Further examination of the treatment of multiply controlled inappropriate mealtime behavior

We systematically replicated Bachmeyer et al. (2009) by examining extinction procedures matched to each function, individually and in combination, to treat the food or liquid refusal of 4 children diagnosed with a feeding disorder whose inappropriate mealtime behavior was maintained by multiple functions (i.e., escape and attention). Previous research suggests that adding differential reinforcement to extinction procedures may result in better treatment outcomes. Therefore, we added differential reinforcement to extinction procedures matched to each function. Differential reinforcement and extinction matched only to escape or attention resulted in low rates of inappropriate mealtime behavior and high, stable levels of acceptance for only 1 child. Consistent with Bachmeyer et al., inappropriate mealtime behavior decreased, and acceptance increased for the remaining 3 children only after we matched differential reinforcement and extinction procedures to both escape and attention.     

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.     

Efficacy of functional analysis for informing behavioral treatment of inappropriate mealtime behavior: A systematic review and meta‐analysis

Children diagnosed with a feeding disorder often exhibit inappropriate mealtime behavior such as throwing or swiping food, which can exacerbate feeding difficulties during treatment. We conducted a meta‐analysis of 86 behavioral treatments for inappropriate mealtime behavior from 23 studies to assess the extent to which treatments based on a pretreatment functional analysis were more efficacious than those treatments not based on a functional analysis. Procedural escape extinction and attention extinction for inappropriate mealtime behavior, as well as differential reinforcement for food acceptance or consumption, represented the most common treatments independent of whether a functional analysis was conducted. No difference was detected between treatments that were and were not based on a functional analysis, and mean effect size across measures was identical (79%). The requirement of a pretreatment functional analysis for inappropriate mealtime behavior is equivocal given that standard care often includes efficacious treatment components that are not informed by a functional analysis.     

Spoon distance fading with and without escape extinction as treatment for food refusal

Little is known about the characteristics of meals that serve as motivating operations (MOs) for escape behavior. In the current investigation, we showed that the distance at which a therapist held a spoon from a child's lips served as an MO for escape behavior. Based on these results, we implemented spoon distance fading, compared fading with and without escape extinction (EE), and compared fading plus EE to EE alone. Initially, inappropriate mealtime behavior decreased during fading, but this effect was not maintained as fading progressed. Inappropriate mealtime behavior was lower initially when we combined fading and EE relative to EE alone, but acceptance increased more rapidly with EE than with fading plus EE. These results suggest that a number of mealtime characteristics might function as MOs for escape behavior and that analyses of MOs may be useful for developing treatments for food refusal.     

Noncontingent and differential reinforcement in the treatment of pediatric feeding problems

We conducted functional analyses of the inappropriate mealtime behavior of 5 children diagnosed with feeding problems. Then, we compared the effects of differential and noncontingent reinforcement, and the relative effects of escape extinction with and without differential or noncontingent reinforcement, when escape extinction appeared necessary. Both reinforcement procedures were effective without escape extinction to treat food refusal for 1 child, but only differential reinforcement was effective without escape extinction to treat the child's liquid refusal. Escape extinction was necessary for 4 of 5 children. The addition of positive reinforcement resulted in beneficial effects (i.e., more stable acceptance, decreased inappropriate mealtime behavior or negative vocalizations) with 3 of 4 children. With escape extinction, differential reinforcement was more effective to treat food refusal for 2 children and noncontingent reinforcement was more effective for 1 child.     

On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal

In the current investigation, we evaluated the relative effects of noncontingent reinforcement (NCR), escape extinction, and a combination of NCR and escape extinction as treatment for the feeding problems exhibited by 4 children. For each participant, consumption increased only when escape extinction was implemented, independent of whether NCR was present or absent. These results were consistent with prior research suggesting that positive reinforcement alone is insufficient for increasing consumption, and that escape extinction often is necessary to increase and maintain food acceptance. However, NCR appeared to decrease inappropriate behavior for some participants.     

On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal

We compared the effects of positive reinforcement alone, escape extinction alone, and positive reinforcement with escape extinction in the treatment of the food and fluid refusal of 4 children who had been diagnosed with a pediatric feeding disorder. Consumption did not increase when positive reinforcement was implemented alone. By contrast, consumption increased for all participants when escape extinction was implemented, independent of the presence or absence of positive reinforcement. However, the addition of positive reinforcement to escape extinction was associated with beneficial effects (e.g., greater decreases in negative vocalizations and inappropriate behavior) for some participants.     

A comparison of functional analysis methods of inappropriate mealtime behavior

Investigators have evaluated two procedural variations for conducting a functional analysis of inappropriate mealtime behavior exhibited by children with feeding problems. One method involves prompting bites only in the escape condition (e.g., Najdowski et al., 2008). Another method involves prompting bites across all conditions (e.g., Piazza et al., 2003). We assessed the food refusal of 3 children diagnosed with a feeding disorder by comparing the two variations. The two methods resulted in different outcomes for 2 of 3 children. Prompting bites only in the escape condition identified a single function (i.e., escape). Prompting bites across all conditions identified multiple functions (i.e., escape and attention). We then examined the relative effects of extinction procedures (individually and in combination) to determine the validity of each method. Results of the treatment evaluation suggested that the procedural variation that failed to identify an attention function for 2 of 3 children produced false negative findings.     

A comparison of two multicomponent treatment packages for food refusal

Food refusal is a severe feeding problem in which children refuse to eat all or most foods, which can be treated effectively using multicomponent intervention packages. This study compared two multicomponent treatment packages on food and drink consumption, inappropriate mealtime behavior, and total intake in a child with food refusal. Bite and drink consumption was consistently higher; inappropriate mealtime behavior was consistently lower; and total intake was greater when differential reinforcement of alternative behavior and escape extinction treatment were implemented compared to response cost, escape extinction, and differential reinforcement of alternative behavior.     

The effects of sleep disruption on the treatment of a feeding disorder

We evaluated the effects of sleep disruption on the mealtime behavior of a young boy with developmental disabilities. Results showed that bite acceptance was less likely to persist during meals following disrupted sleep, but only when escape extinction was not implemented. Findings are discussed in terms of establishing operations and the effects of sleep disruption on the assessment and treatment of feeding problems.     

Escape as reinforcement and escape extinction in the treatment of feeding problems

Given the effectiveness of putative escape extinction as treatment for feeding problems, it is surprising that little is known about the effects of escape as reinforcement for appropriate eating during treatment. In the current investigation, we examined the effectiveness of escape as reinforcement for mouth clean (a product measure of swallowing), escape as reinforcement for mouth clean plus escape extinction (EE), and EE alone as treatment for the food refusal of 5 children. Results were similar to those of previous studies, in that reinforcement alone did not result in increases in mouth clean or decreases in inappropriate behavior (e.g., Piazza, Patel, Gulotta, Sevin, & Layer, 2003). Increases in mouth clean and decreases in inappropriate behavior occurred when the therapist implemented EE independent of the presence or absence of reinforcement. Results are discussed in terms of the role of negative reinforcement in the etiology and treatment of feeding problems.     

Parental use of escape extinctionand differential reinforcement to treat food selectivity.

Escape extinction combined with differential reinforcement for acceptance has been demonstrated to be an effective treatment for food selectivity when implemented by trained professionals in clinic settings. This study evaluated the efficacy of parent-implemented escape extinction in the child''s natural environment using video monitoring to train parents and assess intervention efficacy. Parents were able to use intervention to significantly increase bites accepted and decrease problem behavior.     

A translational evaluation of renewal of inappropriate mealtime behavior

The term renewal describes the recurrence of previously extinguished behavior that occurs when the intervention context changes. Renewal has important clinical relevance as a paradigm for studying treatment relapse because context changes are necessary for generalization and maintenance of most intervention outcomes. The effects of context changes are particularly important during intervention for pediatric feeding disorders because children eat in a variety of contexts, and extinction is an empirically supported and often necessary intervention. Therefore, we used an ABA arrangement to test for renewal during intervention with 3 children diagnosed with a feeding disorder. The A phase was functional reinforcement of inappropriate mealtime behavior in a simulated home setting with the child's caregiver as feeder, B was function‐based extinction in a standard clinic setting with a therapist as feeder, and the return to the A phase was function‐based extinction in a simulated home setting with caregiver as feeder. Returning to Context A resulted in renewal of inappropriate mealtime behavior across children, despite the caregivers' continued implementation of function‐based extinction with high levels of integrity.     

A COMPARISON OF SENSORY INTEGRATIVE AND BEHAVIORAL THERAPIES AS TREATMENT FOR PEDIATRIC FEEDING DISORDERS

We compared the effects of escape extinction (EE) plus noncontingent reinforcement (NCR) with sensory integration therapy as treatment for the feeding problems of 2 children. Results indicated that EE plus NCR was more effective in increasing acceptance, decreasing inappropriate behavior, and increasing amount consumed relative to sensory integration for both children. The results are discussed in terms of the challenges of evaluating sensory‐integration‐based treatments, and the reasons why component analyses of multicomponent treatments like sensory integration are important.     

Comparison of upright and flipped spoon presentations to guide treatment of food refusal

The current study examined the effects of bite placement with a flipped versus upright spoon on expulsion and mouth clean (product measure of swallowing) in the treatment of 3 children diagnosed with a pediatric feeding disorder and oral-motor deficits. For all 3 participants, extinction in the form of nonremoval of the spoon led to improvements in inappropriate mealtime behavior and acceptance of bites; however, re-presentation did not reduce expulsion or improve mouth clean. Results showed a lower level of expulsion and higher percentage of mouth clean during flipped spoon presentations and re-presentations for all participants. Findings from follow-up analyses supported transitioning back to an upright spoon in all 3 cases, although the time required for this to occur differed across participants.     

MOMENTUM VERSUS EXTINCTION EFFECTS IN THE TREATMENT OF SELF-INJURIOUS ESCAPE BEHAVIOR

An individual's self-injurious escape behavior was treated using a high-probability instructional sequence with and without extinction. When presented alone, the high-probability sequence did not reduce self-injurious behavior. When escape extinction was implemented either alone or in combination with the high-probability sequence, self-injury decreased and compliance increased, suggesting that extinction may be a necessary component of the treatment for behavior problems maintained by escape.     

THE USE OF POSITIVE AND NEGATIVE REINFORCEMENT IN THE TREATMENT OF ESCAPE-MAINTAINED DESTRUCTIVE BEHAVIOR

We identified 3 clients whose destructive behavior was sensitive to negative reinforcement (break from tasks) and positive reinforcement (access to tangible items, attention, or both). In an instructional context, we then evaluated the effects of reinforcing compliance with one, two, or all of these consequences (a break, tangible items, attention) when destructive behavior produced a break and when it did not (escape extinction). For 2 clients, destructive behavior decreased and compliance increased when compliance produced access to tangible items, even though destructive behavior resulted in a break. For 1 client, extinction was necessary to reduce destructive behavior and to increase compliance. Subsequently, when the schedule of reinforcement for compliance was faded for all clients, destructive behavior was lower and fading proceeded more rapidly when compliance produced multiple functional reinforcers (i.e., a break plus tangible items or attention) and destructive behavior was on extinction. The results are discussed in terms of the effects of relative reinforcement value and extinction on concurrent operants.