ERIC EJ910161: Spoon Distance Fading with and without Escape Extinction as Treatment for Food Refusal

2010·0.21 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2010, 43, 673–683 NUMBER4 (WINTER2010)
SPOON DISTANCE FADING WITH AND WITHOUT
ESCAPE EXTINCTION AS TREATMENT FOR FOOD REFUSAL
KRISTI D. RIVAS AND CATHLEEN C. PIAZZA
MUNROE-MEYERINSTITUTE
UNIVERSITYOFNEBRASKAMEDICALCENTER
MEETA R. PATEL
CLINIC4KIDZ,SAUSALITO,CALIFORNIA
AND
MELANIE H. BACHMEYER
UNIVERSITYOFIOWA
Littleisknownaboutthecharacteristicsofmealsthatserveasmotivatingoperations(MOs)for
escape behavior. In the current investigation, we showed that the distance at which a therapist
heldaspoonfromachild’slipsservedasanMOforescapebehavior.Basedontheseresults,we
implementedspoondistancefading,comparedfadingwithandwithoutescapeextinction(EE),
andcomparedfadingplusEEtoEEalone.Initially,inappropriatemealtimebehaviordecreased
duringfading,butthiseffectwasnotmaintainedasfadingprogressed.Inappropriatemealtime
behavior was lower initially when we combined fading and EE relative to EE alone, but
acceptanceincreasedmorerapidlywithEEthanwithfadingplusEE.Theseresultssuggestthata
numberofmealtimecharacteristicsmightfunctionasMOsforescapebehaviorandthatanalyses
ofMOs maybeuseful for developing treatments for foodrefusal.
Keywords: fading,feedingdisorder,foodrefusal,escapeextinction,negativereinforcement,
pediatricfeeding disorders, stimulus fading
_______________________________________________________________________________
Over two decades of operant research have 2003; Piazza, Patel, et al., 2003; Reed et al.,
shown that negative reinforcement plays an 2004). For example, Piazza, Fisher, et al.
important role in the maintenance of pediatric conducted functional analyses with 15 individ-
feedingproblems(Bachmeyeretal.,2009;Patel, uals with feeding disorders and found that 90%
Piazza, Martinez, Volkert, & Santana, 2002; of the participants whose functional analyses
Piazza,Fisher,etal.,2003;Piazza,Patel,Gulotta, were differentiated displayed maintenance by
Sevin,&Layer,2003;Reedetal.,2004)andthat escape from bite presentations. Piazza, Patel, et
procedures based on negative reinforcement are al. showed that escape extinction produced
effective as treatment (Ahearn, Kerwin, Eicher, increases in acceptance and decreases in inap-
Shantz, & Swearingin, 1996; Cooper et al., propriatemealtimebehavior,whereasdifferential
1995; Hoch, Babbitt, Coe, Krell, & Hackbert, positive reinforcement (DRA) alone did not.
1994; Patel et al., 2002; Piazza, Fisher, et al., The fact that escape appears to be such an
important reinforcer for children with feeding
This investigation was supported in part by Grant 1 disorders suggests that some dimension of the
K24 HD01380-01 from the Department of Health and mealtime environment serves as a motivating
Human Services, the National Institute of Child Health
operation (MO, Laraway, Snycerski, Michael,
andHuman Development.
Address correspondence to Cathleen C. Piazza, Pediat- & Poling, 2003) for escape from food presen-
ric Feeding Disorders, Munroe-Meyer Institute, 985450 tation. For example, in the escape condition of
Nebraska Medical Center, Omaha, Nebraska 68198 (e-
the Piazza, Fisher, et al. (2003) investigation,
mail:[email protected]).
doi:10.1901/jaba.2010.43-673 therapistspresentedbitesoffoodonaspoonon
673
674 KRISTI D. RIVAS et al.
a fixed-time 30-s schedule, and inappropriate consuming the nonpreferred foods in the
mealtime behavior (e.g., head turning, batting absence of the preferred foods.
at the spoon) resulted in removal of the spoon. The study by Mueller et al. (2004) suggested
Presumably,theestablishingoperation(EO)for that results of MO analyses could be used to
escapebehaviorwasrelatedtofoodpresentation prescribe treatment for children with feeding
(e.g., the spoon, the smell or sight of the food); disorders.Theyusedafadingprocedureinwhich
however, the authors did not identify the onecharacteristicofastimulus(foodquality)was
specific dimension of the mealtime environ- altered gradually, such that participants contin-
ment that was aversive. ued to respond to the altered stimulus in the
Smith, Iwata, Goh, and Shore (1995) samemannerastheydidtotheoriginalstimulus
described a method for evaluating the motivat- (Terrace, 1963). Although participants accepted
ing properties of a stimulus, using self-injurious preferred but not nonpreferred foods during
behavior(SIB)asanexemplar.Afteridentifying baseline, they accepted increasing ratios of
nine individuals whose SIB was maintained by nonpreferredtopreferredfoodsduringtreatment
escape from instructions, they manipulated and ultimately accepted the nonpreferred foods
various properties of the instructions (e.g., rate, alone. Fading has been used to alter a variety of
novelty, duration of instructional session) while food-related characteristics, including volume
maintaining constant consequence conditions (Freeman & Piazza, 1998; Hagopian, Farrell,
(i.e., 30 s of escape from instructions). &Amari,1996;Najdowski,Wallace,Doney,&
Responding was idiosyncratic in that specific Ghezzi, 2003), texture or consistency (Babbitt,
antecedent manipulations functioned as MOs Shore, Smith, Williams, & Coe, 2001; Johnson
for some behaviors but not others. Results of &Babbitt,1993;Shore,Babbitt,Williams,Coe,
the study showed that the strategy of manipu- &Snyder,1998),andsolid(Muelleretal.,2004)
lating antecedent conditions while maintaining or liquid (Patel, Piazza, Kelly, Ochsner, &
constant consequent conditions was useful for Santana, 2001) preferences. However, the ma-
evaluating the motivating properties of stimuli. jority of these studies incorporated multiple
Reed, Dolezal, Cooper-Brown, and Wacker treatment components; thus, the individual
(2005) examined the relation between one contributions of any one component were
child’s disrupted sleep and food refusal. They unclear (e.g., Freeman & Piazza, 1998; Johnson
observed that food refusal was higher following & Babbitt, 1993; Mueller et al., 2004; Naj-
nights when the child had disrupted sleep, dowski et al., 2003; Shore et al., 1998). The
suggestingthatdisruptedsleepservedasanMO purposes of the present investigation were (a) to
for food refusal. This conclusion was tempered evaluate the extent to which distance of the
by the fact that the child’s sleep was not spoonfromthechild’slipsfunctionedasanMO
manipulated experimentally (i.e., disrupted forescapebehavior,(b)toexaminetheefficacyof
sleep was identified post hoc). Mueller, Piazza, a fading procedure that consisted of altering the
Patel, Kelley, and Pruett (2004) showed that distance of the spoon from the lips during food
food acceptance was higher when therapists presentations, (c) to examine the efficacy of
presented preferred rather than nonpreferred fading with escape extinction (EE), and (d) to
foods,eventhoughthesame consequences were compare the effects of fading plus EE with EE
delivered in both conditions. They then used a alone. We chose spoon distance because we
fading intervention by blending the preferred observed clinically that caregivers of children
and nonpreferred foods in specified amounts. with feeding problems engage in tentative
The ratio of preferred to nonpreferred food was feedingbehavior(e.g.,initiallyshowingthechild
decreased gradually until participants were thespoonbeforeattemptingtopresentthespoon
DISTANCE FADING 675
to the child’s lips). In these situations, some measures. Data on inappropriate mealtime
children do not exhibit inappropriate mealtime behavior were collected using a frequency
behavior or negative vocalizations until the measureandwereconvertedtoarate(responses
caregiver presents the spoon closer to the child’s per minute) by dividing the number of
lips. This observation coincides with basic responses by the number of minutes in the
research that has shown that distance of an session. The occurrence of acceptance was
aversive stimulus is negatively correlated with recorded for each bite presentation (therapist
defensiveresponsesinbothhumansandanimals holding the spoon to the child’s lips, excluding
(e.g., Blanchard, Hynd, Minke, Minemoto, & expelledbites),andthesedatawereconvertedto
Blanchard, 2001). a percentage after dividing the number of
occurrences of acceptance by the number of
bite presentations. Data on negative vocaliza-
GENERAL METHOD
tions were recorded using a duration measure
Participants, Setting, and Materials
and were converted to a percentage of total
Three children who had been admitted to a
session after dividing the duration of negative
day-treatment program for pediatric feeding
vocalizations by the duration of the session.
disorders participated. A physician cleared all
children for oral feeding and ruled out any Interobserver Agreement
medical causes for the feeding problem prior to Interobserver agreement was assessed by
treatment. Sessions were conducted in rooms havingtwoobserversrecorddatasimultaneously
(4 m by 4 m) equipped with one-way but independently during 25%, 24%, and 38%
observation windows and sound monitoring. of sessions for David, Ashley, and Oliver,
Materials included utensils (e.g., baby spoon, respectively. Interobserver agreement for inap-
teaspoon), seating equipment (e.g., high chair, propriate mealtime behavior was calculated by
booster seat), food trays, gloves, timers, and dividingthenumberofexactagreements(a10-s
laptop computers. intervalinwhichbothobserversscoredthesame
frequency of inappropriate mealtime behavior)
Response Measurement and Data Collection by the number of intervals and converting this
The dependent variables were inappropriate ratiotoapercentage.Meanagreementwas93%
mealtime behavior, acceptance, and negative (range, 69% to 100%), 96% (range, 86% to
vocalizations. Inappropriate mealtime behavior 100%), and 96% (range, 68% to 100%) for
was defined as turning the head 45 degrees or David, Ashley, and Oliver, respectively.
moreawayfromthespoon,hittingthespoonor Interobserver agreement for acceptance was
the feeder’s arm or hand, or covering the calculated by partitioning each session into 10-s
mouth. Acceptance was defined as the child intervals,dividingthenumberofintervalsduring
opening his or her mouth to allow the bite to whichbothobserversagreedontheoccurrenceor
pass the plane of the lips and enter the mouth nonoccurrenceofacceptancebythetotalnumber
within 5 s of the initial bite presentation. of intervals, and converting this ratio to a
Negativevocalizationsweredefinedasatleast3s percentage. Mean agreement was 99.7% (range,
of crying or whining. 94%to100%),99%(range,84%to100%),and
Prior to all data collection, observers were 98% (range, 89% to 100%) for David, Ashley,
trained by a clinical supervisor and collected and Oliver, respectively.
training data until they attained at least 80% Interobserver agreement for negative vocali-
agreement with a trained observer on three zations was calculated by dividing the smaller
consecutive sessions. Observers used laptop duration by the larger duration and converting
computers to collect data on all dependent this ratio to a percentage. Mean agreement was
676 KRISTI D. RIVAS et al.
98% (range, 80% to 100%), 97% (range, 88% job swallowing your bite’’) if no food larger
to 100%), and 96% (range, 71% to 100%) for than a pea was present in the child’s mouth
David, Ashley, and Oliver, respectively. during the first check (the therapist did not
deliver praise if the absence of food was due to
General Procedure expulsion). The therapist delivered a verbal
We conducted five meals per day, with prompt(e.g.,‘‘swallowyourbite’’)iffoodlarger
approximately 1 to 3 hr between each meal than a pea remained in the child’s mouth and
(e.g., 9:00 a.m., 10:30 a.m., 12:00 p.m., 2:30 repeated the prompt every 30 s until no food
p.m., 4:00 p.m.). Each meal lasted approxi- larger than a pea was in the child’s mouth. An
mately 30 to 45 min and consisted of several exception was made for Oliver, who had a
sessions, with 1- to 2-min breaks between history of gagging and vomiting. The occupa-
sessions. The therapist presented bites to the tional therapist recommended not allowing
childfor5minduringallsessionsexceptduring food to remain in Oliver’s mouth for extended
EE, when the session continued until the child periodsoftime;therefore,weremovedanyfood
swallowed the last bite that entered his or her larger than a pea that was in his mouth 1 min
mouth within the initial 5-min session. The after the bite entered his mouth. The therapist
therapist presented two foods (vegetable, fruit) talkedandplayedwiththechildthroughoutthe
to David and Ashley and one food (banana) to session (except for David, per parental request).
Oliver. We selected these foods based on the Pretreatment distance sessions. The purpose of
physician’s recommendations. Although none these sessions was to identify a spoon-presenta-
of the children had known food allergies, the tion distance that was associated with low rates
physician wanted us to initiate treatment with ofinappropriatemealtimebehaviorasastarting
foods to which the children had been exposed point for fading. We assessed the child’s
previously and then to introduce new foods behavior when the therapist presented the
later to assess potential allergic reactions. These spoon at various distances from the child’s lips,
foods were presented only in feeding sessions which were based on informal assessments
and not at other times. The therapist presented conducted with each child prior to the
foodsinarandomorderacrosssessionsbutina pretreatment assessment. The distances assessed
fixed order within each session. The texture of during the pretreatment sessions were 2.5 cm,
presented food was baby food for Ashley and 12.7cm,25.4cm,and61cmforDavid;2.5cm,
Oliver and pureed table food for David. The 12.7 cm, and 25.4 cm for Ashley; and 2.5 cm,
bolussizewasalevelbabyspoonforAshleyand 12.7 cm, 25.4 cm, and 38.1 cm for Oliver. We
Oliver and a level small maroon spoon for ensured that the therapist presented the spoon
David. Textures, utensils, and bolus sizes were at the correct distance by placing small marks
based on the recommendations of the feeding with measurements (e.g., 2.5 cm, 12.7 cm) on
program’s occupational therapist. the child’s tray.
Across all sessions, the therapist presented General procedures for the pretreatment
bites at the child’s midline accompanied by a distance sessions were described above. The
verbal prompt to ‘‘take a bite’’ approximately therapistplacedthespoonatthechild’smidline
every20sto30s.Thetherapistdeliveredpraise at the specified distance from the child’s lips,
(e.g., ‘‘good job taking your bite’’) following held the spoon for 30 s if the child did not
acceptance. The therapist checked the child’s engageininappropriatemealtimebehavior,and
mouth 30 s after a bite entered the child’s presented the next bite at the end of the
mouth to determine if the child had swallowed interval. The therapist removed the spoon for
it. The therapist delivered praise (e.g., ‘‘good 20 s if the child engaged in inappropriate
DISTANCE FADING 677
behavior and presented the next bite after the Forexample,ifthechild’sinappropriatebehavior
20-s break. We used the distance associated washighandstablewhenthetherapistpresented
with the lowest level of inappropriate behavior thespoon25.4cmfromthelips,weincreasedthe
for the distance conditions of the baseline distance of the spoon to the lips to the previous
assessment, which were 61.0 cm, 12.7 cm, fading distance (e.g., 30.5 cm). Throughout this
and 25.4 cm for David, Ashley, and Oliver, condition,theprocedureswereidenticaltothose
respectively. described previously.
Lips versus distance baseline. The purpose of Fading plus EE. Fading plus EE was identical
this baseline was to establish that presentation to fading except that inappropriate mealtime
of the spoon at the lips was associated with behavior did not produce escape. The spoon
higher rates of inappropriate mealtime behavior followed the child’s lips from the specified
relativetopresentationatthedistanceidentified distance the entire 30-s interval if the child
in the pretreatment sessions. We used the engaged in inappropriate behavior. Once the
procedure recommended by Smith et al. distance of the spoon had been faded to the
(1995) for evaluating the motivating effects of child’s lips, the therapist deposited the bite into
stimuli on behavior. That is, we manipulated the child’s mouth and re-presented expelled
bites. The criterion for fading was identical to
the antecedent stimuli (spoon presentations)
that described above. Each time we changed
while holding the consequence for inappropri-
phases, we presented the spoon at the distance
ate mealtime behavior (escape from spoon
implemented in the previous fading phase.
presentations) constant. Procedures for the lips
Lips baseline probes. We conducted probes
and distance baselines were identical to those
during conditions that included fading to
describedforthepretreatmentdistancesessions,
determine if continued fading was necessary
except that the therapist presented the spoon at
(Patel et al., 2001). We conducted these probes
the child’s lips in the lips condition.
using procedures described for the lips baseline
Fading. The goal offading was topresentthe
condition after the child met criterion for
spoon initially from a distance associated with
decreasing the distance of the spoon once
lowratesofinappropriatemealtimebehaviorand
(Ashley) or twice (David and Oliver) consecu-
then to decrease the distance of the spoon from
tively. We returned to the fading procedure if
the child’s lips gradually while maintaining low
the child’s behavior during the probes did not
ratesofinappropriatebehavior.Thecriterionfor
meet the criterion. We continued with the
decreasing the distance was three consecutive
probes and discontinued fading if the child’s
sessionswithinappropriatebehavior ator below
behavior met the criterion.
1 response per minute, negative vocalizations at
Escape extinction. The therapist followed the
or below 10% for distances between 61 cm and
procedures described abovefor EE,but without
4cm,andacceptanceatorabove80%whenthe
the fading component.
spoonwasfadedtothechild’slips(i.e.,theonly
condition in which acceptance could occur).
STUDY 1
Whenthiscriterionwasmet,thetherapistmoved
thespoon2.5cm(Ashley)or5.1cm(Davidand The purposes of Study 1 were (a) to evaluate
Oliver) closer to the child’s mouth. Ashley’s inappropriate mealtime behavior during pre-
fading distances were smaller because her initial sentation of the spoon at the lips versus a
fadingdistancewasonly12.7cm.Weusedvisual specified distance from the child’s lips when
inspectionofdatatodeterminewhentoincrease inappropriate behavior produced escape, (b) to
the distance of the spoon if the child did not determine whether inappropriate behavior
meet the criterion for decreasing the distance. would remain low and acceptance would
678 KRISTI D. RIVAS et al.
Figure 1. Inappropriatemealtime behavior per minute (top)andpercentage ofacceptance (bottom) for David.
increase during fading, and (c) to evaluate Design
inappropriate behavior and acceptance during We used a combination of multielement and
fading plus EE if fading was ineffective. reversal(ABCA9C)designs.Baseline(A)wasthe
comparison of presentation of the spoon at the
Participants
lips versus a specified distance from the lips
David was a 4.5-year-old boy with gastro- with escape as reinforcement for inappropriate
esophageal reflux disease (GERD), failure to mealtime behavior. Next, we introduced fading
thrive, status post Nissen fundoplication, hy- with periodic lips baseline probes (B). We
pothyroidism, and bronchopulmonary dyspla- added EE to fading (C) because fading did not
sia. He had been referred for poor oral intake decrease inappropriate behavior to acceptably
and gastrostomy (G-) tube dependence. Ashley low rates.
was a 5-month-old girl with typical cognitive
development who had been diagnosed with Results and Discussion
failure to thrive. She had been referred for solid Figure 1 depicts the results for inappropriate
and liquid refusal and G-tube dependence. mealtime behavior and acceptance for David.
DISTANCE FADING 679
Figure2. Inappropriate mealtime behavior per minute(top) andpercentage ofacceptance (bottom)for Ashley.
Figure 2 depicts the results for inappropriate ed the number of occurrences of inappropriate
mealtime behavior and acceptance for Ashley. behavior by the number of bites presented, and
Duringdistancesessions, the childdidnot have converted the ratio to a percentage. Mean
the opportunity to accept bites; therefore, no percentage of bites escaped was 100% in the
dataforacceptanceappearonthegraphsduring lips baseline and 40% for the distance baseline
these sessions. Inappropriate mealtime behavior for David and 100% in the lips baseline and
remained high for David (M 5 34.4 responses 23% for the distance baseline for Ashley.
per minute) and Ashley (M 5 14.9 responses Acceptance was zero for both children.
per minute) in the lips baseline and low for Rates of inappropriate mealtime behavior
David (M 5 1.4) and Ashley (M 5 0.5) in the initially were low for both children during
distance baseline. We also calculated the fading. However, inappropriate behavior in-
percentage of bites escaped during baseline. creased as the distance of the spoon from the
For each bite presentation, we determined child’s lips decreased and remained high during
whether an inappropriate mealtime behavior thelipsbaselineprobes.Bycontrast,fadingplus
occurred following the bite presentation, divid- EEresulted indecreased inappropriate behavior
680 KRISTI D. RIVAS et al.
and increased acceptance for both children. We with failure to thrive and GERD. He had been
examined whether the differences in behavior referred for food and liquid refusal and G-tube
were a function of the rate of bite presentation. dependence.
Rates of bite presentation were similar during
fading (M 5 1.8) and fading plus EE (M 5 Design and Procedure
1.7) for David, but were higher during fading We used a combination of multielement and
(M 5 1.8) than during fading plus EE (M 5 reversal (ABA9B) designs. Baseline (A) was a
0.8) for Ashley. The lower rate of bite
comparison of presentation of the spoon at the
presentation in EE was a function of the higher
lips and 25.4 cm from the lips with escape as
rates of inappropriate behavior, which initially
reinforcement for inappropriate mealtime be-
interfered with the therapist depositing the bite
havior.Next, wecomparedfadingplus EEwith
in Ashley’s mouth. It is unlikely that this
EE alone with lips baseline probes (B). The
difference in rate of bite presentation explained
proceduresforbaseline,fadingplusEE,andEE
the differences in behavior for Ashley. If
were identical to those described above.
anything, a higher presentation rate would be
expected to be associated with higher rates of
Results and Discussion
inappropriate behavior, which was not the case.
Figure 3 depicts Oliver’s rates of inappropri-
One hypothesized advantage of combining
ate mealtime behavior and acceptance. The
fading with EE is that the addition of fading
results for lips versus distance baseline were
might mitigate some potential negative side
identical to those of Study 1; rates of
effects of extinction. This may have been the
inappropriate behavior were higher in the lips
case for David, because inappropriate mealtime
baseline (M 5 22.5 responses per minute) than
behaviordecreasedimmediatelywhenweadded
in the distance baseline (M 5 0.3). Mean
EE to fading. By contrast, inappropriate
percentage of bites escaped was 86% in the lips
mealtime behavior was higher for Ashley when
baseline and 20% in the distance baseline.
we added EE to fading, which may have been
Similar to the findings for Ashley, the rate of
relatedtothefactthatthespoonhadbeenfaded
bite presentation was higher during fading plus
to her lips prior to the introduction of EE. It is
EE(M51.5)thanduringEEalone(M50.6).
possible that rates of inappropriate behavior
The lower rate of bite presentation in EE was a
might have been lower had we introduced EE
function of the higher rates of inappropriate
with the spoon a greater distance from her lips
behavior, which initially interfered with the
and then faded the distance in combination
therapist depositing the bite in Oliver’s mouth.
with EE.
We conducted Study 2 to determine whether
Although the results of Study 1 showed that
the addition of fading to EE would mitigate the
inappropriate mealtime behavior decreased and
negative side effects of EE. Fading plus EE did
acceptance increased during fading plus EE, it
seem to have beneficial effects for Oliver in that
was not clear whether we would have observed
fadingplusEEwasneverassociatedwithelevated
the same results with EE alone. Therefore, we
rates of inappropriate mealtime behavior or
conductedamultielementcomparisonoffading
negative vocalizations (data available from the
plus EE and EE alone in Study 2.
second author). By contrast, initial implementa-
tion of EE was associated with higher rates of
STUDY 2
inappropriate behavior and negative vocaliza-
Participant tions. However, when we reversed to the lips
Oliver was a 10-month-old boy with typical baseline and returned to the multielement
cognitivedevelopmentwhohadbeendiagnosed comparison of fading plus EE and EE alone,
DISTANCE FADING 681
Figure3. Inappropriatemealtime behavior perminute (top) andpercentageofacceptance (bottom) for Oliver.
Oliver’s rates of inappropriate behavior were GENERAL DISCUSSION
similar in both conditions. Although results of previous studies have
Even though low rates of inappropriate shown that escape from eating functions as
mealtime behavior were achieved quickly in negative reinforcement for inappropriate meal-
fading plus EE, high levels of acceptance were time behavior, there is little research that has
not. High levels of acceptance (i.e., above 80%) examined specific mealtime characteristics that
did not occur in fading plus EE until we had alter the effectiveness of escape as reinforce-
conducted 93 sessions, whereas high levels of ment. Recall that Smith et al. (1995) evaluated
acceptanceoccurredinEEaftersixsessions.One MOs for SIB by altering the characteristics of
limitationofthesedataisthatfadingplusEEand demands while maintaining constant conse-
EE alone were implemented in a multielement quence conditions. We extended this research
design. Therefore, it is difficult to determine if by assessing the extent to which spoon distance
the treatments would have been more or less functioned as an MO for inappropriate meal-
effective if implemented in isolation. time behavior. We varied the distance of the
682 KRISTI D. RIVAS et al.
spoon from the child’s lips while providing with less rapid increases in acceptance. This
escapefollowinginappropriatemealtime behav- would be most appropriate for children for
ior. Data from this analysis suggested that the whom volume of oral intake is not an
presence of the spoon at the lips served as an immediateconcern(e.g.,achildwithaG-tube).
EOtoincreaseandthepresenceofthespoonat One disadvantage of fading plus EE was that
a distance from the lips served as an abolishing the time required to produce increases in
operation to decrease the effectiveness of escape acceptance was greater than that of EE alone.
as reinforcement for inappropriate behavior If rate of improvement is a primary concern
(Michael, 1982). (e.g., a child with failure to thrive), then fading
Next,we used the results of the MO analyses plus EE may not be the best treatment option.
to implement distance fading, which was Future research should examine how mitigation
associated with immediate reductions in inap- of negative side effects of extinction and
propriate mealtime behavior. However, inap- treatment efficiency affects acceptability for
propriate behavior increased as the distance of the different components of the intervention.
the spoon from the lips decreased. These Future research should continue to evaluate
findings correspond with results of previous the role of negative reinforcement in the
research on the effects of demand fading maintenance of inappropriate mealtime behav-
without extinction on escape-maintained prob- ior. Data from the current study suggest that
lem behavior during instructional contexts. For analysesofMOscanbeusedtoidentifyspecific
example,Zarcone,Iwata,Smith,Mazaleski,and characteristics of the meal that may alter the
Lerman (1994) observed a reemergence of effectiveness of escape as reinforcement; there-
problem behavior as fading progressed. fore, future research should examine the
The data for Oliver suggested that fading establishing and abolishing effects of other
plus EE was associated with lower rates of mealtime variables (e.g., food type, food
inappropriate mealtime behavior, which is texture) on inappropriate behavior. Future
consistent with literature that has shown that research also should assess whether analyses of
supplementary procedures (e.g., DRA, noncon- MOs can be used to develop treatments for
tingent reinforcement) may be helpful in pediatric feeding disorders in the presence and
reducing inappropriate behavior or negative absence of EE.
vocalizations during EE (Lerman & Iwata,
1995; Lerman, Iwata, & Wallace, 1999; Piazza,
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