Inappropriate Mealtime Behavior Research Articles

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.

Functional analysis screening for inappropriate mealtime behavior

AbstractInappropriate mealtime behavior (IMB) is a class of food refusal behavior that is commonly observed in children with neurodevelopmental disorders or avoidant/restrictive food intake disorder. An abundance of research has demonstrated that IMB is commonly maintained by negative reinforcement in the form of escape from food or drink presentation. Given the common association between IMB and escape as a reinforcer, more efficient methods of conducting functional analyses have been called for. The present study examined the extent to which indirect assessments and a functional analysis screening process reliably predicted an escape function in three children with autism spectrum disorder who engaged in IMB. The results of the two assessments were then compared to a standard functional analysis. For all participants, the functional analysis identified an escape function, which corresponded with both the indirect assessment and screening. Additionally, within‐session analyses of screening sessions further validated the screening process. The functional analysis screening of IMB is discussed in terms of its efficiency, practicality, and experimental design. The results of this study offer a framework for efficiently assessing the function of IMB, while providing recommendations for future research.

Further examination of behavior during extinction‐based treatment of pediatric food refusal

AbstractResearchers have demonstrated the effectiveness of extinction‐based treatments to reduce challenging behavior. Although bursts and temporary increases in emotional responding may occur in some basic and applied studies, recent studies on their prevalence have shown that side effects are far from ubiquitous. Woods and Borrero (2019) determined that bursts of inappropriate mealtime behavior and increases in emotional responding occurred in 30% of data sets during extinction‐based treatment of pediatric feeding difficulties. In the current study, we conducted a retrospective consecutive‐controlled case series by evaluating treatment graphs of inappropriate mealtime behavior, negative vocalizations, active acceptance, and mouth clean for 60 children admitted to an intensive day‐treatment feeding disorders program. We discuss the implications of these findings and provide general recommendations for the use of extinction‐based treatment.

The Efficacy of the Global Intensive Feeding Therapy on Feeding and Swallowing Abilities in Children with Autism Spectrum Disorder: A Pilot Study.

The present investigation aims to explore the efficacy of Global Intensive Feeding Therapy (GIFT) on feeding and swallowing abilities in children with autism spectrum disorder (ASD). GIFT was developed as an intensive rehabilitation approach, divided into 30 sessions for 2 weeks, three times a day. GIFT focused on (a) encouraging desensitization; (b) widening the food repertoire (in terms of both variety and quantity); (c) reducing inappropriate mealtime behaviors; and (d) encouraging the development of appropriate chewing and swallowing abilities. GIFT was preliminarily implemented among 11 children with a diagnosis of ASD. To measure the efficacy of GIFT, the Karaduman Chewing Performance Scale (KCPS), the Brief Autism Mealtime Behavior Inventory (BAMBI), and food repertoire were investigated using Wilcoxon signed-rank test in three different times: baseline (T1), after treatment (T2), and one month after treatment (T3). Using Bonferroni correction, statistically significant differences were found between T1 and T2 for behavioral issues, as measured with BAMBI (p = 0.007), as well as for chewing abilities as measured with KCPS (p = 0.005) and for food acceptance (p = 0.005). These improvements were maintained after a month of follow-up, thanks to the collaboration of families and/or primary caregivers. In conclusion, GIFT seems to be an effective approach to improving behavioral issues, food acceptance, and chewing abilities in children with ASD.

Clinical Outcomes from an Interdisciplinary Outpatient Feeding Treatment Pilot Program.

Many children with developmental disabilities experience feeding challenges, including food refusal and food selectivity. Feeding concerns are often multifaceted and, therefore, an interdisciplinary approach to treatment is needed. A pilot of an interdisciplinary outpatient feeding program was conducted in a hospital medical center by psychologists and occupational therapists. The pilot program focused on caregiver training and improvements in targeted feeding goals in both the clinic and home settings. Treatment outcomes from this pilot program found increases in bite acceptance, decreases in inappropriate mealtime behaviors, increases in caregiver-reported number of foods consumed, and mastery of most individualized feeding goals for children who participated in the treatment program. Additionally, caregivers reported decreased concerns related to feeding and increased confidence in addressing their child's feeding concerns after participation in the treatment. Caregivers also reported high levels of satisfaction with this pilot program and reported the intervention to be feasible.

The Mealtime Behavior Problems of Children with Developmental Disabilities and the Teacher's Stress in Inclusive Preschools.

With an increasing number of children with developmental disabilities entering inclusive preschools, preschool teachers face more behavioral problems in class. Preschool teachers typically attempt to address mealtime behavior problems of children with and without developmental disabilities simultaneously in class. This study used qualitative research to identify the stress triggers of preschool teachers addressing the mealtime behavior problems of children with developmental disabilities. Five preschool teachers attended semi-structured interviews. The results indicated that most children with developmental disabilities had problems with eating only preferred foods, using eating utensils appropriately during mealtime, becoming distracted from eating, and becoming frustrated with the classroom routine. Although solving these problems triggered stress in the preschool teachers, their stress was mainly in response to the children's parents, other children's imitation of inappropriate mealtime behaviors, and classroom schedule time management. Most of the preschool teachers stated that they had insufficient support. Preschool teachers require specialized information and strategies for improving the mealtime behaviors of children with developmental disabilities.

Using an intensive interdisciplinary telehealth model to treat pediatric feeding disorders.

The necessity of treatment using telehealth was apparent during the novel coronavirus (COVID-19) pandemic, as many practitioners were forced to use telehealth as a primary mode of service delivery. Although the telehealth model has been studied for different populations, little is known about its success when applied with children with feeding disorders and complex medical histories. The purpose of this study was to evaluate the efficacy of using a telehealth model from the onset of treatment. All 5 children who participated engaged in low levels of acceptance and high levels of inappropriate mealtime behavior during baseline. Caregivers were taught to implement the treatment with high integrity using behavioral skills training. Procedural integrity increased posttraining, and as a result acceptance increased and inappropriate mealtime behavior decreased. Treatment gains maintained during follow up at 1 month and 1 year. These data are discussed in relation to alternative ways of providing treatment in locations where intensive feeding programs are not available.

A Preliminary Survey of Pediatric Feeding Experience and Practices among Behavior Analysts

We surveyed Board Certified Behavior Analysts (BCBAs®) about their experiences with pediatric feeding problems. Results show that the most common forms of inappropriate mealtime behavior with which behavior analysts have worked are passive refusal, head turns, and elopement from the feeding area. The most common intervention techniques used by BCBA®s when working with feeding problems are shaping and graduated guidance. BCBAs® work most often with occupational therapists and speech-language pathologists when providing feeding-related services. We conclude by providing recommendations to equip behavior analysts to better manage feeding cases.

Evaluating the efficacy of pictorial preference assessments with children who engage in food selectivity

AbstractPreference assessments are used in practice with individuals who engage in food refusal and selectivity to identify foods that a child will readily consume before assessment and treatment. Traditional edible preference assessments may be challenging for children who engage in food refusal or selectivity as the child may not consume foods, but rather engage in inappropriate mealtime behavior simply due to the presence of food. Alternative modality preference assessments, such as pictorial, may offer benefits compared to traditional preference assessment formats (e.g., stimulus preference assessment and paired‐stimulus preference assessment). The use of pictures may reduce any evocative effects of the presence of food and result in choice‐making without inappropriate mealtime behavior. Experiment 1 assessed the correspondence between the hierarchies yielded from pictorial preference assessments (with and without access) to a standard edible preference assessment. Experiment 2 evaluated the accuracy of each preference assessment by presenting foods identified as preferred and non‐preferred to determine if the child would accept them. Results suggested that pictorial preference assessments with access corresponded the most with the traditional edible preference assessment. Also, for one individual, the traditional preference assessment did not accurately identify foods that the participant would consume, while the pictorial preference assessment without access yielded a hierarchy.

On the validity of interpreting functional analyses of inappropriate mealtime behavior using structured criteria.

Visual inspection is the traditional method behavior analysts use to interpret functional-analysis results. Limitations of visual inspection include lack of standardized rules, subjectivity, and inconsistent interrater reliability (Fisch, 1998). To address these limitations, researchers have developed, evaluated, and refined structured criteria to aid interpretation of functional analyses of destructive behavior (Hagopian et al., 1997; Roane et al., 2013; Saini et al., 2018). The current study applied the structured criteria Saini et al. (2018) described to functional analyses of inappropriate mealtime behavior. We assessed its predictive validity and evaluated its efficiency relative to 3 post hoc visual inspection procedures. Validity metrics were lower than those in Saini et al. however, ongoing visual inspection increased the efficiency of functional analyses by more than 30%. We discuss these findings relative to the procedural differences between functional analyses of destructive behavior and inappropriate mealtime behavior.

Accumulated‐ and distributed‐reinforcer arrangements in the treatment of challenging mealtime behavior

AbstractTreatment for inappropriate mealtime behavior often includes extinction and differential reinforcement of alternative behavior (DRA) in a distributed arrangement in which delivery of brief reinforcer access immediately follows each appropriate mealtime response. Alternatively, DRA may be arranged using accumulated reinforcement wherein delivery of longer, continuous access to reinforcers follows the consumption of multiple consecutive bites. Research has suggested that individuals prefer and perform better under accumulated arrangements in academic settings; however, no research to date has evaluated the efficacy of accumulated arrangements with children with feeding disorders. We compared preference for and efficacy of distributed and accumulated (with and without tokens) reinforcement with nonremoval of the spoon. All three treatments effectively reduced inappropriate mealtime behavior and increased acceptance for two participants and decreased packing and increased mouth clean for one participant. Two participants preferred distributed reinforcement and one preferred accumulated reinforcement without tokens. Findings differ from some previous research, which demonstrated that participants favored accumulated arrangements in academic contexts.

Relapse during the treatment of pediatric feeding disorders.

Resurgence and renewal are treatment-relapse phenomena in which previously extinguished behavior returns after the conditions for an alternative response worsen or the context changes, respectively. Recently, researchers have evaluated the prevalence of resurgence and renewal when treating destructive behavior with functional communication training. However, resurgence of inappropriate mealtime behavior has yet to be evaluated; perhaps because treatments involve qualitatively different resurgence opportunities (e.g., increased bite-presentation rate). We evaluated the prevalence of resurgence and renewal of inappropriate mealtime behavior across 22 and 25 applications of extinction-based treatments, respectively. Resurgence occurred in 41% (9/22) of applications, most often following presentation-rate increases. Renewal occurred in 52% (13/25) of applications, most often following feeder changes from therapist to caregiver. We discuss these findings in terms of their ability to inform relapse-mitigation strategies for resurgence and renewal of inappropriate mealtime behavior.

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.

On the role of operant contingencies in the maintenance of inappropriate mealtime behavior: An epidemiological analysis.

Functional analysis is the primary assessment used to determine the function of inappropriate mealtime behavior in children with feeding disorders. Based on single-case experimental design studies and recent reviews, the prevalence of negative reinforcement alone in the maintenance of inappropriate mealtime behavior appears to be much greater than positive reinforcement alone. We conducted a retrospective consecutive-controlled case series to determine the generality of previous findings. Results of the epidemiological analysis support prior research in that negative reinforcement in the form of escape (44.8%), and multiple control (i.e., positive and negative reinforcement) in the forms of escape and attention (37.2%), are considerably more prevalent than positive reinforcement alone (2.5%). We discuss the relationship between functional analysis of inappropriate mealtime behavior and treatment utility. Further, we describe avenues of future research designed to advance the application of functional analysis in feeding disorders beyond inappropriate mealtime behavior.

An evaluation of trial-based functional analyses of inappropriate mealtime behavior.

Functional analyses allow clinicians to develop treatment targeting the variables maintaining a child's inappropriate mealtime behavior (Bachmeyer et al., 2019). Extended functional analyses can be inefficient, potentially delaying the onset of treatment. Researchers have suggested a trial-based functional analysis can increase assessment efficiency (Saini, Fisher, et al., 2019). This study compared trial-based functional analyses to extended functional analyses to determine the variables maintaining inappropriate mealtime behavior. We compared the efficiency and acceptability and evaluated treatments informed by the analyses. Exact correspondence between analyses was low (29%); however, most treatments indicated by the trial-based functional analyses (80%) resulted in improvements in the child's target behavior. The trial-based functional analysis required 71% less time than the extended functional analysis, and caregivers found analyses equally acceptable. Future researchers should continue refining trial-based functional analysis procedures to provide an efficient assessment that leads to efficacious treatment.

A Demonstration of Caregiver-Implemented Functional Analysis of Inappropriate Mealtime Behavior via Telehealth.

Treatment for pediatric feeding disorders is imperative, so clinicians should alter the assessment and treatment process, making it is possible for caregivers to deliver via telehealth. Clinicians must first demonstrate that caregivers can conduct initial assessments in this format. We extended the literature on functional analysis of inappropriate mealtime behavior by demonstrating that caregivers can implement functional analysis procedures via telehealth to identify maintaining variables of inappropriate mealtime behavior. Clinicians determined that escape, attention, and tangibles and escape maintained inappropriate mealtime behavior during solids and liquids meals, respectively.

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.

An evaluation of a renewal-mitigation procedure for inappropriate mealtime behavior.

Renewal, the increase in behavior during extinction following context changes, may be particularly concerning during intervention for feeding disorders because context changes are often necessary for intervention generality and maintenance (Podlesnik et al.,2017). In the current study, we tested for renewal and evaluated a renewal-mitigation procedure when we transferred intervention from a therapist to a caregiver, from clinic to the home, and changed the foods the feeder presented. We used an ABA arrangement to evaluate the generality of the renewal effect with 7 participants who engaged in inappropriate mealtime behavior. Context A was functional reinforcement. Context B was function-based extinction during the control and mitigation conditions and our renewal-mitigation procedure in the mitigation condition. The renewal test was function-based extinction in Context A. We observed renewal of inappropriate mealtime behavior in 4 of 7 participants, and our renewal-mitigation procedure was effective for 4 of 4 participants.

Further examination of the treatment of multiply controlled inappropriate mealtime behavior.

We systematically replicated Bachmeyer et al. (2009) by examining extinction procedures matched to each function, individually and in combination, to treat the food or liquid refusal of 4 children diagnosed with a feeding disorder whose inappropriate mealtime behavior was maintained by multiple functions (i.e., escape and attention). Previous research suggests that adding differential reinforcement to extinction procedures may result in better treatment outcomes. Therefore, we added differential reinforcement to extinction procedures matched to each function. Differential reinforcement and extinction matched only to escape or attention resulted in low rates of inappropriate mealtime behavior and high, stable levels of acceptance for only 1 child. Consistent with Bachmeyer et al., inappropriate mealtime behavior decreased, and acceptance increased for the remaining 3 children only after we matched differential reinforcement and extinction procedures to both escape and attention.

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.