Association for Behavior Analysis International

Social validity in behavior analytic service delivery is paramount. Recent trends in behavior analytic research and service delivery illustrate the intentions of researchers and practitioners to improve social validity of interventions (Ferguson et al., 2018). One sector of behavior analytic service delivery that has been particularly criticized is treatment of children with pediatric feeding disorders (Taylor & Taylor, 2022). Currently, the most empirically supported intervention is escape extinction or non-removal of the spoon (Peterson et al., 2018). This intervention has repeatedly shown rapid effectiveness in the published literature and is warranted for children who experience severe food refusal. Though escape extinction is a well-established behavioral treatment for feeding disorders, the intrusive nature of the procedure has led to questions and misconceptions related to social validity of interventions. The purpose of this symposium is to explore social validity related to various treatments and outcomes for pediatric feeding disorders.

Intermediate

Trauma-informed care necessitates that practitioners understand and consider how their clients feel during treatment. Escape extinction during pediatric feeding treatment may be warranted for some children. Although these procedures are highly effective, it is unclear if any undesired emotional response that occurs during extinction has lingering effects on how children feel during future meals (i.e., a child may be consuming their bites efficiently, but still feel unhappy). Thus, the current study aims to assess the two dimensions of emotion (Gay & Leijdekkers, 2013) for children with pediatric feeding disorders while they receive treatment. Specifically, researchers recorded child indices of happiness and unhappiness (Phipps et al., 2022) to assess emotional valence and measured physiological responses using a wrist-worn biosensor to assess emotional arousal for children with pediatric feeding disorders. The findings from this study reveal the potential emotional experiences of children during treatment and further the discussion on the feasibility of measuring private events to inform practice.

Most day-treatment feeding programs aim to promote substantial and rapid changes in oral intake (Sharp et al., 2020). As such, a child will likely experience a shift in the amount and type of food and liquid consumed, which may impact toileting patterns and continence. Prior research has not targeted or monitored continence throughout a feeding admission despite the importance of independent toileting skills and the relation between intake and urine and stool output (Santos et al., 2017). We also know that modifying an individual’s undergarments can produce changes in toileting continence (Greer et al., 2016). In the current study, a 5-year-old female with Williams-Beuren syndrome, autism spectrum disorder, avoidant/restrictive food intake disorder, and diaper dependency was admitted to a day-treatment feeding program. Therefore, we measured and compared in-toilet eliminations, self-initiations, and nutritional intake while she was in diapers relative to underwear. Overall, in-toilet eliminations and self-initiations remained stable and increased when she wore underwear. We discuss the benefits of a hybrid program in which important adaptive skills like feeding and toileting can be dually addressed and plan to retrospectively review food and liquid intake to determine whether these changes affected outcomes.

Children with avoidant/restrictive food intake disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth and cognition (APA, 2013). They can consume food by mouth but may actively (e.g., turning head, hitting spoon) or passively (e.g., clenching mouth while sitting still) refuse to escape or avoid eating. Behavioral interventions like positive reinforcement and stimulus fading with escape prevention have been shown to increase consumption and decrease refusal in these children. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance procedures may be utilized to prompt an open mouth to deposit food. Research indicates that these procedures are effective and rated as acceptable. However, additional research is warranted as these interventions may be conceptualized as punishment and should be used only if necessary (BACB, 2014). This study replicated an existing physical guidance procedure, the finger prompt (Rubio et al., 2020), and compared its efficacy and acceptability to that of a clinically utilized procedure, a spoon prompt, not yet empirically evaluated. This study further extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and time points.

Avoidant/restrictive food intake disorder (ARFID) is the psychiatric diagnosis for feeding disorders, and requires the failure to achieve proper weight gain, presence of nutritional deficiencies, dependence on eternal or oral supplementation, and/or psychosocial factors such as increased stress in caregivers (DSM-5). The recognized standard of care for chronic and severe pediatric feeding problems is intensive multidisciplinary intervention including psychology, nutrition, medicine, and speech-language pathology/occupational therapy; the most common treatment component being behavioral intervention (Sharp et al., 2016). Recent evaluation of our intensive multidisciplinary program yields positive outcomes such as increases in acceptance and swallowing of new foods, reductions in problematic mealtime behaviors, a high percentage of goals met during the child’s admission, and high caregiver satisfaction across clinical presentations of ARFID (i.e., tube dependence/food refusal and severe food selectivity; Sharp et al., 2020; Volkert et al., 2021). This paper extends the analysis of outcomes for subtypes of ARFID by considering race and ethnicity. A closer examination of these outcomes may illuminate disparities and therefore assist in the identification of steps to enhance program outcomes.