. As there was only one item present, Mr Wright's selection of the remaining second item was not considered to be a choice. These trials were subsequently referred to as 'Hobson's choice' trials.

The action of reaching out to pick a food item was referred to as a grasp. When Mr Wright got the food item into his mouth the grasp was seen as successful. Sometimes he was unable to pick up the food item or he dropped it before it got to his mouth. The choice was still seen as having been made, but the grasp was seen as unsuccessful.

Data collection
Mr Wright's food choices for each trial and grasping success were videotaped. The footage generated all data for analysis.

Results
There were no significant differences in the number of times Mr Wright chose the two food items in session one. This may have been because he did not understand what was required of him at first. By the second session, however, he appeared to have made a choice and indicated his preference.

In sessions 2, 3, 6, 7 and 8, chi-square tests show that Mr Wright chose one of the food items significantly more often than the other. Consequently, it was concluded that he is able to choose which food he prefers (Table 1). The eight sessions were numbered in chronological order. Differences in preference were calculated by subtracting the least chosen item from the most chosen item (difference as a percentage), while the chi square shows whether one food item was chosen significantly more then the other.

Mr Wright did not show a significant preference in sessions 4 and 5. This does not mean that he is not capable of making a choice. It may simply reflect that he liked both items and thus did not have a strong preference for one over the other. This is illustrated by considering Mr Wright's Hobson's choices. There was a significant (negative) correlation between the degree of preference between two food items and the number of Hobson's choices (Fig 1).

When Mr Wright had a strong preference for one item he chose it a great deal more and tended not to attempt to grasp the second item. However, when he had no strong preference, he chose each of the two items more or less equally, and made more Hobson's choices.

Overall food preferences across sessions
As Mr Wright showed a significant preference in five of the sessions (2, 3, 6, 7 and 8), it is possible to rank his food preferences (Table 2). Cheese biscuits are his favourite, and Cheddar cheese his least preferred food.

Grasping food success
Mr Wright found it difficult to grasp items of food. Sometimes he would grasp one and drop it before he put it in his mouth, on other occasions he would not manage to pick it up at all.

Some of the food items were more difficult than others for him to pick up. For example, the cheese biscuits were much flatter than the other food items and so were not grasped as easily as the pieces of chocolate sponge roll, which were sticky. Importantly, Mr Wright's preferences were independent of how easy he found it to grasp a particular item - his favourite item was also the most difficult to grasp.

Improvement in the success of grasping food items
Mr Wright improved in his ability to grasp some food items as he was given the opportunity to practise this skill across the eight sessions.

He showed most improvement in his ability to pick up the cheese biscuits. He managed to get the biscuits into his mouth only 38% of the time during the first session and 73% of the time by the fourth session. Although the cheese biscuits were the most difficult to grasp, they were the most consistent in shape and size and therefore may have been easy to learn to handle.

Discussion
Mr Wright showed that he quickly came to understand the concept of making a choice. He also demonstrated that he has food preferences and can make a choice. We have also learnt about some of the foods that he likes to eat. However, this choice-making procedure has the potential to be used beyond this one intervention.

In order for choice-making opportunities to make a real difference to Mr Wright's life, we must consider what is required to build choice-making into his daily routine.

If he is to benefit significantly his carers must give him opportunities to make choices (Reid, 1987), using events and objects that are relevant to his daily life (Windsor, 1994). This means that his carers would need the time to use these kinds of assessments to identify other foods and drinks that he likes, as well as exploring other aspects of his daily life. Additionally, assessment of preference needs to be repeated over time to assess any change.

With further work, it may be possible to extend Mr Wright's choice-making opportunities to less tangible and more important decisions. For example, one day he may be able to participate in making choices about social activities and aspects of his care.

According to Jackson and Jackson (1998), 'choice must not be seen as an optional extra to be attempted when 'the basics' of care are completed but must be seen as an integral part of each caring situation and as a fundamental human right that is essential to enhance the quality of life of people with a learning disability'.

It must also be acknowledged that it may be difficult to assimilate systematic choice-making opportunities into daily routines. Incorporating these procedures may interrupt people's usual routines and may involve a shift in the power relationship between the carer and client. Specifically, the carer is trying to determine the client's choices rather than making them for him. Despite these challenges, it has been demonstrated that the provision of systematic choice-making opportunities by carers is an attainable goal when appropriate training and support are provided (Parsons and Reid, 1990). Consequently, clients may only benefit when carers demand, and services supply, this training and support.

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