A comparison of Nuk presentation and Nuk redistribution to treat packing

Children with feeding disorders may pack food when they lack the oral‐motor skills, the motivation, or both to swallow. Presenting bites on the tongue with a Nuk brush, or redistribution, replacing packed food on the tongue, are two treatments whose relative efficacy is untested. In the current study, we compared the effects of (a) presenting on an upright spoon, (b) presenting on a Nuk, and (c) redistributing with a Nuk on two product measures of swallowing, which we refer to as 15‐s and 30‐s mouth clean, for three children with feeding disorders. Nuk presentation produced the highest levels of 15‐s mouth clean relative to Nuk redistribution and upright‐spoon presentation across participants. Levels of 30‐s mouth clean were higher during Nuk presentation and Nuk redistribution relative to upright‐spoon presentation for two participants. We discuss the oral‐motor skills and motivational deficits that might account for the findings.     

Comparison of bite-presentation methods in the treatment of food refusal

The current study examined the rate of expulsions and mouth cleans across 3 presentation methods (upright spoon, flipped spoon, Nuk brush) for a 3-year-old girl with a feeding disorder. The participant expelled all bites presented on an upright spoon. Results showed reduced rates of expulsions and increased mouth cleans during the flipped spoon and Nuk brush presentation methods.     

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.     

A flipped spoon and chin prompt to increase mouth clean

We treated the liquid refusal of a 15-month-old girl using 2 antecedent manipulations: flipped spoon and chin prompt. Use of the chin prompt in the absence of the flipped spoon failed to produce increases in mouth clean (a product measure of swallowing). By contrast, modest increases in mouth clean resulted from the implementation of the flipped spoon alone. The greatest increases in mouth clean resulted from the combination of the 2 manipulations.     

Sequential treatment of a feeding problem using a pacifier and flipped spoon

Parents may be reluctant to treat the feeding disorder of a chronically ill child who exhibits distressed behavior during feeding. In this study, we identified a child with chronic medical problems and a feeding disorder who cried during feedings. We introduced treatment components sequentially to address parental concerns about crying. First, we used a pacifier to reduce crying, and then we used a flipped spoon to increase mouth clean. The results showed that a sequential approach to treatment can be effective for children with complex medical and behavioral problems.     

An evaluation of emerging preference for non‐preferred foods targeted in the treatment of food selectivity

Several studies have shown that the acquisition of food consumption does not occur until after escape prevention is implemented. However, the mechanism responsible for the maintenance of food consumption may be due to participants contacting the reinforcing properties of food targeted during intervention such that the food naturally reinforces food consumption. The present study extended the literature on feeding disorders by conducting pre‐ and post‐treatment preference assessments to determine if preference for non‐preferred foods (NPFs) had developed after exposure to a treatment comparison of sequential and simultaneous food presentation; presentation methods were implemented alone and combined with escape prevention in the form of a non‐removal of the spoon (NRS) procedure. Results for three participants with food selectivity indicated that preference for NPFs developed after being exposed to those foods during either treatment sessions or generalization probes. Copyright © 2010 John Wiley & Sons, Ltd.     

Use of a high‐probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction

We evaluated the effects of a high‐probability (high‐p) instructional sequence on the feeding‐related compliance (food acceptance) of a young boy diagnosed with a feeding disorder. The high‐p sequence consisted of three presentations of an empty spoon; the low‐probability (low‐p) instruction was the presentation of a spoon with food. Results showed that acceptance of food increased in the presence and not the absence of the high‐p sequence. Data are discussed in terms of the role of high‐p instructional sequences in the treatment of feeding problems. Copyright © 2007 John Wiley & Sons, Ltd.     

A systematic review of physical guidance procedures as an open‐mouth prompt to increase acceptance for children with pediatric feeding disorders

This article reviews behavioral treatments of pediatric feeding disorders using physical guidance procedures as an open‐mouth prompt (i.e., jaw prompt, finger prompt, Nuk prompt, side deposit) to increase food acceptance. We identified 9 articles containing 35 systematic evaluations. We coded participant and study characteristics and assessed the experimental rigor, quality, and outcomes of each evaluation. Of the high‐quality research present, the finger prompt variation and side deposit reliably increased acceptance. We found mixed results on the efficacy of the jaw prompt, although it was the most widely researched procedure. Further, authors reported interobserver agreement for 100% of the participants, procedural integrity for 60%, social validity for 80%, fading for 5%, and follow‐up for 55%. Based on the invasive nature of physical guidance, we provide recommendations for researchers and clinicians to increase the quality of their treatment evaluations. We discuss limitations, implications for practice, and future research.     

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.     

Using a flipped spoon to decrease packing in children with feeding disorders

We evaluated the effects of redistribution and swallow facilitation with a flipped spoon on packing in 2 children with a feeding disorder. For both participants, packing decreased when we implemented the flipped spoon treatment package. Mechanisms responsible for behavior change and areas of future research are discussed.     

Decreasing expulsions by a child with a feeding disorder: using a brush to present and re-present food

Previous research has demonstrated that extinction in the form of re-presentation of expelled bites is an effective intervention for treating food expulsion. The current study compared the effectiveness of re-presenting expulsions with a spoon to re-presenting with a Nuk brush for a 4-year-old boy with a feeding disorder. Fewer expulsions were observed when using the brush for re-presentation, and further reductions were observed when the brush was also used for initial presentations.     

Blending to Treat Expulsion in a Child with Food Refusal

The current study examined the effect of blending established foods and non‐preferred foods to treat expulsions in a three‐year‐old girl with food refusal and gastrostomy‐tube dependence. Treatment involving differential reinforcement of acceptance, non‐removal of the spoon, and re‐presentation increased consumption of 12 out of the 16 pureed foods; however, high levels of expulsion of four foods continued to disrupt meals. Results showed reduced rates of expulsion and increased mouth clean during blending, evaluated empirically using an ABAB design. Copyright © 2015 John Wiley & Sons, Ltd.     

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.     

Utilizing in-vivo feedback for caregiver training of pediatric feeding protocols

Researchers have used multicomponent behavioral skills training packages including written and verbal instructions, modeling, rehearsal, and feedback when teaching caregivers to implement pediatric feeding treatment protocols (e.g., Anderson & McMillan, 2001; Seiverling et al., 2012). Some investigators have shown that fewer behavioral skills training components may be necessary for effective training (e.g., Mueller et al., 2003; Pangborn et al., 2013). We examined the use of in-vivo feedback following written instructions to train caregivers to implement pediatric feeding treatment protocols using a multiple baseline design across 3 caregiver dyads. Correct implementation of the feeding treatment procedures was low during baseline (written instructions only), increased with only the addition of in-vivo feedback, and remained high during follow-up sessions for all caregivers. Results are discussed in terms of clinical implications and caregiver satisfaction.     

An evaluation of toy quality for increasing self‐control in typically developing preschool children

Children often make impulsive choices, and previous research has shown that access to activities during the delay may enhance self‐control (e.g., Newquist, Dozier, & Neidert, 2012). The purpose of the current study was to extend the results of Newquist et al. (2012) by comparing the effects of access to low‐preference, moderate‐preference, and high‐preference toys during delays. Results showed that (a) all toys increased self‐control for 2 participants when toys were available for all choice options and (b) high‐preference toys (and sometimes moderate‐preference toys) increased self‐control for 3 participants when the toys were available only for large delayed choices.     

Use of a Side Deposit to Increase Consumption in Children with Food Refusal

Research has shown that nonremoval of the spoon and physical guidance procedures can be effective in treating active food refusal (e.g., head turning and spoon pushing) and increasing food consumption. These procedures alone may not be effective in treating more passive food refusal (e.g., sitting still without opening mouth). We defined and evaluated the use of a side deposit procedure using a reversal design. Results showed that this procedure, when added to a treatment package including other components (e.g., nonremoval of the spoon and physical guidance), was effective in increasing food consumption and treating passive food refusal. Copyright © 2015 John Wiley & Sons, Ltd.     

Treating food selectivity as resistance to change in children with autism spectrum disorder

Change-resistant behavior, such as rigid and selective food consumption, is a core symptom of autism that can have significant negative consequences for the child (Flygare Wallén et al., 2018; Levy et al., 2019). In the current study, we used a matching-law-based intervention (Fisher et al., 2019) to treat the change-resistant feeding behavior of 7 young children with autism. The feeder gave the participant a choice between a change-resistant and an alternative food during free- and asymmetrical-choice conditions. Alternative-food consumption increased for 2 participants during asymmetrical choice when the feeder provided a preferred item for consuming the alternative food and no programmed consequence for consuming the change-resistant food. Alternative-food consumption increased for the other 5 participants after the feeder exposed at least 1 food to single choice in which the feeder guided the participant to put the bite of alternative food in his or her mouth if he or she did not do so within 8 s of presentation. Effects of the single-choice contingencies maintained during reversals and generalized to other alternative foods the feeder did not expose to single choice. These results are important because participants consumed alternative foods even when their change-resistant foods were present, which is similar to typical mealtime contexts in which children have choices among foods.     

Understanding the foot‐in‐the‐door effect as a pseudo‐effect from the perspective of the Campbell paradigm

Compliance with a small request (a metaphorical foot‐in‐the‐door) promotes compliance with a subsequent big request. Whereas some explanations expect a drop in the behavioural costs of the big request, others suspect that the effect comes from boosting the underlying attitude. However, evidence for both explanations is equivocal and circumstantial, at best. Drawing on what Kaiser et al. (2010) call the Campbell paradigm, we present an integrative account: Compliance with any request demands a corresponding attitude to counterbalance the costs of the request. In our research, 229 participants were randomly assigned to either a foot‐in‐the‐door (i.e., initially asked to sign a pro‐environmental petition) or a control condition. Small‐request‐compliant participants were more likely than control participants to also comply with the big request and to continue filling out environmental‐issues‐related questionnaires. However, this foot‐in‐the‐door effect occurred without diminishing behavioural costs or increasing attitude levels. Accordingly, the greater likelihood of small‐request‐compliant participants to also comply with the big request can be parsimoniously explained by baseline variability in people's attitude levels that manifests in their compliance with the initial request. We conclude that several of the foot‐in‐the‐door effects reported in the literature carry the risk of representing mere pseudo‐effects.     

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.     

Evaluating different values of effort and reinforcement parameters under concurrent‐ and single‐operant arrangements

If particular parameters (e.g., reinforcer quality) are found to be preferred in a concurrent‐operant arrangement, then these should be incorporated into interventions for maintaining skills in individuals with intellectual disabilities. However, because results from a concurrent‐operant arrangement may not predict those of a single‐operant assessment, interventions with less preferred parameters may also be effective. The purpose of this study was to determine if preference for a particular parameter, determined via concurrent‐operant arrangements, predicted responding when two values of highly and less preferred parameters were manipulated in a single‐operant arrangement. Participants allocated responding to one parameter over another during concurrent‐operant assessments, indicating that certain parameters were highly preferred. However, contingent presentation of two values of less preferred parameters increased compliance to similar levels achieved with two highly preferred parameters in a single‐operant arrangement. These findings suggest that clinicians may have multiple options when selecting parameters for use during intervention.