Impact of continuous testosterone exposure on reproductive physiology, activity, and pain-related behavior in young adult female rats.

Testosterone may reduce pain in cisgender women and transgender men. Rodents can provide a useful model for investigating physiological effects of hormone therapy. To this end, continuous-release testosterone or blank (placebo) capsules were implanted s.c. into young adult female rats, and three weeks later rats were either ovariectomized or sham-ovariectomized. Testosterone treatment that mimicked previously reported endogenous levels in males eliminated estrous cycling and decreased uterine weight. Testosterone also significantly increased body weight and suppressed the increases in daily wheel running observed in placebo controls over time. Subsequent ovariectomy or sham-ovariectomy decreased wheel running in all groups, but testosterone-treated rats recovered significantly more quickly than did placebo-treated rats. Neither testosterone nor ovariectomy significantly altered hindpaw mechanical threshold. Two weeks after sham/ovariectomy surgery, injection of Complete Freund Adjuvant (CFA) into one hindpaw reduced wheel running and mechanical threshold in all groups; running significantly decreased from the first to second day after CFA in testosterone- but not in placebo-treated rats. Morphine 1.0 but not 3.2 mg/kg increased CFA-suppressed wheel running similarly in all groups, whereas both doses of morphine increased CFA-suppressed mechanical threshold. These data suggest that weeks-long testosterone treatment with or without ovariectomy may provide a useful physiological model of testosterone therapy as used in human gender transition. Although testosterone administered at levels similar to those in gonadally intact males tended to hasten female rats' recovery from surgery, it did not decrease maximal pain-related behaviors after surgery or hindpaw inflammatory insult, nor did it alter opioid antinociception.

Development of Medication Administration Protocols for In-Home Pediatric Feeding Cases.

Medication administration can be a significant issue in pediatric populations, and especially with patients with developmental disabilities and comorbid feeding disorders. Research has focused largely on consumption of solids rather than medication and liquids in pediatric feeding programs, with most studies being conducted within specialized hospital settings in the United States. No studies to our knowledge have detailed treatment evaluations for medication administration in pediatric feeding except for a few studies on pill swallowing. We report results of treatment protocols for medication administration using empirically-supported treatments in a short-term intensive home-based behavior-analytic program in Australia. Two males with autism spectrum and pediatric feeding disorders participated. We used a multiple baseline single-case experimental design for medication administration conducted concurrently with a treatment evaluation for solid foods. Consumption increased in number (9; supplements, laxatives, pain relievers), flavors (8; chocolate, blackcurrent and apple, strawberry, lemon-lime, orange, chocolate-vanilla, cherry, apple), forms (4; thin and thick liquids, chewables, gummies), and delivery methods (5; finger-fed, spoon, cup, medicine spoon, medicine cup) within the first treatment session. For one participant, we taught open cup drinking for a variety of liquids (milk, juices, medications). For both participants, we taught self-feeding with utensils for thick liquid medications. Treatment results were similar for solids and participants increased food variety to over 160 across food groups. All goals were met including training parents to maintain gains at home.

Agreement between visual inspection and objective analysis methods: A replication and extension.

Behavior analysts typically rely on visual inspection of single-case experimental designs to make treatment decisions. However, visual inspection is subjective, which has led to the development of supplemental objective methods such as the conservative dual-criteria method. To replicate and extend a study conducted by Wolfe et al. (2018) on the topic, we examined agreement between the visual inspection of five raters, the conservative dual-criteria method, and a machine-learning algorithm (i.e., the support vector classifier) on 198 AB graphs extracted from clinical data. The results indicated that average agreement between the 3 methods was generally consistent. Mean interrater agreement was 84%, whereas raters agreed with the conservative dual-criteria method and the support vector classifier on 84% and 85% of graphs, respectively. Our results indicate that both objective methods produce results consistent with visual inspection, which may support their future use.

Machine Learning to Support Visual Inspection of Data: A Clinical Application.

Practitioners in pediatric feeding programs often rely on single-case experimental designs and visual inspection to make treatment decisions (e.g., whether to change or keep a treatment in place). However, researchers have shown that this practice remains subjective, and there is no consensus yet on the best approach to support visual inspection results. To address this issue, we present the first application of a pediatric feeding treatment evaluation using machine learning to analyze treatment effects. A 5-year-old male with autism spectrum disorder participated in a 2-week home-based, behavior-analytic treatment program. We compared interrater agreement between machine learning and expert visual analysts on the effects of a pediatric feeding treatment within a modified reversal design. Both the visual analyst and the machine learning model generally agreed about the effectiveness of the treatment while overall agreement remained high. Overall, the results suggest that machine learning may provide additional support for the analysis of single-case experimental designs implemented in pediatric feeding treatment evaluations.

Brief Report: Packing Treatment Comparison and Use of a Chaser to Increase Swallowing for a Clinical Case.

Packing involves not swallowing solids or liquids in the mouth. It is a significant mealtime behaviour to treat. Research has shown effectiveness of redistribution, but only two studies in highly specialised hospital settings in the United States have evaluated the use of a chaser. We extended this literature by conducting treatment in the home setting, and comparing a liquid and puree chaser separately to infant gum brush redistribution and a move-on to the next bite presentation component. A 4-year-old male with autism spectrum disorder and gastrostomy tube dependence participated in his home. We used a multielement single-case experimental design. With the liquid chaser, consumption increased to 100%. Swallowing latency was significantly lower with the liquid chaser compared to other packing treatments.

Controlled case series demonstrates how parents can be trained to treat paediatric feeding disorders at home.

AIM: Paediatric feeding disorders are normally managed by specialist clinics. We examined whether treatment gains were maintained when trained parents continued the programme at home and during meals out. METHODS: This controlled consecutive case series recruited 26 children (22 boys) with avoidant/restrictive food intake disorder, from a private paediatric feeding disorders practice in New South Wales, Australia. Their mean age was six (2-13) years. All had severe feeding problems and mealtime skill deficits, and most had autism and developmental delays or intellectual disabilities. The children received intensive, individualised, behaviour-analytic treatment for 11 (6-21.5) days, and the parents were trained to continue it at home. The primary treatment outcomes included the range and amount of food eaten and mealtime behaviour. RESULTS: The children met all of the therapeutic goals agreed at the treatment outset. They ate a mean of 92 different foods and improved how they ate, drank and behaved during mealtimes. The mean differences before and after treatment were clinically and statistically significant, and the gains were maintained during follow-up at a mean of 2.3 years. Parental satisfaction and treatment acceptability were high. CONCLUSION: Specially trained parents successfully continued paediatric eating disorder treatment at home and maintained treatment gains.

Side Deposit with Regular Texture Food for Clinical Cases In-Home.

Objective Research has shown effectiveness of nonremoval of the spoon and physical guidance in increasing consumption and decreasing inappropriate mealtime behavior. The side deposit has been used to treat passive refusal in 2 studies (1 in a highly specialized hospital setting) using lower manipulated-texture foods on an infant gum brush. Methods We extended the literature by using regular texture bites of food with a finger prompt and side deposit (placing bites inside the side of the child's mouth via the cheek) in an intensive home-based program setting in Australia, demonstrating that attention and tangible treatments alone were ineffective prior, fading the tangible treatment, showing caregiver training, and following up. 2 male children with autism spectrum disorder (with texture/variety selectivity; one with liquid dependence) participated in their homes. We used a reversal design to replicate effectiveness of the side deposit added to a treatment package. Results For both participants, we observed a >98% decrease in latency to acceptance, a 100% decrease in inappropriate mealtime behavior, and a 100% increase in consumption with the side deposit added. Variety was increased to over 85 regular texture foods. 100% of admission goals were met. Caregivers were trained to high procedural integrity and the protocol was generalized to school and the community. Gains maintained to 3 and 1.5 years. Conclusion This is important work in adding to the literature and support for the side deposit and expanding to regular texture, as well as replicating and extending empirically supported treatments for feeding internationally to the home setting.

Treatment of avoidant/restrictive food intake disorder for a teenager with typical development within the home setting.

INTRODUCTION: Avoidant/restrictive food intake disorder (ARFID) can occur in children with typical development and persist past childhood. This significantly impacts most areas of children's lives, but may become more evident in teenage years, especially socially. There is an empirically supported treatment for ARFID with 40 years of research backing, this being behaviour-analytic feeding interventions. However, application to individuals over age 12 is lacking, and needs to be investigated for effectiveness. This is important as the addition of ARFID (formerly called feeding disorders) to the DSM-V has seen an increase in new treatments for ARFID by attempting to apply eating disorder treatments to this population including children. More research is needed to identify if already established behavioural intervention procedures are effective for ARFID in individuals with selectivity, without disabilities, older ages, and in settings outside of intensive specialised feeding hospital admissions in the United States. METHOD: A 13-year-old female with ARFID and years of failed treatment attempts participated in her home in Australia. We conducted multiple stimulus without replacement preference assessments and used a changing criterion design with multiple baseline probes. Treatment consisted of demand fading, choice, differential attention, and contingent access. We did not use cognitive or family based treatment. RESULTS: Consumption increased to 100%. Variety reached 61 foods across all food groups. She met 100% of goals and ate at a restaurant. Caregivers reported high satisfaction and social acceptability. Gains were maintained at 9 months. CONCLUSION: This brief, behaviour-analytic in-home treatment was effective in increasing food group variety consumption.

Comparing behavioral treatment of feeding difficulties and tube dependence in children with cerebral palsy and autism spectrum disorder.

BACKGROUND: Feeding disorders are multifaceted with behavioral components often contributing to the development and continuation of food refusal. In these cases, behavioral interventions are effective in treating feeding problems, even when medical or oral motor components are also involved. Although behavioral interventions for feeding problems are frequently employed with children with autism, they are less commonly discussed for children with cerebral palsy. OBJECTIVE: The purpose of this study was to compare the effectiveness of using applied behavior analytic interventions to address feeding difficulties and tube dependence in children with autism and children with cerebral palsy. METHOD: Children ages 1 to 12 years who were enrolled in an intensive feeding program between 2003 and 2013, where they received individualized behavioral treatment, participated. RESULTS: Behavioral treatment components were similar across groups, predominately consisting of escape extinction (e.g., nonremoval of the spoon) and differential reinforcement. For both groups, behavioral treatment was similarly effective in increasing gram consumption and in decreasing refusal and negative vocalizations. A high percentage of individualized goals were met by both groups as well as high caregiver satisfaction reported. CONCLUSIONS: Behavioral interventions for food refusal are effective for children with cerebral palsy with behavioral refusal, just as they are for children with autism.

The Prevalence of Food Allergies in Children Referred to a Multidisciplinary Feeding Program.

OBJECTIVE: To assess the prevalence of food allergy in children presenting to a multidisciplinary feeding program. METHODS: A retrospective chart review was conducted from 302 patients. We recorded history of food reaction, family history of any atopic disease, radioallergosorbent testing, prematurity, birth weight, breastfeeding history, Z-scores, age, and gastrointestinal mucosal biopsy reports with eosinophilic infiltrate. Three categories of possible food allergy were stratified based on increasing evidence of allergy. RESULTS: Possible food allergy was found for 18% (n = 54), likely food allergy for 6% (n = 18), and very likely food allergy for 16% (n = 47) for a total of 40% classified in a food allergy group. Having been breastfed correlated with likelihood of food allergy but tube-feeding dependence did not. CONCLUSION: This study revealed a higher proportion of children in a feeding program with food allergy compared to the general population, but larger prospective studies are needed to confirm the association.

Maintenance of bowel, bladder, and motor functions after sacrectomy.

BACKGROUND CONTEXT: Repeated cohort studies have consistently demonstrated a survival advantage after en bloc resection for locally aggressive primary tumors in the sacrum. A sacrectomy is often required to remove the tumor en bloc, which may necessitate the sacrifice of sacral nerves. This can potentially result in functional complications, including the impairment of gait, bowel function, or bladder function. PURPOSE: To assess the bladder, bowel, and motor functions of patients after resection of a primary sacral tumor. STUDY DESIGN: This was a retrospective cohort study at a single academic institution. PATIENT SAMPLE: Consecutive patients who underwent an en bloc sacral tumor resection at a single institution between December 2002 and June 2012 were included. The study population comprised 73 patients. OUTCOME MEASURES: Patients were classified as having had a low, middle, high, or total sacrectomy based on the level of sacral nerves sacrificed, if applicable. METHODS: Patient data were collected from clinic notes and hospital records that included operative notes, lab studies, and rehabilitation notes. RESULTS: Across all patients, there was no change in bowel function after sacrectomy, whereas bladder and motor functions returned to preoperative (pre-op) levels at 3 and 6 months, respectively. Higher level sacrectomies were associated with worse bowel (p<.001), bladder (p<.001), and motor (p=.027) functions 12 months postoperatively (post-op). At 1 year, none of the six patients with a high or total sacrectomy had intact bladder function and 14.3% (N=7) had intact bowel function. Of patients with a middle sacrectomy, 62.5% (N=8) had intact bladder function and 71.4% (N=7) had intact bowel function at 1 year. Of patients with a low sacrectomy, 91.7% (N=12) had intact bladder function and 91.7% (N=12) had intact bowel function. CONCLUSIONS: Preoperative bladder, bowel, and motor functions, level of sacral tumor involvement, and corresponding level of sacrectomy were the greatest predictors of long-term bladder, bowel, and motor functions. There were no statistically significant changes in bladder, bowel, or motor functions from pre-op to 6 months post-op, and therefore, pre-op functional status was predictive of long-term function.

Inappropriate mealtime behavior: the effects of noncontingent access to preferred tangibles on responding in functional analyses.

An understanding of the functional variables associated with inappropriate mealtime behavior (IMB) is critical to developing an effective and efficient treatment for food refusal. To this aim, functional analysis methodology has been modified for the meal context, and previous research has shown that multiple sources of reinforcement maintain IMB. Functional analysis literature, related to severe problem behavior, suggests that access to preferred stimuli may abolish or compete with social reinforcers in some cases. The role of noncontingent access to preferred stimuli during the assessment of IMB has not been evaluated. The purpose of the current study was to examine the effects noncontingent access to preferred toys/activities on IMB in the presence and absence of social consequences. The specific aims were to evaluate: (1) levels of IMB when the spoon is held stationary at the child's lips when preferred tangible stimuli are present noncontingently vs. absent; (2) levels of IMB when social consequences were provided contingent upon IMB when preferred tangible stimuli are present noncontingently vs. absent. For many participants, levels of IMB were reduced with the inclusion of preferred toys/activities; while for one, levels of IMB increased. Possible implications of these findings on functional analyses of IMB will be discussed.