En behandling paket utan Escape Extinction att behandla mat selektivitet

Summary

Feeding difficulties are a common problem for children with developmental disorders, including autism, and behavioral interventions often include escape extinction. Recent research has begun to evaluate treatments that do not include escape extinction. This manuscript describes a multicomponent treatment package that does not use escape extinction to treat feeding difficulties.

Abstract

Feeding difficulties and feeding disorders are a commonly occurring problem for young children, particularly children with developmental delays including autism. Behavior analytic interventions for the treatment of feeding difficulties oftentimes include escape extinction as a primary component of treatment. The use of escape extinction, while effective, may be problematic as it is also associated with the emergence of challenging behavior (e.g., extinction burst). Such challenging behavior may be an acceptable side effect in treatment cases where feeding problems are severe and chronic (e.g., failure to thrive). However, in more acute cases (e.g., selective eating), the negative side effect may be unwarranted and undesired. More recent research on the behavioral treatment of food selectivity has begun to evaluate treatments for feeding difficulties that do not include escape extinction (e.g., demand fading, behavioral momentum), with some success. However, research to date reveals individual differences in responsiveness to such treatments and no clear preferable treatment has emerged. This manuscript describes a multi-component treatment package that includes shaping, sequential presentation and simultaneous presentation, for the treatment of food selectivity in four young children with developmental delays. This treatment package extends the literature on the behavioral treatment for food selectivity and offers a multi-component treatment protocol that may be clinically applicable across a range of treatment scenarios and settings.

Introduction

Food selectivity, defined as a reluctance to try new foods based on some dimension of the food (e.g., texture, color, or presentation) often characterizes the feeding behavior of young children with autism spectrum disorders (ASD) and other developmental delays^2,4,7,10.

Although children who exhibit food selectivity often eat some foods, these foods are frequently limited in variety (e.g., snacks and carbohydrates) and may not provide adequate nutrition. Food selectivity may never lead to total food refusal requiring medical attention (e.g., a diagnosis of failure to thrive or the insertion of a gastric feeding tube) however, the limited food repertoires of children with food selectivity may lead to nutritional inadequacies.

An effective intervention to increase food acceptance in children with acute food selectivity is escape extinction, in the forms of non-removal of the spoon and/or physical guidance^1,6,11.

Children who engage in severe maladaptive feeding behavior often engage in total food refusal that leads to limited weight gain and growth and may require the use of gastric-tube feedings. When a child’s feeding behavior is impacting their development, escape extinction may be essential to quickly increase food acceptance. For example, Cooper and colleagues⁵ found that escape extinction was a necessary component in the treatment packages of 3 of 4 participants who all exhibited poor growth and engaged in tantrum behavior (e.g., gagging, spitting and screaming) when food was presented.

Escape extinction has been repeatedly demonstrated as a valuable component in treatment packages for children with chronic feeding problems, however; these procedures may not be necessary for children who engage in less severe feeding behavior (i.e., food selectivity). Children who engage in severe feeding behavior may differ from children who engage in food selectivity, in that severe feeding behavior may involve total food refusal where as children with food selectivity may consume some foods, although limited in range and nutritional value.

Consistent consumption of even a limited number of foods may lead to children being responsive to reinforcement-based interventions that do not require the addition of escape extinction. For children with autism, positive reinforcement procedures are viewed as best practice⁹ and should be implemented in the treatment of food selectivity when the child’s behavior may not warrant the use of escape extinction. Recent research on the use of antecedent manipulations and positive reinforcement methodologies as possible alternatives to the use of escape extinction suggest that these methods may be effective for some children who exhibit food selectivity^3,11,12.

Studies evaluating the use of antecedent manipulations to treat food selectivity have incorporated a variety of procedures including, high-p sequences^6,11,12, and sequential and simultaneous food presentation^1,8,13. Results of studies evaluating these procedures have shown that antecedent manipulations are effective in increasing food acceptance for children who engage in food selectivity^12,14. For example, Penrod and colleagues¹² effectively increased food consumption in two children diagnosed with ASD who engaged in active food refusal (e.g., spitting, gagging and vomiting), using a treatment package consisting of a high-p sequence and demand fading procedure.

The way in which preferred and non-preferred foods are presented (e.g., sequential versus simultaneous presentation) may also contribute to the effectiveness of treatment packages for children who engage in food selectivity. Both sequential (i.e., presenting the non-preferred food followed by the preferred food) and simultaneous (i.e., combining a non-preferred and preferred food together) presentation methods have demonstrated some success in increasing food acceptance^13,14. For example, Piazza et al.¹³, found that the simultaneous presentation procedure, without escape extinction was effective in increasing food acceptance in 3 of 4 participants and that sequential presentation was ineffective for 2 participants. In contrast, Pizzo and colleagues¹⁴ successfully used a treatment package consisting of sequential presentation and appetite manipulation to increase food acceptance in a 16-year-old boy with ASD. While the degree to which these presentation procedures are successful without the addition of escape extinction is unclear; some studies suggest that these procedures may be an effective antecedent manipulation for some children. More research is required to determine the utility of both sequential and simultaneous procedures in treatment packages that do not include an escape extinction component.

In designing treatment packages for children who engage in food selectivity, it is important to consider the differences between children who eat a limited number of foods and those who engage in total food refusal as this may impact responsiveness to intervention. For children who engage in food selectivity, parents and clinicians may be less willing to implement intrusive escape extinction procedures since they may not view the child’s behavior as severe enough to warrant these interventions. Tarbox, Schiff and Najdowski¹⁵ suggest that anecdotal reports indicate that escape extinction procedures may be difficult for parents to accept. The authors propose that it may be useful to evaluate the effectiveness of other behavioral treatment procedures that may be less intrusive for cases where escape extinction may be not accepted by the parents.

Results from the studies reviewed provide evidence that antecedent manipulations are an important and powerful component to treatment packages for food selectivity. Antecedent manipulations may take many forms (e.g., high-p sequences and sequential and simultaneous food presentation) and it is important that research focuses on which components may be combined in treatment packages to effectively increase food acceptance without the addition of escape extinction; as these interventions may provide less intrusive alternatives when escape extinction procedures are not necessary. This manuscript describes a treatment package that combines shaping, sequential and simultaneous presentation procedures. These procedures have been effective in increasing food acceptance when combined with other antecedent manipulations but have not previously been combined in a treatment package. The current protocol extends the literature on sequential and simultaneous presentation procedures by including them in a treatment package with a shaping procedure that may serve as a first line of treatment that could be implemented by parents, teachers, and clinicians with limited training before seeking more intensive treatment.

Protocol

This protocol follows Florida International University’s guidelines for research with human subjects and consent is always obtained from parents/caregivers before any treatment is started. In addition, obtain clearance from a physician before the start of treatment.   NOTE: Although specific age ranges and individual variables have not been empirically validated, this protocol has been used clinically for children ages 2-7 with autism and developmental delays. Participants should be…

Representative Results

The procedure of shaping and sequential presentation described can result in initial compliance with behaviors related to eating (e.g., touching the food) that can be strengthened through the use of reinforcement and shaping. By reinforcing successive approximations (shaping steps) behavior can be shaped slowly until reaching the target behavior of eating. The results depicted in Figure 1 show that the technique of shaping is capable of increasing compliance with food acceptance and the steps in…

Discussion

This paper presents a treatment package composed of antecedent manipulations that have demonstrated success in increasing food acceptance for children who exhibit food selectivity. Notably, this paper presents a set of procedures that may be effective without the use of escape extinction. These methods are consistent with previous literature (Penrod et al., 2012) that suggests that a shaping procedure can be used to increase food acceptance with children who engage in active food refusal (e.g., throwing…

Materials

Small table			We have these at our site
small chairs			We have these at our site
paper plates			We have these at our site
plastic silverware			We have these at our site
toys			We have these at our site
placemat			We have these at our site