An evaluation of trial-based functional analyses of inappropriate mealtime behavior.

Functional analyses allow clinicians to develop treatment targeting the variables maintaining a child's inappropriate mealtime behavior (Bachmeyer et al., 2019). Extended functional analyses can be inefficient, potentially delaying the onset of treatment. Researchers have suggested a trial-based functional analysis can increase assessment efficiency (Saini, Fisher, et al., 2019). This study compared trial-based functional analyses to extended functional analyses to determine the variables maintaining inappropriate mealtime behavior. We compared the efficiency and acceptability and evaluated treatments informed by the analyses. Exact correspondence between analyses was low (29%); however, most treatments indicated by the trial-based functional analyses (80%) resulted in improvements in the child's target behavior. The trial-based functional analysis required 71% less time than the extended functional analysis, and caregivers found analyses equally acceptable. Future researchers should continue refining trial-based functional analysis procedures to provide an efficient assessment that leads to efficacious treatment.

A comparison of function- and nonfunction-based extinction treatments for inappropriate mealtime behavior.

Previous literature supports the use of functional analyses to prescribe treatments for children with feeding disorders (Bachmeyer et al., 2009). Nevertheless, clinicians often train caregivers to use healthy contingencies, independent of whether those contingencies are function based. However, it is unclear whether including nonfunction-based contingencies differentially affects inappropriate mealtime behavior. In the current investigation, the caregivers of 3 children with feeding disorders provided escape from bites and drinks and attention following inappropriate mealtime behavior. Results of a functional analysis showed escape from bites or drinks, but not attention, reinforced inappropriate mealtime behavior. We then tested the effects of escape extinction when the feeder either provided or withheld attention following inappropriate mealtime behavior. Inappropriate mealtime behavior decreased and acceptance increased when the feeder implemented escape extinction independent of whether they provided or withheld attention. We discuss the implications of including nonfunction-based components in the treatment of pediatric feeding disorders.

An evaluation of a renewal-mitigation procedure for inappropriate mealtime behavior.

Renewal, the increase in behavior during extinction following context changes, may be particularly concerning during intervention for feeding disorders because context changes are often necessary for intervention generality and maintenance (Podlesnik et al., 2017). In the current study, we tested for renewal and evaluated a renewal-mitigation procedure when we transferred intervention from a therapist to a caregiver, from clinic to the home, and changed the foods the feeder presented. We used an ABA arrangement to evaluate the generality of the renewal effect with 7 participants who engaged in inappropriate mealtime behavior. Context A was functional reinforcement. Context B was function-based extinction during the control and mitigation conditions and our renewal-mitigation procedure in the mitigation condition. The renewal test was function-based extinction in Context A. We observed renewal of inappropriate mealtime behavior in 4 of 7 participants, and our renewal-mitigation procedure was effective for 4 of 4 participants.

Using telehealth to provide outpatient follow-up to children with avoidant/restrictive food intake disorder.

The COVID-19 global health crisis compelled behavior analysts to consider alternatives to face-to-face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day-treatment program; and transitioned to an outpatient follow-up program. In Experiment 1, we analyzed the data of participants who received follow-up both in-clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow-up either in-clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in-clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.

Pediatric Prevention: Feeding Disorders.

Applied behavior analysis has the most empirical support as intervention for pediatric feeding disorders, when a child does not eat or drink a sufficient quantity or variety of food to maintain proper nutrition. Interdisciplinary collaboration is crucial for diagnosis, referral, and management of pediatric feeding disorders because the etiology is complex and multifactorial. Thus, our aim is to provide information about how to recognize a feeding disorder, to delineate the environmental variables implicated in the etiology and maintenance of feeding disorders, and to provide recommendations for prevention and intervention for feeding disorders based on the applied-behavior analytic literature.

Treating food selectivity as resistance to change in children with autism spectrum disorder.

Change-resistant behavior, such as rigid and selective food consumption, is a core symptom of autism that can have significant negative consequences for the child (Flygare Wallén et al., 2018; Levy et al., 2019). In the current study, we used a matching-law-based intervention (Fisher et al., 2019) to treat the change-resistant feeding behavior of 7 young children with autism. The feeder gave the participant a choice between a change-resistant and an alternative food during free- and asymmetrical-choice conditions. Alternative-food consumption increased for 2 participants during asymmetrical choice when the feeder provided a preferred item for consuming the alternative food and no programmed consequence for consuming the change-resistant food. Alternative-food consumption increased for the other 5 participants after the feeder exposed at least 1 food to single choice in which the feeder guided the participant to put the bite of alternative food in his or her mouth if he or she did not do so within 8 s of presentation. Effects of the single-choice contingencies maintained during reversals and generalized to other alternative foods the feeder did not expose to single choice. These results are important because participants consumed alternative foods even when their change-resistant foods were present, which is similar to typical mealtime contexts in which children have choices among foods.

Randomized controlled trial of an applied behavior analytic intervention for food selectivity in children with autism spectrum disorder.

Food selectivity is a common problem for children with autism spectrum disorder (ASD; Schreck, Williams, & Smith, 2004). Behavior-analytic interventions have the most empirical support for feeding disorders (Sharp, Jaquess, Morton, & Miles, 2011). However, there are no randomized controlled trials that have evaluated its effects with a well-defined cohort of children with ASD. In the current investigation, we randomly assigned 6 young children with ASD and food selectivity to either an applied behavior analytic intervention or a wait-list control. We used a crossover randomized controlled trial to evaluate the effects of a multicomponent applied behavior analytic intervention on independent acceptance and mouth clean of 16 novel foods. We subsequently exposed the wait-list control group to the intervention. We also evaluated the effects of the intervention on individual participants with single-case designs. The percentage of independent acceptance and mouth clean increased for the applied behavior analytic intervention group, but not for the wait-list control group until we implemented the intervention.

A translational evaluation of renewal of inappropriate mealtime behavior.

The term renewal describes the recurrence of previously extinguished behavior that occurs when the intervention context changes. Renewal has important clinical relevance as a paradigm for studying treatment relapse because context changes are necessary for generalization and maintenance of most intervention outcomes. The effects of context changes are particularly important during intervention for pediatric feeding disorders because children eat in a variety of contexts, and extinction is an empirically supported and often necessary intervention. Therefore, we used an ABA arrangement to test for renewal during intervention with 3 children diagnosed with a feeding disorder. The A phase was functional reinforcement of inappropriate mealtime behavior in a simulated home setting with the child's caregiver as feeder, B was function-based extinction in a standard clinic setting with a therapist as feeder, and the return to the A phase was function-based extinction in a simulated home setting with caregiver as feeder. Returning to Context A resulted in renewal of inappropriate mealtime behavior across children, despite the caregivers' continued implementation of function-based extinction with high levels of integrity.

Evaluation of Practice Trials to Increase Self-Drinking in a Child with a Feeding Disorder.

Self-drinking is an important skill for children to acquire as they transition from infancy to early childhood; however, the literature is limited (e.g., Collins, Gast, Wolery, Holcombe, & Leatherby, 1991; Peterson, Volkert, & Zeleny, 2015). We manipulated the consequences associated with self-drinking relative to those associated with being fed along the dimension of response effort. Results demonstrated that self-drinking increased when the child could either choose to self-feed one drink or be fed one drink and 5 practice trials with an empty cup.

The Munroe-Meyer Approach: Continuous Integration of Didactic Instruction, Research, and Clinical Practice.

Increased demand for applied behavior analysis (ABA) services has increased the need for additional masters-level practitioners and doctoral-level academicians and clinical directors. Based on these needs, the University of Nebraska Medical Center's (UNMC) Munroe-Meyer Institute has developed a PhD program. The academic structure at UNMC allowed us to create our PhD program in a relatively quick and efficient manner. Our PhD program has many unique features, including (a) close integration of didactic instruction with clinical and research training provided by leading experts in ABA in which students immediately apply concepts introduced in the classroom during coordinated clinical and research practica; (b) structured grant writing training in which students learn to write and submit an NIH-level grant;

A comparison of a modified sequential oral sensory approach to an applied behavior-analytic approach in the treatment of food selectivity in children with autism spectrum disorder.

Treatments of pediatric feeding disorders based on applied behavior analysis (ABA) have the most empirical support in the research literature (Volkert & Piazza, 2012); however, professionals often recommend, and caregivers often use, treatments that have limited empirical support. In the current investigation, we compared a modified sequential oral sensory approach (M-SOS; Benson, Parke, Gannon, & Muñoz, 2013) to an ABA approach for the treatment of the food selectivity of 6 children with autism. We randomly assigned 3 children to ABA and 3 children to M-SOS and compared the effects of treatment in a multiple baseline design across novel, healthy target foods. We used a multielement design to assess treatment generalization. Consumption of target foods increased for children who received ABA, but not for children who received M-SOS. We subsequently implemented ABA with the children for whom M-SOS was not effective and observed a potential treatment generalization effect during ABA when M-SOS preceded ABA.

Increasing self-drinking for children with feeding disorders.

Children with feeding disorders often do not self-drink without treatment. Unfortunately, the literature on self-drinking is scarce. We evaluated differential positive reinforcement to increase self-drinking for 2 children with feeding disorders. Results showed that differential positive reinforcement with tangible items increased self-drinking for both children in the absence of nonremoval of the cup.

A clinical protocol to increase chewing and assess mastication in children with feeding disorders.

Children with feeding disorders often cannot or do not chew when presented with table food. Children with chewing deficits also often swallow the bite before masticating it appropriately, which we will refer to as early swallowing. In the current study, we evaluated a clinical protocol to increase chews per bite, assess mastication, and eliminate early swallowing with three children with feeding disorders. The current study adds to a small body of literature on chewing and mastication of children with feeding disorders. Suggestions for future research are also discussed.