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.     

FOOD NEGLECT AND INFANT DEVELOPMENT

The impact of food insecurity on child development in the general U.S. population is well‐established, yet little is known about the harm of food neglect relative to other types of maltreatment. Due to the harmful physiological impact of inadequate nutrients and the social impact of food‐related stress, it was hypothesized that food neglect would be more likely to impair infant cognitive and language development than physical abuse, sexual abuse, and other forms of neglect. Families of infants (N = 1,951) investigated by Child Protective Services were studied using the second cohort of the National Survey of Child and Adolescent Well‐Being (NSCAW II; NSCAW Research Group, 2002). Results from multivariable logistic regression models that controlled for likely confounding variables showed that the odds of impairment in cognition and language were significantly greater when food neglect was the most serious form of maltreatment. Considering that both food insecurity and child neglect are associated with poverty and parental mental health problems, it will be important for child welfare and mental health professionals to work collaboratively to better the health of these vulnerable children.     

PEER-MEDIATED PROCEDURES TO INDUCE SWALLOWING AND FOOD ACCEPTANCE IN YOUNG CHILDREN

Two studies demonstrated a functional relationship between a peer modeling procedure and the treatment of feeding disorders with 2 young children. In the first experiment, the use of a peer model treatment package was shown to induce swallowing in a child with dysphagia who had never swallowed food or liquid. In the second experiment, a child who consistently declined food was induced to increase food acceptance as a function of the same peer modeling package. In the latter experiment, a peer-mediated procedure, consisting of rotated opportunities to consume food with a peer, was found to increase consumption more than did modeling alone. The first experiment used a multiple baseline design across solids and liquids, and the second used a multiple treatment design. The results of both experiments are discussed as new and nonaversive treatments for feeding disorders of young children who are imitative.     

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.     

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.     

Liquid fading to establish milk consumption by a child with autism

Liquid avoidance by children with developmental disabilities is a common problem but has not been researched extensively. In this study, a 4‐year‐old girl who had autism and food selectivity was taught to drink milk through a liquid fading procedure. The feeding protocol consisted of gradually increasing the concentration of milk in a beverage she consumed 100% of the time. Intervention was implemented by educational staff in a school setting. Milk consumption was achieved rapidly without interruption to the fading sequence. Clinical and research issues related to liquid avoidance and fading treatments are discussed. Copyright © 2005 John Wiley & Sons, Ltd.     

Further evaluation of modified‐bolus‐placement methods during initial treatment of pediatric feeding disorders

Children with feeding disorders might pack or expel food when they lack the oral‐motor skills, the motivation, or both, to swallow. Bolus placement directly on the tongue with a Nuk (e.g., Milnes et al., 2019) or flipped spoon (e.g., Sharp et al., 2010) is a treatment that researchers generally implement after such behavior emerges (e.g., Girolami et al., 2007). However, Wilkins et al. (2014) tested the relative efficacy of Nuk presentation and upright‐spoon presentation during initial treatment of pediatric feeding disorders. In the current study, we compared the effects of (a) upright‐spoon presentation; (b) Nuk presentation; and (c) flipped‐spoon presentation on two product measures of swallowing: 15‐ and 30‐s mouth clean, and expulsion during the initial treatment of feeding disorders with 5 children. We also monitored lip closure during bite presentation and following bolus placement. Nuk presentation produced the highest levels of mouth clean and the lowest rates of expels relative to upright‐spoon presentation and flipped‐spoon presentation. We discuss potential reasons why modified‐bolus‐placement methods improved feeding behavior and how measures of oral‐motor skills might predict its necessity during initial treatment.     

AN EVALUATION OF A PROGRESSIVE HIGH-PROBABILITY INSTRUCTIONAL SEQUENCE COMBINED WITH LOW-PROBABILITY DEMAND FADING IN THE TREATMENT OF FOOD SELECTIVITY

Few studies have examined the effects of the high‐probability instructional sequence in the treatment of food selectivity, and results of these studies have been mixed (e.g., Dawson et al., 2003 ; Patel et al., 2007 ). The present study extended previous research on the high‐probability instructional sequence by combining this procedure with low‐probability demand fading with 2 boys with autism (9 and 10 years old) who had a history of food selectivity and engaged in active food refusal behaviors when presented with novel foods. Response requirements were faded gradually from responses the child would tolerate (e.g., touching the food) to the final requirement of chewing and swallowing the food. The antecedent‐based intervention was implemented in the absence of escape extinction and was effective in increasing food consumption for both participants. Possible mechanisms responsible for the effectiveness of the intervention are discussed along with directions for future research.     

BEHAVIORAL ASSESSMENT AND TREATMENT OF CHRONIC FOOD REFUSAL IN HANDICAPPED CHILDREN

In this study, we examined the eating behavior of four handicapped children, none of whom exhibited self-feeding skills. All children had a history of food refusal and were nutritionally at risk; one child received all nourishment by way of a gastrostomy tube. Baseline data taken during mealtimes indicated that all children accepted very little food, expelled food frequently, and engaged in a number of disruptive behaviors. Treatments consisted of one or more of the following contingent events: social praise, access to preferred foods, brief periods of toy play, and forced feeding. Results of multiple-baseline and reversal designs showed marked behavioral improvement for each child and increases in the amount of food consumed. Further improvements were noted at follow-up, which ranged from 7 to 30 months posttreatment.     

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.     

AN ALTERNATING TREATMENTS COMPARISON OF TWO INTENSIVE INTERVENTIONS FOR FOOD REFUSAL

We compared two treatment packages involving negative reinforcement contingencies for 3 children with chronic food refusal. One involved physically guiding the child to accept food contingent on noncompliance, whereas the other involved nonremoval of the spoon until the child accepted the presented food. Subsequent to baseline, an alternating treatments comparison was implemented in a multiple baseline design across subjects. After each child had been exposed to at least nine sessions of each treatment condition and percentage of bites accepted had increased to at least 80%, the child's caregivers selected the preferred treatment package. The results indicated that both treatments were effective in establishing food acceptance. However, physical guidance was associated with fewer corollary behaviors, shorter meal durations, and parental preference.     

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.     

Randomized controlled trial of an applied behavior analytic intervention for food selectivity in children with autism spectrum disorder

Food selectivity is a common problem for children with autism spectrum disorder (ASD; Schreck, Williams, & Smith, 2004). Behavior‐analytic interventions have the most empirical support for feeding disorders (Sharp, Jaquess, Morton, & Miles, 2011). However, there are no randomized controlled trials that have evaluated its effects with a well‐defined cohort of children with ASD. In the current investigation, we randomly assigned 6 young children with ASD and food selectivity to either an applied behavior analytic intervention or a wait‐list control. We used a crossover randomized controlled trial to evaluate the effects of a multicomponent applied behavior analytic intervention on independent acceptance and mouth clean of 16 novel foods. We subsequently exposed the wait‐list control group to the intervention. We also evaluated the effects of the intervention on individual participants with single‐case designs. The percentage of independent acceptance and mouth clean increased for the applied behavior analytic intervention group, but not for the wait‐list control group until we implemented the intervention.     

Decreasing rumination using a starchy food satiation procedure

A starchy food satiation procedure was evaluated in an ABAB withdrawal design on the post‐meal rumination of a nine‐year‐old girl with autism. During treatment unlimited quantities of starchy foods were provided following each meal. High rates of rumination occurred during baseline conditions, followed by an immediate decrease in rumination during treatment. Rumination decreased to 82 and 97% of baseline during the first and second treatment conditions, respectively. In addition, follow‐up probes were conducted at irregular intervals for 4 years following treatment, during which zero or near‐zero rates of rumination were sustained. This study extends the literature on the functional relation between increased starchy food quantity and rumination in adults to rumination with a young child, and demonstrates maintenance of the treatment effect for 4 years. Copyright © 2002 John Wiley & Sons, Ltd.     

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.     

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.     

Using a chaser to decrease packing in children with feeding disorders

Packing is a problematic mealtime behavior that is characterized by pocketing or holding solids or liquids in the mouth without swallowing. In the current study, we examined the effects of a chaser, a liquid or solid consistently accepted and swallowed by the child, to decrease packing of solid foods in 3 children with feeding disorders. During the chaser procedure, the therapist presented the chaser immediately for 2 children or 15 s after each bite presentation for 1 child. The chaser was effective in decreasing packing for all 3 children. The results are discussed in terms of the clinical importance of the findings and directions for future research.     

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.     

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.