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Background: The purpose of this study was to evaluate the effectiveness of an interdisciplinary home-based feeding program, which is a unique service delivery model. Methods: Data were provided on oral intake, tube feeding elimination, and weight for patients who were dependent on tube feedings (n = 78). Weight data were collected for patients who showed failure to thrive (n = 49). Number of foods consumed and percentage of solids were collected for patients who were liquid-dependent (n = 23), and number of foods consumed were collected for patients who were food-selective (n = 61). Results: Data were analyzed using paired sample t-test with 95% confidence interval. For patients dependent on tube feedings, 81% achieved tube feeding elimination. Tube elimination was achieved after 8 months of treatment on average. All failure-to-thrive patients showed weight gain from baseline to discharge. For liquid-dependent patients, there was an increase in foods consumed from 2 foods at admission to 32 foods at discharge. For food selective patients, there was an increase from 4 foods at admission to 35 foods at discharge. For all dependent variables, results showed statistical significance and a large-sized effect. Conclusions: These data show that an intensive interdisciplinary home-based program can be successful in treating complex feeding problems in children.

Food refusal can be characterized as a severe feeding problem wherein an individual fails to eat sufficient quantity and/or variety of foods/liquids to maintain his or her weight and height (e.g., Babbitt et al. in Pediatric feeding and swallowing disorders: Pathology, diagnosis, and treatment. Singular Publishing Group, San Diego, 1994). In addition, food refusal may encompass selective eating where weight and growth are not of concern but where nutritional status may be compromised. Feeding problems can occur in about 25–45 % of typically developing children and up to 80 % of children with intellectual and developmental disabilities. The etiology of feeding problems is not well understood but may develop as a result of medical issues, anatomical abnormalities and/or oral-motor skill deficits, and behavioral/environmental factors (Rommel et al. in J Pediatr Gastroenterol Nutr 37:75–84, 2003). Given the complex etiology of feeding problems, assessment and treatment should be conducted by an interdisciplinary treatment team of professionals involving speech and language pathologists, registered dieticians, and physicians (Laud et al. in Behav Modif 33:520–536, 2009; Silverman in Nutr Clin Pract 25:160–165, 2010). This chapter reviews empirically-supported assessment and treatment of food refusal and selective eating and provides recommendations for practitioners.

We examined the vocal stereotypy of three boys who were diagnosed with an Autism Spectrum Disorder (ASD). Results of functional analyses indicated that each participant's vocal stereotypy was maintained by non-social consequences. For two participants, verbal reprimands were provided contingent on vocal stereotypy in the presence of a red card (RC). For the third participant, after verbal reprimands alone did not decrease vocal stereotypy, toys were withdrawn contingent on vocal stereotypy in the presence of the RC. For all three participants, vocal stereotypy was permitted without programmed consequences the presence of a green card (GC). The results showed that vocal stereotypy decreased in the presence of the RC for all three participants; however, vocal stereotypy came under inhibitory control of the RC for only one of the three participants. The potential utility of using punishment to develop stimulus control of automatically reinforced problem behavior in academic settings is briefly discussed. Copyright © 2009 John Wiley & Sons, Ltd.

We evaluated the effects of a high-probability (high-p) instructional sequence on the feeding-related compliance (food acceptance) of a young boy diagnosed with a feeding disorder. The high-p sequence consisted of three presentations of an empty spoon; the low-probability (low-p) instruction was the presentation of a spoon with food. Results showed that acceptance of food increased in the presence and not the absence of the high-p sequence. Data are discussed in terms of the role of high-p instructional sequences in the treatment of feeding problems. Copyright © 2007 John Wiley & Sons, Ltd.

Positive- and negative-reinforcement-based procedures typically have targeted acceptance for children with severe food refusal; however, these procedures do not always result in successful swallowing. Once acceptance is achieved, some children expel the food repeatedly or pack (hold or pocket) it in their mouths for extended periods of time. This study evaluated the effects of using food redistribution with a bristled massaging toothbrush to reduce packing and increase consumption in 4 children with severe feeding disorders. Packing was reduced for all children. In addition, latency to clean mouth (the duration of time from acceptance to food no longer being present in the child's mouth in the absence of expulsion) for 2 children decreased when the food-redistribution procedure was used. Results are discussed in terms of the potential operant functions of the food-redistribution procedure.

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.

A concurrent-operantsdesign was used to analyze the repetitive behavior of observing reflective surfaces while simultaneously engaging in erratic gross-motor body movements (EBMs) exhibited by a young boy diagnosed with autism. The assessment involved an evaluation of preference for controlled (i. e., the participant controlled the visual activity on a TV screen) versus uncontrolled (i. e., the participant viewed a previously recorded tape from the controlled condition) TV footage of his EBMs. The analysis indicated that both observing and EBMs were maintained by the direct correspondence between the body movements and the visual stimulation they produced when controlled by the participant. Thus, the EBMs appeared to be maintained on a conjugate schedule of reinforcement.

Consumption of solids and liquids occurs as a chain of behaviors that may include accepting, swallowing, and retaining the food or drink. In the current investigation, we evaluated the relative effectiveness of differential reinforcement of the first behavior in the chain (acceptance) versus differential reinforcement for the terminal behavior in the chain (mouth clean). Three children who had been diagnosed with a feeding disorder participated. Acceptance remained at zero when differential reinforcement contingencies were implemented for acceptance or mouth clean. Acceptance and mouth clean increased for all 3 participants once escape extinction was added to the differential reinforcement procedures, independent of whether reinforcement was provided for acceptance or for mouth clean. Maintenance was observed in 2 children when escape extinction was removed from the treatment package. The mechanism by which consumption increased is discussed in relation to positive and negative reinforcement contingencies.

In a multi-phase investigation, we assessed the problematic hair manipulation of a four-year-old male diagnosed with autism. In phase 1, a functional analysis of hair manipulation resulted in high levels of responding during a no-interaction condition, while near-zero levels were observed in other conditions. In phase 2, hair manipulation was reduced to near-zero levels during a condition in which Billy wore gloves on his hands to attenuate digital-tactile stimulation. In phase 3, a stimulus preference assessment indicated that object manipulation competed with hair manipulation, and that wearing gloves did not alter the amount of time that Billy manipulated preferred objects. The results are discussed in the context of interventions that achieve their effects via reinforcer substitutability or competition. Copyright © 2000 John Wiley & Sons, Ltd.

Feeding problems are common in all children but tend to occur more often in children with developmental disabilities. Feeding problems may range from eating no to minimal food by mouth, liquid dependency, and food selectivity. The etiology of a feeding disorder is multifaceted which involves the interaction between medical, physiological, and behavioral variables. In addition, children with feeding problems often engage in a variety of inappropriate mealtime behaviors to avoid eating. This chapter will provide a description of various feeding problems as well as a summary of the tools currently used to assess feeding problems in children including medical evaluation, assessment of oral and/or sensory motor deficits, swallowing evaluation, and behavioral assessment techniques to identify environmental variables contributing to the feeding problem.

Packing is a problematic mealtime behavior that is characterized by pocketing or holding solids or liquids in the mouth without swallowing. In the current study, we examined the effects of a chaser, a liquid or solid consistently accepted and swallowed by the child, to decrease packing of solid foods in 3 children with feeding disorders. During the chaser procedure, the therapist presented the chaser immediately for 2 children or 15 s after each bite presentation for 1 child. The chaser was effective in decreasing packing for all 3 children. The results are discussed in terms of the clinical importance of the findings and directions for future research.

We compared the effects of escape extinction (EE) plus noncontingent reinforcement (NCR) with sensory integration therapy as treatment for the feeding problems of 2 children. Results indicated that EE plus NCR was more effective in increasing acceptance, decreasing inappropriate behavior, and increasing amount consumed relative to sensory integration for both children. The results are discussed in terms of the challenges of evaluating sensory-integration-based treatments, and the reasons why component analyses of multicomponent treatments like sensory integration are important.

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.

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.

This study examined packing (pocketing or holding accepted food in the mouth) in 3 children who were failing to thrive or had inadequate weight gain due to insufficient caloric intake. The results of an analysis of texture indicated that total grams consumed were higher when lower textured foods were presented than when higher textured foods were presented. The gram intake was related directly to levels of packing. That is, high levels of packing were associated with higher textured foods and low gram intake, and low levels of packing were associated with lower textured foods and high gram intake. All participants gained weight when texture of foods was decreased. Packing remained low during follow-up for 2 participants even when the texture of food was increased gradually over time. These data are discussed in relation to avoidance, response effort, and skill deficit.

We evaluated the effects of escape extinction with and without a high-probability (high-p) instructional sequence on food acceptance and inappropriate behavior for children diagnosed with feeding problems. The high-p sequence consisted of three presentations of a response that was similar topographically (i.e., presentations of an empty nuk®, liquid on a spoon, and a preferred liquid on a spoon) to the low-p response (i.e., presentation of a nuk with food, liquid from a cup, and presentation of a nonpreferred food). Acceptance of food increased in the presence and not the absence of the high-p sequence during initial withdrawals for two of the three children. In addition, the high-p sequence plus escape extinction was associated with reduced levels of inappropriate behavior relative to escape extinction alone for two children. Data are discussed in relation to behavioral momentum, motivating operations, and the relative contributions of the high-p instructional sequence and escape extinction in the treatment of feeding problems.

A treatment with differential or noncontingent reinforcement and nonremoval of the spoon increased the acceptance of one or two of 16 foods for 2 participants with severe food refusal. These differential levels of acceptance were demonstrated empirically in an ABAB design in which A was the presentation of the accepted (preferred) foods and B was the presentation of foods the participants refused (nonpreferred foods). Subsequently, we implemented a blending treatment that consisted of mixing (blending) nonpreferred foods into preferred foods in various ratios (e.g., 10% nonpreferred/90% preferred, 20% nonpreferred/80% preferred). We then presented nonpreferred foods that had been exposed to blending to determine if consumption of nonpreferred foods would increase following the blending treatment. We also conducted periodic reversals in which we presented nonpreferred foods that had not been exposed to the blending treatment. Following initial implementation of the blending treatment, consumption was high for nonpreferred foods that had been blended and low for nonpreferred foods that had not been blended. Consumption increased for all foods (i.e., foods that had been exposed to blending and foods that had not been exposed to blending) after seven or eight foods had been exposed to the blending treatment. Thus, the variety of foods consumed by the participants increased from one or two to 16. These results are discussed in terms of stimulus fading, conditioned food preferences, and escape extinction. DESCRIPTORS: conditioned food preferences, food refusal, negative reinforcement, stimulus fading

The purpose of the current investigation was to apply the functional analysis described by Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) to the inappropriate mealtime behaviors of 15 children who had been referred to an intensive program for the assessment and treatment of severe feeding disorders. During Study 1, we conducted descriptive assessments of children and parents during meals. The results of Study 1 showed that parents used the following consequences for inappropriate mealtime behaviors: coaxing and reprimanding, allowing the child to periodically take a break from or avoid eating, and giving the child preferred food or toys following inappropriate behavior. The effects of these consequences were tested systematically in Study 2 when we conducted analogue functional analyses with the children. During alternating meals, one of the consequences typically used by parents consistently followed inappropriate child behavior. Results indicated that these consequences actually worsened behavior for 10 of the 15 children (67%). These results suggested that the analogue functional analysis described by Iwata et al. may be useful in identifying the environmental events that play a role in feeding disorders.

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.

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 evaluation of food type and texture indicated that both variables affected the expulsions of a 3-year-old with feeding problems. The results of the evaluation were used to prescribe a treatment (reducing the texture of one food type) that reduced expulsion.

Studies on the "interpolation of reinforcement" effect (IRE) suggest that switching from an intermittent (INT) to a continuous (CRF) reinforcement schedule may result in less resistance to extinction than if extinction had followed INT alone. The finding has been examined with both human and animal participants using both free- and restricted-operant research preparations with equivocal results. In the present study, the IRE was examined in four young children diagnosed with autism using a free-operant preparation. Participants were matched into pairs and were exposed, in a counterbalanced order, to extinction following CRF "interpolated" between INT and extinction, and to extinction following INT alone. Resistance to extinction was examined by comparing the number of responses emitted during extinction and the number of sessions required to reach an extinction criterion. Responding may be less resistant to extinction following interpolated CRF reinforcement than following INT alone. Methodological refinements necessary for more conclusively demonstrating the IRE are discussed.

Stimulus fading was combined with differential reinforcement and extinction to increase intake of a calorie-dense fluid by a 6-year-old child with feeding problems. The fading procedure consisted of adding Carnation Instant Breakfast and then milk to water (a fluid the child would drink).

Many aberrant behaviors exhibited by individuals with developmental disabilities are maintained by "automatic reinforcement". These behaviors are often difficult to treat, with the most effective behavioral interventions often resulting in only moderate success. However, a series of recent studies has advanced our ability to understand and treat these behaviors through the innovative use of behavioral assessment. We review the recent development of three categories of assessments: (a) nonhypothesis-based stimulus preference assessments, (b) hypothesis-based stimulus preference assessments, and (c) hypothesis-based assessments incorporating noncontingent reinforcement and sensory extinction procedures. We consider each category's contribution to both our ability to prescribe effective behavioral interventions and our ability to more fully understand the concept of automatic reinforcement.

The purpose of this study was to develop a systematic functional assessment package for aberrant behaviors maintained by nonsocial (automatic) reinforcement. The assessment package included four components: (1) functional analysis, (2) antecedent assessment of specific automatic reinforcement sources, (3) stimulus preference assessment, and (4) treatment evaluation. Functional analysis data indicated automatic reinforcement functions of the stereotypy exhibited by a 10-year-old male and the self-injury (SIB) exhibited by a 30-year-old male. Antecedent assessments of sensory classes indicated that auditory stimulation and tactile stimulation were associated with stereotypy and SIB, respectively. A multiple-stimulus-without-replacement procedure was conducted with each participant to identify the most- and least-preferred stimuli within the identified sensory classes. In an attempt to validate the assessment package for each participant, a DRO procedure was implemented using a reversal design with a multielement component. DRO procedures using stimuli within the targeted sensory classes were successful in eliminating the aberrant behaviors of both participants. The results are discussed in the context of improving the methodology for assessing and treating automatically reinforced behaviors.