Efficacy of functional analysis for informing behavioral treatment of inappropriate mealtime behavior: A systematic review and meta‐analysis

On the efficacy and efficiency of treating pediatric feeding disorder

Inappropriate mealtime behavior (IMB) is a type of feeding challenge within the broader class of food refusal. The purpose of this study was to critically analyze the efficacy of interventions for the treatment of IMB through a meta-analysis of research using single-case experimental designs. We examined the extent to which different interventions resulted in decreases in IMB while also producing increases in food acceptance. This meta-analysis was also used to examine the efficiency of different interventions in achieving clinical significance. We identified 38 studies involving 266 cases in which IMB was treated with a behavioral intervention. The results indicated interventions that combined escape extinction and non-escape extinction had greater effect sizes for both reducing IMB and increasing food acceptance than either escape extinction alone or non-escape extinction alone. However, interventions that included escape extinction were slightly less efficient at decreasing IMB than were interventions that did not include escape extinction. We discuss the implications of these findings and provide recommendations for future research.

"Still work?" Design and effect of interventions used to modify feeding problems in children with autism: A systematic review of studies employing group designs

BACKGROUND

Feeding problems in children with autism jeopardize the well-being of both children with autism and their families. Mixed findings were reported from previous interventions, which were mostly evaluated by single subject research design (SSRD) studies. Moreover, feasibility assessment and social validity measurement were unaddressed by these SSRD studies. To fill this substantial knowledge gap, the present review systematically summarized and evaluated feeding interventions implemented in children with autism, which were assessed by studies employing group designs.

METHOD

An extensive literature search in eight established online databases was conducted, and a total of 17 eligible studies published in 2009-2021 were included for further analysis. A descriptive account of the features of the investigations is provided, including assessment of study quality.

RESULTS

A total of 449 children with autism and 203 parents/caregivers participated in the included studies. The multiple use of five strategic intervention components were highlighted in this review, including nutrition education/consultations, environmental modifications, sensory exposure, cognitive components, and behaviour interventions. The reviewed interventions showed a preliminarily positive effect for modifying feeding problems in children with autism. Furthermore, the evaluation based on the RE-AIM framework (reach, efficacy, adoption, implementation, and maintenance) demonstrated that an interdisciplinary multi-component intervention strategy may achieve high effectiveness and feasibility in improving feeding problems in a wide range of children with autism.

CONCLUSIONS

This review found that interventions achieved and maintained a positive effect on modification of feeding problems in groups of children with autism. Information and gaps identified and summarized in the implementation process may assist both researchers and stakeholders to further support these vulnerable children.

Evaluating a Treatment Package for Avoidant/Restrictive Food Intake Disorder to Increase Food Variety

There is a dearth of published research evaluating behavior-analytic assessment and treatment of avoidant/restrictive food intake disorder (ARFID) given the recent revisions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In this study, therapists conducted periodic food preference assessments to help guide treatment for a typically developing child with ARFID and food selectivity. Further, therapists evaluated a treatment package including demand fading, escape prevention, and self-monitoring to increase food variety. Consumption increased during treatment with target foods; however, preference shifts were minor when compared to the pretreatment food preference assessment. Variety continued to increase overtime using the same treatment package and treatment effects were generalized to family meals and other locations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00821-0.

Comparing Simultaneous and Sequential Food Presentation to Increase Consumption of Novel Target Foods

Two methods of food presentation (simultaneous and sequential) were compared in an adapted alternating treatment design to determine effects on consumption of target foods for three children with autism in a school setting. Preferred and nonpreferred target foods were nominated by parents, and consumption of reported preferred and nonpreferred foods was directly tested. Preferred and nonpreferred foods were then paired together and assigned to one of two conditions. In the simultaneous condition, bites of preferred and nonpreferred food were presented at the same time, with the nonpreferred food placed behind or inside the preferred food. In the sequential condition, a bite of preferred food was delivered contingent on consumption of a bite of nonpreferred food. Consumption increased in the sequential condition for two out of three participants. Implications for treatment of food selectivity in a school setting are discussed.This study describes two simple interventions to increase consumption of nonpreferred foods that can be implemented in a classroom settingThese data contribute to previous studies comparing sequential versus simultaneous presentation of foods by conducting the procedures in participants' natural settingResults indicate the efficacy of sequential presentation of preferred and nonpreferred foods without the use of escape extinctionResults also suggest further research comparing sequential versus simultaneous food presentation is warranted, given the few direct comparisons that currently exist and their overall mixed results regarding relative efficacy.

Avoidant/Restrictive Food Disorder (ARFID), Food Neophobia, Other Eating-Related Behaviours and Feeding Practices among Children with Autism Spectrum Disorder and in Non-Clinical Sample: A Preliminary Study

Previous research shows that children with autism spectrum disorder (ASD) may experience several difficulties-including those related to eating-and this area of research needs to be explored further. This study had two main objectives: (1) comparison of the clinical (autism spectrum disorder) and non-clinical sample of children in terms of avoidant/restrictive food disorder, food neophobia, other eating-related behaviours and feeding practices; (2) assessment of selected predictors of food neophobia. The final sample included 54 children and parents from the clinical sample (ASD) and 51 from the non-clinical sample. Parents completed: the autism spectrum rating scales (ASRS), the eating disorders in youth questionnaire (EDY-Q), the children food neophobia scale (CFNS), the child eating behaviour questionnaire (CEBQ), the child feeding questionnaire (CFQ), and a socio-demographic survey. Our analysis allowed us to partially confirm the first hypothesis since the clinical sample (vs. the non-clinical group) had significantly higher scores in such variables as (a) avoidant/restrictive food disorder (ARFID), (b) food neophobia, (c) other eating-related behaviours: emotional under-eating, desire to drink, food fussiness, (d) feeding practices: pressure to eat. Moreover, our analysis of predictors of food neophobia in the clinical and non-clinical samples also allowed us to partially confirm the second hypothesis because it turned out that only in the clinical sample (vs. the non-clinical sample) were the predictors significantly associated with food neophobia, but only two of them (food fussiness and selective eating). In conclusion, our study showed that children with ASD (compared to children without this diagnosis) experience increased difficulties in eating behaviours, and their parents present a stronger intensity of the feeding practice based on pressure to eat. This study showed that feeding problems for children in the ASD sample are a significant problem, and it is still worth exploring this area in research.

Using an intensive interdisciplinary telehealth model to treat pediatric feeding disorders

The necessity of treatment using telehealth was apparent during the novel coronavirus (COVID-19) pandemic, as many practitioners were forced to use telehealth as a primary mode of service delivery. Although the telehealth model has been studied for different populations, little is known about its success when applied with children with feeding disorders and complex medical histories. The purpose of this study was to evaluate the efficacy of using a telehealth model from the onset of treatment. All 5 children who participated engaged in low levels of acceptance and high levels of inappropriate mealtime behavior during baseline. Caregivers were taught to implement the treatment with high integrity using behavioral skills training. Procedural integrity increased posttraining, and as a result acceptance increased and inappropriate mealtime behavior decreased. Treatment gains maintained during follow up at 1 month and 1 year. These data are discussed in relation to alternative ways of providing treatment in locations where intensive feeding programs are not available.

A Retrospective Consecutive Controlled Case Series of Underspoon: A Modified-Bolus Placement to Address Behavior That Interfere With Swallowing

Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

Description and evaluation of a function-informed and mechanisms-based framework for treating challenging behavior

Individualization and iterative design are essential components of the assessment and treatment of challenging behavior. Currently, there are few validated frameworks for engaging in iterative processes. Due to the nature of single-case design, empirically rigorous evaluations of decision-tree processes are particularly prohibitive. Notwithstanding, evaluations are needed. In this paper we first describe a function-informed and mechanisms-based (FIMB) framework for selecting treatment components employed by a university-based practicum experience designed to expose pre-service practitioners to a valid treatment process for challenging behavior. Then, we share a completed retrospective consecutive case series across a 6-year period in which we conducted a technique analysis to identify which procedures were most commonly selected in the practicum, and the impact of those choices on client outcomes. The results suggest that the model can be highly effective for some, but not all, cases. Implications are discussed.

Using Chained or Tandem Schedules With Functional Communication Training: A Systematic Review

Chained and tandem schedules are a common method for thinning schedules of reinforcement following functional communication training (FCT) in the treatment of problem behavior. We conducted a systematic literature review and meta-analysis of chained and tandem schedules following FCT to describe treatment characteristics and evaluate effects. We identified 38 articles and found reductions in problem behavior across four measures. Results of a random-effects multilevel meta-analysis of rigorous evaluations showed a significant effect of chained or tandem schedules + FCT on problem behavior relative to baseline. We observed resurgence in 77% of cases and 31% of schedule-thinning transitions. Results showed chained schedules resulted in greater reductions in problem behavior relative to tandem schedules. Exploratory moderator analyses suggested extinction, combined reinforcement, and delay and denial tolerance training procedures were associated with greater reductions in problem behavior relative to other treatment characteristics. Implications for practice and future research are discussed.

On the role of operant contingencies in the maintenance of inappropriate mealtime behavior: An epidemiological analysis

Functional analysis is the primary assessment used to determine the function of inappropriate mealtime behavior in children with feeding disorders. Based on single-case experimental design studies and recent reviews, the prevalence of negative reinforcement alone in the maintenance of inappropriate mealtime behavior appears to be much greater than positive reinforcement alone. We conducted a retrospective consecutive-controlled case series to determine the generality of previous findings. Results of the epidemiological analysis support prior research in that negative reinforcement in the form of escape (44.8%), and multiple control (i.e., positive and negative reinforcement) in the forms of escape and attention (37.2%), are considerably more prevalent than positive reinforcement alone (2.5%). We discuss the relationship between functional analysis of inappropriate mealtime behavior and treatment utility. Further, we describe avenues of future research designed to advance the application of functional analysis in feeding disorders beyond inappropriate mealtime behavior.

An evaluation of trial-based functional analyses of inappropriate mealtime behavior

Functional analyses allow clinicians to develop treatment targeting the variables maintaining a child's inappropriate mealtime behavior (Bachmeyer et al., 2019). Extended functional analyses can be inefficient, potentially delaying the onset of treatment. Researchers have suggested a trial-based functional analysis can increase assessment efficiency (Saini, Fisher, et al., 2019). This study compared trial-based functional analyses to extended functional analyses to determine the variables maintaining inappropriate mealtime behavior. We compared the efficiency and acceptability and evaluated treatments informed by the analyses. Exact correspondence between analyses was low (29%); however, most treatments indicated by the trial-based functional analyses (80%) resulted in improvements in the child's target behavior. The trial-based functional analysis required 71% less time than the extended functional analysis, and caregivers found analyses equally acceptable. Future researchers should continue refining trial-based functional analysis procedures to provide an efficient assessment that leads to efficacious treatment.

A Comparison of re-presentation and modified chin prompt to treat different topographies of liquid expulsion

Treatment of one behavior in the chain of consumption might be associated with the emergence of other problematic behaviors. For example, some children with feeding disorders expel liquid. Moreover, the form in which children expel liquid might vary and influence whether a treatment to reduce liquid expulsion will result in clinically meaningful outcomes. In the current investigation, we first identified topographies of liquid expulsion (e.g., forceful, run out) for each child. We then compared and evaluated the effects of 2 procedures, a modified chin prompt and re-presentation, on the liquid expulsion of 3 children with feeding disorders. For 2 participants, expulsion decreased to clinically meaningful levels with a modified chin prompt or re-presentation. However, for 1 participant, expulsion decreased to clinically meaningful levels only when we combined the modified chin prompt and re-presentation as part of a treatment package. We discuss possible mechanisms underlying the effects of a modified chin prompt and re-presentation, in addition to areas for future research.