UNMC Munroe-Meyer Institute
Treatment of Pediatric Feeding Disorders
Cathleen C. Piazza
University of Nebraska Medical Center’s Munroe-Meyer Institute
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PEDIATRIC FEEDING DISORDERS
Identified when a child fails to consume a sufficient variety or quantity of food to maintain nutritional status
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INTERDISCIPLINARY APPROACH
Consider an interdisciplinary evaluation prior to initiation of treatment
Practice within your scope of competence
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EATING AND DRINKING UTENSILS
Rubber- Coated Baby
Spoons
Maroon Spoons Nuk Brush
Cut-out (nosey) cups
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Piazza, Fisher, et al. (2003) conducted functional analyses of inappropriate mealtime behavior of 15 children diagnosed with a pediatric feeding disorder.
FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS
Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Katz, R. M., Sevin, B. M.,
Gulotta, C. S., & Patel, M. R. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 37, 187-204.
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Condition Consequence for Inappropriate
Behavior
Bite Presentation
ESCAPE 30 s of escape remove for 20 s
ATTENTION 30 s of attention remains at midline
TANGIBLE 30 s of access tangible
remains at midline
CONTROL no differential consequence
remains at midline
Functional Analysis
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Escape ConditionFeeder delivers 30 s of escape following inappropriate behavior.
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Attention ConditionFeeder delivers 30 s of attention following inappropriate behavior.
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Control ConditionFeeder provides continuous access to toys and attention. No
differential consequence following inappropriate behavior.
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2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36INA
PP
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IAT
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EH
AV
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PE
R M
INU
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Tom
ATTENTION VS CONTROL ESCAPE VS CONTROL
ATTENTION
CONTROL
ESCAPE
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
SESSIONS
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67% of participants displayed high levels of inappropriate mealtime behavior in one or more test conditions.
90% of participants whose functional analyses were differentiated displayed sensitivity to negative reinforcement.
80% of participants whose functional analyses were differentiated displayed sensitivity to multiple reinforcing contingencies.
FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS
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Functional Analysis ResultsN = 38
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60
ESCAPE(ESC)
ATTENTION
(ATT)
TANGIBLE (TANG)
UNDIF ESC + ATT + TANG
ESC+ TANG
ESC+ ATT
PE
RC
EN
TAG
E O
F C
AS
ES
FUNCTION
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FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS
The findings suggest that: Negative reinforcement plays a primary role
in the maintenance of feeding problems. Children with feeding problems may be
sensitive to other reinforcement contingencies.
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FOOD TRIAL Accept
Green beans 1 YChicken 2 NApplesauce 3 NPotato 4 YGreen beans 5 YChicken 6 YApplesauce 7 YPotato 8 YGreen beans 9 YChicken 10 Y
TOTAL Accept 8
% 80%
FOOD TRIAL Accept
Potato 1 NApplesauce 2 NGreen beans 3 NChicken 4 NPotato 5 NApplesauce 6 YGreen beans 7 NChicken 8 NPotato 9 NApplesauce 10 Y
TOTALAccept 2
% 20%
Meal 1 Meal 2FOOD TRIAL Accept
Applesauce 1 YPotato 2 NChicken 3 YGreen beans 4 NApplesauce 5 YPotato 6 NChicken 7 YGreen beans 8 YApplesauce 9 NPotato 10 Y
TOTALAccept 6
% 60%
Meal 3
In this example, the child accepted 80%, 20%, and 60% of the bites, respectively, in each of the meals. Because acceptance of bites is variable (unpredictable), you should wait to start treatment.
EXAMPLE BASELINE DATA
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EXAMPLE BASELINE DATA
In this example, the child’s level of acceptance is between 20% and 80%. This is a variable (unpredictable) level of acceptance. It would be difficult to predict what the child’s level of acceptance will be at the next meal. If behavior is unpredictable, then it is better to wait to start treatment. Also, acceptance is increasing (getting better) at the last meal, which is another reason to wait to start treatment.
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AC
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PT
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BIT
ES
Baseline
2 4 6 8 10 12
MEALS
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EXAMPLE BASELINE DATA
In this example, we continued the baseline for 3 more meals. Now, the level of acceptance is more consistently between 50% and 60%. This is now a stable level of acceptance. Acceptance is decreasing at the last meal. It would be a good time to start treatment.
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PT
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BIT
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Baseline
2 4 6 8 10 12MEALS
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PT
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Baseline
2 4 6 8 10 12
MEALS
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EXAMPLE BASELINE DATA
FOOD TRIAL Accept
Green beans 1 NChicken 2 NApplesauce 3 NPotato 4 NGreen beans 5 NChicken 6 NApplesauce 7 YPotato 8 NGreen beans 9 NChicken 10 N
TOTAL Accept 1
% 10%
FOOD TRIAL Accept
Potato 1 NApplesauce 2 YGreen beans 3 NChicken 4 NPotato 5 NApplesauce 6 NGreen beans 7 NChicken 8 NPotato 9 NApplesauce 10 N
TOTALAccept 1
% 10%
Meal 1 Meal 2FOOD TRIAL Accept
Applesauce 1 YPotato 2 NChicken 3 NGreen beans 4 NApplesauce 5 NPotato 6 NChicken 7 NGreen beans 8 NApplesauce 9 YPotato 10 N
TOTALAccept 2
% 20%
Meal 3
In this example, the child accepted 10%, 20%, and 10% of the bites, respectively, in each of the meals. Because acceptance of bites is low and predictable, you could start your treatment at the next meal.
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EXAMPLE BASELINE DATA
In this example, the child’s level of acceptance is between 10% and 20%. This is a low and stable level of acceptance. You can predict that at the next meal, the child will accept between 10% and 20% of bites. If behavior is predictable, then it is a good time to start treatment.
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Baseline
2 4 6 8 10 12
MEALS
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Functional Analysis
Function-Based Treatment
ChaserChin prompt
Facilitation/Re-distribution
FadingTexture
GENERAL TREATMENT PROGRESSION
Expulsion/
Packing
Effective Treatment
AvoidanceFading
Momentum
No Change
Parent Training
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EE or EE+Sr+/Sr-
Nonremoval of the spoon – feeder keeps spoon or cup at
child’s lips and deposits bite or drink at first opportunity
Differential reinforcement of alternative behavior (DRA) –
feeder delivers a preferred item or activity following
appropriate behavior (e.g., mouth clean)
Noncontingent reinforcement (NCR) – throughout the meal
(a) feeder interacts with child, (b) feeder interacts with child
and preferred items or activities are available, or (c)
preferred items or activities are available
Differential negative reinforcement of alternative behavior
(DNRA) – feeder delays presentation of bite following
appropriate behavior (e.g., mouth clean)
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STUDIES ON ESCAPE EXTINCTION
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
LaRue, R. H., Stewart, V., Piazza, C. C., & Volkert, V. M. (2011). Escape as reinforcement and escape extinction in the treatment of feeding problems. Journal of Applied Behavior Analysis, 44, 719-735.
Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374.
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.
Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshal, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37, 27-41.
Escape extinction (EE) may be a necessary component of treatment.
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Reinforcement of the First Behavior in the Chain (Acceptance) vsReinforcement of the Terminal Behavior in the Chain (Mouth Clean)
Sr+ Acceptance Sr+ Swallowing (Mouth Clean)
Studies on the Effects of Reinforcement
Does it make a difference?
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90100
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TAG
E A
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TAN
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Sunshine
DRAACC
DRA MC
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N
Sunshine
140
10 20 30 40 50 60 70 80 90 100 110 120 130 140
SESSION
BL DRA DRA + EE DRA DRA + EE
BL DRA DRA + EE DRA DRA + EE
0
0
Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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Jarred
DRAACC DRA
MC
SESSION
PE
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EN
TAG
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CL
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N
0102030405060708090
100
Jarred
10 20 30 40 50 60 70 80 90 100 110 120 130
BL DRA DRA + EE DRA DRA + EE
BL DRA DRA + EE DRA DRA + EE
0
0
Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374.
UNMC Munroe-Meyer Institute
What Are the Effects of Differential Positive Reinforcement with and without Escape Extinction?
Differential Sr+ Escape Extinction
Studies on the Effects of Reinforcement
Does it make a difference?
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Condition Consequence for
Inappropriate Behavior
Bite Presentation
Consequence for Mouth
Clean
ESC 20 s of escape removed for 20 s
brief praise
DRA + ESC
20 s of escape removed for 20 s
access to Sr+
EE no differential consequence
remained at child’s lips
brief praise
DRA + EE no differential consequence
remained at child’s lips
access to Sr+
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.
UNMC Munroe-Meyer Institute
What Are the Effects of Noncontingent Positive Reinforcement with and without Escape Extinction?
Noncontingent Sr+ Escape Extinction
Studies on the Effects of Reinforcement
Does it make a difference?
UNMC Munroe-Meyer Institute
Condition Consequence for
Inappropriate Behavior
Bite Presentatio
nConsequence
for Mouth Clean
ESC 20 s of escape removed for 20 s
brief praise
NCR + ESC
20 s of escape removed for 20 s
access to Sr+throughout
EE no differential consequence
remained at child’s lips
brief praise
NCR + EE no differential consequence
remained at child’s lips
access to Sr+throughout
Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshal, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37, 27-41.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
442 4 6 8 10 12 14 16 18 20 22 24 26 28 30 34 36 38 40 42
SESSIONS
320
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E A
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EP
TAN
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ESC BL vs. DRA+ESC
EE vs. DRA+EEESC BL vs.DRA+ESC EE vs. DRA+EE
ESC BL DRA + ESCEE
DRA + EE
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
44
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2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 34 36 38 40 42
SESSION
% N
EG
AT
IVE
VO
CA
LIZ
AT
ION
S
DRA + ESC
ESC BL
32
DRA + EE
EE
0
ESC BL vs DRA+ESC
EE vs. DRA+EEESC BL vsDRA+ESC EE vs. DRA+EE
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.
UNMC Munroe-Meyer Institute
What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers?
Effects of Function-Based Treatment
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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INA
PP
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LTIM
E
BE
HA
VIO
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MIN
UT
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0 2 4 6 8 10 12 14 16 18 20 22 24
SESSION
ESCAPE
CONTROL
ATTENTION
SAVANNAH
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
Condition Consequence for Inappropriate
Behavior
Bite Presentation
ATTN + ESC 20 s of attention plus escape
removed for 20 s
EE + ATTN 20 s of attention remained at child’s lips
AE + ESC 20 s of escape removed for 20 s
EE + AE no differential consequence
remained at child’s lips
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
ATTN + ESC
EE + ATTN vs. AE + ESC
EE + ATTN vs. AE + ESC
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8
12
16
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24
28
INA
PP
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PR
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LTIM
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BE
HA
VIO
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ER
MIN
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SAVANNAH
EE + AE EE + AE
EE + ATTN
AE + ESC
ATTN+ ESC
EE + ATTN vs. AE + ESC
EE + ATTN vs. AE + ESC
EE + AE EE + AE
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PE
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TAG
E A
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EP
TAN
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SAVANNAH
EE + ATTN
AE + ESC
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers?
Effects of Function-Based Treatment
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
Acceptance and Mouth Clean Increased With Escape Extinction but Not Attention Extinction
Inappropriate Behavior Maintained at Low Levels with Escape Extinction in the Absence of Attention Extinction
Levels of Acceptance and Mouth Clean Were Higher and More Stable with Escape AND Attention Extinction
Important to Treat Both Functions when Inappropriate Mealtime Behavior is Multiply Maintained
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How Effective is Function- versus Sensory-Based Treatment?
Comparison of Function-Based and Sensory-Based Treatments
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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SESSION
ESCAPE ESC + SI EE + NCR ESC + SI EE + NCR
0 10 20 30 40 50 60 70 80 90 100 110
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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ESCAPE ESC+ SI EE + NCR ESC+ SI EE + NCR
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer Institute
COMPARISON OF FUNCTION- VS SENSORY-BASED TREATMENTS
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.
Sensory integration-based treatment produced no change in behavior.
Escape extinction was associated with increased acceptance and decreased inappropriate behavior.
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FADING Blending
Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety
of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied
Behavior Analysis, 37, 159-170.
Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001). Using a fading
procedure to increase fluid consumption in a child with feeding problems. Journal of
Applied Behavior Analysis, 34, 357-360.
Spoon distance Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading
with and without escape extinction as treatment for food refusal. Journal of Applied
Behavior Analysis, 43, 673-683.
Spoon to cup Groff, R. A., Piazza, C. C., Zeleny, J. R., & Dempsey, J. R. (2011). Spoon-to-cup fading as
treatment for cup drinking in a child with intestinal failure. Journal of Applied Behavior
Analysis, 44, 949-954.
Syringe to cup and spoon Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as
treatment for feeding refusal. Journal of Applied Behavior Analysis.
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HP
0
10
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60
70
80
90
100
PUDDING
YOGURT
PANCAKE
WAFFLE
STRAWBERRIE
S
APPLESAUCE
P B J
BREAD AND B
UTTER
CREAMED C
ORN
CORN ON T
HE COB
PEACHES
CHICKEN N
UGGETS
ORANGES
FRENCH FRIE
S
CARROTS
GREEN BEANS
FOODS
PE
RC
EN
TAG
E A
PP
RO
AC
H +
CO
NS
UM
E
LP
Based on: Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis, 25, 491-498.
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Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis, 37, 159-170.
BLENDING
Sample Yogurt/Green Bean Blends
80/20 60/40 40/60 20/80
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55
SESSIONS
APPLE SAUCE/CARROTS
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100
0 5 10 15 20 25 30 35 40 45 50
PE
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EN
TAG
E M
OU
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CL
EA
N
CARROT
POTATO
50/5060/40
70/30
80/20
90/10
AP
PL
ES
AU
CE
John
Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis, 37, 159-170.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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SESSION
PE
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TAG
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CL
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N
10% 20% 20% 30%100% 10% 20% 30% 30%
0%5% 30%
Water + *CIB FadingDRA + EXT
CIB + Milk FadingDRA + EXT
100
% M
ilk/
CIB
100
% C
IB/W
ater
Rev
ersa
l
Wat
er
Mo
ther
Rev
ersa
l
Th
erap
ist
Mo
ther
100% Milk/CIB
Rev
ersa
l
300
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
Rev
ersa
l
DRA + EXT
Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001). Using a fading procedure to increase fluid consumption in a child with feeding problems. Journal of Applied Behavior Analysis, 34, 357-360..
*CIB = Carnation Instant Breakfast
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
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6
12
18
24
30
36
42
48
54
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INA
PP
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LTIM
EB
EH
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INU
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Lips ESC Baseline (BL)
vs Fading ESC BL
Fading+EE vs Escape Extinction (EE)
Lips Escape
(ESC) BL Fading+EE vs EE
25.4 cm
Lips ESC BL
FadingESC BL
EE
20.3cm
15.2 cm
LipsESC BLProbe
10.2 cm
15.2 cm
15.2cm
10.2 cm
LipsESC BLProbe
5.1 cmLips
Fading+EE
Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis, 43, 673-683.
SESSION
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20
40
60
80
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0 10 20 30 40 50 60 70 80 90 100 110 120
SESSION
PE
RC
EN
TAG
E A
CC
EP
TAN
CE
Fading+EE vs EE(Escape Extinction)
Lips ESC BL Fading+EE vs EE
Lips ESC BL vs Fading
ESC BL
LipsESC BL
EE LipsESC BLProbe
LipsESC BLProbe
Lips
Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis, 43, 673-683.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
5 cm 4 cm3 cm
2 cm
1 cm
0.5 cm
Flush
Deposit liquid from syringe
Deposit from cupHole in cup bottom
Syringe on outside of cup, recessed from lip
Deposit from cup
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.
Deposit from syringe
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.
5 cm 4 cm 3 cm 2 cm 1 cm
Bottom TopNext toIn mouth At lips
Deposit Syringe
Deposit Syringe Deposit Spoon Deposit Syringe
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
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10 20 30 40 50 60 70 80 90 100 110
PE
RC
EN
TAG
E M
OU
TH
CL
EA
N
Session
BL
EE 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 5 4 3 2 1 Bottom
TopNext
to0.1 EESpoon
EE SpoonProbe
Syringe Volume Fading (ml)
Syringe to Spoon Fading
cmIn
mouth
LipsIn
mouthIn
mouth
Top
Top
Top
Spoon Position
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.
0.1 to 1.0Spoon
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
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10 20 30 40 50 60 70 80 90 100 110
PE
RC
EN
TAG
E M
OU
TH
CL
EA
N
SESSION
BL
Cup
Spoon
EE + AE BL
Escape Extinction (EE) +Attention Extinction (AE)
Spoon-to- Cup Fading
1-Year Follow Up
3.8 cm 3.2 cm 2.6 cm 2.1 cm 1.5 cm
3.8 3.2 2.6 2.1 1.5
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
SWALLOW FACILITATION AND RE-DISTRIBUTION
Dempsey, J., Piazza, C. C., Groff, R. A., & Kozisek, J. M. (2011). A flipped
spoon and chin prompt to increase mouth clean. Journal of Applied
Behavior Analysis, 44, 961-965.
Gulotta, C. S., Piazza, C. C., Patel, M. R., & Layer, S. A. (2005).
Using food redistribution to reduce packing in children with severe food
refusal. Journal of Applied Behavior Analysis, 38, 39-50.
Rivas, K. R., Piazza, C. C., Kadey, H. J., Volkert, V. M., & Stewart, V.
(2011). Sequential treatment of a feeding problem using a pacifier and
flipped spoon. Journal of Applied Behavior Analysis, 44, 318-391.
Volkert, V. M., Vaz, P. C. M., Piazza, C. C., Frese, J., & Barnett, L. (2011).
Using a flipped spoon to decrease packing in children with feeding
disorders. Journal of Applied Behavior Analysis, 44, 617-621.
Wilkins, J. W., Piazza, C C., Groff, R. A., Volkert, V. M., Kozisek, J. K., &
Milnes, S. M. (in review). Utensil manipulation during initial treatment of
pediatric feeding problems. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
NUK WITH FACILITATION
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
FLIPPED SPOON
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
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0 5 10 15 20
Baseline Flipped Spoon Baseline Flipped Spoon Parent Training
3-weekfollow-up
Tracey
Pe
rce
nta
ge
of
Pa
ck
ed B
ite
s
Volkert, V. M., Vaz, P. C. M., Piazza, C. C., Frese, J., & Barnett, L. (2011). Using a flipped spoon to decrease packing in children with feeding disorders. Journal of Applied Behavior Analysis, 44, 617-621.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
RE-DISTRIBUTION
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
4
8
12
16
20
24
28
32
36
40
10 20 30 40 50 60 70
BASELINE (BL)
Spoon
Nuk
RE-PRESENTATION BL RE-PRES
0
EX
PE
LS
PE
R B
ITE
SESSION Wilkins, J. W., Piazza, C C., Groff, R. A., Volkert, V. M., Kozisek, J. K., & Milnes, S. M. (in review). Utensil manipulation during initial treatment of pediatric feeding problems. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
CHIN PROMPT
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer InstituteRe-presentation Re-presentation plus chin prompt Re-presentation Re-presentation plus chin prompt
Wilkins, J. W., Piazza, C. C., Groff, R. A., & Vaz, P. C. M. (2011). Chin prompt plus re-presentation as treatment for expulsion in children with feeding disorders. Journal of Applied Behavior Analysis, 44, 513-544.
0
1
2
3
4
5
6
7
10 20 30 40 50 60 70 80 90 100 110 120 130 140
EX
PE
LS
PE
R B
ITE
SESSION
BASELINE (BL) CHIN PROMPT CHIN PROMPTBL
0
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
Chaser – feeder presents a solid or liquid that the child swallows reliably following depositing a solid or liquid the child does not swallow reliably Vaz, P. C. M., Piazza, C. C., Stewart, V., Volkert, V. M.,
Groff, R. A., & Patel, M. R. (2012). Using a chaser to decrease packing in children with feeding disorders. Journal of Applied Behavior Analysis, 45, 97-105.
Chaser
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
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0 2 4 6 8 10 12 14 16 18 20 22 24
PE
RC
EN
TAG
E P
AC
K
SESSION
Baseline
Chaser
Vaz, P. C. M., Piazza, C. C., Stewart, V., Volkert, V. M., Groff, R. A., & Patel, M. R. (2012). Using a chaser to decrease packing in children with feeding disorders. Journal of Applied Behavior Analysis, 45, 97-105
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., & Swartzwelder, D. M. (2005). A systematic evaluation of food textures to decrease packing and increase oral intake in children with pediatric feeding disorders. Journal of Applied Behavior Analysis, 38, 89-100.
Patel, M. R., Piazza, C. C., Santana, C. M., & Volkert, V. M. (2002). An evaluation of food type and texture in the treatment of a feeding problem. Journal of Applied Behavior Analysis, 35,183-186.
TEXTURE OR CONSISTENCY MANIPULATION
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
PURREED WET GROUND
CHOPPED TABLE TEXTURE (1/4x1/4x1/4)
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
0
10
20
30
40
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60
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100
PE
RE
CE
NTA
GE
PA
CK
PUREE PUREEWET GROUND WET GROUND
SESSION10 20 30 405 15 25 35 45
Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., & Swartzwelder, D. M. (2005). A systematic evaluation of food textures to decrease packing and increase oral intake in children with pediatric feeding disorders. Journal of Applied Behavior Analysis, 38, 89-100.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
AVOIDANCE
Rivas, K. M., Piazza, C. C., Roane, H. S., Volkert, V. M., Stewart, V., Kadey, H. J., & Groff, R. A. (in review). Analysis of self-feeding in children with feeding disorders. Journal of Applied Behavior Analysis.
Vaz, P. C. M., Volkert, V. M., & Piazza, C. C. (2011). Using negative reinforcement to increase self-feeding in a child with food selectivity. Journal of Applied Behavior Analysis, 44, 915-920.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
AVOIDANCE
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
Functional Analysis
Function-Based Treatment
ChaserChin prompt
Facilitation/Re-distribution
FadingTexture
GENERAL TREATMENT PROGRESSION
Expulsion/
Packing
Effective Treatment
AvoidanceFading
Momentum
No Change
Parent Training
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
SUMMARY
EE or EE+Sr+/Sr- was an effective treatment for 43% of the interventions.
Although EE may be a necessary treatment, it may not be sufficient for many children with severe feeding problems.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute
SUMMARY
We used other procedures in addition to EE for 53% of the interventions.
UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer InstituteUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center