Association for Behavior Analysis International

When left untreated, pediatric feeding problems can result in poor weight gain, weight loss, malnutrition, dehydration, electrolyte imbalances, impairment in cognitive, emotional, and/or academic functioning, compromised immune function, and dependency on tube feedings (Cohen, Piazza, & Navanthe, 2006). This symposium combines 4 data-based presentations on the treatment of pediatric feeding problems from 4 different feeding programs: The Munroe-Meyer Institute, The Kennedy Krieger Institute, University of North Carolina Wilmington, and The Kelberman Center. Following the 4 presentations, Dr. Meeta Patel (Clinic 4 Kidz) will discuss all of the presentations and the implications of the presenter's findings. The first presentation will focus on the relative effects of positive reinforcement and escape extinction, individually and in combination, to treat food refusal. The second presentation will focus on the evaluation and comparison of two procedures, a modified chin prompt and reclined seating, to treat expulsion. The third presentation will focus on the use of a side deposit to increase consumption in children with food refusal. The last presentation will include an evaluation of a chaser to treat packing.

A combination reversal and multi-element design was used to compare the relative effects of positive reinforcement and escape extinction, individually and in combination, to treat the food refusal of a child diagnosed with a feeding disorder. Positive reinforcement involved adult attention and preferred toys, provided differentially (contingent on bite acceptance) or noncontingently (continuously). Interobserver agreement was collected for 33% of the sessions and agreement was 96%. Bite acceptance did not increase and inappropriate mealtime behavior did not decrease with noncontingent positive reinforcement only. Differential positive reinforcement only resulted in increased acceptance, but not to clinically acceptable levels, and inappropriate mealtime behavior remained high. Acceptance increased to clinically acceptable levels and inappropriate mealtime behavior decreased only when escape extinction was used. Noncontingent reinforcement combined with escape extinction resulted in lower levels of inappropriate mealtime behavior and more stable acceptance than escape extinction only and escape extinction combined with differential reinforcement.

Re-presentation is an effective intervention for decreasing expulsion for some children with feeding disorders. However, for other children, additional treatment components may be necessary to reduce expulsion to clinically acceptable levels. In the current talk, I will describe data and the successful treatment of 2 children with persistent expulsion. First, we implemented nonremoval of the spoon and re-presentation to treat the liquid refusal for both children. When expulsion failed to decrease to acceptable levels, we used a combination multi-element and reversal design to compare and evaluate the effectiveness of two different treatment components (a modified chin prompt and reclined seating) when combined with the original treatment package. During the condition that included the modified chin prompt, the feeder placed the cup between the child's lips while supporting the chin. When the child relaxed the jaw, the feeder deposited the drink while applying gentle, upward pressure to the chin to prompt the mouth to close. During the condition that included the reclined seating, the child sat in a slightly reclined highchair throughout the meal. The conditions with the modified chin prompt and the reclined seating both resulted in lower levels of expels per drink relative to the original treatment package alone.

Research has shown that non-removal of the spoon and physical guidance procedures (e.g., jaw prompt, finger prompt) can be effective in treating active food refusal (e.g., head turning, pushing spoon) and increasing food consumption. However, these procedures alone may not be effective in treating more passive food refusal (e.g., sitting still without opening mouth). Researchers have referenced a procedure used to treat passive food refusal that includes placement of the food in the side of the mouth; however, to our knowledge, no research to date has evaluated this treatment, although it may exist in practice. Therefore, using a reversal design, we evaluated the use of a side deposit procedure using a NUK brush for 2 children who engaged in passive refusal when non-removal of the spoon with and without physical guidance procedures (i.e., jaw prompt and finger prompt) were ineffective. Results showed this procedure was effective as part of a multi-component treatment package in increasing food consumption and treating passive food refusal.

Vaz, Piazza, Volkert and Groff (2012) evaluated the use of a chaser to treat packing in three children diagnosed with feeding disorders. In the current study, we replicated and extended their findings with two children diagnosed with autism and food selectivity. The targeted texture for both participants was table texture. In the first case, the child sufficiently masticated bites of target food prior to the presentation of the chaser; thus, no further modifications were necessary to increase levels of swallowing. In the second case, the child did not masticate bites of target foods (i.e., she packed whole pieces of food) therefore; it was necessary to use a chaser in combination with a reduced texture (i.e., chopped). In a follow-up assessment we used a fading procedure to advance this participant to a more age-appropriate texture. We also evaluated the long-term necessity of the chaser across individual foods. In both cases, the use of a liquid chaser was associated with increased levels of swallowing.