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

Treatment of Pediatric Feeding Disorders

Cathleen C. Piazza

University of Nebraska Medical Center’s Munroe-Meyer Institute

UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer Institute

PEDIATRIC FEEDING DISORDERS

Identified when a child fails to consume a sufficient variety or quantity of food to maintain nutritional status


INTERDISCIPLINARY APPROACH

Consider an interdisciplinary evaluation prior to initiation of treatment

Practice within your scope of competence


EATING AND DRINKING UTENSILS

Rubber- Coated Baby

Spoons

Maroon Spoons Nuk Brush

Cut-out (nosey) cups

http://www.beyondplay.com/CATALOG/ORA2.HTM

http://www.beyondplay.com/ITEMS/T496.HTM


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.


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

Functional Analysis


Escape ConditionFeeder delivers 30 s of escape following inappropriate behavior.


Attention ConditionFeeder delivers 30 s of attention following inappropriate behavior.


Control ConditionFeeder provides continuous access to toys and attention. No

differential consequence following inappropriate behavior.


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ATTENTION VS CONTROL ESCAPE VS CONTROL

ATTENTION

CONTROL

ESCAPE

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


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 ResultsN = 38

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ESCAPE(ESC)

ATTENTION

(ATT)

TANGIBLE (TANG)

UNDIF ESC + ATT + TANG

ESC+ TANG

ESC+ ATT

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FUNCTION



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.


FOOD TRIAL Accept

Green beans 1 YChicken 2 NApplesauce 3 NPotato 4 YGreen beans 5 YChicken 6 YApplesauce 7 YPotato 8 YGreen beans 9 YChicken 10 Y

TOTAL Accept 8

% 80%

FOOD TRIAL Accept

Potato 1 NApplesauce 2 NGreen beans 3 NChicken 4 NPotato 5 NApplesauce 6 YGreen beans 7 NChicken 8 NPotato 9 NApplesauce 10 Y

TOTALAccept 2

% 20%

Meal 1 Meal 2FOOD TRIAL Accept

Applesauce 1 YPotato 2 NChicken 3 YGreen beans 4 NApplesauce 5 YPotato 6 NChicken 7 YGreen beans 8 YApplesauce 9 NPotato 10 Y

TOTALAccept 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



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.

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Baseline

2 4 6 8 10 12

MEALS



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.

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FOOD TRIAL Accept

Green beans 1 NChicken 2 NApplesauce 3 NPotato 4 NGreen beans 5 NChicken 6 NApplesauce 7 YPotato 8 NGreen beans 9 NChicken 10 N

TOTAL Accept 1

% 10%

FOOD TRIAL Accept

Potato 1 NApplesauce 2 YGreen beans 3 NChicken 4 NPotato 5 NApplesauce 6 NGreen beans 7 NChicken 8 NPotato 9 NApplesauce 10 N

TOTALAccept 1

% 10%

Meal 1 Meal 2FOOD TRIAL Accept

Applesauce 1 YPotato 2 NChicken 3 NGreen beans 4 NApplesauce 5 NPotato 6 NChicken 7 NGreen beans 8 NApplesauce 9 YPotato 10 N

TOTALAccept 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.



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.

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MEALS


Functional Analysis

Function-Based Treatment

ChaserChin prompt

Facilitation/Re-distribution

FadingTexture

GENERAL TREATMENT PROGRESSION

Expulsion/

Packing

Effective Treatment

AvoidanceFading

Momentum

No Change

Parent Training


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)


STUDIES ON ESCAPE EXTINCTION


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.


Reinforcement of the First Behavior in the Chain (Acceptance) vsReinforcement 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?


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Sunshine

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SESSION

BL DRA DRA + EE DRA DRA + EE


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What Are the Effects of Differential Positive Reinforcement with and without Escape Extinction?

Differential Sr+ Escape Extinction




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


access to Sr+



What Are the Effects of Noncontingent Positive Reinforcement with and without Escape Extinction?

Noncontingent Sr+ Escape Extinction




Condition Consequence for

Inappropriate Behavior

Bite Presentatio

nConsequence

for Mouth Clean

ESC 20 s of escape removed for 20 s

brief praise

NCR + ESC

20 s of escape removed for 20 s

access to Sr+throughout

EE no differential consequence


brief praise

NCR + EE no differential consequence


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.


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SESSIONS

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ESC BL vs. DRA+ESC

EE vs. DRA+EEESC BL vs.DRA+ESC EE vs. DRA+EE

ESC BL DRA + ESCEE

DRA + EE



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DRA + ESC

ESC BL

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DRA + EE

EE

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ESC BL vs DRA+ESC

EE vs. DRA+EEESC BL vsDRA+ESC EE vs. DRA+EE



What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers?

Effects of Function-Based Treatment



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ESCAPE

CONTROL

ATTENTION

SAVANNAH



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




ATTN + ESC

EE + ATTN vs. AE + ESC


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EE + AE EE + AE

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ATTN+ ESC



EE + AE EE + AE

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What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers?

Effects of Function-Based Treatment


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


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.


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ESCAPE ESC + SI EE + NCR ESC + SI EE + NCR

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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.


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


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.


HP

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PUDDING

YOGURT

PANCAKE

WAFFLE

STRAWBERRIE

S

APPLESAUCE

P B J

BREAD AND B

UTTER

CREAMED C

ORN

CORN ON T

HE COB

PEACHES

CHICKEN N

UGGETS

ORANGES

FRENCH FRIE

S

CARROTS

GREEN BEANS

FOODS

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CO

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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.


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 60/40 40/60 20/80


55

SESSIONS

APPLE SAUCE/CARROTS

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POTATO

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90/10

AP

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AU

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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.


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10% 20% 20% 30%100% 10% 20% 30% 30%

0%5% 30%

Water + *CIB FadingDRA + EXT

CIB + Milk FadingDRA + EXT

100

% M

ilk/

CIB

100

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IB/W

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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


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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

FadingESC BL

EE

20.3cm

15.2 cm

LipsESC BLProbe

10.2 cm

15.2 cm

15.2cm

10.2 cm

LipsESC BLProbe

5.1 cmLips

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


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Fading+EE vs EE(Escape Extinction)

Lips ESC BL Fading+EE vs EE

Lips ESC BL vs Fading

ESC BL

LipsESC BL

EE LipsESC BLProbe

LipsESC BLProbe

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.


5 cm 4 cm3 cm

2 cm

1 cm

0.5 cm

Flush

Deposit liquid from syringe

Deposit from cupHole 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



5 cm 4 cm 3 cm 2 cm 1 cm

Bottom TopNext toIn mouth At lips

Deposit Syringe

Deposit Syringe Deposit Spoon Deposit Syringe


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TopNext

to0.1 EESpoon

EE SpoonProbe

Syringe Volume Fading (ml)

Syringe to Spoon Fading

cmIn

mouth

LipsIn

mouthIn

mouth

Top

Top

Top

Spoon Position


0.1 to 1.0Spoon


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Escape Extinction (EE) +Attention Extinction (AE)

Spoon-to- Cup Fading

1-Year Follow Up

3.8 cm 3.2 cm 2.6 cm 2.1 cm 1.5 cm

3.8 3.2 2.6 2.1 1.5


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


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.


NUK WITH FACILITATION


FLIPPED SPOON


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Baseline Flipped Spoon Baseline Flipped Spoon Parent Training

3-weekfollow-up

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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.


RE-DISTRIBUTION


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Nuk

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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.


CHIN PROMPT

UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer InstituteRe-presentation Re-presentation plus chin prompt Re-presentation Re-presentation plus 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.

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BASELINE (BL) CHIN PROMPT CHIN PROMPTBL

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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


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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


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


PURREED WET GROUND

CHOPPED TABLE TEXTURE (1/4x1/4x1/4)


0

10

20

30

40

50

60

70

80

90

100

PE

RE

CE

NTA

GE

PA

CK

PUREE PUREEWET GROUND WET GROUND

SESSION10 20 30 405 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.


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.


AVOIDANCE


Functional Analysis

Function-Based Treatment

ChaserChin prompt

Facilitation/Re-distribution

FadingTexture

GENERAL TREATMENT PROGRESSION

Expulsion/

Packing

Effective Treatment

AvoidanceFading

Momentum

No Change

Parent Training


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.


SUMMARY

We used other procedures in addition to EE for 53% of the interventions.

UNMC Munroe-Meyer InstituteUNMC Munroe-Meyer InstituteUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center

Documents

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