Escape Extinction Research Articles

Adapting preference assessments and reinforcement schedules to increase mask wearing with adults with intellectual disabilities

AbstractNew or infrequently contacted stimuli may present challenges for people with intellectual disabilities (ID) and autism spectrum disorder (ASD). Throughout the Covid‐19 pandemic, facemasks emerged as a new stimulus that may cause distress, especially for those who may not understand the need for a mask. Further, the inability to tolerate wearing a facemask could limit safe access to public locations for people with ID and ASD. Most approaches to increasing health routines involve some form of escape extinction, a practice that may not be feasible or safe for some individuals and in some settings. As an alternative, approaches based on adapting stimulus features, including preferences, and positive reinforcement, may produce equally effective interventions. To evaluate this, we first assessed preference of eight adults with ID living in a residential facility, for four different types of facemasks and the standard facility face masks. Access to a variety of masks increased mask‐wearing for two participants. We then evaluated reinforcement schedule manipulations without escape extinction to increase mask wearing for four participants from Study 1. For all four participants, we successfully increased mask wearing using a reinforcement schedule that was sustainable in their everyday environment.

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.

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.

Reduction in Feeding Problems and Impact on Family Following a 12-Week Interdisciplinary Group Feeding Intervention for Children With Feeding Problems and Their Caregivers

Caregivers and their children with clinical levels of feeding problems participated in Picnic Group, an outpatient interdisciplinary family group treatment program for children with feeding disorders and their caregivers at a large regional pediatric hospital. The manualized treatment is based on an interdisciplinary systematic approach that draws from sensory integration, communication, and cognitive behavioral strategies (e.g., classical conditioning, systematic desensitization, communication of automatic thoughts) to increase pleasurable interactions with food over a 12-week period and includes caregiver and child intervention components. Escape extinction techniques such as nonremoval of the spoon were not used in treatment. Caregivers completed measures focused on their children’s feeding behaviors and family strain at baseline and at the end of the 12-week intervention. Wilcoxon signed-rank tests compared measures between baseline and the end of treatment. Results indicated that at the 12th week, caregivers generally reported one less feeding problem, fewer specific types of eating and mealtime problematic behaviors, and decreased impact of feeding problems on the family. Children were able to work up a hierarchy of food interactions with more foods per group session than at the first session. Caregivers of children with a developmental diagnosis showed the most decrease in caregiver strain. Outpatient interdisciplinary group treatment can decrease feeding problems and caregiver strain in families with children with feeding disorders.

Motivating children with feeding disorders to self‐feed: An evaluation of using differential reinforcement and manipulation of establishing operations to increase self‐feeding

AbstractSelf‐feeding is a behavioral cusp vital to independence, growth, and development. Previous studies demonstrate that interventions like escape extinction in the form of physical guidance are effective at increasing self‐feeding in children with feeding disorders. However, these interventions may not be effective for all children. In the present study, we evaluated the effects of a treatment package that involved increasing the quality of feeder attention and access to tangibles to decrease the comparative value of escape from the self‐feeding demand for two children with feeding disorders using a nonconcurrent multiple baseline design. Despite demonstrating the skills to self‐feed preferred foods and consume target foods, neither child self‐fed target foods independently. Following differential reinforcement with the manipulation of establishing operations, both children demonstrated improvement in self‐feeding bites of target foods. In addition, caregivers were trained to implement the protocol with high procedural integrity.

Pheromones for amphibian conservation – considering new approaches in conservation breeding programmes

Pheromones for amphibian conservation – considering new approaches in conservation breeding programmes

Prioritizing choice and assent in the assessment and treatment of food selectivity

Food selectivity affects up to 72% and 45% of individuals with and without disabilities, respectively, and there is a need for interventions that rely on positive, unrestrictive strategies. We evaluated an assessment and treatment package for food selectivity for young children with developmental disabilities that prioritized caregiver collaboration, client autonomy, and did not rely on restrictive procedures (e.g. escape extinction). The process involved: (a) collaborating with caregivers on the selection of foods and design of the children’s functional analyses; (b) indirectly and directly measuring food preferences prior to treatment; (c) evaluating the sensitivity of mealtime problem behavior to environmental variables through an interview-informed synthesized contingency analysis (IISCA); and (c) incorporating the assessment results into a progressive treatment process consisting of choice-making opportunities and differential reinforcement of successive approximations to consumption. Children also had the ability to opt in and out of treatment sessions. The treatment was effective in increasing consumption of nonpreferred foods and successfully extended to caregivers. Practical implications and directions for future research are discussed.

An Evaluation of a Telehealth Caregiver Training Package to Treat Food Selectivity.

Telehealth behavioral interventions are increasingly necessary when in-person services are not accessible (e.g., due to geographic location, time, cost, and health and safety restrictions). There is a growing evidence-base for the effectiveness of telehealth interventions but few demonstrations of telehealth interventions for pediatric feeding disorders. The purpose of this study was to evaluate a telehealth caregiver training package to teach caregivers to implement a feeding intervention, in their home as primary interventionists, to treat their children's food selectivity. To address some previously documented caregiver concerns regarding some intervention procedures (e.g., nonremoval of the spoon or escape extinction) and ensure caregivers could safely/feasibility implement intervention, the intervention included differential reinforcement of bites consumed within a 3-minute opportunity. All three caregivers demonstrated high levels of correct performance following training and all children demonstrated increases in the number of bites consumed and decreases in disruptive behaviors. Findings suggest training caregivers via telehealth may be a viable option to treat some children's food selectivity without first requiring in-person services.

Effects of reinforcer type on the durability of treatment for escape‐maintained behavior

AbstractIn the absence of escape extinction, evidence suggests that positive reinforcement may decrease escape‐maintained behavior. A variety of reinforcers (e.g., food, tokens, and escape) have been used to strengthen alternative behavior in prior research. But, the differential effects of these reinforcers on an intervention's capacity to maintain low rates of problem behavior in the absence of escape extinction during schedule thinning remains unknown. The current study evaluated whether interventions incorporating the use of tokens would equal the effects (in terms of the intervention's capacity to maintain low rates of problem behavior during schedule thinning) of interventions that incorporated escape or food. Results showed that for two of three participants diagnosed with intellectual and developmental disabilities, token reinforcement produced therapeutic effects during schedule thinning. For all participants, the intervention involving negative reinforcement for compliance was either ineffective or deteriorated as the schedule of reinforcement was thinned.

Just Right Challenge Feeding Protocol: Case-Report for Guiding Clinical Reasoning and Future Research in Food Selectivity Treatment

Food selectivity impacts health and quality of life for children with developmental disabilities. Best practice protocols are still in development and use of escape extinction, systematic desensitization and parent education are elements that may be part of effective multi-component treatment. The Just Right Challenge Feeding Protocol (JRCFP) includes each of these elements to drive changes in food acceptance for children with developmental disabilities. This case-report provides detailed information about how a group of children progress through treatment. Children in this case-report had 15 or less foods in their food inventory and profiles indicating the presence of sensory over-responsivity. Every 5–10 weeks, each child moved up one step in the Food Interaction Hierarchy (e.g. touch, taste, eat). Significant increases in vegetable and fruit acceptance and mealtime quality are noted and parent compliance on home program assignments is described. This information is valuable for guiding clinical reasoning and future research of treatment for food selectivity.

Reducing Escape without Escape Extinction: A Systematic Review and Meta-Analysis of Escape-Based Interventions

Reducing Escape without Escape Extinction: A Systematic Review and Meta-Analysis of Escape-Based Interventions

Tolerance of face coverings for children with autism spectrum disorder.

Healthcare professionals and government officials have advised the use of personal protective equipment, such as face masks and face shields, to assist with limiting the spread of the SARS‐CoV‐2 (COVID‐19). Due to the prevalence of challenging behavior associated with other medical routines, the present study evaluated a treatment package composed of graduated exposure, prompts, reinforcement, and escape extinction on tolerance of wearing a face covering for up to 5 min for 12 children with ASD in a systematic replication of Cox et al. (2017) and Sivaraman et al. (2020). We also extended previous research by measuring generalization of face covering type (i.e., face shield) and the efficacy of a treatment extension for tolerating a face covering for up to 15 min during the participants' trial‐based instruction and play periods.

Assessment of children's and caregivers' preferences for treatments for escape-maintained problem behavior.

This study assessed children's and caregivers' preferences for various arrangements of negative reinforcement, including differential negative reinforcement of an alternative behavior (DNRA), noncontingent escape (NCE), and escape extinction. In the first treatment comparison, the DNRA and NCE treatments similarly decreased problem behavior, but all 3 children preferred DNRA. By contrast, 3 of 4 caregivers preferred escape extinction, likely due to increased compliance in this condition. In a second treatment comparision with 1 child, a multiple schedule and then a chained schedule were introduced to increase the practically of the initial DNRA treatment. The child continued to prefer the treatment with contingent reinforcement in both comparisons, and his caregivers preferred the chained schedule. Results further support the selection of treatments that include contingent reinforcement, and the evaluation serves as a model for progressing through treatment options until child and caregiver preferences align.

A comparison of function‐ and nonfunction‐based extinction treatments for inappropriate mealtime behavior

Previous literature supports the use of functional analyses to prescribe treatments for children with feeding disorders (Bachmeyer et al., 2009). Nevertheless, clinicians often train caregivers to use healthy contingencies, independent of whether those contingencies are function based. However, it is unclear whether including nonfunction-based contingencies differentially affects inappropriate mealtime behavior. In the current investigation, the caregivers of 3 children with feeding disorders provided escape from bites and drinks and attention following inappropriate mealtime behavior. Results of a functional analysis showed escape from bites or drinks, but not attention, reinforced inappropriate mealtime behavior. We then tested the effects of escape extinction when the feeder either provided or withheld attention following inappropriate mealtime behavior. Inappropriate mealtime behavior decreased and acceptance increased when the feeder implemented escape extinction independent of whether they provided or withheld attention. We discuss the implications of including nonfunction-based components in the treatment of pediatric feeding disorders.

Increasing passive compliance to wearing a facemask in children with autism spectrum disorder.

The current study taught 6 children with autism spectrum disorder (ASD) to increase passive compliance of wearing a facemask across sequentially increasing durations of time. A changing‐criterion design embedded within a nonconcurrent multiple baseline design was used to evaluate the effectiveness of a resetting differential reinforcement of other behavior (DRO) without escape extinction procedure on passive compliance. Terminal probe sessions determined DRO fading intervals. Results showed that 2 participants acquired mastery level passive compliance (30 min) without fading during the initial baseline sessions. The remaining 4 participants acquired mastery level passive compliance following fading intervals within the DRO intervention. Participants' passive compliance generalized across 2 novel settings. This study replicates previous studies and extends empirical support for the use of DRO without escape extinction interventions for increasing passive compliance with medical devices in children with ASD.

Further evaluation of noncontingent reinforcement to treat mealtime problem behavior

AbstractWe evaluated the effects of noncontingent reinforcement (NCR) without escape extinction (EE) on problem behavior emitted by a young boy with autism spectrum disorder during meals. Results indicated that NCR (i.e., continuous access to a highly preferred activity) was effective in reducing problem behavior and moderately increasing food acceptance. Subsequently, we evaluated a total session‐based thinning of the NCR schedule. Although problem behavior remained low during schedule thinning, differential reinforcement was necessary to maintain adequate levels of food acceptance.

A systematic literature review of antecedent and reinforcement‐based behavioral feeding interventions without the implementation of escape extinction

AbstractRestrictive and avoidant patterns of eating behavior can be seen in children with and without a diagnosed disability, and these patterns may then lead to avoidant/restrictive food intake disorder. The three main categories of feeding problems often observed in children are food refusal, refusal to self‐feed, and food selectivity. This literature review includes 21 articles that implemented feeding interventions, without the use of escape extinction or other intrusive interventions, to increase food acceptance. Each article was analyzed across several dimensions (participants, setting, assessments conducted, experimental design, intervention implemented, and outcome and generalization). From this analysis, information regarding the use of antecedent and reinforcement‐based practices for feeding intervention is discussed, as well as limitations in the current literature and suggestions for future research.

Using a Token Economy to Treat Escape-Maintained Problem Behavior Without Extinction.

The use of extinction procedures when treating escape-maintained problem behavior can be undesirable and impractical for practitioners to use. To mitigate the risks associated with escape extinction, we explored the effectiveness of a delayed reinforcement token system without the use of extinction in school and home settings to treat escape-maintained problem behavior of students with autism spectrum disorder. In lieu of escape extinction (e.g., blocking), the researchers implemented a 30 s break contingent on problem behaviors and a token (to be exchanged at the end of the session) contingent on compliance. The results of a multiple probe design indicated substantial increases in compliance and reductions in problem behavior for all four participants. These findings suggest that extinction is not necessary to eliminate escape-maintained problem behavior in children with autism.

Observational Effects on the Food Preferences of Children With Autism Spectrum Disorder

Research addressing food selectivity has involved intrusive techniques such as escape extinction. It is possible that observational learning methods employed in previous studies could provide the desired results with respect to food selectivity without the need for invasive physical interventions. The purpose of this study was to evaluate the effectiveness of an observational learning procedure on the selection of food items of three children diagnosed with autism spectrum disorder. Baseline consisted of a simple task after which a choice was presented between high- and low-preferred foods. The intervention consisted of observing an adult engage in the same task and selecting the low-preferred food while making favorable comments and engaging with the food in novel ways. The results of a reversal design demonstrated that selection of the low-preferred food only occurred following the introduction of the intervention, and all three participants engaged in flexible responding as a result of the intervention.

Combining Stimulus Fading with Simultaneous Stimulus Presentation in a School Setting for Food Selectivity in a Child with Autism Spectrum Disorder

The participant was a boy diagnosed with autism spectrum disorder (ASD) who displayed severe food selectivity, which raised concerns about imbalanced nutrient consumption. The intervention used combined stimulus fading with simultaneous stimulus presentation without escape extinction (EE) and was implemented by teachers in a school setting. In intervention I, which used only stimulus fade-in of non-preferred foods, favorable results were not obtained. In intervention II, simultaneous stimulus presentation of a preferred food combined with stimulus fade-in of non-preferred foods, Silva’s consumption was stabilized at 100% consumption of three non-preferred foods. When intervention II was terminated, the child’s mother requested the inclusion of two additional non-preferred foods, so the intervention was extended based on a fading protocol planned with and to be used by the mother. The effects of the intervention were maintained at the 3-month post-intervention follow-up. The child’s parents and teachers showed high acceptance of this intervention. The current study offers further evidence that combining antecedent-based interventions without EE has the potential to yield favorable results with some children.