AN EVALUATION OF THE HIGH-PROBABILTY INSTRUCTION SEQUENCE
WITH AND WITHOUT DEMAND FADING IN THE TREATMENT OF FOOD
SELECTIVITY
A Thesis
Presented to the faculty of the Department of Psychology
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF ARTS
in
Psychology
(Applied Behavior Analysis)
by
Diana Lynn Morgan
SPRING
2014
AN EVALUATION OF THE HIGH-PROBABILTY INSTRUCTION SEQUENCE
WITH AND WITHOUT DEMAND FADING IN THE TREATMENT OF FOOD
SELECTIVITY
A Thesis
by
Diana Lynn Morgan
Approved by:
__________________________________, Committee Chair
Becky Penrod , Ph.D
__________________________________, Second Reader
Rebecca Cameron, Ph.D
_____________________________________, Third Reader
Jill Young, Ph.D
____________________________
Date
ii
Student: Diana Lynn Morgan
I certify that this student has met the requirements for format contained in the University
format manual, and that this thesis is suitable for shelving in the Library and credit is to
be awarded for the thesis.
__________________________, Graduate Coordinator___________________
Jianjian Qin, Ph.D
Date
Department of Psychology
iii
Abstract
of
AN EVALUATION OF THE HIGH-PROBABILTY INSTRUCTION SEQUENCE
WITH AND WITHOUT DEMAND FADING IN THE TREATMENT OF FOOD
SELECTIVITY
by
Diana Lynn Morgan
The high-probability instructional sequence with and without demand fading has been
used in the treatment of food refusal to establish consumption of non-preferred or novel
foods. Previous research suggests that this may be an effective treatment in increasing
consumption for children who engage in food refusal. The present study aimed to extend
previous research by comparing the effectiveness of the high-p sequence alone (as
described by Patel et. al) and when combined with demand fading (as described by
Penrod et al.) with children who engage in active food refusal. A multi-element design
was used to evaluate the relative effects of the high-p sequence with and without demand
fading. Results indicated that both treatments were ineffective in establishing
consumption. However, the high-p sequence combined with demand fading was effective
in increasing behaviors closer to the terminal response. Implications and
recommendations are discussed as they relate to increasing consumption.
_______________________, Committee Chair
Becky Penrod, Ph.D
_______________________
Date
iv
ACKNOWLEDGMENTS
The author would like to thank her thesis committee, Dr. Becky Penrod, Dr. Rebecca
Cameron, and Dr. Jill Young for their efforts in the development and fulfillment of this
research project. Specifically, the author would like to thank Dr. Becky Penrod for her
ongoing support and dedication to the completion of this study. The experience I have
gained in working with Dr. Penrod has been invaluable to my academic and professional
development. In addition, I would like to express my appreciation and gratitude to all of
the members of the Sacramento State Pediatric Behavior Research Lab. Their feedback,
encouragement, and friendship have made this a process a memorable experience. I
would like to express thanks to my research assistants, Kristin Griffith, Colleen Whelan,
and Tim Howland for their continuous dedication and assistance with data collection and
procedural implementation throughout this entire project. As a final note, I would to
express much appreciation to my husband and family for their ongoing support and
encouragement throughout this process.
v
TABLE OF CONTENTS
Page
Acknowledgments ………………………………………………………………………...v
List of Tables……………………………………………………………………………..ix
List of Figures …………………………………………………………………………….x
Chapter
1.
INTRODUCTION ……………………………………………………………….…..1
Demand Fading…………….………………………………………………..........3
High-Probability Instructional Sequences…..…………………..………………...5
2.
METHOD ……………………………………………………………………..........11
Participants ………………………………………………………….……….......11
Setting and Materials.……………………………………………….……….......13
Experimental Design….….………………………………………………………14
Response Measurement and Data collection of the Dependent Variable….…….14
Independent Variable...…………………………….…………………………….14
Procedural Integrity.………………………………..…………………………....15
Interobserver Agreement...………………………………………………………15
Pre-treatment Preference Assessment..……………………………………….....16
Compliance Assessment and Probes...…………………………………………...20
Baseline Procedures...……………………………………………………………25
Instructional Procedures...………………………………………………………..26
vi
3.
RESULTS ……………………………………………………………….…….........29
Evan….……………………………………………………….…………….........29
Sandy………………………...………………………………………………...…31
4.
DISCUSSION ………………………………………………………..…….….…....35
Appendix A. Pre-treatment Parent Interview: Feeding…….………………………..…41
Appendix B. Pre-treatment Parent Interview: Behavior and Compliance.………….…42
Appendix C.
Food Related Compliance Assessment Data Sheet….…………………..43
Appendix D.
General Compliance Assessment Data Sheet….………………….…..…44
Appendix E. Baseline Data Sheet……….……………...……………………...……....45
Appendix F.
Treatment Data Sheet …..……………………......……………………....46
References ………………………..……………………………………………………...47
vii
LIST OF TABLES
Tables
Page
1.
Results of Food Related Compliance Assessment…...…………..........................24
2.
Demand Fading Low-p Instruction Steps…….…………………….....................28
viii
LIST OF FIGURES
Figures
Page
1.
Pre-treatment preference assessment results for Evan…………………...…….....18
2.
Pre-treatment preference assessment results for Sandy………………………..…19
3.
Second pre-treatment preference assessment results for Sandy……………...…...20
4.
Results for Evan…………...………………………...…………………………...31
5.
Results for Sandy.…………………………..……………………………………34
ix
1
Chapter 1
INTRODUCTION
Feeding problems can occur in typically developing children as well as children
with developmental disabilities. However, the prevalence of feeding problems is
significantly higher for children with developmental disabilities (Ahearn, Kerwin, Eicher,
Luken, 2001; Bachmeyer, 2009). Children with autism spectrum disorders (ASD) are said
to be at greater risk of developing feeding problems (Ahearn, Castine, Nault, & Green,
2001; Bandini et al., 2010; Schreck, Williams, & Smith, 2004). Among these feeding
problems is food selectivity, which has been characterized as consumption of a limited
variety of foods (Bandini et al.; Levin & Carr, 2001; Penrod, Gardella, & Fernand, 2012),
which can occur by food group, texture, brand, color, etc. (Levin & Carr). Another
characteristic of food selectivity is refusal of less-preferred and/or novel foods (Bandini
et al.; Levin & Carr). Food selectivity is problematic because even though a child may
consume enough of their preferred foods to maintain an appropriate weight, their limited
diet is often associated with nutritional deficits, which may pose a health risk for the child
(Bandini et al.; Kern & Marder, 1996; Luiselli, Ricciardi, & Gilligan, 2005; Penrod,
Gardella, & Fernand).
Research on food selectivity has suggested that it may be a form of noncompliance (Bachmeyer et al., 2009; Dawson et al., 2003; Kern & Marder, 1996) and
often includes inappropriate mealtime behavior (Bachmeyer et al.; Kern & Marder; Levin
2
& Carr, 2001). Research has found that although the etiology of food refusal behavior
varies across children it is frequently developed and maintained by both positive and
negative reinforcement contingencies (Bachmeyer et al.; Freeman & Piazza, 1998; Kern
& Marder; Penrod, Gardella, & Fernand, 2012). Specifically, a child’s food refusal
behavior may be negatively reinforced when the caregiver removes the food or terminates
the meal in an effort to reduce or terminate the child’s inappropriate mealtime behavior.
A child’s food refusal behavior may be positively reinforced in one of two ways: access
to attention or tangible items. For example, a caregiver may provide attention in the form
of coaxing the child to eat the food or vocal redirection of the child’s inappropriate
mealtime behavior. Similarly, a caregiver may offer access to a toy or preferred food after
the child has begun to engage in inappropriate mealtime behavior. Any of these scenarios
establish a history of reinforcement for the parent and the child that may lead the
caregiver to only present preferred foods to the child and no longer present novel or lesspreferred foods in order to avoid inappropriate mealtime behavior (Kern & Marder, 1996;
Penrod, Gardella, & Fernand, 2012).
Given that limited diets characteristic of food selectivity are associated with
potential nutritional deficits and health risks, identification of effective treatment
procedures is critical. Research in this area has shown that escape extinction procedures
that terminate the previous reinforcement contingency between inappropriate mealtime
behavior and removal of non-preferred/novel foods, are highly effective in increasing
food acceptance and expanding the number of foods in one’s diet (Bachmeyer et al. 2009;
3
Freeman & Piazza, 1998; Najdowski et al., 2003; Penrod et al., 2010). Since the
effectiveness of escape extinction procedures in decreasing food refusal behavior as well
as increasing food acceptance has been well documented in the literature, it is commonly
included as one component of treatment packages designed to address food selectivity
(e.g., Bachmeyer et al; Freeman & Piazza; Najdowski et al.; Penrod et al.). However,
although effective, escape extinction is a consequence-based procedure and is often
associated with an initial increase in inappropriate mealtime behavior (Bachmeyer et al.;
Dawson et al., 2003; Penrod et al.); to address this problem, researchers have turned their
attention to antecedent-based interventions. Given that food selectivity has been
conceptualized as a form of noncompliance (Dawson et al.), recent studies have explored
the efficacy of antecedent-based interventions that have been shown to be effective in
increasing compliance in other areas (Penrod et al., 2012), specifically, demand fading
(or in this context bite fading) and the use of high-probability instructional sequences.
Demand Fading
Demand fading (e.g., bite fading) is one example of an antecedent-based
intervention included as a component of treatment packages to address food selectivity
(Penrod et al., 2010; Knox et al., 2012; Luiselli, 2000; Najdowski et al., 2003; Najdowski
et al., 2010). Knox and colleagues implemented a treatment package including
prompting, reinforcement, and bite fading to address food selectivity in an adolescent
with autism. Bite fading was implemented by systematically increasing the number of
bites the participant was required to consume prior to accessing reinforcement. This
4
procedure was effective in increasing consumption of less-preferred foods. Other studies
utilizing bite fading as a component of treatment have had similar results, suggesting that
bite fading (as part of a treatment package) is a valuable component in increasing
consumption of less-preferred foods. However, when evaluating the independent effects
of bite fading, research has shown that bite fading alone is not generally an effective
treatment (Najdowski et al., 2003; Penrod et al., 2010).
In 2010, Penrod and colleagues conducted a component analysis of various
components that are often included in treatment packages for food selectivity. In this
study researchers systematically evaluated the effectiveness of treatment components in 3
phases. Treatment components were sequentially introduced; in other words, one
additional treatment component was added in each phase. A participant moved on to the
next phase if the previous phase was shown to be ineffective in increasing food
consumption. The different phases consisted of the following: baseline, which included
differential reinforcement of alternative behavior (i.e., food consumption) and escape for
refusal behaviors (DRA + escape); Phase 1- DRA + escape + bite fading; Phase 2 - DRA
+ escape + bite fading + reinforcer manipulation, in which the magnitude of
reinforcement was increased; and Phase 3 - DRA + bite fading + reinforcer manipulation
+ escape extinction. For two participants, progression to Phase 3 was necessary in order
to increase food consumption, and for one participant, food consumption increased in
Phase 2 when the magnitude of reinforcement was increased. These results suggest that
bite fading alone may not be sufficient to increase food consumption. Given these results,
5
recent research has continued to explore new strategies that may be effective in
increasing food consumption without the need for escape extinction.
High-Probability Instructional Sequences
Behavioral momentum and the use of high-probability sequences is another
antecedent-based intervention that has been studied and recently included as a primary
treatment or as part of a treatment package to treat food refusal and food selectivity.
The concept of behavioral momentum (derived from Newton’s law of motion),
was first introduced by Nevin, Mandell, and Atak, in an experimental study with rats in
1983. This idea of behavioral momentum was applied to the treatment of noncompliance
in adults with severe mental retardation in a study conducted by Mace and colleagues in
1988. Behavioral momentum has been defined as the tendency for behavior to persist
following a change in environmental conditions with a positive correlation between
response persistence and the rate of reinforcement (Mace et al.). The purpose of the Mace
et al. study was to evaluate the effectiveness of a high-probability command sequence
(high-p) in increasing compliance with low-probability (low-p) “do” and “don’t”
commands. The high-p commands were instructions that each participant had
demonstrated compliance with prior to beginning the study. A high-p command sequence
was used to establish behavioral momentum prior to presenting a low-p command. The
high-p command sequence consisted of three to four high-p instructions presented 10 s
apart. Following compliance with the high-p sequence a low-p command was presented.
The researchers hypothesized that presentation of the high-p command sequence would
6
establish a momentum in responding that would increase the likelihood of the participant
responding to the low-p commands after contacting reinforcement for compliance with
high-p commands. Results demonstrated that the high-p sequence was effective in
increasing compliance to low-commands as well as decreasing the latency to complete
low-p commands.
Results of the study conducted by Mace and colleagues (1988) had significant
implications for future research and treatment of noncompliant behavior. Much research
has been done since 1988 that has explored the use of behavioral momentum and highprobability sequences to increase compliance across many different response
topographies in academic and classroom settings (Belfiore, Basile, & Lee, 2008; Belfiore,
Lee, Scheeler, & Klein, 2002; Belfiore, Lee, Vargas, & Skinner, 1997; Lee, Belfiore,
Scheeler, Hua, & Smith; 2004; Lee & Laspe, 2003). In all of these studies the high-p and
low-p responses were topographically similar. For example, participants were presented
with three easy math problems prior to one difficult problem or participants were asked to
write three single words prior to being presented with an open ended writing task
(Belfiore, Lee, Vargas, & Skinner; Lee & Laspe).
Recent research has begun to explore the use of high-p sequences to decrease
food selectivity, characterized as noncompliance. Dawson and colleagues in 2003
evaluated the effectiveness of a high-p sequence with and without the use of an escape
extinction procedure to increase food acceptance in a 3-year-old girl who engaged in
active food refusal behavior (i.e., food refusal that co-occurs with other problem
7
behaviors). In contrast to earlier research, in this study, the high-p instructions were
topographically different (one-step instructions that were not food related) from the low-p
instruction (“take a bite”). Results demonstrated that the high-p sequence was only
effective when combined with escape-extinction. It is possible that the reinforcement
provided for compliance with high-p instructions was not sufficient to establish
compliance with low-p instructions due to the instructions being topographically
dissimilar.
Patel and colleagues (2007) conducted a similar study to that of Dawson et al.
(2003); however, Patel and colleagues used high-p instructions that were topographically
similar (“take a bite” with presentation of an empty spoon) to the low-p instructions
(“take a bite” with the presentation of the non-preferred food on the spoon). Also, the
participant in this study engaged in passive food refusal (defined as noncompliance with
demands to eat non-preferred foods in the absence of problem behavior) rather than
active food refusal demonstrated by the participant in the study conducted by Dawson
and colleagues. Results demonstrated that the high-p sequence was effective in increasing
bite acceptance without the use of an escape extinction procedure. Results of the study
conducted by Patel and colleagues may have been due to the use of topographically
similar high-p instructions, as opposed to the topographically different high-p instructions
used by Dawson and colleagues. However, the successfulness of the procedure could also
be related to the type of food refusal that the participant displayed. It is unknown whether
the procedure would be equally effective with a participant with active food refusal.
8
Penrod, Gardella, and Fernand (2012) further evaluated and extended the research
on the use of a high-p sequence in the treatment of food selectivity by combing the high-p
sequence with demand fading to address food selectivity in two boys with autism who
displayed active food refusal. In this study the researchers used a high-p sequence that
was topographically different (but still food related) from the low-p instruction combined
with a demand fading procedure in which the difficulty of the low-p instruction was
systematically increased until the terminal response of consuming the bite of food was
achieved. The high-p instruction consisted of two instructions that the participant had
previously demonstrated compliance with (e.g., smelling the food and licking the food).
The low-p instruction was the next instruction in the demand fading sequence, or the next
approximation to the terminal response requirement (e.g., balancing the food on the
tongue). The high-p and low-p instructions shifted throughout the experiment as the
demands increased, working up to the terminal low-p instruction to “take a bite” of the
non-preferred food. Once compliance was achieved with a given low-p instruction (e.g.,
balancing the food on the tongue) that instruction then became part of the high-p
sequence and a new low-p instruction was introduced (e.g., bite the food into two pieces).
These procedures were effective in increasing consumption of non-preferred foods for
both participants, thus providing further support that food selectivity can be addressed
without the use of escape extinction procedures.
Results of the study conducted by Penrod et al. (2012) demonstrated that
topographically different high-p and low-p instructions were effective in treating food
9
selectivity; however, unlike the study conducted by Dawson et al. (2003), the high-p
instructions were food related whereas those used by Dawson et al. were completely
unrelated to food or eating. In both the study conducted by Dawson et al. and Penrod et
al. participants engaged in active food refusal behavior; the difference between these two
studies was the nature of the high-p instructions (as previously described) and in Penrod
et al., the high-p instructional sequence was combined with demand fading, thus it is
possible that food consumption increased as a result of the demand fading component;
recall that in the Dawson et al. study, the high-p instructional procedure was not found to
be effective. In the study conducted by Patel et al., the participant engaged in passive
food refusal; in this study the high-p instructional sequence was found to be effective and
it was suggested that one possibility for the difference between this study and Dawson et
al. was that the participant in Dawson et al. engaged in active food refusal behavior as
opposed to passive food refusal. Given the differences across these three studies, the
conditions under which a high-p instructional sequence is likely to be effective in
increasing food consumption are not clear. Thus, the present study aimed to extend
previous research by comparing the effectiveness of the high-p instructional sequence
alone (as described by Patel et. al) and when combined with demand fading (as described
by Penrod et al.) with children who engage in active food refusal.
Based on the previous research utilizing high-p instructional sequences to treat
food refusal behavior it was expected that the high-p instructional sequence combined
with demand fading would be more effective than the high-p instructional sequence alone
10
when treating food selectivity in children who display active versus passive food refusal
behavior.
11
Chapter 2
METHOD
Participants
One girl diagnosed with autism and one typically developing boy participated in
the study. Participants were selected based on referrals from local agencies in the
community. The children selected as participants in the study were required to have an
imitative repertoire (i.e., the ability to copy or follow the actions of another person), and
basic listener silks (e.g., the ability to follow one-step instructions). Other criteria for
inclusion in the study included resistance to trying novel foods (active food refusal) and a
restricted diet within at least one of the following food groups: fruits, vegetables, protein,
dairy, or starch. In order to determine if a participant was appropriate for this study,
parents were interviewed by the researcher and asked to provide information regarding
the child’s previous and current diet (See Appendix A). Parents were asked to identify 6
foods that the child did not prefer from one or more of the food groups listed above as
well as 6 highly preferred foods. Additionally parents were asked to complete a
questionnaire regarding information about the child’s overall behavior and compliance
(See Appendix B).
Evan was a 2.8 year old boy with a history of food selectivity. At the start of the
study Evan’s parents reported that he primarily consumed chocolate donuts or French
toast sticks for breakfast and a cheese quesadilla or Nutella sandwich for lunch and
12
dinner. Additionally, Evan consumed milk with all meals and ate a variety of carb-based
snacks (e.g., gold fish, veggie sticks, and crackers) and chocolate (e.g., M&Ms and
Oreos). His parents reported that mealtime was a “high anxiety event” and that Evan
refused to sit at the table during mealtime and engaged in tantrum behaviors and gagging
when asked to try new or non-preferred foods. Evan was referred by his pediatrician to a
Speech Pathologist in August 2013, due to parent concerns regarding his limited diet and
food selectivity. At the recommendation of the Speech Pathologist Evan’s parents tried
several strategies to increase his participation in mealtimes and consumption of new
foods by presenting meals at a child-sized table and encouraging Evan to simply touch or
play with new foods; however, these strategies were not successful in increasing his
consumption of new foods. Evan never had any exposure to or experience with the use of
demand fading or high probability instructional sequences.
Sandy was a 7.11 year old girl with a diagnosis of autism. Sandy received inhome early intensive behavioral treatment (EIBT) since age three. Sandy was enrolled in
a 3rd grade special day class and discontinued her participation in the EIBT program
approximately one month into the study. At the start of the study Sandy’s mother
reported that she primarily ate goldfish as all or part of each meal during the day and only
drank water or root beer. Additionally her mother reported that for lunch Sandy ate 2
bags of fruit snacks (brand specific), 2 vanilla cupcakes without frosting purchased only
from Walmart, and sometimes would eat pancakes. Soon after beginning the study,
Sandy’s mother reported that she had begun giving Sandy Pediasure daily per the
13
doctor’s recommendation and that with some persistence Sandy would drink it. During
mealtimes, her mother reported that Sandy would sit with the family but would not eat
the foods presented to her. When instructed to try new or non-preferred foods it was
reported that Sandy would push the food away and would begin to gag and engage in
tantrums if the food was not removed. Sandy’s mother reported that she had tried
restricting access to goldfish in an attempt to get Sandy to eat other foods; however
Sandy refused to consume other foods and she began to lose weight so the goldfish were
reintroduced in order to maintain Sandy’s weight. During participation in the EIBT
program the provider attempted to establish consumption of string cheese using a
“first…then” contingency (i.e., first eat the string cheese and then you can have root
beer”); however, Sandy’s mother reported that this strategy was not effective and after 6
months was discontinued because Sandy never put the cheese in her mouth.
Setting and Materials
Baseline and training sessions were conducted in the Pediatric Behavior Research
Laboratory at California State University, Sacramento.
The materials used for feeding sessions included a table with two chairs, preferred
and non-preferred foods, plates, napkins, and utensils. Basic data collection materials
included paper data sheets, a clipboard, pens, and a digital video camera.
Two to five consecutive feeding sessions (i.e., alternating baseline, treatment I,
and treatment II sessions described below), with 5 min breaks between each session were
conducted each day with the total duration of sessions each day not exceeding 60
14
minutes. Sessions were trial based, thus the duration of each session varied. Sessions
were conducted one to two times per week. All basic session procedures were followed
as described by Penrod, Gardella, and Fernand (2012).
Experimental Design
A multi-element design was used to evaluate the relative effects of the high-p
instructional sequence with and without demand fading.
Response Measurement and Data Collection of the Dependent Variable
Data were collected using paper and pencil data sheets throughout each session.
Each session was also recorded via a video camera and later coded for interobserver
agreement purposes. The dependent variable included the percentage of bites consumed
following the presentation of the low-p instruction as well as percentage of compliance
with low-p instructions. Bite consumption was defined as accepting the food followed by
a clean mouth check and compliance was defined as following a given instruction after
the initial presentation or prompt (described below).
Independent Variable
The independent variable included delivery of two high-p instructions to take a
bite of an empty spoon (treatment I described below) or two high-p instructions requiring
contact with the target food that were considered approximations to the terminal response
of bite consumption (treatment II described below), followed by a low-p instruction to
take a bite of the non-preferred food (treatment I) or a low-p instruction to engage in the
next demand fading step (treatment II) as well as contingent delivery of social praise (for
15
Evan) or social praise and tickles (for Sandy) for compliance with high-p instructions,
and high-preferred edibles plus social praise for compliance with low-p instructions. The
goal of treatment was to increase compliance with instructions closer to the terminal
response and to establish consumption of new or non-preferred foods.
Procedural Integrity
Two independent observers collected procedural integrity data on all trials for
therapist prompting and delivery of the appropriate reinforcer. Procedural integrity data
were calculated as the total number of correct implementations divided by the total
number of correct and incorrect implementations and then multiplied by 100 for a
percentage of correct implementations. Procedural integrity data were collected for 90%
of sessions for Evan and 93% of sessions for Sandy. Procedural integrity data for
prompting averaged 99.4% (90-100%) for Evan and 99.3% (80-100%) for Sandy.
Procedural integrity data for delivery of the appropriate reinforcer averaged 99.4% (90100%) for Evan and 99.3% (90-100%) for Sandy.
Interobserver Agreement
Two independent observers collected interobserver agreement (IOA) data for
bites consumed, compliance with low-p instructions, and procedural integrity. IOA for
compliance and consumption was assessed on100% of Evan’s sessions and 100% of
Sandy’s sessions. IOA for procedural integrity was calculated on 88% of sessions for
Evan and 83% of sessions for Sandy. IOA was calculated using point-by-point
agreement, and reported as a percentage by dividing the number of agreements by the
16
total number of trials and then multiplying by 100. An agreement for consumption or
compliance was scored when both observers scored either the occurrence or
nonoccurrence of behavior. An agreement for procedural integrity was scored when both
observers scored either a plus (+) for correct implementation or a minus (-) for incorrect
implementation of prompting or reinforcer delivery; observers had to agree on both
measures in order for the trial to count as an agreement. IOA for Evan was 100% for
compliance to low-p instructions, 100% for bites consumed, and 99.1% for procedural
integrity. IOA for Sandy was 99.8% for compliance to low-p instructions, 100% for bites
consumed, and 99.9% for procedural integrity.
Pre-treatment Preference Assessment
A paired-choice preference assessment was conducted prior to the start of the
study to ensure that all non-preferred food items identified by parents were truly nonpreferred and to identify participants’ relative preference for high-preferred foods that
could be delivered as reinforcement for consumption of non-preferred/novel foods and
compliance with low-p instructions (a total of six non-preferred and six highly preferred
food items). Paired-choice preference assessment procedures were followed as outlined
by Fisher et al. (1992). Prior to beginning the preference assessment each participant was
prompted to sample each of the food items. The food items were then presented in pairs
until each food was presented in a pair with every other food item. The food selections
were then scored and reported as a percentage of trials selected and consumed (number of
trials the food was selected and consumed divided by total number of presentations and
17
then multiplied by 100). The foods were then rank ordered and three (for Evan) or six
(for Sandy) of the foods consumed at zero percent were then used in the compliance
assessment. Additionally the top three foods selected during 80% or more trials were then
used as reinforcers throughout the study. Parents were asked to restrict access to the food
items identified as highly preferred. For both participants, none of the non-preferred/new
foods were consumed during the preference assessment. Figure 1 depicts results of the
preference assessment for Evan and Sandy.
For Sandy, none of the foods identified as highly preferred by her mother were
chosen at the specified criteria of 80% or above. Therefore, a second preference
assessment was conducted using the three preferred foods that she selected and consumed
during the initial preference assessment as well as two social activities (i.e., high-5s and
tickles) selected by the researcher based on observation during rapport building with the
researcher prior to the first preference assessment as well as from parent report of
Sandy’s preferences. Since the social activities were not tangible, they were represented
by colored circles (i.e., tickles was represented by a blue circle and high-5s was
represented by a red circle), and were taught prior to the second preference assessment.
The association of the colored circles with the corresponding social activity was taught
by presenting a colored circle and prompting Sandy to touch the circle, which was
immediately followed by delivery of the corresponding social activity for approximately
15 seconds. This procedure was repeated until Sandy consistently touched the presented
colored circle each time it was placed in front of her. Following the second preference
18
assessment the foods and activities were rank ordered and the top two items selected
during 60% or more trials were then used as reinforcers throughout the study. Figure 3
depicts the second preference assessment results for Sandy.
Figure 1. Pre-treatment preference assessment results for Evan. Pretreatment preference
assessment results for Evan contained six non-preferred and six highly preferred edibles.
M&Ms, goldfish, and Oreos were the most highly-preferred edibles with all selected
during 80% or more of trials and thus were used as reinforcers throughout the study. All
other foods were selected during 0% of trials.
19
Figure 1. Pre-treatment preference assessment results for Sandy. Pretreatment preference
assessment results for Sandy contained six non-preferred and six highly preferred edibles.
Soft cookie, root beer, and cupcake were the most frequently consumed edibles; however,
none were considered highly preferred as they were each selected during less than 40% of
trials. All other foods were selected during 0% of trials.
20
Figure 3. Second pre-treatment preference assessment results for Sandy. Second pretreatment preference assessment results for Sandy using the top three most preferred
edibles from the first preference assessment as well as two social activities selected by
the researcher. Tickles and root beer were the top two highest preferred activities/edibles
and were thus used as reinforcers throughout the study.
Compliance Assessments and Probes
Two compliance assessments were conducted prior to the start of the study. The
first compliance assessment was conducted using the foods to be included in the baseline
21
and treatment procedures and the second compliance assessment was conducted using
non-food related instructions.
Food Related Compliance Assessment
The food related compliance assessment was conducted in order to demonstrate
that acceptance of an empty spoon was a high-p response as well as to probe compliance
with each of the demand fading steps to ensure that the instructions that would be
presented as high-p instructions were in fact instructions for which the child
demonstrated compliance with. This assessment also ensured that foods used in each of
the baseline and treatment conditions were similar in relation to the participant’s
compliance with each. Table 1 depicts results of the initial compliance assessments for
Evan and Sandy. Additionally, a compliance assessment was conducted for the treatment
II food following mastery of a given low-p demand fading step. This compliance
assessment probe was conducted in order to identify if any generalization had occurred
and to determine if it was necessary to continue with the demand fading sequence as
outlined or if it was possible to skip a step.
Acceptance of an empty spoon as well as all demand fading steps were assessed
once with three to six foods consumed during 0% of trials in the preference assessment.
Each session began with one presentation of an empty spoon followed by one trial of
each of the demand fading steps.
A trial consisted of an empty spoon or single bite of food presented in front of the
child and the therapist stating the instruction for the given demand fading step (e.g.,
22
“Touch the apple” or “Smell the apple”) plus a model of the desired response. If the child
did not engage in the target response within 5 s, an additional vocal plus model prompt
was delivered (“Copy me” or “Do what I’m doing” while the researcher modeled the
behavior) and the food remained present for an additional 5 s. If the child did not imitate
the researcher, the bite of food was removed and that trial was then terminated. The next
trial was presented approximately 20 s following the end of the previous trial. Any food
refusal or inappropriate mealtime behavior was ignored. Food refusal behaviors were
defined as vocally refusing the food upon presentation (e.g., “No” or “I don’t like it”) or
non-vocally refusing the food (e.g., gagging, pushing the food away, spitting out the
food, or vomiting). Compliance resulted in brief verbal praise.
For Evan, three foods that were consumed during 0% of trials during the
preference assessment were used in the compliance assessments (foods included apple,
hotdog, and corn). During the first compliance assessment (apple), Evan complied with
60% of trials. However, during the second (hotdog) and third (corn) compliance
assessments Evan complied with 20% and 10% of trials, respectively. Due to the
decrease in performance a fourth compliance assessment with apple was conducted on
the same day to assess for consistency of performance across foods; Evan complied with
10% of trials. As a result of Evan’s decreasing compliance across foods on a given day,
the researcher conducted a second compliance assessment with all three foods on a
different day to attempt to identify a pattern in Evan’s compliance across the three foods.
During compliance assessments five (hot dog), six (corn), and seven (apple) Evan
23
complied with 30%, 10%, and 10% of trials, respectively. This second set of compliance
assessments allowed the researcher to identify that Evan wasn’t necessarily more
compliant with one food more than another, but more so demonstrated decreases in
compliance following the initial compliance assessment of each day. Given the observed
pattern and inconsistent compliance it was decided that for treatment II (described below)
the starting demand fading step for the low-p instruction was holding the food in order to
establish consistent compliance across foods and sessions.
For Sandy, three foods that were consumed during 0% of trials during the
preference assessment were used in the first compliance assessments (foods included
tomato, macaroni and cheese, and string cheese). During the first set of compliance
assessments Sandy complied with 10%, 20%, and 50% (tomato, macaroni and cheese,
and string cheese respectively) of trials. Given that the percentage of compliance with the
string cheese was higher than the other two foods, a second set of compliance
assessments was conducted with three additional foods that were consumed during 0% of
trials during the preference assessment (foods included pizza, peanut butter sandwich,
and apple). During the second set of compliance assessments Sandy complied with 50%,
30%, and 60% (pizza, peanut butter sandwich, and apple respectively) of trials. After a
review of Sandy’s compliance with the six different foods, string cheese, pizza, and apple
were selected based on Sandy’s similar compliance with each of those foods.
Additionally, given that Sandy licked each of the selected foods during the compliance
24
assessments, the starting demand fading step for the low-p instruction was holding the
food on her tongue.
Table 1
Results of Food Related Compliance Assessment
Evan
Sandy
#1 (apple)
60%
#1 (tomato)
10%
#2 (hot dog)
20%
#2 (macaroni and cheese)
20%
#3 (corn)
10%
#3 (string cheese)
50%
#4 (apple)
10%
#4 (pizza)
50%
#5 (hot dog)
30%
#5 (peanut butter
30%
sandwich)
#6 (corn)
10%
#7 (apple)
10%
#6 (apple)
60%
Note. Results represent percentage of compliance with demand fading steps during each
compliance assessment.
General Compliance Assessment
A general compliance assessment was conducted in order to assess each
participant’s level of compliance with general instructions given by a parent. For this
assessment the parent of each participant was asked to present 5 one-step imitation
actions and 5 one-step simple instructions (See Appendix D). While parents interacted
with their child the researcher observed from approximately 10 feet away and recorded
25
the number of times that each instruction or action was presented as well as the
participants’ response to given instructions or imitation actions. Evan complied with 90%
of given instructions and 80% of imitation actions. Sidney complied with 80% of given
instructions and 100% of imitation actions. The rationale for the general compliance
assessment was to determine if noncompliance occurred across activities or if it was
specific to feeding, as this information may be useful in predicting responsiveness to
treatment.
Baseline Procedures
During an initial baseline, the foods to be used in the treatment phases (Treatment
I: high-p alone and Treatment II: high-p plus demand fading) and food to be used during
a continuous baseline condition were alternated. Each baseline session consisted of 10
trials. Each condition was associated with a different therapist (treatment I with therapist
1, treatment II with therapist 2, and baseline with therapist 3).
Noncontingent access to 1 small bite of high-preferred food (for Evan) or 1 drink
of high-preferred beverage (for Sandy) was provided at the beginning of each baseline
session in order to establish a motivating operation. A trial consisted of a single bite of
food presented in front of the child and the therapist stating, “Take a bite” while
modeling the target behavior (i.e., consuming a bite of food). If the child did not consume
the food within 5 s, a vocal plus model prompt was delivered (“Take a bite” while the
researcher modeled the behavior). If the child still did not comply with the instruction,
the bite of food was removed and that trial was terminated. The next trial was presented
26
approximately 20 s following the end of the previous trial. Any food refusal or other
inappropriate mealtime behavior was ignored. Food refusal behaviors were defined as
vocally refusing the food upon presentation of the food (e.g., “No” or “I don’t like it”) or
non-vocally refusing the food (e.g., gagging, pushing the food away, spitting out the
food, or turning away from the food). Verbal praise plus high-preferred food (i.e.,
M&Ms, Oreos, or goldfish for Evan) or 1 drink of the high-preferred beverage (i.e., root
beer for Sandy) was delivered contingent on consumption following the initial instruction
or prompt.
Instructional Procedures
Two instructional treatments were utilized during the treatment phase. Treatment
I used the same high-p and low-p sequences as those used by Patel et al. (2007).
Treatment II used the same high-p and low-p instructions and demand fading steps as
those used by Penrod et al. (2012). The first instructional treatment (I) included a set of
two high-p instructions followed by a low-p instruction within the same response class as
the high-p instruction. For this phase the high-p instruction consisted of the presentation
of an empty spoon and the low-p instruction was the presentation of a bite of the nonpreferred food. The second instructional treatment (II) included two high-p instructions
made up of the two previously mastered demand fading steps followed by a low-p
instruction which was the next demand fading step that the participant had not mastered.
Table 2 depicts the demand fading steps and instructions associated with each. All
27
instructions during treatment II were performed with the non-preferred food (e.g., “Smell
the chicken, kiss the chicken, lick the chicken”).
For both instructional treatments, a given step met mastery criteria following two
consecutive sessions of 100% compliance with the high-p and low-p instructions in the
absence of refusal behavior. Following mastery of a given demand fading step in
treatment II, a compliance assessment of all demand fading steps (as previously described
above) was completed with the treatment II food. If the participant complied with the
next step in the demand fading sequence then that step would be considered mastered and
included in the high-p sequence and the next step in the demand fading sequence would
be used as the next low-p instruction. This procedure was attempted for both participants;
however, when a demand step was skipped, and not formally targeted as a low-p
instruction, both participants demonstrated significant decreases in compliance with the
low-p instruction. Thus it was determined that for both participants the demand fading
sequence would be followed as outlined regardless of performance in the compliance
assessment probes.
Noncontingent access to 1 small bite of high-preferred food (for Evan) or 1 drink
of high-preferred beverage and 10-15 seconds access to a high-preferred social activity
was provided at the beginning of each treatment session in order to establish a motivating
operation. Specifically, the participant was allowed to sample the designated reinforcer to
increase motivation to comply with low-p instructions in order to gain additional access
to the reinforcer. A trial consisted of a single bite of food or empty spoon presented in
28
front of the child and the therapist stating, “Take a bite” or other instruction related to the
given demand fading step for treatment II (e.g., “Touch the food” or “Hold the food”)
plus a model of the desired response. Prompting procedures and problem behavior were
addressed in the same manner as in baseline. Compliance with the high-p instructions
resulted in verbal praise (for Evan) or verbal praise plus social activity (i.e., tickles for
Sandy) and compliance with the low-p instruction result in praise plus 1 small bite of the
high-preferred food (i.e., M&Ms, Oreos, or goldfish for Evan) or 1 drink of the highpreferred beverage (i.e., root beer for Sandy).
Table 2
Demand Fading Low-p Instruction Steps
Demand Fading Step
Instruction
1
“Touch the (food)”
2
“Hold the (food)”
3
“Smell the (food)”
4
“Kiss the (food)”
5
“Lick the (food)”
6
“Hold the (food) on your
tongue”
“Put the (food) in your
mouth”
“Chew the (food)”
7
8
9
“Take a bite”
(final step)
Note. Demand fading steps were based on those used by Penrod et al (2012).
29
Chapter 3
RESULTS
Evan
Figure 4 depicts the percentage of compliance with low-p instructions throughout
the study. During the baseline sessions, none of the foods were ever consumed. During
treatment I compliance with the low-p instruction occurred during 0% of trials. Treatment
II was effective in increasing behaviors closer to the terminal response of food
consumption, although consumption of the non-preferred food did not occur. In treatment
II holding the food was the first low-p instruction with touching the food serving as both
of the high-p instructions. Mastery for holding the food was reached in three sessions,
following which a compliance assessment probe was conducted for all treatment steps.
Results of the compliance assessment showed that Evan complied with steps up to and
including licking the food; thus the low-p instruction for the next phase of treatment II
was holding the food on his tongue for 3 seconds, with kissing the food and licking the
food as the two high-p instructions. During the first session with this sequence (session
16) Evan complied with both high-p and low-p instructions for the first three trials, he
then complied with the high-p instruction only, for trial five and six, and then engaged in
refusal behavior and did not comply with high-p or low-p instructions for trials seven
through ten. During the next session of treatment II (session 19) Evan engaged in refusal
behavior for all trials and did not comply with high-p or low-p instructions. Following
30
this session, the high-p and low-p instructions were modified to reestablish compliance
with high-p and low-p instructions; the modified low-p instruction was to kiss the food,
with the high-p instructions being to hold the food and smell the food. Compliance with
the modified instructions (session 21) immediately increased to 100%. Researchers
continued to conduct compliance assessment probes following mastery of each treatment
II low-p demand fading step; however the demand fading sequence was followed in
order, regardless of Evan’s performance given his previous regression when demand
fading steps were skipped. Following mastery of the low-p instruction to kiss the food in
two sessions, Evan also mastered licking the food in two sessions. For the next low-p
instruction to hold the food on his tongue, the first score was 90% (session 36) followed
by a score of 100% (session 39). Following session 40, Evan’s parents made the decision
to discontinue sessions due to personal family circumstances which prevented researchers
from continuing through the remaining demand fading steps leading to the terminal
response. Consumption did not occur during any trials for treatment or baseline foods
during the study.
31
Figure 4. Results for Evan. Percentage of compliance with low-p instructions that
occurred during the baseline and treatment conditions.
Sandy
Figure 5 depicts the percentage of compliance with low-p instructions throughout
the study. During the baseline sessions, none of the foods were ever consumed. During
all treatment I trials, compliance with the low-p instruction to take a bite of the food
never occurred. Treatment II was effective in increasing behaviors closer to the terminal
response of food consumption, although consumption of the non-preferred food did not
occur. In treatment II holding the food on her tongue for three seconds was the first low-p
instruction with kissing the food and licking the food serving as the high-p instructions.
32
During the first treatment II session, Sandy complied with high-p and low-p instructions
during 0% of trials; additionally, Sandy complied with the high-p instructions 0% of trials
during the first treatment I session as well. Given the significant change in Sandy’s
performance from the initial pre-treatment compliance assessment one remedial session
was conducted to reestablish consistent acceptance of the empty spoon. During the
remedial training session, an empty spoon was presented on the plate with no other foods
present; the high-p instruction was to touch the spoon with the low-p instruction to take a
bite of the empty spoon. Compliance with high-p instructions resulted in verbal praise
and compliance with the low-p instruction resulted in delivery of moderately preferred
social activities (i.e., wiggly arms and high-5s). Following remedial training, compliance
with high-p instructions during treatment I increased to 100%; specifically, she accepted
the empty spoon. Additionally the low-p instruction for treatment II was modified to hold
the food, with touching the food serving as both high-p instructions. Compliance with the
low-p instructions for the following two treatment II session (sessions 13 and 16)
remained at 0%. Following session 16, a modified prompting procedure was added and
reinforcement was delivered for compliance with high-p and low-p instructions (tickles
and root beer, respectively) for both treatment conditions. The assignment of reinforcers
to high-p and low-p instructions was based on anecdotal observation of Sandy’s
preference during previous sessions. The modified prompting procedure was as follows:
following two vocal plus model instructions, if compliance did not occur within five
seconds, Sandy was physically prompted to engage in the target behavior (the therapist
33
hand over hand guided Sandy to engage in the target behavior). For treatment I the
physical prompt consisted of touching the food to her lips. This prompt procedure was
implemented for both treatment conditions in order to maintain consistency across
conditions and avoid any confounds. After the implementation of the modified prompt
procedure and reinforcement for high-p sequences, compliance with low-p instructions in
treatment II increased to 90% or higher for all demand fading steps up to holding the food
on her tongue (sessions 19 through 55). Upon introduction of the low-p instruction to
hold the food on her tongue for three seconds, compliance with low-p instructions
dropped to 0%. Given this significant decrease in performance, during the next session of
treatment II the low-p instruction was reduced to holding the food on her tongue for one
second, following which compliance increased to 70%. Consumption did not occur
during any trials for treatment or baseline foods during the study.
34
Figure 5. Results for Sandy. Percentage of compliance with low-p instructions that
occurred during the baseline and treatment conditions.
35
Chapter 4
DISCUSSION
The present study sought to evaluate the effects of high-p instructional sequences with
and without demand fading in increasing consumption of non-preferred foods in two
children with food selectivity; in specific, the high-p instructional sequence described by
Patel et al. (2007) was compared to the high-p instructional sequence combined with
demand fading, as described by Penrod et al. (2012). Results of the present study
demonstrated that neither the high-p sequence alone or in combination with demand
fading was effective in increasing consumption of non-preferred foods for both
participants. Although consumption was not achieved in treatment II (high-p sequence
combined with demand fading) for either participant, treatment II successfully increased
behavior closer to the terminal response of consumption thus extending the previous
research conducted by Penrod and colleagues. These results suggest that the demand
fading sequence may have been the critical component responsible for the increased
consumption observed in the Penrod et al. study with children with active refusal
behavior; however, because consumption was not achieved in this study, this conclusion
remains speculative. Future research should further examine the critical component in
increasing consumption; specifically evaluating if the high-p instructional sequence is
necessary or if demand fading alone would be sufficient to establish consumption of nonpreferred foods.
36
Although the high-p sequence combined with demand fading was not successful
in establishing consumption of the target food, it may still be a useful procedure.
Specifically, parents could be taught to implement this procedure at home while on a
waiting list for more intensive treatment. Future research should also explore if this
procedure may reduce problematic behavior that may occur once escape extinction
procedures are implemented. At the beginning of the study Sandy engaged in high rates
of problem behavior when presented with low-p instructions including the terminal
response. However, after exposure to treatment with the demand fading sequence, it was
observed anecdotally that general compliance began to increase and overall problem
behavior decreased (e.g., complying with instructions to sit down and remain seated for
the duration of the session). Additionally, it was also observed that later in the study
when problem behavior did occur, the intensity of problem behavior was much less than
at the beginning of the study. Specifically, at the beginning of the study Sandy engaged in
screaming, crying, elopement, and head banging when prompted to touch the nonpreferred food to her lips. At the end of the study, Sandy independently touched the food
to her lips in the absence problem behavior. This is an important observation because it
suggests that even though the demand fading procedure was not successful in increasing
consumption, it was successful in increasing general compliance as well as compliance
with behaviors closer to the terminal response. Thus, this may be a helpful procedure for
parents or clinicians to implement with a child prior to beginning more intensive feeding
treatments that may include escape extinction procedures. First establishing general
37
compliance and compliance with behaviors closer to the terminal response may
ultimately help to reduce the potential of problem behavior increasing in frequency,
intensity, and duration (characteristic of an extinction burst) when more intensive feeding
treatments such as escape extinction are implemented.
The present study demonstrated experimental control and replication of results
across participants; however, there are some limitations that should be taken into
consideration. First, the present study was not successful in establishing consumption of
the target non-preferred food in the treatment II procedure. Although treatment II was
successful in increasing behavior closer to the terminal response, the terminal response of
consumption was not reached. Second, the reinforcement and prompting procedures for
treatments I and II had to be modified for Sandy in order to establish compliance with
high-p and low-p instructions, thus deviating from the reinforcement and prompting
procedures used for Evan. Also, the additional reinforcement for high-p and low-p
instructions make it difficult to determine if it was the additional reinforcement or the
high-p instructional sequence that was responsible for behavior change in treatment II.
Third, due to the discontinuation of participation it was not possible to complete checks
for maintenance of the behaviors achieved in treatment or the generalization of these
behaviors to other caregivers. Future research should also further evaluate the
maintenance and generalization of behavior established using the high-p instructional
sequence combined with demand fading achieved by Penrod and colleagues in 2012.
38
In addition to the above limitations, it should also be noted that participant
characteristics were not well controlled for which may account for why results of the
current study differed from those reported in previous studies. Specifically, Evan had a
fairly short history of food selectivity (approximately one and a half years) whereas
Sandy’s history of food selectivity was much longer (approximately 7 years). One would
expect better treatment outcomes for Evan given his relatively short history; however,
based on information provided in the behavior and compliance parent interview, Evan
likely had an additional history of general non-compliance at home with parents which
may have contributed to failure to establish consumption of the non-preferred food during
treatment. Similarly, information provided in the behavior and compliance parent
interview indicated that Sandy had a fairly loose structure and low expectations at home.
Participant characteristics may play a significant role in determining the success
of antecedent based interventions such as high-p sequences and demand fading. The
participants in this study had the same general profile as those described by Penrod et al.
(2012), however characteristics of participants in the current study significantly differed
from the participant in the Patel et al. (2007) study. The participant in the study
conducted by Patel and colleagues was reported to use 2-3 word phrases, followed
complex commands, and demonstrated passive food refusal behavior which was
described as non-compliance in the absence of problem behavior. In contrast, participants
in the current study only followed simple one-step instructions and imitation actions.
Evan spoke using 1-3 word phrases; however, Sandy demonstrated a limited vocabulary
39
in that she inconsistently used only single words to communicate wants/needs and
primarily engaged in echolalic vocalizations. Additionally, the child’s history of food
refusal behavior (i.e., duration of time) should also be considered, as previously
mentioned. Specifically, an older child that has a longer history of food selectivity may
respond slower to this type of procedure, as was the case with Sandy who was 7.11 years
at the start of the study. Another potential predictive characteristic is the structure of the
family household as a whole (e.g., rules present in the home, consequences for following
or not following those rules, and overall daily routines and structure). Both Evan and
Sandy’s parents indicated in the behavior and compliance questionnaire that there were
limited household rules and the consequences for following or breaking the rules in
existence were fairly unclear. Given the information provided by both Evan and Sandy’s
parents in the behavior and compliance parent interview, it was expected that general
compliance in the compliance assessment would be representative of that. However, both
Evan and Sandy performed at 80% or better during the general compliance assessment. It
is likely that the instructions included in that assessment did not accurately assess
compliance to every day instructions that they were each presented with by parents at
home that may have provided a better overall picture of their general compliance with
parents. Future research should reevaluate the instructions used in the general compliance
assessment to identify instructions that may provide researchers and clinicians with a
better representation of the child’s general level of compliance to instructions given by
parents or caregivers. This information may help predict how well a child will respond to
40
intervention. Specifically, if a child complies with less than 60% of general instructions
issued by parents or caregivers, this is an indicator that the child’s noncompliance is not
isolated and expands to other areas outside of mealtime. Knowing this information
would assist researchers and clinicians in identifying the best course of treatment; if a
child displays strong compliance to instructions from parents, then they could move
forward with treatments specifically targeting food selectivity. However, if the child
displays weak compliance to instructions from parents, then the researcher or clinician
might intervene more effectively by first implementing treatment that targets increasing
compliance in a demand context outside of food consumption. For a child that displays
general non-compliance across demand types, it may be best to start with instructions that
can be prompted in order to establish general compliance and instruction following and
this is not possible with food consumption, as eating is one of the few behaviors that a
child has complete control over. Thus, having more information about the child’s overall
level of compliance will better guide researchers and clinicians in decision-making
regarding the type of treatment that may be most beneficial for the child at that time.
Future research should continue to evaluate the strength of the high-p sequence with and
without demand fading as well as participant characteristics that may help to predict the
effectiveness of this treatment compared to other treatment options such as EE.
41
APPENDIX A
Pre-treatment Parent Interview: Feeding
Pre-Treatment Parent Interview
Date:
Child’s name:
Child’s age:
Child’s weight:
Child’s height:
Family status (married/single/divorced):
1.
Interviewer(s):
Parents/guardian:
Phone number:
Email:
Child’s diagnosis:
Siblings:
Feeding
What foods does your child currently eat from each food group?

Fruits: _________________________________________________________

Vegetables: _____________________________________________________

Dairy products: __________________________________________________

Meats: _________________________________________________________

Breads/cereals: __________________________________________________

Sweets/snacks:__________________________________________________
2.
Are there foods that your child previously ate, but does not eat now? Why?
3.
Please describe what your child typically eats for breakfast, lunch, and dinner.

Breakfast: _________________________________________________________

Lunch: ___________________________________________________________

Dinner: ___________________________________________________________
4.
What are feelings regarding what your child currently eats? What would you like to change?
5.
What techniques do you use during meal times (offering choice, praise, coaxing, preparing different meal, etc.)?
6.
What does meal time presentation look like (who presents/prepares the meal, does child feed self, location, seating, others
present during meal time)?
7.
Describe your child’s behavior during meal times
8.
What are your child’s most preferred and least preferred foods? What foods would you like your child to start eating?
9.
Please rate the following questions on a scale from 1 to 5, with 1 meaning extremely dissatisfied, 2 meaning dissatisfied, 3
meaning minimally satisfied, 4 meaning quite satisfied with some room for improvement, and 5 meaning extremely
satisfied.
Question:
Please Circle One:
Are you satisfied with the foods your child currently eats?
1
2
3
4
5
Are you satisfied with the quantity of food your child eats?
1
2
3
4
5
Are you satisfied with how your child behaves during meals?
1
2
3
4
5
Are you satisfied with your child’s self-feeding skills?
1
2
3
4
5
Are you satisfied with your child’s current weight?
1
2
3
4
5
42
APPENDIX B
Pre-treatment Parent Interview: Behavior and Compliance
Date:
Child’s name:
Child’s age:
Child’s weight:
Child’s height:
Family status (married/single/divorced):
Pre-Treatment Parent Interview
Interviewer(s):
Parents/guardian:
Phone number:
Email:
Child’s diagnosis:
Siblings:
1.
General Information
Is your child currently taking any medications?
2.
Describe your child’s treatment history
3.
What is your child’s primary form of communication?
4.
Does your child imitate others?
5.
Does your child respond to social contingencies (praise, pleasing others)?
6.
Does your child show interest in interacting with peers?
7.
Tell us about your family (what do you like to do together, day time/night time routines, what does a typical week
day/weekend look like).
What changes would you like to see, if any, in your family life (things you would like to do as a family that you aren’t
doing now, changes you would like to see in your daily routines)?
What do you think the biggest barrier is to these things happening?
8.
9.
1.
General Compliance
What are some of the “house rules” that all members in the family are expected to follow? That the children are expected to
follow?
2.
Does your child follow these rules? How do you respond if your child does not follow a given rule? How do you respond if
your child does follow a rule?
3.
What are your expectations for your child (does he/she have a bed time, chores, mealtime schedule, homework, etc.)?
4.
How does your child respond when you give him/her instructions? What instructions does he/she follow willingly? What
are chEvanging instructions for him/her to follow? How do you let him/her know when he/she is doing a good job? How
do you let him/her know when he/she is not doing what you want him/her to do?
5.
How does your child respond to changes in routine? How do you prepare for changes in your child’s routine? Does your
child engage in any other rigid behavior?
6.
Does your child engage in any compulsive or repetitive behavior? How do you respond?
7.
Are there any tasks/activities that your child used to do that they don’t do now?
8.
Does your child engage in any non-compliance? What does this look like? What are the common antecedents to noncompliance? How do you respond?
9.
How do you respond if your child wants something a different way than the way you are doing it?
10. What are some situations that make your child uncomfortable/anxious/upset? What does he/she typically do in these
situations? How do you respond to his/her behavior? What are some ways that you have tried to help him/her “cope” in
these situations? How have these strategies worked for you? For your child?
43
APPENDIX C
Food Related Compliance Assessment Data Sheet
Date: _______________
Researcher: _____________________________
Primary / IOA
Participant:______________________________
Foods: 1.________________
2.________________
3.________________
Instructions
Present all demand fading steps for each food item , run this 1x for each food. Trial
presentation is as follows: present the empty spoon or single bite of food and the vocal
instruction paired with a model of the target response for 5 seconds. If the participant
does not engage in the target response then repeat the instruction and model for 5
additional seconds. Any refusal or inappropriate mealtime behavior should be ignored. If
the participant engages in the target response, score as (+) and deliver brief verbal praise.
If the participant does not comply, score as (-) and remove the food. Regardless of the
response, present the next trial immediately following the end of a given trial.
Food:
1. “Take a bite” (empty spoon)
2. “Touch the (food)”
3. “Hold the (food)”
4. “Smell the (food)”
5. “Kiss the (food)”
6. “Lick the (food)”
7. “Put the (food) on your tongue”
(holds it for 3 seconds)
8. “Put the (food) in your mouth”
9. “Chew the (food)” (chews it at least
5 time)
10. “Take a bite” (bite of food)
1
2
3
44
APPENDIX D
General Compliance Assessment Data Sheet
Please present the below instructions/imitation tasks to your child in a way that you
would naturally. Researchers will indicate a + if the child complies with the given
instruction and a minus if the child does not comply with the given instruction.
Instructions
stand up
come here
sit down
give me (item)
clean up
Imitation
rolling toy car
clapping hands
waving
standing up
putting toy away
45
APPENDIX E
Baseline Data Sheet
Condition: Baseline
Bite
Date: _______
Prompt
Session #: _______
Trial Pres.
Initials: _______
SR+
PB
1
2
3
4
5
6
7
8
9
10
Comments:
Condition: Baseline
Bite
1
2
3
4
5
6
7
8
9
10
Comments:
Prompt
Date: _______
Session #: _______
Trial Pres.
Initials: _______
SR+
PB
46
APPENDIX F
Treatment Data Sheet
Condition: Treatment
HP
Prompt
Date: _______
HP
Prompt
LP
Prompt
Session #: _______
Trial Pres.
Initials: _______
SR+
PB
1
2
3
4
5
6
7
8
9
10
Comments:
Condition: Treatment
HP
1
2
3
4
5
6
7
8
9
10
Comments:
Prompt
Date: _______
HP
Prompt
LP
Prompt
Session #: _______
Trial Pres.
Initials: _______
SR+
PB
47
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