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.     

FUNCTIONAL ANALYSIS AND TREATMENT OF MULTIPLY CONTROLLED INAPPROPRIATE MEALTIME BEHAVIOR

Functional analyses identified children whose inappropriate mealtime behavior was maintained by escape and adult attention. Function‐based extinction procedures were tested individually and in combination. Attention extinction alone did not result in decreases in inappropriate mealtime behavior or a significant increase in acceptance. By contrast, escape extinction alone resulted in a decrease in inappropriate mealtime behavior and an increase in acceptance. However, inappropriate mealtime behavior did not decrease to clinically acceptable levels. A combined extinction technique (i.e., escape and attention extinction) resulted in a decrease in inappropriate mealtime behavior to clinically acceptable levels and high and stable acceptance.     

Spoon-to-cup fading as treatment for cup drinking in a child with intestinal failure

We treated a child with intestinal failure who consumed solids on a spoon but not liquids from a cup. We used spoon-to-cup fading, which consisted of taping a spoon to a cup and then gradually moving the bowl of the spoon closer to the edge of the cup. Spoon-to-cup fading was effective for increasing consumption of liquids from a cup.     

Additive,Multi-Component Treatment of Emerging Refusal Topographies in a Pediatric Feeding Disorder

This case study describes inter-disciplinary treatment of chronic food refusal and tube dependency in a 2-year-old female with a pediatric feeding disorder. Evidence-based behavioral components—including escape extinction (EE), differential reinforcement of alterative mealtime behavior (DRA), and stimulus fading—were introduced sequentially as the focus of treatment shifted to address refusal topographies along the chain of behaviors associated with consumption. The assessment process, treatment planning and sequencing, and generalization of treatment gains to caregivers are presented in detail. In doing so, the study illustrates the core features involved in applying a flexible, evidenced-based approach to treat severe feeding difficulties.     

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.     

EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR WITH AND WITHOUT INSTRUCTIONAL FADING

Three individuals with developmental disabilities participated in a study of the treatment of self-injurious behavior (SIB) maintained by negative reinforcement (escape from educational tasks). Treatment was implemented in a multiple baseline design across subjects, in which two treatments were compared in a multielement format. Both treatment conditions included an escape-extinction component in which SIB no longer produced escape. One of the conditions also included a fading component in which the frequency of instructions was initially reduced to zero and then was gradually faded back in across sessions until the instructional rate matched that of the original baseline. Results indicated that extinction alone reduced SIB to the end-of-treatment criterion in fewer sessions than did extinction plus fading for all 3 subjects. For 2 of the 3 subjects, however, there was an initial increase in the frequency of SIB at the outset of treatment with extinction (an extinction burst) that was not observed when extinction was combined with the fading component.     

The Effects of Choice Between Nonpreferred Foods on the Food Consumption of Individuals with Food Selectivity

Previous research has concluded that presenting individuals with the opportunity to choose is a viable treatment for escape‐maintained behavior. Considering that food refusal behavior has been generally described as avoidant behavior, the present study aimed to evaluate the role of choice between nonpreferred foods on the food consumption and problematic mealtime behavior of two children with food selectivity. Each participant was allowed to choose between four nonpreferred foods in the choice condition and was not allowed to choose in the no‐choice condition. Further, the role of choice as an antecedent manipulation in mediating extinction‐induced responding was evaluated when choice alone was demonstrated to be ineffective in increasing consumption and a nonremoval of the spoon procedure was introduced. Results indicated that providing choices was effective in increasing the food consumption of one participant and was advantageous in decreasing emotional responding when a nonremoval of the spoon procedure was introduced for the second participant. Copyright © 2015 John Wiley & Sons, Ltd.     

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.     

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.     

STIMULUS (INSTRUCTIONAL) FADING DURING EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR

Three individuals with developmental disabilities were exposed to a series of assessment conditions to identify the source of reinforcement for their self-injurious behavior. In each case, self-injury occurred most often in instructional (demand) situations containing a brief time-out from the task contingent on self-injury, indicating that the behavior was an escape response (i.e., maintained by negative reinforcement). Treatment was implemented in a multiple baseline across subjects design and consisted of extinction (prevention of escape) plus instructional fading (initial elimination of instructions followed by their gradual reintroduction). Results showed that the combined treatment produced immediate and large reductions in self-injury that were maintained as the frequency of instructions was increased across sessions to match the original baseline rate of presentation. Results of a component analysis conducted with 1 subject suggested that stimulus fading accelerated the behavior-reducing effects of extinction.     

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.     

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.     

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.     

An evaluation of differential reinforcement with stimulus fading as an intervention for medical compliance

Individuals with autism spectrum disorder (ASD) often exhibit noncompliance during medical exams. One intervention used to address this concern is differential reinforcement. Although differential reinforcement includes extinction, it may not be feasible or safe to implement extinction during medical exams. In the current study, we evaluated differential reinforcement without extinction and differential reinforcement without extinction plus stimulus fading, for increasing compliance during routine medical exams exhibited by 4 individuals with ASD. An indirect assessment identified problematic medical procedures, and a functional analysis showed that participants' disruptive behavior was maintained by escape from medical tasks. Differential reinforcement without extinction was insufficient in increasing medical compliance with 3 of 4 participants. The addition of a modified stimulus fading procedure that involved gradually introducing smaller components of problematic exam steps was effective in increasing medical compliance with all exam steps.     

Increasing variety of foods consumed by blending nonpreferred foods into preferred foods

A treatment with differential or noncontingent reinforcement and nonremoval of the spoon increased the acceptance of one or two of 16 foods for 2 participants with severe food refusal. These differential levels of acceptance were demonstrated empirically in an ABAB design in which A was the presentation of the accepted (preferred) foods and B was the presentation of foods the participants refused (nonpreferred foods). Subsequently, we implemented a blending treatment that consisted of mixing (blending) nonpreferred foods into preferred foods in various ratios (e.g., 10% nonpreferred/90% preferred, 20% nonpreferred/80% preferred). We then presented nonpreferred foods that had been exposed to blending to determine if consumption of nonpreferred foods would increase following the blending treatment. We also conducted periodic reversals in which we presented nonpreferred foods that had not been exposed to the blending treatment. Following initial implementation of the blending treatment, consumption was high for nonpreferred foods that had been blended and low for nonpreferred foods that had not been blended. Consumption increased for all foods (i.e., foods that had been exposed to blending and foods that had not been exposed to blending) after seven or eight foods had been exposed to the blending treatment. Thus, the variety of foods consumed by the participants increased from one or two to 16. These results are discussed in terms of stimulus fading, conditioned food preferences, and escape extinction. DESCRIPTORS: conditioned food preferences, food refusal, negative reinforcement, stimulus fading     

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.     

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.     

A component analysis of a parent‐conducted multi‐component treatment for food selectivity

Treatment packages including differential reinforcement of alternative (DRA) behavior and escape prevention in the form of a non‐removal of the spoon procedure have been shown to successfully increase food consumption. However, when these treatment components are introduced simultaneously, the treatment component(s) responsible for behavior change cannot be determined. The purpose of this study was to conduct a sequential component analysis of the following treatment components: Bite fading, manipulation of reinforcer magnitude, and escape prevention. For two participants, food consumption did not increase until after escape prevention was introduced. For one participant, increased food consumption was observed after the magnitude of reinforcement was increased; therefore, escape prevention was not necessary. Results were maintained at a 12‐week follow‐up for all participants. Copyright © 2010 John Wiley & Sons, Ltd.