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.     

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.     

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.     

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.     

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.     

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.     

A COMPARISON OF SIMULTANEOUS AND DELAYED REINFORCEMENT AS TREATMENTS FOR FOOD SELECTIVITY

This study compared the relative efficacy of providing simultaneous or delayed reinforcement on food acceptance during meals. The participant was a 7-year-old boy with pervasive developmental disorder and a history of food selectivity. Results indicated that both procedures were effective in increasing acceptance; however, the simultaneous reinforcement procedure produced more rapid behavior change and a higher overall percentage of food acceptance.     

Effect of two methods of introducing foods during feeding treatment on acceptance of previously rejected items

The effects of using a single food item (e.g. bread) versus using multiple items (e.g. bread, pasta, and rice) when establishing food acceptance via an escape prevention procedure were investigated with six children who presented with food selectivity. Eating was exposed to a differential reinforcement of food acceptance treatment package but food acceptance did not improve. Criterion levels of appropriate eating (> 80% acceptance, < 20% expulsion, and < 20% disruption) were subsequently established with either nonremoval of the spoon or physical guidance for each of the participants. Three of the children were presented with only one food item during acquisition of acceptance. The other children were presented with three different food items from the same food group. It was found that acquisition of acceptance was more rapid for the single‐item group but that food acceptance was more likely to generalize to previously rejected items for the multi‐item group. The implications for clinical intervention are discussed. Copyright © 2002 John Wiley & Sons, Ltd.     

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.     

Effective instructional procedures for teaching individuals with severe disabilities in motor skills

The purpose was to describe effective instructional procedures used to teach motor skills to individuals with severe disabilities. Five effective instructional procedures supported with experimental data in adapted physical education are identified through the review of literature: (a) response shaping, (b) increasing prompt hierarchy, (c) decreasing prompt hierarchy, (d) constant time delay, and (e) progressive time delay. The characteristics, documentations, guidelines, and recommendations for application of these procedures are described.     

Treating liquid expulsion in children with feeding disorders

In the current investigation, we compared and evaluated the effects of two intervention procedures, a modified chin prompt and reclined seating, on the liquid expulsion of 2 children with feeding disorders. For both participants, expulsion decreased to clinically meaningful levels when we added the modified chin prompt or reclined seating to a treatment package consisting of differential reinforcement of acceptance, nonremoval of the cup, and re‐presentation. We discuss possible mechanisms underlying the effects of the 2 interventions and areas for future research.     

USE OF COMPONENT ANALYSES TO IDENTIFY ACTIVE VARIABLES IN TREATMENT PACKAGES FOR CHILDREN WITH FEEDING DISORDERS

We evaluated the separate components in treatment packages for food refusal of 4 young children. First, treatment packages were implemented until food acceptance improved. Next, a component analysis was conducted within a multielement or reversal design to identify the active components that facilitated food acceptance. The results indicated that escape extinction was always identified as an active variable when assessed; however, other variables, including positive reinforcement and noncontingent play, were also identified as active variables for 2 of the children. The results suggest that the component analysis was useful for identifying variables that affected food acceptance.     

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).     

An analysis of modifications to the three-step guided compliance procedure necessary to achieve compliance among preschool children

After a 3‐step guided compliance procedure (vocal prompt, vocal plus model prompt, vocal prompt plus physical guidance) did not increase compliance, we evaluated 2 modifications with 4 preschool children who exhibited noncompliance. The first modification consisted of omission of the model prompt, and the second modification consisted of omitting the model prompt and decreasing the interprompt interval from 10 s to 5 s. Each of the modifications effectively increased compliance for 1 participant. For the remaining 2 participants, neither modification was effective; differential reinforcement in the form of contingent access to a preferred edible item was necessary to increase compliance. Problem behavior varied across participants, but was generally higher during guided compliance conditions and lower during differential reinforcement conditions.     

OPERANT CONTROL OF PATHOLOGICAL TONGUE THRUST IN SPASTIC CEREBRAL PALSY

Pathological tongue thrust (reverse swallowing) has been associated with neuromuscular disorders and linked to dental malocclusion, articulation problems, difficulty in eating, and excessive drooling. In this study, observable tongue thrust in a 10-year-old retarded male was modified during mealtime using a procedure consisting of differential reinforcement (presentation of food contingent upon tongue in) and punishment (gently pushing the tongue back into the mouth with a spoon). Results of a reversal design showed substantial decreases in tongue thrust and food expulsion, and a large increase in observed chewing. These data compared favorably with data obtained for other retarded persons not judged to be tongue thrusters; in addition, the objective results of the treatment program were substantiated via pre-post evaluations done by occupational and physical therapists. These findings suggest that operant techniques may be an effective means of treating tongue thrust and its associated problems, and that further development and evaluation of behavioral interventions may provide a desirable alternative to more intrusive surgical or mechanical procedures.     

SEQUENTIAL APPLICATION OF CAREGIVER TRAINING TO IMPLEMENT PEDIATRIC FEEDING PROTOCOLS

The purpose of this study was to evaluate the effectiveness of current caregiver training practices by implementing training components sequentially, to teach parents mealtime protocols. A multiple baseline design was implemented across two caregiver dyads. Therapist‐fed meals were conducted prior to training to identify an effective intervention to increase food acceptance and decrease food refusal. The package consisted of seven components: observation, written and verbal protocol review, video review, structured observation, modeling, role play, and immediate feedback. Correct implementation of mealtime protocols, by caregivers, were evaluated throughout the training process by having caregivers conduct meal sessions following each training component to determine if additional training was necessary. Results showed that the training procedures were effective in teaching caregivers to implement mealtime protocols, and systematic introduction of the training components produced systematic and incremental changes in correct caregiver implementation. In addition, all participants completed training without requiring all seven training components. Copyright © 2012 John Wiley & Sons, Ltd.     

INCREASING THE IMMUNIZATION OF PRESCHOOL CHILDREN; AN EVALUATION OF APPLIED COMMUNITY INTERVENTIONS

We evaluated the relative impact of four procedures designed to encourage parents to obtain immunizations for their children. In a public health setting, the families of 1,133 immunization-deficient preschool children were randomly assigned to six conditions: (a) a general prompt; (b) a more client-specific prompt; (c) a specific prompt and increased public health clinic access; (d) a specific prompt and monetary incentives; (e) contact control; and (f) no contact control. All interventions, except the general prompt, produced some evidence of improvement when compared with the control groups. The monetary incentive group revealed the largest effect, followed by the increased access group, specific prompt group, and general prompt group, respectively. The data suggest that relatively powerful and immediate effects on preschoolers' clinic attendance for immunization may be produced by monetary incentives in conjunction with client-specific prompts. However, client-specific prompts alone appear to be the most cost-effective of the interventions.     

Further examination of the treatment of multiply controlled inappropriate mealtime behavior

We systematically replicated Bachmeyer et al. (2009) by examining extinction procedures matched to each function, individually and in combination, to treat the food or liquid refusal of 4 children diagnosed with a feeding disorder whose inappropriate mealtime behavior was maintained by multiple functions (i.e., escape and attention). Previous research suggests that adding differential reinforcement to extinction procedures may result in better treatment outcomes. Therefore, we added differential reinforcement to extinction procedures matched to each function. Differential reinforcement and extinction matched only to escape or attention resulted in low rates of inappropriate mealtime behavior and high, stable levels of acceptance for only 1 child. Consistent with Bachmeyer et al., inappropriate mealtime behavior decreased, and acceptance increased for the remaining 3 children only after we matched differential reinforcement and extinction procedures to both escape and attention.     

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.