Association for Behavior Analysis International

Pediatric feeding disorders can range from concerns with volume of food consumed (food refusal) and dietary variety (food selectivity). The purpose of the current symposium will be to survey innovative treatments for pediatric feeding disorders that span both areas. The initial presentations will examine interventions designed to address behaviors that emerge during the course of treatment and interfere with swallowing. The first presentation will determine if the emergence of expulsion is a common corollary effect during treatment of food refusal with nonremoval of the utensil and whether re-presentation is an efficacious treatment for expulsion of solids. The second presentation will compare flipped spoon presentation and redistribution to reduce packing for two children with a feeding disorder. The third presentation will describe a behavioral treatment package to increase compliance with medication administration for two children with severe feeding problems and other medical conditions which required daily medication administration. The final presentation will replicate Peterson, Piazza, and Volkert (2106) and compare a modified version of Sequential Oral Sensory (M-SOS) to an applied behavior analytic approach to treat food selectivity for two participants with autism.

Treating food or liquid refusal with escape extinction procedures reliably results in increased acceptance and decreased inappropriate mealtime behavior. However, problematic behaviors may emerge or persist in response to treatment, interfering with consumption. Coe et al. (1997) and Sevin et al. (2002) showed that treatment of refusal with nonremoval of the utensil (escape extinction procedure) resulted in emergence of expulsion. Both investigators used re-presentation (i.e., feeder scooped up expelled food and placed it into the mouth), to decrease expulsion to near-zero levels. Their results raise the question of whether emergence of expulsion is a common corollary effect during treatment of refusal with nonremoval of the utensil and whether re-presentation is an efficacious treatment for expulsion. A preceding investigation found expulsion emerged during treatment of liquid refusal with nonremoval of the cup and re-presentation was an effective treatment for expulsion. The current investigation evaluated whether treatment of food refusal with nonremoval of the spoon for 12 children resulted in similar findings. Results indicated that 6 (50%) children exhibited expulsion during the evaluation. The incorporation of re-presentation resulted in lower expulsion for 4 (67%) of the 6 children, relative to nonremoval of the spoon alone. Implications will be discussed.

For children with feeding disorders, nonremoval procedures combined with reinforcement are often used by practitioners to treat initial food refusal (Volkert & Piazza, 2012; Volkert, Patel, & Peterson, 2016). However, this treatment may not always be sufficient to increase food consumption because problematic behaviors such as packing or expulsion emerge. Antecedent- and consequence-based interventions have both been effective to decrease packing (holding food in the mouth) or increase mouth clean (converse of packing) for children with feeding disorders. Depositing the bite using a flipped spoon or Nuk upon presentation has been shown to increase mouth clean (Sharp, Harker, & Jaquess, 2010; Wilkins et al., 2014) and re-distribution and/or swallow facilitation has been effective to decrease packing (Gulotta, Piazza, Patel, & Layer, 2005; Volkert, Vaz, Piazza, Frese, & Barnett, 2011). To our knowledge, flipped spoon presentation and redistribution have not been directly compared to reduce packing, and this was the aim of the current study.

Children with a diagnosis of a pediatric feeding disorder may display inappropriate behaviors in order to avoid/escape food so consuming a medication may be even more difficult. There is a limited number of scientific studies available focusing on increasing medication compliance in children with feeding problems. The purpose of this study was to use a behavioral treatment package to increase compliance with medication administration for two children with severe feeding problems and other medical conditions which resulted in daily medication administration. The treatment package for the first participant included stimulus fading, positive reinforcement, and escape extinction. The treatment package for the second participant included a visual cue, stimulus fading, positive reinforcement, self-monitoring, and avoidance. A multiple-probe design was used to evaluate treatment effectiveness for the first participant and a reversal design for the second participant. For the first participant, data showed that in baseline mouth cleans remained low after the specified time criteria and chewing remained high. During the course of treatment, chewing had significantly reduced during baseline and treatment phases but mouth cleans only improved when the treatment package was implemented. By the end of treatment, the child successfully accepted and swallowed all medication without chewing and packing. For the second participant, duration to swallow medication was high in baseline and with the implementation of treatment package, duration decreased to acceptable levels. In addition, both participants were able to consume medications with their caregivers with high integrity. These data are discussed in relation to positive and negative reinforcement and the appropriate treatment combinations that can facilitate better treatment outcomes for children who display oral aversion.

Many children with autism spectrum disorder display food selectivity (consumption of a limited variety of foods; Schreck, Williams, & Smith, 2004). The Sequential Oral Sensory (SOS) approach is a commonly used treatment for food selectivity; however to our knowledge, there is no empirical support for SOS. Peterson, Piazza, & Volkert (2016) compared a modified version of SOS (M-SOS) to an ABA approach and demonstrated that consumption of target foods increased for children who received ABA, but not for children who received M-SOS. In the current study, we replicated the findings of Peterson, Piazza, & Volkert. Thus far, we enrolled two participants with autism and food selectivity and used a multiple baseline across foods design. Acceptance did not increase for the M-SOS participant; however, we observed high levels of acceptance for the ABA participant. Additionally, we observed increased levels of acceptance for one of the two other foods not in treatment (i.e., generalization).