Evaluating a Treatment Package for Avoidant/Restrictive Food Intake Disorder to Increase Food Variety.

There is a dearth of published research evaluating behavior-analytic assessment and treatment of avoidant/restrictive food intake disorder (ARFID) given the recent revisions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In this study, therapists conducted periodic food preference assessments to help guide treatment for a typically developing child with ARFID and food selectivity. Further, therapists evaluated a treatment package including demand fading, escape prevention, and self-monitoring to increase food variety. Consumption increased during treatment with target foods; however, preference shifts were minor when compared to the pretreatment food preference assessment. Variety continued to increase overtime using the same treatment package and treatment effects were generalized to family meals and other locations. Supplementary Information: The online version contains supplementary material available at 10.1007/s40617-023-00821-0.

Using an intensive interdisciplinary telehealth model to treat pediatric feeding disorders.

The necessity of treatment using telehealth was apparent during the novel coronavirus (COVID-19) pandemic, as many practitioners were forced to use telehealth as a primary mode of service delivery. Although the telehealth model has been studied for different populations, little is known about its success when applied with children with feeding disorders and complex medical histories. The purpose of this study was to evaluate the efficacy of using a telehealth model from the onset of treatment. All 5 children who participated engaged in low levels of acceptance and high levels of inappropriate mealtime behavior during baseline. Caregivers were taught to implement the treatment with high integrity using behavioral skills training. Procedural integrity increased posttraining, and as a result acceptance increased and inappropriate mealtime behavior decreased. Treatment gains maintained during follow up at 1 month and 1 year. These data are discussed in relation to alternative ways of providing treatment in locations where intensive feeding programs are not available.

Evaluating Outcome Measure Data for an Intensive Interdisciplinary Home-Based Pediatric Feeding Disorders Program.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of an interdisciplinary home-based feeding program, which is a unique service delivery model. METHODS: Data were provided on oral intake, tube feeding elimination, and weight for patients who were dependent on tube feedings (n = 78). Weight data were collected for patients who showed failure to thrive (n = 49). Number of foods consumed and percentage of solids were collected for patients who were liquid-dependent (n = 23), and number of foods consumed were collected for patients who were food-selective (n = 61). RESULTS: Data were analyzed using paired sample t-test with 95% confidence interval. For patients dependent on tube feedings, 81% achieved tube feeding elimination. Tube elimination was achieved after 8 months of treatment on average. All failure-to-thrive patients showed weight gain from baseline to discharge. For liquid-dependent patients, there was an increase in foods consumed from 2 foods at admission to 32 foods at discharge. For food selective patients, there was an increase from 4 foods at admission to 35 foods at discharge. For all dependent variables, results showed statistical significance and a large-sized effect. CONCLUSIONS: These data show that an intensive interdisciplinary home-based program can be successful in treating complex feeding problems in children.

Rapid Fabrication of Renewable Carbon Fibres by Plasma Arc Discharge and Their Humidity Sensing Properties.

Submicron-sized carbon fibres have been attracting research interest due to their outstanding mechanical and electrical properties. However, the non-renewable resources and their complex fabrication processes limit the scalability and pose difficulties for the utilisation of these materials. Here, we investigate the use of plasma arc technology to convert renewable electrospun lignin fibres into a new kind of carbon fibre with a globular and porous microstructure. The influence of arc currents (up to 60 A) on the structural and morphological properties of as-prepared carbon fibres is discussed. Owing to the catalyst-free synthesis, high purity micro-structured carbon fibres with nanocrystalline graphitic domains are produced. Furthermore, the humidity sensing characteristics of the treated fibres at room temperature (23 °C) are demonstrated. Sensors produced from these carbon fibres exhibit good humidity response and repeatability in the range of 30% to 80% relative humidity (RH) and an excellent sensitivity (0.81/%RH) in the high RH regime (60-80%). These results demonstrate that the plasma arc technology has great potential for the development of sustainable, lignin-based carbon fibres for a broad range of application in electronics, sensors and energy storage.

3D-Printed Enzyme-Embedded Plastics.

A simple and environmentally friendly approach toward the thermoplastic processing of rapidly degradable plastic-enzyme composites using three-dimensional (3D) printing techniques is described. Polycaprolactone/Amano lipase (PCL/AL) composite films (10 mm × 10 mm; height [h] = ∼400 µm) with an AL loading of 0.1, 1.0, and 5.0% were prepared via 3D printing techniques that entail direct mixing in the solid state and thermal layer-by-layer extrusion. It was found that AL can tolerate in situ processing temperatures up to 130 °C in the solid-state for 60 min without loss of enzymatic activity. The composites were degraded in phosphate buffer (8 mg/mL, composite to buffer) for 7 days at 37 °C and the resulting average percent total weight loss (WLavg %) was found to be 5.2, 92.9, and 100%, for the 0.1, 1.0, and 5.0% films, respectively. The degradation rates of PCL/AL composites were found to be faster than AL applied externally in the buffer. Thicker PCL/AL 1.0% films (10 mm × 10 mm; h = ∼500 µm) were also degraded over a 7 day period to examine how the weight loss occurs over time with 3.0, 18.1, 36.4, 46.4, and 70.2% weight loss for days 1, 2, 3, 4, and 7, respectively. Differential scanning calorimetry (DSC) analysis shows that the film's percent crystallinity (Dxtal%) increases over time with Dxtal% = 46.5 for day 0 and 53.1% for day 7. Scanning electron microscopy (SEM) analysis found that film erosion begins at the surface and that water can penetrate the interior via surface pores activating the enzymes embedded in the film. Controlled release experiments utilizing dye-loaded PCL/AL/dye (AL = 1.0%; dye = 0.1%) composites were degraded over a 7 day period with the bulk of the dye released by the fourth day. The PCL/AL multimaterial objects containing AL-resistant polylactic acid (PLA) were also printed and degraded to demonstrate the application of this material on more complex structures.

Patient-Derived Tumor Explants As a "Live" Preclinical Platform for Predicting Drug Resistance in Patients.

An understanding of drug resistance and the development of novel strategies to sensitize highly resistant cancers rely on the availability of suitable preclinical models that can accurately predict patient responses. One of the disadvantages of existing preclinical models is the inability to contextually preserve the human tumor microenvironment (TME) and accurately represent intratumoral heterogeneity, thus limiting the clinical translation of data. By contrast, by representing the culture of live fragments of human tumors, the patient-derived explant (PDE) platform allows drug responses to be examined in a three-dimensional (3D) context that mirrors the pathological and architectural features of the original tumors as closely as possible. Previous reports with PDEs have documented the ability of the platform to distinguish chemosensitive from chemoresistant tumors, and it has been shown that this segregation is predictive of patient responses to the same chemotherapies. Simultaneously, PDEs allow the opportunity to interrogate molecular, genetic, and histological features of tumors that predict drug responses, thereby identifying biomarkers for patient stratification as well as novel interventional approaches to sensitize resistant tumors. This paper reports PDE methodology in detail, from collection of patient samples through to endpoint analysis. It provides a detailed description of explant derivation and culture methods, highlighting bespoke conditions for particular tumors, where appropriate. For endpoint analysis, there is a focus on multiplexed immunofluorescence and multispectral imaging for the spatial profiling of key biomarkers within both tumoral and stromal regions. By combining these methods, it is possible to generate quantitative and qualitative drug response data that can be related to various clinicopathological parameters and thus potentially be used for biomarker identification.

Comparative Analysis of Risk Factors in Declined Kidneys from Donation after Brain Death and Circulatory Death.

Background and objectives: Kidneys from donation after circulatory death (DCD) are more likely to be declined for transplantation compared with kidneys from donation after brain death (DBD). The aim of this study was to evaluate characteristics in the biopsies of human DCD and DBD kidneys that were declined for transplantation in order to rescue more DCD kidneys. Materials and Methods: Sixty kidney donors (DCD = 36, DBD = 24) were recruited into the study and assessed using donor demographics. Kidney biopsies taken post cold storage were also evaluated for histological damage, inflammation (myeloperoxidase, MPO), von Willebrand factor (vWF) expression, complement 4d (C4d) deposition and complement 3 (C3) activation using H&E and immunohistochemistry staining, and Western blotting. Results: More DBD donors (16/24) had a history of hypertension compared with DCDs (8/36, p = 0.001). The mean warm ischemic time in the DCD kidneys was 12.9 ± 3.9 min. The mean cold ischemic time was not significantly different between the two groups of kidney donors (DBD 33.3 ± 16.7 vs. DCD 28.6 ± 14.1 h, p > 0.05). The score of histological damage and MPO, as well as the reactivity of vWF, C4d and C3, varied between kidneys, but there was no significant difference between the two donor types (p > 0.05). However, vWF reactivity might be an early indicator for loss of tissue integrity, while C4d deposition and activated C3 might be better predictors for histological damage. Conclusions: Similar characteristics of DCD were shown in comparison with DBD kidneys. Importantly, the additional warm ischemic time in DCD appeared to have no further detectable adverse effects on tissue injury, inflammation and complement activation. vWF, C4d and C3 might be potential biomarkers facilitating the evaluation of donor kidneys.

Microplastic contamination in Auckland (New Zealand) beach sediments.

We report the first large-scale investigation of microplastic contamination in beach sediments across Auckland, New Zealand's most populous region. Sediment samples were taken from the high tide and intertidal zones at 39 sites across estuary, harbour and ocean environments of the East and West Coasts. Microplastic contamination was present at the majority of beaches studied with a mean abundance of 459 particles.m-2 ranging from 0 to 2615 particles.m-2. High variability was observed between the sites, indicating the importance of small-scale factors on microplastic contamination. Samples from high and intertidal zones showed no significant difference in microplastic contamination (p = 0.225). The West Coast beaches exhibited higher microplastic contamination compared with East Coast beaches (p = 0.004). Microplastics were predominately fibres (88%), with lower proportions of fragments (8%) and films (4%). The majority of the microplastics analysed were regenerated cellulose (34%), polyethylene terephthalate (22%) and polyethylene (15%).

Patient-derived explants (PDEs) as a powerful preclinical platform for anti-cancer drug and biomarker discovery.

Preclinical models that can accurately predict outcomes in the clinic are much sought after in the field of cancer drug discovery and development. Existing models such as organoids and patient-derived xenografts have many advantages, but they suffer from the drawback of not contextually preserving human tumour architecture. This is a particular problem for the preclinical testing of immunotherapies, as these agents require an intact tumour human-specific microenvironment for them to be effective. In this review, we explore the potential of patient-derived explants (PDEs) for fulfilling this need. PDEs involve the ex vivo culture of fragments of freshly resected human tumours that retain the histological features of original tumours. PDE methodology for anti-cancer drug testing has been in existence for many years, but the platform has not been widely adopted in translational research facilities, despite strong evidence for its clinical predictivity. By modifying PDE endpoint analysis to include the spatial profiling of key biomarkers by using multispectral imaging, we argue that PDEs offer many advantages, including the ability to correlate drug responses with tumour pathology, tumour heterogeneity and changes in the tumour microenvironment. As such, PDEs are a powerful model of choice for cancer drug and biomarker discovery programmes.

Lowering Perfusate Temperature From 37°C to 32°C Diminishes Function in a Porcine Model of Ex Vivo Kidney Perfusion.

BACKGROUND: Ex vivo perfusion (EVP) is a novel method of preservation. However, optimal perfusion conditions remain undetermined. Reducing the temperature of the perfusate to subnormothermia may be beneficial during EVP and improve early graft function. The aim of this study was to investigate whether subnormothermia would influence the conditioning effect of EVP when compared with normothermic perfusion, and standard cold static storage (CS). METHODS: Porcine kidneys underwent static CS for 23 hours followed by 1 hour of EVP using leukocyte-depleted blood at a mean temperature of 32°C or 37°C. After this, kidneys were reperfused with whole autologous blood at 37°C for 3 hours to assess renal function and injury. These were compared with a control group that underwent 24 hours CS. RESULTS: During EVP, kidneys perfused at 37°C had a higher level of renal blood flow and oxygen consumption compared with EVP at 32°C (P = 0.001, 0.002). During reperfusion, 32°C EVP kidneys had lower creatinine clearance and urine output than control (P = 0.023, 0.011) and a higher fractional excretion of sodium, serum potassium, and serum aspartate transaminase than 37°C EVP kidneys (P = 0.01, 0.023, 0.009). CONCLUSIONS: Tubular and renal functions were better preserved by a near-physiological temperature of 37°C during 1 hour of EVP, when compared to EVP at 32°C or cold storage.

Hydrogen sulphide as a novel therapy to ameliorate cyclosporine nephrotoxicity.

BACKGROUND: Calcineurin inhibitors have significant nephrotoxic side effects, which can exacerbate ischemia-reperfusion injury in renal transplantation. Novel therapeutic agents such as hydrogen sulphide (H2S) may reduce these harmful effects. This study investigated the effects of H2S on cyclosporine (CsA) induced nephrotoxicity. MATERIALS AND METHODS: Porcine kidneys were subjected to 15 min of warm ischemia and 2 h of static cold storage. They were reperfused for 3 h with oxygenated normothermic autologous whole blood on an isolated organ reperfusion apparatus. Kidneys were treated with CsA during reperfusion (n = 6) or cyclosporine and 0.25 mmol/L of H2S infused 10 min before and 20 min after reperfusion (n = 6). These were compared with untreated controls (n = 7). RESULTS: CsA caused a significant reduction in renal blood flow during reperfusion, which was reversed by H2S (area under the curve renal blood flow CsA 257 ± 93 versus control 477 ± 206 versus CsA + H2S 478 ± 271 mL/min/100 g.h; P = 0.024). Urine output was higher after 2 h of reperfusion in the CsA + H2S group (CsA + H2S 305 ± 218 versus CsA 78 ± 180 versus control 210 ± 45 mL; P = 0.034). CsA treatment was associated with an increase in tubular injury, which was not reversed by H2S (area under the curve fractional excretion of sodium, control 77 ± 53 versus CsA 100 ± 61 versus CsA + H2S 111 ± 57%.h; P = 0.003). Histologic evaluation showed significant vacuolation and glomerular shrinkage in the CsA group. These were significantly reduced by H2S (P = 0.005, 0.002). CONCLUSIONS: H2S reversed the vasoconstriction changes associated with CsA treatment during reperfusion.

Pharmacotherapy for posttraumatic stress disorder at a Veterans Affairs facility.

PURPOSE: Results of a study of psychotropic prescribing patterns in a Veterans Affairs (VA) population with posttraumatic stress disorder (PTSD) are presented. METHODS: VA prescription records were reviewed to identify veterans with PTSD at a large VA healthcare center and evaluate their medication regimens for conformance with a VA practice guideline that calls for the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) as first-line therapies for PTSD; the VA guideline does not recommend second-generation antipsychotics (SGAs) and benzodiazepines for PTSD symptom control. The primary objective was to determine if veterans with PTSD who were receiving an SGA had first received SSRI or SNRI therapy in accordance with VA recommendations. RESULTS: Among 308 veterans who met the inclusion criteria, the average number of SSRI or SNRI agents prescribed prior to initiation of SGA therapy was 0.88. Only 19.8% of patients (n = 61) had been prescribed 2 SSRI or SNRI agents, with 48.4% of patients (n = 149) having received 1 agent. All evaluated courses of SSRI and SNRI therapy prior to SGA initiation were of sufficient duration (range, 5-30 months), and mean adherence rates were >80%. Current or past benzodiazepine use was documented in about 55% of patients (n = 170). CONCLUSION: SSRIs and SNRIs were under-utilized for the treatment of PTSD at the study site in patients receiving an SGA. The current use of benzodiazepines in these patients was lower than a reported national average for VA patients.

Hydrogen sulfide reduces inflammation following abdominal aortic occlusion in rats.

BACKGROUND: Remote renal ischemia-reperfusion injury (IRI) following infra-renal aortic occlusion leads to acute kidney injury and systemic inflammation. Hydrogen sulfide is a mediator of IRI and can ameliorate tissue injury in many organ systems. Its role in vascular surgery has yet to be established. We assessed the role of hydrogen sulfide in a rodent model of aortic occlusion. METHODS: Wistar rats were divided into sham, control, and treatment groups (n = 6). Inflammation was assessed using a nonrecovery protocol. The infra-renal aorta was cross-clamped for 60 min and animals were reperfused for 120 min. Ten minutes before clamp release, treatment animals received hydrogen sulfide (10, 30, or 50 µg/kg) and control animals received 0.9% saline injected into the retroperitoneum. Renal injury and histology were assessed by a recovery protocol. The procedure was identical to the nonrecovery arm but with a single dose of hydrogen sulfide (30 µg/kg) and animals were recovered for 7 days. RESULTS: There was no difference in animal weight between the groups (P = 0.337). In the nonrecovery arm, there was a reduction in serum levels of tumor necrosis factor alpha in sulfide-treated animals compared with controls (909 ± 98 vs. 607 ± 159 pg/mL; P = 0.0038). There was also a reduction in myeloperoxidase-positive cells in renal tissue in the sulfide-treated animals compared with controls (8 ± 4 vs. 17 ± 9; P = 0.03). There was no difference in histological injury score or endothelin-1 levels. In the recovery arm, there was no difference in renal function, Kidney Injury Molecule-1 levels, or histological injury scores. CONCLUSION: Hydrogen sulfide has systemic and renal anti-inflammatory effects in remote IRI following aortic occlusion in rats.

Sildenafil citrate in a donation after circulatory death experimental model of renal ischemia-reperfusion injury.

INTRODUCTION: Phosphodiesterase-5 inhibitors prevent the breakdown of cyclic guanosine 3',5'-monophosphate (cGMP) and therefore may be useful in reducing the detrimental effects of ischemia-reperfusion (I/R) injury. The aim of this study was to assess the effects of the phosphodiesterase-5 inhibitor sildenafil, on I/R injury in a porcine model of donation after circulatory death kidney transplantation. METHODS: Kidneys were subjected to 20 min warm ischemia followed by 2 or 18 hr of cold storage (n=6 kidneys per group). After preservation kidneys were reperfused on an ex vivo perfusion system for 3 hr with an oxygenated blood based solution. Kidneys were treated with 1.4 mg/kg sildenafil infused 10 min before and for 20 min after reperfusion (n=6 kidneys per group). Renal function and injury markers were measured throughout reperfusion. RESULTS: Prolonged cold ischemia (CI) significantly reduced levels of cGMP (2 hr 3.5 [1.5-5.7] vs. 18 hr 1.2 [0.3-2.8] pmol/mL; P=0.010). The administration of sildenafil significantly increased the levels (P=0.047, 0.064). Sildenafil improved the renal blood flow for the first 30 min in the 2-hr group (sildenafil, 81.8 [43.8-101.9] vs. control 40.2 [6.4-76.9] mL/min/100 g; P=0.026) and up to 60 min in the 18-hr group (sildenafil, 67.4 [38.0-87.0] vs. control 36.2 [30.5-50.0] mL/min/100 g; P=0.009) during reperfusion. Renal function was significantly impaired after 18-hr CI (P=0.0.26), and treatment with sildenafil did not improve renal function in the 2-hr (P=0.384) or 18-hr CI (P=0.099) groups. CONCLUSION: Sildenafil had a vasodilatory action and increased levels of cGMP but did not affect recovery of renal function or protect against I/R injury.

The effects of arterial pressure during normothermic kidney perfusion.

BACKGROUND: Ex vivo normothermic perfusion (EVNP) can reverse some of the detrimental effects of ischemic injury. However, in kidneys with warm and cold ischemic injury the optimal perfusion pressure remains undetermined. The aim of this study was to evaluate the effects of two different arterial pressures during EVNP. METHODS: Porcine kidneys underwent static cold storage for 23 h followed by 1 h of EVNP using leukocyte depleted blood at a mean arterial pressure of either 55 or 75 mm Hg. After this, kidneys were reperfused for 3 h to assess renal function and injury. This was compared with a control group that underwent 24 h cold storage. RESULTS: During EVNP, kidneys perfused at 75 mm Hg had a higher renal blood flow, increased oxygen consumption (median 59.9 mL/min/g (range 30.1-78.6] versus 31.8 [8.2-53.8] mL/min/g; P = 0.026), and produced more urine (P = 0.002) than kidneys perfused at 55 mm Hg. During ex vivo reperfusion, renal blood flow was significantly higher in the 75 mm Hg and 55 mm Hg groups compared with the control (area under the curve median 75 mm Hg 462 [228-745], 55 mm Hg 454 [254-923] versus control 262 [215-442] mL/min/100g.h; P = 0.040). There was a significant loss of renal function and increase in tubular injury in the 55 mm Hg group kidneys (P = 0.001, 0.007). Levels of endothelin 1 were significantly reduced in the 75 mm Hg group (P = 0.026). CONCLUSIONS: A mean arterial pressure of 75 mm Hg during EVNP resulted in less tubular damage and less endothelial injury during ex vivo reperfusion compared with kidneys perfused at 55 mm Hg.

The conditioning effect of ex vivo normothermic perfusion in an experimental kidney model.

BACKGROUND: A short period of isolated normothermic perfusion (NP) can be used to improve the condition of the kidney after periods of warm and cold ischemic injury. However, the mechanisms underlying this beneficial effect have not been determined. MATERIALS AND METHODS: Porcine kidneys were retrieved after 10 min of warm ischemic injury and stored by either static cold storage (CS) for 24 h (control) or CS for 23 h followed by 1 h of NP at 38°C with leukocyte-depleted autologous blood (NP). After preservation, kidneys in both groups underwent 3 h of ex vivo reperfusion to assess the injury (n = 6). RESULTS: NP kidneys had significantly lower levels of intrarenal resistance (NP 2.28 ± 1.1 versus control 3.86 ± 1.2 mm Hg/mL/h; P = 0.040), maintained their acid base homeostasis (P = 0.080), and had higher levels of oxygen consumption (NP 42.6 ± 19.5 versus control 20.8 ± 5.7 mL/min/g; P = 0.026) and reduced tubular injury (P = 0.008) compared with kidneys in the control group during reperfusion. There were no significant differences in the levels of inflammatory cytokines (interleukin [IL]-1ß, IL-8, or tumor necrosis factor-α; P > 0.05) or in renal function (creatinine clearance NP 2.6 ± 1.3 versus control 3.0 ± 1.5 mL/min/100 g; P = 0.070). However, levels of IL-6 were significantly raised in the NP group after reperfusion (P = 0.016). Levels of heat shock protein 70 were upregulated after 1 h of NP and expression increased during reperfusion to a significantly higher level than in the control group (P = 0.045). CONCLUSION: Kidneys undergoing a short period of NP had improved metabolic function and less tubular injury compared with static cold-stored kidneys. The increased expression of heat shock protein 70 and IL-6 suggests that NP may upregulate mechanisms that condition the kidney.

A comparison of sensory integrative and behavioral therapies as treatment for pediatric feeding disorders.

We compared the effects of escape extinction (EE) plus noncontingent reinforcement (NCR) with sensory integration therapy as treatment for the feeding problems of 2 children. Results indicated that EE plus NCR was more effective in increasing acceptance, decreasing inappropriate behavior, and increasing amount consumed relative to sensory integration for both children. The results are discussed in terms of the challenges of evaluating sensory-integration-based treatments, and the reasons why component analyses of multicomponent treatments like sensory integration are important.

Using a chaser to decrease packing in children with feeding disorders.

Packing is a problematic mealtime behavior that is characterized by pocketing or holding solids or liquids in the mouth without swallowing. In the current study, we examined the effects of a chaser, a liquid or solid consistently accepted and swallowed by the child, to decrease packing of solid foods in 3 children with feeding disorders. During the chaser procedure, the therapist presented the chaser immediately for 2 children or 15 s after each bite presentation for 1 child. The chaser was effective in decreasing packing for all 3 children. The results are discussed in terms of the clinical importance of the findings and directions for future research.

Escape as reinforcement and escape extinction in the treatment of feeding problems.

Given the effectiveness of putative escape extinction as treatment for feeding problems, it is surprising that little is known about the effects of escape as reinforcement for appropriate eating during treatment. In the current investigation, we examined the effectiveness of escape as reinforcement for mouth clean (a product measure of swallowing), escape as reinforcement for mouth clean plus escape extinction (EE), and EE alone as treatment for the food refusal of 5 children. Results were similar to those of previous studies, in that reinforcement alone did not result in increases in mouth clean or decreases in inappropriate behavior (e.g., Piazza, Patel, Gulotta, Sevin, & Layer, 2003). Increases in mouth clean and decreases in inappropriate behavior occurred when the therapist implemented EE independent of the presence or absence of reinforcement. Results are discussed in terms of the role of negative reinforcement in the etiology and treatment of feeding problems.

Spoon distance fading with and without escape extinction as treatment for food refusal.

Little is known about the characteristics of meals that serve as motivating operations (MOs) for escape behavior. In the current investigation, we showed that the distance at which a therapist held a spoon from a child's lips served as an MO for escape behavior. Based on these results, we implemented spoon distance fading, compared fading with and without escape extinction (EE), and compared fading plus EE to EE alone. Initially, inappropriate mealtime behavior decreased during fading, but this effect was not maintained as fading progressed. Inappropriate mealtime behavior was lower initially when we combined fading and EE relative to EE alone, but acceptance increased more rapidly with EE than with fading plus EE. These results suggest that a number of mealtime characteristics might function as MOs for escape behavior and that analyses of MOs may be useful for developing treatments for food refusal.