1. UNMC Munroe-Meyer Institute Treatment of Pediatric Feeding Disorders Cathleen C. Piazza University of Nebraska Medical Center’s Munroe-Meyer Institute

2. 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

3. UNMC Munroe-Meyer Institute INTERDISCIPLINARY APPROACH  Consider an interdisciplinary evaluation prior to initiation of treatment  Practice within your scope of competence

4. UNMC Munroe-Meyer Institute EATING AND DRINKING UTENSILS Rubber- Coated Baby Spoons Maroon Spoons Nuk Brush Cut-out (nosey) cups

5. UNMC Munroe-Meyer Institute  Piazza, Fisher, et al. (2003) conducted functional analyses of inappropriate mealtime behavior of 15 children diagnosed with a pediatric feeding disorder. FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS  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.

6. UNMC Munroe-Meyer Institute ConditionConsequence for Inappropriate Behavior Bite Presentation ESCAPE30 s of escaperemove for 20 s ATTENTION30 s of attentionremains at midline TANGIBLE30 s of access tangible remains at midline CONTROLno differential consequence remains at midline Functional Analysis

7. UNMC Munroe-Meyer Institute Escape Condition Feeder delivers 30 s of escape following inappropriate behavior.

8. UNMC Munroe-Meyer Institute Attention Condition Feeder delivers 30 s of attention following inappropriate behavior.

9. UNMC Munroe-Meyer Institute Control Condition Feeder provides continuous access to toys and attention. No differential consequence following inappropriate behavior.

10. UNMC Munroe-Meyer Institute 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. SESSIONS

11. UNMC Munroe-Meyer Institute  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. FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS

12. UNMC Munroe-Meyer Institute Functional Analysis Results N = 38 0 10 20 30 40 50 60 ESCAPE (ESC) ATTENTION (ATT) TANGIBLE (TANG) UNDIF ESC + ATT + TANG ESC + TANG ESC + ATT PERCENTAGE OF CASES FUNCTION

13. UNMC Munroe-Meyer Institute 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.

14. UNMC Munroe-Meyer Institute FOODTRIAL Accept Green beans 1Y Chicken 2N Applesauce 3N Potato 4Y Green beans 5Y Chicken 6Y Applesauce 7Y Potato 8Y Green beans 9Y Chicken 10Y TOTAL Accept 8 % 80% FOODTRIAL Accept Potato 1N Applesauce 2N Green beans 3N Chicken 4N Potato 5N Applesauce 6Y Green beans 7N Chicken 8N Potato 9N Applesauce 10Y TOTAL Accept 2 % 20% Meal 1 Meal 2 FOODTRIAL Accept Applesauce 1Y Potato 2N Chicken 3Y Green beans 4N Applesauce 5Y Potato 6N Chicken 7Y Green beans 8Y Applesauce 9N Potato 10Y TOTAL Accept 6 % 60% Meal 3 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. EXAMPLE BASELINE DATA

15. UNMC Munroe-Meyer Institute 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. 0 10 20 30 40 50 60 70 80 90 100 0 PERCENTAGE OF ACCEPTED BITES Baseline 24681012 MEALS

16. UNMC Munroe-Meyer Institute EXAMPLE BASELINE DATA 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. 0 10 20 30 40 50 60 70 80 90 100 0 PERCENTAGE OF ACCEPTED BITES Baseline 24681012 MEALS 0 10 20 30 40 50 60 70 80 90 100 0 PERCENTAGE OF ACCEPTED BITES Baseline 24681012 MEALS

17. UNMC Munroe-Meyer Institute EXAMPLE BASELINE DATA FOODTRIAL Accept Green beans 1N Chicken 2N Applesauce 3N Potato 4N Green beans 5N Chicken 6N Applesauce 7Y Potato 8N Green beans 9N Chicken 10N TOTAL Accept 1 % 10% FOODTRIAL Accept Potato 1N Applesauce 2Y Green beans 3N Chicken 4N Potato 5N Applesauce 6N Green beans 7N Chicken 8N Potato 9N Applesauce 10N TOTAL Accept 1 % 10% Meal 1Meal 2 FOODTRIAL Accept Applesauce 1Y Potato 2N Chicken 3N Green beans 4N Applesauce 5N Potato 6N Chicken 7N Green beans 8N Applesauce 9Y Potato 10N TOTAL Accept 2 % 20% Meal 3 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.

18. 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. 0 10 20 30 40 50 60 70 80 90 100 0 PERCENTAGE OF ACCEPTED BITES Baseline 24681012 MEALS

19. UNMC Munroe-Meyer Institute Functional Analysis Function-Based Treatment Chaser Chin prompt Facilitation/Re- distribution Fading Texture GENERAL TREATMENT PROGRESSION Expulsion/ Packing Effective Treatment Avoidance Fading Momentum No Change Parent Training

20. UNMC Munroe-Meyer Institute 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)

21. UNMC Munroe-Meyer Institute STUDIES ON ESCAPE EXTINCTION  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.  Escape extinction (EE) may be a necessary component of treatment.

22. UNMC Munroe-Meyer Institute 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) Studies on the Effects of Reinforcement Does it make a difference?

23. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 102030405060708090100110120130 PERCENTAGE ACCEPTANCE Sunshine DRA ACC DRA MC 0 10 20 30 40 50 60 70 80 90 100 PERCENTAGE MOUTH CLEAN Sunshine 140 102030405060708090100110120130140 SESSION BLDRA DRA + EE DRADRA + EE BLDRADRA + EEDRADRA + EE 0 0 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.

24. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 102030405060708090100110120130 PERCENTAGE ACCEPTANCE Jarred DRA ACC DRA MC SESSION PERCENTAGE MOUTH CLEAN 0 10 20 30 40 50 60 70 80 90 100 Jarred 102030405060708090100110120130 BLDRA DRA + EE DRA DRA + EE BLDRADRA + EEDRADRA + EE 0 0 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.

25. UNMC Munroe-Meyer Institute What Are the Effects of Differential Positive Reinforcement with and without Escape Extinction? Differential Sr+ Escape Extinction Studies on the Effects of Reinforcement Does it make a difference?

26. UNMC Munroe-Meyer Institute ConditionConsequence for Inappropriate Behavior Bite Presentation Consequence for Mouth Clean ESC20 s of escaperemoved for 20 s brief praise DRA + ESC 20 s of escaperemoved for 20 s access to Sr+ EEno differential consequence remained at child’s lips brief praise DRA + EEno 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.

27. UNMC Munroe-Meyer Institute What Are the Effects of Noncontingent Positive Reinforcement with and without Escape Extinction? Noncontingent Sr+Escape Extinction Studies on the Effects of Reinforcement Does it make a difference?

28. UNMC Munroe-Meyer Institute ConditionConsequence for Inappropriate Behavior Bite Presentatio n Consequence for Mouth Clean ESC20 s of escaperemoved for 20 s brief praise NCR + ESC 20 s of escaperemoved for 20 s access to Sr+ throughout EEno differential consequence remained at child’s lips brief praise NCR + EEno differential consequence remained at child’s lips 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.

29. UNMC Munroe-Meyer Institute 44 246810121416182022242628303436384042 SESSIONS 320 0 10 20 30 40 50 60 70 80 90 100 PERCENTAGE ACCEPTANCE ESC BL vs. DRA+ESC EE vs. DRA+EE ESC BL vs. DRA+ESC EE vs. DRA+EE ESC BL DRA + ESC EE DRA + EE 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.

30. UNMC Munroe-Meyer Institute 44 0 10 20 30 40 50 60 70 80 90 100 246810121416182022242628303436384042 SESSION % NEGATIVE VOCALIZATIONS DRA + ESC ESC BL 32 DRA + EE EE 0 ESC BL vs DRA+ESC EE vs. DRA+EE ESC BL vs DRA+ESC EE vs. DRA+EE 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.

31. UNMC Munroe-Meyer Institute What Are the Effects of Function- Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers? Effects of Function-Based 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.

32. UNMC Munroe-Meyer Institute 0 2 4 6 8 10 12 14 16 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE 024681012141618202224 SESSION ESCAPE CONTROL ATTENTION SAVANNAH 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.

33. UNMC Munroe-Meyer Institute ConditionConsequence for Inappropriate Behavior Bite Presentation ATTN + ESC20 s of attention plus escape removed for 20 s EE + ATTN20 s of attentionremained at child’s lips AE + ESC20 s of escaperemoved for 20 s EE + AEno 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.

34. UNMC Munroe-Meyer Institute ATTN + ESC EE + ATTN vs. AE + ESC EE + ATTN vs. AE + ESC 0 4 8 12 16 20 24 28 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE SAVANNAH EE + AE EE + ATTN AE + ESC ATTN + ESC EE + ATTN vs. AE + ESC EE + ATTN vs. AE + ESC EE + AE 0 10 20 30 40 50 60 70 80 90 100 0102030405060708090100110 SESSION PERCENTAGE ACCEPTANCE SAVANNAH EE + ATTN AE + ESC 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.

35. UNMC Munroe-Meyer Institute What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers? Effects of Function-Based 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.  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

36. UNMC Munroe-Meyer Institute How Effective is Function- versus Sensory-Based Treatment? Comparison of Function-Based and Sensory-Based Treatments 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.

37. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 PERCENTAGE ACCEPTANCE SESSION ESCAPEESC + SIEE + NCRESC + SIEE + NCR 0102030405060708090100110 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.

38. UNMC Munroe-Meyer Institute 0 5 10 15 20 25 30 35 40 45 50 55 0102030405060708090100110 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE SESSION ESCAPEESC+ SIEE + NCR ESC+ SI EE + NCR 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.

39. UNMC Munroe-Meyer Institute COMPARISON OF FUNCTION- VS SENSORY-BASED TREATMENTS  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.  Sensory integration-based treatment produced no change in behavior.  Escape extinction was associated with increased acceptance and decreased inappropriate behavior.

40. 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.

41. UNMC Munroe-Meyer Institute HP 0 10 20 30 40 50 60 70 80 90 100 PUDDING YOGURT PANCAKE WAFFLE STRAWBERRIES APPLESAUCE P B J BREAD AND BUTTER CREAMED CORN CORN ON THE COB PEACHES CHICKEN NUGGETS ORANGES FRENCH FRIES CARROTS GREEN BEANS FOODS PERCENTAGE APPROACH + CONSUME LP 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.

42. UNMC Munroe-Meyer Institute 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. BLENDING Sample Yogurt/Green Bean Blends 80/20 60/4040/60 20/80

43. UNMC Munroe-Meyer Institute 55 SESSIONS APPLE SAUCE/CARROTS 0 10 20 30 40 50 60 70 80 90 100 05101520253035404550 PERCENTAGE MOUTH CLEAN CARROT POTATO 50/50 60/40 70/30 80/20 90/10 APPLESAUCE John 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.

44. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 51015202535 40 4550556065707580859095 SESSION PERCENTAGE MOUTH CLEAN 10%20% 30%100% 10%20%30% 0%5%30% Water + *CIB Fading DRA + EXT CIB + Milk Fading DRA + EXT 100% Milk/CIB 100% CIB/Water Reversal Water Mother Reversal Therapist Mother 100% Milk/CIB Reversal 30 0 Reversal DRA + EXT 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.. *CIB = Carnation Instant Breakfast

45. UNMC Munroe-Meyer Institute 0 6 12 18 24 30 36 42 48 54 0102030405060708090 100 110120130 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE Lips ESC Baseline (BL) vs Fading ESC BL Fading+EE vs Escape Extinction (EE) Lips Escape (ESC) BL Fading+EE vs EE 25.4 cm Lips ESC BL Fading ESC BL EE 20.3 cm 15.2 cm Lips ESC BL Probe 10.2 cm 15.2 cm 15.2 cm 10.2 cm Lips ESC BL Probe 5.1 cm Lips Fading+EE 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. SESSION

46. UNMC Munroe-Meyer Institute 0 20 40 60 80 100 0102030405060708090100110120 SESSION PERCENTAGE ACCEPTANCE Fading+EE vs EE (Escape Extinction) Lips ESC BL Fading+EE vs EE Lips ESC BL vs Fading ESC BL Lips ESC BL EE Lips ESC BL Probe Lips ESC BL Probe Lips 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.

47. UNMC Munroe-Meyer Institute 5 cm 4 cm 3 cm 2 cm 1 cm 0.5 cm Flush Deposit liquid from syringe Deposit from cup Hole in cup bottom 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. Deposit from syringe

48. UNMC Munroe-Meyer Institute 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. 5 cm4 cm3 cm2 cm1 cm BottomTop Next to In mouth At lips Deposit Syringe Deposit Spoon Deposit Syringe

49. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 102030405060708090100110 PERCENTAGE MOUTH CLEAN Session BL EE 0.2 0.3 0.40.5 0.6 0.70.80.91.0 54321 Bottom Top Next to 0.1 EE Spoon EE Spoon Probe Syringe Volume Fading (ml) Syringe to Spoon Fading cm In mouth Lips In mouth In mouth Top Spoon Position 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. 0.1 to 1.0 Spoon

50. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 102030405060708090100110 PERCENTAGE MOUTH CLEAN SESSION BL Cup Spoon EE + AE BL Escape Extinction (EE) + Attention Extinction (AE) Spoon-to- Cup Fading 1-Year Follow Up 3.8 cm3.2 cm 2.6 cm 2.1 cm 1.5 cm 3.8 3.2 2.6 2.1 1.5

51. 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.

52. UNMC Munroe-Meyer Institute NUK WITH FACILITATION

53. UNMC Munroe-Meyer Institute FLIPPED SPOON

54. UNMC Munroe-Meyer Institute Percentage of Packed Bites 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.

55. UNMC Munroe-Meyer Institute RE-DISTRIBUTION

56. UNMC Munroe-Meyer Institute SESSIONS 0 4 8 12 16 20 24 28 32 36 40 10203040506070 BASELINE (BL) Spoon Nuk RE-PRESENTATION BL RE-PRES 0 EXPELS PER BITE 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.

57. UNMC Munroe-Meyer Institute CHIN PROMPT

58. UNMC Munroe-Meyer Institute Re-presentation Re-presentationplus chin promptRe-presentation Re-presentationplus chin prompt 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, 513- 544. 0 1 2 3 4 5 6 7 102030405060708090100110120130140 EXPELS PER BITE SESSION BASELINE (BL) CHIN PROMPT BL 0

59. UNMC Munroe-Meyer Institute  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. Chaser

60. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 024681012141618202224 PERCENTAGE PACK SESSION Baseline Chaser 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

61. UNMC Munroe-Meyer Institute  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. TEXTURE OR CONSISTENCY MANIPULATION

62. UNMC Munroe-Meyer Institute PURREED WET GROUND CHOPPED TABLE TEXTURE (1/4x1/4x1/4)

63. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 PERECENTAGE PACK PUREE WET GROUND SESSION 10 2030 40 5 15 25 35 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.

64. 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.

65. UNMC Munroe-Meyer Institute AVOIDANCE

66. UNMC Munroe-Meyer Institute Functional Analysis Function-Based Treatment Chaser Chin prompt Facilitation/Re- distribution Fading Texture GENERAL TREATMENT PROGRESSION Expulsion/ Packing Effective Treatment Avoidance Fading Momentum No Change Parent Training

67. 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.

68. UNMC Munroe-Meyer Institute SUMMARY  We used other procedures in addition to EE for 53% of the interventions.

69. UNMC Munroe-Meyer Institute University of Nebraska Medical Center