An ABAC comparison of two intensive interventions for food refusal.

An ABAC comparison of two treatment packages for food refusal, physical guidance and nonremoval of the spoon, was conducted with two children with limited food acceptance. Both of these treatment packages included prevention of escape from presented food. Subsequent to baseline, one of the two treatment packages was implemented for each child. The treatment packages were implemented ABAC for one child and ACAB for the other child. Once the percentage of bites accepted had increased to at least 75% with the initial exposure to a treatment package, that treatment was withdrawn with a subsequent exposure to the second treatment package. The results indicated that both treatment packages were effective in establishing food acceptance. Also, initial exposure to either of the two treatment packages facilitated acquisition of food acceptance during the second exposure. Parental preference of the treatment package may have been influenced by the order of exposure to the treatment conditions.

Dysphagia in children with a 22q11.2 deletion: unusual pattern found on modified barium swallow.

OBJECTIVES: To delineate feeding dysfunction in a population of children with a 22q11.2 deletion and report the associated findings noted during the modified barium swallow (MBS). STUDY DESIGN: Seventy-five children with a chromosome 22q11.2 deletion and history of persistent feeding difficulty received a feeding evaluation, including an MBS for those children for whom there was concern about airway penetration. RESULTS: A consistent pattern of feeding difficulty, independent of palatal or cardiac involvement, emerged from the evaluations. This group typically has trouble coordinating the suck/swallow/breath pattern, resulting in slow nipple feedings interrupted by gagging or regurgitation. Recurrent vomiting and constipation are common. With advancement to chewable table foods, gagging or refusal develops, related to an immature oral transport pattern. The MBS studies demonstrate pharyngeal hypercontractility, cricopharyngeal prominence, and/or diverticula. CONCLUSIONS: Because of the consistency of dysphagic symptoms and MBS findings, we propose that dysmotility, especially through the pharyngoesophageal segment, is central to the dysphagia affecting this group. Dysphagia related to dysmotility may be underdiagnosed in this population or erroneously attributed to cardiac disease. Therefore attention to feeding status and investigation with MBS and gastrointestinal studies as warranted are recommended for all patients with a 22q11.2 deletion and feeding problems.

The relationship between food refusal and self-injurious behavior: a case study.

Food refusal and self-injurious behavior often co-occur in children with developmental disabilities and mental retardation. The subject of the case study was a 3-yr-old boy with food refusal, self-injurious behavior and developmental delay. Using an alternating treatment design, positive reinforcement for acceptance combined with either nonremoval of the spoon or guidance for refusal increased food acceptance and resulted in a decrease in self-injurious behavior despite not being targeted. Although the contingencies for acceptance, refusal and self-injurious behavior remained constant, self-injurious behavior increased with an increase in grams consumed. A combined treatment of positive reinforcement for acceptance, guidance for refusal, position change and gastrojejunal feedings resulted in a decrease in self-injurious behavior and an increase in grams consumed.

An alternating treatments comparison of two intensive interventions for food refusal.

We compared two treatment packages involving negative reinforcement contingencies for 3 children with chronic food refusal. One involved physically guiding the child to accept food contingent on noncompliance, whereas the other involved nonremoval of the spoon until the child accepted the presented food. Subsequent to baseline, an alternating treatments comparison was implemented in a multiple baseline design across subjects. After each child had been exposed to at least nine sessions of each treatment condition and percentage of bites accepted had increased to at least 80%, the child's caregivers selected the preferred treatment package. The results indicated that both treatments were effective in establishing food acceptance. However, physical guidance was associated with fewer corollary behaviors, shorter meal durations, and parental preference.

Radionuclide studies of the upper gastrointestinal tract in children with feeding disorders.

The case of a female infant with a feeding disorder and with inadequate growth is described. In her workup, there was no evidence of an organic disorder. Barium studies of the upper GI tract showed normal anatomy and function. A radionuclide milk scan was helpful in demonstrating mild reflux and significantly delayed gastric emptying. There was a good response to therapy.

The costs of eating: a behavioral economic analysis of food refusal.

Behavioral economic concepts were applied to the analysis and treatment of pediatric feeding disorders in a clinical setting. In Experiment 1, children who chronically refused food were presented with varying amounts of food on a spoon (empty, dipped, quarter, half, and level). Each child exhibited a different but orderly demand function of response (acceptance, expulsion, and mouth clean) by cost (increasing spoon volume) for a constant pay-off of toys and social interaction. In Experiment 2, physical guidance or nonremoval of the spoon for food refusal was initiated at the smallest spoon volume with low levels of acceptance, and was subsequently introduced at the largest spoon volume with moderate levels of acceptance. Treatment was effective in increasing acceptance, and these effects generalized hierarchically across untargeted spoon volumes. The results of both studies provide preliminary support that increasing spoon volume can be equated conceptually with increasing response effort, and that the change from differential reinforcement to physical guidance or nonremoval of the spoon appears to have altered the elasticity of each child's demand function.

Effect of position and support on oral-motor skills of a child with bronchopulmonary dysplasia.

The effects of position (upright vs reclining) and support (held vs chair) on the development and maintenance of feeding behavior were examined in a child with bronchopulmonary dysplasia and gastroesophageal reflux. A reclining position initially facilitated acceptance and swallowing with relatively rapid generalization to an upright position. Oral-motor skills did not differ across levels of support. Practice of emerging motor skills preceded increases in vomiting, as well as episodes of respiratory distress. This study illustrates a methodology that can be employed to elucidate complex interrelationships among oral-motor skills, gross motor skills and functioning, and symptoms of gastroesophageal reflux.

Cerebral palsy.

Over the last century, our understanding of cerebral palsy has broadened. For example, we now know that it results more commonly from prenatal abnormalities than from perinatal difficulties. Yet, in most cases we are still no closer to understanding the operant mechanism of injury or how the injury results in the expressed motor disorder. Hopefully, the strides being made in neurodevelopmental physiology and neurotransmitter communication will help elucidate the mechanism of injury in cerebral palsy and thereby lead to methods of prevention. Meanwhile, comprehensive clinical evaluation and treatment and periodic reassessment will help tailor strategies to the individual needs of the child. This should enable the child with cerebral palsy to optimize his or her function in society.