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.     

An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal

Consumption of solids and liquids occurs as a chain of behaviors that may include accepting, swallowing, and retaining the food or drink. In the current investigation, we evaluated the relative effectiveness of differential reinforcement of the first behavior in the chain (acceptance) versus differential reinforcement for the terminal behavior in the chain (mouth clean). Three children who had been diagnosed with a feeding disorder participated. Acceptance remained at zero when differential reinforcement contingencies were implemented for acceptance or mouth clean. Acceptance and mouth clean increased for all 3 participants once escape extinction was added to the differential reinforcement procedures, independent of whether reinforcement was provided for acceptance or for mouth clean. Maintenance was observed in 2 children when escape extinction was removed from the treatment package. The mechanism by which consumption increased is discussed in relation to positive and negative reinforcement contingencies.     

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.     

Use of the high-probability instructional sequence and escape extinction in a child with food refusal

We used the high-probability (high-p) instructional sequence with and without escape extinction in the treatment of food refusal. Acceptance increased and refusal decreased only with the introduction of escape extinction. These results raise important questions about the high-p sequence in the treatment of food refusal.     

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.     

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.     

Using negative reinforcement to increase self-feeding in a child with food selectivity

We examined the effects of a negative reinforcement-based treatment on the self-feeding of 1 child with food selectivity by type and texture. Self-feeding increased when the child could choose to either self-feed 1 bite of a target food or be fed 1 bite of the target food and 5 bites of another food. Possible mechanisms that underlie the effectiveness of the intervention and implications for future research are discussed.     

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.     

Examining extinction bursts in the treatment of pediatric food refusal

Escape extinction has been shown to be highly effective in the treatment of food refusal; however, unpleasant side effects such as extinction bursts may accompany extinction procedures. Bursting has been reported to occur in 24% to 39% of all cases for which extinction was used as a component during treatment of problem behavior. Although commonly used in treatments, the occurrence of extinction bursts in the treatment of pediatric food refusal has not been studied. This study measured the frequency of bursting in 10 children for whom escape extinction was used to treat food refusal. Results showed that extinction bursts were observed in 30% of the children included in the study, although they were relatively brief and resolved quickly. Considerations for using escape extinction in interventions will be discussed.     

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.     

Acquisition of cup drinking using previously refused foods as positive and negative reinforcement

We used previously refused foods as positive and negative reinforcement in the acquisition of cup drinking. Cup drinking increased with positive and negative reinforcement, both alone and in combination (without escape extinction), indicating that treatment of food refusal can establish some foods as appetitive stimuli whereas others remain aversive.     

Using reinforcer pairing and fading to increase the milk consumption of a preschool child

The present study replicates and extends previous research on the treatment of food selectivity by implementing pairing and fading procedures to increase a child's milk consumption during regularly scheduled preschool meals. The treatment involved mixing a small amount of chocolate syrup into a glass of milk and gradually eliminating the chocolate. The procedure and data collection were implemented by preschool teachers and resulted in increased milk drinking at school, which was maintained at home.     

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     

An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity

In the current investigation, we compared two methods of food presentation (simultaneous vs. sequential) to increase consumption of nonpreferred food for 3 children with food selectivity. In the simultaneous condition, preferred foods were presented at the same time as nonpreferred food (e.g., a piece of broccoli was presented on a chip). In the sequential condition, acceptance of the nonpreferred food resulted in presentation of the preferred food. Increases in consumption occurred immediately during the simultaneous condition for 2 of the 3 participants. For 1 participant, increases in consumption occurred in the simultaneous condition relative to the sequential condition, but only after physical guidance and re-presentation were added to treatment. Finally, consumption increased for 1 participant in the sequential condition, but only after several sessions. These results are discussed in terms of possible mechanisms that may alter preferences for food (i.e., establishing operations, flavor-flavor conditioning).     

Use of a multicomponent treatment for food refusal

We examined the use of a multicomponent treatment for food refusal exhibited by a 5-year-old boy who had been diagnosed with mild to moderate mental retardation. Treatment consisted of access to highly preferred tangible items, which were removed contingent on problem behavior or not accepting a bite, and differential reinforcement of alternative behavior. Treatment resulted in an increase in food acceptance to 100% of bite offers and near-zero rates of problem behavior. In addition, the participant's caregivers were successfully trained to implement the treatment.     

Analysis of establishing operations for self-injury maintained by escape

Self-injurious behavior (SIB) can be maintained through negative reinforcement when, in the context of training or task requirements, it produces escape as a consequence. Several studies have demonstrated methods for identifying and treating SIB maintained by negative reinforcement; however, few analyses of the establishing operations associated with demand situations have been conducted. The current series of studies illustrates a method for identifying some establishing operations for escape by systematically altering certain dimensions of the demand context while maintaining an escape contingency for SIB. Dimensions assessed in these studies included task novelty, duration of instructional sessions, and rate of task presentation. Data indicate that these variables can have establishing properties for behavior maintained by escape. Implications of the results are discussed, as are potential refinements and extensions of the assessment procedures.     

Using food redistribution to reduce packing in children with severe food refusal

Positive- and negative-reinforcement-based procedures typically have targeted acceptance for children with severe food refusal; however, these procedures do not always result in successful swallowing. Once acceptance is achieved, some children expel the food repeatedly or pack (hold or pocket) it in their mouths for extended periods of time. This study evaluated the effects of using food redistribution with a bristled massaging toothbrush to reduce packing and increase consumption in 4 children with severe feeding disorders. Packing was reduced for all children. In addition, latency to clean mouth (the duration of time from acceptance to food no longer being present in the child's mouth in the absence of expulsion) for 2 children decreased when the food-redistribution procedure was used. Results are discussed in terms of the potential operant functions of the food-redistribution procedure.     

The effects of variable-time delivery of food items and praise on problem behavior reinforced by escape

Prior research indicates that reinforcement of an appropriate response (e.g., compliance) can produce concomitant reductions in problem behavior reinforced by escape when problem behavior continues to produce negative reinforcement (e.g., Lalli et al., 1999). These effects may be due to a preference for positive over negative reinforcement or to positive reinforcement acting as an abolishing operation, rendering demands less aversive and escape from demands less effective as negative reinforcement. In the current investigation, we delivered a preferred food item and praise on a variable-time 15-s schedule while providing escape for problem behavior on a fixed-ratio 1 schedule in a demand condition for 3 participants with problem behavior maintained by negative reinforcement. Results for all 3 participants showed that variable-time delivery of preferred edible items reduced problem behavior even though escape continued to be available for these responses. These findings are discussed in the context of motivating operations.     

A further refinement of procedures addressing food selectivity

Individuals with autism and/or developmental disabilities are more likely than their typically developing peers to be food selective. Evidence‐based treatment packages for food refusal and selectivity include the use of reinforcement, escape extinction, and manipulation of antecedent events . In the current study, the variety of foods consumed by two adolescent males with food selectivity were systematically increased to include a variety of foods across all of the food groups. A changing criterion design was used to systematically increase the expectation of the amount and variety of foods that were consumed.