JOURNAL OF APPLIED BEHAVIOR ANALYSIS
2014, 47, 834–839
SYRINGE FADING AS TREATMENT FOR FEEDING REFUSAL REBECCA A. GROFF, CATHLEEN C. PIAZZA, VALERIE M. VOLKERT, CANDICE M. JOSTAD
UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE
The efficacy of nonremoval of the cup or spoon as treatment for feeding refusal is dependent on prevention of escape from presentations. In the current investigation, 1 child with feeding refusal escaped presentations during nonremoval of the cup and spoon by clenching his teeth. Therefore, we used a syringe to deposit liquids and solids, increased the volume of liquids and solids in the syringe, and conducted syringe-to-cup and syringe-to-spoon fading. Key words: escape extinction, fading, feeding disorder, pediatric feeding disorders
Treatments based on escape extinction of feeding refusal are hypothesized to be effective by preventing escape from drinking or eating. However, procedures like nonremoval of the cup or spoon may not be effective if the therapist is unable to deposit the bite or drink (e.g., due to teeth clenching). A syringe might be an effective alternative utensil because the therapist can place the tip of the syringe between the lips in the absence of an open mouth and deposit the food or liquid between the cheek and gum. It is unknown whether this method results in increased acceptance and whether acceptance is maintained after fading from syringe to cup or syringe to spoon. To date, the only demonstration of utensil fading as treatment of pediatric feeding disorders has been spoon-to-cup fading (Babbitt, Shore, Smith, Williams, & Coe, 2001; Groff, Piazza, Zeleny, & Dempsey, 2011). In the current investigation, we evaluated the use of a syringe to present increasing amounts of liquids and pureed solids and then conducted syringe-to-cup and syringeto-spoon fading with a child who did not open his mouth during initial treatment.
Address correspondence to Cathleen C. Piazza, MunroeMeyer Institute, University of Nebraska Medical Center, 985450 Nebraska Medical Center, Omaha, Nebraska 68198 (e-mail: [email protected]
). doi: 10.1002/jaba.162
METHOD Participant Cullen was a typically developing 4-year-old boy who had been admitted to a day-treatment program for total refusal and 100% gastrostomytube dependence. Data Collection Observers collected data on laptop computers and scored (a) acceptance when Cullen opened his mouth and allowed the therapist to deposit liquids or solids within 5 s of presentation, not including depositing liquids or solids during representation; (b) mouth clean once per presentation when nothing larger than a grain of rice (volumes from 0.1 cc to 0.5 cc) or pea (volumes from 0.6 cc to 2.0 cc) was in Cullen’s mouth 30 s after the food or liquid entered the mouth; and (c) inappropriate behavior when the utensil was within arm’s reach of Cullen and he touched the utensil or therapist’s arm below the elbow, covered his mouth, or turned his head 45° from the utensil. We present the data as percentage of acceptance (frequency of acceptance divided by number of presentations) and mouth clean (frequency of mouth clean divided by number of presentations that entered Cullen’s mouth) and inappropriate behavior per minute (frequency of inappropriate behavior divided by duration of utensil within arm’s reach).
SYRINGE FADING We assessed reliability during 33% of liquid sessions and 26% of solid sessions. We calculated percentage agreement for acceptance and mouth clean as the number of 10-s intervals with agreement divided by number of intervals. We calculated agreement for inappropriate behavior as number of 10-s intervals observers scored the same behavior frequency divided by number of intervals. Mean agreement for acceptance, mouth clean, and inappropriate behavior, respectively, was 96%, 96%, and 90% for liquids and 97%, 98%, and 99% for solids. Design We analyzed the effects of fading with extinction separately for liquids and solids using a brief experimental design with probes. During liquids, A was baseline with a cup; B was extinction, using nonremoval of the cup; C was fading with extinction, using nonremoval of the syringe. We also conducted extinction probes with the cup (B) to demonstrate functional control of fading with extinction. During solids, A was baseline with a spoon; B was extinction, using nonremoval of the spoon and planned ignoring (Bachmeyer et al., 2009); C was fading with extinction, using nonremoval of the syringe. We conducted extinction probes with the spoon (B) to demonstrate functional control of fading with extinction. Procedure We conducted two separate functional analyses of inappropriate behavior for liquids and solids, evaluating the effects of escape and attention relative to control (Bachmeyer et al., 2009). The functional analyses demonstrated that inappropriate behavior was maintained by escape in the liquids analysis and escape and attention in the solids analysis, which informed the baseline and extinction treatment. General procedure. Trained therapists conducted five 30- to 45-min meal blocks daily. Each block consisted of five to seven sessions. Therapists presented liquids and solids at
different blocks. Therapists presented vanilla Pediasure with fiber in liquid sessions or a pureed texture of string cheese, crackers, mixed vegetables, and strawberries in a random order during solids sessions. The therapist presented 2 cc of liquid in a pink cut-out cup or 1 cc of puree on a small Maroon spoon, with the exception of the fading phase. Presentations occurred approximately every 30 s, with five presentations per session during baseline, fading, and postfading escape extinction for both liquids and solids. For escape extinction, therapists presented bites or drinks approximately every 15 s. Therapists touched the utensil to Cullen’s lips, said “Take a drink [bite],” and delivered praise for acceptance. The therapist said “show me” 30 s after the food or liquid entered Cullen’s mouth, delivered praise for mouth clean or said “swallow” for packing (liquid or solid larger than a grain of rice for volumes from 0.1 cc to 0.5 cc or pea for volumes from 0.6 cc to 2.0 cc in the mouth), and presented the next drink or bite. Packing after the fifth presentation resulted in mouth checks every 30 s until Cullen swallowed or 10 min elapsed from session initiation. The therapist removed liquids or solids in the mouth after 10 min. Baseline, cup and spoon. Following inappropriate behavior, the therapist (a) removed the utensil for 30 s (liquids and solids) and (b) delivered attention (solids). The utensil remained in its presentation position for 30 s in the absence of acceptance and inappropriate behavior. Extinction, cup and spoon. Therapists implemented escape extinction in liquids sessions and escape and attention extinction in solids sessions. During this phase, the therapist held the utensil at Cullen’s lips, deposited the food or liquid when he opened his mouth, and re-presented expulsions with the utensil. Sessions continued until Cullen swallowed all five bites or drinks or 10 min passed. During solids sessions, the therapist discontinued attention for inappropriate behavior.
REBECCA A. GROFF et al.
Fading, general procedure. The syringe was used so that the therapist could deposit liquids or solids into Cullen’s mouth between the gums and cheek if he did not open his mouth within 5 s of presentation. We used visual inspection to determine fading steps; stable levels of acceptance and mouth clean above 80% advanced the fading procedure (e.g., from 0.1 cc to 0.2 cc) and below 80% resulted in implementation of the previous fading step (e.g., from 0.2 cc to 0.1 cc). The therapist re-presented expulsions with the syringe (liquids) or her gloved finger (solids). Liquid volume fading. The therapist implemented extinction with a 1-cc syringe to present volumes from 0.1 cc to 1.0 cc and a 3-cc syringe for volumes from 1.1 cc to 2 cc. We started fading with 0.1 cc of liquid and increased the volume in 0.1-cc increments to the target volume of 2 cc, then began syringe-to-cup fading. Syringe-to-cup fading. The therapist implemented extinction with 2 cc of liquid in a 3-cc syringe as follows (see Supporting Information, left panel). First, we taped the syringe with liquid below the empty cup with 5 cm of the syringe protruding from the cup’s lip. Next, we moved the syringe with liquid toward the cup’s lip in successive 1-cm increments (4 cm, 3 cm, 2 cm, 1 cm) and then in two successive 0.5-cm increments such that the syringe tip and cup lip were flush. Next, we altered the position of the syringe by inserting it inside the cup through a hole in the cup’s bottom with the syringe recessed 1 cm from the cup’s lip. The therapist presented the cup to Cullen’s lips with the bottom of the cup tipped at a 45° angle and depressed the syringe to deposit the liquid into the cup so that Cullen accepted the liquid from the cup. The next step was identical except that we deposited the liquid from the syringe into the cup first and presented the cup with liquid to Cullen’s lips (deposited from cup). Next, we taped the syringe to the outside of the cup and presented liquid from the cup. Based on the data from the cup probe after this step, we discontinued fading and continued extinction with 2 cc of liquid in the cup. Next, we decreased
the presentation interval to 15 s and increased volume to 4 cc. Solids volume fading. The therapist implemented extinction described above and presented 0.1 cc of solids in a 1-cc syringe. We increased the volume of presented solids in 0.1-cc increments up to the target volume of 1 cc, then began syringe-to-spoon fading. Syringe-to-spoon fading. The therapist implemented extinction with 1 cc of solids in a 1-cc syringe as follows (see Supporting Information, right panel). First, we taped the syringe with solids below the empty spoon with 5 cm of the syringe protruding from the lip of the spoon. We then altered the distance from the syringe tip to spoon lip in 1-cm increments (4 cm, 3 cm, 2 cm, 1 cm) until the syringe tip and spoon lip were flush. Next, we altered the position of the syringe by taping it on top of the empty spoon. Then, the therapist simultaneously presented the untaped spoon and syringe into Cullen’s mouth, squirted the food from the syringe onto the spoon, and deposited the food in Cullen’s mouth from the spoon (in mouth). Next, the therapist simultaneously presented the untaped spoon and syringe to Cullen’s lips, squirted the food from the syringe onto the spoon, and deposited the spoon with food into his mouth (at lips). Because of responding, we created a new step by taping the syringe to the side of the spoon with the tip of the syringe and spoon’s lip flush, placed the syringe and spoon in the mouth, and deposited the solids into the mouth with the syringe (next to). Based on the data from the spoon probe following next to, we discontinued fading and continued extinction with 1 cc of solids on the spoon. Extinction probes. Probes were identical to the extinction condition described above; the therapist presented 2 cc of liquid in the cup in liquids probes and 1 cc of solids on the spoon in solids probes. During volume fading for liquids and solids, the therapist conducted one probe after the volume in the syringe was 0.5 cc and another after the volume in the syringe was 1.0 cc. During
SYRINGE FADING liquid volume fading, the therapist conducted probes after every fading step after the volume reached 1.0 cc. During syringe-to-cup and syringe-to-spoon fading, the therapist conducted probes after every fading step, except after 5 cm in solids due to oversight. Probes were continued if acceptance and mouth clean were 80% or above, were discontinued if acceptance or mouth clean was below 80%, and were not conducted after a repeated fading step. RESULTS AND DISCUSSION During baseline and extinction sessions with liquids, levels of acceptance (see Figure 1, top) and mouth clean were low. Mean inappropriate behavior was 31 and 3.8 per minute in baseline and extinction, respectively. During extinction, Cullen clenched his teeth, and typically 10 min elapsed without accepting or swallowing all presentations. Across volume fading, means for acceptance, mouth clean, and inappropriate behavior, respectively, were 98%, 98%, and 3.4 per minute. Levels of acceptance and mouth clean were also low during the volume fading probes. During syringe-to-cup fading (distance and position), means were 100%, 100%, and 1.7 per minute for acceptance, mouth clean, and inappropriate behavior, respectively. Levels of acceptance and mouth clean were low during initial liquids probes. Means were 100%, 100%, and 0.5 per minute for acceptance, mouth clean, and inappropriate behavior, respectively, during the probe after the syringe was outside the cup. We continued with the cup, and these levels persisted when we changed the presentation interval to 15 s and increased the volume to 4 cc (data not shown). During baseline and extinction sessions with solids, acceptance (see Figure 1, bottom) and mouth clean were low. Inappropriate behavior was 36.3 and 0.3 per minute during baseline and extinction, respectively. During solids volume fading, means for acceptance, mouth clean, and
inappropriate behavior were 95%, 93%, and 0.5 per minute, respectively. Acceptance was inconsistent during the probes after fading with 0.5 cc and 1.0 cc. During syringe-to-spoon fading (distance and position), acceptance and mouth clean were high until the step at lips. In the step next to, means were 100%, 100% and 0 per minute for acceptance, mouth clean, and inappropriate behavior, respectively. Means for acceptance, mouth clean, and inappropriate behavior were 37%, 0%, and 0.5 per minute, respectively, for probes during syringe-to-spoon fading until the step next to. Means for acceptance, mouth clean, and inappropriate behavior were 80%, 100%, and 0.3 per minute, respectively, in the probe after the step next to. Therefore, we continued with the spoon. These data are important because they demonstrate the efficacy of presentation of liquids and pureed solids in a syringe as an option for children who do not open their mouths during extinction. As the data show, Cullen began to open his mouth to accept the syringe at high levels when the therapist presented liquids and after only a few trials of the therapist depositing the solids into his mouth with the syringe. By contrast, he rarely opened his mouth to accept the spoon or cup before fading. We were able to use the syringe to increase initial acceptance of liquids and solids, increase the volume of liquids and solids, and then fade from the syringe to the cup in liquids and the spoon in solids. The fading procedure was efficient; we conducted the assessment in 20 days (49 meals) and 9 days (22 meals) for liquids and solids, respectively. We hypothesized that the syringe plus extinction was effective because Cullen could not avoid the deposit of food or liquid even if he did not open his mouth. One limitation is that we did not probe the terminal bolus sizes in the syringe before volume fading. Second, we did not evaluate the contribution of extinction to fading. Future studies should address these limitations.
REBECCA A. GROFF et al.
ESCAPE EXTINCTION (EE)
PERCENTAGE OF DRINKS WITH ACCEPTANCE
Syringe Tip to Cup Lip Syringe Distance 5 cc to Flush Position
Syringe-Volume Fading (0.1 cc-2.0 cc)
BL EE Cup
100 90 80 70 60 50 40 30 20 EE Cup Probe
SESSION ESCAPE + ATTENTION EXTINCTION (EE AE)
PERCENTAGE OF BITES WITH ACCEPTANCE
EE AE Spoon
Syringe Tip to Spoon Tip Distance 5 cm to Flush
Syringe-Volume Fading From 0.1cc to 1.0 cc
Syringe to Spoon Position
EE AE Spoon
100 90 80 70
EE Spoon Probe
60 50 40 30
20 10 0 0
Figure 1. Top panel: Levels of acceptance during escape baseline; escape extinction; syringe volume fading (each arrow represents a 0.1-cc increase in liquid volume from the initial volume of 0.1 cc to the final volume of 2.0 cc); syringe-to-cup fading (distance), each arrow represents successive fading steps of 5 cm, 4 cm, 3 cm, 2 cm, 1 cm, 0.5 cm, flush; syringe-tocup fading (position), each arrow represents successive fading steps of hole in cup bottom, deposit from cup, syringe outside cup; and escape extinction probes with the cup. Bottom panel: Levels of acceptance during escape and attention baseline; escape and attention extinction; syringe volume fading (each arrow represents a 0.1-cc increase in liquid volume from the initial volume of 0.1 cc to the final volume of 1.0 cc); syringe-to-spoon fading (distance), each arrow represents successive fading steps of 5 cm, 4 cm, 3 cm, 2 cm, 1 cm, flush; syringe-to-spoon fading (position), each arrow represents successive fading steps of top, in mouth, at lips, in mouth, top, in mouth, top, and next to; and escape and attention extinction probes with the spoon.
SYRINGE FADING REFERENCES Babbitt, R. L., Shore, B. A., Smith, M., Williams, K. E., & Coe, D. A. (2001). Stimulus fading in the treatment of adipsia. Behavioral Interventions, 16, 197–207. doi: 10.1002/bin.94 Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed, G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional analysis and treatment of multiply controlled inappropriate mealtime behavior. Journal of Applied Behavior Analysis, 42, 641–658. doi: 10.1901/jaba.2009.42641 Groff, R. A., Piazza, C. C., Zeleny, J. R., & Dempsey, J. R. (2011). Spoon-to-cup fading as treatment for cup drinking in a child with intestinal failure. Journal of
Applied Behavior Analysis, 44, 949–954. doi: 10.1901/ jaba.2011.44-949 Received June 6, 2012 Final acceptance May 16, 2014 Action Editor, Jennifer Zarcone
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at the publisher’s website.
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