Pittsburg State University

Pittsburg State University Digital Commons

Electronic Theses & Dissertations

Fall 12-13-2019

Behavior Skills Training to Improve Parent Treatment Fidelity and

Generalization in a Feeding Program
Melissa Stiffler
Pittsburg State University, [email protected]

Follow this and additional works at: https://digitalcommons.pittstate.edu/etd

Part of the Applied Behavior Analysis Commons

Recommended Citation
Stiffler, Melissa, "Behavior Skills Training to Improve Parent Treatment Fidelity and Generalization in a
Feeding Program" (2019). Electronic Theses & Dissertations. 354.
https://digitalcommons.pittstate.edu/etd/354

This Thesis is brought to you for free and open access by Pittsburg State University Digital Commons. It has been
accepted for inclusion in Electronic Theses & Dissertations by an authorized administrator of Pittsburg State
University Digital Commons. For more information, please contact [email protected].
BEHAVIOR SKILLS TRAINING TO IMPROVE PARENT TREATMENT FIDELITY
AND GENERALIZATION IN A FEEDING PROGRAM

A Thesis Submitted to the Graduate School

in Partial Fulfillment of the Requirements
for the Degree of
Master of Science

Melissa Jo Stiffler

Pittsburg State University

Pittsburg, Kansas

November, 2019
BEHAVIOR SKILLS TRAINING TO IMPROVE PARENT TREATMENT FIDELITY
AND GENERALIZATION IN A FEEDING PROGRAM

Melissa Jo Stiffler

APPROVED:

Thesis Advisor _______________________________________________

Dr. Ryan Speelman, Psychology and Counseling

Committee Member ______________________________________________

Dr. Julie Allison, Psychology and Counseling

Committee Member ______________________________________________

Dr. Jamie Wood, Psychology and Counseling

Committee Member ______________________________________________

Dr. Brian Sims, Teaching and Leadership
 ACKNOWLEDGEMENTS

I would like to thank my committee members Dr. Ryan Speelman, Dr. Julie

Allison, Dr. Brian Sims, and Dr. Jamie Wood, each of whom has provided patient advice

and guidance throughout the research process. I would also like to express my very

profound gratitude to my parents, my husband, and my sons for providing me with

unfailing support and continuous encouragement throughout my years of study and

through the process of researching and writing this thesis. This accomplishment would

not have been possible without them. Thank you.

iii
BEHAVIOR SKILLS TRAINING TO IMPROVE PARENT TREATMENT FIDELITY
AND GENERALIZATION IN A FEEDING PROGRAM

An Abstract of the Thesis by

Melissa Jo Stiffler

Feeding problems are five times more likely to occur in children with autism spectrum

disorder (ASD) than in typically developing peers (Sharp, et al., 2013). Though behavior

analytic protocols have demonstrated efficacy, less research has investigated methods to

transfer technology to non–professional caregivers. This study utilized a behavioral skills

training (BST) procedure to increase generalization of treatment methods from the clinic

to the home environment for three parent-child dyads. Meal observations were conducted

prior to treatment to determine baseline rates of behavior, specifics of the child’s food

refusal, oral motor deficits, and nutritional needs. Baseline observations were used to

develop an individualized treatment protocol for each child and a multiple baseline

design was used to demonstrate the effects of behavioral skills training on increased

treatment fidelity and generalization effects of feeding strategies. Results indicate that

behavioral skills training may be used to increase treatment fidelity and generalization

effects for caregivers implementing behavioral feeding strategies with their children who

display severe food selectivity.

Keywords: parent training, food selectivity, feeding therapy, feeding difficulties

iv
 TABLE OF CONTENTS
CHAPTER PAGE

I. INTRODUCTION ........................................................................................................1
Review of the Literature: Pediatric Feeding Interventions .....................................2
Review of the Literature: Parent Training ..............................................................7
Behavior Skills Training: Overview .......................................................................8
Behavior Skills Training: Applications in Parent Training ..................................10
Behavior Skills Training: Parent Training in Feeding Interventions ....................13
Purpose of the Study ..............................................................................................17

II. METHOD ....................................................................................................................19

Participants and Setting..........................................................................................19
Grace and Becky ...............................................................................................19
Angie and Luke .................................................................................................20
Dorothy and Autumn ........................................................................................20
Baseline ..................................................................................................................21
Treatment ...............................................................................................................26
Instructions plus Modeling ...............................................................................26
Rehearsal ...........................................................................................................26
Feedback ...........................................................................................................27
Data Collection and Inter-observer Agreement .....................................................27
Experimental Design ..............................................................................................27

III. RESULTS ...................................................................................................................28

Interpretation of the Data .......................................................................................28
Grace and Becky ...............................................................................................29
Angie and Luke .................................................................................................31
Dorothy and Autumn ........................................................................................32
Inter-observer Agreement Data..............................................................................33
Social Validity Questionnaire ................................................................................34

IV. DISCUSSION ............................................................................................................36

Outcomes of the Study ...........................................................................................36
Limitations .............................................................................................................39
Future Directions ...................................................................................................40

REFERENCES ..................................................................................................................42

APPENDICES ...................................................................................................................48
APPENDIX A: Procedural Integrity Checklist.....................................................49
APPENDIX B: Operational Definitions of Treatment Components ....................50
APPENDIX C: Parent Training Packet ................................................................53
APPENDIX D: Mealtime Data Sheet ...................................................................62
APPENDIX E: Social Validity Questionnaire ......................................................63

v
 LIST OF FIGURES

FIGURE 1: Multiple Baseline Graph Across Participants .............................................65

vi
 CHAPTER I

Introduction

Autism Spectrum Disorder (ASD) is characterized by deficits in social/emotional

reciprocity, deficits in communication, and stereotyped/repetitive patterns of behavior or

interests (American Psychiatric Association, 2013). In conjunction with

stereotyped/repetitive patterns of behavior, numerous studies have found a link between

ASD and an increased risk of food selectivity. A study by Bandini et al. (2010) suggested

that children with ASD refused 41.7% of foods presented, while typically developing

peers refused 18.9% of foods presented. Sharp et al. (2013) found that food selectivity

puts these children at an increased risk of nutrient deficits, specifically lower intake of

calcium and protein. Long-term calcium deficiencies may increase risk of osteomalacia

and osteoporosis. Osteomalcia and osteoporosis result in soft or weakened bones,

increasing the risk of breaking or fracturing bones. In addition, Sharp and colleagues

(2013) noted that research has demonstrated long-term food selectivity and feeding

problems increase the risk of growth retardation, invasive medical procedures such as

feeding tube placement, developmental delays, psychological and social deficits, and

poor academic performance. General definitions of food selectivity include restriction of

foods to approximately 20 or fewer foods. As noted previously, an individual’s nutrition

may be compromised as a result of food selectivity, and restriction may exclude entire

1
food groups (U.S. Department of Health and Human Services and U.S. Department of

Agriculture, 2015).

Feeding difficulties often increase stress on families. Severe behaviors may be

exhibited during mealtimes such as crying, aggression, gagging, or vomiting. As a result,

caregivers may prepare alternative meals for the individual and/or families may avoid

eating at restaurants or in other public spaces. These factors often negatively influence

the quality of life for the individual and their family as well as exacerbate rigid food

preferences. Evidence based treatments are warranted for these families to improve their

quality of life and reduce inherent medical risks associated with selective food

preferences.

Review of the Literature: Pediatric Feeding Interventions

A variety of applied behavior analytic interventions have been used to improve

acceptance and tolerance of non-preferred foods in clinical settings and have been

implemented by trained professionals. In order to effectively treat problem behaviors, a

practitioner should first identify consequences or variables that maintain a given

behavior. This allows a practitioner to identify the reasons or why a behavior occurs;

often referred to as a function. By identifying the function of the behavior, interventions

can then address the underlying causes opposed to how the behavior looks, often referred

to as topography or symptom of a larger problem. Iwata, Dorsey, Slifer, Bauman, and

Richman (1994) outlined a procedure to identify the function of problem behaviors in a

method referred to as an analog functional analysis. Experimental conditions were

conducted in which the participant was exposed to a variety of scenarios in which

problem behavior resulted in delivery of different potential maintaining consequences. In

2
a controlled environment, extraneous variables are eliminated and inferences can be made

about the maintaining function of problem behaviors by manipulating antecedents or

stimulus cues and expected outcomes or consequences. As outlined by Iwata and

colleagues, maintaining functions of behavior include escape (the task or demand is

removed), attention (in the form of social disapproval), automatic reinforcement (some

property of the behavior produces a pleasurable experience for the individual) and/or

access to tangibles (items, edibles, preferred activities, etc.).

Piazza, Fisher, et al. (2003) demonstrated that analog functional analysis could be

applied to food refusal and inappropriate mealtime behaviors to determine maintaining

consequential variables most commonly associated with refusal. In this study, nine

children were exposed to functional analysis conditions in which food refusal resulted in

either negative reinforcement (removal of the spoon), positive reinforcement in the form

of attention (statements about the food or the child’s behavior), or positive reinforcement

in the form of tangible items (preferred toys, foods, or drinks). Extending Iwata’s (1994)

methods, Piazza, Fisher, et al. (2003) identified maintaining functions in the context of

food refusal by applying these consequences in a systematic and controlled manner. For

these participants the function of food refusal and inappropriate mealtime behaviors as

was identified as either escape (behavior resulted in negative reinforcement), attention

(behavior resulted in positive reinforcement in the form of conversation about the food or

the child’s behavior), or tangibles (behavior resulted in access to preferred toys, foods or

drinks). This experiment demonstrates that while behaviors across individuals may share

topography or overt looks, the reasons or functions are idiosyncratic.

3
 For food refusal behaviors that have been maintained by removal of the non-

preferred food, escape extinction procedures may be utilized to increase food acceptance.

In escape extinction procedures, the problem behavior no longer results in the termination

of the aversive stimulus (Cooper, Heron, & Heward, 2007). In the case of feeding

difficulties, this would include no longer removing the non-preferred food contingent on

the occurrence of problem behaviors. Specific interventions that have been used to

address escape extinction include non-removal of the spoon and physical guidance. In

non-removal of the spoon procedures, the spoon is held at the child’s mouth until the bite

is accepted (Ahearn, 2002; Didden, Seys, & Schouwink, 1999; Hoch, Babbit, Coe, Krell,

& Hackert, 1994; Piazza, Patel, Gulotta, Sevin, & Layer, 2003). In physical guidance,

hand over hand guidance is used to deposit the bite into the child’s mouth by applying

slight pressure to the lower mandible to open the mouth (Ahearn, 2002; Ahearn, Kerwin,

Eicher, Shantz, & Swearingin, 1996; Piazza, Patel, et al., 2003).

Differential reinforcement procedures are often used in conjunction with escape

extinction procedures, in which an alternative behavior produces reinforcement while

another behavior is placed on extinction (Cooper, Heron, & Heward, 2007). In feeding

interventions, differential reinforcement involves reinforcing behaviors that are

conducive to mealtimes and bite acceptance, while withholding reinforcement for those

behaviors that are incompatible with appropriate mealtime behaviors, such as expelling

foods, batting at the spoon, leaving the table, etc. (Alaimo, Seiverling, Anderson, &

Sturmey, 2018; Patel, Piazza, Martinez, Volkert, & Santana, 2002; Piazza, Patel, et al.,

2003). For example, in a differential reinforcement procedure, reinforcement in the form

of preferred items and attention may be provided for accepting a bite within 5 seconds of

4
the bite presentation and having no food in the mouth 30 seconds after the bite

presentation, while withholding reinforcement if the child bats at the spoon or expels the

bite.

Other strategies that have been paired with escape extinction procedures to

decrease occurrence of incompatible mealtime behaviors are non-contingent

reinforcement and environmental enrichment. Non-contingent reinforcement involves

delivery of stimuli with known reinforcing properties at predetermined times regardless

of learner behavior (Cooper, Heron, & Heward, 2007). In environmental enrichment,

preferred items such as toys, food, or activities are available on a continuous basis

regardless of learner behavior (Smith, 2011). In non-contingent reinforcement or

environmental enrichment procedures for feeding difficulties, the child is provided with

reinforcing items throughout the meal that are not contingent on bite acceptance, to

increase the reinforcing properties of the meal (Allison et al., 2012; Reed et al., 2004).

In simplest terms, behavior results in getting something (positive reinforcement)

or getting out of something (negative reinforcement). Both positive and negative

reinforcement have been used to treat feeding difficulties. Positive reinforcement is the

addition of a consequence that increases the future probability of whichever behavior

immediately precedes it (Cooper, Heron, & Heward, 2007). In procedures utilizing

positive reinforcement for feeding difficulties, praise or preferred items are presented,

contingent on bite acceptance (Piazza, Patel, et al., 2003). Negative reinforcement is

defined as the removal of an aversive stimulus that makes it more likely that a behavior

will occur again in the future (Cooper, Heron, & Heward, 2007). In negative

reinforcement procedures addressing food refusal, experimenters implemented a token

5
economy in which the child earned tokens contingent on bite acceptance and then could

exchange the tokens to end the meal (Kahng, Boscoe, & Byrne, 2003). In addition,

escape extinction procedures, namely, non-removal of the spoon, have been paired with

other treatment methods, such as differential reinforcement to reduce food refusal in

children diagnosed with autism (e.g. Patel et al., 2002; Piazza, Patel, et al., 2003; Ahearn

et al., 1996).

Other strategies involve manipulating the food prior to any demands or

occurrence of behavior in some way to increase the probability of acceptance, often

referred to as antecedent manipulations (Cooper, Heron, & Heward, 2007). Simultaneous

food presentation is an antecedent manipulation in which, a preferred condiment or food

is placed on the spoon with the non-preferred food. Repeated pairings of the preferred

food with the non-preferred food creates a taste preference for the non-preferred food

(Ahearn, 2003). A similar procedure involves blending purees of preferred foods with

purees of non-preferred foods. Mueller, Piazza, Patel, Kelley, and Pruett (2004).

Mueller et al (2004) used a procedure in which a preferred food and a non-preferred food

were blended together in increasing ratios to treat food refusal. Initially the ratio of non-

preferred food was low and the preferred food high. The ratio was gradually increased so

that the majority of the blend was the non-preferred food and the proportion of the

preferred food was low. For instance, applesauce was a preferred food for one participant

and chicken was a non-preferred food. Initially applesauce comprised 90% of the blend,

while chicken comprised the remaining 10% of the blend. The blend ratio was gradually

increased to 90% chicken and 10% applesauce in an incremental fashion (i.e., 90%

applesauce/10% chicken, 80% applesauce/20% chicken, 70% applesauce, 30% chicken,

6
60% applesauce/40% chicken, 50% applesauce/50% chicken, 40% applesauce/60%

chicken, 30% applesauce/70% chicken, 20% applesauce/80% chicken, 10%

applesauce/90% chicken).

Review of the Literature: Parent Training

The procedures outlined above have been well documented in increasing food

acceptance in children with ASD who display severe food selectivity and food refusal

(Ahearn, 2002; Ahearn, 2003; Ahearn et al., 1996; Alaimo et al., 2018; Allison, et al.,

2012; Didden et al., 1999; Hoch et al., 1994; Kahng et al., 2003; Mueller et al., 2004;

Patel et al., 2002; Piazza, Patel, et al., 2003; Reed, et al., 2004). In addition to food

acceptance and dietary variety being obtained during clinic based sessions, there is a need

for the treatment methods to be implemented by the caregiver and generalized to the

home and other settings in which the individual with ASD often eats. Because the

majority of the individual’s time is spent with caregivers, it is important for the

caregivers to be proficient in implementing the feeding treatments outside of the clinic

based setting. Previous research has examined parent implemented treatment protocols to

address feeding difficulties in children. For example, Najdowski, Wallace, Doney, and

Ghezzi (2003) taught parents to conduct a modified functional analysis during a meal to

determine consequences maintaining food refusal. Following functional assessment,

parents were taught to implement differential reinforcement and escape extinction

procedures congruent with maintaining variables. Valdimarsdottir, Halldorsdottir, and

Sigurdardottir (2010) provided parents with oral and written instructions, video of

experimenter implementation, and performance feedback after meal sessions with their

child. Results indicate gains were generalized across people; i.e. transferred from

7
experimenters to parents. Gains were also generalized across settings; i.e. transferred

from the preschool setting to the home setting. Other studies have found similar results

(Aclan & Taylor, 2017) indicating that practice with experimenter feedback may be the

critical component

Behavior Skills Training: Overview

While the aforementioned research found effective strategies for training parents

in implementation of specific feeding protocols, there is a need for a structured and

proven methods for training parents to implement individualized treatment protocols

across functions (escape, attention, etc.). Practitioners often observe a range of behaviors

and needs based on an individual child’s feeding difficulties. Though research has

demonstrated utility in addressing feeding difficulties and generalizing to parents and

home environments, no standardized training procedure that can be used by practitioners

to train parents has been documented.

In traditional training approaches, verbal instructions are given, sometimes

accompanied by printed instructions. This approach assumes that if an individual is able

to recite instructions, he or she will be able to implement the actions instructions provide.

Despite this assumption, much research has demonstrated this is not accurate (Bailey &

Burch, 2010). Occasionally other components such as modeling are added. While

research suggests the addition of modeling improves effectiveness, critical components

such as rehearsal and feedback are absent (LaBrot, Radley, Dart, Moore, & Cavell,

2018).

8
 Behavior Skills Training (BST) is an empirically validated approach to skill

acquisition that includes 1) Instructions 2) Modeling 3) Rehearsal and 4) Feedback

(Miltenberger, 2016). This method requires the trainee to demonstrate the target skill in

the setting in which it is expected to be demonstrated following training. For example,

in a feeding session, the child initially increases consumption of target foods with a

therapist in a clinical setting. The child’s behavior of eating the target food falls under

the stimulus control of the clinical setting and the therapist’s presentation, through the

repeated pairing of consequences delivered by the therapist following acceptance of the

food. Using a BST approach, the parent presents the food in the clinical setting

practicing the treatment methods that have been modeled. The trainer provides in session

and/or post session feedback on the parent’s performance of the target skills until fluency

is achieved providing an advantage of the BST model over traditional training models.

All components of BST are discussed in detail below.

Instructions

Instructions are a specific description of the behavior the learner is expected to

perform Instructions may be delivered in both written and verbal formats. The rationale

behind this step of BST is to give the learner a clear understanding of what is being

taught, how it is going to be taught, and a detailed description of the skills to be learned

(Miltenberger, 2016).

Modeling

Following instructions, the next step in BST is to model the skills that are being

targeted for acquisition. In modeling the learner observes the instructor or others

9
proficient in the skill, act out or engage in the skill that is being learned (Gruber &

Poulson, 2016; MacDonald & Ahearn, 2015). Modeling may occur in situ, that is in the

natural environment that the behavior is expected to be performed in, or via video

modeling in which the learner observes a video in which others perform the skill to be

learned. This allows the trainee to observe essential components of the skill in a typical

context in which it is to be performed in the future (Miltenberger, 2016).

Rehearsal with Feedback

Next, rehearsal sessions are conducted in which the learner has the opportunity to

practice the behavior after instructions and modeling have taken place. Rehearsal is an

important part of BST for several reasons. During this step of training the teacher is able

to provide feedback on correct or incorrect implementation of the skill being learned.

This step provides an opportunity for the teacher to reinforce the learner’s correct

implementation and assess if the learner is able to perform the skill overtly (Miltenberger,

2016). The trainer provides corrective feedback, in the form of a description of the skills

that were performed incorrectly and those that were performed correctly. This process is

repeated until the trainee is fluent and all the essential components of the trained skill are

demonstrated. Through this process the trainer shapes the expected behavior by

reinforcing closer and closer approximations to the target skill (Cooper, Heron, &

Heward, 2007) until the learner is able to perform the skill to criterion.

Behavior Skills Training: Applications in Parent Training

Behavioral skills training has been used effectively to teach parents or caregivers

to implement a range of interventions with their children. In a study by Dogan et al.,

10
(2017), BST was used to teach parents to be social skills trainers for their children

diagnosed with ASD. In this study BST was used to teach the parents to correctly utilize

the steps in BST which in turn, parents used to teach social skills to their children. First

instructions included a handout that outlined the BST procedure. The investigator

reviewed the material contained in the handout, specifying how to correctly use the BST

steps to teach a specific social skill. Vignettes were used throughout each step to give the

parents a description of the social interaction and rationale for the skill being taught.

Following instructions, parents observed the investigators model the correct use of BST.

This included the investigators modeling the use of BST steps to teach graduate students

social skills outlined in the vignettes. A puppet was used during modeling to ensure that

that there were enough conversational partners to demonstrate the social skills being

taught. Next, the parent engaged in the modeling process with the investigators, playing

the role of the child. The investigator modeled each step of the BST procedure,

providing that parent who was playing their child, appropriate feedback including

descriptive praise and corrective feedback. Following modeling, the parent switched

roles with the investigator and role played the learning scenario as the instructor and the

investigator as their child. Parents were provided with feedback following the role play

sessions and were required to rehearse the steps with feedback until a predetermined

mastery criteria was met. Follow up probes were conducted, in which the parents

demonstrated the maintenance of the skills taught. The results of the study indicate that

BST was an effective intervention in increasing parents’ correct use of BST to teach their

children social skills.

11
 Lafasakis and Sturmey (2007) demonstrated the effectiveness of BST in training

parents to correctly implement discrete-trial teaching (DTT). In discrete-trial teaching, a

three term contingency comprises a highly structured instructional unit, including an

antecedent (i.e the instruction), a behavior or response from the learner, and a

consequence (i.e social praise or a preferred item delivered for correct responding

(Lovaas, Koegel, Simmons, & Long, 1973). Lafasakis and Sturmey (2007) provided

instructions that included a typed list of the 10 components of discrete-trial teaching as

outlined by the researchers. During baseline, the parents were instructed to conduct

discrete-trial teaching to the best of their ability. Following baseline, parents were

provided with a graph of their performance during baseline and the researcher discussed

the parent’s performance during baseline. Next, the researcher modeled three discrete

trials with the child while the parent observed. The parents were then asked to perform

three discrete trials previously modeled. Descriptive feedback was provided immediately

following the performance and included positive comments about components performed

correctly, such as “You did a nice job getting eye contact before beginning the trial”.

Corrective feedback was provided on components performed incorrectly and included

statements such as “Next time, make sure to deliver reinforcement immediately after a

correct response”. Modeling and rehearsal continued with feedback for 10 minutes per

session. Sessions continued until parent’s demonstrated implementation of the

components of discrete-trial teaching at 90% accuracy for two consecutive training

sessions. Results indicate BST is an effective and efficient teaching strategy to increase

parent implemented DTT.

12
 In a study by Miles and Wilder (2009), caregivers were taught to implement a

guided compliance procedure in which gradually more intrusive prompts are used

contingent on non-compliance. Three caregivers participated in the study, including two

parents and one nanny who provided care for six children. In this study, the researchers

utilized instructions to provide a written description of each component in the guided

compliance treatment. The researchers provided the parents with feedback on baseline

performance and provided a graphic display of their performance as part of the feedback.

Next, the researchers asked the parents to rehearse the guided compliance procedure with

their child for three uninterrupted trials. The researchers provided corrective feedback on

components that had been implemented incorrectly and then modeled correct

implementation of the procedure with the children for four trials. Rehearsal and

modeling were repeated with feedback until the caregiver was able to implement the

procedure with 100% accuracy for three consecutive trials. The researchers demonstrated

that BST was effective in teaching caregivers to implement a guided compliance

procedure to increase child compliance with directives.

Behavior Skills Training: Parent Training in Pediatric Feeding

BST has been used in several studies to increase parent implementation of feeding

protocols for their children with food selectivity. Anderson and McMillan (2001) utilized

BST to teach parents to use escape extinction and differential reinforcement to treat food

selectivity. The participants in this study were the parents of a 5-year-old boy diagnosed

with pervasive developmental disabilities. In this study parents were provided with

instructions in written format and were presented verbally to them by the researchers.

The intervention involved the parents presenting a bite of food on a spoon and holding

13
the spoon to their child’s lips until the child opened his mouth and allowed the bite to be

deposited in his mouth. Parents were instructed to provide immediate praise and a sip of

a preferred beverage, milk. Following the first three meals, the researchers provided

feedback and coaching on a weekly basis. This study demonstrated that parents could be

taught to implement a feeding procedure to increase the acceptance of non-preferred

foods using a BST model.

While treatment packages have demonstrated success, it is unclear what

components are responsible for the change. Mueller et al. (2003) compared the use of

written instructions only to a multicomponent treatment package to train parents to

implement pediatric feeding protocols. Verbal instructions plus modeling and rehearsal

were compared to simplified packages consisting of verbal instructions and modeling,

verbal instructions and rehearsal, and verbal instructions only. Participants were assigned

to two groups; Study 1 and Study 2. Study 1 included three parents of two children who

exhibited severe feeding problems. Study 2 included six parents of three children who

exhibited severe feeding problems. Feeding interventions for each child were

individualized but all included an escape extinction procedure, non-removal of the spoon,

paired with either differential reinforcement or non-contingent reinforcement. In Study

1, the baseline data was collected on parent implementation of the protocols after

receiving written instructions only. Following baseline, the parents received additional

training including verbal instructions, modeling, and rehearsal. Feedback was not

provided to two of the three parents. One parent received feedback following a session

due to incorrect implementation of the treatment protocol.

14
 The results of Study 1 suggest that modeling and rehearsal significantly increased

correct implementation of feeding protocols by parents and that feedback was necessary

for the third parent to increase correct implementation. Two parents received verbal

instructions and modeling only, two parents received verbal instructions and rehearsal

only, and two parents received verbal instructions only. Verbal instructions, modeling,

and rehearsal components in Study 2 were identical to those in Study 1. Taken together

the results of Mueller et al. (2003) indicate that while the multicomponent training

package used in Study 1 was efficient to increase correct implementation of the treatment

protocol, simplified training packages such as those used in Study 2, were also effective

in increasing correct implementation. The authors state that the simplified training

packages can be delivered in reduced amounts of time, which could provide a clinical

advantage of the multicomponent treatment package due to time constraints. While

correct implementation of the procedures by parents yielded high percentages across all

treatment packages, there was variability in the correct implementation of the treatment

package for the majority of the parents. Variability could result in the child contacting

contingencies that could potentially maintain feeding difficulties for their children. In

addition, only one parent in both studies received feedback. Results of that feedback

increased correct performance for that parent and is likely that it could have increased

correct performance to higher levels for the other participants as well.

Long term gains often hinge on a parent’s ability to implement effective feeding

procedures as well as generalize these skills from a tightly controlled clinic to the home

environment. Najdowski et al. (2010) evaluated a home-based parent training approach

using preference assessments, differential reinforcement, and demand fading to teach

15
parents to first conduct preference assessments to identify preferred foods. Commonly

used preference assessment involve the presentation of one or more stimuli, in this case

food, in a systematic manner in which structured trials are presented and selection is

recorded for each trial. Results are calculated based on the number of times a stimuli was

selected out of the total number of presentations (Cooper, Heron, & Heward, 2007).

Next, parents were taught to implement a differential reinforcement plus escape

extinction treatment or a differential reinforcement, non-removal of the spoon, plus

demand fading treatment. Demand fading involves systematically increasing bite sizes

based on the child’s acceptance of the food, starting with a rice size bite and increasing to

a full spoonful or by systematically increasing the number of bites consumed during the

meal. The treatment package involved written instructions that the investigators read

through while modeling them with another investigator. Following the instruction and

modeling procedure, parents role-played the procedures with the investigator to allow the

parents practice being the therapist. Immediately following this training, the parents

conducted sessions with their child in the home setting while the investigator provided

feedback as needed or when the parents asked questions. Results were positive as the

number of bites for each child was increased, demonstrating the effectiveness of a BST

model to train parents to implement feeding protocols in the home setting.

Other home-based training studies have shown success in treating young children

ranging in age from 21 to 54 months, that had been referred to a psychology clinic for

chronic selective food refusal (Werle, Murphy, & Budd, 1993). During baseline parents

were instructed to “behave as they naturally would with their child during mealtime. A

treatment package consisted of basic educational information on child nutrition and

16
strategies to introduce new foods. Instructions and handouts outlined how to implement

attention contingent on their child’s positive mealtime behavior as well as planned

ignoring when disruptive behaviors occurred. In addition, parents were trained to use a

mild corrective procedure consisting of a firm “no” paired with blocking attempts to

leave the mealtime area and for two of the mothers, time out. The intervention included

instruction, role play, and rehearsal with feedback. Dependent variables were mean

episodes of parent behavior per minute, which included positive attention and trained vs

vague prompts. Results support the use of BST in treating food selectivity and in

addition provide an empirically validated approach to transfer technology to parents.

Similar studies have used BST to train parents on implementation of escape extinction

and differential reinforcement strategies to address food selectivity (Seiverling, Williams,

Sturmey, & Hart, 2012).

Purpose of the Study

Although feeding difficulties may originate due to organic or medical factors such

as oral motor deficits, allergies, or texture sensitivity, parent response to feeding

difficulties may increase and reinforce those behaviors. Food refusal may be generalized

to foods other than those that behaviors originated with, resulting in food selectivity.

Parent responses may include attention in the form of negotiations, bribery, disapproval

for food refusal, or removal of non-preferred foods. In these instances problematic

mealtime behaviors are likely to increase in the future through the process of negative

reinforcement. Due to the complex learning history associated with feeding difficulties

and food selectivity, treatment effects may be initially gained in a clinic based setting

with a therapist with whom there is not a long learning history. A BST approach can be

17
utilized to train parents on the implementation of the feeding intervention and the

treatment effects generalized to the parent and the home setting. Clinic based services

offer the ability to provide a multi-disciplinary approach to address nutrition, oral motor

deficits, and behavioral interventions. The current study aims to extend the work of

Anderson and McMillan (2001), Mueller et al. (2003), Najdowski et al. (2010), Werle et

al. (1993), and Seiverling et al. (2012), by increasing treatment fidelity using a behavioral

skills training model in caregiver implementation of treatment in the clinic setting, during

generalization to the home setting, as well as, provide practitioners with a technological

description and access to training materials used in the training process.

18
 CHAPTER II

Method

Participants and Settings

Three caregiver-child dyads admitted to a feeding clinic participated in the current

study. Participants were selected based on their child’s admittance into a feeding

program for severe food selectivity and parents having little or no experience with

behavioral treatment of food selectivity. A fourth participant began participation in the

study, however, the caregiver withdrew due to a change in school placement.

Grace and Becky. “Grace” was the grandmother of “Becky”, a 13-year-old girl

diagnosed with autism, who met the criteria of feeding difficulties and had been admitted

to an outpatient feeding program. Becky exhibited severe food selectivity, consuming a

total of 6 foods at the time of assessment. In addition to the limited number of foods that

Becky consumed, she also followed rigid rules about what foods could be eaten at certain

times of the day. These rules included that she ate popcorn in the morning, waffle fries

(from a specific restaurant) for lunch, and pepperoni pizza (from a specific restaurant) in

the evening. Outside of these ‘meals’, Becky ate three other foods throughout the day

including one brand of cookies, goldfish, and snack crackers.

19
 Angie and Luke. “Angie” was the mother of “Luke”, a 5 year old boy with a

diagnosis of autism, who met the criteria of feeding difficulties and had been admitted to

an outpatient feeding program. Luke exhibited severe food selectivity, excluding entire

food groups from his diet including most fruits and vegetables with the exception of

applesauce and french fries. At the time of assessment, Luke consumed a restricted

number of foods and engaged in problematic behaviors when his parents attempted to

introduce new foods or foods that Luke had previously consumed, but had not recently

been presented. Behaviors displayed when presented with new foods included

screaming, lying on the floor while crying, throwing food items, refusing to eat preferred

foods that were presented at the same time as the new food, and refusing to eat any foods

including preferred foods for several hours after the meal.

Dorothy and Autumn. “Dorothy” was the mother of, “Autumn" a 6 year old girl

diagnosed with autism, who met the criteria of feeding difficulties and had been admitted

to an outpatient feeding program. At the time of assessment, Autumn exhibited severe

food selectivity consuming mostly starchy foods and excluded entire food groups

including fruits and vegetables.

Therapy goals for each child included consuming a balanced diet most days of the

week, in proportions consistent with the Dietary Reference Intakes (DRI)

recommendations and with the recommended United States Department of Agriculture

(USDA) food patterns for children their age, sex, and physical activity level (Institute of

Medicine, 2006; U.S. Department of Health and Human Services and U.S. Department of

Agriculture, 2015). Therapy goals also included increasing variety and volume of

vegetables, fruits, whole grains, dairy, and lean proteins. Initially treatment goals were

20
obtained in the clinical setting with a highly trained feeding therapist under the

supervision of a Board Certified Behavior Analyst and in collaboration with a Registered

Dietician and Speech and Language Pathologist. After treatment goals were obtained

with the therapist presenting the meals, treatment effects were generalized to the

caregiver within the feeding clinic. Behavioral skills training was used to train parents to

implement treatment components with high fidelity and ultimately to generalize the

treatment goals to the home setting.

Baseline

Baseline sessions were conducted for each participant. Targeted foods for all

participants were selected by their caregivers in consultation with a Registered Dietician

to address nutritional inadequacies. Caregivers provided a 5 minute (minimum) recorded

video of a meal in the home setting, in which each parent demonstrated current strategies

used to increase food acceptance. Baseline data were collected on caregiver

implementation of basic treatment components described below and added as a separate

attachment in Appendix B. These components consisted of the following skills identified

by the researcher as basic components to most feeding interventions implemented in the

outpatient feeding program and the operational definitions were provided in writing to the

participants during the initial stage of training:

1) Neutrality to food refusal behaviors (includes verbal statements made to the child,

the care givers facial expression, and body language)

• If your child makes a negative comment about the food (i.e “That’s yucky!!”,

“Gross!!”, “I don’t want to eat that!”, “I’m going to throw up if I eat that”, etc. do

21
 not argue or try to persuade your child to take the bite, do not attend to the

comment, redirect the conversation to a non-food related topic.

• If your child, grimaces, gags, vomits, tries to push the spoon away, cries, screams,

etc., remain calm, maintain a neutral expression and do not smile/frown/grimace

in reaction to the behavior, do not make comments about the behavior that is

occurring, and keep body posture neutral (avoid crossing arms, placing hands on

hips, sighing, groaning, etc.)

2) Escape extinction (non-removal of the bite presentation until acceptance occurs)

• If your child does not accept the bite within 5 seconds of presentation, maintain

the bite presentation by holding the spoon within 2 inches of your child’s mouth

until your child opens their mouth to accept the bite.

• If your child is self-feeding, and does not take the bite within 5 seconds of you

saying “Take a bite”/placing the loaded spoon in front of them on the

plate/pointing to the food, etc., maintain the bite presentation by restating the

request every 15-30 seconds.

3) Environmental enrichment or non-contingent reinforcement (may include preferred

items, attention for appropriate behaviors, etc.)

Environmental Enrichment:

• Toys/preferred items are present and available regardless of behavior or

acceptance of food

Non-Contingent Reinforcement:

22
• Social praise for appropriate behaviors during the meal are delivered on a preset

time schedule regardless of food acceptance or refusal. Interactions are provided

throughout the meal that are not food related. i.e. “I like how you’re sitting in

your chair.”, “You’re a cool kid, I like hanging out with you.”, questions or

comments about the child’s day, what they are going to be doing later, things that

they like, etc.

4) Positive meal time conversations

• Avoid talking about the food or making statements about what will or will not

happen if your child takes a bite of the food.

5) Positive reinforcement delivered contingent on bite acceptance, (tangible or social

praise)

• After your child has accepted a bite, a statement such as “Great job”, “Thank

you”, “Awesome”, or a high five, a smile, etc delivered in a matter of fact tone

may be delivered occasionally throughout the meal.

• If environmental enrichment is not being used and preferred items are not readily

available, a toy or access to a preferred item may be made available for a brief

period of time following the acceptance of the bite (20-30 seconds). At the end of

the interval, prior to asking your child to take another bite, you should take

control of the item by saying “My turn”, or similar phrase.

6) Prompting procedures for bite acceptance

• Present a bite of food to your child. If your child independently accepts the bite

within 5 seconds, provide your child brief praise or a preferred item.

23
• If your child does not accept the bite within 5 seconds, provide a verbal prompt

“Take a bite”. If you child accepts the bite, provide brief praise or a preferred

item.

• If your child does not accept the bite within 5 seconds, provide a brief/partial

physical prompt by placing your hand over their hand and beginning to move it

toward but not all the way to their mouth. If your child continues to move the

spoon to their mouth and places the bite in their mouth, provide brief praise or a

preferred item.

• If your child does not accept the bite within 5 seconds, provide physical guidance,

placing your hand over their hand and guiding the spoon to their mouth. If your

child accepts the bite, provide brief praise or a preferred item.

• If your child does not accept the bite, maintain the bite presentation within 2

inches of your child’s mouth until they have accepted the bite.

7) Representation of expelled bites

• If your child spits out a bite of food, scoop the food back onto the spoon and

represent the bite. If the food is expelled and falls on the floor, or is otherwise not

able to be represented, present another bite of the same food.

8) Mouth clean before next bite presentation

• If your child often holds foods in their mouth or cheeks, make sure that your child

has swallowed the first bite prior to presenting another bite of food. You may

model saying “Ahh” and opening mouth, say “Let me see”, using a small spoon to

pull the cheek back to check for pocketed bites.

24
 • Do not present another bite if your child is actively chewing a bite. If needed you

can present a drink, to get your child to swallow the bite so that the next bite can

be presented.

9) Food weighed pre and post session

• Prior to beginning a meal, weigh your child’s food including the tray, bowls or

containers, spoons, napkins, and food. After you and your child have finished the

meal, weigh the tray with the dishes and napkins and any food that was expelled

or not consumed during the session. Record both of these weights on the data

sheet. You will calculate the total grams of food your child consumed during the

session by taking the pre meal weight and subtracting the post meal weight.

10) Parent collected data during session.

• You will be expected to collect data on bite acceptance and incompatible

mealtime behaviors during the session. You will be provided training on data

collection.

Percentage of components implemented correctly was calculated by dividing the

number of skills implemented correctly divided by the total number of skills required

during the session and multiplied by 100%. Because not all components might be needed

during a session, the total number that were applicable during a meal were used as the

total number of skills (i.e., if a bite of food was not expelled during a meal, the caregiver

would not have the opportunity to represent an expelled bite and therefore that

component was not included in the total count).

25
Treatment

Instructions plus Modeling. Participants were initially provided with written

instructions, containing information on functions of behavior, their child’s particular

behaviors during mealtimes, and treatment options with rationales for each treatment.

Contents of the packet were reviewed with the caregiver while a therapist conducted a

therapeutic meal with their child. The caregiver was able to observe the meal through a

one-way mirror while reviewing written instructions with the investigator. Caregivers

observed the therapist implementing the treatment protocol with their child during

therapeutic meals.

Rehearsal: Once the child had accepted full serving sizes of target foods for three

consecutive meals, with incompatible mealtime behaviors occurring on 20% or fewer bite

presentations, the caregiver was integrated into the therapeutic meal. Initially both the

caregiver and therapist sat with the child and provided positive reinforcement in the form

of verbal praise throughout the meal. Next, the caregiver presented the meal with the

therapist in the feeding clinic and received feedback regarding correct/incorrect

implementation of treatment components. Next, the therapist left the room and the

caregiver presented the meal, while the therapist or the investigator observed through the

one way mirror, while providing feedback via an earbud and microphone. Data were

collected once the caregiver presented meals in the feeding clinic independently i.e.

without the therapist present. Caregiver mastery criteria was set at 80% or more of the

aforementioned treatment components implemented correctly across two meal sessions.

Caregivers then presented meals in the home environment utilizing the treatment

protocol. In home meals were recorded and reviewed with caregivers.

26
 Feedback. All feedback was provided via recorded video of the in-home sessions.

Experimenters provided corrective feedback for any component demonstrated incorrectly

until mastery criteria was met. In-home mastery criteria was identical to the feeding

clinic criteria.

Data Collection and Inter-observer Agreement

The dependent variable for all participants was percentage of treatment protocol

components implemented correctly. Percentage correct was calculated by dividing the

number of components implemented correctly divided by the total number of components

in the treatment protocol and multiplied by 100%.

A second observer independently collected data on caregiver implementation of

treatment protocol components for at least 30% of sessions in each phase of baseline and

treatment. Inter-observer agreement was calculated by dividing the total number of

agreements by the total number of agreements plus disagreements and multiplying by

100%. The mean total inter-observer agreement across all participants was 89.6%.

Experimental Design

A multiple baseline across participants was used to evaluate the effectiveness of

BST in increasing accuracy of parent implementation of their child’s feeding

intervention. Baseline data was collected for each participant and a treatment protocol

for each participant’s child was determined based on baseline observations. Participants

were taught to implement all treatment components using a BST approach. Data was

collected on each participant’s correct or incorrect implementation of the treatment

protocol before and after the BST training.

27
 CHAPTER III

Results

Interpretation of the Data

This study evaluated an evidence based training method to increase generalization

effects in a feeding program by increasing correct implementation of treatment

components by caregivers. Results demonstrated that behavioral skills training was an

effective training method to increase correct implementation and generalization across

settings of treatment components for all caregivers who completed the training protocol.

In addition, results suggest that rehearsal of the target behaviors with feedback on

performance were essential components in increasing the accuracy of responding for all

participants. Figure 1 displays the percentage of treatment components implemented

correctly during baseline meals, following instructions and modeling, with rehearsal and

feedback in the clinical setting, and during generalization to the home setting. Data was

collected using a procedural integrity checklist (see Appendix A) based on the treatment

components that were identified as being common within the agency’s feeding clinic

protocols. The components assessed across participants are as follows: 1) Neutrality to

food refusal behaviors (includes verbal statements made to the child, the care givers

facial expression, and body language), 2) Escape extinction (non-removal of the bite

presentation until acceptance occurs), 3) Environmental enrichment or non-contingent

28
reinforcement (may include preferred items, attention for appropriate behaviors, etc,) 4)

Positive meal time conversations, 5) Positive reinforcement delivered contingent on bite

acceptance, (tangible or social praise), 6) Prompting procedures for bite acceptance, 7)

Representation of expelled bites, 8) Mouth clean before next bite presentation, 9) Food

weighed pre and post session, and 10) Parent collected data during session. (See

Appendix B for detailed definitions of each treatment component)

Three out of four caregivers completed all steps of the training sequence. Kathy,

Carl’s mother, withdrew from the study before implementation of the behavior skills

training package due to a transition in placement for Carl. Grace (Becky’s grandmother),

Angie (Luke’s mother), and Dorothy (Autumn’s mother) completed all steps of the

behavioral skills training protocol.

Grace and Becky. Baseline data indicates a mean of less than 4% of components

correctly implemented, with a range in scores from 0% to 14%. The data indicate a

steady and stable trend in Grace’s implementation of each treatment component and it is

reasonable to predict that without intervention, this trend in mealtime implementation of

the treatment components would continue at the same rate and level. Following the first

phase of training, data indicated that instructions plus modeling improved Grace’s

implementation of treatment components (M = 22%, range: 0% - 33%). An immediate

increase in level was observed when treatment was implemented and the data stabilized

with little variability prior to the next phase of training. Treatment effect was also

demonstrated as the values of the data points in each treatment phases differed from the

values during the previous phase, referred to as non-overlapping data points. Non-

overlapping data points are calculated by dividing the total number of data points in one

29
phase that fall in the same range as the previous phase and dividing by the total number

of data points in the phase that is being evaluated. The percentage of non-overlapping

data points from baseline to the first phase of training was 67%, indicating an initial

treatment effect. After the initial phase of training, Grace implemented two of the

components during one home meal, including remaining neutral when incompatible

mealtime behaviors occurred and providing positive reinforcement contingent on bite

acceptance in the form of social praise and providing a tangible item. However,

instructions and modeling did not increase the implementation of all components to

criterion level, which had been predetermined to be 80% or more of total treatment

components implemented correctly throughout the entire meal. Following the next phase

of training in which the caregiver presented meals and implemented treatment

components while receiving feedback from the researcher, the caregiver was able to

consistently implement the treatment components (see Figure 1). (M = 86%, range: 71%

- 100%). The percent of non-overlapping data points following this phase of training

increased to 100% demonstrating a functional relation between the number of BST

components successfully completed and the accuracy of implementation. Figure 1.

Illustrates fidelity improved from 15% to 80% across treatment phases. Mastery criterion

was set at a minimum 80% treatment fidelity across at least two meals. Grace met this

criteria following three rehearsal trials. During the generalization phase of training, data

indicated that Grace was able to successfully generalize implementation of the treatment

components to the home setting (M = 92%, range: 88% - 100%). In – home treatment

fidelity increased slightly above feeding clinic levels further suggesting that the feeding

30
intervention was generalized to the home environment and indicated that Grace

implemented the treatment components with a high rate of accuracy.

Angie and Luke. In the baseline condition correct implementation of treatment

components was at a steady, low rate (M = 0%, range: 0% - 0%). This stable, invariable

data indicated that this trend in implementation was likely to occur without intervention.

Following the first phase of training, data indicated that instructions plus modeling

produced an increase in correct implementation of treatment components (M = 17%,

range: 13% - 25%) with a high rate of non-overlapping data points (100%). A change in

level was also observed, increasing from 0% during baseline to 20% following the first

phase of training. Angie demonstrated the ability to consistently implement an

environmental enrichment procedure in which she provided Luke unrestricted access to

moderately preferred toys during the meal, as well as an increase in focusing on positive

mealtime behaviors. However, while some treatment effect was demonstrated, correct

implementation did not reach criterion. During the next phase of training in which Angie

presented meals in the clinic while receiving feedback from the researcher on

implementation of treatment components, there was a rapid increase in correct

implementation of treatment components, improving from 38% to 100% across three

meals (M = 72%, range: 38% - 100%). The percentage of non-overlapping data points

during this phase was 100% with a significant increase in level from 20% to 75%. This

change in level and high percent of non-overlapping data points, indicates a functional

relation between the number of BST components successfully completed and the

accuracy of implementation, suggesting that all components of BST are essential in

increasing skill acquisition (see Figure 1). Angie met implementation criterion (80% or

31
above of treatment components implemented correctly across at least two meals) during

the fourth clinic based meal. During the generalization phase of training, implementation

of the treatment components was generalized to the home with a high rate of fidelity (M

= 97%, range, 88% - 100%). The percentage of non-overlapping data points decreased to

0% indicating generalization effects as correct implementation remained at an increased

level from the previous phase (increasing from 75% to 90%).

Dorothy and Autumn. Data collected for Dorothy during baseline was stable and

invariable at 0% correct implementation of treatment components during each meal. The

low, stable, and invariable rate of implementation of treatment components during

baseline suggest that without intervention, this trend in data would continue. Following

the first phase of training data indicated an immediate increase in mean and level with

low variability (M = 22%, range: 13%-38%). The percentage of non-overlapping data

points from baseline to the first phase of training was 100%, indicating some treatment

effect however, the change in level was minimal (0%-30%) and Dorothy did not meet

performance criterion. While performance criterion was not met following instructions

and modeling, Dorothy demonstrated the ability to consistently implement environmental

enrichment procedures, in which she provided Autumn unrestricted access to moderately

preferred toys throughout meals. In addition Dorothy increased use of positive

reinforcement in the form of social praise for desired behaviors and took pre and post

meal weights. Data following rehearsal with feedback in the clinic setting indicates that

there was an immediate and significant change in mean and level (M = 84%, range: 63%-

100%) with 100% non-overlapping data points between the phases of training. A

function relationship was demonstrated between the number of BST components

32
completed and accuracy of implementation of treatment components, as criterion was met

only after all steps of BST had been completed (see Figure 1). In the final phase of

training, generalization to the home setting was demonstrated with Dorothy

implementing the treatment components with a high rate of fidelity (M = 96%, range:

88% - 100%). The percentage of non-overlapping data points (0%) indicates that

Dorothy was able to maintain the high rate of treatment fidelity demonstrated during the

clinic based meals.

In summary, experimental control was demonstrated in this multiple baseline

across participants design by demonstrating that changes in the dependent variable

(percent of treatment components implemented correctly) occurred when and only when

the intervention was applied. While the treatment was not able to be withdrawn as in a

reversal design due to the inability of the researcher to withdraw what the participants

had learned, results were replicated between multiple training phases for and across all

participants demonstrating a treatment effect (see Figure 1).

Inter-Observer Agreement

To ensure the reliability of the measurement system used, a second independent

observer collected data for each participant during 30-38% of each phase of training.

Inter-observer agreement (IOA) for all participants was calculated using a point-by-point

agreement ratio, as the treatment components being assessed afforded discrete

opportunities for a particular skill to be assessed. To calculate the percentage of

agreement between observers, the total number of treatment components that were scored

the same by each observer was divided by the total number of treatment components

observed during a meal and multiplied by 100. Because the goal was for the caregiver to

33
score a 2 to demonstrate skill acquisition (implemented the treatment component on 80-

100% of bite presentations), scores were grouped so that disagreements between 0 and 1

were not calculated as disagreements. For Grace IOA during baseline was 100%,

following instructions and modeling IOA was 80%, in clinic rehearsal with feedback IOA

was 71%, and in home with feedback IOA was 100%. The average overall IOA

percentage for Grace was 88% (range, 71-100%). For Angie average IOA during

baseline was 100%, following instructions IOA was 88%, in clinic with rehearsal average

IOA was 88%, and in home with rehearsal IOA was 88%. The average overall percent of

agreement for Angie was 88% (range, 75-100%). IOA for Dorothy during baseline was

100%, following instructions IOA was 100%, in clinic with rehearsal IOA was 63%, and

in home with rehearsal IOA was 100%. The average overall percent of agreement for

Dorothy was 93% (range, 63-100%). IOA averages for each phase across participants

was also calculated with the following results; baseline 100%, following instructions and

modeling 92% (range, 80-100%), in clinic rehearsal with feedback 74% (range, 63-88%),

and in home rehearsal with feedback 92% (range, 75-100%).

Social Validity Questionnaire

Hoch, Babbitt, Coe, Krell, and Hackbert (1994), utilized a questionnaire in their

study to access acceptability and overall satisfaction in a pediatric feeding program. The

author of this study utilized the same questionnaire to assess the satisfaction and

acceptability of the BST procedure. Following completion of the BST package,

caregivers were asked to complete a social validity questionnaire consisting of 14

questions regarding acceptability of training procedures and overall satisfaction with the

feeding program. Questions were rated on a scale from 1 – 5. A score of 1 indicated that

34
the caregiver strongly disagreed with the statement or was extremely dissatisfied with the

care and/or procedures used. A score of 5 indicated that the caregiver completely agreed

with the statement or was extremely satisfied with the service and/or training procedure.

(See Appendix for questionnaire and complete rating scale) Caregivers were asked to

complete and return the survey anonymously to increase the probability that they would

provide honest feedback rather than answering in a way that they may have perceived as

expected by the researcher. Outcomes of the survey indicated a high level of overall

satisfaction, with 90% of questions across participants being rated as a 5, and the

remaining 10% being rated as a 4. No questions were rated below a 4 by any

participants.

35
 CHAPTER IV

Discussion

Outcomes of the Study

This study evaluated the effects of behavior skills training (BST) on accurate

caregiver implementation of feeding treatment components with generalization to the

home environment. While treatment gains in the clinic setting are beneficial,

generalization of treatment implementation to the home setting are socially valid and

ultimate outcomes for families addressing feeding difficulties. Any treatment gains

observed in the clinic must be carried over to natural environments, as this is where the

child will receive the majority of their nutritional needs. Current findings demonstrate

that BST was effective in the clinic and promoted generalization of parent

implementation of treatment components to the home setting.

The training procedure implemented with caregivers included first providing a

training packet that included descriptions of basic functions of behaviors, how those

functions may apply to inappropriate mealtime behaviors, descriptions of potential

interventions that may be used with their child in the clinical setting, and operational

definitions of each treatment component included in the BST packet (see Appendix C).

Detailed instructions outlined consistent data collection methods so that researchers,

trainers, and caregivers accurately recorded results (see Appendix D). Second, caregivers

36
observed feeding sessions with a highly trained therapist who implemented treatment

components with their child. Highly trained is defined as a Registered Behavior

Technician implementing the treatment protocol under the observation of a Board

Certified Assistant Behavior Analyst. Observations provided caregivers with the

opportunity to ask questions regarding treatment instructions or any portion of the

observation with the therapist and their child. Researchers labeled treatment components

as they were modeled by the therapist. Parents moved to the next training phase after

their child accepted target foods selected by parents at the onset of services. Third, the

caregiver gradually participated in treatment with the child. Researchers provided

instantaneous feedback on correct or incorrect implementation of the treatment

components. Mastery criteria was set at 80% or more of treatment components

implemented correctly, at which point parents presented a meal in the home setting. Data

on implementation of treatment components was collected using a procedural integrity

checklist. Each item corresponds to an operationally defined treatment component (see

Appendix A and Appendix B). As indicated by the results of this study, all components

of the behavior skills treatment package were required to reach acceptable treatment

fidelity. The data indicate that caregivers generalized implementation of the treatment

components to the home environment following behavior skills training (See Figure 1).

While many studies have demonstrated the effectiveness of interventions to

increase food acceptance, dietary variety, chewing, texture fading, etc. in children with

feeding difficulties, (Ahearn, 2002; Ahearn, 2003; Ahearn et al., 1996; Alaimo et al.,

2018; Allison, et al., 2012; Didden et al., 1999; Hoch et al., 1994; Kahng et al., 2003;

Mueller et al., 2004; Patel et al., 2002; Piazza, Patel, et al., 2003; Reed, et al., 2004) the

37
available research on teaching caregivers to effectively implement feeding protocols is

limited. This study aimed to adhere to the seven dimensions of the field as outlined by

Baer, Wolf, and Risley (1968). In this landmark article in the field of behavior analysis,

the authors discussed seven core dimensions to distinguish the field as an applied field

from that of laboratory research. Applied behavior analysis addresses behaviors that are

socially significant to the individual (applied), those that are measurable and observable

(behavioral), and utilizes visual analysis of data to guide treatment decisions (analytic).

In addition, methods should be described in a technological manner that may be easily

replicated by the typically trained reader. Behavioral techniques should also be

conceptually systematic, effective, and generalizable. Conceptually systematic

techniques have been derived from the basic research in the study of behavior and have

been demonstrated to be effective. Effective behavioral techniques are those that produce

results that are meaningful to the individual and/or society. In addition, behavioral

techniques should be generalizable to other settings, behavior change agents, and across

time. One limitation of many of the available articles on the training of caregivers to

implement pediatric feeding protocols, is the lack of technologically sound descriptions

of the processes, materials, and training procedures used, so that practitioners in the field

might replicate the training procedures utilized in the study and found to be effective in

increasing accuracy of caregiver implementation of those protocols.

Review of the literature revealed many empirical articles on BST, feeding, and

parent training, lacked a thorough technological description of procedures and materials

used to implement the training package. Often robust data demonstrated the

effectiveness of the training methodologies, however replication of the training package

38
was limited due to broad descriptions of the specific procedures used in each phase of

training. It was the intent of this study to extend upon the work of Anderson and

McMillan (2001), Mueller et al. (2003), Najdowski et al. (2010), Werle et al. (1993), and

Seiverling et al. (2012), to provide tangible guidelines for practitioners to train caregivers

on implementation of feeding protocols. This study expanded upon previous

investigations by outlining all treatment components in a technological manner so that a

casually trained observer could replicate the results. This study also provided the training

materials used with caregivers.

Limitations

One limitation of this study is that caregivers may not have had the opportunity to

implement each treatment component during the various phases of the study. For

example, one treatment component that was not utilized during the majority of sessions

across all participants was ‘Representation of expelled bites’. If the child did not expel a

bite during the meal, the caregiver would not have the opportunity to follow the protocol

for representing the bite, thus they were not scored on this component. This varying

number of treatment components from one meal to the next may influence the data, as

meals in which there are fewer treatment components would require implementation of

more treatment components than a meal in which all 10 components were required (i.e.,

to meet criterion a caregiver may have to implement 4 out of 5 treatment components in

one meal but 8 out of 10 in another meal).

Another limitation was in the potential subjective interpretation of several

treatment components. In review of IOA data collected, the treatment components which

were most often disagreed upon were “Neutrality to incompatible mealtime behaviors”,

39
“Positive mealtime conversations”, and “Prompting procedures for bite acceptance”.

These items can be operationally defined in an objective manner, however, boundary

criteria or what constitutes as an occurrence non-occurrence of “neutrality”, remains

somewhat of a professional judgement call. The discrepancy for these components may

have been due to varying interpretations of the operational definition. Adding additional

exemplars and increasing the objectivity of the definitions may resolve this discrepancy.

Another potential source of discrepancy in scoring of these components may be the

scoring criteria. Each treatment component was scored on a scale from 0 - 2. Criteria for

scoring was as follows; 0) the component was not implemented during that meal (but

should have been), 1) the treatment component was implemented on less than 80% of bite

presentations (in which the component was required) 2) the treatment component was

implemented on 80-100% of bite presentations. Because data was not collected on each

component for each bite presented during the meal, the criteria may not have been

objectively evaluated. Modifying the procedural integrity checklist to score each

component on each bite presented would provide objective criteria for scoring.

Future Directions

While this study provided information on the effectiveness of behavior skills

training to increase correct implementation of treatment components by caregivers,

improvements in their child’s food acceptance was not represented and correlations

between increases in accurate implementation of treatment components and

improvements in bite acceptance and incompatible mealtime behaviors could not be

evaluated. Future studies could add beneficial data to the field by evaluating the

40
correlation between accurate caregiver implementation of treatment protocols and the rate

of bite acceptance and incompatible mealtime behaviors.

In addition, while the treatment components that were selected were identified as

common components across clients receiving services in the researcher’s feeding clinic, a

component analysis should be conducted to evaluate which components are essential to

increased acceptance of bites and reductions in incompatible mealtime behaviors.

41
 References

Aclan, M. D., & Taylor, R. S. (2017). An evaluation of a caregiver training protocol on

the generalization and maintenance of successful pediatric feeding interventions.

Behavioral Interventions, 32, 182-189.

Ahearn, W. H. (2002). Effect of two methods of introducing foods during feeding

treatment on acceptance of previously rejected items. Behavioral Interventions,

17, 111-127.

Ahearn, W. H. (2003). Using simultaneous presentation to increase vegetable

consumption in a mildly selective child with autism. Journal of Applied Behavior

Analysis, 36, 361-365.

Ahearn, W. H., Kerwin, M. E., Eicher, P. S., Shantz, J., & Swearingin, W. (1996). An

alternating treatments comparison of two intensive interventions for food refusal.

Journal of Applied Behavior Analysis, 29, 321-332.

Alaimo, C., Seiverling, L., Anderson, K., & Sturmey, P. (2018). A comparison of two

multicomponent treatment packages for food refusal. Behavioral Interventions,

33, 93-101.

Allison, J., Wilder, D. A., Chong, I., Lugo, A., Pike, J., & Rudy, N. (2012). A

comparison of differential reinforcement and noncontingent reinforcement to treat

food selectivity in a child with autism. Journal of Applied Behavior Analysis, 45,

613-617.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th Edition ed.). Arlington, Virginia.

42
Anderson, C. M., & McMillan, K. (2001). Parental use of escape extinction and

differential reinforcement to treat food selectivity. Journal of Applied Behavior

Analysis, 34, 511-515.

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied

behavior analysis. Journal of Applied Behavior Analysis, 1, 91-97.

Bailey, J., & Burch, M. (2010). 25 Essential skills & strategies for the professional

behavior analyst. New york, NY: Taylor and Francis Group, LLC.

Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., . . .

Must, A. (2010). Food selectivity in children with autism spectrum disorders and

typically developing children. Journal of Pediatrics, 152, 259-264.

doi:10.1016/j.jpeds.2010.02.013

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd

ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

Didden, R., Seys, D., & Schouwink, D. (1999). Treatment of chronic food refusal in a

young developmentally disabled child. Behavioral Interventions, 14, 213-222.

Dogan, R. K., King, M. L., Fischetti, A. T., Lake, C. M., Matthews, T. L., & Warzak, W.

J. (2017). Parent-implemented behavioral skills training of social skills. Journal

of Applied Behavior Analysis, 50, 805-818.

Gruber, D. J., & Poulson, C. L. (2016). Graduated guidance delivered by parents to teach

yoga to children with developmental delays. Journal of Apllied Behavior

Analysis, 49, 193-198. doi:10.1002/jaba.260

43
Hoch, T. A., Babbit, R. L., Coe, D. A., Krell, D. M., & Hackert, L. (1994). Combining

positive reinforcement and escape extinction procedures to treat persistent food

refusal. Behavior Modification, 18, 106-128.

Institute of Medicine. (2006). Dietary Reference Intakes: The Essential Guide to Nutrient

Requirements. Washington, DC: The National Academies Press.

doi:https://doi.org/10.17226/11537

Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994).

Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis,

27, 197-209.

Kahng, S., Boscoe, J. H., & Byrne, S. (2003). The use of an escape contingency and a

token economy to increase food acceptance. Jorunal of Applied Behavior

Analysis, 36, 349-353.

LaBrot, Z. C., Radley, K. C., Dart, E., Moore, J., & Cavell, H. (2018). A component

analysis of behavioral skills training for effective instruction delivery. Journal of

Family Psychotherapy, 29, 122-141.

Lafasakis, M., & Sturmey, P. (2007). Training parent implementation of discrete-trial

training: Effects on generalization of parent teaching and child correct

responding. Journal of Applied Behavior Analysis, 40, 685-689.

Lovaas, O. I., Koegel, R., Simmons, J. Q., & Long, J. S. (1973). Some generalization and

follow-up measures on autistic children in behavior therapy. Journal of Applied

Behavior Analysis, 6, 131-166.

44
MacDonald, J., & Ahearn, W. H. (2015). Teaching observational learning to children

with autism. Journal of Applied Behavior Analysis, 48, 800-816.

doi:10.1002/jaba.257

Miles, N. I., & Wilder, D. A. (2009). The effects of behavioral skills training on caregiver

implementation of guided compliance. Journal of Applid Behavior Analysis, 42,

405-410.

Miltenberger, R. G. (2016). Behavior modification: Principles and procedures (6th ed.).

Boston, MA: Cenagage Learning.

Mueller, M. M., Piazza, C. C., Moore, J. W., Kelley, M. E., Bethke, S. A., Pruett, A. E., .

. . Layer, S. A. (2003). Training parents to implement pediatric feeding protocols.

Journal of Applied Behavior Analysis, 36, 545-562.

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.

Najdowski, A. C., Wallace, M. D., Doney, J. K., & Ghezzi, P. M. (2003). Parental

assessment and treatment of food selectivity in natural settings. Journal of

Applied Behavior Analysis, 36, 383-386.

Najdowski, A. C., Wallace, M. D., Reagon, K., Penrod, B., Higbee, T. S., & Tarbox, J.

(2010). Utilizing a home-based parent training approach in the treatment of food

selectivity. Behavioral Interventions, 25, 89-107.

45
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., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. R., Katz, R. M., . . .

Blakely-Smith, A. (2003). Functional analysis of inappropriate mealtime

behaviors. Journal of Applied Behavior Analysis, 36, 187-204.

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.,

& Gutshall, 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, 27-42.

Seiverling, L., Williams, K., Sturmey, P., & Hart, S. (2012). Effects of behavioral skills

training on parental treatment of children's food selectivity. Journal of Applied

Behavior Analysis, 45, 197-203.

Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulner, C. A., . . .

Jaquess, D. L. (2013). Feeding problems and nutrient intake in children with

autism spectrum disorders: A meta-analysis and comprehensive review of the

literature. Journal of Autism and Developmental Disorders, 43, 2159-2173.

46
Smith, R. G. (2011). Developing antecedent interventions for problem behavior. In W.

Fisher, C. C. Piazza, & H. S. Roane (Eds), Handbook of Applied Behavior

Analysis (pp. 299-300). New York, NY: The Guilford Press.

U.S. Department of Health and Human Services and U.S. Department of Agriculture.

(2015). 2015-2020 Dietary Guidelines for Americans (8th ed.). Retrieved from

http://health.gov/dietaryguidelines/2015/guidelines/.

Valdimarsdottir, H., Halldorsdottir, L. Y., & Sigurdardottir, Z. G. (2010). Increasing the

variety of foods consumed by a picky eater: Generalization of effects across

caregivers and settings. Journal of Applied Behavior Analaysis, 43, 101-105.

Werle, M. A., Murphy, T. B., & Budd, K. S. (1993). Treating chronic food refusal in

young children: Home-based parent training. Journal of Applied Behavior

Analysis, 26, 421-433.

47
APPENDIX
 Appendix A: Procedural Integrity Checklist

Check Components of Client’s Was the procedure

Treatment Protocol implemented correctly?
(See notes at bottom of
page)
Neutral
- Comments 0 1 2
- Facial Expressions
- Body Language
-
Extinction Procedures:
- Non-Removal of the Spoon
- Physical Guidance 0 1 2

Non-Contingent Reinforcement:
- Tangibles 0 1 2
- Attention
Or
Environmental Enrichment

Positive mealtime conversations

0 1 2

Positive Reinforcement
- Comments 0 1 2
- Tangibles

Prompting procedures for bite acceptance 0 1 2

Representation of Expelled Bites

0 1 2
Mouth Clean 0 1 2

Pre and Post weights taken

0 1 2
Data collection
0 1 2
Things You Did That were Great!! Things Child Did That Were Great!! Things To Work On
1. 1. 1.

2. 2. 2.

3. 3. 3.

49
 Appendix B: Operational Definitions of Treatment Components

MEALTIME COMPONENTS
1) Neutrality to food refusal behaviors (includes verbal statements made to the child, the
care givers facial expression, and body language)
• If your child makes a negative comment about the food (i.e “That’s yucky!!”,
“Gross!!”, “I don’t want to eat that!”, “I’m going to throw up if I eat that”, etc do
not argue or try to persuade your child to take the bite, do not attend to the
comment, redirect the conversation to a non-food related topic.
• If your child), grimaces, gags, vomits, tries to push the spoon away, cries,
screams, etc, remain calm, maintain a neutral expression and do not
smile/frown/grimace in reaction to the behavior, do not make comments about the
behavior that is occurring, and keep body posture neutral (avoid crossing arms,
placing hands on hips, sighing, groaning, etc)
2) Escape extinction (non-removal of the bite presentation until acceptance occurs)
• If your child does not accept the bite within 5 seconds of presentation, maintain
the bite presentation by holding the spoon within 2 inches of your child’s mouth
until your child opens their mouth to accept the bite.

• If your child is self-feeding, and does not take the bite within 5 seconds of you
saying “Take a bite”/placing the loaded spoon in front of them on the
plate/pointing to the food, etc, maintain the bite presentation by restating the
request every 15-30 seconds.
3) Environmental enrichment or non-contingent reinforcement (may include preferred
items, attention for appropriate behaviors, etc)
Environmental Enrichment:
• Toys/preferred items are present and available regardless of behavior or
acceptance of food

Non-Contingent Reinforcement
• Social praise for appropriate behaviors during the meal are delivered on a preset
time schedule regardless of food acceptance or refusal. Interactions are provided
throughout the meal that are not food related. i.e. “I like how you’re sitting in
your chair.”, “You’re a cool kid, I like hanging out with you.”, questions or
comments about the child’s day, what they are going to be doing later, things that
they like, etc.
4) Positive meal time conversations

50
 • Avoid talking about the food or making statements about what will or will not
happen if your child takes a bite of the food.
5) Positive reinforcement delivered contingent on bite acceptance, (tangible or social
praise)

• After your child has accepted a bite, a statement such as “Great job”, “Thank
you”, “Awesome”, or a high five, a smile, etc delivered in a matter of fact tone
may be delivered occasionally throughout the meal.
• If environmental enrichment is not being used and preferred items are not readily
available, a toy or access to a preferred item may be made available for a brief
period of time following the acceptance of the bite (20-30 seconds). At the end of
the interval, prior to asking your child to take another bite, you should take
control of the item by saying “My turn”, or similar phrase.
6) Prompting procedures for bite acceptance
• Present a bite of food to your child. If your child independently accepts the bite
within 5 seconds, provide your child brief praise or a preferred item.
• If your child does not accept the bite within 5 seconds, provide a verbal prompt
“Take a bite”. If you child accepts the bite, provide brief praise or a preferred
item.
• If your child does not accept the bite within 5 seconds, provide a brief/partial
physical prompt by placing your hand over their hand and beginning to move it
toward but not all the way to their mouth. If your child continue to move the
spoon to their mouth and places the bite in their mouth, provide brief praise or a
preferred item.
• If your child does not accept the bite within 5 seconds, provide physical guidance,
placing your hand over their hand and guiding the spoon to their mouth. If your
child accepts the bite, provide brief praise or a preferred item.
• If you child does not accept the bite, maintain the bite presentation within 2
inches of your child’s mouth until they have accepted the bite.
7) Representation of expelled bites
• If your child spits out a bite of food, scoop the food back onto the spoon and
represent the bite. If the food is expelled and falls on the floor, or is otherwise not
able to be represented, present another bite of the same food.
8) Mouth clean before next bite presentation
• If your child often holds foods in their mouth or cheeks, make sure that your child
has swallowed the first bite prior to presenting another bite of food. You may
model saying “Ahh” and opening mouth, say “Let me see”, using a small spoon to
pull the cheek back to check for pocketed bites.

51
 • Do not present another bite if your child is actively chewing a bite. If needed you
can present a drink, to get your child to swallow the bite so that the next bite can
be presented.
9) Food weighed pre and post session
• Prior to beginning a meal, weigh your child’s food including the tray, bowls or
containers, spoons, napkins, and food. After you and your child have finished the
meal,
weigh the tray with the dishes and napkins and any food that was expelled or not
consumed during the session. Record both of these weights on the data sheet.
You will calculate the total grams of food your child consumed during the session
by taking the pre meal weight and subtracting the post meal weight.

10) Parent collected data during session.

• You will be expected to collect data on bite acceptance and incompatible
mealtime behaviors during the session. You will be provided training on data
collection.

52
 Appendix C: Parent Training Packet

FEEDING CLINIC

Behavior Intervention Training Packet

Consultant:

Melissa Stiffler, B.S., BCaBA, LABA

53
 Understanding Behaviors

What do we know about problem behavior?

• Problem behaviors are learned in the same way as appropriate behaviors.

• Problem behaviors serve a function for the person.

• The behaviors interfere with learning, social interactions, and can be harmful.

Functions of Behavior

• Both appropriate and inappropriate behaviors serve a function or are supported by the

environment.

• If a behavior is NOT occurring it is not being supported.

• If a behavior is occurring it is being supported.

There are 2 functions of behavior:

• To get something

o Attention

o Tangible

o Self Stimulatory

• To get out of something:

o Escape

o Avoidance

54
To Get Something
• Delivered by others

o Getting toys, preferred foods

o Getting peer or adult attention *(good or bad)

o Access to activities

• Within Oneself

Self-stimulatory behaviors: Sometimes what the person does is reinforcing by itself, or

intrinsically reinforcing. For example, creative activities often are intrinsically motivating,

that is painting a picture or playing the guitar is satisfying to the person and they do not

need someone to tell them that the painting is good or that the music sounds good.

To Get out of Something

• Through others

o Escape from an activity, task, person, sound, etc.

o Avoidance

• Within oneself

o Pain attenuation – taking Tylenol to get rid of a headache

55
Food Refusal Functions of Behavior

Attention: When a child refuses food (crying, gagging, pushing foods away, making

negative statements about the food) the parent may give the child reasons why s/he

should eat the food (“If you try a bite, then you will get _____”, and/or threats such as “If

you don’t try a bite, you won’t get dessert” etc.) Another form of attention that a parent

might provide may be statements of disappointment or other negative statements (“I’m

really sad that you didn’t eat that”, “Why won’t you just eat your vegetable?!” etc.).

Both types of attention may increase the food refusal behavior, in an attempt to get

continued attention and interaction from the parent.

Escape: A child may engage in crying, gagging, pushing foods away, hitting,

screaming, etc. because when they do, the food is removed and they are not required to

taste it or eat it. In addition, they may be presented with preferred foods in its place.

56
Interventions That May be Used in Clinic:

Non-Contingent Reinforcement:

• We may give your child something reinforcing (i.e tickles, toys, statements of praise for

desired behaviors, etc) throughout the session on a time interval that is determined prior

to the meal, as long as your child is not engaging in food refusal behaviors.

Environmental Enrichment:

• We may provide toys or attention throughout the meal regardless of behavior, to increase

the appeal of the mealtime setting. This may be used during initial sessions to create a

positive experience in the meal setting. As your child becomes more comfortable during

the meal and has demonstrated success with foods, the amount of attention or the number

of toys may be reduced to more closely resemble meals outside of the clinic.

Social Praise:

Social praise should be delivered throughout the meal, for any behaviors NOT

RELATED to food. Examples include commenting on the toy that your child is engaged with,

talking with your child about NON FOOD RELATED topics, or making statements about your

child that are NOT RELATED to food. i.e. “You’re really good at this game!”, “Thanks for

sitting at the table with me!”, “How was your day at school?”, etc.

• Following bite acceptance, a brief, neutral statement may be made such as “Thank you”,

“Good job”, etc

• Try to avoid making negative statements about your child’s behavior during the session.

You may be tempted to tell your child to stop pushing the food away, or not to spit out a

bite, or to stop engaging in other problem behaviors.

57
 • A method that often helps one become aware of negative statements is to wear a rubber

bracelet or a silly band around his or her wrist. Each time they state something using a

negative (example: no, stop, don’t, not a choice, etc) the person switches the band to the

other wrist. It is an awareness technique that will help one to notice how often they are

making these types of statements.

Extinction Procedures for Attention:

Extinction occurs when reinforcement that has been maintaining a behavior, is no longer

provided for that behavior. In other words, when the child no longer gets what they want based

on engaging in that behavior. In mealtimes this may mean that crying no longer results in the

food being removed. When your child engages in incompatible mealtime behaviors (refusing

food, making negative comments about the food, gagging, pushing food away, crying, vomiting,

turning his head away from the food, etc), the person presenting the meal will NOT comment on

the behavior or engage in conversation with them about the behavior. Social praise should still be

provided for behaviors not related to the incompatible mealtime behaviors. Your child may still

have access to preferred toys and attention even if these behaviors are occurring (conversation

and interaction should not involve the food).

Types of Extinction Procedures

• Non-Removal of the Spoon: If your child does not accept the bite within 30 seconds of

the initial presentation, or engages in incompatible mealtime behaviors you will maintain

the bite presentation. If your child is self-feeding, this means that you will keep the

loaded spoon in front of them on a plate and restate “Take a bite” every 15-30 seconds

until your child accepts the bite. If your child is not self-feeding, you will continue to

hold the spoon 1-2 inches in front of their mouth until they open their mouth to accept the

bite.

58
 • Physical Guidance – If your child does not accept the bite within 5 seconds of you

presenting the bite, physical guidance will be used to move the spoon towards their

mouth and deposit the bite into their mouth when they open their mouth to accept the

bite. To do this, you will place your hand on your child’s hand and guide the spoon to

their mouth.

Redirection:
When your child engages in incompatible mealtime behaviors, the person presenting the

meal may redirect your child’s attention to a preferred activity, change the conversation, or ask

your child to perform a simple task (touch your nose, make your car go fast, etc).

Blending Procedure:

In this procedure a food that your child already eats that is a puree, such as applesauce or

mashed potatoes, is mixed with a target food that has been pureed in the blender. For example, if

your child accepts applesauce, another fruit such as peaches may be pureed and mixed with the

applesauce. Initially the food that your child currently eats will be the majority of the blended

food with a small amount of the target food. Based on bite acceptance, the proportion of target

food will be gradually and systematically increased while the other food is decreased.

Simultaneous Presentation:

This intervention is similar to the previous one, except that the foods are not pureed and

blended together. A food that your child currently eats or a condiment such as ketchup will be

presented on the spoon with the target food. For example, if your child likes goldfish, a goldfish

with a rice size bite of green bean would be presented. Based on your child’s acceptance, the size

of the green bean would be increased gradually over time while the goldfish is gradually

decreased and eliminated from the bite.

59
Fading:

Because introducing a new food may be overwhelming for your child if a large portion is

presented, a very small amount may be initially presented. In a fading procedure a rice size bite

of the food is presented until your child is consistently accepting that bite size within 5 seconds of

the bite presentation, and with few to no problem behaviors. Once your child is able to do this,

the bite size may be increased to a pea size bite, etc. The bite sizes that we generally use are as

follows; rice, pea, 2 pea, half level, full level, full rounded. However, if needed we can adjust

bite size to meet your child’s needs.

60
 Examples Positive Mealtime Conversations

Do Say:

“You worked so hard! I’m proud of you”

“That was new, huh?”

“What are we going to do later?”

“That toy is really cool”

“That was funny (watching a video)”

“I think that you are awesome!”

Do NOT Say:

“I know that doesn’t taste good”

“If you don’t do a good job eating, you will lose ____”

“If you do a good job eating, then we will have _____ later.”

“You can take a bigger bite.”

“Just try it, please.”

“You won’t throw up.”

61
 Appendix D: Mealtime Data Sheet

Other:_________

Other:_________
______________
Bite Number

Bite Number
Vocalization

Vocalization
Acceptance

Acceptance
Disruption

Disruption
_____
Expel

Expel
Food

Food
Pack

Pack
Neg.

Neg.
Gag

Gag
1. 26.
2. 27.
3. 28.
4. 29.
5. 30.

6. 31.
7. 32.
8. 33.
9. 34.
10. 35.

11. 36.
12. 37.
13. 38.
14. 39.
15. 40.

16. 41.
17. 42.
18. 43.
19. 44.
20. 45.

21. 46.
22. 47.
23. 48.
24. 49.
25. 50
Acceptance: Accepts bite into mouth within 5 seconds of the bite presentation
Expel: Food larger than the size of a pea outside of the mouth after acceptance
Pack: Food larger than the size of a pea in the mouth 30 s after acceptance
Mouth Clean: No food larger than a pea inside the mouth 30 s after acceptance
Disruption: Turning head away from spoon, hitting spoon, covering mouth, touching feeder’s hand (when bite is presented
Negative Vocalization: crying, whining for longer than 3 consecutive seconds during a bite presentation. Making non favorable
statements about the food.

* Data sheet adapted from Treating Eating Problems of Children with Autism Spectrum
Disorders and Developmental Disabilities: Interventions for Professionals and Parents by
Keith E Williams and Richard M. Foxx

62
 Appendix E: Social Validity Questionnaire

Discharge Parental Satisfaction Questionnaire

Rate each item from 1 – 5 using the following rating scale:
1 - (quite dissatisfied/not effective at all/totally disagree/no improvement)
2 - (dissatisfied/not effective, disagree/no)
3 - (nuetral)
4 - (satisfied, effective, agree, yes, some improvement)
5 - (very satisifed, very effective, totally agree, marked improvement)

1. In an overall, general sense, how satisfied were you with

1 2 3 4 5
the service you received?
☐ ☐ ☐ ☐ ☐
2. In general, how effective were treatment
1 2 3 4 5
recommendations for your child?
☐ ☐ ☐ ☐ ☐
3. The training sessions were presented in a concise and easy
1 2 3 4 5
to understand manner.
☐ ☐ ☐ ☐ ☐
4. Th amount of work required by the program was at a
1 2 3 4 5
reasonable level to be most effective.
☐ ☐ ☐ ☐ ☐
5. If a a friend were in need of similar help, would you
1 2 3 4 5
recommend our program to him/her?
☐ ☐ ☐ ☐ ☐
6. At home, will you continue to use the treatment program?
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
7. I feel that when I do use these recommendations, they will
1 2 3 4 5
be effective when applied consistently.
☐ ☐ ☐ ☐ ☐
8. I feel that the methods involved with the treatment
1 2 3 4 5
recommendations were ethically sound.
☐ ☐ ☐ ☐ ☐
9. The Feeding Team:

a. Was flexible and open to work with

1 2 3 4 5
☐ ☐ ☐ ☐ ☐
b. Was knowledgeable and thoroughouly trained
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
c. Was cooperative and easy to work with
1 2 3 4 5
☐ ☐ ☐ ☐ ☐

63
 d. Was helpful in solving problems as they arose
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
e. Showed positive regard for my child
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
f. Showed positive regard for the family
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
g. Was empathic and sensitive to the child
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
10. Has the implementaiton of the treatment program helped
1 2 3 4 5
reduce any other behavior problems or increase other
☐ ☐ ☐ ☐ ☐
skills?
11. At the time of dischare, were your child’s problems worse
1 2 3 4 5
(1), the same (3), or absent (5)?
☐ ☐ ☐ ☐ ☐
12. If for some reason you needed to seek help again, would
1 2 3 4 5
you come back to our program?
☐ ☐ ☐ ☐ ☐
13. Have you noticed an improvement in your child’s health?
1 2 3 4 5
☐ ☐ ☐ ☐ ☐
14. To what extent has our program achieved the goals set at
1 2 3 4 5
admission?
☐ ☐ ☐ ☐ ☐

Additional Comments:
Click here to enter text.

* Questionnaire originally used by Hoch, T. A., Babbit, R. L., Coe, D. A., Krell, D. M., &
Hackert, L. (1994). Combining positive reinforcement and escape extinctino
procedures to treat persistent food refusal. Behavior Modification, 18, 106-128.

64
Figure 1: Multiple Baseline Graph Across Participants

65