1. Assessment and Treatment of Feeding Disorders in Children
Cathleen C. Piazza, Ph.D.
University of Nebraska Medical Center’s Munroe-Meyer Institute

2. Feeding Behavior
No human activity has greater biological and social significance than feeding.

3. Achievement of feeding milestones.
Achievement of adequate physical growth.
Feeding Behavior
Successful feeding is measured against a set of social and cultural standards.

4. PEDIATRIC FEEDING DISORDERS
Identified when a child fails to consume a sufficient variety or quantity of food to maintain nutritional status

5. FEEDING PROBLEMS AND AUTISM
Approximately 30% to 80% of children
Untreated feeding problems are associated with poor physical growth and learning and behavior problems

6. TYPICAL VS. DISORDERED FEEDING
Accepts breast or bottle
Starts baby food around 4 to 6 months of age
Transitions to mashed table foods by 12 months of age
Has difficulty breast or bottle feeding
Consistently rejects baby food
Has difficulty transitioning to mashed table foods

7. TYPICAL VS. DISORDERED FEEDING
Picky eating emerges at 18 months of age
Variety will reemerge with exposure
Variety will be sufficient to provide adequate nutrition
Reaction to non-preferred food is excessive
Inflexible food preferences may change, but variety remains restricted
Variety does not provide adequate nutrition

8. TYPICAL VS. DISORDERED FEEDING
Preferences are influenced by peers
Eating persists in different environmental conditions
Will eat non- preferred food when hungry
Insensitive to social cues around eating
Eating is disrupted in different conditions
Will not eat non- preferred food even when hungry

9. PEDIATRIC FEEDING DISORDERS
Child has any one of the following:
Child has three consecutive months of weight loss
Child is diagnosed with dehydration or malnutrition, which results in emergency treatment
Child has nasogastric tube with no increase in the amount of calories from oral feeding for 3 consecutive months

10. TPYICAL
DISORDERED
Child should maintain growth along his or her own curve.
Growth should not decelerate.

11. PEDIATRIC FEEDING DISORDERS
Meal lengths over 30 minutes are the best predictor of a feeding disorder relative to any other target behavior.

12. INTERDISCIPLINARY APPROACH
Consider a comprehensive, interdisciplinary evaluation before starting treatment

13. INTERDISCIPLINARY APPROACH
Interdisciplinary team evaluation:
Medicine: Rule out physical causes of feeding problem
Nutrition: Evaluate adequacy of current intake
Social Work: Evaluate family stressors
Speech/Occupational Therapy: Evaluate oral-motor status and safety
Psychology: Assess contribution of environmental factors

14. MEDICAL CONDITIONS -
Approximately 60% of children with feeding problems also have medical problems.

15. CALORIC NEEDS BY AGE (KCALS)
(YEARS) 1
2-3
4-8
9-13
14-18
900
1000
FEMALE
1200
1600
1800
MALE
1400
2200

16. NUTRITIONAL REQUIREMENTS
AGE
(YEARS) 1
2-3
4-8
9-13
14-18
FAT (%KCAL)
30-40
30-35
25-35
DAIRY (C) 2 3
PROTEIN (OZ)
1.5 3F 4M 5 5F 6M
FRUITS (C)
1.5F 2M
VEGETABLES (C)
3/4 1F
1.5M 2F
2.5M
2.5F 3M
GRAINS (OZ) 4F 5M 6F 7M

18. ORAL-MOTOR DYSFUNCTION
Approximately 40% of children diagnosed with a feeding disorder will have an oral-motor skill deficit.

20. SETTING GOALS FOR TREATMENT
Goals should be:
Individualized
Observable
Measurable
Sample goals:
Increase total oral intake to 50% of needs
Increase variety by 8 new foods
Increase acceptance of solids to 80%
Decrease inappropriate mealtime behavior to 1 per minute or less

21. ASSESSMENT Why is it important to structure meals?
Creates a predictable environment for the child
Ensures the expectations of the meal are clear to the child
Allows for systematic changes when doing treatment components
-playing a game, Farnam street,
-exam

22. HOW DO WE STRUCTURE THE MEAL?
Identify foods you will present
Identify food type
Specify foods by name, food group, brand, recipe
Identify food texture
Precisely describe how you make the texture

23. SPECIALTY PRODUCTS
Consult a speech or occupational therapist if your child has swallowing difficulties.
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Consult a dietitian if your child has poor weight gain or poor nutrition.

24. EATING AND DRINKING UTENSILS
Rubber- Coated Baby Spoons
Maroon Spoons
Nuk Brush
Cut-out (nosey) cups

25. HOW DO WE STRUCTURE THE MEAL?
Solids
UTENSIL TYPE
BOLUS
Coated baby spoon
¼ level spoon
½ level spoon
Level spoon
Small maroon spoon
Large maroon spoon
Sample guideline for selecting bolus

26. HOW DO WE STRUCTURE THE MEAL?
Length of meal
Time based (e.g., 5 min, 15 min)
Bite or drink based (e.g., 1 bite, 5 bites)
Set the child up for success
What is feasible for follow through?

27. OPERATIONALLY DEFINING BEHAVIOR
Concise, detailed definition of behavior
Used to remove ambiguity and ensure all data collectors are measuring same behavior

28. SAMPLE DATA SHEETS FOOD TRIAL FOOD TRIAL FOOD TRIAL FOOD TRIAL
Name of each food
Bite or presen-
tation number
Child behaviors
of concern
Sample data sheet for a child who refuses food and engages in inappropriate behavior
FOOD
TRIAL 1 2 3 4
FOOD
TRIAL
Accept
Inapprop
Behavior
Green beans 1
Chicken 2
Applesauce 3
Potato 4
Sample data sheet for a child who does not swallow food consistently (holds food in mouth) and gags
Sample data sheet for a child who spits food out of his or her mouth and cries
FOOD
TRIAL
Swallow
Gag
Chips 1
Hamburger 2
Peas 3
Peach 4
FOOD
TRIAL
Spit out
Cries
Fish 1
Rice 2
Pears 3
Broccoli 4

29. SAMPLE DATA SHEET
Sample data for a child who refuses food and engages in inappropriate behavior.
FOOD
TRIAL
Accept
Inapprop
Behavior
Green beans 1 Y N
Chicken 2
Applesauce 3
Potato 4
Child did not have inappropriate behavior during presentation of green beans.
Child accepted green beans.
Child had inappropriate behavior during presentation of chicken.
Child did not accept chicken.
Child did not accept applesauce.
Child had inappropriate behavior during presentation of applesauce.
Child accepted potato.
Child had inappropriate behavior during presentation of potato.
Y = Yes
N = No

30. HOW DO I USE THIS INFORMATION TO DEVELOP A TREATMENT FOR MY CHILD?
1. Start a baseline. The baseline gives you information about your child’s current behavior. You will use this baseline to determine if child behavior is improving once you start treatment. Don’t try to take a short cut and skip this step.
2. What is a baseline? It’s a series of things you do consistently during meals. Just do what you have been doing, only do the same thing every meal. For example, make the meals the same length, use the same utensils.
3. Take data. The data will be the ONLY way you will know whether your child’s behavior is improving. Don’t try to take a short cut and skip this step.

31. HERE’S AN EXAMPLE OF A BASELINE
There is no “right” way or “wrong” way of doing a baseline. Here’s an example, but what you do will be specific to you and your child.
Meal length: 10 minutes
Utensil: Small maroon spoon
Amount on spoon: Fill the bowl of the spoon
Foods that you will present: Chicken, green beans, peaches, potato
Number of bites: 4 bites of each food (8 bites total)
Procedure:
At meal time, tell your child it is “time to eat”. Tell your child to sit at the table.
Once your child is seated at the table, put the plate of food in front of him and say “It’s time to eat.”
Set a timer for 10 minutes.
Remind your child once every minute, “It’s time to eat.” (one reminder every minute in a 10-minute meal = 10 reminders). Only give the reminder at the scheduled time and not at any other time.
Any time your child puts a bite in his mouth or swallows a bite, say “Good job” as enthusiastically as you can.
If your child has inappropriate behavior (e.g., pushes the plate away) or cries, do not respond. Wait until the scheduled time for the reminder and say, “It’s time to eat.”
At the end of 10 minutes, remove the plate and allow your child to leave the table.

32. EXAMPLE BASELINE DATA 1 N 2 3 4 5 6 7 Y 8 9 10 10% 1 Y 2 N 3 4 5 6 7 8
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
Accept
Green beans 1 N
Chicken 2
Applesauce 3
Potato 4 5 6 7 Y 8 9 10
TOTAL Accept %
10%
FOOD
TRIAL
Accept
Applesauce 1 Y
Potato 2 N
Chicken 3
Green beans 4 5 6 7 8 9 10
TOTAL %
20%
FOOD
TRIAL
Accept
Potato 1 N
Applesauce 2 Y
Green beans 3
Chicken 4 5 6 7 8 9 10
TOTAL %
10%

33. 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. 10 20 30 40 50 60 70 80 90
100
PERCENTAGE OF
ACCEPTED BITES
Baseline 2 4 6 8 12
MEALS
-here we have some baseline top, the top panel represents the child’s 5 s acc, the bottom panel represents the child’s imtb during the meal
Each data point represents one an average for 5 bites, each data point represents one session not one meal because you might conduct 5 sessions in one meal block which would be 25 bite presentations
-we divide the meal into these 5-bite sessions to make it easier on the child, I do five bites then they get a little break, we also break it up in this way to be able to look at the pattern of the data

34. EXAMPLE BASELINE DATA 1 Y 2 N 3 4 5 6 7 8 9 10 80% 1 N 2 3 4 5 6 Y 7 8
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 1
Meal 2
Meal 3
FOOD
TRIAL
Accept
Green beans 1 Y
Chicken 2 N
Applesauce 3
Potato 4 5 6 7 8 9 10
TOTAL %
80%
FOOD
TRIAL
Accept
Potato 1 N
Applesauce 2
Green beans 3
Chicken 4 5 6 Y 7 8 9 10
TOTAL %
20%
FOOD
TRIAL
Accept
Applesauce 1 Y
Potato 2 N
Chicken 3
Green beans 4 5 6 7 8 9 10
TOTAL %
60%

35. 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. 10 20 30 40 50 60 70 80 90
100
PERCENTAGE OF
ACCEPTED BITES
Baseline 2 4 6 8 12
MEALS
-here we have some baseline top, the top panel represents the child’s 5 s acc, the bottom panel represents the child’s imtb during the meal
Each data point represents one an average for 5 bites, each data point represents one session not one meal because you might conduct 5 sessions in one meal block which would be 25 bite presentations
-we divide the meal into these 5-bite sessions to make it easier on the child, I do five bites then they get a little break, we also break it up in this way to be able to look at the pattern of the data

36. EXAMPLE BASELINE DATA MEALS10 20 30 40 50 60 70 80 90
100
PERCENTAGE OF
ACCEPTED BITES
Baseline 2 4 6 8 12
MEALS 10 20 30 40 50 60 70 80 90
100
PERCENTAGE OF
ACCEPTED BITES
Baseline 2 4 6 8 12
MEALS
-here we have some baseline top, the top panel represents the child’s 5 s acc, the bottom panel represents the child’s imtb during the meal
Each data point represents one an average for 5 bites, each data point represents one session not one meal because you might conduct 5 sessions in one meal block which would be 25 bite presentations
-we divide the meal into these 5-bite sessions to make it easier on the child, I do five bites then they get a little break, we also break it up in this way to be able to look at the pattern of the 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.

37. I DID MY BASELINE. THE LEVELS OF ACCEPTANCE ARE STABLE. NOW WHAT?
100
Baseline
Treatment ? 90 80 70 60
PERCENTAGE OF
ACCEPTED BITES 50 40 30 20 10 2 4 6 8 10 12
MEALS

38. REINFORCEMENT-BASED TREATMENT
Reinforcement can be an effective way to increase consumption.
There are certain ways to use reinforcement so that it will work.

39. REINFORCEMENT-BASED TREATMENT
For reinforcement to work:
You have to use something that is highly preferred by your child.
Reinforcement has to be immediate.
You cannot let your child have the reinforcer at any other time (only use the reinforcer for eating).

40. In some cases, you can use tokens, which the child can exchange after the meal for access to preferred items and/or activities.

41. FADING-BASED TREATMENT
Fading can be an effective way to increase consumption.
There are certain ways to use fading so that it will work.

42. FADING-BASED TREATMENT
What is fading?
Fading involves identifying something your child will do now (e.g., eats yogurt consistently).
Gradually changing what your child does now or gradually changing the expectations of what you want your child to do.
The gradual changes result in changes in what or how your child eats.

43. SYRINGE-TO-SPOON FADING
When to Use: Child will swallow liquids or pureed foods from a syringe, but will not accept foods from a spoon.
5 cm
4 cm
3 cm
2 cm
1 cm
Bottom
Top
Next to
In mouth
At lips
Deposit Syringe
Deposit Spoon

44. BLENDING
When to Use: Child eats at least three foods reliably and has no concerns with weight.
Examples of Blends

45. 3.8 cm
3.2 cm
2.6 cm
2.1 cm
1.5 cm
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,

46. TEXTURE FADING
When to Use: Child eats at least a few smooth foods (e.g., yogurt, applesauce) consistently, but eating is more variable with foods at higher textures. Only use if the child is able to chew the higher-textured food.

47. BITE FADING
When to Use: Child will eat a variety of foods, but only in small amounts.
STEP
# SPOONS OF FOOD
TO PRESENT 1 2 3 4 5 6 7 8

48. LIQUIDS TO SOLIDS
When to Use: Child will drinks liquids from a cup, but will not eat solids from a spoon.
1.5 cm
2.1 cm
2.6 cm
3.2 cm
3.8 cm

49. SOLIDS TO LIQUIDS
When to Use: Child will eat pureed solids from a spoon, but will not drink liquids from a cup.
3.8 cm
3.2 cm
2.6 cm
2.1 cm
1.5 cm

50. How to Progress Using a Fading Procedure
Example Criterion = 3 meals in a row with accept 75% or greater, move to next step.
Meal 1
Meal 2
Meal 3
FOOD
TRIAL
Accept
Green beans 1 Y
Chicken 2 N
Applesauce 3
Potato 4 5 6 7 8 9 10
TOTAL %
80%
FOOD
TRIAL
Accept
Potato 1 N
Applesauce 2 Y
Green beans 3
Chicken 4 5 6 7 8 9 10
TOTAL %
80%
FOOD
TRIAL
Accept
Applesauce 1 Y
Potato 2 N
Chicken 3
Green beans 4 5 6 7 8 9 10
TOTAL %
80%

51. FADING-BASED TREATMENT
Fading works best when:
You are consistent. Make a plan, then follow it.
Make changes gradually. Most common mistake is making changes too fast.

52. TREATMENT PLAN EXAMPLE
Example of treatment plan:
Joe eats only a few foods consistently.
He eats french fries, spaghetti, candy, cookies, and crackers.
He does not eat any vegetables, few fruits, and no meat.
He eats applesauce, yogurt, and pudding.

53. TREATMENT PLAN EXAMPLE
Our treatment plan will have several parts:
Reinforcement for consumption.
Blending.
Bite fading.

54. TREATMENT PLAN EXAMPLE
Reinforcement for consumption.
Joe’s favorite activity is watching a video on his I pad.
Joe will be able to watch the video only during meals. The video will not be available at any other time.

55. TREATMENT PLAN EXAMPLE
We need to make sure that Joe maintains his weight.
Joe will eat breakfast, lunch, and dinner with the family.
During the family meal, Joe will have a plate of food with a small amount of food the family is eating.
The plate also will have foods that we know Joe will eat.
We will not serve spaghetti or pudding at these meals.

56. TREATMENT PLAN EXAMPLE
We will start treatment at a specific time (not during a family meal) so the family meal will not be disrupted.
Mom will do the treatment at 10 am.
We will choose one food (peaches) to target for treatment first.
For at least three days at 10 am, mom will present a plate with 4 teaspoons of pureed peaches on a plate in front of Joe.
She will set a timer for 5 minutes.
Once a minute, mom will tell Joe to “Take a bite”.

57. TREATMENT PLAN EXAMPLE
Joe takes a bite of peaches on the first day, but never takes another bite of peaches for the next 3 meals.

58. TREATMENT PLAN EXAMPLE
We decide to use a combination treatment.
We will use blending with pudding.
We will use bite fading in which we start by presenting 1 bite of the blended food.
We will let Joe watch his video for 30 seconds each time he takes a bite of the blended food.

59. TREATMENT PLAN EXAMPLE
The procedures will be similar to baseline.
Mom will do the treatment at 10 am.
She will set a timer for 5 minutes.
Once a minute, mom will tell Joe to “Take a bite.”

60. TREATMENT PLAN EXAMPLE
Here are the treatment procedures.
Mom will place one bite on the plate (bite fading).
The bite will be 1 teaspoon of pudding mixed (blended) with peaches (90% pudding/10% peaches).
If Joe eats the bite within 5 minutes, mom will allow him to watch his video for 30 seconds (reinforcement).

61. TREATMENT PLAN EXAMPLE
The rule for fading to the next step will be three meals in a row with acceptance 75% or higher, which we will call a “pass”.
The rule for fading to the previous step will be three meals in a row with acceptance less than 75%, which we will call a “fail”.

62. JOE’S DATA
Joe accepted 1 bite during each of the meals, except Meal 6.
Meal 5
Meal 6
Meal 7
Meal 8
Meal 9
FOOD
TRIAL
Accept
90% Pudding/
10% Peaches 1 Y
TOTAL ACCEPT %
100%
TRIAL
Accept 1 N 0%
TRIAL
Accept 1 Y
100%
TRIAL
Accept 1 Y
100%
TRIAL
Accept 1 Y
100%
1 bite
Three meals in a row with acceptance > 75%.
100
Baseline 90 80 70 60
PERCENTAGE OF
ACCEPTED BITES 50 40 30 20 10 2 4 6 8 10 12
MEALS

63. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND 1
90% pudding/10% peaches 2 3 4 5
80% pudding/20% peaches 6
70% pudding/30% peaches 7
60% pudding/40% peaches 8
50% pudding/50% peaches 9
40% pudding/60% peaches 10
30% pudding/70% peaches 11
20% pudding/80% peaches 12
10% pudding/90% peaches 13
100% peaches
# OF BITES CHANGE
BLEND STAYS THE SAME
# OF BITES
STAYS THE SAME
BLEND CHANGES

64. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND
PASS (P) OR FAIL (F) 1
90% pudding/10% peaches P 2
Three meals in a row with acceptance > 75%. Go to Step 2.
1 bite
100
Baseline 90 80 70 60
PERCENTAGE OF
ACCEPTED BITES 50 40 30 20 10 2 4 6 8 10 12
MEALS

65. JOE’S DATA Joe accepted 2 bites during each of the meals. 1 Y 2 TOTAL
STEP 2
FOOD
TRIAL
Accept
90% Pudding/
10% Peaches 1 Y 2
TOTAL %
100%
TRIAL
Accept 1 Y 2
100%
TRIAL
Accept 1 Y 2
100%
Three meals meals in a row with acceptance > 75%. Go to Step 3.
1 bite
2 bites
100
Baseline 90 80 70
PERCENTAGE OF
ACCEPTED BITES 60 50 40 30 20 10 2 4 6 8 10 12
MEALS

66. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND
PASS (P) OR FAIL (F) 1
90% pudding/10% peaches P 2 3
1 bite
2 bites
100
Baseline 90 80 70
Three meals with in a row acceptance > 75%. Go to Step 3. 60
PERCENTAGE OF
ACCEPTED BITES 50 40 30 20 10 2 4 6 8 10 12
MEALS

67. JOE’S DATA Joe accepted 2 bites during each of the meals. 1 Y 2 3 N
STEP 3
Meal 14
Meal 15
Meal 16
FOOD
TRIAL
Accept
90% Pudding/
10% Peaches 1 Y 2 3 N
TOTAL ACCEPT %
67%
TRIAL
Accept 1 Y 2 N 3
67%
TRIAL
Accept 1 Y 2 3 N
67%
2 BITES
3 BITES
1 BITE
100
Baseline 90 80 70 60
PERCENTAGE OF
ACCEPTED BITES 50 40
Three meals in a row with acceptance < 75%. Go back to Step 2. 30 20 10 2 4 6 8 12 14 16
MEALS 10

68. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND
PASS (P) OR FAIL (F) 1
90% pudding/10% peaches P 2 3 F
1 BITE
2 BITES
3 BITES
100
Baseline 90 80 70 60
PERCENTAGE OF
ACCEPTED BITES 50 40
Three consecutive meals with acceptance < 75%. Go back to Step 2. 30 20 10 2 4 6 8 10 12 14 16
MEALS

69. TREATMENT PLAN EXAMPLE
Joe accepted 2 bites during each of the meals.
Meal 17
Meal 18
Meal 19
STEP 2
FOOD
TRIAL
Accept
90% Pudding/
10% Peaches 1 Y 2
TOTAL %
100%
TRIAL
Accept 1 Y 2
100%
TRIAL
Accept 1 Y 2
100% 10 20 30 40 50 60 70 80 90
100
Baseline 2 4 6 8 12
MEALS
Three meals in a row with acceptance >75%. Go to Step 3. 14 16
1 BITE
2 BITES
3 BITES 18
PERCENTAGE OF
ACCEPTED BITES

70. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND
PASS (P) OR FAIL (F) 1
90% pudding/10% peaches P 2 3 F

71. TREATMENT PLAN EXAMPLE
STEP #
# BITES
BLEND 1
90% pudding/10% peaches 2 3 4 5
80% pudding/20% peaches 6
70% pudding/30% peaches 7
60% pudding/40% peaches 8
50% pudding/50% peaches 9
40% pudding/60% peaches 10
30% pudding/70% peaches 11
20% pudding/80% peaches 12
10% pudding/90% peaches 13
100% peaches
Continue to follow the treatment plan until you reach the goal.

72. What is the Key to Effective Treatment?
CONSISTENCY!!

73. University of Nebraska Medical Center

74. ADDITIONAL READINGS

75. AVOIDANCE
Rivas, K. M., Piazza, C. C., Roane, H. S., Volkert, V. M., Stewart, V., Kadey, H. J., & Groff, R. A. (in press). 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,
Kelley, M. E., Piazza, C. C., Fisher, W. W., & Oberdorff, A. J. (2003). Acquisition of cup drinking using previously refused foods as positive and negative reinforcement. Journal of Applied Behavior Analysis, 36,

76. AUTISM
Tang, B., Piazza, C. C., Dolezal, D., & Stein, M. T. (2011). Severe feeding disorder and malnutrition in two children with autism. Journal of Developmental and Behavioral Pediatrics. 32(3),
Kodak, T., & Piazza, C. C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child and Adolescent Psychiatric Clinics of North America, 17(4),

77. 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,

78. CHEWING
Volkert, V. M., Piazza, C. C., Vaz, P. C. M., & Frese, J. (2013). A pilot study to increase chewing in children with feeding disorders. Behavior Modification, 37,
Volkert, V. M., Peterson, K. M., Zeleny, J. R., & Piazza, C. C. (2014). A clinical protocol to increase chewing and assess mastication in children with feeding disorders. Behavior Modification.

79. 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,
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,
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,
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,
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,
Kelley, M. E., Piazza, C. C., Fisher, W. W., & Oberdorff, A. J. (2003). Acquisition of cup drinking using previously refused foods as positive and negative reinforcement. Journal of Applied Behavior Analysis, 36,
Freeman, K. A., & Piazza, C. C. (1998). Combining stimulus fading, reinforcement, and extinction to treat food refusal. Journal of Applied Behavior Analysis, 31,

80. FADING Bite Blending Liquid to baby food Spoon distance Spoon to cup
Freeman, K. A., & Piazza, C. C. (1998). Combining stimulus fading, reinforcement, and extinction to treat food refusal. Journal of Applied Behavior Analysis, 31,
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,
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,
Liquid to baby food
Bachmeyer, M. H., Gulotta, C. S., & Piazza, C. C. (2013). Liquid to baby food fading in the treatment of food refusal. Behavioral Interventions, 34,
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,
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,
Syringe to cup and spoon
Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in press). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.

81. SIMULTANEOUS PRESENTATION
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,
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,
Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H., Delia, M. D., & Lancaster, B. M. (2002). An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35,

82. FUNCTIONAL ANALYSIS
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,
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,

83. HIGH-PROBABILTY REQUESTS
Patel, M. R., Reed, G. K., Piazza, C. C., Mueller, M., Bachmeyer, M. H., & Layer, S. A. (2007). Use of a high-probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction. Behavioral Interventions, 22(4),
Patel, M. R., Reed, G. K., Piazza, C. C., Bachmeyer, M. H., Layer, S. A., & Pabico, R. S. (2006). An evaluation of a high-probability instructional sequence to increase acceptance of food and decrease inappropriate behavior in children with pediatric feeding disorders. Research in Developmental Disabilities, 27,
Dawson, J. E., Piazza, C. C., Sevin, B. M., Gulotta, C. S., Lerman, D., & Kelley, M. L. (2003). Use of the high-probability instructional sequence and escape extinction in a child with food refusal. Journal of Applied Behavior Analysis, 36,

84. PARENT TRAINING
Mueller, M. M., Piazza, C. C., Moore, J. W., Kelley, M. E., Bethke, S. A., Pruett, A. E., Oberdorff, A. J., & Layer, S. A. (2003). Training parents to implement pediatric feeding protocols. Journal of Applied Behavior Analysis, 36,

85. REVIEWS AND BOOK CHAPTERS
Piazza, C. C. (2008). Feeding disorders and behavior: what have we learned? Developmental Disabilities Research Reviews, 14(2),

86. SELF-FEEDING
Rivas, K. M., Piazza, C. C., Roane, H. S., Volkert, V. M., Stewart, V., Kadey, H. J., & Groff, R. A. (in press). 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,
Piazza, C. C., Anderson, C., & Fisher, W. (1994). Teaching clients with Rett syndrome to self-feed. Developmental Medicine and Child Neurology, 35,

87. SENSORY INTEGRATION
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,

88. TEXTURE OR CONSISTENCY MANIPULATION
Kadey, H., Piazza, C. C., Rivas, K. M., & Zeleny, J. (2013). An evaluation of texture manipulations to increase swallowing. Journal of Applied Behavior Analysis, 46,
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,
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,

89. TREATMENT OF EXPULSION
Wilkins, J. W., Piazza, C C., Groff, R. A., Volkert, V. M., Kozisek, J. K., & Milnes, S. M. (in press). Utensil manipulation during initial treatment of pediatric feeding problems. Journal of Applied Behavior Analysis.
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,
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,

90. TREATMENT OF MOUTH CLEAN AND PACKING
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,
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,
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,
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,

91. UTENSIL MANIPULATION
Wilkins, J. W., Piazza, C. C., Groff, R. A., Volkert, V. M., Kozisek, J. M., & Milnes, S. M. (in press). Utensil manipulation during initial treatment of pediatric feeding problems. Journal of Applied Behavior Analysis.