Simulation and counterconditioning as adjuncts to pharmacotherapy for invasive pediatric procedures.

Behavioral counterconditioning was conducted during simulated medical routines to supplement medical management of five children's distress during invasive procedures (bone marrow aspiration, lumbar puncture, tracheostomy care, venipuncture, and finger pricks). Preferred activities were paired in vivo with medical stimuli, and differential positive reinforcement was provided contingent on engagement with the preferred activities and on compliance with adult instructions, first during simulations and later during actual procedures. Data on cooperation, escape/avoidance, and negative vocalizations were evaluated using both single-subject experimental methods and a baseline-treatment group statistical comparison. Results support the benefits of this approach as an adjunctive intervention to decrease behavioral distress in some children requiring repeated invasive procedures. Discussion emphasizes the potential for training medical personnel to implement these techniques preventively, for decreasing or discontinuing sedation for some children treated under local anesthesia, and for preparing children with developmental disabilities for invasive procedures.

Teaching developmentally disabled children with chronic illness to swallow prescribed capsules.

Child noncompliance with prescribed medical regimens, including nonacceptance of oral medication, frequently impedes medical treatment and achievement of clinical aims. During this study, we used a single-subject experimental design to evaluate the effectiveness of a capsule-swallowing training curriculum specifically developed to promote acceptance of oral medication by multihandicapped children. Four such children participated, each diagnosed with a chronic pediatric illness requiring daily intake of oral medication. Training consisted of verbal instruction, demonstration, reinforcement for swallowing candies/capsules progressively larger in size, ignoring mild inappropriate behavior, and gradually providing less guidance and structure. In each case, the curriculum produced routine independent swallowing of prescribed capsules/tablets. Follow-up assessments, coupled with parent satisfaction ratings, suggest that skill acquisition was both enduring and clinically significant. This study validates a brief, readily exportable, and effective approach to teaching handicapped children to swallow capsules.

Behavioral assessment and treatment of pediatric feeding disorders.

Pediatric feeding disorders are estimated to occur in as many as one in every four infants and children, and when serious can require numerous, costly and sustained interventions. For over a decade research has cumulated evidence on the contributions of Behavior Analysis in understanding and remediating some types of pediatric feeding disorders. The systematic use of this body of evidence in conjunction with other approaches (medical, nutrition, occupational therapy, physical therapy, and so forth) is being carried out on an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described here, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach which incorporates behavioral procedures.

Phone phobia, phact or phantasy? An operant approach to a child's disruptive behavior induced by telephone usage.

The clinical efficacy of a contingency management program for treating a developmentally disabled girl referred for telephone phobia was evaluated using both a multiple baseline across settings design and a reversal design. A descriptive analysis indicated that the 'phobia' was in all probability an operant, rather than a respondent. The treatment, consisting of differential reinforcement, extinction and time-out, was effective in reducing the frequency and intensity of disruptive behaviors in response to telephone usage. Follow-up assessments at 1, 3, and 6 months revealed that treatment gains were maintained.

A swallow induction avoidance procedure to establish eating.

Swallow induction has been used to shape swallowing behavior in dysphagic children and to accelerate swallowing in nondysphagic children with profound mental retardation who display primitive swallows. Swallow induction may be considered a type of prompt. This project coupled swallow induction with a modified delayed prompting paradigm to establish eating in a 3.5-year-old girl. Coupling these procedures produced prompt swallowing and established oral consumption. Follow-ups at 1, 2, 6 and 12 months demonstrated maintenance and further improvement of the newly acquired feeding skills. Implications for treatment and further research are discussed.

Antecedent manipulation in the treatment of primary solid food refusal.

A 4-year-old with primary solid food refusal was treated with systematic fading of utensil type and food texture, using a multiple probe design across food groups. The subject was a multi-handicapped boy hospitalized for feeding problems, self-injurious behaviors, and sleep cycle reversal. At admission, the subject received all nutrition in the form of a liquid nutritional supplement through regular bottle feedings every half hour. Craniofacial anomalies and past multiple facial surgeries precluded the use of a physical prompting procedure. During the first treatment phase, pureed foods were presented with a preexisting stimulus (a regular baby bottle). Accepted presentations were reinforced with music delivered through headphones. All other behaviors received neutral consequences. In the second treatment phase, undiluted pureed foods were presented in bottles, which allowed experimenter control of the size of the bolus entering the mouth. Consequences were identical to those in Treatment 1. Next, spoon-feedings were introduced with the same consequences in place. Reinforcement with a newly acquired preferred food was initiated and faded to a variable ratio three (VR3) schedule. This fading procedure was effective in teaching this young multihandicapped child to consume a nutritionally balanced diet of pureed foods with an average acceptance of 94% and a concomitant decrease in inappropriate mealtime behaviors.

Contingency contacting. Combining positive reinforcement and escape extinction procedures to treat persistent food refusal.

Chronic food refusal has traditionally been treated with forced feeding and other physical prompting-based procedures when positive reinforcement procedures prove inadequate. Potential problems with such procedures, however, include exacerbation of feeding difficulties and health risks, as well as low parental approval and probability of implementation. Contingency contacting maximizes contact between oral acceptance and positive reinforcement, prevents escape functions of inappropriate behaviors, and requires minimal physical contact between feeder and child. Performances of two children exhibiting chronic food refusal were observed under baseline, positive reinforcement, and contingency contacting conditions. Positive reinforcement increased acceptance only slightly and did not change negative vocalization or interruption for one child. Contingency contacting rapidly increased acceptance and grams of food consumed, and decreased negative vocalization and interruption for both children. Withdrawal to positive reinforcement decreased acceptance for both children and grams consumed for one. Reinstituting contingency contacting rapidly increased acceptance and recovery of grams consumed for one child. Parental approval ratings and treatment and research implications are discussed.

Use of texture fading in the treatment of food selectivity.

Children with feeding disorders often display severe food selectivity. For many of these children, consuming highly textured foods may be aversive or potentially dangerous because of frequent gagging. The purpose of this study was to demonstrate the efficacy of texture fading in the treatment of food selectivity displayed by 4 children. Treatment involved the gradual addition of higher textures based on the results of periodic probes. In addition, food acceptance and swallowing were reinforced, while food refusal and food expulsion were placed on extinction. Results showed that all participants successfully advanced to consumption of age-appropriate texture and volume. The results suggest that texture fading with intermittent probes at higher textures may be an effective method for the treatment of food selectivity by texture.

Use of extinction and reinforcement to increase food consumption and reduce expulsion.

Extinction and reinforcement contingencies were used to treat 2 children with feeding disorders. Positive reinforcement and avoidance extinction effectively increased food acceptance but also increased food expulsion. Reduced expulsion and increased swallowing were achieved by repeated presentation of expelled food, a second extinction component

Adiposity in children: is mental retardation a critical variable?

Several authors have suggested that obesity is more prevalent amongst children with mental retardation than non-mentally retarded children. However, studies on which this suggestion is based typically lack adequate control groups. The current research compared adiposity amongst mentally retarded versus non-mentally retarded children. Study 1 compared 110 mentally retarded children with 107 non-mentally retarded children (162 males, 61 females; age range 11 months-20 years). The independent (predictor) variables included IQ and mental retardation. Dependent (criteria) variables were BMI and age-corrected BMI. Study 2, using the National Health and Nutrition Examination Survey-II data bank compared 20 children with reported mental retardation with 4015 control children on three variables: BMI, age-corrected BMI, and subscapular to triceps skinfold ratio. Results of both studies found no significant difference in adiposity or body fat distribution between mentally retarded and non-mentally retarded children. Moreover, no significant difference emerged when either age or gender were controlled and no curvilinear or interaction effects were observed.

Behavior analysis and intervention during hospitalization for brain trauma rehabilitation.

Continued problematic behavior in children and adolescents after brain trauma is a major barrier to medical care, rehabilitation, and eventual independent living. The present study demonstrates the application of already well-developed behavior analysis techniques to the early posttrauma expression of behavior problems during hospital recovery. To satisfy concerns regarding both cost and individualized treatment, interventions were carried out primarily by regular hospital staff (nurses and therapists), medical record data were used to document gains, and time series, within subject designs were used to show experimental control. Four patients (three male and one female) ranging in age from 10 to 16 years, received intervention based on behavior analysis techniques, which reduced disruption and increased cooperation with therapy and medical care. Behavior analysis techniques will be relevant to future rehabilitation research to the extent that the posttrauma patient's behavior is effected by environmental consequences as demonstrated here.

Decreased resting metabolic rate among persons with Down Syndrome.

OBJECTIVE: To compare the resting metabolic rates (RMRs) of adults with and without DS while controlling for potential confounds. DESIGN: Observational, cross-sectional study. SETTING: Outpatient core of the New York Obesity Research Center. SUBJECTS: Thirteen adults (nine males and four females) with DS were compared to 77 adults without DS. MEASUREMENTS: RMR was measured by indirect calorimetry. Fat mass (FM) and fat free mass (FFM) were determined using dual energy X-ray absorptiometry (DXA). Thyroid function (thyroxin, T3 uptake, and free T4) were determined from fasting blood samples for all DS subjects and a subset of the controls. RESULTS: An analysis of covariance was conducted in which DS status was the independent variable. Covariates were sex, FFM, FM, age, and T4. After controlling for sex, FFM, FM, age, and height, persons with DS had lower RMRs than persons without DS (F(1,83) = 7.697, P = 0.007; eta = 0.29). In terms of kcalories, the adjusted means were 1333.5 for DS subjects and 1670.1 for non-DS subjects, a difference of 20.8% relative to the grand mean. When thyroxine was added to the regression the effect of DS on RMR was of questionable significance. CONCLUSION: This research demonstrates that persons with DS have lower RMRs than do persons without DS. This difference persists after controlling for obvious confounds and was of a moderate magnitude.