A Clinical Demonstration of a Treatment Package for Food Selectivity

Food selectivity is the most commonly reported and researched feeding problem in children with autism spectrum disorders (ASD) (Seiverling, Williams, Ward-Horner, & Sturmey, 2011). Children have been found to be selective by food type, texture, color, temperature, freshness, as well as other dimensions. In children with ASD, eating a narrow range of foods has been shown to be associated with a variety of problems such as reduced bone cortical thickness (Hediger, England, Mollov, Yu, & Manning-Courtney, 2008), Vitamin A, D, and C deficiencies (Clark, 1993; Duggen, Westra, & Rosenberg, 2007; Uyanik, Dogangun, Kavaalp, Kormaz, & Dervent, 2006), and iron deficiencies (Latif, Heinz, & Cook, 2002). In addition, Lockner, Crowe, and Skipper (2008) found that parents of children with ASD were more likely to give their children non-prescription vitamin/mineral supplements when compared with parents of children without ASD whose children were not as picky and resistant to trying to new foods. This suggests that parents of children with ASD may be more concerned regarding inadequacies in their children's diet variety. Parents may also find mealtimes stressful when attempting to encourage a child with food selectivity to take bites of new or non-preferred foods, as often children will engage in high levels of disruptive behaviors when their preferred foods are not presented (Williams & Seiverling, 2010). The interventions described in studies of food selectivity involve multiple treatment components. These components often include the following: a) stimulus fading combined with reinforcement schedule thinning, in which some dimension of the meal is gradually changed, such as portion sizes being gradually increased; b) differential reinforcement, in which inappropriate behavior is ignored and child acceptance of the presented bites of food is reinforced with verbal praise or access to tangible reinforcers; and c) escape extinction (EE), in which the child is required to consume either a specified number of bites before exiting the eating area, and escape-maintained problem behavior does not lead to termination of the meal. The EE procedure often occurs in one of two forms: (1) non-removal of the spoon, which involves presenting the food until the child accepts it; or (2) physical guidance, which involves physically prompting the child to take a bite. Most intervention studies for food selectivity, as well as for food refusal, have implemented treatment packages involving differential reinforcement, fading, and some form of EE (Anderson & McMillan, 2001; Freeman & Piazza, 1998; Najdowski, Wallace, Doney, & Ghezzi, 2003; McCartney, Anderson, & English, 2005). Further, component analyses have demonstrated that although positive reinforcement is sometimes sufficient, EE is often a necessary component of effective treatments for food selectivity and food refusal (Cooper et al., 1995; Hoch, et al., 2001; Penrod, Wallace, Reagon, Betz, & Higbee, 2010). Although often necessary, EE has been associated with high rates of inappropriate collateral behaviors, especially in the initial stages of treatment and when physical guidance is a component (Gentry & Luiselli, 2008). Thus, these collateral behaviors may at times lead families and clinicians to approach the use of EE with hesitation. Although several studies have demonstrated the effectiveness of treatments of food selectivity that do not involve EE (Ahearn, 2003; Buckley, Strunk, & Newchok, 2005; Gentry & Luiselli, 2008; Levin & Carr, 2001; Patel, Reed, Piazza, Mueller, Backmeyer, & Layer, 2007) it is typically unknown whether EE will be a necessary component prior to implementing an intervention. Therefore, EE is often implemented in food selectivity cases. Given the negative side effects that sometimes accompany EE, it is worthwhile to explore alternative approaches that do not include EE or that use minimal use of EE. …