Association for Behavior Analysis International

Escape extinction is widely used in intensive multidisciplinary feeding programs to treat various topographies of food refusal, presumed to be reinforced by escape or avoidance of the mealtime context (Saini et al., 2019; Sharp et al., 2010). In this symposium, presenters will discuss a range of additives to escape extinction for treating problematic behavior exhibited by children diagnosed with pediatric feeding disorder. Presenters will begin with an overview of the existing literature on the effects of treatment with and without escape extinction on inappropriate mealtime behavior and present on a clinical dataset in which response covariation was an observed side effect. Presenters will transition to discussing how noncontingent reinforcement may mitigate negative side effects associated with escape extinction and the use of a modified bolus placement to assist with reducing expels and packing.

Researchers and clinicians interested in learning more about considerations for the use of escape extinction in the treatment of pediatric feeding disorders or avoidant/restrictive food intake disorder.

Inappropriate mealtime behavior (IMB) is a type of feeding challenge within the broader class of food refusal behavior. Although there have been some single-case studies examining the extent to which behavioural interventions can aide in reducing IMB, the relative efficacy and generality of these studies is unclear. The purpose of this systematic review was to critically analyze the efficacy of interventions for the treatment of IMB through a meta-analysis of single-subject experimental designs. We identified 38 studies involving 307 cases in which IMB was treated with a behavioral intervention. Results indicated that combined escape extinction and non-escape extinction interventions had greater effect sizes than escape extinction alone or non-escape extinction alone. Escape extinction alone had greater effects sizes compared to non-escape extinction alone. However, escape extinction alone resulted in a higher percentage of negative side effects compared to non-escape extinction alone and combined interventions. We discuss the implications of these findings and provide recommendations for future research.

Escape extinction is a well-established treatment for increasing acceptance and decreasing inappropriate mealtime behavior of children with feeding disorders. Sevin et al. (2002) found that when extinction was in place, both desired (acceptance) and undesired (expel, packing) behavior increased during the initial three sessions. In the current study, we assessed response covariation of both desired and undesired behavior during extinction-based treatment of inappropriate mealtime behavior. We analyzed the data of 60 children with food refusal, liquid refusal, or both, resulting in 90 data sets. We observed an extinction burst in 7% of data sets. During these initial sessions, we also observed an increase in or emergence of other undesired behavior (expel, packing; 81%, 47%, respectively), as well as an increase in desired behavior (acceptance, consumption; 44%, 70%, respectively). We analyzed the efficiency and stability of treatment effects and will discuss these findings to provide an all-encompassing review of child behavior during extinction.

Adding noncontingent reinforcement to escape extinction might result in lower levels of inappropriate mealtime behavior, negative vocalizations, or both for children with feeding disorders. Unfortunately, making firm conclusions about the role of noncontingent reinforcement is difficult because of the minimal number of systematic evaluations and the procedural variations across studies. We also do not know whether the removal of noncontingent reinforcement results in undesirable side effects and how children with feeding disorders respond to treatment components that may be necessary, like schedule thinning. Therefore, we first conducted a concise review of the feeding literature and found that only five studies directly evaluated noncontingent reinforcement with and without escape extinction. However, 8 out of 10 randomly selected studies from 2017-2022 incorporated some type of noncontingent reinforcement arrangement (e.g., attention, tangibles). Finally, we compared escape extinction alone and escape extinction with noncontingent reinforcement on the acceptance, inappropriate mealtime behavior, and negative vocalizations across two sets of foods with a 3-year-old male enrolled in a day-treatment feeding program. So far, results indicate that both treatments produced clinically meaningful outcomes, but we observed fewer bouts of negative vocalizations during escape extinction plus noncontingent reinforcement. Additional findings and implications will be discussed.

Placement of bites on the tongue has been evaluated as an initial treatment for pediatric feeding disorder (Ibañez, 2021; Wilkins et al., 2014), specifically for decreasing packing and expulsion. When evaluating modified bolus placement, previous studies have typically compared flipped and upright baby or maroon spoons and Nuk presentation. However, Bloomfield et al. (2021) included a comparison between a Nuk and flipped E-Z spoon for both initial bolus placement and redistribution of packed food for one of their participants with severe oral-motor skills deficits, which introduced a potential new tool to the field. The purpose of the current study is to extend Ibañez et al. (2021) and Bloomfield et al. (2021) by evaluating the effectiveness of the E-Z spoon as a tool for modified bolus placement in the initial treatment of children with pediatric feeding disorder.