Use of a Side Deposit to Increase Consumption in Children with Food Refusal

On the efficacy and efficiency of treating pediatric feeding disorder

Inappropriate mealtime behavior (IMB) is a type of feeding challenge within the broader class of food refusal. The purpose of this study was to critically analyze the efficacy of interventions for the treatment of IMB through a meta-analysis of research using single-case experimental designs. We examined the extent to which different interventions resulted in decreases in IMB while also producing increases in food acceptance. This meta-analysis was also used to examine the efficiency of different interventions in achieving clinical significance. We identified 38 studies involving 266 cases in which IMB was treated with a behavioral intervention. The results indicated interventions that combined escape extinction and non-escape extinction had greater effect sizes for both reducing IMB and increasing food acceptance than either escape extinction alone or non-escape extinction alone. However, interventions that included escape extinction were slightly less efficient at decreasing IMB than were interventions that did not include escape extinction. We discuss the implications of these findings and provide recommendations for future research.

Utensil Fading to Increase Appropriate Utensil Acceptance

Escape extinction is an empirically supported treatment to increase food and drink acceptance in children with feeding difficulties. However, nonremoval of the spoon or cup may not be effective in isolation when children press their lips closed or clench their teeth. Physical guidance procedures may circumvent this concern, though this is not always the case and may require the bite or drink be deposited with an alternate utensil. Previous research has demonstrated the effectiveness of spoon-to-cup, syringe-to-cup, and syringe-to-spoon fading in typically developing children with gastrostomy tube dependence. The current study extends the existing research literature by replicating spoon-to-cup fading with a child with autism spectrum disorder who was an oral feeder, and by demonstrating the effectiveness of finger-to-spoon fading. We also provide an additional clinical example for syringe-to-cup fading for a child with autism spectrum disorder who was an oral feeder.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-024-00911-7.

Evaluation of two physical guidance procedures in the treatment of pediatric feeding disorder

Children with pediatric feeding disorder may refuse to consume an adequate variety and/or volume of food to maintain expected growth. They can consume food but may actively or passively refuse, resulting in escape or avoidance of eating. Behavioral interventions like positive reinforcement with escape extinction can increase consumption. However, sometimes these interventions are insufficient, especially in treating passive refusal. In these cases, physical guidance may be used to prompt an open mouth to deposit food. Research indicates open-mouth prompts are effective and rated as acceptable. This study replicated an existing physical guidance procedure, the finger prompt, and compared its efficacy and acceptability with that of a spoon prompt. This study extended research by defining and measuring passive refusal as a dependent variable and assessing social validity among different stakeholders and times. Both prompts were effective in treating food refusal, and caregivers rated the finger prompt as more preferred.

Development of Medication Administration Protocols for In-Home Pediatric Feeding Cases

Medication administration can be a significant issue in pediatric populations, and especially with patients with developmental disabilities and comorbid feeding disorders. Research has focused largely on consumption of solids rather than medication and liquids in pediatric feeding programs, with most studies being conducted within specialized hospital settings in the United States. No studies to our knowledge have detailed treatment evaluations for medication administration in pediatric feeding except for a few studies on pill swallowing. We report results of treatment protocols for medication administration using empirically-supported treatments in a short-term intensive home-based behavior-analytic program in Australia. Two males with autism spectrum and pediatric feeding disorders participated. We used a multiple baseline single-case experimental design for medication administration conducted concurrently with a treatment evaluation for solid foods. Consumption increased in number (9; supplements, laxatives, pain relievers), flavors (8; chocolate, blackcurrent and apple, strawberry, lemon-lime, orange, chocolate-vanilla, cherry, apple), forms (4; thin and thick liquids, chewables, gummies), and delivery methods (5; finger-fed, spoon, cup, medicine spoon, medicine cup) within the first treatment session. For one participant, we taught open cup drinking for a variety of liquids (milk, juices, medications). For both participants, we taught self-feeding with utensils for thick liquid medications. Treatment results were similar for solids and participants increased food variety to over 160 across food groups. All goals were met including training parents to maintain gains at home.

Evaluation of an Individualized Levels System to Increase Consumption for an Adolescent with Food Refusal

A levels system is an intervention that uses a combination of behavioral principles, such as differential reinforcement and response cost, in order to increase appropriate behaviors and simultaneously decrease problem behaviors. Within a levels system, an individual must meet a pre-determined behavioral criterion in order to gain access to various levels of reinforcement. For example, engaging in higher rates of inappropriate behavior will result in access to highly preferred items or activities, while higher rates of inappropriate behavior will access to lesser preferred activities. Although levels systems have been applied in group settings, as well as in the individual treatment of severe problem behavior, their use has not been explored in the treatment of food refusal. The current study implemented a levels system to target increasing the variety and volume of food consumed by a 12-year-old female diagnosed with fetal alcohol spectrum disorder (FASD) effects, mild intellectual disability, and attention-deficit/hyperactivity disorder (ADHD). At the end of her admission, the participant had increased her variety consumed at an age-appropriate volume significantly, as well as the volume of food consumed.

CHARGE Syndrome and Comorbid Feeding Difficulties: A Summary of Outcomes following Behavior Analytic Treatment

CHARGE syndrome is a genetic disorder caused by mutation of the CHD7 gene. Children with CHARGE syndrome often experience vision and hearing impairments, delayed growth and development, heart abnormalities, and artesia/stenosis of the chonae. Although not part of the diagnostic criteria, many individuals with CHARGE syndrome experience feeding and gastrointestinal difficulties. Interventions most commonly recommended and utilized to address feeding difficulties for children with CHARGE syndrome include tube feedings (medical approach) and oral-motor therapy. Despite the effectiveness of a behavior analytic approach to address feeding difficulties for a variety of pediatric populations, this approach is not routinely considered as a viable treatment option to address feeding difficulties for children with CHARGE syndrome. Outcome data of four children with CHARGE syndrome who participated in an intensive behavioral-based feeding program were reviewed. Variables reviewed included percentage of admission goals achieved, treatment strategies utilized, and changes in growth status, feeding tube dependence, texture and variety of foods consumed, and occurrence of inappropriate mealtime behavior. Outcomes evaluated in this review support the effectiveness of a behavior analytic approach for addressing feeding difficulties for children with CHARGE syndrome.

Use of a Move-on Component to Increase Consumption for a Clinical Paediatric Feeding Case In-Home

Research from specialised hospital feeding programmes in the United States has shown effectiveness of a variety of treatments for packing (not swallowing food or liquid in the mouth) to increase swallowing and consumption. One potential component used in clinical practice has not been evaluated in the literature to our knowledge. This component is move-on and involves moving on to the next bite presentation rather than waiting for swallowing (i.e., clean mouth). A 5-year-old female with autism spectrum disorder and avoidant/restrictive food intake disorder participated in a home setting in Australia. We used a withdrawal/reversal single-case experimental design for a move-on component added to a treatment package. With move-on added, latency to clean mouth decreased and consumption increased to 100%. After the treatment evaluation, additional procedures (interspersal, redistribution) were needed in full plate and portion meals. Food variety was increased to 116 regular texture foods across all food groups. All (100%) of admission goals were met. Parents were trained to high procedural integrity, and the protocol was generalised to the community. Gains maintained to 1-month follow-up.

Machine Learning to Support Visual Inspection of Data: A Clinical Application

Practitioners in pediatric feeding programs often rely on single-case experimental designs and visual inspection to make treatment decisions (e.g., whether to change or keep a treatment in place). However, researchers have shown that this practice remains subjective, and there is no consensus yet on the best approach to support visual inspection results. To address this issue, we present the first application of a pediatric feeding treatment evaluation using machine learning to analyze treatment effects. A 5-year-old male with autism spectrum disorder participated in a 2-week home-based, behavior-analytic treatment program. We compared interrater agreement between machine learning and expert visual analysts on the effects of a pediatric feeding treatment within a modified reversal design. Both the visual analyst and the machine learning model generally agreed about the effectiveness of the treatment while overall agreement remained high. Overall, the results suggest that machine learning may provide additional support for the analysis of single-case experimental designs implemented in pediatric feeding treatment evaluations.

A systematic review of physical guidance procedures as an open-mouth prompt to increase acceptance for children with pediatric feeding disorders

This article reviews behavioral treatments of pediatric feeding disorders using physical guidance procedures as an open-mouth prompt (i.e., jaw prompt, finger prompt, Nuk prompt, side deposit) to increase food acceptance. We identified 9 articles containing 35 systematic evaluations. We coded participant and study characteristics and assessed the experimental rigor, quality, and outcomes of each evaluation. Of the high-quality research present, the finger prompt variation and side deposit reliably increased acceptance. We found mixed results on the efficacy of the jaw prompt, although it was the most widely researched procedure. Further, authors reported interobserver agreement for 100% of the participants, procedural integrity for 60%, social validity for 80%, fading for 5%, and follow-up for 55%. Based on the invasive nature of physical guidance, we provide recommendations for researchers and clinicians to increase the quality of their treatment evaluations. We discuss limitations, implications for practice, and future research.

Side Deposit with Regular Texture Food for Clinical Cases In-Home

Objective Research has shown effectiveness of nonremoval of the spoon and physical guidance in increasing consumption and decreasing inappropriate mealtime behavior. The side deposit has been used to treat passive refusal in 2 studies (1 in a highly specialized hospital setting) using lower manipulated-texture foods on an infant gum brush. Methods We extended the literature by using regular texture bites of food with a finger prompt and side deposit (placing bites inside the side of the child's mouth via the cheek) in an intensive home-based program setting in Australia, demonstrating that attention and tangible treatments alone were ineffective prior, fading the tangible treatment, showing caregiver training, and following up. 2 male children with autism spectrum disorder (with texture/variety selectivity; one with liquid dependence) participated in their homes. We used a reversal design to replicate effectiveness of the side deposit added to a treatment package. Results For both participants, we observed a >98% decrease in latency to acceptance, a 100% decrease in inappropriate mealtime behavior, and a 100% increase in consumption with the side deposit added. Variety was increased to over 85 regular texture foods. 100% of admission goals were met. Caregivers were trained to high procedural integrity and the protocol was generalized to school and the community. Gains maintained to 3 and 1.5 years. Conclusion This is important work in adding to the literature and support for the side deposit and expanding to regular texture, as well as replicating and extending empirically supported treatments for feeding internationally to the home setting.

Evaluation of Empirical Pretreatment Assessments for Developing Treatments for Packing in Pediatric Feeding Disorders

A significant problem among children with feeding disorders is packing (i.e., pocketing or holding accepted food in the mouth), which could hinder successful treatment. Previous research has identified effective treatments to reduce packing; however, an assessment model to guide treatment decisions is lacking. In the present study, we used a multielement design to identify conditions under which low levels of packing occurred for 4 children with feeding disorders. Results were used to empirically inform treatment selection to decrease packing for 3 children. Assessments indicated that packing was related to texture, food preference, or response effort and subsequently informed individualized treatments, which led to decreased levels of packing. Results suggest that this model may be useful in the design of treatment packages for children who engage in packing at clinically problematic levels.

Simultaneous Presentation to Decrease Packing in a Child With a Feeding Disorder

Children with feeding disorders may pack food (i.e., hold food in the mouth for a prolonged period of time). Treatments to target packing exist, including reinforcement contingencies, redistribution, and chasers, but these strategies are not always effective. Simultaneous presentation has also been used to reduce packing; however, it has not been faded out. The current study expanded this literature by using a treatment package, which included simultaneous presentation, to decrease packing in a 4-year-old boy with autism and food selectivity who packed nonpreferred foods. The simultaneous presentation component was then systematically faded out until generalization occurred.

Evaluation of a finger prompt variation in the treatment of pediatric feeding disorders

Children with feeding disorders often engage in refusal behavior to escape or avoid eating. Escape extinction combined with reinforcement is a well-established intervention to treat food refusal. Physical guidance procedures (e.g., jaw prompt, finger prompt) have been shown to increase food acceptance and decrease inappropriate mealtime behavior when more commonly employed escape extinction (e.g., nonremoval of the spoon) procedures are ineffective. The finger prompt, however, has not been extensively evaluated as a treatment adjunct to target food refusal, thus necessitating further examination. The purpose of this prospective study was to assess a variation of a finger prompt procedure to treat food refusal and to assess caregivers' acceptability of the procedure. Three children age 1 to 4 years admitted to an intensive feeding disorders program and their caregivers participated. The finger prompt was effective in increasing bite acceptance across all participants and decreasing or maintaining low levels of inappropriate behavior for 2 participants. The procedure was also acceptable to all caregivers.

A systematic review of functional analysis in pediatric feeding disorders

We conducted a systematic review of the functional analysis of inappropriate mealtime behavior in peer-reviewed studies in PsycINFO, ERIC, PubMed, and the Journal of Applied Behavior Analysis between 2000-2016. We identified 18 studies involving 86 functional analyses. We coded descriptive data and calculated summary statistics in addition to conducting a quality appraisal of the literature. We identified escape, exclusively or in part, as the maintaining reinforcer for inappropriate mealtime behavior in 92% of cases. Results indicate that differentiated functional analyses of inappropriate mealtime behavior can be obtained, and outcomes are consistent with etiological theories of food refusal behavior. We discuss procedural differences across studies as well as directions for future research.

Behavioral Interventions for Pediatric Food Refusal Maintain Effectiveness Despite Integrity Degradation: A Preliminary Demonstration

Food refusal is commonly treated using behavioral treatment packages consisting of differential reinforcement of alternative behavior (DRA) and escape extinction. However, the effectiveness of such behavioral interventions is inextricably linked to the integrity with which the procedures are conducted. Although previous research has evaluated the effects of treatment integrity failures for behavioral interventions related to severe problem behavior and academic skill acquisition, the effects of these failures in the area of pediatric food refusal remain unknown. We conducted a parametric analysis to assess the effects of varying levels of errors on the treatment efficacy of contingent tangibles and attention, and escape extinction. Once stable responding was observed during an initial evaluation of treatment, participants were exposed to sessions of reduced-integrity treatment in descending order (i.e., 80%, 60%, 40%, and 20%) and subsequently exposed to full-integrity treatment (100% integrity). For one participant, integrity errors became detrimental to treatment when the level of integrity was decreased to 40%. For the other two participants, contingent tangibles and attention, and escape extinction remained effective despite being implemented with low integrity. Our preliminary demonstration suggests that behavioral interventions for pediatric food refusal remain effective despite considerable treatment integrity degradation.

Assessment of Parental Acceptability and Preference for Behavioral Interventions for Feeding Problems

The present study evaluates the treatment acceptability and preference for behavioral interventions for feeding problems with parents of children with Autism Spectrum Disorder and other developmental disabilities. The impact of behavioral severity on acceptability and preference was also evaluated by comparing results of parents who responded with respect to a vignette of a child with food refusal with those who responded to a vignette of a child with food selectivity. Overall, parents rated differential reinforcement of alternative behavior as the most preferred and most acceptable strategy across both food selectivity and food refusal groups. Escape extinction was the least acceptable and least preferred across both groups, and the severity of the behavior had no impact on acceptability or preference scores. Implications for future research on the social validity of feeding interventions are provided.