Association for Behavior Analysis International

Escape extinction is a well-established treatment for increasing acceptance and decreasing inappropriate mealtime behavior of children with feeding disorders (Volkert & Piazza, 2012), but some researchers have characterized escape extinction as intrusive because of potential negative side effects. One potential negative side effect is an increase in emotional responding (Lerman & Iwata, 1996). Woods and Borrero (2019) found that extinction-induced negative vocalizations occurred in three of 10 data sets (30%). In the current study, we assessed whether negative vocalizations occurred during extinction of inappropriate mealtime behavior for children diagnosed with a pediatric feeding disorder. We analyzed data of 79 children with food refusal, liquid refusal, or both, resulting in 121 data sets (67 and 54 data sets for solid and liquid intake, respectively). We observed an initial increase in negative vocalizations following extinction implementation in 70% of the data sets. However, we also observed that negative vocalizations decreased to zero within an average of six treatment sessions or after approximately 70 min of exposure to extinction. We discuss these findings as they relate to caregiver preference for escape extinction over other interventions as well as treatments that could be added to escape extinction to reduce negative vocalizations (e.g., noncontingent attention).

A levels system is typically comprised of differential reinforcement, a response cost, and punishment (Hagopian, 2002). Specifically, levels systems involve the manipulation of a participant’s access to/ restriction of reinforcement based upon a specific behavioral criterion. While levels systems have been used to intervene on various problem behaviors (Grace, Thompson, & Fisher, 1996; Hagopian et al., 1996) and to increase independence and self-feeding during meals (Gonzalez, Taylor, Borrero, & Sangkavasi, 2013), current literature has not yet documented their use in treating food refusal - specifically with the goal of increasing volume and overall meal completion. The current study examined the effectiveness of a levels system to treat food refusal in a 12-year-old female with a mild intellectual disability, fetal alcohol syndrome, attention-deficit/hyperactivity disorder, and a history of being significantly underweight (body mass index below the 1st percentile). Results indicated that a levels system was successful in increasing the volume of food consumed at each meal and decreasing refusal during the meal. Specifically, by the end of treatment the participant was consuming an age appropriate volume and variety of food at each meal within an appropriate mealtime duration.

Applied behavior-analytic (ABA) interventions are the most empirically supported approach to the assessment and treatment of pediatric feeding disorders (Volkert & Piazza, 2012). Despite the effectiveness of behavior-analytic interventions, interventions with limited empirical support are often the first-line treatments for feeding difficulties (Peterson, Piazza, & Volkert, 2017). Food chaining is a sensory-integration approach often recommended by occupational and speech and language therapists that introduces new foods into a child’s diet by building off the child’s past successful eating history. The current study used a nonconcurrent multiple-baseline design to compare a food chaining approach to an ABA approach, that consistent of noncontingent attention and escape extinction, for the treatment of food selectivity for 3 children with feeding disorders. We observed an increase in acceptance of target foods and a decrease in inappropriate mealtime behavior only after exposure to the ABA treatment. Results are consistent with previous research supporting the use of behavior-analytic interventions over sensory-based interventions in the treatment of pediatric feeding disorders (Addison et al., 2012; Peterson, Piazza, & Volkert, 2017). We discuss implications for creating and implementing empirically supported treatments for children with feeding difficulties.

Currently, 40-70% of infants born prematurely or with significant medical conditions have a severe feeding disorder, and studies have shown that 70% of children who refused to eat during infancy will continue to experience feeding problems at the age of four years. Infants quickly learn to associate formula, breast milk, and bottles with pain and danger because of the way that infants are fed in most neonatal intensive care units. This project will describe how the application of principles from classical and operant conditioning can be applied to address feeding issues during infancy. We will also present data demonstrating that behavioral treatment during infancy can prevent severe feeding disorders that require costly and intensive treatment later in childhood.