UNMC Munroe-Meyer Institute
Treatment of Pediatric Feeding Disorders
Cathleen C. Piazza
University of Nebraska Medical Center’s Munroe-Meyer Institute
UNMC Munroe-Meyer Institute
PEDIATRIC FEEDING DISORDERS
 Identified when a child fails to consume a
sufficient variety or quantity of food to maintain
nutritional status
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INTERDISCIPLINARY APPROACH
 Consider an interdisciplinary evaluation
prior to initiation of treatment
 Practice within your scope of competence
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EATING AND DRINKING UTENSILS
RubberCoated Baby
Spoons
Maroon
Spoons
Cut-out (nosey) cups
Nuk Brush
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FUNCTIONAL ANALYSIS OF
PEDIATRIC FEEDING DISORDERS
 Piazza, Fisher, et al. (2003) conducted
functional analyses of inappropriate
mealtime behavior of 15 children diagnosed
with a pediatric feeding disorder.
 Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Katz, R. M., Sevin, B. M.,
Gulotta, C. S., & Patel, M. R. (2003). Functional analysis of inappropriate mealtime
behaviors. Journal of Applied Behavior Analysis, 37, 187-204.
UNMC Munroe-Meyer Institute
Functional Analysis
Condition
Consequence for
Inappropriate
Behavior
Bite Presentation
ESCAPE
30 s of escape
remove
for 20 s
ATTENTION
30 s of attention
remains at
midline
TANGIBLE
30 s of access
tangible
remains at
midline
CONTROL
no differential
consequence
remains at
midline
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Escape Condition
Feeder delivers 30 s of escape following inappropriate behavior.
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Attention Condition
Feeder delivers 30 s of attention following inappropriate behavior.
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Control Condition
Feeder provides continuous access to toys and attention. No
differential consequence following inappropriate behavior.
INAPPROPRIATE BEHAVIOR PER MINUTE
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ATTENTION VS CONTROL
28
ESCAPE VS CONTROL
26
24
22
20
18
16
14
ESCAPE
12
ATTENTION
10
8
Tom
6
CONTROL
4
2
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
SESSIONS
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis
and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42,
641-658.
UNMC Munroe-Meyer Institute
FUNCTIONAL ANALYSIS OF
PEDIATRIC FEEDING DISORDERS
 67% of participants displayed high levels of
inappropriate mealtime behavior in one or more
test conditions.
 90% of participants whose functional analyses
were differentiated displayed sensitivity to
negative reinforcement.
 80% of participants whose functional analyses
were differentiated displayed sensitivity to
multiple reinforcing contingencies.
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PERCENTAGE OF CASES
60
50
Functional Analysis Results
N = 38
40
30
20
10
0
ESCAPE
(ESC)
ATTENTION
(ATT)
TANGIBLE
(TANG)
UNDIF
ESC +
ATT + TANG
FUNCTION
ESC
+ TANG
ESC
+ ATT
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FUNCTIONAL ANALYSIS OF
PEDIATRIC FEEDING DISORDERS
 The findings suggest that:
 Negative reinforcement plays a primary role
in the maintenance of feeding problems.
 Children with feeding problems may be
sensitive to other reinforcement
contingencies.
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EXAMPLE BASELINE DATA
In this example, the child accepted 80%, 20%, and 60% of the bites, respectively, in each of the meals.
Because acceptance of bites is variable (unpredictable), you should wait to start treatment.
Meal 3
Meal 2
Meal 1
FOOD
TRIAL
FOOD
TRIAL
Accept
Accept
FOOD
TRIAL
Accept
Green beans
1
Y
Potato
1
N
Applesauce
1
Y
Chicken
2
N
Applesauce
2
N
Potato
2
N
Applesauce
3
N
Green beans
3
N
Chicken
3
Y
Potato
4
Y
Chicken
4
N
Green beans
4
N
Green beans
5
Y
Potato
5
N
Applesauce
5
Y
Chicken
6
Y
Applesauce
6
Y
Potato
6
N
Applesauce
7
Y
Green beans
7
N
Chicken
7
Y
Potato
8
Y
Chicken
8
N
Green beans
8
Y
Green beans
9
Y
Potato
9
N
Applesauce
9
N
10
Y
Applesauce
10
Y
Potato
10
Y
TOTAL
Accept
8
TOTAL
Accept
2
TOTAL
Accept
6
%
80%
%
20%
%
60%
Chicken
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EXAMPLE BASELINE DATA
In this example, the child’s level of
acceptance is between 20% and 80%. This
is a variable (unpredictable) level of
acceptance. It would be difficult to predict
what the child’s level of acceptance will be
at the next meal. If behavior is
unpredictable, then it is better to wait to
start treatment. Also, acceptance is
increasing (getting better) at the last meal,
which is another reason to wait to start
treatment.
Baseline
100
PERCENTAGE OF
ACCEPTED BITES
90
80
70
60
50
40
30
20
10
0
0
2
4
6
8
MEALS
10
12
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EXAMPLE BASELINE DATA
Baseline
100
PERCENTAGE OF
ACCEPTED BITES
90
80
70
60
50
40
30
20
10
0
0
100
2
Baseline
4
6
8
10
12
MEALS
PERCENTAGE OF
ACCEPTED BITES
90
In this example, we continued the baseline for 3
more meals. Now, the level of acceptance is more
consistently between 50% and 60%. This is now a
stable level of acceptance. Acceptance is
decreasing at the last meal. It would be a good
time to start treatment.
80
70
60
50
40
30
20
10
0
0
2
4
6
MEALS
8
10
12
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EXAMPLE BASELINE DATA
In this example, the child accepted 10%, 20%, and 10% of the bites, respectively, in each of the meals.
Because acceptance of bites is low and predictable, you could start your treatment at the next meal.
Meal 1
Meal 2
Meal 3
FOOD
TRIAL
FOOD
TRIAL
FOOD
TRIAL
Accept
Accept
Accept
Green beans
1
N
Applesauce
1
Y
Potato
1
N
Chicken
2
N
Potato
2
N
Applesauce
2
Y
Applesauce
3
N
Chicken
3
N
Green beans
3
N
Potato
4
N
Green beans
4
N
Chicken
4
N
Green beans
5
N
Applesauce
5
N
Potato
5
N
Chicken
6
N
Potato
6
N
Applesauce
6
N
Applesauce
7
Y
Chicken
7
N
Green beans
7
N
Potato
8
N
Green beans
8
N
Chicken
8
N
Green beans
9
N
Applesauce
9
Y
Potato
9
N
10
N
Potato
10
N
Applesauce
10
N
Chicken
TOTAL
Accept
1
TOTAL
Accept
2
TOTAL
Accept
1
%
10%
%
20%
%
10%
UNMC Munroe-Meyer Institute
EXAMPLE BASELINE DATA
In this example, the child’s level of
acceptance is between 10% and 20%. This is
a low and stable level of acceptance. You
can predict that at the next meal, the child
will accept between 10% and 20% of bites. If
behavior is predictable, then it is a good time
to start treatment.
Baseline
100
PERCENTAGE OF
ACCEPTED BITES
90
80
70
60
50
40
30
20
10
0
0
2
4
6
8
MEALS
10
12
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GENERAL TREATMENT PROGRESSION
Functional Analysis
Function-Based
Treatment
Chaser
Chin prompt
Facilitation/Redistribution
Fading
Texture
Avoidance
Fading
Momentum
Effective Treatment
Parent
Training
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EE or EE+Sr+/Sr Nonremoval of the spoon – feeder keeps spoon or cup
at child’s lips and deposits bite or drink at first
opportunity
 Differential reinforcement of alternative behavior (DRA)
– feeder delivers a preferred item or activity following
appropriate behavior (e.g., mouth clean)
 Noncontingent reinforcement (NCR) – throughout the
meal (a) feeder interacts with child, (b) feeder interacts
with child and preferred items or activities are available,
or (c) preferred items or activities are available
 Differential negative reinforcement of alternative
behavior (DNRA) – feeder delays presentation of bite
following appropriate behavior (e.g., mouth clean)
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STUDIES ON ESCAPE EXTINCTION
 Escape extinction (EE) may be a necessary
component of treatment.
 Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J.
(2009). Functional analysis and treatment of multiply controlled inappropriate mealtime
behavior. Journal of Applied Behavior Analysis, 42, 641-658.
 LaRue, R. H., Stewart, V., Piazza, C. C., & Volkert, V. M. (2011). Escape as reinforcement and
escape extinction in the treatment of feeding problems. Journal of Applied Behavior
Analysis, 44, 719-735.
 Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An
evaluation of two differential reinforcement procedures with escape extinction to treat food
refusal. Journal of Applied Behavior Analysis, 35, 363-374.
 Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative
contributions of positive reinforcement and escape extinction in the treatment of food
refusal. Journal of Applied Behavior Analysis, 36, 309-324.
 Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., &
Gutshal, K. A. (2004). On the relative contributions of noncontingent reinforcement and
escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37,
27-41.
UNMC Munroe-Meyer Institute
Studies on the Effects of Reinforcement
Reinforcement of the First Behavior in the Chain (Acceptance) vs
Reinforcement of the Terminal Behavior in the Chain (Mouth Clean)
Sr+ Acceptance
Sr+ Swallowing (Mouth Clean)
Does it make a difference?
PERCENTAGE ACCEPTANCE
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BL
100
90
80
70
60
50
40
30
20
10
0
PERCENTAGE MOUTH CLEAN
DRA
DRA + EE
DRA
MC
DRA
ACC
Sunshine
10
0
100
90
80
70
60
50
40
30
20
10
0
DRA + EE
DRA
BL
20
30
DRA
40
50
60
70
DRA + EE
80
90
100
DRA
110
120
130
140
DRA + EE
Sunshine
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
SESSION
Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two
differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied
Behavior Analysis, 35, 363-374.
PERCENTAGE ACCEPTANCE
UNMC Munroe-Meyer Institute
BL
100
90
80
70
60
50
40
30
20
10
0
DRA
ACC
DRA + EE
DRA
DRA
MC
Jarred
0
PERCENTAGE MOUTH CLEAN
DRA + EE
DRA
10
BL
100
90
80
70
60
50
40
30
20
10
0
20
30
DRA
40
50
60
70
DRA + EE
80
90
100
DRA
110
120
130
DRA + EE
Jarred
0
10
20
30
40
50
60
70
80
90
100
110
120
130
SESSION
Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two
differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied
Behavior Analysis, 35, 363-374.
UNMC Munroe-Meyer Institute
Studies on the Effects of Reinforcement
What Are the Effects of Differential Positive
Reinforcement with and without Escape Extinction?
Differential Sr+
Escape Extinction
Does it make a difference?
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Condition
Consequence
for
Inappropriate
Behavior
Bite
Presentation
Consequence
for Mouth
Clean
ESC
20 s of escape
removed
for 20 s
brief praise
DRA +
ESC
20 s of escape
removed
for 20 s
access to Sr+
EE
no differential
consequence
remained at
child’s lips
brief praise
DRA + EE
no differential
consequence
remained at
child’s lips
access to Sr+
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of
positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior
Analysis, 36, 309-324.
UNMC Munroe-Meyer Institute
Studies on the Effects of Reinforcement
What Are the Effects of Noncontingent Positive
Reinforcement with and without Escape Extinction?
Noncontingent Sr+
Escape Extinction
Does it make a difference?
UNMC Munroe-Meyer Institute
Condition Consequence
for
Inappropriate
Behavior
ESC
NCR +
ESC
EE
Bite
Presentatio
n
20 s of escape
removed
for 20 s
20 s of escape
removed
for 20 s
no differential remained at
consequence child’s lips
NCR + EE no differential
consequence
remained at
child’s lips
Consequence
for Mouth
Clean
brief praise
access to Sr+
throughout
brief praise
access to Sr+
throughout
Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshal, K. A. (2004). On the relative
contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied
Behavior Analysis, 37, 27-41.
UNMC Munroe-Meyer Institute
PERCENTAGE ACCEPTANCE
ESC BL vs.
DRA+ESC
EE vs. DRA+EE
100
ESC BL vs.
DRA+ESC
EE vs. DRA+EE
DRA + EE
90
80
70
60
50
40
30
20
ESC BL DRA + ESC
EE
10
0
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
36
38
40
42
SESSIONS
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative
contributions of positive reinforcement and escape extinction in the treatment of food
refusal. Journal of Applied Behavior Analysis, 36, 309-324.
44
% NEGATIVE VOCALIZATIONS
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ESC BL vs
DRA+ESC
100
EE vs. DRA+EE
90
ESC BL vs
DRA+ESC EE vs. DRA+EE
EE
80
DRA + ESC
70
60
DRA + EE
50
40
ESC BL
30
20
10
0
0
2
4
6
8
10 12 14 16 18 20
22
24
26
28
30 32 34
36
38
40 42 44
SESSION
Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative
contributions of positive reinforcement and escape extinction in the treatment of food
refusal. Journal of Applied Behavior Analysis, 36, 309-324.
UNMC Munroe-Meyer Institute
Effects of Function-Based Treatment
What Are the Effects of FunctionBased Treatment for Children
Whose Inappropriate Mealtime
Behavior is Maintained by Multiple
Reinforcers?
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and
treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
INAPPROPRIATE MEALTIME
BEHAVIOR PER MINUTE
UNMC Munroe-Meyer Institute
16
14
12
SAVANNAH
ESCAPE
10
8
ATTENTION
6
CONTROL
4
2
0
0
2
4
6
8
10
12
14
16
18
20
22
24
SESSION
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and
treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
Condition
Consequence for
Inappropriate
Behavior
Bite
Presentation
ATTN + ESC
20 s of attention
plus escape
removed
for 20 s
EE + ATTN
20 s of attention
remained at
child’s lips
AE + ESC
20 s of escape
removed
for 20 s
EE + AE
no differential
consequence
remained at
child’s lips
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and
treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
ATTN
+ ESC
EE + ATTN vs.
AE + ESC
INAPPROPRIATE MEALTIME
BEHAVIOR PER MINUTE
28
EE + AE
AE + ESC
24
20
SAVANNAH
16
12
8
4
EE + ATTN
0
ATTN
+ ESC
EE +
ATTN
100
PERCENTAGE ACCEPTANCE
EE + ATTN vs.
AE + ESC
EE + AE
EE + ATTN vs.
AE + ESC
EE + ATTN vs.
AE + ESC
EE + AE
EE + AE
90
80
70
60
50
40
30
SAVANNAH
20
10
AE + ESC
0
0
10
20
30
40
50
60
SESSION
70
80
90
100
110
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and
treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
Effects of Function-Based Treatment
What Are the Effects of Function-Based Treatment for Children Whose
Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers?
 Acceptance and Mouth Clean Increased With Escape
Extinction but Not Attention Extinction
 Inappropriate Behavior Maintained at Low Levels with
Escape Extinction in the Absence of Attention Extinction
 Levels of Acceptance and Mouth Clean Were Higher and
More Stable with Escape AND Attention Extinction
 Important to Treat Both Functions when Inappropriate
Mealtime Behavior is Multiply Maintained
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and
treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.
UNMC Munroe-Meyer Institute
Comparison of Function-Based and
Sensory-Based Treatments
How Effective is Function- versus
Sensory-Based Treatment?
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012).
A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding
disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer Institute
PERCENTAGE ACCEPTANCE
ESCAPE
ESC + SI
EE + NCR
ESC + SI EE + NCR
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
100
110
SESSION
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012).
A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding
disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer Institute
ESCAPE
ESC+ SI
EE + NCR
ESC+ SI EE + NCR
INAPPROPRIATE MEALTIME
BEHAVIOR PER MINUTE
55
50
45
40
35
30
25
20
15
10
5
0
0
10
20
30
40
50
60
70
80
90
100
110
SESSION
Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012).
A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding
disorders. Journal of Applied Behavior Analysis, 45, 455-471.
UNMC Munroe-Meyer Institute
COMPARISON OF FUNCTION- VS
SENSORY-BASED TREATMENTS
 Sensory integration-based treatment
produced no change in behavior.
 Escape extinction was associated with
increased acceptance and decreased
inappropriate behavior.
 Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M.,
& Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as
treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45,
455-471.
UNMC Munroe-Meyer Institute
FADING
 Blending


Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004).
Increasing variety of foods consumed by blending nonpreferred foods into
preferred foods. Journal of Applied Behavior Analysis, 37, 159-170.
Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001).
Using a fading procedure to increase fluid consumption in a child with feeding
problems. Journal of Applied Behavior Analysis, 34, 357-360.
 Spoon distance

Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance
fading with and without escape extinction as treatment for food refusal. Journal of
Applied Behavior Analysis, 43, 673-683.
 Spoon to cup

Groff, R. A., Piazza, C. C., Zeleny, J. R., & Dempsey, J. R. (2011). Spoon-to-cup
fading as treatment for cup drinking in a child with intestinal failure. Journal of
Applied Behavior Analysis, 44, 949-954.
 Syringe to cup and spoon

Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe
fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer Institute
HP
PERCENTAGE APPROACH + CONSUME
100
90
80
70
60
50
40
30
20
LP
10
0
FOODS
Based on: Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A
comparison of two approaches for identifying reinforcers for persons with severe and profound
disabilities. Journal of Applied Behavior Analysis, 25, 491-498.
UNMC Munroe-Meyer Institute
BLENDING
Sample Yogurt/Green Bean Blends
80/20
60/40
40/60
20/80
Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods
consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis, 37,
159-170.
UNMC Munroe-Meyer Institute
APPLE SAUCE/CARROTS
100
80/20
50/50
90/10
60/40
80
APPLESAUCE
PERCENTAGE MOUTH CLEAN
90
70
70/30
60
CARROT
50
POTATO
40
30
20
John
10
0
0
5
10
15
20
25
30
35
40
45
50
55
SESSIONS
Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods
consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis, 37,
159-170.
Water + *CIB Fading
DRA + EXT
0% 5% 10% 20% 30% 20% 30% 100% 10% 20% 30%
100
100%
Milk/CIB
Reversal
Mother
Reversal
Reversal
Reversal
Reversal
10
Reversal
20
Reversal
30
Reversal
40
Reversal
50
100% CIB/Water
60
Reversal
70
Reversal
80
30%
Therapist
Mother
Water
90
CIB + Milk Fading
DRA + EXT
Reversal
DRA +
EXT
100% Milk/CIB
PERCENTAGE MOUTH CLEAN
UNMC Munroe-Meyer Institute
0
0
5
10
15
20
25 30
35
40
45
50
55
60
65
70
75
80
85 90 95
SESSION
*CIB = Carnation Instant Breakfast
Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001). Using a fading
procedure to increase fluid consumption in a child with feeding problems. Journal of Applied
Behavior Analysis, 34, 357-360..
UNMC Munroe-Meyer Institute
INAPPROPRIATE MEALTIME
BEHAVIOR PER MINUTE
Lips ESC
Baseline (BL)
vs Fading
ESC BL
54
Fading
ESC
BL
48
42
36
Lips
Fading+EE vs Escape Escape
(ESC) BL
Extinction (EE)
Lips
ESC
BL
Fading+EE vs EE
EE
Lips
ESC BL
Probe
Fading+EE
20.3
cm
30
24
18
15.2 cm
25.4
12
cm
6
Lips
ESC BL
Probe
10.2
cm
15.2
cm
15.2
cm
10.2 cm 5.1 cm
Lips
0
0
10
20
30
40
50
60
70
80
90
100
110
120
130
SESSION
Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without
escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis, 43, 673-683.
PERCENTAGE ACCEPTANCE
UNMC Munroe-Meyer Institute
Lips ESC BL
vs Fading
Fading+EE vs EE
ESC BL
(Escape Extinction)
Lips
ESC
BL
Fading+EE vs EE
100
Lips
80
60
40
Lips
ESC BL
Probe
EE
Lips
ESC BL
Lips
ESC BL
Probe
20
0
0
10
20
30
40
50
60
70
80
90
100
110
120
SESSION
Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without
escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis, 43, 673-683.
UNMC Munroe-Meyer Institute
4 cm
5 cm
2 cm
3 cm
Flush
1 cm
Deposit liquid
from syringe
Hole in cup
bottom
Deposit from syringe
0.5 cm
Deposit from cup
Syringe on outside
of cup, recessed
from
lip
Deposit from cup
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for
feeding refusal. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer Institute
Deposit Syringe
5 cm
Bottom
4 cm
Top
Deposit Syringe
3 cm
In mouth
2 cm
At lips
Deposit Spoon
1 cm
Next
to
Deposit
Syringe
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment
for feeding refusal. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer Institute
Syringe Volume
Fading (ml)
PERCENTAGE MOUTH CLEAN
Spoon
BL EE
Syringe to Spoon Fading
cm
0.1 to 1.0
0.1
Spoon Position
Top
0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
5
4 3 2 1
Bottom
In
mouth
100
Lips
Top
Top
In
Next
In
mouth mouth
to
Top
Spoon
EE
90
80
70
EE
Spoon
Probe
60
50
40
30
20
10
0
10
20
30
40
50
60
70
80
90
100
110
Session
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for
feeding refusal. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer Institute
Escape Extinction (EE) +
Attention Extinction (AE)
PERCENTAGE MOUTH CLEAN
BL EE + AE
Spoon-toCup Fading
BL
100
3.8 3.2 2.6 2.1 1.5
90
1-Year
Follow Up
80
70
Spoon
60
Cup
50
40
30
20
10
0
10
3.8 cm
20
30
3.2 cm
40
50
60
SESSION
2.6 cm
70
80
2.1 cm
90
100
110
1.5 cm
UNMC Munroe-Meyer Institute
SWALLOW FACILITATION AND RE-DISTRIBUTION

Dempsey, J., Piazza, C. C., Groff, R. A., & Kozisek, J. M. (2011). A
flipped spoon and chin prompt to increase mouth clean. Journal of
Applied Behavior Analysis, 44, 961-965.

Gulotta, C. S., Piazza, C. C., Patel, M. R., & Layer, S. A. (2005). Using
food redistribution to reduce packing in children with severe food
refusal. Journal of Applied Behavior Analysis, 38, 39-50.

Rivas, K. R., Piazza, C. C., Kadey, H. J., Volkert, V. M., & Stewart, V.
(2011). Sequential treatment of a feeding problem using a pacifier and
flipped spoon. Journal of Applied Behavior Analysis, 44, 318-391.

Volkert, V. M., Vaz, P. C. M., Piazza, C. C., Frese, J., & Barnett, L. (2011).
Using a flipped spoon to decrease packing in children with feeding
disorders. Journal of Applied Behavior Analysis, 44, 617-621.

Wilkins, J. W., Piazza, C C., Groff, R. A., Volkert, V. M., Kozisek, J. K., &
Milnes, S. M. (in review). Utensil manipulation during initial treatment
of pediatric feeding problems. Journal of Applied Behavior Analysis.
UNMC Munroe-Meyer Institute
NUK WITH FACILITATION
UNMC Munroe-Meyer Institute
FLIPPED SPOON
UNMC Munroe-Meyer Institute
Percentage of Packed Bites
Baseline
Flipped Spoon
Baseline
Flipped Spoon
Parent Training
100
90
80
70
60
50
40
30
Tracey
20
3-week
follow-up
10
0
0
5
10
15
20
Volkert, V. M., Vaz, P. C. M., Piazza, C. C., Frese, J., & Barnett, L. (2011). Using a flipped
spoon to decrease packing in children with feeding disorders. Journal of Applied Behavior
Analysis, 44, 617-621.
UNMC Munroe-Meyer Institute
RE-DISTRIBUTION
UNMC Munroe-Meyer Institute
EXPELS PER BITE
BASELINE (BL)
RE-PRESENTATION
40
36
32
28
24
20
16
12
8
4
0
BL
RE-PRES
Spoon
Nuk
0
10
20
30
40
50
60
70
SESSION
Wilkins, J. W., Piazza, C C., Groff, R. A., Volkert, V. M., Kozisek, J. K., & Milnes, S. M. (in review). Utensil
manipulation during initial treatment of pediatric feeding problems. Journal of Applied Behavior
Analysis.
UNMC Munroe-Meyer Institute
CHIN PROMPT
UNMC Munroe-Meyer Institute
Re-presentation
Re-presentation plus chin prompt
Re-presentation
CHIN PROMPT
BASELINE (BL)
BL
Re-presentation plus chin prompt
CHIN PROMPT
7
EXPELS PER BITE
6
5
4
3
2
1
0
0
10
20
30
40
50
60
70
80
90
100 110 120 130 140
SESSION
Wilkins, J. W., Piazza, C. C., Groff, R. A., & Vaz, P. C. M. (2011). Chin prompt plus re-presentation as
treatment for expulsion in children with feeding disorders. Journal of Applied Behavior Analysis, 44, 513544.
UNMC Munroe-Meyer Institute
Chaser
 Chaser – feeder presents a solid or
liquid that the child swallows reliably
following depositing a solid or liquid
the child does not swallow reliably
 Vaz, P. C. M., Piazza, C. C., Stewart, V., Volkert, V. M.,
Groff, R. A., & Patel, M. R. (2012). Using a chaser to
decrease packing in children with feeding disorders.
Journal of Applied Behavior Analysis, 45, 97-105.
UNMC Munroe-Meyer Institute
100
PERCENTAGE PACK
90
80
70
60
Baseline
50
40
Chaser
30
20
10
0
0
2
4
6
8
10
12
14
16
18
20
22
24
SESSION
Vaz, P. C. M., Piazza, C. C., Stewart, V., Volkert, V. M., Groff, R. A., & Patel, M. R. (2012). Using a chaser to
decrease packing in children with feeding disorders. Journal of Applied Behavior Analysis, 45, 97-105
UNMC Munroe-Meyer Institute
TEXTURE OR CONSISTENCY MANIPULATION


Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., & Swartzwelder, D. M.
(2005). A systematic evaluation of food textures to decrease packing and
increase oral intake in children with pediatric feeding disorders. Journal of
Applied Behavior Analysis, 38, 89-100.
Patel, M. R., Piazza, C. C., Santana, C. M., & Volkert, V. M. (2002). An
evaluation of food type and texture in the treatment of a feeding problem.
Journal of Applied Behavior Analysis, 35,183-186.
UNMC Munroe-Meyer Institute
PURREED
WET GROUND
CHOPPED
TABLE TEXTURE (1/4x1/4x1/4)
UNMC Munroe-Meyer Institute
PUREE
WET GROUND PUREE WET GROUND
PERECENTAGE PACK
100
90
80
70
60
50
40
30
20
10
0
5
10
15
20
30
25
SESSION
35
40
45
Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., & Swartzwelder, D. M. (2005). A systematic evaluation of food textures
to decrease packing and increase oral intake in children with pediatric feeding disorders. Journal of Applied Behavior
Analysis, 38, 89-100.
UNMC Munroe-Meyer Institute
AVOIDANCE


Rivas, K. M., Piazza, C. C., Roane, H. S., Volkert, V. M., Stewart, V., Kadey, H.
J., & Groff, R. A. (in review). Analysis of self-feeding in children with feeding
disorders. Journal of Applied Behavior Analysis.
Vaz, P. C. M., Volkert, V. M., & Piazza, C. C. (2011). Using negative
reinforcement to increase self-feeding in a child with food selectivity.
Journal of Applied Behavior Analysis, 44, 915-920.
UNMC Munroe-Meyer Institute
AVOIDANCE
UNMC Munroe-Meyer Institute
GENERAL TREATMENT PROGRESSION
Functional Analysis
Function-Based
Treatment
Chaser
Chin prompt
Facilitation/Redistribution
Fading
Texture
Avoidance
Fading
Momentum
Effective Treatment
Parent
Training
UNMC Munroe-Meyer Institute
SUMMARY
 EE or EE+Sr+/Sr- was an effective treatment for
43% of the interventions.
 Although EE may be a necessary treatment, it
may not be sufficient for many children with
severe feeding problems.
UNMC Munroe-Meyer Institute
SUMMARY
 We used other procedures in addition to EE for
53% of the interventions.
University
of Nebraska
Medical Center
UNMC
Munroe-Meyer
Institute