USE OF TEXTURE FADING IN THE TREATMENT OF FOOD SELECTIVITY

Children with feeding disorders often display severe food selectivity. For many of these children, consuming highly textured foods may be aversive or potentially dangerous because of frequent gagging. The purpose of this study was to demonstrate the efficacy of texture fading in the treatment of food selectivity displayed by 4 children. Treatment involved the gradual addition of higher textures based on the results of periodic probes. In addition, food acceptance and swallowing were reinforced, while food refusal and food expulsion were placed on extinction. Results showed that all participants successfully advanced to consumption of age-appropriate texture and volume. The results suggest that texture fading with intermittent probes at higher textures may be an effective method for the treatment of food selectivity by texture.     

An evaluation of food type and texture in the treatment of a feeding problem

An evaluation of food type and texture indicated that both variables affected the expulsions of a 3-year-old with feeding problems. The results of the evaluation were used to prescribe a treatment (reducing the texture of one food type) that reduced expulsion.     

Evaluation of empirical pretreatment assessments for developing treatments for expulsion in pediatric feeding disorders

A common problem among children with feeding disorders is expulsion (removing or spitting food or drink from the mouth), which interferes with treatment success when the goal is consumption. Previous research has identified effective treatments to reduce expulsion, most commonly—re-presentation (presenting the expelled bite or a new bite of the same food immediately following the expulsion). However, there is not currently an assessment model in place to inform treatment decisions with a goal to reduce expulsion. In the present study, we used a multielement design to identify conditions under which little or no expulsion occurred with three children with feeding disorders. The results of the assessment were then used to inform treatment selection aimed to eliminate expulsion. The comparisons of the assessment included physical prompt, bite number, texture, preference, bite presentation style, and size of the bite. Results suggest that this assessment was useful for the design of individualized treatments for children who frequently expel food.     

USE OF EXTINCTION AND REINFORCEMENT TO INCREASE FOOD CONSUMPTION AND REDUCE EXPULSION

Extinction and reinforcement contingencies were used to treat 2 children with feeding disorders. Positive reinforcement and avoidance extinction effectively increased food acceptance but also increased food expulsion. Reduced expulsion and increased swallowing were achieved by repeated presentation of expelled food, a second extinction component.     

SEPARATE AND COMBINED EFFECTS OF METHYLPHENIDATE AND A BEHAVIORAL INTERVENTION ON DISRUPTIVE BEHAVIOR IN CHILDREN WITH MENTAL RETARDATION

We investigated the separate and combined effects of a behavioral intervention and methylphenidate (Ritalin®) on disruptive behavior and task engagement in 3 children with severe to profound mental retardation. The behavioral intervention involved differential reinforcement of appropriate behavior and guided compliance. All 3 children demonstrated decreased disruptive behavior and improved task engagement in response to the behavioral intervention. Two of the 3 children demonstrated similar improvement in response to methylphenidate. Although both interventions were highly effective for these 2 participants, the relative efficacy of the interventions varied between the 2 children. There was no evidence of an additive or synergistic effect of the two interventions, but the high efficacy of each intervention alone limited our ability to detect such effects.     

Bite size and texture assessments to prescribe treatment for severe food selectivity in autism

Separate evaluations of bite size (amount of food on the spoon) and food texture were used to prescribe treatment changes in a feeding protocol for a 3‐year‐old male with autism and severe food selectivity. Each evaluation revealed distinct behavioral topographies, with an increase in disruptive behaviors associated with increased bite sizes and decreased swallowing and higher rates of gagging associated with higher textures. The results of each evaluation were used to successfully guide increases in volume and texture during therapeutic meals. Results highlight the importance of considering both aversion to food as well as oral motor skills when designing treatment for children with food selectivity. Copyright © 2009 John Wiley & Sons, Ltd.     

Ten-year follow-up of a successful treatment of self-injurious behavior

Ten years ago, self-injurious behavior that produced blindness in a man with profound mental retardation was treated through behavioral intervention. This person's behavioral history was reviewed for 12 years prior to the intervention through examination of his clinical record and for 10 years following the intervention through examination of his clinical record, direct observation, and interviews with staff. Physical injury occurred only once in the last 46 months; physical restraint has not been used in 10 years; and for the past 9 years, no more than one medication has been prescribed for the control of behavior or seizures. Suggestions are presented for designing behavioral interventions at the beginning of treatment to maintain reductions in behavior.     

The Relationship of Functional Variables and Psychopathology to Aggressive Behavior in Persons With Severe and Profound Mental Retardation

A number of hypotheses have emerged regarding the etiology of physical aggression in persons with mental retardation. Although a multicomponent model is appropriate, results of functional analysis-based studies have yielded promising results in identifying instigating and maintaining factors of aggression. However, the relationship between functional variables and conditions such as psychiatric diagnosis to aggressive behavior has yet to be investigated in persons with mental retardation. We conducted a study examining the prevalence of environmental or physical factors in aggressive behavior in mentally retarded persons with and without psychiatric disturbance. One hundred and thirty-five individuals with mental retardation who exhibited physical aggression were assessed with the Questions About Behavior Function Scale (QABF) to identify environmental or physical contribution to aggressive behavior. One or more behavioral functions were identified for 75% of the participants. Additionally, of 66 of the participants scoring above the clinical cutoff on an assessment for dual diagnosis, 75% met criteria for an environmental or physical function for aggression. No significant differences in number of participants with an identifiable function of aggression were found between the no dual diagnosis and dual diagnosis groups. Our findings underscore the importance of identifying functions underlying aggressive behavior in persons with mental retardation, and the need to consider functional variables regardless of psychiatric condition in treatment planning efforts for such individuals.     

ASSESSING FOOD PREFERENCES AMONG PERSONS WITH PROFOUND MENTAL RETARDATION: PROVIDING OPPORTUNITIES TO MAKE CHOICES

Increased attention has been directed recently to assisting persons with severe handicaps to express preferences concerning events in their lives. We evaluated a program for assessing choice-making skills to provide opportunities for persons with profound mental retardation to express food and drink preferences. In Experiment 1, the assessment procedure involving repeated, paired-item presentations resulted in active choice making and the identification of preferences for all 5 participants. Results also indicated that caregiver opinion was not predictive of participant food and drink preferences. A survey of service providers supported the importance of meal-related choices in this population. In Experiment 2, the practicality of the assessment procedure was supported by demonstrating that (a) routine caregivers could apply the procedure with appropriate supervision to provide choice opportunities, and (b) results of the procedure were predictive of participant choices when a less structured and more normal opportunity to express a preference was provided during regular mealtimes. Results are discussed in terms of extending the developing technology of preference and reinforcer identification to other important areas for persons with severe disabilities.     

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.     

Staff management procedures and changes in the distribution of nontargeted activities by residential staff members: A secondary analysis

Staff management procedures are increasingly used to improve quality of care in residential facilities for individuals with mental retardation. Typically, residential staff members are prompted to increase and then maintain their frequency of activities within one or more target categories of behavior (e. g., training residents) and are regularly fed back on their performance. There is, however, no evidence as to what are the effects of staff management procedures on other, nontargeted activities of residential staff. Six groups of residential staff members (n=49) and 58 individuals with severe and profound levels of mental retardation participated. Observational data on staff behaviors were collected within eight mutually exclusive and exhaustive categories. When a procedure of staff management was in effect, a statistically significant increase in the time spent on the target categories of stimulative custodial care and training was associated with a statistically significant (a) increase in time spent on organization, (b) decrease in time spent on routine custodial care, and (c) decrease in time being engaged in off-task behavior. There were no statistically significant differences found with respect to staff members' time spent on housekeeping, in offering individuals recreational activities, and in taking rest.     

Interstitial deletion on chromosome 5q33.3q35.1 in a 6-year-old girl -- neuropsychological findings and follow-up in an extremely rare chromosomal aberration.

Interstitial deletion on chromosome 5q33.3q35.1 is an extremely rare chromosomal aberration for which a characteristic syndrome could not yet be delineated. In most patients with 5q deletions severe mental retardation is described. Recently, Spranger et al. (2000) described the case of a 4-year-old girl with a de novo deletion on 5q33.3q35.1 presenting only with mild psychomotor delay, minor facial anomalies, and seizures. The patient was admitted for outpatient neuropsychological assessment when she was 6.2 years old. Neurocognitive tests revealed an overall developmental delay of about 32 months and an intelligence score in the range of mild mental retardation. Her cognitive phenotype was characterized by a considerable visual-spatial deficit in the form of disorganized drawings or block designs indicating a profound lack of cohesion and overall global organization (decay of gestalt). The patient's behavioral phenotype was dominated by a distinct disinhibition syndrome demonstrating severe hyperactivity, utilization behavior, and aggressive behavior.     

An evaluation of in vivo desensitization and video modeling to increase compliance with dental procedures in persons with mental retardation

Fear of dental procedures deters many individuals with mental retardation from accepting dental treatment. This study was conducted to assess the effectiveness of two procedures, in vivo desensitization and video modeling, for increasing compliance with dental procedures in participants with severe or profound mental retardation. Desensitization increased compliance for all 5 participants, whereas video modeling increased compliance for only 1 of 3 participants.     

An economical,humane, and effective method for short—term suppression of hand mouthing

Self-injurious behavior (SIB) is a serious health hazard, especially among individuals with severe and profound mental retardation, sometimes leading to drastic therapeutic measures. Environments in which there are long periods with minimal opportunities for constructive activity are conducive to the development of SIB, but even highly motivated, hard-working caregivers sometimes have difficulty providing sufficient personal interactions to prevent it. In this case study, one person's self-injurious hand mouthing was significantly reduced by analyzing her toy play and consistently providing her with preferred toys. The results showed that careful and consistent attention to assuring that preferred materials are available for self-entertainment may be an effective and efficient method for managing some cases of SIB during times when other activities and treatments are unavailable.     

THE COSTS OF EATING: A BEHAVIORAL ECONOMIC ANALYSIS OF FOOD REFUSAL

Behavioral economic concepts were applied to the analysis and treatment of pediatric feeding disorders in a clinical setting. In Experiment 1, children who chronically refused food were presented with varying amounts of food on a spoon (empty, dipped, quarter, half, and level). Each child exhibited a different but orderly demand function of response (acceptance, expulsion, and mouth clean) by cost (increasing spoon volume) for a constant pay-off of toys and social interaction. In Experiment 2, physical guidance or nonremoval of the spoon for food refusal was initiated at the smallest spoon volume with low levels of acceptance, and was subsequently introduced at the largest spoon volume with moderate levels of acceptance. Treatment was effective in increasing acceptance, and these effects generalized hierarchically across untargeted spoon volumes. The results of both studies provide preliminary support that increasing spoon volume can be equated conceptually with increasing response effort, and that the change from differential reinforcement to physical guidance or nonremoval of the spoon appears to have altered the elasticity of each child's demand function.     

MEASURING AND INCREASING THE HAPPINESS OF PEOPLE WITH PROFOUND MENTAL RETARDATION AND PHYSICAL HANDICAPS

Applied research in mental retardation has focused on skill training and education to the relative neglect of measuring and increasing happiness in the lives of people with mental retardation. Here we report the results of four preliminary studies that were conducted to develop and demonstrate methodologies for measuring happiness in people with profound mental retardation and other severe handicaps. These results suggest that: (1) facial expressions can provide a valid measure of happiness, and can be measured reliably by relatively untrained observers; (2) the rate of spontaneous smiling is highly variable across individuals; (3) some individuals’ happiness can be increased dramatically by very simple social interactions; and (4) clients’ differential emotional reactions to various caregivers may be useful in tracking the development of social relationships. Suggestions for future research include systematic replication of these preliminary findings with a larger number and variety of subjects, and demonstration of how these measures can be applied to quality assurance systems.     

OBSERVATION AND COMPARISON OF MEALTIME BEHAVIORS IN A SAMPLE OF CHILDREN WITH AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDERS AND A CONTROL SAMPLE OF CHILDREN WITH TYPICAL DEVELOPMENT

Despite widespread use of behavioral observations to evaluate child feeding behaviors in research and clinical practice, few studies have comprehensively characterized mealtimes or identified features that differentiate children with and without disordered feeding; these were the aims of the current study. Mealtime observations were conducted for 18 children with avoidant restrictive food intake disorder (ARFID) and 21 typically developing children. Observations were coded inductively, and associations between disorder and observed mealtime actions were examined. Most behaviors were observed across both clinical and nonclinical mealtimes, and many did not differ in frequency between children with and without ARFID. However, significant group differences were observed in the frequencies of behaviors relating to food intake, visual and physical engagement with feeding, and movement during mealtimes. The comparability of behaviors across clinical and nonclinical groups suggests that eating behaviors exist on a continuum from “normal” to “abnormal,” with group differences relating to frequency rather than type of behavior. The behavioral differences observed in this study suggest that identification of children with ARFID should focus on child engagement with food and restlessness during mealtimes. Reliance on emotional and escape‐maintained behaviors will lead to underrecognition of families in need of clinical support.     

Measuring behavior in genetic disorders of mental retardation

As researchers have examined the so-called "behavioral phenotypes" of different genetic mental retardation conditions, the measurement of behavior becomes increasingly important. From earlier, more global examinations of noteworthy behaviors or profiles, recent researchers have moved from reliance on a single, all-encompassing questionnaire to more multimethod, multireporter approaches. This paper summarizes strengths and weaknesses in utilizing parent-report questionnaires and checklists; psychiatric nosology and specific psychiatric questionnaires; observational studies; reports from individuals with mental retardation themselves; profile analyses of psychometric test and subtest scores; and "grouping" analyses of items (factor analysis) and people (cluster analysis). Although we advocate a mixture of approaches to behavioral assessment, in future work researchers will require more theoretically driven methods for studying behavior, greater acknowledgment that the child's behavior is simply one event in ongoing interactions-transactions with other people, and more attention to age-related changes in behavioral phenotypes.     

Intelligence Testing and its Implications for Disability Evaluation in Individuals with Mental Retardation

Disability evaluation in mental retardation, which is done through assessment of intelligence, has certain inherent problems. The situation gets more complex if the person has additional disabilities, which is very likely in mental retardation. As an initiative, this study aims to study problems faced in intelligence testing in persons with mental retardation. The study included 88 randomly selected files of the individuals with mental retardation registered at the National Institute for the Mentally Handicapped (NIMH) Regional Centre, Kolkata during 2007-08. Each file was reviewed for information on diagnosis mental retardation, associated conditions and the intelligence testing reports. The results indicated that specific factors including both the characteristics of mental retardation and the nature of the tests available were interfering with intelligence testing. The problems are discussed in the context of current constructs related to mental retardation, diagnostic systems and legislation.