Association for Behavior Analysis International

Approximately 25% to 45% of typically developing children and up to 80% of children with a developmental disability display feeding problems (Manikam & Perman, 2000; Volkert & Piazza, 2012). Volkert and Piazza (2012) determined that escape extinction was one of the most effective and empirically supported treatments for pediatric feeding disorders. The purpose of the current symposium is to review effective treatments for feeding disorders including escape extinction, differential positive and negative reinforcement of alternative behavior and discuss factors influencing generalization of treatment effects. The first presentation will evaluate differential reinforcement of alternative behavior and escape extinction to determine their effects on resistance to change, a core symptom of Autism Spectrum Disorder. The second presentation will compare enriched versus non-enriched differential negative reinforcement with and without escape extinction to increase acceptance and swallowing. The third presentation will evaluate renewal of inappropriate mealtime behavior associated with drinking from an open cup following a context change from therapist to caregiver. The last presentation will examine the effects of escape extinction as treatment for inappropriate mealtime behavior.

Researchers and clinicians interested in learning more about the direct and indirect effects of escape extinction as treatment for pediatric feeding disorders.

Researchers report that up to 72% of children diagnosed with autism spectrum disorder (ASD) have feeding difficulties (Shreck, Williams, & Smith, 2004). Food selectivity is the most common among this population. Although the etiology of feeding disorders is often unknown, we hypothesize that food selectivity is another form of resistance to change. Resistance to change is one of the repetitive and restricted response patterns that make up a core symptom of ASD. In the current study, we demonstrated that our behavior-analytic intervention reduced food selectivity to clinically acceptable levels for seven participants between the ages of 2 and 8 diagnosed with ASD. We were able to shift the participants’ responding from resistive feeding responses (e.g., always selecting chicken nuggets and French fries) to alternative, appropriate feeding responses (e.g., selecting healthier target foods like green beans and baked beans) by using differential reinforcement of alternative behavior and escape extinction. The treatment effects maintained when escape extinction was no longer in place and generalized to foods not yet targeted. These results have implications for the treatment of other symptoms of resistance to change as well as the generalization of treatment effects from one symptom to another.

Feeding problems in children with Autism Spectrum Disorder can result in malnutrition and delayed development. Behavioral interventions have been shown to be widely effective in increasing consumption of a range of foods in the absence of problem behaviors. The change in environmental cues from the treatment context (e.g., clinic) into novel contexts (e.g., home), however, can result in relapse of previously eliminated inappropriate mealtime behaviors. The present study sought to evaluate whether, after effectively reducing problem behavior associated with independent drinking from an open cup, problem behavior would return if the intervention was conducted under different contextual stimuli. During baseline, participants were exposed to an escape condition implemented by their primary caregiver (Context A), during which instances of problem behavior resulted in removal of the cup. Next, a trained therapist (Context B) implemented escape extinction and a fading procedure to increase self-fed acceptances from an open-cup. As participants continued to be exposed to the treatment, caregivers were trained to implement the intervention to high levels of treatment integrity. Upon reaching mastery criteria, caregivers implemented the treatment package as a return to Context A. Results and implications for treatment will be discussed in the context of research and theory on renewal.

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 its potential negative side effects. Two potential negative side effects that may be relevant to escape extinction are increases in emotional responding (Lerman & Iwata, 1996) and extinction-induced variability (Sevin, Gulotta, Sierp, Rosica, & Miller, 2002). Despite the criticisms, no studies to date have examined how often increases in emotional responding and extinction-induced variability occur during escape extinction to increase acceptance and decrease inappropriate mealtime behavior for children with feeding disorders. Therefore, the current study evaluated the negative side effects of escape extinction with negative vocalizations as our measure of emotional responding and packing and expulsion as our measure of extinction-induced variability. We analyzed the data of 82 children with food refusal, liquid refusal, or both, resulting in 124 data sets (69 and 55 data sets for solid and liquid intake, respectively). We observed increased negative vocalizations, expulsion, and packing in 70%, 83%, and 48% of the data sets, respectively. Participants’ increased acceptance during escape extinction occasioned the opportunity for expulsion and packing.