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.     

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.     

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.     

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.     

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.     

Noncontingent peer attention as treatment for disruptive classroom behavior

A functional analysis isolated peer attention as the primary maintaining variable for disruptive behavior displayed by a student with attention deficit hyperactivity disorder. Using a brief reversal design, noncontingent reinforcement was then shown to reduce disruptive behavior relative to the peer attention condition. Implications for assessing behavior disorders in mainstream school settings are discussed.     

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.     

Analysis of response covariationamong multiple topographies of food refusal

This study examined the effects of sequentially introducing treatment across multiple topographies of food refusal. Treatment with nonremoval of the spoon produced an increase in food acceptance and a decrease in disruption, but expulsion of food increased. When expulsion was treated, packing of food increased. Finally, when packing was treated, all refusal behaviors remained low, and acceptance continued to occur at high and stable levels.     

Functional analysis and treatment of self-injury associated with transitions.

We applied functional analysis methodology to the assessment and treatment of 2 individuals' self‐injurious behavior (SIB), which was reported to be occasioned by transitions from one activity or location to another. A structural (task) analysis of activity transitions identified at least three separate components that might influence behavior either alone or in combination: (a) termination of a prechange activity, (b) initiation of a postchange activity, and (c) movement from one location to another. Results of preference and avoidance assessments were used to identify activities to which participants were exposed in varying arrangements during transitions in a functional analysis. Results of 1 participant's functional analysis indicated that his SIB was maintained by avoidance of having to change locations, regardless of the activity terminated prior to the change or the activity initiated following it. The 2nd participant's analysis revealed the same function but also an additional one: avoidance of certain task initiations. This information was used to identify transition contexts during intervention and to design treatment procedures appropriate for a given context and behavioral function. A procedure involving advance notice of an upcoming transition had no effect on SIB, and differential reinforcement of alternative behavior (DRA) had limited effects in the absence of extinction. Sustained decreases in SIB were observed when DRA was combined with extinction and response blocking. Further extensions of functional analysis methodology to the assessment of problem behavior in situations characterized by multiple or protracted stimulus changes are discussed.     

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.     

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.     

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.     

An experimental analysis of task refusal: A comparison of negative reinforcement contingencies and transitions between academic tasks

The purpose of the study was to do an experimental analysis of academic task refusal for one girl with a developmental disability. Task refusal was analyzed in two experimental analyses. First, an analysis testing if the behavior was maintained by negative reinforcement, and the second, an analysis testing if the behavior was the result of transitioning between academic tasks differing in preference. Task refusal did not occur in the demand condition of the functional analysis, indicating that the behavior was not maintained by escape from demands. Conversely, task refusal occurred solely in the second experimental analysis when transitioning from a high-preferred to a low-preferred academic task. In this case, the context of terminating a preferred academic task and transitioning to a less preferred academic task was aversive but not the demand itself. In addition, when an embedded break condition was compared to a no break condition in a multielement design, task refusal was reduced to zero levels.     

Brief functional analysis and treatment of tantrums associated with transitions in preschool children

A brief functional analysis was used to examine the influence of termination of prechange activities and initiation of postchange activitieson tantrums exhibited by 2 preschool children. For 1 participant, tantrums were maintained by access to certain (pretransition) activities. For a 2nd participant, tantrums were maintained by avoidance of certain task initiations. Although advance notice of an upcoming transition was ineffective, differential reinforcement of other behavior plus extinction reduced tantrums for both participants.     

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.     

The influence of therapist attention on self-injury during a tangible condition

This study investigated the effects of therapist attention on the self-injurious behavior (SIB) of a 6-year-old girl with developmental disabilities. After results of a functional analysis indicated that SIB was maintained by attention and tangible reinforcement, tangible conditions with and without contingent verbal attention were compared. Results suggested that the inclusion of verbal attention in a tangible condition may confound functional analysis outcomes for behavior that is maintained by attention.     

Infant food refusal and parental social support

The purpose of this study was to examine the relations between various aspects of social support and maternal and infant outcome variables in a group of families having infants showing food refusal compared to a control group. In the case of early food refusal, the results indicated that access to emotional support and satisfaction with support were related to maternal psychosomatic health. The relationships were interpreted as showing that social support has moderating effects on negative outcomes of food refusal.     

A comparison of procedures for programming noncontingent reinforcement schedules

We compared two methods for programming and thinning noncontingent reinforcement (NCR) schedules during the treatment of self-injurious behavior (SIB). The participants were 3 individuals who had been diagnosed with mental retardation. Results of functional analyses indicated that all participants' SIB was maintained by positive reinforcement (i.e., access to attention or food). Following baseline, the effects of two NCR schedule-thinning procedures were compared in multielement designs. One schedule (fixed increment) was initially set at fixed-time 10-s reinforcer deliveries and was also thinned according to fixed-time intervals. The other schedule (adjusting IRT) was initially determined by participants' baseline interresponse times (IRTs) for SIB and was thinned based on IRTs observed during subsequent treatment sessions. Results indicated that both schedules were effective in initially reducing SIB and in maintaining response suppression as the schedules were thinned.     

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.     

Systematic application and removal of protective equipment in the assessment of multiple topographies of self-injury

We evaluated the effects of systematic application and removal of protective equipment on three topographies of self-injurious behavior (SIB) exhibited by a girl who had been diagnosed with autism. Results showed that when protective equipment was applied, SIB decreased to near-zero levels. In addition, withdrawal of protective equipment for specific topographies of SIB (by removing only the corresponding padding) increased rates of SIB only for that topography of SIB. Next, a functional analysis of hand SIB showed that protective equipment suppressed this behavior in all conditions and that the behavior was maintained by automatic reinforcement when padding was removed. Results are discussed in terms of sensory extinction as a possible mechanism responsible for response suppression.