An evaluation of a renewal-mitigation procedure for inappropriatemealtime behavior
Sarah D. Haney , Cathleen C. Piazza, Kathryn M. Peterson andBrian D. Greer
University of Nebraska Medical Center’s Munroe-Meyer Institute
Renewal, the increase in behavior during extinction following context changes, may be particu-larly concerning during intervention for feeding disorders because context changes are often nec-essary for intervention generality and maintenance (Podlesnik et al., 2017). In the currentstudy, we tested for renewal and evaluated a renewal-mitigation procedure when we transferredintervention from a therapist to a caregiver, from clinic to the home, and changed the foods thefeeder presented. We used an ABA arrangement to evaluate the generality of the renewal effectwith 7 participants who engaged in inappropriate mealtime behavior. Context A was functionalreinforcement. Context B was function-based extinction during the control and mitigation con-ditions and our renewal-mitigation procedure in the mitigation condition. The renewal test wasfunction-based extinction in Context A. We observed renewal of inappropriate mealtime behav-ior in 4 of 7 participants, and our renewal-mitigation procedure was effective for 4 of4 participants.Key words: avoidant/restrictive food intake disorder, escape extinction, feeding disorder, mit-
igation, renewal, translational research
The diagnosis avoidant/restrictive food intakedisorder describes children who do not consumeenough calories or nutrients to maintain weightor grow (American Psychiatric Association,2013). Children with this diagnosis often engagein inappropriate mealtime behavior, like battingat the spoon, to avoid bite or drink presenta-tions. Although researchers have demonstratedthe effectiveness of escape extinction for decreas-ing inappropriate mealtime behavior in clinical
settings, less is known about the generalizationand long-term maintenance of escape extinctionin other contexts.Context is one variable that may affect the
generality and long-term maintenance ofextinction (e.g., Kelley et al., 2015; Podlesniket al., 2017). Context is any stimulus that exertscontrol over behavior (e.g., Bouton et al.,2011; Kelley et al., 2015; Podlesnik et al.,2017; Todd, 2013). Researchers hypothesizethat context changes may be responsible forincreases in previously extinguished behavior, arelapse phenomenon called renewal (Boutonet al., 2011; Kelley et al., 2015; Podlesniket al., 2017). Context theory states that renewaloccurs because the context functions as a dis-criminative stimulus for the extinction contin-gencies, and the effects of these discriminativestimuli are specific to the original extinctioncontext. The effects of extinction do not havegenerality outside the original extinction con-text (Bouton et al., 2011; Podlesnik et al.,2017; Trask et al., 2017; Wathen & Podlesnik,2018), perhaps because the stimuli that were
Sarah D. Haney is now at the Kennedy Krieger Insti-tute, Baltimore, Maryland. Cathleen C. Piazza andKathryn M. Peterson are now at Children’s SpecializedHospital, Somerset, New Jersey, and Graduate School ofApplied and Professional Psychology, Rutgers University.Brian D. Greer is now at Children’s Specialized Hospital-Rutgers University Center for Autism Research, Educa-tion, and Services, and Rutgers Robert Wood JohnsonMedical School.Sarah Haney conducted this investigationin partial fulfillment of the requirements for the degree ofDoctor of Philosophy from the University of NebraskaMedical Center.Address correspondence to Cathleen Piazza at:
cp945@gsapp.rutgers.edu or Sarah Haney at:sdh7787@gmail.comdoi: 10.1002/jaba.815
Journal of Applied Behavior Analysis 2021, 54, 903–927 NUMBER 3 (SUMMER)
© 2021 Society for the Experimental Analysis of Behavior
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present in the original context are not presentwhen the context changes (Wathen &Podlesnik, 2018).The study of renewal is particularly relevant
during intervention for children with avoidant/restrictive food intake disorder for several rea-sons. First, context changes are commonbecause children feed in many environmentswith different individuals. Second, studies haveshown that inappropriate mealtime behaviormay reemerge following changes in the feeder(Kelley et al., 2018) and feeder and setting com-bined (Ibañez et al., 2019). Third, inappropriatemealtime behavior that emerges during contextchanges may contact reinforcement, which maymaintain the behavior over time (Kelley et al.,2018; Mitteer et al., 2018). Borrero et al.(2010) showed that the most common conse-quence that caregivers delivered following inap-propriate mealtime behavior was escape in theform of removal of bite or drink presentationsor meal termination. Attention was the secondmost common caregiver consequence. Fourth,results of studies on functional analysis of inap-propriate mealtime behavior have shown thatescape functions as negative reinforcement forinappropriate mealtime behavior for most chil-dren with feeding disorders (Bachmeyer et al.,2019; Girolami & Scotti, 2001; Najdowskiet al., 2008; Piazza et al., 2003). These data sug-gest that if inappropriate mealtime behaviorreemerges, caregivers are likely to deliver escapeand possibly attention and these consequencesare likely to function as reinforcement. Fifth,Mitteer et al. (2018) showed that undesirablecaregiver behavior (e.g., providing the func-tional reinforcer following destructive behavior)may also relapse during context changes, whichsuggests that caregivers may provide reinforce-ment for inappropriate mealtime behavior dur-ing context changes. This is problematic forchildren with feeding disorders because insuffi-cient calories or nutrients may have negativeshort- and long-term consequences like poorgrowth and behavior and learning problems,
respectively (Freedman et al., 1999; Petersonet al., 2018; Volkert & Piazza, 2012) and causecaregiver anxiety, depression, and stress (Bryant-Waugh et al., 2010; Greer et al., 2007; Kreipe &Palomaki, 2012). Lastly, studying renewal mayinform strategies to improve the generality andlong-term maintenance of intervention effects(Ibañez et al., 2019; Kelley et al., 2018; Podlesniket al., 2017; Wathen & Podlesnik, 2018).Our standard clinical practice provides an
opportunity to evaluate renewal in children withavoidant/restrictive food intake disorder and par-allels the ABA arrangement researchers have usedto study renewal (Bouton et al., 2011). When weadmit a child, we observe caregivers feeding thechild in the clinic using the consequences theyprovide at home, which we define as ContextA. Because admitted children have complex feed-ing problems, trained therapists often implementthe child’s intervention in the clinic initially,which is Context B. Next, we train caregivers toimplement the intervention. Thus, the return toContext A is the caregiver implementing theintervention in the clinic. Caregivers implementthe intervention in the home after their imple-mentation integrity in the clinic is high, which isan additional context change. More contextchanges may be necessary for individual children,such as new settings (e.g., daycare), feeders(e.g., babysitter), foods, or textures.Two studies have demonstrated renewal dur-
ing feeding interventions (Ibañez et al., 2019;Kelley et al., 2018). In Context A in Ibañezet al. (2019), the caregiver provided functionalreinforcement for inappropriate mealtime behav-ior in a simulated home setting. In Context B, atherapist implemented function-based extinctionin a clinic room. In the return to Context A, thecaregiver implemented function-based extinctionin a simulated home setting. Renewal of inap-propriate mealtime behavior occurred across par-ticipants even though caregivers implementedextinction with high levels of integrity.Researchers have shown that caregivers pro-
vide escape following inappropriate mealtime
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behavior (Borrero et al. 2010) and that escapefunctions as reinforcement for inappropriatemealtime behavior (Girolami & Scotti, 2001;Nadjowski et al., 2008; Piazza et al. 2003).Researchers have also shown that inappropriatemealtime behavior (Ibañez et al., 2019; Kelleyet al. 2018) and undesirable caregiver behavior(Mitteer et al., 2018) may reemerge followingcontext changes during intervention. Thus, devel-oping and testing procedures to mitigate renewalis important. We could find only one study thatassessed renewal-mitigation for inappropriatemealtime behavior. Kelley et al. (2018) used anABABA+BA arrangement and evaluated a changefrom therapist to caregiver during function-basedextinction for two participants with avoidant/restrictive food intake disorder. Inappropriatemealtime behavior returned for both participantsduring the first renewal test when caregiversimplemented extinction. During the return toContext B, the therapist implemented extinction.Context A + B was their renewal-mitigation pro-cedure in which the caregiver sat next to the ther-apist while the therapist implemented extinction.During the second renewal test when the care-giver implemented extinction, renewal did notoccur for one participant. Rate of inappropriatemealtime behavior was lower and less persistentfollowing the mitigation procedure for the otherparticipant. One limitation was that repeatedexposure to the context change, like in the rever-sal design Kelley et al. used, may reduce the likeli-hood that behavior will return (Sweeney &Shahan, 2013; Wacker et al., 2011). Thus, wecannot be certain that the results were due to therenewal-mitigation procedure or to repeated expo-sure to the context change.In the current study, we extended the findings
of Ibañez et al. (2019) by evaluating renewal ofinappropriate mealtime behavior during function-based extinction in the control condition and ofKelley et al. (2018) by developing and evaluatinga renewal-mitigation procedure in our mitigationcondition. Results of previous research have shownthat renewal may be less likely when cues for
extinction are present in contexts previously asso-ciated with reinforcement (Bernal-Gamboa,Gámez, & Nieto, 2017; Kelley et al., 2018; Nietoet al., 2017; Todd et al., 2012). Researchers havealso shown that increasing the similarity betweenacquisition and extinction contexts may mitigaterenewal when returning to contexts associatedwith reinforcement (Bandarian-Balooch &Neumann, 2011; Todd et al., 2012). Combiningrenewal-mitigation procedures may mitigaterenewal more effectively than these proceduresindividually (Bandarian-Balooch & Neumann,2011; Bernal-Gamboa, Nieto, & Uengoer, 2017;Krisch et al., 2018). For example, Bandarian-Balooch and Neumann (2011) used an ABArenewal arrangement to evaluate renewal of shockexpectancy in humans and found that the combi-nation of implementing extinction in multiplecontexts (i.e., varying light intensities) and con-text similarity was most effective at mitigatingrenewal relative to these procedures alone.Our renewal-mitigation procedure used a
therapist–caregiver pairing procedure like Kelleyet al. (2018) when we changed the feeder fromtherapist to caregiver, food-fading when wechanged the foods the feeder presented, and con-text similarity when we changed from the clinicto the home. Context A was the caregiver ortherapist delivering function-based reinforce-ment for inappropriate mealtime behavior in thecontrol and mitigation conditions. Context Bwas the therapist implementing function-basedextinction in the control and mitigation condi-tions and implementing the renewal-mitigationprocedure in the mitigation condition. We eval-uated rate of inappropriate mealtime behavior ina return to Context A in which the caregiver ortherapist implemented function-based extinctionin the control and mitigation conditions.
Method
ParticipantsParticipants were seven children who met the
criteria for avoidant/restrictive food intake disorder
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admitted to an intensive day-treatment programand their caregivers between 2018 and 2020. Par-ticipants attended the program 5 days per weekfrom approximately 9:00 a.m. to 5:00 p.m. Inclu-sion criteria were the participant (a) was between2 and 18 years old, (b) was safe for oral feedingper a pediatrician or speech pathologist,(c) received 50% or more of daily calories fromsupplemental feeding or had a diet that was nutri-tionally inadequate per our registered dietitian, and(d) had at least 3 months of outpatient feedingtherapy without progress. Exclusion criteria were(a) the participant did not meet the inclusioncriteria, (b) the participant engaged in packing,expulsion, or both that did not improve duringescape extinction, and (c) acceptance, mouth clean,inappropriate mealtime behavior, or a combinationof these behaviors did not improve during escapeextinction. We excluded four children from thestudy, one for persistent packing, one for persistentexpulsion, and two because acceptance and inap-propriate mealtime behavior did not improve. Ourprogram’s registered dietitian used the Centers forDisease Control and Prevention (2010) growthchart for ages 2-20 for John, Maisy, Hope, Emilia,Diego, and Julian and the 22q11 deletion syn-drome growth chart for girls ages 2-20 (Tarquinioet al., 2012) for Jade to calculate each child’sbody-mass index, height, and weight. Seven chil-dren, three males and four females, between theages of 3 to 6 met the inclusion criteria and partic-ipated in the study. Table 1 describes participantdemographics, nutritional information, and growthparameters upon admission into the PediatricFeeding Disorders Program.
Setting and MaterialsFeeders conducted control and mitigation ses-
sions with participants in 4-m by 4-m clinicrooms with adjacent observation rooms with one-way observation and two-way audio and sound.Clinic rooms contained a rectangular table, uten-sils, a food tray, a scale, a chair for the feeder, andweight-appropriate seating for the participant;
and colored bowls, tablecloths, and cards for Emi-lia, Diego, and Julian. Caregivers conductedJade’s sessions in their home, and therapistsobserved these sessions using Vidyo, a securevideo-conferencing software. John and Emilia satin a Special Tomato Soft-Touch sitter, and Maisyand Julian sat in a booster seat. We secured thesitter and booster seat to a kitchen chair. Hopesat in a regular kitchen chair. Diego and Jade satin a highchair.Caregivers selected 16 foods that the partici-
pant currently did not consume, four fruits,four proteins, four starches, and four vegetableswith input from the dietitian. Caregivers ofJohn, Maisy, Hope, and Jade also selected anage-, calorically, and nutritionally appropriateliquid as increasing liquid consumption was atarget of their treatment.
FeedersFeeders were the participant’s biological mother
(Maisy, Hope, Emilia, Jade, and Diego) and father(John and Hope) and trained clinic therapists.Therapists also served as observers. Training fortherapists included didactic modules with posttests,competency training for session and food prepara-tion, and in-vivo training to competency for partic-ipant assessment and treatment and caregiver-training procedures, wherein the therapist mustimplement the procedures with a confederate childacross a variety of child responses with 80% orhigher integrity in the absence of corrective feed-back before implementing these procedures with achild or caregiver. We collected data on therapistintegrity and provided feedback if necessary whenthe therapist implemented the procedures with achild or caregiver to ensure that the therapistmaintained 80% or higher integrity.
Dependent Variables, ProceduralIntegrity, and ReliabilityObservers used BDataPro® to collect data on
inappropriate mealtime behavior, acceptance,and procedural integrity in the control and
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Table1
ParticipantDem
ographics,NutritionalInformation,
andGrowth
Parametersu
ponAdm
issionintotheFeedingProgram
%Needs
Metby
Mouth
Nutritio
nalInadequacies
Growth
Parameters
Nam
eAge
Diagnoses
CaloriesProtein
Fluids
HeightWeight
BodyMass
Index
Food
Consumed
John
6Autism
114%
348%
136%
chromium,iron,
manganese,
potassium,selenium,and
vitamins
EandB3
33rd
12th
17th
Pediasure1.0,
yogurt,fruitbaby
food,and
pudding
Maisy
4EhlersDanlossynd
rome;historyof
food
allergies,gastrostom
y-tube
depend
ence,failure
tothrive,F
ood
ProteinIndu
cedEnterocolitis
Synd
rome,andmilk
soyprotein
intolerance
43%
204%
32%
calcium,chrom
ium,copper,
magnesium
,manganese,
potassium,and
vitaminsB5andD
<1st
<1st
1st
3-5oz
ofPu
raminoviabottle,w
ater,
beans,eggs,p
eaches,chips,b
read,
macaroniand
cheese,and
hotdog
Hope
5History
ofdevelopm
entald
elay;
resolved
neurologicaldefectwith
facialdrooping;and
nasojejunal-,
gastrostom
y-,and
gastrostom
y-jejunostom
y-tube
depend
ence
28%
126%
13%
biotin;folate;vitaminsA,B
1,B2,
B6,
B12,C
,D,and
E7th
3rd
13th
Juice,chocolatemilk,chicken
nuggets,steak,
French
fries,bread,
potatoes,p
ineapple,apple,o
range,
andapplesauce
Emilia5
History
ofgaggingandvomiting,o
ral
motor
skill
deficitswith
difficulty
swallowing,andasoyallergy
84%
160%
40%
calcium,iron,
manganese,p
otassium
,andvitamin
D68
th32
nd
12th
Ensure,Pediasure1.0,
juice,chips,
cookies,crackers,d
onuts,andrice
cakes
Diego
3Totalparenteralnu
trition
depend
ence
anddiagnosesof
intestinalfailure
andshortbowel
synd
rome
80%
221%
91%
None
19th
40th
68th
59mlo
fNeocateJr.from
abottle
approxim
atelyevery2hr
while
awake,goldfish
crackers,and
peanut
butter
balls
Jade
4DiGeorgesynd
rome(22q11
deletio
nsynd
rome)andhistoryof
congenitalh
eartdefect,
gastrostom
y-tube
depend
ence,
dysphagia,gastroesophagealreflux
disease,Nissanfund
oplication,
and
oralmotor
skill
deficit
73%
210%
60%
calcium,selenium,and
vitamin
D14
th7th
9th
Did
notconsum
eanyfruits,
proteins,starches,or
vegetables
orally
Julian
5Autism
89%
189%
43%
calcium;chrom
ium;m
agnesium
;manganese;p
otassium
;zinc;and
vitaminsB5,
B7,
D,and
E
67th
72nd
68th
Juice,water,cereal,crackers,chips,
corndogs,p
eanu
tbu
tter
andjelly
sand
wiches,goldfish
crackers,
banana,grapes,fruitsnacks,o
reos,
andpoptarts.
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mitigation conditions (Bullock et al., 2017).During caregiver training, observers scoredoccurrences and nonoccurrences of proceduralintegrity on each intervention component usingan Excel spreadsheet that generated a graphfrom the inputted data.
Dependent VariablesObservers scored the frequency of inappropri-
ate mealtime behavior when the spoon or cupwas within arm’s reach of the participant andeach time the participant (a) moved the middleof their mouth 45� or more in any direction or6.4 cm in any direction away from the utensil;(b) changed direction or paused for 1 s and thenmoved the head another 45� in any direction or6.4 cm in any direction relative to the previousposition; or if the participant’s hand, arm, oranything in the participant’s hand (e.g., bib)touched the utensil, food, liquid, or any part ofthe feeder’s hand or arm from the elbow downthat the feeder was using to implement the feed-ing procedure; (c) threw the spoon or cup;(d) placed their hand, arm, toy, or bib within5 cm of the mouth; and (e) moved more than2.5 cm from and was no longer touching thespoon, cup, feeder’s hand or arm from the elbowdown, or the participant’s own mouth and thenreturned to the spoon, cup, feeder’s hand or armfrom the elbow down, or the participant’s ownmouth. A presentation occurred the first time thefeeder touched the utensil to the participant’slips to offer the participant the opportunity toaccept that bite or drink initially. Observersscored the occurrence of acceptance when theparticipant (a) opened their mouth and was notcrying, screaming, yelling, or making refusalstatements or (b) opened their mouth and leanedforward while engaging in negative vocalizationsand the feeder deposited the bite or drink within5 s of the initial presentation. A deposit occurredwhen the entire bite or drink passed the plane ofthe wet vermillion of the participant’s lips, andno food or liquid remained on the spoon or inthe cup when the feeder removed the utensil
from the participant’s lips. The number ofopportunities for observers to score acceptancecorresponded to the number of bites or drinksthe feeder presented. We defined an entire biteor drink as the volume of solids or liquids thefeeder presented on the utensil minus a pea-sizedvolume or smaller.BDataPro® converted the frequency of inap-
propriate mealtime behavior to responses perminute by dividing the number of inappropriatemealtime behaviors during the session by theduration the utensil was within arm’s reach of theparticipant. BDataPro® converted acceptance to apercentage after dividing the number of accep-tances by the total number of presentations.
Procedural IntegrityCorrect-utensil placement assessed procedural
integrity for components specific to the feeder’sutensil use. Observers scored duration ofcorrect-utensil placement in the control andmitigation conditions by activating a durationkey on BDataPro® when the feeder met the cri-terion for correct-utensil placement anddeactivating the duration key when the feederdid not meet the criterion for correct-utensilplacement for 3 s or more. Across all conditionsof the study, observers scored correct-utensilplacement when the feeder presented the utensiltouching the participant’s lips at the scheduledinterval; removed the utensil after the bite ordrink entered the mouth; and held the utensilto the side of the participant’s mouth if the par-ticipant coughed, gagged, or vomited while thefeeder was holding the utensil at the partici-pant’s lips. Observers scored correct-utensilplacement during function-based reinforcementif the feeder removed the utensil after the occur-rence of inappropriate mealtime behavior.Observers scored correct-utensil placement dur-ing function-based extinction when the feederheld the spoon touching the participant’s lipsuntil they could deposit the bite or drink intothe mouth, or the time-cap elapsed and used theutensil to re-present the expelled bite or drink
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into the mouth within 3 s of expulsion.BDataPro® converted duration of correct-utensil placement to a percentage after divid-ing the duration of correct-utensil placementby the total session time. Mean correct-utensilplacement during function-based reinforce-ment in Context A was 99% (range, 99% to100%) for caregivers and 99% (range, 99%to 100%) for therapists during the controlcondition, and 99% (range, 91% to 100%)for caregivers and 99% (range, 99% to 100%)for therapists during the mitigation condition.Mean correct-utensil placement duringfunction-based extinction in Context B was99% (range, 88% to 100%) for therapists dur-ing the control condition, and 99% (range,88% to 100%) for caregivers and 99% (range,89% to 100%) for therapists during the miti-gation condition. Mean correct-utensil place-ment during the renewal test in Context Awas 99% (range, 98% to 100%) for caregiversand 99% (range, 88% to 100%) for therapistsduring the control condition, and 99% (range,99% to 100%) for caregivers and 99% (range,99% to 100%) for therapists during the miti-gation condition.Correct procedure assessed procedural integ-
rity for components other than those specific tothe feeder’s utensil use. Observers scored correctprocedure if the feeder completed every compo-nent described below and did not score correctprocedure if the feeder did not perform a com-ponent or performed a component incorrectly.Observers scored the occurrence of correct proce-dure in the control and mitigation conditionsafter the mouth check or at the end of the pre-sentation interval if the feeder (a) used the cor-rect utensil and presented the specified bolussize, (b) delivered a vocal prompt to “Take abite (drink)” while touching the utensil to theparticipant’s lips within 5 s of the scheduledpresentation, (c) deposited the bite or drinkwithin 5 s of presentation if the participant metcriterion for acceptance, (d) delivered vocal,behavior-specific praise within 5 s of acceptance
and mouth clean (i.e., no food in the mouth atthe mouth check in the absence of spitting outthe bite or drink), (e) delivered a vocal promptto “Show me, ahh” while conducting a mouthcheck approximately 30 s after the feeder depos-ited the bite or drink into the participant’smouth, (f) delivered the vocal prompt to “Swal-low your bite (drink)” within 5 s of the mouthcheck if the participant packed (i.e., held foodor liquid larger than a pea-size volume in themouth) and delivered the swallow prompt every30 s if the participant packed on the fifth bite ordrink presentation until there was no food orliquid in the participant’s mouth or until10 min elapsed, (g) provided no differentialconsequences for coughing, gagging, orvomiting, and (h) presented the next bite ordrink within 5 s of the next scheduled presenta-tion interval. Observers scored correct proce-dure for caregivers and therapists separatelywhen therapists fed and caregivers deliveredother components of the extinction interventionduring the mitigation condition. BDataPro®
converted correct procedure to a percentageafter dividing the number of bite or drink pre-sentations with correct procedure by the totalnumber of bite or drink presentations. Meancorrect procedure during function-based rein-forcement in Context A was 98% (range, 80%to 100%) for caregivers and therapists duringthe control condition, and 97% (range, 80% to100%) for caregivers and 99% (range, 80% to100%) for therapists during the mitigation con-dition. Mean correct procedure duringfunction-based extinction in Context B was99% (range, 80% to 100%) for therapists dur-ing the control condition, and 98% (range,80% to 100%) for caregivers and 100% fortherapists during the mitigation condition.Mean correct procedure during the renewal testin Context A was 99% (range, 80% to 100%)for caregivers and 100% for therapists duringthe control condition, and 97% (range, 80% to100%) for caregivers and 100% for therapistsduring the mitigation condition.
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Observers scored occurrences of incorrectattention once during each presentation intervalin the control and mitigation conditions whenthe feeder (a) did not provide behavior-specificpraise within 5 s of acceptance and mouth clean,(b) delivered behavior-specific praise if the biteor drink entered the participant’s mouth after5 s of presentation, or (c) delivered behavior-specific praise if there was food or liquid in theparticipant’s mouth at the mouth check.Observers also scored incorrect attention duringescape baseline and function-based extinctionwhen the feeder delivered attention within 5 s ofinappropriate mealtime behavior. Observersscored incorrect attention during the escape andattention baseline when the feeder did notdeliver attention within 5 s of inappropriatemealtime behavior. BDataPro® converted incor-rect attention to a percentage after dividingoccurrences of incorrect attention by the totalnumber of bite presentations in the session.Mean incorrect attention during function-basedreinforcement in Context A was 1% (range, 0%to 20%) for caregivers and 0% for therapistsduring the control condition, and 0.3% (range,0% to 20%) for caregivers and 0% for therapistsduring the mitigation condition. Mean incorrectattention during function-based extinction inContext B was 0% for therapists during the con-trol condition and 0.6 % (range, 0% to 20%)for caregivers, and 0% for therapists during themitigation condition. Mean incorrect attentionduring the renewal test in Context A was 0.5%(range, 0% to 20%) for caregivers and 0% fortherapists during the control condition, and 1%(range, 0% to 20%) for caregivers and 0% fortherapists during the mitigation condition.
Interobserver AgreementTwo observers simultaneously and indepen-
dently collected data on a mean of 54% and66% of sessions in the control and mitigationconditions, respectively. We trained observersto collect data on BDataPro® and on a stream-lined Excel spreadsheet with 80% or higher
interobserver agreement for three consecutivesessions.The BDataPro® software calculated inter-
observer agreement by dividing each session into10-s intervals. BDataPro® calculated exact agree-ment coefficients for inappropriate mealtimebehavior by dividing the number of exact agree-ments (observers scored the same frequency ofbehavior in an interval) by the number of exactagreements plus disagreements (observers scoreddifferent frequencies of behavior in an interval)and converting this ratio to a percentage. Meaninterobserver agreement was 94% (range, 73%to 100%) and 96% (range, 71% to 100%) forinappropriate mealtime behavior during the con-trol and mitigation conditions, respectively.BDataPro® calculated total agreement coeffi-cients for acceptance, correct-utensil placement,correct procedure, and incorrect attention bydividing the total number of agreements(i.e., both observers scored the occurrence ornonoccurrence of the behavior in the interval)by the total number of agreements plus disagree-ments (one observer scored and the otherobserver did not score the occurrence of thebehavior in the interval) and converting thisratio to a percentage. Mean interobserver agree-ment during the control condition was 99%(range, 80% to 100%) for acceptance, 99%(range, 90% to 100%) for correct-utensil place-ment, 99% (range, 80% to 100%) for correctprocedure, and 99% (range, 80% to 100%) forincorrect attention. Mean interobserver agree-ment during the mitigation condition was 98%(range, 80% to 100%) for acceptance, 99%(range, 85% to 100%) for correct-utensil place-ment, 98% (range, 80% to 100%) for correctprocedure, and 99% (range, 80% to 100%) forincorrect attention.
Experimental DesignControl and Mitigation ConditionsWe used a three-phase ABA arrangement to
evaluate the control and mitigation conditions.
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During Context A, the caregivers of John,Maisy, Hope, Emilia, Diego, and Jade and atherapist for Julian delivered function-basedreinforcement for inappropriate mealtime behav-ior. During Context B, a therapist implementedfunction-based extinction of inappropriate meal-time behavior during the control and mitigationconditions. The therapist also implemented themitigation procedure in the mitigation condi-tion. During the renewal test in Context A, thecaregivers of John, Maisy, Hope, Emilia, Diego,and Jade and a therapist for Julian implementedfunction-based extinction of inappropriate meal-time behavior.
General ProcedureFeeders conducted five 40-min meals per
day with at least 40 min between the end ofone meal and the start of the next meal. Eachsession generally consisted of five bite or drinkpresentations with approximately 1 minbetween each session during which feeders andobservers prepared for the next session. Thenumber of sessions per meal depended on theduration of each session within the meal, whichdepended on the participant’s behavior. Meannumber of sessions per meal was four forMaisy; five for John, Hope, Emilia, Diego, andJulian; and six for Jade. The feeder generallyconducted control sessions in some meals andmitigation sessions in other meals. The feederonly presented solids to Emilia, Diego, andJulian. The feeder generally presented solids insome meals and liquids in other meals for John,Maisy, Hope, and Jade. The only time thefeeder conducted the control and mitigationconditions in the same meal was if the partici-pant’s behavior met the criterion to changephases and implement the contingencies in thenext context, such as a change from Context Ato Context B, and we needed to equate thenumber of sessions between conditions beforechanging phases. For example, if the participantmet criterion in solids sessions during Meal
1 in Context A to change to Context B, thenthe feeder stopped conducting solids sessions inMeal 1 in Context A so that we could transi-tion to solids sessions in Context B in Meal2. If 20 min or more remained in Meal 1 andthe participant had not met criterion to changeto Context A in liquids sessions, then thefeeder conducted liquids sessions in Context Afor the rest of Meal 1.Feeders presented 1 cc of pureed food, which
was table food blended until smooth with liq-uid added as needed, on a small maroon spoonin solids sessions. Feeders leveled the bolus byscooping pureed food onto the spoon, scrapingthe bowl of the spoon on the side of the dishto flatten the bolus, and scraping the bottom ofthe spoon’s bowl on the dish to remove excesspuree. The feeder presented eight of the16 caregiver-selected foods, two fruits, two pro-teins, two starches, and two vegetables, duringthe control and mitigation conditions for John,Maisy, Hope, Emilia, Jade, and Julian; 16 care-giver-selected foods during the control and mit-igation conditions for Diego. The feederpresented the same foods in every condition inevery phase to control for potential differencesin participant behavior as a function of foodtype (Patel et al., 2002) and randomly selectedthe order of food presentation before the startof the session.Feeders presented 2 cc of Vanilla Pediasure
1.0 with and without fiber in a small pink cut-out cup for Jade and John, respectively. Feederspresented 4 cc of Vanilla Puramino Junior andPeptamin Junior 1.5 in a pink cut-out cup forMaisy and Hope, respectively.During each session, the feeder presented a
bite or drink by touching the utensil to the par-ticipant’s lips while saying, “Take a bite(drink).” The feeder deposited the bite or drinkif the participant met criterion for acceptanceand delivered behavior-specific praise for accep-tance. The feeder conducted a mouth checkapproximately 30 s after they deposited the biteor drink into the participant’s mouth by saying,
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“Show me, ahh.” If the participant did not opentheir mouth within 3 s of the prompt, the feederinserted a small rubber-coated spoon betweenthe participant’s lips with the bowl of the spoontouching the participant’s lower lip and turnedthe spoon 90� such that the bowl of the spoonfaced the participant’s teeth to prompt the par-ticipant to open their mouth. If the child didnot open their mouth within 3 s of this prompt,the therapist inserted the spoon between theparticipant’s teeth and used the same procedureto prompt the participant to open their mouth.The feeder delivered behavior-specific praise formouth clean or a verbal prompt to “Swallowyour bite (drink)” if the participant was packingand presented the next bite or drink. If the par-ticipant showed the feeder a mouth clean before30 s elapsed to signal the mouth check, thefeeder delivered behavior-specific praise andwaited until the mouth-check interval elapsedbefore presenting the next bite or drink. If theparticipant had packed food or liquid in theirmouth after the fifth bite or drink presentation,the feeder conducted a mouth check and deliv-ered the verbal prompt to swallow every 30 suntil no food or liquid was in the participant’smouth or until 10 min had elapsed from sessioninitiation. The feeder wiped out the partici-pant’s mouth after the session. The feeder deliv-ered no differential consequence for coughing,gagging, or vomiting. The feeder moved theutensil to the side of the participant’s mouth ifthe participant coughed, gagged, or vomitedwhile the utensil was at the participant’s lipsand moved the utensil back to the participant’slips when the participant stopped coughing,gagging, or vomiting.
Control and Mitigation ConditionsBefore the current study, we conducted an
unstructured observation in which the caregiverpresented preferred and nonpreferred food andliquid to the participant. Next, we conducted astructured observation in which we observed
the caregiver (a) attempt to feed the participantbites of pureed food, (b) attempt to feed theparticipant liquids from a cup, (c) prompt theparticipant to self-feed bites of pureed food,(d) prompt the participant to self-feed bites oftable-textured food, and (e) prompt the partici-pant to self-feed liquids from a cup. Third, atherapist conducted a paired-choice preferenceassessment (Fisher et al., 1992) and a functionalanalysis based on the procedure Bachmeyeret al. (2009) described.One purpose of the study was to assess
whether renewal of inappropriate mealtimebehavior occurred when we implementedfunction-based-extinction intervention for chil-dren with avoidant/restrictive food intake disor-der. The context changes were changing from(a) a therapist to a caregiver as feeder for John,Maisy, Hope, and Emilia in the clinic; (b) froma therapist feeding four foods in the clinic to acaregiver feeding four different foods in theclinic for Diego; (c) from a therapist as feeder inthe clinic to a caregiver as feeder at home forJade; and (d) from a clinic room to a simulatedhome room for Julian. We compared levels ofrenewal in the mitigation condition with thoseof the control condition to determine whetherthe mitigation procedure was effective. A secondpurpose was to assess whether our renewal-mitigation procedures would prevent renewalfollowing these context changes in the mitiga-tion condition. The arrangement for the mitiga-tion condition was like the control conditionexcept that we implemented our renewal-mitigation procedure during extinction inContext B. We assessed renewal effects duringliquids and solids intervention for John, Maisy,Hope, and Jade and during solids interventionfor Emilia, Diego, and Julian. We used coloredstimuli to aid Emilia, Diego, and Julian’s dis-crimination of the conditions because the feederpresented pureed food in both conditions,which do not have as many distinctive proper-ties as the same foods at table texture. We alsorandomly chose the order of sessions during the
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renewal test across the control and mitigationconditions with each participant. We conductedrenewal-test sessions in the control conditionfirst and the mitigation condition second withJohn, Maisy, Emilia, and Jade and vice versawith Hope, Diego, and Julian.We randomly assigned solids for John and
Hope and liquids for Maisy and Jade to the con-trol condition and liquids for John and Hopeand solids for Maisy and Jade to the mitigationcondition. We randomly assigned one fruit, oneprotein, one starch, and one vegetable to a foodset for Emilia, Diego, and Julian. For Emilia,we randomly assigned Set 1 foods (baked bean,green bean, pancake, pear), orange bowls, andan orange table cloth to the control conditionand Set 2 foods (banana, carrot, chicken,potato), blue bowls, and a blue table cloth tothe mitigation condition. For Diego, we ran-domly assigned Set 1 foods (banana, cauliflower,egg, pancake), Set 2 foods (applesauce, greenbean, hamburger, oatmeal), blue bowls, and ablue 10-cm x 17-cm card to the control condi-tion and Set 3 foods (avocado, broccoli, sweetpotato, tuna), Set 4 foods (chicken, potato,strawberry, squash), orange bowls, and anorange 10-cm x 17-cm card to the mitigationcondition. For Julian, we randomly assigned Set1 foods (applesauce, carrot, chicken, potato),orange bowls, an orange table cloth, and anorange 91-cm by 122-cm card to the controlcondition and Set 2 foods (baked bean, greenbean, pear, wheat bread), blue bowls, a bluetable cloth, and a blue 91-cm by 122-cm cardto the mitigation condition.The feeder started each corresponding phase
of the control and mitigation conditions andtransitioned from Context A to Context B onthe same day and from Context B to therenewal test on the same day. For example, thefeeder conducted the last session of Context Bin the control condition and the first session ofContext A in the control condition on Tuesday.In addition, we transitioned from Context B tothe renewal test in the same meal for John,
Hope, Diego, Jade, and Julian and in consecu-tive meals (e.g., Meal 3 and Meal 4) for Maisyand Emilia. The feeder followed the generalprocedure described above and the specific pro-cedure described below for the control and miti-gation conditions. We equated the number ofsessions in each context across the control andmitigation conditions before changing fromcontext to context to ensure that our manipula-tions, rather than unequal exposure to theexperimental conditions, produced the observedeffects. For example, if the number of sessionsfor Context A was 10 in the control condition,then the number of sessions for Context A inthe mitigation condition was 10.
Context A Reinforcement (Control and Miti-gation Conditions)The caregivers of John, Maisy, Hope, Emi-
lia, Diego, and Jade and a therapist for Juliandelivered functional reinforcement followinginappropriate mealtime behavior in the clinicfor John, Maisy, Hope, Emilia, and Diego, inthe home for Jade, or in a simulated home forJulian. The therapist and observer were in theadjacent observation room during sessions forJohn, Maisy, Hope, Emilia, Diego; in the clinicobserving via a secure video application forJade; or in the simulated home for Julian. Thefunctional reinforcers were escape and attentionfor John, Maisy, Hope, Emilia, and Diego;escape and attention during solids and escapeduring liquids for Jade; and escape for Julian.
Context B Extinction (Control Condition)A therapist conducted sessions with the par-
ticipant in a clinic room. The therapist andobserver were in the clinic room during sessionsin the control condition and during caregivertraining. The therapist implemented escape andattention extinction for John, Maisy, Hope,Emilia, Diego and for Jade during solids andescape extinction for Jade during liquids andfor Julian. During escape extinction, the feederkept the utensil touching the lip until the
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participant opened their mouth such that thefeeder could deposit the bite or drink into themouth or until the 10-min cap elapsed. Thefeeder used the utensil to scoop expelled bitesor drinks and re-presented them into the par-ticipant’s mouth and blocked inappropriatemealtime behavior during presentations and re-presentations with their nonfeeding hand.Feeders maintained high levels of correct-utensil placement during extinction sessions,and no additional blocking from others wasnecessary. If the participant was expelling at thenext scheduled presentation, the feeder re-pres-ented the bite until the participant kept thebolus in their mouth for 3 s and presented thenext bite or drink. The feeder re-presentedbites following expulsions that occurred duringthe mouth check for the fifth presentation untilthe participant had no food or liquid in themouth or until the 10-min cap elapsed. Thefeeder started the next session if one was sched-uled. The feeder provided no differential atten-tion following inappropriate mealtimebehavior. During the attention-extinction com-ponent, the feeder provided no differential con-sequence for inappropriate mealtime behavior.Caregiver Training (Control Condition).
Therapists used behavioral skills training toteach the caregivers of John, Maisy, Hope,Emilia, Diego, and Jade to implement theintervention before they implemented the inter-vention in Context A. First, the caregiver wasin the observation room and watched the thera-pist implement the extinction intervention dur-ing the last three sessions of Context B. Wecounted the number of sessions required forthe participant to meet criteria to change to therenewal test in the control and mitigation con-ditions to identify the last three sessions ofContext B. If the participant met criteria tochange from Context B to Context A in themitigation condition first, we used the numberof sessions from Context B in the mitigationcondition to identify the last three sessions ofContext B for the control condition. Second, a
therapist gave the caregiver a written protocoland explained the purpose of the extinctionintervention. The caregiver read the interven-tion protocol, and the therapist answered ques-tions. Third, therapists trained the caregiver ina clinic room without the participant present.The therapist narrated and modeled an inter-vention component, and the caregiver role-played the modeled intervention componentwith another therapist as a confederate partici-pant. This pattern of therapist-narrate andmodel-caregiver role-play continued until thetherapist had narrated and modeled and thecaregiver had role-played every interventioncomponent. Finally, the therapist narrated andmodeled the entire extinction intervention, andthe caregiver role-played the entire extinctionintervention.Confederate children used a script that
ensured that they emitted every behavior thecaregiver would encounter with their child sothe caregiver could observe and practiceresponses to each possible participant behavior.We also used direct observations of the partici-pant’s behavior in the functional analysis andfunction-based baseline to program the fre-quency of the scripted confederate-child behav-iors during role-play. For example, if theparticipant frequently coughed and gagged, thescript programmed the confederate child tocough and gag on multiple trials so the caregiverreceived additional practice for participant-specific behavior.The order of trained and practiced interven-
tion components was (a) consequences foracceptance and mouth clean, (b) prompts atthe bite- or drink-presentation interval and themouth check, and (c) the entire protocol. Weused an additive approach during caregiverrole-plays with the confederate child. The care-giver implemented the intervention compo-nents they previously mastered during trialswith the confederate child when we were teach-ing the caregiver a new intervention compo-nent. For example, after the therapist trained
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the caregiver to deliver consequences, the care-giver continued to deliver consequences whilethey were learning to deliver the prompts. Ther-apists provided behavior-specific praise for cor-rect protocol implementation and deliveredcorrective feedback for incorrect protocol imple-mentation during and after each trial. The mas-tery criterion for role-play was that the caregiverimplemented the intervention with 80% orhigher integrity for one 5-bite or drink sessionfor consequences and prompts and three consec-utive 5-bite or drink sessions for the entireextinction intervention. After the caregiver metthe role-play criterion while implementing theentire extinction intervention with the confeder-ate child, the caregiver implemented the extinc-tion intervention with their child during therenewal test in Context A (see below).
Context B Extinction (Mitigation Condition)A therapist fed the participant and
implemented the extinction intervention asdescribed for the control condition. The thera-pist and observer were in the clinic room dur-ing caregiver training and during sessions in themitigation condition. We also used the proce-dure described below to train the caregiver toimplement the extinction intervention and totransition from the therapist to the caregiver asfeeder for John, Maisy, Hope, Emilia, Diego,and Jade and to introduce Sets 1 and 3 foodsfor Diego. The caregiver observed the first threesessions of the extinction intervention from theadjacent observation room and reviewed theintervention protocol with a therapist before westarted caregiver fading.Caregiver Training and Mitigation Proce-
dure (Mitigation Condition). We used a train-ing procedure like that described for the controlcondition except that after the caregiver demon-strated mastery with the confederate child, thetherapist and caregiver conducted sessions with theparticipant. During these sessions, the therapist fedthe participant and the caregiver implemented themastered intervention component(s). The therapist
and caregiver conducted sessions with the partici-pant until the caregiver demonstrated mastery ofthe intervention component during those sessionswith the participant. The therapist and caregiverthen repeated the sequence of therapist narrate andmodel, caregiver role-play with confederate child,therapist and caregiver implement interventioncomponent(s) with the participant until the care-giver demonstrated mastery implementing theentire extinction intervention with the participantwith the therapist sitting next to the caregiver. Themastery criterion during sessions with the partici-pant was 80% or higher correct-utensil placementand correct procedure and 20% or lower incorrectattention for three consecutive five-bite or drinksessions for each intervention component.The next step was for the therapist and
observer to fade out of the room. The masterycriterion for therapist-position fading was 80%or higher acceptance, correct-utensil placement,and correct procedure; 20% or lower incorrectattention; and zero instances of inappropriatemealtime behavior for three consecutive five-bite or drink sessions. The therapist movedfrom sitting approximately 0.3 m from care-giver; to across the table, approximately 0.9 mfrom caregiver; to next to the clinic-room door,approximately 1.5 m from caregiver. Theobserver left the room when the therapistmoved across the table. The therapist providedimmediate corrective feedback for most care-giver errors and occasionally at the end of thesession. For example, the therapist remindedthe caregiver at the end of the session to presentall four foods if the caregiver did not do so dur-ing the session. Therapists provided frequentpositive feedback and used an informal methodof fading the number of positive feedback state-ments as they faded out of the room. Therapistsgenerally based the number of positive feedbackstatements on caregivers’ procedural integrityfrom the previous sessions. Therapists deliveredgradually fewer positive feedback statementsafter sequential sessions with low or decreasingcaregiver errors and more positive feedback
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statements after sequential sessions withincreased errors.For Diego, we used the same caregiver-
fading procedure described above and faded inSet 3 foods presented in Context A of the miti-gation condition into Context B of the mitiga-tion condition. We randomly selected to fadeDiego’s mother in as feeder before fading in Set3 foods. The therapist and Diego’s mother ini-tially presented Set 4 foods during caregiverfading. Next, Diego’s mother faded in one Set3 food at a time. She presented one Set 3 foodwith three Set 4 foods until she had introducedall Set 3 foods after which she faded the ratioof Set 3 foods to Set 4 foods. Diego’s motheralways presented one fruit, one protein, onestarch, and one vegetable. The criterion forintroducing a Set 3 food and fading the ratio ofSet 3 foods to Set 4 foods was the same as themastery criterion for therapist-position fading.We also randomized the bite number in whichDiego’s mother introduced each Set 3 food tocontrol for order effects. For example, sheintroduced tuna on Bite 3 of one session andavocado on Bite 5 of a different session. AfterDiego’s mother introduced a Set 3 food duringone session, she presented the Set 3 food andthe same three Set 4 foods in random orderduring two more sessions. Next, she presentedtwo Set 3 foods and two Set 4 foods for onesession, then three Set 3 foods and one Set4 food for three sessions.For Jade, we used the same caregiver-fading
procedure described above. We also used con-text similarity for Jade and Julian by using aCrosstour video projector to display a pictureof the participant’s view from their mealtimechair in the home or simulated home, respec-tively, onto the clinic room wall and placeditems from the participant’s home (e.g., toys,lamps, paintings) in the clinic room. We pro-jected a 1.2-m x 2.4-m picture of the family’skitchen approximately 1.2 m away from Jadeon the wall in front of her, which showed adining table, table centerpiece, clock, kitchen
island with stools, appliances (e.g., refrigerator,stove), and toys. We placed 16 items fromJade’s home including toys (e.g., puzzles,blocks, books) and a table centerpiece in theclinic room. We projected a 1.2-m x 3.4-m pic-ture of the simulated home approximately0.9 m away from Julian on the wall to hisright, which showed a table with a blue table-cloth, blue bowls and a framed picture of hishome kitchen; lamp; bookshelf with storagebins, candles, framed picture of people; twopaintings; an end table with flowers in a vaseand candles; and kitchen appliances (e.g.,refrigerator, sink, microwave). We could notproject the picture in front of him because ofthe layout of the clinic room. We placed18 items, including a lamp, paintings, candles,framed pictures, and an end table with decora-tions shown in the picture in the clinic room.For both participants, we positioned the itemsin the clinic room to mirror their arrangementin the projected picture.
Context A Extinction (Renewal Test, Controland Mitigation Conditions)The contingencies and contextual arrange-
ments during the renewal tests in Context Awere identical in the control and mitigationconditions. The caregivers of John, Maisy,Hope, Emilia, Diego, and Jade and a therapistfor Julian implemented the extinction interven-tion as described for the Context B controlcondition in the clinic with John, Maisy,Hope, Emilia, and Diego; in the home withJade; and in the simulated home with Julian.Diego’s mother presented Set 1 foods and Set3 foods during the control and mitigation con-ditions, respectively. We conducted at least fiveconsecutive sessions of the renewal test in thecontrol and mitigation conditions across partic-ipants. The therapist and observer were in theadjacent observation room for John, Maisy,Hope, Emilia, and Diego; in a clinic roomobserving over Vidyo for Jade, or in the simu-lated home for Julian. Therapists delivered
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corrective feedback as necessary over the two-way audio system from the adjacent observa-tion room for John, Maisy, Hope, Emilia, andDiego and over Vidyo for Jade to ensure care-givers maintained high levels of integrity.
Social ValidityWe gave caregivers a 5-item questionnaire
and asked them to rate the acceptability of thecontrol and mitigation training procedures.The first author calculated the mean acceptabil-ity rating for the conditions separately by sum-ming ratings across each condition and dividingthat sum by the total number of completedquestionnaires. Caregiver acceptability of thetraining procedures was slightly higher for themitigation condition (4.6 out of 5) relative tothe control condition (4.4 out of 5).
Results
The first author reviewed caregiver-integritydata from the first five sessions of the renewaltest to ensure that changes in rates of inappro-priate mealtime behavior were not a functionof low feeder integrity. During the renewal testin the control and mitigation conditions, meancorrect-utensil placement and mean correctprocedure was above 98%, and mean incorrectattention was below 1% across feeders. Weidentified renewal if rate of inappropriate meal-time behavior during any of the first fiverenewal-test sessions was above the rate of inap-propriate mealtime behavior during the lastthree sessions of Context B. We identified amitigation effect in the mitigation condition ifwe identified renewal during the control condi-tion and if rate of inappropriate mealtimebehavior during the first five renewal-test ses-sions was lower than rate of inappropriatemealtime behavior during the last three sessionsof Context B.Figure 1 shows mean inappropriate mealtime
behavior per minute during the control (top)and mitigation (bottom) conditions for John
(top left), Maisy (top right), Hope (bottomleft), and Emilia (bottom right). We evaluatedrenewal following a change in the feeder fromtherapist to caregiver and assessed caregiver fad-ing as our mitigation procedure. During Con-text A of the control condition in which thecaregiver delivered function-based reinforce-ment, rate of inappropriate mealtime behaviorwas high and variable for John’s solids (M =67; range, 43 to 86), Maisy’s liquids (M = 26;range, 24 to 29), Hope’s solids (M = 25; range,13 to 40), and Emilia’s Set 1 foods (M = 42;range, 22 to 77). During Context A of the mit-igation condition in which the caregiver deliv-ered function-based reinforcement, rate ofinappropriate mealtime behavior was high andvariable for John’s liquids (M = 65; range, 23to 132), Maisy’s solids (M = 25; range, 7 to45), Hope’s liquids (M = 37; range, 21 to 52),and Emilia’s Set 2 foods (M = 34; range, 9to 61).During Context B of the control condition in
which the therapist implemented extinction, rateof inappropriate mealtime behavior decreasedand was variable for John’s solids (M = 20;range, 0 to 55) and was low and relatively stablefor Maisy’s liquids (M = 0.5; range, 0 to 5),Hope’s solids (M = 0.3; range, 0 to 6), andEmilia’s Set 1 foods (M = 0.7; range, 0 to 7).During Context B of the mitigation conditionin which the therapist implemented extinctioninitially and faded the caregiver in as the feeder,rate of inappropriate mealtime behaviordecreased and was low and stable for John’s liq-uids (M = 3; range, 0 to 27), Maisy’s solids (M =0.4; range, 0 to 6), Hope’s liquids (M = 0.3;range, 0 to 4), and Emilia’s Set 2 foods (M =0.7; range, 0 to 6).During the renewal test of the control condi-
tion in which the caregiver implementedextinction, rate of inappropriate mealtimebehavior increased and was low and variablebefore decreasing to zero for John’s solids (M =9; range, 0 to 21) and Maisy’s liquids (M = 3;range, 0 to 9) and remained at zero for Hope’s
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Figure 1Inappropriate Mealtime Behavior Following a Caregiver Context Change
Note. The control condition is displayed on top and the mitigation condition is displayed on bottom for John (top left),Maisy (top right), Hope (bottom left), and Emilia (bottom right).
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solids and Emilia’s Set 1 foods. During therenewal test of the mitigation condition inwhich the caregiver implemented extinction,rate of inappropriate mealtime behaviorincreased slightly for one session before decreas-ing to zero for John’s liquids (M = 0.4; range,0 to 4) and Emilia’s Set 2 foods (M = 0.7;range, 0 to 4), was low and stable beforedecreasing to zero for Maisy’s solids (M = 0.4;range, 0 to 4), and remained at zero for Hope’sliquids. Overall, we observed renewal for Johnand Maisy only and observed higher and morepersistent rates of responding during therenewal test of the control condition relative tothe mitigation condition.Figure 2 shows mean inappropriate mealtime
behavior per minute during the control (top)and mitigation (bottom) conditions for Diego.We evaluated renewal following a change in the
feeder and food from a therapist feeding oneset of foods to a caregiver feeding a different setof foods during intervention for solids refusaland assessed caregiver and food fading as ourmitigation procedure. During Context A of thecontrol condition with Set 1 foods in whichthe caregiver delivered function-based reinforce-ment, rate of inappropriate mealtime behaviorwas high and variable (M = 77; range, 32 to103). During Context A of the mitigation con-dition with Set 3 foods in which the caregiverdelivered function-based reinforcement, rate ofinappropriate mealtime behavior was high andvariable (M = 90; range, 62 to 115).During Context B of the control condition
with Set 2 foods in which the therapistimplemented extinction, rate of inappropriatemealtime behavior was moderately high and var-iable then decreased and was low and stable (M= 4; range, 0 to 52). During Context B of themitigation condition with Set 4 foods in whichthe therapist implemented extinction and care-giver and food fading, rate of inappropriatemealtime behavior was moderately high and var-iable then decreased to zero (M = 10; range, 0to 60). During the renewal test in which thecaregiver implemented extinction, rate of inap-propriate mealtime behavior remained at zero inthe control condition with Set 1 foods and waslow and stable in the mitigation condition withSet 3 foods (M = 1; range, 0 to 7). For Diego,we did not observe renewal in either condition.Figure 3 shows mean inappropriate mealtime
behavior per minute during the control (top)and mitigation (bottom) conditions for Jade.We evaluated renewal following a change in thefeeder and setting from therapist in the clinic tocaregiver in the home during intervention forliquids refusal (control condition) and solidsrefusal (mitigation condition). We assessed care-giver fading and context similarity as our mitiga-tion procedure. During Context A in which thecaregiver delivered function-based reinforcementin the home, rate of inappropriate mealtimebehavior was variable in the control condition
Figure 2Inappropriate Mealtime Behavior Following a Caregiver andFood Context Change
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with liquids (M = 26; range, 5 to 66) and mitiga-tion condition with solids (M = 18; range, 5to 58).During Context B of the control condition
with liquids in which the therapistimplemented extinction in the clinic, rate ofinappropriate mealtime behavior was low andvariable then decreased to zero (M = 2; range,0 to 20). During Context B of the mitigationcondition with solids in which the therapistimplemented extinction in the clinic, faded thecaregiver in as the feeder, and used context sim-ilarity (i.e., arranged the clinic room with itemsfrom home), rate of inappropriate mealtimebehavior was low and variable then stabilizedat zero (M = 1; range 0 to 11). Duringthe renewal test in which the caregiverimplemented extinction in the home, rate ofinappropriate mealtime behavior increased andwas low and variable in the control condition
with liquids (M = 3; range, 0 to 6) andremained zero in the mitigation condition withsolids. For Jade, we observed renewal in thecontrol condition only.Figure 4 shows mean inappropriate mealtime
behavior per minute during the control (top)and mitigation (bottom) conditions for Julian.We evaluated renewal following a change in thesetting from clinic to a simulated home andassessed context similarity as our mitigationprocedure during intervention for solids refusal.During Context A in which the therapist deliv-ered function-based reinforcement in a simu-lated home, rate of inappropriate mealtimebehavior was high and variable in the controlcondition with Set 1 foods (M = 52; range, 33to 78) and mitigation condition with Set 2foods (M = 60; range, 43 to 86). During Con-text B of the control condition with Set 1 foodsin which the therapist implemented extinction
Figure 3Inappropriate Mealtime Behavior Following a Caregiver andSetting Context Change
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Figure 4Inappropriate Mealtime Behavior Following a Setting Con-text Change
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in a clinic room, rate of inappropriate mealtimebehavior decreased and was low and variable(M = 5; range, 0 to 26).During Context B of the mitigation condi-
tion with Set 2 foods in which the therapistimplemented extinction in a clinic room andused context similarity, rate of inappropriatemealtime behavior decreased and was low andvariable (M = 4; range, 0 to 14). During therenewal test in which the therapist implementedextinction in the simulated home, rate of inap-propriate mealtime behavior remained low andvariable in the control condition with Set 1foods (M = 7; range, 0 to 13) and remained zeroin the mitigation condition with Set 2 foods.For Julian, we observed renewal in the controlcondition only.Figure 5 depicts the proportion of baseline
rate of inappropriate mealtime behavior during
the renewal test in the control and mitigationconditions. The first author divided the meanrate of inappropriate mealtime behavior for thefirst five sessions of the renewal test by the meanrate of inappropriate mealtime behavior for theentire phase of reinforcement in Context A tocalculate proportion of baseline rate. We usedthe first five sessions of the renewal test becausefive was the fewest number of sessions we con-ducted for the renewal test across the controland mitigation conditions for all participants.The proportion of baseline rate was between0 and 0.4 during the control condition andbetween 0 and 0.2 during the mitigation condi-tion across participants, showing that inappro-priate mealtime behavior was generally higherduring the renewal test of the control conditionrelative to the mitigation condition acrossparticipants.
Discussion
The current study extended the findings ofIbañez et al. (2019) by evaluating renewal of inap-propriate mealtime behavior following changes infeeder, food, setting, and a combination of these.We observed renewal of inappropriate mealtimebehavior following a change from therapist tocaregiver as feeder for two of four participants,John and Maisy, from therapist in clinic to care-giver in the home with one participant, Jade, andfrom clinic to simulated home for one participant,Julian. These effects occurred even though feedersimplemented the extinction intervention withhigh levels of integrity. These results differ fromthose of Ibañez et al., who observed renewal ofinappropriate mealtime behavior in all threeparticipants.The current study extended the findings of
Kelley et al. (2018) in three ways. First, we eval-uated renewal and renewal-mitigation concur-rently instead of sequentially because repeatedexposure to context changes may decrease thelikelihood of renewal (Sweeney & Shahan,2013; Wacker et al., 2011). Second, we
Figure 5Proportion of Baseline Rate of Inappropriate MealtimeBehavior Across Participants
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Note. Proportion of baseline rate of inappropriate meal-time behavior during the first five sessions of the renewaltest in the control (top) and mitigation (bottom) condi-tions across participants.
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evaluated systematic fading as a renewal-mitigation procedure following a change in feederfrom therapist to caregiver. We used behavioralskills training to teach caregivers the intervention.Caregivers practiced an intervention component(e.g., consequences) with a confederate participantbefore implementing the component with theparticipant. We continued this procedure(i.e., model, practice with confederate participant,implement with participant) until the caregiverimplemented the entire intervention with the par-ticipant. Caregivers may signal reinforcementavailability due to their history of providing rein-forcement for inappropriate mealtime behavior(Borrero et al., 2010; Najdowski et al., 2008;Piazza et al., 2003). Introducing the caregiver asfeeder is likely an essential context change duringintervention; therefore, evaluating renewal-mitigation procedures when the caregiver imple-ments the intervention is important. We graduallyincreased the number of intervention componentsthe caregiver implemented (i.e., consequences,consequences + praise, entire protocol) to increaseopportunities for the caregiver to develop stimuluscontrol for extinction of inappropriate mealtimebehavior. Rate of inappropriate mealtime behaviorwas lower for John and Maisy and persisted acrossfewer sessions for John in the mitigation conditionfollowing the mitigation procedure relative to thecontrol condition. These results suggest that sys-tematic caregiver fading decreased the magnitudeand persistence of renewal but may not haveprevented it.Interestingly, John’s inappropriate mealtime
behavior decreased more rapidly and maintainedat lower rates in Context B of the mitigationcondition relative to the control condition.Therefore, we wondered whether the differentialefficacy of extinction, mitigation procedure, orboth influenced renewal because respondingduring the renewal test was lower and less per-sistent in the mitigation condition relative tothe control condition. By contrast, Maisy’sresults suggest that the mitigation procedurewas responsible for the difference in renewal
effects between the control and mitigation con-ditions. Caregivers in Kelley et al. (2018) satnext to the therapist while the therapistimplemented extinction and only implementedextinction during the renewal test. Kelley et al.observed renewal for one of two participants.However, the magnitude and persistence ofrenewal decreased following the mitigation pro-cedure for the other participant, as in the cur-rent study.Third, we evaluated the efficacy of context
similarity and the combination of systematicfading and context similarity following changesin feeder and food, feeder and setting, and set-ting. These are common context changes forchildren we treat with avoidant/restrictive foodintake disorder and that caregivers report aschallenging. We did not observe renewal fol-lowing a feeder and food change for Diego butdid observe renewal following a feeder and set-ting change for Jade and a setting change forJulian.For Jade, we evaluated renewal following
changes in the feeder and setting because Jadeengaged in inappropriate mealtime behavior dur-ing sessions in the home but not in the clinic.Therefore, the home was the relevant stimuluscondition under which inappropriate mealtimebehavior occurred. A combined feeder and settingchange is common during intervention for inap-propriate mealtime behavior because children feedin different environments (e.g., home, school) withmany individuals (e.g., grandparents, peers). Jade’sresults replicate those of Ibañez et al. (2019) andSaini et al. (2018) and demonstrate that changesin the implementer and setting produce renewal ofnegatively reinforced socially significant behavior.The absence of renewal during the renewal test ofthe mitigation condition, which was systematicfading and context similarity, replicate those ofprevious studies on context similarity as an effec-tive mitigation procedure (Bandarian-Balooch &Neumann, 2011; Todd et al., 2012). Results alsosuggest that renewal-mitigation procedures may bemore effective when combined (Bandarian-
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Balooch & Neumann, 2011; Bernal-Gamboa,Nieto, & Uengoer, 2017; Krisch et al., 2018);however, research on renewal mitigation of sociallysignificant behavior is limited.For Julian, we evaluated renewal following a
setting change because Julian’s caregivers couldnot attend required sessions due to their workschedules. As in Mitteer et al. (2018), whoshowed renewal of undesirable caregiver behav-ior following a setting change, renewal of inap-propriate mealtime behavior occurred duringthe renewal test of the control condition forJulian. Julian’s results and those of Mitteeret al. suggest that changes in the setting mayevoke renewal of negatively reinforced sociallysignificant behavior.Interestingly, the most robust renewal effects
occurred for Jade and Julian. The commonalitybetween their arrangements was a settingchange; therefore, we wondered whether thesetting exerts more control over inappropriatemealtime behavior than does the caregiver.Results of our study and previous researchshow that a stimulus change such as in imple-menter or setting may exert more control overbehavior than the contingency (e.g., Ibañezet al., 2019; Saini et al., 2018). Before inter-vention, the occurrence of inappropriate meal-time behavior may have discouraged caregiversfrom feeding their child outside of the home.Thus, reinforcement for inappropriate meal-time behavior likely occurs primarily in thehome. Participants in our study had a relativelyshort history of reinforcement and a morerecent history of extinction of inappropriatemealtime behavior in the clinic. Therefore, theclinic may have signaled extinction of inappro-priate mealtime behavior, which competed withthe participant’s history of reinforcement withthe caregiver. Alternatively, there may be morestimuli in the home that signal reinforcementavailability (e.g., kitchen chair, table) relative tothe caregiver as the only signal for reinforce-ment availability in the clinic. However, thecurrent study did not assess to which stimuli
participants attended or which stimuli exertedcontrol over inappropriate mealtime behaviorand could be a direction for future research.Results of previous research have suggested
that behavior that is more resistant to extinc-tion initially may be more likely to reemergefollowing context changes (Podlesnik &DeLeon, 2015). When renewal occurred in thecontrol condition, the number of sessions untilthe rate of inappropriate mealtime behavior waszero during Context B was greater in the con-trol condition relative to the mitigation condi-tion for John, Maisy, Jade, and Julian. Thisdifference was small for Maisy (i.e., two ses-sions). Researchers have also suggested thatbehavior that is more persistent during extinc-tion may be more likely to relapse followingcontext changes (Kimball et al., 2018;Podlesnik et al., 2017). In the current study,inappropriate mealtime behavior occurred dur-ing more sessions of extinction in Context B inthe control condition relative to the mitigationcondition for John, Maisy, Jade, and Julian.This difference was small for Maisy (i.e., threesessions).When we observed renewal of inappropriate
mealtime behavior during the renewal test ofthe control condition for John, Maisy, and Jade,we observed concomitant decrements in per-centage of acceptance. Researchers haveobserved similar disruption of interventioneffects between responses targeted for extinctionand responses targeted for acquisition duringABA renewal arrangements with other sociallysignificant behavior (Ibañez et al., 2019; Kelleyet al., 2018; Saini et al., 2018). These resultssuggest that context changes may producerenewal of a previously extinguished responseand decrements in the alternative appropriateresponse, which is an important considerationfor evaluating procedures to enhance the gener-ality of an intervention.We evaluated proportion of baseline rate of
inappropriate mealtime behavior during therenewal test in the control and mitigation
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conditions to quantify renewal and compareour results across participants and with previousresearch. Proportion of baseline values near 1.0demonstrate closer approximations to rate ofinappropriate mealtime behavior during rein-forcement in Context A. Proportion of baselinerate of inappropriate mealtime behavior duringthe renewal test was greater during the controlcondition relative to the mitigation conditionacross participants except Maisy. We comparedour proportion of baseline data to that ofIbañez et al. (2019) and Saini et al. (2018)who evaluated renewal of negatively reinforcedsocially significant behavior. Our proportion ofbaseline values were generally lower than thoseof Ibañez et al. and Saini et al.One limitation of the current study was the
potential for carry-over effects from alternatingbetween the control and mitigation conditions.We tried to increase the discriminability betweenthe conditions by assigning solids or liquids toeach condition for John, Maisy, Hope, and Jadeand using colored stimuli (i.e., tablecloths, bowls,cards) for Emilia, Diego, and Julian. However,the caregiver’s presence in the mitigation condi-tion may have influenced responding in the con-trol condition and decreased the likelihood ofrenewal for participants with whom we changedthe feeder. Additionally, the conditions may nothave been discriminable to Emilia and Diegobecause feeders presented pureed foods in bothconditions, which are not as visually distinctive asthe same foods at table texture. For example,pureed potato and cauliflower look identical. Sim-ilarly, the history of contacting reinforcement andextinction in the presence of the same coloredstimuli during the control and mitigation condi-tions may have decreased the discriminabilitybetween phases in each condition and influencedthe likelihood of renewal (Saini et al., 2018).Alternatively, order effects may have influencedresponding during the renewal test. We random-ized the order of the renewal tests across partici-pants, but exposure to the renewal test in onecondition may have influenced responding during
the other condition. We transitioned from Con-text B to the renewal test in the same meal forJohn, Hope, Diego, Jade, and Julian and in con-secutive meals (e.g., Context B in last session ofMeal 3 and renewal test in first session of Meal 4)for Maisy and Emilia. Research has suggested thattime alone may function as a context change(Bouton & García-Gutiérrez, 2006); therefore,the 40-min break between meals may haveinfluenced our results. However, we transitionedfrom Context B to the renewal test in the samemanner (i.e., same meal or consecutive meal) inthe control and mitigation conditions for eachparticipant and observed differential respondingwithin and across participants. For example, weobserved renewal in the control condition onlyfor Jade and Julian and did not observe renewalin either condition for Hope and Diego despitetransitioning from Context B to the renewal testin the same meal. Further, some of our mitigationprocedures included multiple components(e.g., caregiver and therapist’s position fading forcaregiver fading procedure) and therefore, it is notpossible to determine which component(s) wereresponsible for our outcomes.The results of the current study suggest that
renewal may occur during intervention for inap-propriate mealtime behavior for children withavoidant/restrictive food intake disorder, partic-ularly following changes in the feeder, setting,and a combination of these changes. This is thefirst study to our knowledge to evaluate system-atic fading and context similarity alone and incombination as renewal-mitigation proceduresfor socially significant behavior. Our resultsshowed that systematic fading alone decreasedthe magnitude and persistence of renewal fol-lowing a feeder change and prevented renewalfollowing a feeder and setting change when weused the procedure with context similarity.These findings highlight the importance ofusing a fading approach to caregiver trainingduring intervention for feeding disorders. Asystematic-fading training approach may pro-vide more opportunities for the caregiver to be
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associated with the extinction contingency andreduce the likelihood of generalization failureswhen the caregiver implements the interventionalone. Training caregivers to implement theintervention while the child is still engaging inproblem behavior may provide them withopportunities to practice implementing theintervention and reduce the likelihood that thecaregiver will reinforce problem behavior out-side of the clinic setting (e.g., home). Contextsimilarity alone effectively prevented renewalfollowing a setting change, suggesting that pro-gramming common stimuli may prevent gener-alization failures to settings outside of the clinicand enhance intervention generality. Renewal-mitigation procedures such as systematic fadingand context similarity alone and in combinationmay be effective at preventing or decreasing themagnitude of renewal, but we need to furtherunderstand the conditions under which renewalof inappropriate mealtime behavior occurs andthe conditions under which renewal-mitigationprocedures will be efficacious. These findingsare important because these context changes areoften necessary for intervention generality andmaintenance and are changes that caregiversreport as most challenging, particularly duringintervention for children with avoidant/restric-tive food intake disorder.
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Received May 1, 2020Final acceptance December 14, 2020Action Editor, Carrie Borrero
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An evaluation of a renewal-mitigation procedure for inappropriate mealtime behavior
Method
Participants
Setting and Materials
Feeders
Dependent Variables, Procedural Integrity, and Reliability
Dependent Variables
Procedural Integrity
Interobserver Agreement
Experimental Design
Control and Mitigation Conditions
General Procedure
Control and Mitigation Conditions
Context A Reinforcement (Control and Mitigation Conditions)
Context B Extinction (Control Condition)
Caregiver Training (Control Condition)
Context B Extinction (Mitigation Condition)
Caregiver Training and Mitigation Procedure (Mitigation Condition)
Context A Extinction (Renewal Test, Control and Mitigation Conditions)
Social Validity
Results
Discussion
REFERENCES
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