trating food refusal in adolescent with asperger's disorder

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DOI: 10.1177/15346501103735002010 9: 260 originally published online 18 June 2010Clinical Case Studies

Michael P. Roth, Keith E. Williams and Candace M. PaulTreating Food and Liquid Refusal in an Adolescent With Asperger's Disorder

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Treating Food and LiquidRefusal in an Adolescent

With Aspergers Disorder

Michael P. Roth1, Keith E. Williams2,

and Candace M. Paul2

Abstract

Food refusal is a complicated condition that has both medical and social implications. In this study,

a 16-year-old boy with Aspergers disorder, dependent on gastrostromy tube feedings for9 years, is treated with a behavioral intervention. The intervention consists of several components,including stimulus fading for both solids and liquids, a token economy for solids, and an escapeprevention component for liquids. Before treatment, the participant consumes three different

foods and water. After treatment, the participant is consuming 78 foods and 13 beverages. Atthe end of 14 days of treatment, all of the participants intakes are received orally, tube feedingsare eliminated, and the patient has gained more than 1 pound on oral feedings. The intervention

is generalized to both home and school settings, and maintenance of treatment gains is reportedby parents 3 months after the end of treatment.

Keywords

food refusal, autism spectrum disorder, token economy, stimulus fading

1 Theoretical and Research Basis

Food refusal has been described as a child failing to consume enough by mouth to maintain nutri-

tional needs and having a height-to-weight ratio below the 5th percentile (Williams, Hendy, &

Knecht, 2008). It has been linked to medical conditions, for example, gastroesophogeal reflux

disease; cystic fibrosis (Field, Garland, & Williams, 2003; Linscheid, 2006; Piazza, Patel, Gulotta,

Sevin, & Layer, 2003); genetic disorders, for example, TreacherCollin syndrome, RusselSilversyndrome (Ahearn, Castine, Nault, & Green, 2001; Coe et al., 1997); and psychological issues, for

example, choking phobia (Burklow & Linscheid, 2004).

Till date, only one study has examined the use of a token economy in the treatment of food

refusal. Kahng, Boscoe, and Byrne (2003) found that a token economy in conjunction with dif-

ferential negative reinforcement of alternative behavior was more effective in increasing food

acceptance and reducing refusal behaviors than would a token economy with differential posi-

tive reinforcement of alternative behavior with or without physical guidance. Though this study

1Pennsylvania State University, Harrisburg

2Penn State Milton S. Hershey Medical Center

Corresponding Author:

Keith E. Williams, Feeding Program, 905 W. Governor Road, Hershey, PA 17033

E-mail: [email protected]

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Roth et al. 261

demonstrated utility of a token economy as a component of treatment, the study had some

limitations. The study involved only pureed fruits and vegetables and included no foods of

higher texture or other additional food groups such as dairy, fats, grains, and meats. The food

was presented on a Nuk brush, and it was unclear whether there was a transition to other feeding

utensils. Furthermore, it was not reported whether the participant had advanced his feeding skillsat the time of follow-up. This study was, however, unique in that it did not involve the use of

escape prevention.

Although a range of interventions has been used to treat food refusal in children and adoles-

cents, most interventions consist of several components, including some form of escape preven-

tion in which the child is required to consume the food offered (Kerwin, 1999). One escape

prevention procedure, often termed exit criterion, involves having the child to eat a specified

amount of food, often initially a single bite, before being allowed to exit the session (Farrel,

Hagopian, & Kurtz, 2001; Paul, Williams, Riegel, & Gibbons, 2007). Another component that

has been included in interventions for food refusal is some form of stimulus fading, which has

typically involved the gradual increase in bite size or texture (Freeman & Piazza, 1998; Luiselli,

2000; Luiselli, & Gleason, 1987; Paul et al., 2007). Fading has also been used to increase vol-ume of previously avoided drinks without eliciting negative behaviors (Babbitt, Shore, Smith,

Williams & Coe, 2001; Luiselli, Ricciardi, & Gilligan, 2005; Patel, Piazza, Kelley, Ochsner, &

Santana, 2001). This study examined use of a multicomponent intervention that included a

token economy and fading procedure for solid food and a fading procedure plus escape preven-

tion for liquids.

Objectives

The goal of treatment was to eliminate need for gastrostomy tube feeds by increasing the volume

and variety of foods eaten to meet all of the participants nutritional needs. Liquid consumptionwould also be increased both to increase caloric intake and to ensure adequate hydration.

2 Case Presentation

Tyler (pseudonym) was a 16-year-old White boy diagnosed with Aspergers disorder. Tyler was

enrolled in a public school and participated in general education classes with his peers. He

attended a learning-support classroom to receive additional instruction for math, but otherwise

received no additional educational services. Tyler resided at home with his biological parents

and younger brother.

3 Presenting Complaints

Tyler was referred to the feeding program, due to lack of weight gain, poor growth, and food

refusal. Before treatment Tylers weight was 29.94 kilograms, and his height was 141centime-

ters, which was below the 3rd percentile in height and weight compared to boys of his age.

Furthermore, it was calculated that Tyler had the height of an average 10-year-old and the weight

of an average 9.5-year-old.

According to Tylers parents, Tylers began to refuse most foods at 5 years of age but was a

very selective eater at 4 years of age. They also reported that his diet became progressively more

selective until his intake was so limited that he became nutritionally compromised and required

tube feedings. His parents did not report medical conditions that could serve as a possible etiol-

ogy to his initial food refusal, and a review of his medical records did not reveal possible biologi-

cal factors. His parents did report that by the age of 16, Tyler had been dependent on gastrostomy

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262 Clinical Case Studies 9(4)

tube feeds for 9 years. Before treatment, his daily nutritional needs were met predominantly by

32 ounces of Nutren 2.0 formula delivered through gastrostomy tube. Tyler drank only water and

ate small amounts of a specific brand of three different foods. Though these three foodsbowtie

pasta, ham steak, and cerealwere of different textures, Tyler mentioned not liking how some

foods felt in his mouth. In addition to being selective by type and texture, he only used specificutensils and dishes and only ate dinner. Tyler was given the diagnosis of food refusal as he did

not eat enough to sustain growth; however, he did not fit the more typical pattern of children with

food refusal. A recent review of food refusal examined 38 interventions studies and found that

212 of 218 participants described in these food refusal intervention studies had some form of

medical issue that could have served as an etiology to the food refusal (Williams, Field, &

Seiveling, 2010). In a sample of children referred to feeding programs, the most common feed-

ing problem found among the children with autism spectrum disorders was food selectivity

(Field et al., 2003), but the severity of the feeding problems in these children was not as extreme

as exhibited by Tyler.

4 History

Tyler had a gastrostomy tube placed at 7 years of age, secondary to poor growth and malnutrition.

Other than his chronic refusal to eat, Tyler presented with no medical conditions (e.g., gastro-

esophageal reflux disease, oral-motor deficits, delayed gastric emptying, vomiting, etc.) that

would have interfered with his ability to eat or drink. Tyler had been diagnosed with Aspergers

disorder as a preschooler. Previous attempts to address his food refusal by community providers

and by two outpatient visits to a feeding program were not successful in improving his food and

beverage intake.

5 Assessment

Before treatment, Tylers parents completed a developmental, medical, and feeding history. The

parents also provided a list of all food and liquids eaten before treatment. In reviewing the history

with Tylers parents, they described behaviors such as refusal to speak on a telephone or demon-

strating distress at the sound of a vacuum that rose to the level of specific phobias.

Baseline meals were conducted and data collected on the dependent measures are described

in Section 7.1. In these baseline meals, Tyler was presented with six foods and told he could eat

any of the foods presented but was not required to eat anything. During baseline meals, Tyler

was presented with both the three foods he ate before treatment as well as novel foods from all

food groups. During baseline, Tyler ate only foods he had previously eaten and avoided all novelfoods. After three baseline meals, during which Tyler ate only small amounts of previously eaten

foods, it was decided to implement treatment. As Tyler had only eaten the same foods for several

years, and the baseline meals confirmed this pattern of consumption, it was determined that

additional baseline meals were not necessary.

Potential reinforcers were determined by interviewing both Tyler and his parents. These rein-

forcers included access to his laptop, preferred videos, and computer games.

5.1 Interobserver Agreement

Interobserver agreement data were recorded to account for experimenter bias while providing

treatment to Tyler. Data were collected by having either an independent observer collecting data

through a one-way observation mirror or by observing videorecordings of meals. These data were

compared to the data collected by the therapist who conducted the meal session. Interobserver



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Roth et al. 263

agreement for bites consumed, negative vocalization,andgaggingwas calculated for 28% of the

meals conducted and was calculated to be 93.38%, 100%, and 100%, respectively. For the depen-

dent variable liquid consumed,no agreement data were collected. Each beverage consumed was

weighed before and after treatment (using the same kitchen scale).

5.2 Treatment Integrity

Meals were videorecorded across the course of treatment. These videorecordings were rated

using a 14-item treatment integrity checklist developed by the experimenters to ensure consistent

implementation of treatment procedures. Each video was rated by an experimenter who was not

involved in implementation of the meal being rated. Overall treatment integrity was calculated

to be 99.6% of the 17 sessions recorded.

6 Case Conceptualization

The participants age and high level of functioning makes him dissimilar to not only to previouspatients treated for food refusal in this feeding program (who tend to be younger and have more

significant delays in development) but also to participants in other published food refusal inter-

vention studies (Williams, Field, & Seiveling, 2010). A significant consideration in the develop-

ment of this intervention were the characteristics of the participant. His parents described him as

being anxious, which led us to focus more on the use of establishing operations and antecedent

manipulations rather than the escape extinction procedures used in past research (Williams &

Seiverling, 2010). Although escape extinction has been shown to be a highly effective compo-

nent in the treatment of food refusal, like all extinction procedures, it can be accompanied with

negative side-effects such as crying or tantrums. One of the unique aspects to this intervention

was the way in which the daily schedule of meals was presented. Though the daily schedule ofmeals is often not mentioned in articles describing the treatment of food refusal, some descrip-

tions of interventions describe participants receiving between three (Linscheid, 2006) and five

(Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005) meals or sessions per day. In this treat-

ment, a meal was presented, the participant completed the meal, exchanged his tokens for time

in his arcade, and then when the time earned in the arcade had elapsed, another meal was

presented. Thus, the participant controlled the number of meals that occurred per day through his

response effort in meals. The greater number of bites and drinks consumed at a meal would not

only result in more minutes spent in his arcade but would also limit the number of meals pre-

sented per day. The participant learned this relationship quickly and would verbalize during

meals that he would eat more to get a long break.Even though this intervention consisted of several components including appetite manipula-

tion, stimulus fading for both solids and liquids, token economy for solids, and escape prevention

for liquids, it was not clear which of the components were necessary in producing the positive

outcome. Appetite manipulation, in this case the elimination of tube feeds, has been suggested as

being the most important component in the treatment of food refusal (Linscheid, 2006) and

was probably important in this intervention. Before elimination of the tube feeds, the participant

was not able to consume enough calories to meet caloric goals, but after elimination of the tube

feeds his intake increased rapidly and dramatically. Before treatment, the participant refused to

taste novel foods to the point of crying and gagging for his parents. The stimulus fading for both

the solids and liquids possibly reduced the response effort to the point that the participant was

able to successfully consume bites and drinks without collateral behaviors. Numerous times

across the course of treatment, the participant verbalized that he liked a particular food or that the

food tasted good to foods that his parents reported he had previously refused without tasting. The



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stimulus fading may have made it possible for the participant to taste novel foods and thus

develop preferences for them. It has been suggested that positive reinforcement alone cannot

increase acceptance of food in children with food refusal but may decrease negative vocaliza-

tions and inappropriate behavior in some children (Piazza, 2008).

Although our participant verbalized his liking for the preferred activities in his arcade, itwas not clear whether access to these items was responsible for his eating behavior. Though his

solid and liquid consumption dramatically increased during treatment when compared to base-

line, functional control was not demonstrated. We did demonstrate that the treatment package

increased intake when compared to baseline. Though we had planned a usewithdraw design,

removing the token economy, to examine the effectiveness of the treatment, this plan was not

successful. On the fifth day of treatment, meal without the token economy was conducted. At this

meal, the participants intake was equivalent to previous treatment meals. When the participant

was informed that he would not be earning tokens, he stated he liked his arcade, but just really

needed a break, perhaps indicating that the tokens were not as important in increasing feeding

behavior as was the backup reinforcer of earning time for a break. Although the participants

performance in this probe meal was equivalent with meals conducted with the token economy, itwas decided to continue the token economy until his intake goals were met and then eliminate

the token economy for generalization training. For the last 3 days of treatment, the participant

was offered meals without the token economy in a variety of settings in preparation for dis-

charge. This intervention could also be conceptualized as being based on negative reinforcement,

with the participant being able to avoid frequent meals by expending a greater response effort

during meals and taking a greater number of bites and drinks.

Although the solid food portion of this intervention could be conceptualized as being based

on positive reinforcement as tokens were earned for consumption, it is likely that negative rein-

forcement, in terms of avoiding more frequent meals by expending a greater response effort and

eating more, is a significant factor in the success of the intervention. There was no escape pre-vention component for solid foods; however, it was included for liquids to ensure a minimal level

of liquid consumption because the participant had been dependent on tube feeds for 9 years and

it was unclear whether he would drink enough to maintain hydration. There were only 11 meals

during the entire course of treatment when the participant had to sit in the therapy room beyond

the 15-minute meal duration to complete his liquids. The escape prevention contingency never

came into effect after the eighth day of treatment. Given the participants success with the food,

it is possible that the escape prevention component was not necessary.

7 Course of Treatment and Assessment of Progress

Treatment sessions were conducted in a therapy room equipped with two tables, three chairs, an

observation window, and a camcorder. Tokens consisted of three stacks of laminated cards in the

shape of a lions paw, each of a different color. Also, an electronic kitchen scale was used to

measure liquid consumption before and after every meal.

7.1 Dependent Measures

Data were collected on four variables. The participants solid intake was measured by bites

consumed, operationally defined as the number of bites the participant placed in his mouth and

swallowed. Liquid consumedwas measured in ounces by subtracting the postweights of the

beverages offered from their preweights. Water and other beverages (e.g., milk, juice) were

measured separately.Number of solid foods was used as a measure of diet variety and determined

by counting each food eaten by the participant, but only if two tablespoons of that food was



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In meals where the participant did not consume the beverages within the 15-minute period, a

timer was set to record the time that had elapsed between the end of the session and the con-

sumption of the drinks. The participant was required to finish the three rated beverages before

leaving the room and exchanging his tokens. This was the only escape prevention contingency

used in the intervention.There was also a stimulus-fading criterion for the liquids. If the participant completed any

rated beverage within the 15-minute time limit, the quantity of this particular beverage was

increased by 0.25 ounce. If the participant did not finish a particular drink before the timer rang,

it remained at the same quantity for the next session. Once the drinks were consumed (either

before or after the timer rang), the participant was permitted to exchange the tokens for access to

the arcade. Once the participant was in the arcade, the timer was set to the number of tokens

exchanged (1 bite/1 drink =1, 2, or 3 minutes of arcade time depending on the rating of food and

drink consumed). On each treatment day, the participant picked three beverages from his rated

liquid list that were not used during the previous treatment day. As it was expected that there

would not be an even distribution of beverages among the three categories, multiple drinks were

sometimes used from the same category. For example, two drinks from Category 2, one drinkfrom Category 3, and no drink from Category 1. Again, having the child choose different bever-

ages on subsequent days was done to increase exposure to a wider range of drinks.

7.2.3 Liquid Procedure Modified. As gastrostomy tube feeds were eliminated on the firstday of treatment and the participant was not receiving the nutritional supplement administered

through a gastrostomy tube, it was decided to increase milk consumption as a means of increas-

ing the participants daily caloric intake. This was accomplished by modifying the liquid proce-

dure on the third day of treatment. Milk was also systematically increased using the same

criterion as the other beverages. Milk was included for all meals and as milk was increased the

amount of water was decreased by the same amount. Consistent with the other beverages,

changes in volume of milk were not made, unless the milk was completely consumed before thetimer sounded. By the eighth day of treatment, Tyler was drinking a range of beverages in addi-

tion to milk and water. It was decided at this point to reduce the number of beverages offered to 3,

one drink from his rated liquid list, milk and water.

7.3 Generalization Training

During the last 3 treatment days, meals were conducted as they would be in the participants

home and school settings. For each meal, the participant was given one main dish or entre

(e.g., Salisbury steak, turkey sandwich, cheeseburger, peanut butter and jelly sandwich, French

toast sticks), and three or four side dishes (e.g., cooked vegetables, salad, fresh fruit, cookies,chips). During each session for each of these 3 days, no food items were presented consecu-

tively. Data were collected on each bite consumed during each generalization meal. Throughout

the generalization training, no tokens were distributed and no foods were ranked. However, the

participant did receive breaks contingent on the number of bites consumed. It was determined

that if the participant consumed less than 25 bites he would receive a 20-minute break, but if he

consumed 25 bites or more then he received at least a 45-minute break. During these breaks, he

was not permitted to watch preferred videos, play electronic games, or use his laptop. He was

allowed to take walks, look at books, or magazines and converse with parents or staff.

7.4 OutcomesThere was a substantial increase in bites consumedacross the course of treatment as shown in

Figure 1. As demonstrated in Figure 1, the participant consumed 10 bites in the first treatment



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Roth et al. 267

0

10

20

30

40

50

60

1 4 7 10 1 3 1 6 19 2 2 2 5 28 3 1 3 4 37 4 0 4 3 46 4 9 5 2 55 5 8 6 1 64 6 7 7 0 73 7 6 7 9 82 8 5 8 8 91

Numberofbitesconsumed

Meal

Baseline

Treatment

Generalization

Figure 1.Number of bites consumed per mealNote: The data depict three baseline meals (solid diamond) followed by the treatment package (solid square). A singleprobe meal without token economy (open triangle) was conducted with a return to the treatment package. The finalphase depicts generalization without the token economy (open triangle). The graph only shows number of bites anddoes not display the increase in bite size that occurred across treatment.

meal and 45 bites on the last treatment meal. As described in the solid food procedure, bite size

for each food was increased as Tyler met criterion for that food; thus, the bite size of each food

started at the size of a grain of rice, then progressed to pea size, half teaspoon, and finally fullteaspoon size. Although not depicted in the graphs, the bite size of foods was increased as each

particular food met criterion. Thus, not only did the number of bites increase across the course of

treatment but the size of the individual bites also increased. Across treatment, the number of

meals per day decreased as the number of bites increased. These changes are shown in Figure 2.

Liquid consumedwas measured in terms of ounces consumed, with water and milk displayed

as separate data paths in Figure 3. On the third day of treatment, milk was introduced, and

3.25 ounces were consumed for the day. On the last treatment day, a total of 31 ounces of milk

were consumed. In only 11 of the 93 meals did the participant take longer than the allotted

15 minutes to consume the liquids for a particular meal. All of these 11 meals were in the initial

8 days of treatment.Again, before treatment, the participant consumed only three foods; at the end of treatment,

the number of solid foodsthat the participant consumed totaled 78 foods. At the 1-month follow-

up, the participants parents reported he had added an additional 27 new foods to his diet. Before

treatment, the participant drank only water. At the end of treatment, the number of liquidscon-

sumed was a total of 13 different drinks and at the 1-month follow-up visit the participant had

added 2 more drinks to his diet. Tyler drank only water before treatment; he drank milk and a

variety of other beverages, mostly juices, by the end of treatment. When analyzing data from the

two aberrant behaviors recorded, negative vocalization and gagging, it was found that on the first

treatment day the participant had engaged in a total eight occurrences of these two behaviors,

and, after the first day of treatment, the participant never exceeded two instances of negative

vocalizing or gagging when combined per day as shown in Figure 4.

Before treatment, the participant was largely dependent on tube feeds, receiving 2000 calories

per day through tube feeds. All tube feeds were eliminated, and the participant remained off all



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0

1

2

3

4

5

6

7

8

9

0

5

10

15

20

25

30

35

40

45

50

1 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Mealsconducted

Averagenumberofbitescons

umed

Treatment Day

Average number of bitesconsumedMeals

BL Treatment Generalization

Figure 2.Average number of bites consumed per treatment dayNote: This graph depicts the increase in bites per meal across both the treatment and generalization (solidsquares) phases. Stimulus fading was used across the course of the treatment phase, where the size of the biteswas systematically increased. The number of bites increased further across the generalization phase. The graphonly shows average number of bites consumed per day and does not display the average increase in bite size thatoccurred across each day.

0

1

2

3

4

5

6

7

8

9

0

1

2

3

4

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6

7

8

1 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Mealsconducted

Average

volumeconsumed(ounces)

Treatment day

Water

Milk

Meals

TreatmentBL Generalization

Figure 3.Average volume of liquids consumed per treatment dayNote: On each day of treatment, the researchers added the total number of ounces consumed for both milk andwater and divided it by the number of sessions conducted each day. The z-axis measures the number of mealsconducted, the abscissa measures what treatment day the data were recorded, and the ordinate measures the

average volume of liquid consumed. The solid black squares represent average water consumption per meal pertreatment day, whereas the solid black circle markers represent average milk consumption per meal per treatmentday. The figure demonstrates that as milk was increased water was decreased, through the specified fading protocol.Before treatment, the participant only drank water.



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Roth et al. 269

tube feeds at the 1-month follow-up. Across the 3-week course of treatment, the participant

gained 1 pound and 4 ounces.

7.5 Social Validation of Treatment Protocol

A total of 5 weeks after the conclusion of the study, the participants parents were sent a satisfac-

tion questionnaire. They were asked 13 questions pertaining to their satisfaction of the program

and using a 5-point Likert-type scale, they reported the highest level of satisfaction for every

question. The parents also reported that family meals were more enjoyable and that family stress

was reduced. The parents also provided additional comments describing their childs success

stating that now their child never hesitates to taste a novel food, began bringing a lunch to school,

and even eats leftover food from other family members plates.

8 Complicating Factors

There were no complicating factors in the clients history of significant importance that was not

already discussed in the client history section. Tyler was compliant for a majority of treatment

and displayed low rates of inappropriate behavior as demonstrated in Figure 4.

9 Managed Care Considerations

Tylers treatment was rapid and produced long-term success. In a previous study, the cost of tube

feeding was reported for several patients. The lowest of the costs reported was US$16, 320 per

year for the cost of the tube feeding supplies and formula (Williams, Riegel, Gibbons, & Field,

2007). Tylers treatment was paid by state medical assistance who was charged less than US$500/

day as a result of a contractual arrangement between the medical facility and the medical

0

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10 11 12 13 14

NumberofOccurrence

s

Treatment day

Negative vocalizations

Gagging

Total of abherrant behaviors

Figure 4.Aberrant behaviorsNote: The table depicts the data collected for both negative vocalization (open square) and gagging (open diamond)during each treatment day. As demonstrated, when combining the occurrences of each behavior (open circle), thebehaviors never appeared more than twice after the initial day of treatment.



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assistance program and the state. We estimate the cost of treatment to the state medical assistance

program was lower than the cost of tube feeding for a period of 1 year. Tyler had received tube

feedings for 9 years; if intensive treatment had been provided earlier with this same level of suc-

cess, the cost savings would have been substantial.

10 Follow-Up

Follow-up visits were scheduled 2 and 4 weeks after treatment in the clinic. During these visits,

Tyler and his parents met with the licensed psychologist and graduate intern feeding therapist to

discuss ongoing progress, to record stature to weight proportions and answer any questions that

Tyler and his parents may have had, and to construct a timeline for the complete removal of

Tylers gastrostomy tube. It was decided at these follow-up meetings that the gastrostomy tube

would be removed in the spring due to the predicted active flu season. In addition, follow-up was

also conducted over the phone once a week for 2 months. During the placed phone calls, Tylers

variety of foods and liquids consumed as well as any weight or height gains that were made since

the previous visit or phone call were discussed.As discussed earlier, Tyler continued to add new foods and beverages to his diet after dis-

charge. He eats meals without the token economy and is gaining weight at faster rate than when

he was dependent on tube feedings.

11 Treatment Implications of the Case

It is with little argument that gastrostomy tubes and other tube feeding methods (e.g., nasogastric

intubation) can be considered life saving. However, the effect of gastrostomy tube placement on

an individuals quality of life has been reported as being both physically and socially intrusive

and producing adverse psychological consequences (Jordan, Philpin, Warring, Cheung, &Williams, 2006). The current study demonstrated a successful intervention for the treatment of

food refusal that was brief in duration (14 days), easy to implement, and generalized to both the

home and school settings. This type of intervention, in which the number of meals and the dura-

tion of reinforcement is dependent on the participants amount of response effort, may be well

suited for older children or adolescents who could understand the contingencies and for whom

more intrusive escape prevention techniques are less socially acceptable.

12 Recommendations to Clinicians and Students

To further develop the literature in this area, it is recommended that future clinicians and studentsattempt a scientific design that underlines the effectiveness of each component of this treatment

package. Though it is believed that the combination of appetite manipulation, stimulus fading,

and reinforcement made the treatment successful, the contribution of each component was not

assessed.

This study also had the participant evaluate the difficulty of each novel food and rate each

food on the basis of the perceived difficulty in eating that food. Although this was not difficult

for staff, it was not clear whether this was necessary. It is also recommended that future studies

examine other possible alternatives to having a participant earn break time without having to

rank foods according to a level of perceived difficulty.

Declaration of Conflicting Interests

The authors declared that they had no conflicts of interests with respect to their authorship or the publica-

tion of this article.



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Roth et al. 271

Funding

The authors received no financial support for the research and/or authorship of this article.

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Bios

Michael Roth, M.A., recently graduated with his Masters in Applied Behavior Analysis from the Penn

State University, Harrisburg Campus. His clinical interests include working with children with autism spec-

trum disorders.

Keith Williams, Ph.D., is the Director of the Feeding Program at the Penn State Hershey Medical Center.

His research interests include the study of ingestive behaviors in children with chronic health problems.

Candace Paul, M.A., is a Feeding Therapist II in the Feeding Program at the Penn State Hershey Medical

Center. Her research interests include working with children with food selectivity and choking phobias.

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