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Treatment of Pediatric Feeding Disorders

Treatment of Pediatric Feeding Disorders. Cathleen C. Piazza University of Nebraska Medical Center’s Munroe-Meyer Institute. PEDIATRIC FEEDING DISORDERS. Identified when a child fails to consume a sufficient variety or quantity of food to maintain nutritional status.

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Treatment of Pediatric Feeding Disorders

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

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

  3. INTERDISCIPLINARY APPROACH • Consider an interdisciplinary evaluation prior to initiation of treatment • Practice within your scope of competence

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

  5. FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS • Piazza, Fisher, et al. (2003) conducted functional analyses of inappropriate mealtime behavior of 15 children diagnosed with a pediatric feeding disorder. • Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Katz, R. M., Sevin, B. M., Gulotta, C. S., & Patel, M. R. (2003). Functional analysis of inappropriate mealtime behaviors. Journal of Applied Behavior Analysis, 37, 187-204.

  6. Functional Analysis

  7. Escape ConditionFeeder delivers 30 s of escapefollowing inappropriate behavior.

  8. Attention ConditionFeeder delivers 30 s ofattentionfollowing inappropriate behavior.

  9. Control ConditionFeeder provides continuous access to toys and attention. No differential consequence following inappropriate behavior.

  10. 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 ATTENTIONVS CONTROL ESCAPEVSCONTROL INAPPROPRIATE BEHAVIOR PER MINUTE ESCAPE ATTENTION Tom CONTROL SESSIONS 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  11. FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS • 67% of participants displayed high levels of inappropriate mealtime behavior in one or more test conditions. • 90% of participants whose functional analyses were differentiated displayed sensitivity to negative reinforcement. • 80% of participants whose functional analyses were differentiated displayed sensitivity to multiple reinforcing contingencies.

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

  13. FUNCTIONAL ANALYSIS OF PEDIATRIC FEEDING DISORDERS • The findings suggest that: • Negative reinforcement plays a primary role in the maintenance of feeding problems. • Children with feeding problems may be sensitive to other reinforcement contingencies.

  14. EXAMPLE BASELINE DATA In this example, the child accepted 80%, 20%, and 60% of the bites, respectively, in each of the meals. Because acceptance of bites is variable (unpredictable), you should wait to start treatment. Meal 3 Meal 2 Meal 1

  15. EXAMPLE BASELINE DATA In this example, the child’s level of acceptance is between 20% and 80%. This is a variable (unpredictable) level of acceptance. It would be difficult to predict what the child’s level of acceptance will be at the next meal. If behavior is unpredictable, then it is better to wait to start treatment. Also, acceptance is increasing (getting better) at the last meal, which is another reason to wait to start treatment. Baseline 100 90 80 70 60 PERCENTAGE OF ACCEPTED BITES 50 40 30 20 10 0 0 2 4 6 8 10 12 MEALS

  16. EXAMPLE BASELINE DATA Baseline Baseline 100 100 90 90 80 80 70 70 60 60 PERCENTAGE OF ACCEPTED BITES PERCENTAGE OF ACCEPTED BITES 50 50 40 40 In this example, we continued the baseline for 3 more meals. Now, the level of acceptance is more consistently between 50% and 60%. This is now a stable level of acceptance. Acceptance is decreasing at the last meal. It would be a good time to start treatment. 30 30 20 20 10 10 0 0 0 2 4 6 8 10 12 0 2 4 6 8 10 12 MEALS MEALS

  17. EXAMPLE BASELINE DATA In this example, the child accepted 10%, 20%, and 10% of the bites, respectively, in each of the meals. Because acceptance of bites is low and predictable, you could start your treatment at the next meal. Meal 3 Meal 1 Meal 2

  18. EXAMPLE BASELINE DATA Baseline 100 90 80 70 In this example, the child’s level of acceptance is between 10% and 20%. This is a low and stable level of acceptance. You can predict that at the next meal, the child will accept between 10% and 20% of bites. If behavior is predictable, then it is a good time to start treatment. 60 PERCENTAGE OF ACCEPTED BITES 50 40 30 20 10 0 0 2 4 6 8 10 12 MEALS

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

  20. EE or EE+Sr+/Sr- • Nonremoval of the spoon – feeder keeps spoon or cup at child’s lips and deposits bite or drink at first opportunity • Differential reinforcement of alternative behavior (DRA) – feeder delivers a preferred item or activity following appropriate behavior (e.g., mouth clean) • Noncontingent reinforcement (NCR) – throughout the meal (a) feeder interacts with child, (b) feeder interacts with child and preferred items or activities are available, or (c) preferred items or activities are available • Differential negative reinforcement of alternative behavior (DNRA) – feeder delays presentation of bite following appropriate behavior (e.g., mouth clean)

  21. STUDIES ON ESCAPE EXTINCTION • Escape extinction (EE) may be a necessary component of treatment. • Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658. • LaRue, R. H., Stewart, V., Piazza, C. C., & Volkert, V. M. (2011). Escape as reinforcement and escape extinction in the treatment of feeding problems. Journal of Applied Behavior Analysis, 44, 719-735. • Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374. • Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324. • Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshal, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37, 27-41.

  22. Reinforcement of the First Behavior in the Chain (Acceptance) vsReinforcement of the Terminal Behavior in the Chain (Mouth Clean) Studies on the Effects of Reinforcement Sr+ Acceptance Sr+ Swallowing (Mouth Clean) Does it make a difference?

  23. DRA + EE BL DRA DRA DRA + EE 100 90 80 DRA MC 70 60 DRA 50 PERCENTAGE ACCEPTANCE ACC 40 30 20 10 Sunshine 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 0 BL DRA DRA + EE DRA DRA + EE 100 90 80 70 60 PERCENTAGE MOUTH CLEAN 50 40 30 20 10 Sunshine 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 SESSION Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374.

  24. DRA + EE DRA + EE BL DRA DRA 100 90 80 70 60 PERCENTAGE ACCEPTANCE 50 DRA 40 DRA ACC MC 30 20 10 Jarred 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 BL DRA DRA + EE DRA DRA + EE 100 90 80 70 60 50 PERCENTAGE MOUTH CLEAN 40 30 20 10 Jarred 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130 SESSION Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escape extinction to treat food refusal. Journal of Applied Behavior Analysis, 35, 363-374.

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

  26. Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.

  27. What Are the Effects of Noncontingent Positive Reinforcement with and without Escape Extinction? Studies on the Effects of Reinforcement NoncontingentSr+ Escape Extinction Does it make a difference?

  28. Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshal, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37, 27-41.

  29. ESC BL vs. DRA+ESC ESC BL vs. DRA+ESC EE vs. DRA+EE EE vs. DRA+EE 100 DRA + EE 90 80 70 60 PERCENTAGE ACCEPTANCE 50 40 30 ESC BL 20 DRA + ESC EE 10 0 0 32 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 34 36 38 40 42 44 SESSIONS Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.

  30. ESC BL vs DRA+ESC ESC BL vs DRA+ESC EE vs. DRA+EE EE vs. DRA+EE 100 EE 90 80 DRA + ESC 70 60 DRA + EE 50 % NEGATIVE VOCALIZATIONS 40 ESC BL 30 20 10 0 0 32 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 34 36 38 40 42 44 SESSION Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.

  31. What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers? Effects of Function-Based Treatment Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  32. 16 14 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE 12 SAVANNAH ESCAPE 10 8 ATTENTION 6 CONTROL 4 2 0 0 2 4 6 8 10 12 14 16 18 20 22 24 SESSION Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  33. Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  34. ATTN + ESC EE + ATTN vs. AE + ESC EE + ATTN vs. AE + ESC EE + AE EE + AE 28 AE + ESC 24 20 SAVANNAH 16 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE 12 8 4 EE + ATTN 0 ATTN + ESC EE + ATTN vs. AE + ESC EE + ATTN vs. AE + ESC EE + AE EE + AE EE + ATTN 100 90 80 70 60 PERCENTAGE ACCEPTANCE 50 40 30 SAVANNAH 20 10 AE + ESC 0 0 10 20 30 40 50 60 70 80 90 100 110 SESSION Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  35. Effects of Function-Based Treatment What Are the Effects of Function-Based Treatment for Children Whose Inappropriate Mealtime Behavior is Maintained by Multiple Reinforcers? • Acceptance and Mouth Clean Increased With Escape Extinction but Not Attention Extinction • Inappropriate Behavior Maintained at Low Levels with Escape Extinction in the Absence of Attention Extinction • Levels of Acceptance and Mouth Clean Were Higher and More Stable with Escape AND Attention Extinction • Important to Treat Both Functions when Inappropriate Mealtime Behavior is Multiply Maintained Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641-658.

  36. How Effective is Function- versus Sensory-Based Treatment? Comparison of Function-Based and Sensory-Based Treatments • Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.

  37. ESCAPE ESC + SI EE + NCR ESC + SI EE + NCR 100 90 80 70 60 PERCENTAGE ACCEPTANCE 50 40 30 20 10 0 80 90 100 110 0 10 20 30 40 50 60 70 SESSION • Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.

  38. ESCAPE ESC+ SI EE + NCR EE + NCR ESC+ SI 55 50 45 40 35 30 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE 25 20 15 10 5 0 0 10 20 30 40 50 60 70 80 90 100 110 SESSION • Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.

  39. COMPARISON OF FUNCTION- VS SENSORY-BASED TREATMENTS • Sensory integration-based treatment produced no change in behavior. • Escape extinction was associated with increased acceptance and decreased inappropriate behavior. • Addison, L. R., Piazza, C. C., Patel, M. R., Bachmeyer, M. H., Rivas, K. M., Milnes, S. M., & Oddo, J. (2012). A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders. Journal of Applied Behavior Analysis, 45, 455-471.

  40. FADING • Blending • Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis,37, 159-170. • Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001). Using a fading procedure to increase fluid consumption in a child with feeding problems. Journal of Applied Behavior Analysis, 34, 357-360. • Spoon distance • Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis,43, 673-683. • Spoon to cup • Groff, R. A., Piazza, C. C., Zeleny, J. R., & Dempsey, J. R. (2011). Spoon-to-cup fading as treatment for cup drinking in a child with intestinal failure. Journal of Applied Behavior Analysis, 44, 949-954. • Syringe to cup and spoon • Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.

  41. HP 100 90 80 70 60 PERCENTAGE APPROACH + CONSUME 50 40 30 20 LP 10 0 YOGURT PUDDING WAFFLE PANCAKE ORANGES CARROTS P B J PEACHES FRENCH FRIES APPLESAUCE GREENBEANS STRAWBERRIES CREAMED CORN CHICKEN NUGGETS BREAD AND BUTTER CORN ON THE COB Based on: Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis, 25, 491-498. FOODS

  42. BLENDING Sample Yogurt/Green Bean Blends 80/20 60/40 40/60 20/80 • Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis,37, 159-170.

  43. APPLE SAUCE/CARROTS 100 80/20 90 50/50 90/10 60/40 80 APPLESAUCE 70 70/30 60 CARROT 50 POTATO PERCENTAGE MOUTH CLEAN 40 30 20 John 10 0 55 0 5 10 15 20 25 30 35 40 45 50 SESSIONS • Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett, A. (2004). Increasing variety of foods consumed by blending nonpreferred foods into preferred foods. Journal of Applied Behavior Analysis,37, 159-170.

  44. DRA + EXT Water + *CIB Fading DRA + EXT CIB + Milk Fading DRA + EXT 100% 10% 20% 30% Milk/CIB 30% 0% 5% 10% 20% 30% 20% 30% 100% 100 90 80 Water Reversal Therapist 70 Mother 60 Reversal PERCENTAGE MOUTH CLEAN 50 40 100% CIB/Water 100% Milk/CIB Reversal 30 Reversal Reversal Reversal Reversal Reversal Reversal Reversal Reversal Reversal Mother 20 10 0 0 40 5 10 15 20 25 30 35 45 50 55 60 65 70 75 80 85 90 95 SESSION *CIB = Carnation Instant Breakfast Patel, M. R., Piazza, C. C., Kelly, M. L., Ochsner, C. A., & Santana, C. M. (2001). Using a fading procedure to increase fluid consumption in a child with feeding problems. Journal of Applied Behavior Analysis, 34, 357-360..

  45. Lips ESC Baseline (BL) vs Fading ESC BL Lips Escape (ESC) BL Fading+EEvsEscape Extinction (EE) Fading+EEvs EE Fading ESC BL 54 48 EE Lips ESC BL 42 Lips ESC BL Probe Fading+EE 36 20.3 cm 30 INAPPROPRIATE MEALTIME BEHAVIOR PER MINUTE Lips ESC BL Probe 15.2 cm 24 Lips 10.2 cm 18 5.1 cm 15.2 cm 15.2 cm 10.2 cm 25.4 cm 12 6 0 0 10 20 30 40 50 60 70 80 90 110 120 130 100 SESSION Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis,43, 673-683.

  46. Lips ESC BL vs Fading ESC BL Lips ESC BL Fading+EEvsEE (Escape Extinction) Fading+EEvs EE 100 Lips 80 60 Lips ESC BL Probe Lips ESC BL Probe PERCENTAGE ACCEPTANCE EE Lips ESC BL 40 20 0 0 10 20 30 40 50 60 70 80 90 100 110 120 SESSION Rivas, K. D., Piazza, C. C., Patel, M. R., & Bachmeyer, M. H. (2010). Spoon distance fading with and without escape extinction as treatment for food refusal. Journal of Applied Behavior Analysis,43, 673-683.

  47. 4 cm 2 cm 5 cm 3 cm Flush 1 cm Deposit liquid from syringe 0.5 cm Hole in cup bottom Syringe on outside of cup, recessed from lip Deposit from cup Deposit from syringe Deposit from cup Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.

  48. Deposit Syringe 5 cm 4 cm 3 cm 2 cm 1 cm Next to In mouth Bottom Top At lips Deposit Syringe Deposit Syringe Deposit Spoon Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.

  49. Syringe Volume Fading (ml) Syringe to Spoon Fading cm Spoon Position 0.1 to 1.0 EE Spoon Spoon Top Lips Top Top In mouth In mouth BL EE Next to In mouth 5 4 3 2 1 0.6 0.3 0.1 0.2 0.4 0.5 0.7 0.8 0.9 1.0 Bottom Top 100 90 80 70 EE Spoon Probe 60 PERCENTAGE MOUTH CLEAN 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 110 Session Groff, R. A., Piazza, C. C., Volkert, V. M., & Jostad, C. M. (in review). Syringe fading as treatment for feeding refusal. Journal of Applied Behavior Analysis.

  50. Escape Extinction (EE) + Attention Extinction (AE) Spoon-to- Cup Fading EE + AE BL BL 100 2.6 3.8 1.5 3.2 2.1 90 1-Year Follow Up 80 Spoon 70 60 Cup PERCENTAGE MOUTH CLEAN 50 40 30 20 10 0 10 20 30 40 50 60 70 80 90 100 110 SESSION 3.8 cm 3.2 cm 2.1 cm 2.6 cm 1.5 cm

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