Discussion 5

Reducing Rapid Eating in Adults With Down Syndrome: Using Token Reinforcement to Increase Interresponse Time Between Bites

Brandon K. May1, 2 and Rocco Catrone2, 3 1 Department of Psychiatry, Washington University in St. Louis

2 Department of Psychological and Behavioral Sciences, Southern Illinois University Carbondale 3 Department of Applied Behavior Analysis, Chicago School of Professional Psychology

Individuals with developmental disabilities are more likely to eat rapidly. Rapid eating is correlated with choking, vomiting, aspiration, overeating, and obesity, all of which negatively affect quality of life. Behavioral strategies have been used to slow eating pace but often require invasive techniques, such as response blocking, to achieve clinically important reductions. The current study extended previous research by implementing a treatment package that included the use of a timer, differential reinforcement of low rates of behavior, and token reinforcement system to reduce rapid eating exhibited by three adults with Down syndrome residing in an independent supported living facility. The results demonstrated that this treatment package increased the interresponse time between bites to criteria for all three participants.

Keywords: rapid eating, token economy, differential reinforcement, Down syndrome

Being overweight or obese is a socially signifi- cant problem in the United States that negatively affects both quality of life and longevity. Obesity is defined as having a body mass index (BMI) greater than the 95th percentile for age and sex ($30), whereas being overweight is defined by a BMI of 25–29. According to the Centers for Disease Con- trol and Prevention (CDC, 2019), 71.6% of adults over the age of 20 in the United States are over- weight or obese. Individuals withDown syndrome (DS) are at greater risk of being overweight and obese and more likely to experience secondary

health conditions than their nondisabled peers (World Health Organization, 2010). Obesity rates for children with DSwere reported at 47.8%, com- paredwith the general pediatric population that had an obesity rate of 12.1% (Basil et al., 2016). When combining overweight and obesity in children with DS, prevalence rates were as high as 70% (Bertapelli et al., 2016), compared with 18.5% in typically developing children (CDC, 2019). Increased overweight and obesity rates in individ- uals with DS contribute to a higher prevalence of cardiovascular and respiratory disease, diabetes, and cancer (World Health Organization, 2010); obstructive sleep apnea (Basil et al., 2016); and reduced life expectancy (Patja et al., 2000). Biological factors are important determinants of

BMI in individuals with DS. For example, individ- uals with DS have reduced metabolic rates. Even when controlling for other biological differences, individuals with DS burn fewer calories than their non-DS peers (Murray & Ryan-Krause, 2010). Additionally, individuals with DS are likely to ex- periencedifferences in their endocrine systemcom- pared with non-DS peers. Leptin is a hormone that regulates appetite andweight.Higher rates of leptin resistance are observed in individuals with DS,

This article was published Online First June 10, 2021. Brandon K. May https://orcid.org/0000-0001-8445-

8841

Informed consent was obtained from all individual participants included in the study. Both authors declare no conflicts of interest. Procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Correspondence concerning this article should be addressed to Brandon K. May, Department of Psychiatry, Washington University, St. Louis 660 S. Euclid Avenue, St. Louis, MO 63110, United States. Email: [email protected]

273

Behavior Analysis: Research and Practice © 2021 American Psychological Association 2021, Vol. 21, No. 3, 273–281 ISSN: 2372-9414 https://doi.org/10.1037/bar0000213

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which may increase caloric consumption during meals (Magge et al., 2008). The thyroid produces hormones that regulate themetabolism of proteins, carbohydrates, and lipids. Hypothyroidism is the secondmost commonmedical condition in individ- uals with DS and includes clinical symptoms such as weight gain, fatigue, weakness, constipation, delayed growth, and hypotonia (Artioli, 2017). In addition to the biological factors outlined previ- ously, behavioral patterns are associated with increasedobesity rates in individualswithDS. Eating patterns represent both a functional cause

of overweight and obesity (Otsuka et al., 2006) and an intervention target (Hausman & Kahng, 2015) for individuals withDS. Nutritional treatments that have been recommended for individuals with DS include food education and the provision of a bal- anced and healthy diet. However, more studies are needed to evaluate the efficacy of nutritional inter- ventions in individualswithDS(Artioli, 2017). Rapid eating has long been reported as a concern

in thepopulationof individualswithdevelopmental disabilities. An early report by Favell et al. (1980) estimated the prevalence of rapid eating at 28% for this population.More recent research has also iden- tified that rapid eatingmay be problematic for indi- viduals with developmental disabilities (e.g., Anglesea et al., 2008; Echeverria & Miltenberger, 2013; Valentino et al., 2018; Wright & Vollmer, 2002), although prevalence rates were not esti- mated. Rapid eating is associated with overeating (Azrin et al., 2008) and health problems, including obesity (Otsuka et al., 2006), choking (Wright & Vollmer, 2002), vomiting, and aspiration (Kedesdy &Budd, 1998). Eating at a slower pace is a recom- mended strategy for reducing caloric consumption because it allows hormones to be secreted to indi- cate satiety (Andrade et al., 2008). This relation may be especially important for individuals with DS, who are already at increased risk of hormonal differences (Magge et al., 2008) andmetabolic dys- regulation (Murray & Ryan-Krause, 2010). For example, eating at a slower pace has been associ- ated with increased blood glucose and ghrelin lev- els (Sobki et al., 2010), both of which have been associated with reductions in caloric intake during meals (Andrade et al., 2008). This finding implies that eating more slowly represents an intervention target for overeating and obesity. Given the poten- tial impact of rapid eating and the health benefits of eating at a slowerpace, interventions that remediate rapideatingarecritical.

Severaldifferent studieshaveusedbehavior ana- lytic approaches to reduce rapid eating. Valentino et al. (2018) implemented a vibrating timer system to reduce rapid eating in a child with autism spectrum disorder (ASD) and successfully faded the intensity of vibrations while maintaining an appropriateeatingpace.Epsteinet al. (1976) imple- mented a differential reinforcement of incompati- ble behavior (DRI) program to reduce the rapid eating displayed by six children. During this inter- vention, the researchers instructed, and provided praise for, theparticipants to set their eatingutensils on the table between bites. Bite rate and food con- sumedwereboth reducedduring this intervention. Differential reinforcement of low rates of behav-

ior (DRL) procedures have also been used by sev- eral researchers to reduce rapid eating, both with andwithout the useof timers. For example,Lennox et al. (1987) examined the use of a spaced-respond- ing DRL procedure among three adults with pro- found intellectual disabilities. Attempts to take a bite before the 15-s interval elapsed resulted in response blocking and resetting of the interval. Physical prompting coupled with a vocal prompt was necessary to produce clinically acceptable reductions ineatingpace for twoof the threepartici- pants. Favell et al. (1980) provided verbal praise andbitesofpreferred foodscontingentongradually increasing the interresponse time (IRT) between bites in four adults with developmental disabilities. Response blocking was necessary for participants to initially contact the reinforcement contingency; however, prompts were then faded from physical blocking paired with a vocal prompt to the vocal prompt alone. The DRL procedure has also been effective incombinationwitha timer. Wright and Vollmer (2002) also employed a

DRL procedure to reduce the pace of eating in an adolescent female with developmental disabilities. An adjusting DRL based on mean IRT was intro- duced. This approach gradually reinforced longer IRT durations between bites. An audible timer was used to signal the end of the 15-s interval. Attempts to take a bite prematurely resulted in the same response blocking and redirection techniques used byLennox et al. (1987), pairedwith a vocal prompt to“eat slowly”and the resettingof the interval.This procedure was effective in increasing the IRT to the 15-s mark, and eventually, prompts were faded to only the vocal prompt issued after each bite. Both Lennox et al. (1987) and Wright and Vollmer (2002) reported higher rates of malad- aptive behaviors, including tantrums and self-

274 MAY AND CATRONE

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injurious behavior, as a result of the response- blocking component of treatment. Anglesea et al. (2008) evaluated the use of a

vibrating pager to prompt an appropriate eating pace in three teenagers with autism. Participants wore an active vibrating pager, which vibrated ev- ery 10–25 s, andwere taught to take a bitewhen the pager vibrated. This training involved physical prompting to place the hand on the pager; physical guidance to take a bite when the pager buzzed, coupled with praise for doing so; and response blocking of premature bites with redirection to place the hand back on the pager. All participants learned to eat to the pace of the pager within five training sessions, and mealtime duration was increased. In a study by Echeverria and Miltenberger

(2013), two adult participants with moderate intel- lectual disabilities learned to eat to the pace of the pager using modeling, physical and vocal prompt- ing, response blocking, and praise. Researchers then evaluated apager-alone condition and apager- plus-verbal-prompts condition. In the pager-alone condition, the participant wore the vibrating pager and received praise for eating to the pace of the pager. In the pager-plus-verbal-prompts condition, apromptwas issuedwhen theparticipant attempted to take a bite before the vibration. The results showed that the verbal prompt was necessary in order to achieve desirable outcomes. Page et al. (2017) implemented a similar procedure that also includeda timerplusa rule toeatonlyafter the timer vibrated. A vocal prompt issued when the partici- pant attempted to take a bite before the timer vibratedwas necessary to increase the IRT to target levels. Token economies are generalized conditioned

reinforcement systems in which tokens (e.g., stick- ers, poker chips, tally marks) are provided contin- gent on the demonstrationof target behaviors.Over the past few decades, token reinforcement systems have been utilized to increasemyriad target behav- iors in individuals with developmental disabilities, including behaviors to promote physical fitness. Token reinforcement systems have been utilized to increase walking frequency (Krentz et al., 2016), pedaling rate on an exercise bike (Bennett et al., 1989), and exercise intensity during treadmill exer- cise (May&Treadwell, 2020) in adultswith devel- opmental disabilities. Token reinforcement has also demonstrated efficacy in improving mealtime behavior (Sisson & Dixon, 1986). Rosenstein and Price (1994) increased total duration to meal

completion by providing tokens contingent on eat- ing meals at a specified pace. Token reinforcement schedules were thinned while maintaining an appropriate eating pace, suggesting that this is an effective approach to the reduction of rapid eating. Given the previous efficacy of the use of token economies, DRL, and timer systems, the current study combined these strategies to increase the IRT between bites to target criteria without the use of response-contingentblocking.

Method

Participants

Three participants with DS residing in an inde- pendent supported living (ISL) facility for high- functioning adults with developmental disabilities participated in this study. Table 1 reports the demo- graphic information for the participants. As part of admissions criteria to the ISL, participants were required to secure employment or a volunteer posi- tion for 20 hr per week, self-administer medication with minimal oversight, and communicate needs effectively (hunger, pain, preferred item manding, etc.). Eachof the three participantswas classified as obese (BMI .30) and was referred for this inter- vention by their case manager due to rapid eating. Participants had participated in a token economy targeting physical health for approximately 1 year prior to implementing this study, but interventions targeting eatingpacehadnotbeen implemented.

Setting

The ISL campus consisted of two buildings: the commons and the residential apartments. At 4,700 square feet, the Commons Building was con- structed of two floors and included a living room, recreation room, arts and crafts room, library, media room, staff offices, a community kitchen and attached dining room, exercise room, and rest- rooms. The kitchen consisted of two industrial-size

Table 1 Participant Demographic Information

Participant name Age

Biological gender Height Weight BMI

Marley 42 F 4 011} 193 39 Sloan 26 F 5 04} 197 33.8 Nala 40 F 5 05} 182 30.3

Note. BMI = body mass index.

REDUCING RAPID EATING 275

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refrigerators, two stoves, two ovens, and a large island that contained two sinks and two dish- washers. The attached dining room included four rowsof tables and chairs, each seatingup to20peo- ple. The community token board was positioned at eye level on a wall of the entryway to the kitchen andattacheddining room.

Response Definitions

A bite was defined by closing of the lips around food. For the purpose of measuring IRT, the time between the closing of lips around one bite of food to the closing of the mouth around the next bite of food was measured. Consistent with previous research on eating pace, rapid eatingwas defined as bites that occurred with an IRT between bites of less than 15 s and was recorded based on the dura- tion between each bite. Mean (M) IRT was calcu- lated at the conclusion of the meal by adding the total IRTdurationanddividingby total bites.

Staff Training Procedures

Staff participated in a 1-hour behavior skills training (BST) to learn how to implement all procedures included in the treatment package. During the didactic portion of the training, staff members were instructed to implement the fol- lowing procedures: (a) Inform each participant of their target IRT prior to the session, (b) set and reset the timer following each bite, (c) re- cord the IRT following each bite, (d) average the IRT duration per bite for the dinner, and (e) implement the token contingency. All tasks weremodeled by the experimenter in a role-play scenario. Staff then performed the task, and feedback was provided. A task analysis was posted near the token board as a written prompt for the staff members to implement with proce- duralfidelity.

Staff Demographics

Eight direct support staff employed by the ISL facility were responsible for the implemen- tation of this procedure. Direct care staff ranged from 27 to 50 years of age (M = 34.2) and had a range of 2–28 years of experience in a related field (M = 7.3). Two staff members held an asso- ciate’s degree, one held a bachelor’s degree, and five held amaster’s degree.

General Procedures

Sessionsoccurredduringdinner acrossall condi- tions. Dinner was selected due to the structured na- ture of this meal because participants sat together for a family-style meal each evening. This allowed for more systematic implementation of this proce- dure. The staff member responsible for the imple- mentation of this procedure rotated each shift, and assignmentswerepostedona staff schedule located adjacent to the token board. Participants could earn one token per dinner contingent on eating with a mean IRT above that session’s criterion. Thus, par- ticipants couldearnup to seven tokensperweek.

Baseline Procedures

During the baseline condition, IRT was meas- ured between bites of food during dinner. No feed- back or tokens were provided to participants. This condition continued until steady-state responding wasachieved.

Timer and DRL Procedures

During intervention, a timer was set to the target IRT for the given session (e.g., 10 s). The partici- pant was instructed to wait until the timer sounded prior to taking the next bite of food. The timer was reset once the participant took the next bite of food. ADRLwas implemented in which verbal praise (e.g., “Nice job eating slowly”) was provided contingent on each bite taken after the timer sounded. If participants took a bite prior to the timer sounding, verbal praise was withheld and corrective feedbackwas provided (e.g., “You are eating too fast”), but responseswere not blocked.

Token Reinforcement Procedures

Token implementation included placing a token on the token board contingent on eating at the assigned IRT during dinner or placing an “X” on the tokenboard if theparticipant ate faster than their targeted pace. At the conclusion of dinner, IRTs weremeasured, and tokenswereprovidedby a des- ignated staff member if the participant’s average IRT during this meal was greater in duration than the prescribed duration. For example, if the pre- scribed IRT between bites was 10 s, the participant would earn a token if their average IRT between bites was greater than 10 s for the entirety of their meal. No announcements were made regarding participant token attainment. However, the token

276 MAY AND CATRONE

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board was visible to participants immediately fol- lowingdinner.

Token Exchange Procedures

Tokens were tallied and announced during a house meeting at the end of the week and could be exchanged at any time throughout theweek for pre- ferred items, contingent on staff availability. Tokens could be exchanged eachweek or saved for more expensive options. Participants often chose to exchange their tokens during this house meeting. The menu of preferred items/activities was devel- oped by the participants with staff support during individual and group interviews. Participants iden- tified a menu of options that included low-calorie snacks, $5gift cards toahealthy restaurant, one-on- one timewith staff, and so forth.

Previous Token Economy

All participants were involved in a token econ- omy targeting physical health behavior for 1 year prior to program implementation. Individual goals to increase water consumption, frequency of exer- cise, and so forth were targeted. Tokens were pro- vided each day contingent on meeting related goals. Eating pace was not targeted prior to this study.

Experimental Design

Anonconcurrentmultiple baseline across partic- ipants (Watson &Workman, 1981) was combined with a changing-criterion design (Hartmann & Hall, 1976; Kazdin, 1982) to systematically increase target IRTs during dinner. All target IRT targets are presented in Table 2. The first increase

frombaseline for each participantwas 10%.Subse- quent phases for all participants varied in length, and the duration IRT increased as a way to strengthenexperimental control. Increaseswerede- pendent on participant responding but required at least three consecutive data points at or above criteria before moving to the next target criterion (Kazdin, 1982). A return to baseline was also included to demonstrate that the programmed con- tingencies correlated with the change in target behavior, as recommendedbyKleinet al. (2017).

Integrity Procedures

Total count interobserver agreement (IOA) was assessed by having two independent experimenters record the IRT for each participant during 28.5%of dinners across participants and conditions. The total number of intervals in which the observers agreed on the duration between bites was divided by the total number of intervals, yielding a percent- age of agreement. IOAwas assessed at 89%.Treat- ment integrity was assessed during the session and via permanent product. Specifically, an independ- ent observer recorded whether the assigned staff member followed thesamefive-stepprocedureout- lined in theBSTprocedures in the staff training sec- tion. Treatment integrity was assessed during 28.5% of sessions and averaged 85% across the study.

Results

Mean IRT per bite per session is displayed for each participant in Figure 1. Data for all three participants showed a consistent grouping pat- tern around each criterion, including a reversal

Table 2 Mean Criterion IRT Between Bites for Each Participant

Nala Marley Sloan

Criterion IRT target Average IRT IRT target Average IRT IRT target Average IRT

Criterion 1 BL 6.91 BL 4.34 BL 2.55 Criterion 2 7.5 7.83 5 5.75 3 3.36 Criterion 3 10 10.88 7.5 7.88 4.5 4.33 Criterion 4 11 11.75 9 9.38 5.5 6.08 Criterion 5 BL 7.4 10 10.58 10 9.02 Criterion 6 13 12.21 BL 5.7 12.5 12.88 Criterion 7 15 15.74 13 12.5 BL 4.67 Criterion 8 15 14.42 13.5 14 Criterion 9 15 15.4

Note. IRT = interresponse time; BL = baseline.

REDUCING RAPID EATING 277

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condition in which tokens were not provided contingent on eating pace. The results indicated that the treatment packagewas effective in shap- ing the IRT per bite to the target duration of 15 s for all three participants, without the addition

of response blocking. Target criteria for Nala, Marley, and Sloan were achieved following seven, six, and five criteria changes plus a return to baseline. Table 2 displays the average IRT per bite for each criterion.

Figure 1 Mean Session Interresponse Time (Bites/Second) for Participants During Each Session

Note. BL = baseline.

278 MAY AND CATRONE

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Discussion

Previous research suggests that treatment procedures targeting eating pace may require the use of aversive procedures, such as response blocking, to reach criteria. The implementation of response-blocking procedures to reduce rapid eating increased rates ofmaladaptive behaviors, such as tantrums and self-injurious behavior, in multiple studies (e.g., Lennox et al., 1987; Wright & Vollmer, 2002). The current study evaluated the efficacy of a nonaversive treat- ment package consisting of a timer, DRL, and token reinforcement system without response blocking. The results demonstrate that IRT du- ration between bites can be safely and system- atically shaped in adults with DS without the need for aversive procedures, such as response blocking. This research also extends the appli- cation of token reinforcement to a new area of physical health behavior. Although this study omitted aversive contingen-

cies, such as response blocking, utilized in previous research (e.g., Lennox et al., 1987), two strategies implemented may have functioned as punishers. Placing an “X” on the token board for a given par- ticipant who did not meet IRT criteria on a given night was intended as a permanent product to aid treatment integrity. If tokens had not been posted at the conclusion of a given dinner, the difference between a staff omission and a participant not earn- ing a token couldnot be ascertained.Bymarking an “X,” experimenters could improve accurate data collection. However, the possibility exists that the mechanism for behavioral change was a negative- reinforcement contingency rather than the intended positive-reinforcement contingency. The correc- tive feedbackprovidedwhenparticipants took their nextbitemayhave functionedas a reprimand rather than a neutral feedback system depending on the individual’s learning history. Thus, participants may have been eatingmore slowly to avoid having an “X”placednext to their nameon the tokenboard or to avoid corrective feedback rather than to access the verbal praise and/or generalized conditioned reinforcer (tokens). The utility of the reduction of rapid eating is

to reduce caloric consumption during mealtime. Although this premise is well established in the physiological sciences (Andrade et al., 2008), including a measure of caloric consumption as a function of eating pace would have been benefi- cial towardmeasurement of the desired outcome

(e.g., obesity). This study would also have been strengthened by tracking physiological out- comes, such as weight, over the course of the study. A component analysis would aid in identify-

ing the functional mechanism of behavior change in future research. The treatment pack- age implemented in this study included a rule (to eat more slowly), a timer, a DRL with verbal praise or corrective feedback, and a token econ- omy. Separating the effects of each intervention may have produced a clearer demonstration of the effects. Additionally, a rule-only condition should be included following baseline and prior to token implementation. Although previous attempts to slow eating pace with these partici- pants had been unsuccessfully implemented by ISL staff prior to this study, which makes the likelihood of behavior change produced by a rule-only condition unlikely, demonstration of this should have been included. This intervention was time consuming for

direct support staff to implement. Because staff members were required to track and implement the DRL procedures for every bite of food, their complete and undivided attention was required for the entirety of dinner. This led to treatment integrity that was below desired standards. Future studies should focus on variations more readily implemented in applied settings (i.e., video modeling, self-monitoring) in order to increase treatment integrity and/or applicability to community providers. Previous research decreased the total duration of

mealtime (Murray & Ryan-Krause, 2010), and although this strategy would be more easily imple- mented in applied settings, the validity of such a procedure is not as precise. For example, if the total duration of mealtime is the measure, participants may eat rapidly until the last bite, then wait for the timer to sound. An extension in which participants monitored their own IRTduration between bites by setting and resetting the timer would have encour- aged results that would be more easily maintained andgeneralized tonovel settings. Despite the listed limitations, the current study

helps to aid in the utilization of DRL and token economies as a viable option for addressing rapid eating. Future researchwould be needed in order to fully understand the effects such interventionsmay have on a variety of populations and the interaction between these twomethodologies.

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280 MAY AND CATRONE

T hi sd oc um

en ti sc op yr ig ht ed

by th e A m er ic an

Ps yc ho lo gi ca lA

ss oc ia tio n or on e of its

al lie d pu bl is he rs .

T hi sa rt ic le is in te nd ed

so le ly fo rt he

pe rs on al us e of th e in di vi du al us er an d is no tt o be

di ss em

in at ed

br oa dl y.

Th is

d oc

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ReceivedAugust 24, 2020 Revision receivedFebruary5, 2021

AcceptedFebruary10,2021 n

REDUCING RAPID EATING 281

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