Association for Behavior Analysis International

Behavioral interventions, specifically escape extinction and positive reinforcement, are considered well-established treatments for pediatric feeding disorders. However, further research to understand the necessity of these and other consequence-based procedures in the development of function-based interventions is warranted. Moreover, further development and examination of antecedent interventions is necessary for cases in which escape extinction is ineffective or unacceptable. This symposium presents three studies that extend the existing behavioral feeding literature in these ways. Kirkwood and colleagues will present a study that further examines the use of consequence-based procedures in the treatment of the multiply controlled inappropriate mealtime behavior of 3 children diagnosed with feeding disorders. Wall and colleagues will present a study demonstrating the effects of an antecedent-based intervention, stimulus fading, to establish cup drinking in a child diagnosed with a feeding disorder when escape extinction did not result in treatment success. Finally, Cried and colleagues will present a study examining the effects of backward chaining to establish self-drinking after the successful treatment of liquid refusal.

Behavioral intervention is a well-established treatment for chronic food refusal; however, the evidence base regarding treatment of liquid refusal is limited. Failure to consume an adequate amount of liquids is associated with a number of poor health outcomes, including restricted calorie intake, dehydration, and constipation. The purpose of this study is to demonstrate the use of a stimulus fading protocol to establish cup drinking in a 2-year-old female with total food and liquid refusal. Prior to the current study, treatment involving non-removal of the spoon was successful in increasing intake of solids; however, use of a similar extinction-based protocol with 3.5 cc of formula presented in a cup resulted in high rates of expulsion. In order to promote acquisition of cup drinking, treatment involved reducing the bolus to 0.5 cc and systematically increasing the volume of formula by 0.5 cc until the terminal volume of 3.5 cc was achieved. A decision rule guided advancement in liquid volume and probe sessions (3.5 cc) were conducted between each step of the fading procedure as a control condition in a multiple probe experimental design. Results showed lower level of expulsion and higher percentage of mouth clean.

Children diagnosed with feeding disorders often exhibit inappropriate mealtime behavior that may be maintained by multiple reinforcement contingencies (Piazza et al., 2003). Previous research (Bachmeyer et al., 2009) has shown that extinction of both sources of reinforcement may be necessary to achieve treatment success. Functional analyses identified children whose inappropriate mealtime behavior was maintained by negative reinforcement (escape) and positive reinforcement (adult attention). Using a combined multi-element and reversal design, we compared function-based interventions (i.e., differential reinforcement and extinction procedures) individually and combination in the treatment of food or liquid refusal of 3 children diagnosed with a feeding disorder. Interobserver agreement was conducted on at least 33% of sessions. Agreement was above 80% for each child. Food/liquid acceptance increased and inappropriate mealtime behavior decreased to clinically acceptable levels with an intervention matched to only one function (i.e., escape) for one child. By contrast, food/liquid acceptance increased and inappropriate mealtime behavior decreased to clinically acceptable levels only with the intervention matched to both functions for 2 children. Results suggest that it was necessary to treat both functions to successfully treat the food/liquid refusal of 2 of the 3 children. Implications of these findings will be discussed.

Backward chaining (BC) is a well-supported treatment for teaching various skills, including establishing self-feeding with utensils. There are, however, few reports regarding how to establish independent cup drinking in young children with pediatric feeding disorders. The current study demonstrates the use of BC to establish self-drinking from an open cup with a 2-year-old male with a history of chronic food and liquid refusal. Prior to the current study, behavioral intervention increased oral intake of solids and liquids and subsequent treatment involving a least-to-most prompting sequence (e.g. verbal, model, hand-over-hand guidance) established self-feeding involving solids. Least-to-most prompting was, however, ineffective in establishing independent drinking. A BC procedure was developed using a task analysis of the steps necessary to promote self-drinking and a decision rule guided progression through BC steps. Probes involving least-to-most prompting were conducted between each step as a control condition in a multiple probe experimental design. Results indicated that BC represents a potential tool to teach a child to independently drink from an open cup.