ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION … · ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION IN THE TREATMENT OF FEEDING PROBLEMS ROBERT H. LARUE RUTGERS, THE STATE UNIVERSITY

ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION IN THETREATMENT OF FEEDING PROBLEMS

ROBERT H. LARUE

RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY

VICTORIA STEWART, CATHLEEN C. PIAZZA, AND VALERIE M. VOLKERT

UNIVERSITY OF NEBRASKA MEDICAL CENTER’S

MUNROE-MEYER INSTITUTE

MEETA R. PATEL

CLINIC 4 KIDZ, SAUSALITO, CALIFORNIA

AND

JASON ZELENY

UNIVERSITY OF NEBRASKA MEDICAL CENTER’S

MUNROE-MEYER INSTITUTE

Given the effectiveness of putative escape extinction as treatment for feeding problems, it issurprising that little is known about the effects of escape as reinforcement for appropriate eatingduring treatment. In the current investigation, we examined the effectiveness of escape asreinforcement for mouth clean (a product measure of swallowing), escape as reinforcement formouth clean plus escape extinction (EE), and EE alone as treatment for the food refusal of 5children. Results were similar to those of previous studies, in that reinforcement alone did notresult in increases in mouth clean or decreases in inappropriate behavior (e.g., Piazza, Patel,Gulotta, Sevin, & Layer, 2003). Increases in mouth clean and decreases in inappropriatebehavior occurred when the therapist implemented EE independent of the presence or absence ofreinforcement. Results are discussed in terms of the role of negative reinforcement in the etiologyand treatment of feeding problems.

Key words: escape, escape extinction, feeding disorders, food refusal, food selectivity,gastroesophageal reflux disease, negative reinforcement, pediatric feeding disorders, transplant

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Results of both basic and applied studies haveshown that negative reinforcement plays acentral role in the maintenance of humanbehavior (Iwata, 1987). In a typical negativereinforcement paradigm, a response producesthe removal, reduction, postponement, or pre-vention of aversive stimulation, resulting inan increase in the probability of the response(Hineline, 1977). Many examples of human

behavior that is maintained by negative rein-forcement exist (Iwata, 1987). Feeding prob-lems in children represent one example.

Many children with feeding disorders havemedical problems (e.g., gastroesophageal refluxdisease, GERD) that cause eating to be pain-ful (Di Lorenzo et al., 2005; Garb & Stunkard,1974). Thus, mealtime may be associated withpain, which may increase the probabilitythat the child will exhibit refusal behavior(e.g., crying, batting at the spoon). Parentssometimes respond to refusal by removing,postponing, or terminating bite presentations(Borrero, Woods, Borrero, Masler, & Lesser,2010; Piazza, Fisher, et al., 2003). The child

Requests for reprints should be addressed to CathleenC. Piazza (e-mail: [email protected]).

doi: 10.1901/jaba.2011.44-719

This investigation was supported in part by Grant 1K24 HD01380-01 from the Department of Health andHuman Services, the National Institute of Child Healthand Human Development.

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2011, 44, 719–735 NUMBER 4 (WINTER 2011)

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then learns that refusal behavior producesescape from eating.

To illustrate, Borrero et al. (2010) conducteddescriptive assessments with 25 children withfeeding problems and their caregivers. Follow-ing the descriptive assessments, the authorscalculated conditional probabilities for caregiverresponses to inappropriate child behavior. Theresults of the conditional probability analysisshowed that refusal frequently was followed bymeal termination and escape from spoon orcup presentations. Piazza, Fisher, et al. (2003)conducted functional analyses to examine therole of negative reinforcement in the mainte-nance of feeding problems. Of the 10 childrenwhose functional analyses were differentiated,90% displayed inappropriate behavior that wasmaintained by escape from bite or drink pre-sentations.

Given the importance of negative reinforce-ment in the maintenance of feeding problems, itis surprising that its effects following appropri-ate eating have not been evaluated. By contrast,investigators have used negative reinforcementfor appropriate behavior in the treatment ofother behavior problems (Lalli et al., 1999;Roberts, Mace, & Daggett, 1995; Steege et al.,1990; Vollmer, Marcus, & Ringdahl, 1995).For example, Lalli et al. (1999) compared theeffects of positive (edible items) and negative(escape) reinforcement for compliance in theabsence of escape extinction (EE) for individ-uals whose destructive behavior was maintainedby escape from instructions. Positive reinforce-ment was more effective in increasing compli-ance and reducing destructive behavior than wasnegative reinforcement.

Nonetheless, it is not clear if the resultsof Lalli et al. (1999) are applicable to feedingproblems for several reasons. First, Lalli et al.used edible items as reinforcement, and theseitems may not consistently function as rein-forcement for children who refuse to eat. Inaddition, children with feeding problems mayrespond differently to positive and negative

reinforcement-based treatment than childrenwith destructive behavior. For example, Piazza,Patel, Gulotta, Sevin, and Layer (2003), incontrast with Lalli et al., showed that positivereinforcement in the absence of EE did notproduce increases in acceptance for fourchildren with feeding problems. Althoughpositive reinforcement alone was not effective,positive reinforcement in combination with EEdid produce beneficial effects (i.e., reducedinappropriate behavior or negative vocaliza-tions) for some children. Therefore, it maybe productive to conduct similar analyses ofnegative reinforcement for appropriate eatingalone and in combination with EE.

The purpose of the current investigation wasto extend the literature on the role of negativereinforcement in the treatment of food refusal.First, we conducted functional analyses todemonstrate that inappropriate behavior wasmaintained, at least in part, by negativereinforcement in the form of escape from biteor drink presentations (Bachmeyer et al., 2009).Next, we evaluated the effects of concurrentescape contingencies (30-s break) followingboth mouth clean (a product measure ofswallowing) and inappropriate behavior relativeto when escape was available for inappropriatebehavior only. We then examined the effects ofescape for mouth clean in conjunction with EE(nonremoval of the spoon) and compared it toEE alone.

METHOD

Participants, Setting, and Materials

The participants were five children who hadbeen admitted to an intensive outpatient pe-diatric feeding disorders program. They wereincluded in this study because their primarypresenting problem was solid or liquid refusalor selectivity, and the children’s parents indi-cated that using escape as reinforcement forappropriate eating or drinking and EE wouldbe acceptable. In addition, the results of afunctional analysis indicated that inappropriate

720 ROBERT H. LARUE et al.

behavior was maintained, at least in part, byescape from bite or drink presentations.

Lauren was a 2-year-old girl whose medicalhistory included a small bowel transplant. Shehad been admitted for solid and liquid refusal,gastrostomy (G-) tube dependence, and paren-teral nutrition dependence. She consumed nosolids or liquids by mouth. George was a 5-year-old boy whose medical history included akidney transplant. He had been admitted forsolid and liquid refusal and G-tube dependence.He consumed no solids or liquids by mouth.Carl was an 18-month-old boy whose medicalhistory included insufficient oral intake andGERD. He had been admitted for foodselectivity by type and texture, packing, andvomiting. He consumed approximately 90% ofhis nutritional needs by mouth, consisting ofbottle-fed Elecare formula and Stage 2 jarredbaby food (chicken and gravy only). Charleswas a 5-year-old boy whose medical historyincluded G-tube dependence. He had beenadmitted for insufficient oral intake and tex-ture selectivity. Charles consumed approxi-mately 65% of his nutritional needs by mouth,consisting of Stage 2 jarred baby foods andliquids from a bottle. Frank was a 21-month-old boy whose medical history included GERDand dysphagia. He had been admitted forinsufficient oral intake and nasogastric-tubedependence. Frank consumed approximately38% of his nutritional needs by mouth,consisting of Stages 1 and 2 jarred baby foodand milk with Carnation Instant Breakfast(CIB). Prior to admission, each child partici-pated in a medical evaluation to rule out or treatany possible medical causes of the feedingproblem and to evaluate the child’s safety andappropriateness for oral feeding. All childrenwere cleared by their physician for the program.

Therapists conducted sessions in rooms (4 mby 4 m) with one-way observation and sound.The room was equipped with age-appropriateseating (i.e., high chair with a removable trayor a table), food or drink, eating or drinking

utensils, and a bib that folded at the bottom toform a receptacle.

Data Collection and Interobserver Agreement

Observers recorded acceptance, mouth clean,and inappropriate behavior on laptop computersusing an event-recording procedure. Observersscored the occurrence of acceptance and mouthclean. During solid sessions, observers scoredacceptance if the child leaned toward the spoon,opened his or her mouth, and allowed the entirebolus of food (except for an amount smallerthan the size of a pea) to enter the mouth within5 s of the presentation in the absence of negativevocalizations and inappropriate behavior. Dur-ing liquid sessions, observers scored acceptanceif the child leaned toward the cup, opened hisor her mouth, and allowed any portion of theliquid to enter the mouth within 5 s of thepresentation in the absence of negative vocali-zations and inappropriate behavior. A presen-tation occurred when the therapist placed thespoon or cup touching the child’s lips, notincluding when the therapist placed the spoonor cup at the lips following re-presentation. Weused different definitions for solids and liquidsbecause it took longer for the therapist todeposit the bolus of liquids into the child’smouth than it did for the therapist to depositthe bolus of solids. The first time the bite ordrink entered the child’s mouth, the observeractivated a timer for 30 s to signal the feeder tocheck the child’s mouth (see Procedure for moredetail). The observers scored mouth clean at the30-s check if (a) the entire bolus had entered thechild’s mouth (except for an amount smallerthan the size of a pea) and (b) no food or liquidlarger than the size of a pea was in the child’smouth, which did not include the absence offood or liquid as a result of expulsion (spittingout the food). The observers scored a pack atthe 30-s check if (a) the entire bolus had enteredthe child’s mouth (except for an amount smallerthan the size of a pea) and (b) food or liquidlarger than the size of a pea remained in thechild’s mouth. If no bites or drinks entered the

ESCAPE AS REINFORCEMENT 721

child’s mouth during a session, the child did nothave the opportunity to have a mouth clean. Ifthe child expelled the bite or drink during the30-s interval and did not have any solids orliquids larger than the size of a pea in his or hermouth at the 30-s check, the observer did notscore either a mouth clean or a pack. Observersscored expel each time the child spit out foodlarger than the size of a pea. Observers scoredthe frequency of inappropriate behavior eachtime the child turned his or her head 45udegrees or more away from the spoon or cup;hit the spoon, cup, or feeder’s arm or hand; orcovered his or her mouth while the spoon orcup was at (i.e., within 4 cm of) the child’s lips.

Data for acceptance and mouth clean wereconverted to a percentage after dividing thenumber of occurrences of acceptance or mouthclean by the number of bite or drink presen-tations (denominator for acceptance) or thenumber of bites or drinks that entered thechild’s mouth (denominator for mouth clean).Data on inappropriate behavior were convertedto responses per minute by dividing the numberof inappropriate behaviors by the duration oftime the spoon or cup was at the child’s lips.

Interobserver agreement for acceptance andmouth clean was calculated by partitioning thesession into 10-s intervals; summing occurrence(a 10-s interval in which both observers scoredthe behavior) and nonoccurrence (a 10-s in-terval in which both observers did not score thebehavior) agreements; dividing by the sum ofoccurrence agreements, nonoccurrence agree-ments, and disagreements (a 10-s interval inwhich one observer scored the occurrence ofand the other observer did not score anoccurrence of the behavior); and convertingthe ratio to a percentage. Exact agreementscoefficients for inappropriate behavior werecalculated by dividing the number of agree-ments (a 10-s interval in which both observersscored the same frequency of inappropriatebehavior) by the number of agreements plusdisagreements (a 10-s interval in which the

observers scored a different frequency of inap-propriate behavior) and converting the ratio to apercentage.

During the functional analysis, a secondobserver simultaneously but independentlyscored 30%, 31%, 32%, 59%, 39%, and 75%of sessions for Lauren, George, Carl, Charles(solids), Charles (liquids), and Frank, respec-tively. Mean agreement was 100% for accep-tance, 100% for mouth clean, and 83% (range,70% to 100%) for inappropriate behavior forLauren; 100% for acceptance, 100% for mouthclean, and 85% (range, 68% to 100%) forinappropriate behavior for George; 100% foracceptance, 100% for mouth clean, and 85%(range, 69% to 100%) for inappropriate be-havior for Carl; 100% for acceptance, 100% formouth clean, and 94% (range, 83% to 100%)for inappropriate behavior for Charles (solids);100% for acceptance, 100% for mouth clean,and 94% (range, 75% to 100%) for inappro-priate behavior for Charles (liquids); and 100%for acceptance, 100% for mouth clean, and86% (range, 73% to 100%) for inappropriatebehavior for Frank.

A second observer simultaneously but inde-pendently scored 33%, 49%, 36%, 32%, 33%,and 47% of sessions for Lauren, George, Carl,Charles (solids), Charles (liquids), and Frank,respectively, during the treatment analysis.Mean agreement was 97% (range, 89% to100%) for acceptance, 95% (range, 65% to100%) for mouth clean, and 97% (range,93% to 100%) for inappropriate behavior forLauren; 98% (range, 85% to 100%) foracceptance, 99% (range, 89% to 100%) formouth clean, and 99% (range, 79% to 100%)for inappropriate behavior for George; 97%(range, 88% to 100%) for acceptance, 98%(range, 86% to 100%) for mouth clean, and96% (range, 86% to 100%) for inappropriatebehavior for Carl; 99% (range, 95% to 100%)for acceptance, 99% (range, 92% to 100%) formouth clean, and 99% (range, 93% to 100%)for inappropriate behavior for Charles (solids);


96% (range, 76% to 100%) for acceptance,99% (range, 84% to 100%) for mouth clean,and 97% (range, 86% to 100%) for inappro-priate behavior for Charles (liquids); 97%(range, 47% to 100%) for acceptance, 97%(range, 60% to 100%) for mouth clean, and98% (range, 85% to 100%) for inappropriatebehavior for Frank.

Design

We used a pairwise design (Iwata, Duncan,Zarcone, Lerman, & Shore, 1994) in thefunctional analysis to compare levels of inap-propriate behavior in the test and controlconditions for all participants except Charles(liquids and solids). We used a reversal designwith Charles for liquids and solids. We used acombination of multielement and ABAB de-signs to compare levels of acceptance, mouthclean, and inappropriate behavior in thetreatment analysis. During baseline (A), wealternated between escape for inappropriatebehavior and escape for inappropriate behaviorand mouth clean. During the B phase, wealternated between EE and EE plus escape formouth clean.

General Procedure

For the current analysis, a trained therapistconducted approximately three meals per daywith at least 1 hr between the start of each meal(e.g., 9:00 a.m., 12:00 p.m., 4:00 p.m.). Eachmeal consisted of multiple five-bite or five-drink sessions with brief breaks (e.g., 1 to 2 min)between sessions. The focus of treatment wassolids for Lauren, George, and Carl; solids andliquids for Charles; and liquids for Frank. Thecaregivers of Lauren, George, Carl, and Charlesselected approximately 8 to 16 foods for thetherapist to present during meals. The therapistrandomly selected three (Lauren) or four(George, Carl, and Charles) of the caregiver-identified foods to present in each meal, withthe caveat that the therapist presented all of thefoods in each phase of the assessment to controlfor any possible differences in behavior due to

food type. The therapist presented only proteinsand vegetables to Lauren and George based onthe physician’s recommendation. The therapistpresented Carl and Charles with one food fromeach of the food groups of fruit, protein, starch,and vegetable. Foods were a pureed texture forall children. The therapist selected the orderof food presentation randomly prior to thesession. The therapist presented each bite on asmall Maroon spoon containing 10.92 cc (Lau-ren) or 0.85 cc (all other children) of food. Thetherapist presented 2 cc (Charles) or 4 cc (Frank)of CIB mixed with whole milk (based on therecommendation of the program dietitian) in apink cut-out cup. The program speech therapistprescribed the texture, utensils, and bolus sizes.

The therapist presented the spoon or cuptouching the midline of the child’s lipsaccompanied by a verbal prompt to ‘‘take abite [drink]’’ approximately every 30 s. Thetherapist delivered brief verbal praise followingacceptance. The therapist said ‘‘show me’’ 30 safter the bite or drink entered the child’s mouthto determine if the child had swallowed. If thechild did not open his or her mouth followingthe verbal prompt, the therapist used a smallrubber-coated baby spoon to prompt the childto open his or her mouth. The prompt con-sisted of the therapist inserting the spoon intothe child’s mouth and turning it 90u, accom-panied by a second verbal ‘‘show me’’ prompt.The therapist delivered brief praise for mouthclean following the first 30-s mouth check andpresented the next bite or drink. The therapistdid not provide any differential consequence ifthe child cried, gagged, coughed, or vomited.

The therapist delivered a verbal prompt to‘‘swallow your bite [drink]’’ if any food or drinklarger than the size of a pea remained in thechild’s mouth at the 30-s check (referred to as apack). The therapist then presented the nextbite or drink. If the therapist had presented allfive bites or drinks, and the child was packingafter the 30-s check, the therapist repeated theverbal prompt to ‘‘swallow your bite [drink]’’


every 30 s until no food or drink larger than thesize of a pea was in the child’s mouth. Thetherapist would have terminated the meal at30 min if the child had not swallowed all fivebites, but this was never necessary in anycondition for any child.

Functional analysis. We conducted a func-tional analysis (Bachmeyer et al., 2009) witheach participant to assess the extent to whichescape functioned as reinforcement for inap-propriate behavior. During the functionalanalysis, the therapist followed the generalprocedures described above in addition to thespecific procedures for each condition describedbelow. In all conditions, the therapist held thespoon or cup stationary (i.e., once the therapistpositioned the spoon or cup, it did not move)for 30 s if the child did not accept the biteor drink and did not engage in inappropriatebehavior. The therapist did not re-presentexpelled bites or drinks. During the controlcondition, the therapist provided no differentialconsequence for inappropriate behavior andinteracted with the child (e.g., sang) in thepresence of toys identified via a stimuluspreference assessment throughout the session.During the escape condition, the therapistremoved the spoon or cup for 30 s if the childengaged in inappropriate behavior and present-ed the next bite or drink after the 30-s escapeinterval. The therapist did not provide anyother differential consequence following thechild’s inappropriate behavior (e.g., the thera-pist did not reprimand the child). Toys werenot available. During the attention condition,the therapist provided 30 s of attention (e.g.,‘‘you like peas’’) following inappropriate behav-ior while the spoon or cup remained stationaryfor 30 s. The therapist presented the next biteafter the 30-s attention interval. Toys were notavailable. During the tangible condition (Frankonly), the therapist provided 30 s of a tangibleitem (one of three highly preferred toys identifiedvia stimulus preference assessment) after inap-propriate behavior. The therapist presented the

next bite after the 30-s interval. We conducteda tangible condition for Frank because weobserved that his parents gave him toys whenhe engaged in inappropriate behavior duringmeals.

Treatment Evaluation of Negative Reinforcement

The therapist followed the general proce-dures described above in addition to thespecific procedures for the conditions describedbelow.

Escape for inappropriate behavior. The proce-dures were identical to the escape condition ofthe functional analysis.

Escape for inappropriate behavior and mouthclean. The procedures were identical to theescape for inappropriate behavior conditionexcept that mouth clean resulted in a 30-sbreak from bite or drink presentations. That is,the therapist waited for 30 s after a mouth cleanto present the next bite or drink. The therapistdid not deliver additional reinforcers followingmouth clean. We chose 30 s as the reinforce-ment interval for mouth clean because theresults of the functional analysis showed that a30-s escape interval functioned as reinforcementfor inappropriate behavior. The goal of thestudy was to evaluate whether that same intervalwould function as reinforcement for mouthclean.

Escape extinction. The therapist held thespoon or cup at the child’s lips and depositedthe bite or drink any time the child’s mouth wasopen if the child did not accept the bite or drinkwithin 5 s of presentation. The therapist re-presented (i.e., scooped up the bite or drinkwith the spoon or cup and placed the bite ordrink back into the child’s mouth) expelledbites or drinks and provided no differentialconsequences for inappropriate behavior. Re-presentation did not reset the 30-s mouth checkclock. That is, the therapist checked for amouth clean 30 s after the bite or drink enteredthe child’s mouth the first time and every 30 sthereafter if the child had not swallowed the bite


or drink, independent of whether the childexpelled the bite or drink within the 30-sinterval. The session ended when the child hadswallowed all five bites or drinks.

Escape extinction plus escape for mouth clean.The procedure was similar to EE with theaddition that mouth clean resulted in a 30-sbreak (as described above).

RESULTS

Results of the functional analyses are depictedin the top, middle, and bottom panels ofFigure 1 for Lauren, George, and Carl andin Figure 2 (solids for Charles, top; liquidfor Charles, middle; Frank, bottom). For allparticipants, rates of inappropriate behaviorwere higher in the escape condition than in

Figure 1. Inappropriate behavior per minute during escape and control conditions of the functional analysis forLauren (top), George (middle), and Carl (bottom).


the control condition. Rates of inappropriatebehavior were lower in the attention, tangible(Frank), and control conditions. Acceptanceand mouth clean (data not shown) remained atzero for all participants. These results suggestedthat inappropriate behavior was maintained, atleast in part, by negative reinforcement in theform of escape.

Percentage of acceptance, percentage ofmouth clean, and rate of inappropriate behaviorfrom the treatment evaluation are depictedin Figures 3 (Lauren), 4 (George), 5 (Carl), 6(Charles, solids), 7 (Charles, liquids), and 8(Frank). The general pattern of responding wassimilar for all participants. Acceptance remainedlow and inappropriate behavior remained high

Figure 2. Inappropriate behavior per minute during escape and control conditions of the functional analysis forCharles (liquids, top), Charles (solids, middle), and Frank (bottom).


in both escape for inappropriate behavior andescape for inappropriate behavior and mouthclean conditions. There were no acceptance andno opportunities for mouth clean (therefore, nodata appear on the panels for mouth clean) inthe initial baseline. Acceptance and mouth cleanincreased and inappropriate behavior decreased

during both EE and EE plus escape for mouthclean. Removal of EE resulted in decreasesin acceptance and increases in inappropriatebehavior for all participants; few or no op-portunities for mouth clean for Lauren, Carl,Charles (liquids), Charles (solids), and Frank;and no change in mouth clean for George.

Figure 3. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for Lauren.


Reimplementation of EE and EE plus escape formouth clean produced increases in acceptanceand mouth clean (except for George) anddecreases in inappropriate behavior. For George,

reimplementation of EE and EE plus escape formouth clean produced increases in acceptanceand decreases in inappropriate behavior andmore variability in mouth clean initially.

Figure 4. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for George.


DISCUSSIONThe results of studies on functional analysis

of feeding disorders suggest that negativereinforcement in the form of escape fromeating plays a major role in the maintenance ofinappropriate mealtime behavior (Girolami &Scotti, 2001; Najdowski et al., 2008; Piazza,

Fisher, et al., 2003). Similarly, the resultsof the functional analyses of the five childrenin the current investigation showed thattheir inappropriate behavior was maintained,at least in part, by negative reinforcementin the form of escape from bite or drinkpresentations.

Figure 5. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for Carl.


Although the results of the functionalanalyses showed that escape functioned asreinforcement for inappropriate behavior, es-cape did not appear to be a reinforcer for mouthclean when escape was available concurrently for

inappropriate behavior (except, perhaps, forGeorge). There may be a number of reasonswhy. First, none of the children accepted bitesor drinks in the initial baseline; therefore,none of the children had an opportunity to

Figure 6. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for Charles (solids).


experience the reinforcement contingency formouth clean. However, after we implementedEE, all of the children contacted reinforcementfor mouth clean, and Lauren, George, Carl, andCharles (liquids) contacted the contingency

again in the reversal. Nevertheless, high levelsof mouth clean were not sustained in thereversal to baseline for any of the childrenexcept George. It is possible that escapeas reinforcement sustained mouth clean for

Figure 7. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for Charles (liquids).


George during the reversal. For the otherchildren, it is possible that longer escapeintervals for mouth clean relative to the lengthof escape for inappropriate behavior would havebeen effective in biasing responding towardmouth clean. Future studies should manipulate

the length of the escape interval for bothinappropriate and appropriate behavior todetermine how reinforcement duration affectsresponding. Future research also could manip-ulate other parameters of reinforcement (e.g.,quality, rate) to identify the manipulations that

Figure 8. Percentage of acceptance (top), percentage of mouth clean (middle), and inappropriate behavior perminute (bottom) from the treatment analysis for Frank.


would bias responding in favor of appropriatebehavior (Athens & Vollmer, 2010).

In the current investigation, we implementedthe reinforcement contingency for mouth cleanrather than for acceptance, because Patel,Piazza, Martinez, Volkert, and Santana (2002)showed that levels of acceptance and mouthclean were equivalent, independent of whetheracceptance or mouth clean produced positivereinforcement. However, future studies shouldevaluate whether escape following acceptance ismore effective than escape following mouthclean.

Piazza et al. (1997) suggested that respondingmight be biased toward inappropriate behaviorwhen escape is available for both appropriateand inappropriate behavior. In the currentinvestigation, the child could avoid eatingaltogether if he or she engaged in inappropriatebehavior in baseline. By contrast, the childcould access breaks from spoon or cuppresentations only following mouth clean ifthe child consumed the bite or drink. There-fore, inappropriate behavior may have requiredless effort than mouth clean. Responding alsomay have favored inappropriate behavior dueto the child’s history of reinforcement. Borreroet al. (2010) showed that the conditionalprobability of a parent terminating the meal orremoving the spoon or cup following inappro-priate behavior was higher than the probability ofthose same events following acceptance. Resultsof Borrero et al. suggest that children withfeeding disorders may have a long history of mealtermination and spoon or cup removal followinginappropriate behavior and that inappropriatebehavior is more effective than consumption forproducing meal termination or escape.

Although escape for mouth clean alone wasnot effective, acceptance and mouth cleanincreased and inappropriate behavior decreasedwhen the therapist implemented EE. Theseresults replicate those of a number of studiesthat have demonstrated the possible necessityof EE in the treatment of feeding problems

(Ahearn, Kerwin, Eicher, Shantz, & Swearingin,1996; Cooper et al., 1995; Hoch, Babbitt, Coe,Krell, & Hackbert, 1994; Patel et al., 2002;Piazza, Patel, et al., 2003; Reed et al., 2004). Butwhy does EE appear to be so important fortreating severe feeding problems?

Escape from eating is hypothesized tobecome a reinforcer for food refusal whenmedical conditions cause eating to be painful(Piazza, Fisher, et al., 2003). For example,children with GERD may associate eating withthe pain that occurs when excess acid is releasedinto the stomach or esophagus. Basic studieswith both animals and humans have shown thatpairing eating with an aversive event may resultin learned or conditioned taste aversions (e.g.,Garb & Stunkard, 1974). For example, Garcia,Kimeldorf, and Koelling (1955) exposed rats toa noxious stimulus (e.g., emetic agent) pairedwith a flavor and showed that the rats avoidedthe flavor even after removal of the noxiousstimulus. These aversions may develop afteronly one or a few trials and after significantdelays between eating and the aversive event(e.g., vomiting; Garcia, Hankins, & Rusiniak,1974; Lindberg, Alvin, Chezik, & Ray, 1982;Riley & Clarke, 1977). These taste aversions inanimals may be similar to the food refusal seenin children with severe feeding problems.

Like any avoidance behavior, once tasteaversions develop, they have been notoriouslydifficult to extinguish in experiments withnonhuman species because the avoidance re-sponse prevents the organism from contactingthe change from negative reinforcement toextinction (e.g., Bernstein, 1991; Garcia, Ervin,& Koelling, 1966; Garcia et al., 1955, 1974).The parallel in feeding disorders displayed byyoung children is that even if the child’s medicalproblems are treated and eating no longerproduces pain, the child never learns that eatingis no longer painful if he or she continues torefuse to eat. That is, if the child never contactsfood, he or she never has the opportunity tolearn that eating is no longer painful. In fact,


animal studies have shown that under somecircumstances, extinction of the taste aversionoccurs only when the animal has direct contactwith the aversive taste (e.g., the taste is infus-ed into the oral cavity; Spector, Smith, &Hollander, 1981, 1983). The results of thecurrent investigation and others on EE (Ahearnet al., 1996; Cooper et al., 1995; Hoch et al.,1994; Piazza, Patel, et al., 2003) are similar inthat, in some cases, consumption increases onlywhen the child has direct contact with the foodor drink through EE, which is why EE might becritical as treatment when the feeding problemis severe.

Although EE was effective, the presence ofescape as reinforcement for mouth clean inconjunction with EE did not appear tocontribute to the treatment effects. These resultsare different from those of Piazza, Patel, et al.(2003) and Reed et al. (2004), who showedthat the presence of positive reinforcement incombination with EE was associated with somebeneficial effects (i.e., reduced inappropriatebehavior or negative vocalizations). It is notclear why escape as reinforcement for mouthclean in combination with EE did not contrib-ute to treatment effects.

One question that remains unanswered iswhy some children develop feeding problems(Rommel, DeMeyer, Feenstra, & Veereman-Wauters, 2003) and others do not. Forexample, the majority of newborns exhibitspitting or vomiting (Belknap & McEvoy,1994); nevertheless, most of these children donot develop feeding disorders. In addition, notall children diagnosed with a feeding disorderhave diagnosed medical problems (Rommelet al.). It may be that children who developfeeding disorders have particular sensitivity toescape as reinforcement or have differentialexposure to escape during eating (Borrero et al.,2010). In addition, other variables (e.g.,attention, access to preferred foods or activities)also may function as reinforcement for foodrefusal (Bachmeyer et al., 2009; Piazza, Fisher,

et al., 2003). Future research should examinethe risk factors for the development of feedingproblems. Children identified to be at riskcould be followed over time to examine theirreinforcement histories to determine if differ-ential sensitivity or exposure to escape influenc-es the development of feeding problems. Futureresearch also should examine how biological(e.g., GERD) and behavioral variables interactin both the etiology and treatment of feedingproblems.

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Received September 24, 2010Final acceptance February 9, 2011Action Editor, Jennifer Zarcone


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ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION … · ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION IN THE TREATMENT OF FEEDING PROBLEMS ROBERT H. LARUE RUTGERS, THE STATE UNIVERSITY