Chin prompt plus re-presentation as treatment for expulsion in children with feeding disorders

Expulsion (spitting out food) is a problem behavior observed in many children with feeding disorders. In the current investigation, we identified 4 children diagnosed with a feeding disorder who exhibited high rates of expulsion. Treatment with re-presentation (placing expelled liquids or solids back into the child's mouth) was not effective in reducing expulsion. Therefore, we added a chin-prompt procedure (the feeder applied gentle upward pressure to the child's chin and lower lip) for the initial presentation and the re-presentation. Chin prompt plus re-presentation resulted in low rates of expulsion for all 4 children. The results are discussed in terms of the potential underlying mechanisms behind the effectiveness of the chin-prompt procedure.     

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.     

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.     

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.     

Food preferences before and during treatment for a pediatric feeding disorder

Little is known about the food preferences of children with a feeding disorder and medical diagnoses. Therefore, we conducted repeated paired-stimulus-preference assessments with foods to which we either exposed or did not expose 3 children with a feeding disorder and medical diagnoses during clinical treatment. Responding was relatively equivalent for exposure and nonexposure foods throughout the preference assessments, suggesting that preferences for foods did not change due to exposure during treatment.     

Noncontingent and differential reinforcement in the treatment of pediatric feeding problems

We conducted functional analyses of the inappropriate mealtime behavior of 5 children diagnosed with feeding problems. Then, we compared the effects of differential and noncontingent reinforcement, and the relative effects of escape extinction with and without differential or noncontingent reinforcement, when escape extinction appeared necessary. Both reinforcement procedures were effective without escape extinction to treat food refusal for 1 child, but only differential reinforcement was effective without escape extinction to treat the child's liquid refusal. Escape extinction was necessary for 4 of 5 children. The addition of positive reinforcement resulted in beneficial effects (i.e., more stable acceptance, decreased inappropriate mealtime behavior or negative vocalizations) with 3 of 4 children. With escape extinction, differential reinforcement was more effective to treat food refusal for 2 children and noncontingent reinforcement was more effective for 1 child.     

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.     

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.     

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.     

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.     

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.     

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.     

Training parents to implement pediatric feeding protocols

Four different multicomponent training packages were evaluated to increase the treatment integrity of parents implementing pediatric feeding protocols. In Study 1 we exposed 3 parents to a training package that consisted of written protocols (baseline), verbal instructions, therapist modeling, and rehearsal training. Results suggested that the package was successful in increasing treatment integrity of the feeding protocols to high levels. Study 2 investigated three different parent-training packages comprised of components used in Study 1. Two parents were exposed to written protocols, verbal instructions, and modeling; 2 parents were exposed to written protocols, verbal instructions, and rehearsal; and 2 parents were exposed to written protocols and verbal instructions. Results of Study 2 showed that each parent-training package produced very high treatment integrity. Follow-up data in the clinic and home for 5 participants suggested that the results were durable for up to 3 months. These results demonstrate a first step in the transfer and application of research findings into routine clinical practice because we evaluated several methods for training parents to implement behavioral feeding protocols, and we demonstrated that these methods resulted in high levels of treatment integrity in a controlled clinical setting.     

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.     

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.     

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.     

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.