inappropriate meal time bx

A translational evaluation of renewal of inappropriate mealtime behavior

VIVIAN F. IBAÑEZ, CATHLEEN C. PIAZZA AND KATHRYN M. PETERSON

UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

The term renewal describes the recurrence of previously extinguished behavior that occurs when the intervention context changes. Renewal has important clinical relevance as a paradigm for studying treatment relapse because context changes are necessary for generalization and mainte- nance of most intervention outcomes. The effects of context changes are particularly important during intervention for pediatric feeding disorders because children eat in a variety of contexts, and extinction is an empirically supported and often necessary intervention. Therefore, we used an ABA arrangement to test for renewal during intervention with 3 children diagnosed with a feeding disorder. The A phase was functional reinforcement of inappropriate mealtime behavior in a simulated home setting with the child’s caregiver as feeder, B was function-based extinction in a standard clinic setting with a therapist as feeder, and the return to the A phase was function-based extinction in a simulated home setting with caregiver as feeder. Returning to Context A resulted in renewal of inappropriate mealtime behavior across children, despite the caregivers’ continued implementation of function-based extinction with high levels of integrity. Key words: feeding disorder, inappropriate mealtime behavior, generalization, maintenance,

pediatric feeding disorders, renewal, translational, treatment integrity

Researchers have identified context as one fac- tor that may influence generalization and long- term maintenance of intervention outcomes (e.g., Kelley, Liddon, Ribeiro, Greif, & Podlesnik, 2015; Stokes & Baer, 1977). Researchers describe context as the exteroceptive stimuli associated with learning, such as an experimental chamber, a color, or an odor (e.g., Kincaid, Lattal, & Spence, 2015), and contextual control as the condition under which learning occurs (Podlesnik, Kelley, Jimenez-Gomez, & Bouton, 2017). For example, Bouton and Bolles (1979) trained rats in Context A and extinguished responding in Context B, and associated each context with different

exteroceptive stimuli. When Bouton and Bolles returned the rats to Context A and continued extinction, the trained response returned, which Bouton and Bolles referred to as the renewal effect. Results of Bouton and Bolles (1979) suggest

that learning was specific to the context in which it occurred, and numerous researchers have demonstrated renewal of extinguished behavior in - respondent- (e.g., Bouton & King, 1983; Bouton & Peck, 1989; Bouton & Swartzentruber, 1989; Gunther, Denniston, & Miller, 1998; Nakajima, Tanaka, Urushihara, & Imada, 2000; Rauhut, Thomas, & Ayres, 2001) and operant- (Trask, Schepers, & Bouton, 2015) conditioning arrangements. In fact, Bouton, Todd, Vurbic, and Winterbauer (2011) suggested that operant extinc- tion is relatively specific to the context in which the organism learns that the response no longer produces reinforcement. Renewal has important clinical relevance as a

paradigm for studying treatment relapse. Relapse, when previously extinguished undesir- able behavior returns (Mace & Critchfield, 2010), is a common problem among individuals

This study was based on a dissertation submitted in partial fulfillment of the first author’s doctoral degree from the University of Nebraska Medical Center. We thank Wayne W. Fisher and Brian D. Greer for their helpful guidance throughout the study. We also thank Jaime G. Crowley, Tara J. Johnson, Caitlin A. Kirkwood, Holly M. Ney, Jocelin L. Merciez, and Ryan C. Ortega, for their assistance in completing this study. Vivian Ibañez is now at the University of Florida. Address correspondence to: Vivian Ibañez (vibanez@ufl.

edu) or Cathleen Piazza ([email protected]) doi: 10.1002/jaba.647

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2019, 52, 1005–1020 NUMBER 4 (FALL)

© 2019 Society for the Experimental Analysis of Behavior

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with behavioral-health disorders that negatively impacts the long-term effectiveness of interven- tion. Results of renewal studies suggest that extinguished behavior will return or relapse in the absence of a change in implemented contin- gencies simply by changing the context in which extinction occurs. Researchers have used a three- phase arrangement (ABA, ABC, or AAC) to study renewal, in which a reinforcement phase in Context A is followed by two phases of extinction in either Contexts B and A in ABA renewal, in Contexts B and C in ABC renewal, or in Contexts A and C in AAC renewal. The focus of these arrangements is the pattern of responding associated with the context changes. For example, Kelley et al. (2015) conducted a translational study in which researchers provided reinforcement to participants for task comple- tion in Context A, extinguished task completion in Context B, and continued extinction in Context A. Although task completion decreased to zero during extinction in Context B, responding increased during extinction in the return to Context A. Researchers also have demonstrated renewal with ABC and AAC arrangements, but the ABA arrangement pro- duces the most robust demonstrations of renewal (Podlesnik et al., 2017). Despite the clinical relevance of renewal to

behavioral-health disorders, few studies have evaluated operant renewal with a socially signif- icant problem like pediatric feeding disorders. Pediatric feeding disorders are an excellent sub- ject for a variety of reasons. Basic studies show that context changes during extinction reliably produce renewal. Clinical studies on pediatric feeding disorders show that extinction is an empirically supported and often necessary inter- vention component (Volkert & Piazza, 2012). In addition, researchers have conducted most feeding intervention studies in clinic settings with highly trained therapists (e.g., Ahearn, Kerwin, Eicher, Shantz, & Swearingin, 1996; Babbitt, Hoch, & Coe, 1994; Gulotta, Piazza, Patel, & Layer, 2005; Kadey, Piazza, Rivas, &

Zeleny, 2013; Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005; Piazza, Fisher, et al., 2003; Volkert, Vaz, Piazza, Frese, & Barnett, 2011; Wilkins, Piazza, Groff, & Vaz, 2011), who then train caregivers to implement inter- vention. Even if the caregiver serves as the ini- tial change agent (Seiverling, Williams, Sturmey, & Hart, 2012; Tarbox, Schiff, & Najdowski, 2010), children feed in many con- texts, and teachers, relatives, or day-care pro- viders also may implement intervention. Although these factors suggest that we should expect renewal to occur, only one study has evaluated renewal systematically during inter- vention for pediatric feeding disorders (Kelley, Jimenez-Gomez, Podlesnik, & Morgan. 2018). Not only is the study of renewal in children

with feeding disorders relevant for the reasons cited above, it is particularly important for chil- dren with severe feeding problems, like those we admit to our day-treatment program. These children often have complex medical problems and oral-motor-skill deficits that may compro- mise their health and safety during oral feeding. Thus, these children warrant initial interven- tion in a setting where professionals can closely monitor the child. For this reason, trained ther- apists implement intervention initially with our day-treatment patients. Using therapists as change agents also allows us to ensure high levels of integrity during initial intervention and to determine whether the intervention is efficacious before we ask caregivers to imple- ment it. After we demonstrate intervention effi- cacy, we train caregivers, generalize the intervention to the home and other settings (e.g., daycare), discharge the child from the day-treatment program, and admit the child to the outpatient program. When caregivers implement the intervention in the home after discharge from the day-treatment program, they sometimes observe relapse. This relapse is particularly frustrating for caregivers if they are implementing the intervention with high integ- rity. Our experience is that caregivers are more

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likely to discontinue or change the interven- tion, drop out of therapy, or both during periods of relapse. Relapse is particularly con- cerning for children with severe feeding disor- ders because inadequate calories, hydration, and nutrition can have short- and long-term negative effects on behavior, development, and health (Freedman, Dietz, Srinivasan, & Beren- son, 1999). Therefore, a better understanding of relapse, with the long-term goal of mitigat- ing it, is critical for the treatment of severe feeding disorders. To that end, we tested for ABA renewal in

the current study, in which A was functional reinforcement of inappropriate mealtime behavior in a simulated home setting with the child’s caregiver as the feeder, B was function- based extinction of inappropriate mealtime behavior in a standard clinic setting with a clinic therapist as feeder, and a return to A was function-based extinction in the simulated home setting with the child’s caregiver as the feeder.

METHOD

Participants Participants were patients in an intensive

day-treatment feeding program Monday through Friday from about 9:00 am to about 5:00 pm. Carlos was a 3-year-old boy whose diagnoses included autism spectrum disorder, apraxia, global developmental delays, and food selectivity. At the time of admission, Carlos reportedly received 100%, 209%, and 46% of his daily calories, protein, and fluids, respec- tively, via 8-oz sippy-cup feedings of Pediasure with Fiber at 7:30 a.m., 12:00 p.m., and 5:30 p.m., and via McDonald’s chicken nug- gets, graham crackers, Kellogg’s Eggo Bites Chocolatey Chip Pancakes, and Idahoan Four Cheese mashed potatoes. Our program’s regis- tered dietician estimated that Carlos’ intake of nutrients was adequate only due to his con- sumption of Pediasure with Fiber. Carlos’

caregiver was the referral source. Fernando was a 3-year-old boy whose diagnoses included bot- tle dependence; food refusal; allergies to soy, dairy, and gluten; colitis; chronic diarrhea; speech delays; and a history of pneumonia. At the time of admission, Fernando reportedly received 78%, 146%, and 66% of his daily cal- ories, protein, and fluids, respectively, via 8-oz sippy-cup feedings of Elecare Jr. mixed with almond milk at 8:00 a.m., 12:00 p.m., 6:00 p. m., and 7:00 p.m., and via small amounts of crackers, fruit snacks, and applesauce. Our pro- gram’s registered dietician estimated that Fernando’s mean intake was low in vitamins D and K, pantothenic acid, phosphorous, and potassium. Fernando’s pediatrician referred him for bottle dependence and food refusal. Pierre was a 4-year-old boy whose diagnoses included gastrostomy-tube dependence; gastroesophageal reflux disease and a history of vomiting, which resulted in a Nissen Fundoplication; tetralogy of fallot; and pulmonary atresia. At the time of admission, Pierre reportedly received 71%, 137%, and 102% of his daily calories, protein, and fluids, respectively, via 3.5-oz gastrostomy- tube feedings of a caregiver-prepared blended- food diet every 30 min from 7:30 a.m. to 9:00 p.m., delivered via gravity at 100 mL per hour. Our program’s registered dietician esti- mated that Pierre’s mean intake met 100% of his nutritional needs only due to gastrostomy- tube feedings of a blended-food diet, and that his growth was inadequate. Pierre’s pediatrician referred him for gastrostomy-tube dependence. Lorenzo was a 2-year-old boy whose diagnoses included gastrostomy-tube dependence, vomiting, failure to thrive, gastroesophageal reflux disease, hypercalcemia, developmental delays, and a history of prematurity. At the time of admission, Lorenzo reportedly received 100%, 148%, and 54% of his daily calories, protein, and fluids, respectively, via 5-oz gastrostomy-tube feedings of Pediasure 1.5 at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p. m., delivered via pump at 200 mL per hour.

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Our program’s registered dietician estimated that Lorenzo’s intake of nutrients was adequate only due to his consumption of Pediasure 1.5. Lorenzo’s pediatrician referred him for gastrostomy-tube dependence. Before the current study, each child partici-

pated in an interdisciplinary evaluation conducted by a dietitian, a pediatric gastroenterologist, mas- ter’s and bachelor’s level feeders with specialized training in feeding and behavior analysis, a psy- chologist, and a speech and language pathologist to confirm the safety of oral feeding.

Feeders Clinic therapists conducted sessions during

the functional analysis and during the B phase of the renewal analysis in the solids and liquids standard clinic settings. Caregivers who con- ducted sessions in the A phases of the analysis were the participants’ biological mothers.

Settings and Materials We conducted sessions in three settings in a

university-based tertiary care facility. Settings contained utensils, food trays, a scale, and timers. The solids and liquids standard clinic set- tings were 4-m x 4-m therapy rooms in a pedi- atric feeding disorders clinic. These rooms contained one-way observation windows, a rectangular table, a sanitizer dispenser on the wall, and a chair. The solids simulated home set- ting was in a semiprivate area of an early inter- vention clinic. This room contained a square table with a red table cloth, a table lamp, a compact refrigerator, a coffee maker, a small pantry shelf containing a variety of foods (e.g., chips, applesauce), a variety of home dec- orations (e.g., a framed photo of a family, a bowl of plastic fruit, a painting hung on the wall, artificial flowers in a vase), striped curtains that covered two freestanding room partitions, and a chair. The liquids simulated home setting was in a kitchen of a recreational therapy pro- gram. This room contained a large table with

chairs, materials in a typical kitchen (e.g., full- size refrigerator, toaster, stove, blender, stand mixer, a counter with snacks, pots, pans), and a chair. Carlos sat in a Special Tomato Soft- Touch sitter that we secured to a regular chair. Fernando and Lorenzo sat in a high chair. Pie- rre sat in a booster seat. We asked the caregiver to select eight target

foods from a list provided by the first author that the child did not eat currently, but that the caregiver wanted the child to eat. Generally, we targeted two foods from each of the food groups of fruits, proteins, starches, and vegeta- bles, or foods from the food group(s) that con- tained nutrients for which the child’s diet was deficient per our program’s dietitian. We also incorporated dietary recommendations from other professionals, such as the child’s physi- cian, when appropriate. The feeder presented the foods at a pureed texture, which is table food blended in a blender until smooth with liquid added as needed. The bolus size was a level small maroon spoon for all children. The caregiver also selected a liquid such as Pediasure or milk that the child did not currently con- sume orally and that was calorically and nutri- tionally appropriate for the child per our program dietitian. The feeder presented 2 cc of liquids in a pink cut-out cup.

Dependent Variables, Reliability, and Procedural Integrity Trained observers sat in a room with one-way

observation windows adjacent to the therapy room during standard clinic-setting sessions and in an unoccupied therapy room or a private office in the clinic during simulated home-setting ses- sions. Observers used Vidyo, a HIPAA-compliant telehealth video conferencing platform, to watch simulated home-setting sessions on iPads, one of which was in the simulated home setting and one of which was in the room with the observer. Observers used laptop computers to collect data using the DataPal 1.0 program.

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Observers scored inappropriate mealtime behavior when the utensil was in arm’s reach of the child and the child turned his head 45� or greater away from the utensil during a bite or drink presentation; used his hand to contact the utensil, food or drink, or the feeder’s hand or arm anywhere from the elbow down while the feeder was presenting the bite or drink; threw food, liquids, or utensils; or blocked his mouth with his hand, bib, or toys. Observers scored acceptance when the child opened his mouth in the absence of inappropriate meal- time behavior or leaned forward and opened his mouth while engaging in negative vocaliza- tions such that the feeder deposited the entire bite except for food or drink of pea size or smaller, within 5 s of presentation. A presenta- tion occurred when the feeder touched the midline of the child’s lips with the utensil. Observers recorded whether acceptance

occurred during each bite presentation and fre- quency of inappropriate mealtime behavior. We converted acceptance to a percentage after dividing the number of acceptances by the number of bite or drink presentations. We converted the frequency of inappropriate meal- time behavior to responses per minute by dividing the number of inappropriate mealtime behaviors during the session by the duration the utensil or bite was in arm’s reach. At least one observer scored feeder proce-

dural integrity for correct context, correct uten- sil presentation, incorrect praise, and incorrect attention during 87% of sessions. Observers wrote a yes or a no on an excel spreadsheet to indicate whether the feeder conducted the ses- sion in the correct context, as described above. We converted correct context to a percentage by dividing the instances of correct context by the total number of sessions. Mean correct con- text was 100% across participants. Observers scored duration of correct utensil

presentation by pressing a key on the data- collection program that activated a timer when the feeder met the criterion for correct spoon

presentation and pressed the key, which deactivated the timer, if the feeder did not meet the criterion for 3 s or more. Observers scored correct utensil presentation when the feeder (a) presented the utensil to the child’s lips; (b) removed the utensil after the bite or drink entered the child’s mouth; and (c) presented the next bite or drink approximately 30 s after the previous bite or drink entered the child’s mouth, except as indicated below. Observers scored cor- rect utensil presentation during function-based extinction when the feeder (a) held the utensil touching the child’s lips until the child opened his or her mouth and allowed the feeder to deposit the bite or drink; (b) left the utensil touching the child’s lips if the bite of food or drink did not remain on the utensil and the feeder needed to obtain another bite or drink; (c) deposited the bite or drink when the child opened his or her mouth; (d) held the utensil to the side of the child’s lips if the child vomited, coughed, or gagged while the feeder was holding the utensil at the child’s lips; (e) scooped up expelled food or liquid within 3 s of expulsion (any food or liquid larger than a pea passed the plane of the lips after the feeder deposited the bite or drink) and placed the utensil with the bite or drink back to the child’s lips. Observers also scored correct utensil presentation during function-based extinction if the child was engag- ing in expulsion when it was time for the feeder to present the next bite or drink and the feeder presented the next bite or drink when the expelled food or liquid remained in the child’s mouth for 3 s. The criterion for correct utensil presentation was relatively conservative because (a) the feeder had to keep the utensil touching the child’s lips, which can be difficult during ini- tial escape-extinction sessions; and (b) observers stopped the correct utensil placement timer for any 3-s deviation from the protocol. We converted duration of correct utensil presentation to a percentage after dividing the duration of cor- rect utensil presentation by the session duration. Mean correct utensil presentation was 98%

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(range, 97% to 100%) and 94% (range, 93% to 100%) across therapists and caregivers, respectively. Observers scored the occurrence of incorrect

attention during function-based extinction each time the feeder provided attention (e.g., repri- mands, coaxes) within 3 s of inappropriate meal- time behavior (Borrero, Woods, Borrero, Masler, & Lesser, 2010). We divided the occur- rences of incorrect attention by the number of inappropriate mealtime behaviors and converted the ratio to a percentage. Mean incorrect atten- tion was 0% and 3% (range, 0% to 5%) across therapists and caregivers, respectively. Observers scored incorrect praise if the

feeder did not provide behavior-specific praise within 5 s of acceptance and mouth clean, pro- vided praise when bites or drinks entered the mouth after 5 s, or when there was food or liq- uid larger than the size of a pea in the mouth at the time of mouth check. We converted incorrect praise to a percentage after dividing the instances of incorrect praise by the total opportunities to provide correct and incorrect praise. Feeders provided incorrect praise during a mean of 0% and 4% (range, 0% to 6%) of opportunities across therapists and caregivers, respectively. A second observer simultaneously, but inde-

pendently, scored a mean of 87% of sessions. We trained observers before the study to collect data with greater than 85% interobserver agree- ment for three consecutive sessions. The Dat- aPal Reli 1.0 software calculated interobserver agreement by partitioning each session into 10-s intervals. DataPal calculated total agree- ment coefficients for acceptance, correct utensil presentation, incorrect attention, and incorrect praise by dividing the number of agreements (defined as both observers scoring or not scoring an occurrence of the behavior in the interval) by the total number of agreements plus disagreements and converting this ratio to a percentage. Mean interobserver agreement across participants was 98% (range, 93% to

100%) for acceptance, 95% (range, 92% to 98%) for correct utensil placement, 97% (range, 95% to 98%) for incorrect attention, and 98% (range, 96% to 99%) for incorrect praise. We calculated interobserver agreement for correct context by dividing the smaller number by the larger number and converting the ratio to a percentage. Mean interobserver agreement across participants was 100% for correct context. DataPal calculated exact agree- ment coefficients for inappropriate mealtime behavior by dividing the number of exact agreements (defined as observers scoring the same frequency of the behavior in the interval) by the number of exact agreements plus dis- agreements and converting this ratio to a per- centage. Mean interobserver agreement across participants was 93% (range, 92% to 96%) for inappropriate mealtime behavior.

Experimental Design We used a pairwise design (Bachmeyer

et al., 2009; Iwata, Duncan, Zarcone, Lerman, & Shore, 1994) for the functional analysis to compare levels of inappropriate mealtime behavior in the test (escape, atten- tion, tangible) versus the control conditions. For the renewal evaluation, we used a three- phase arrangement (i.e., ABA) embedded in a nonconcurrent multiple baseline design across participants during solids and liquids sessions. During Context A, the child’s caregiver deliv- ered functional reinforcement contingent on inappropriate mealtime behavior in a simulated home setting. During Context B, the clinic therapist conducted function-based extinction in a standard therapy room. During a return to Context A, the child’s caregiver conducted function-based extinction in the simulated home setting.

General Procedure Each child followed an individualized sched-

ule of five 40-min meals a day with at least

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40 min between the end of one meal and the beginning of the next. The feeder presented solids in some meals and liquids in other meals, but did not present solids and liquids together in the same meal. The feeder conducted multi- ple four-bite or four-drink sessions in each meal. The number of sessions per meal depended on the duration of each session within the meal (i.e., the duration of a single session depended on the child’s behavior). There were approximately 1-min breaks between sessions, during which feeders and observers prepared for the next session (e.g., recorded gram consumption, set up data- collection computer program). Before each meal with solid food, the feeder

randomly selected one caregiver-selected food from each of the food groups of fruit, protein, starch, and vegetable, to present during the ses- sions. The feeder randomly selected the order in which to present the four foods before each session. The feeder used the same foods and presented them in the same order when he or she alternated between conditions (i.e., pairwise functional analysis). The feeder presented every caregiver-selected food in each phase and in every condition to control for potential differ- ences in the child’s behavior as a function of food type (Patel, Piazza, Santana, & Volkert, 2002). The feeder presented a bite or drink by

touching the child’s lips with the utensil and saying, “Take a bite (drink).” The feeder pres- ented a bite or drink approximately 30 s after they had presented or deposited the previous bite or drink, depending on the child’s behavior. Contingent on food acceptance, the feeder pro- vided praise and activated a timer for 30 s. The feeder conducted a mouth check when 30 s elapsed by saying, “Show me, Ahh” while modeling an open mouth. The feeder inserted a rubber-coated baby spoon between the child’s lips and turned it 90� if the child did not open his mouth within 3 s of the verbal and model prompt. The feeder provided praise

(e.g., “Great job swallowing your bite!”) for mouth clean, defined as no food or liquid in the mouth larger than the size of a pea. The feeder delivered a verbal prompt to “Swallow your bite (drink)” if any food or liquid larger than the size of a pea was in the child’s mouth at the 30-s check. The feeder conducted a mouth check every 30 s until no food or liquid larger than the size of a pea was in the mouth or until 10 min had elapsed from the start of the session if the child had food or liquid larger than the size of a pea in their mouth during the mouth check for the fourth bite or drink. However, observers did not score mouth clean or pack for these subse- quent mouth checks. The feeder provided no differential consequence for coughing, gagging, or vomiting.

Functional Analysis We asked each caregiver to feed her child as

she would at home before we conducted the functional analysis, and we used our direct observations of caregiver-fed meals and care- giver report to inform the conditions of each child’s functional analysis. For example, a ther- apist conducted escape, attention, and tangible conditions if we observed that the caregiver delivered escape, attention, and a tangible after inappropriate mealtime behavior, but only escape and attention conditions if we observed the caregiver deliver escape and attention. A therapist conducted a functional analysis of inappropriate mealtime behavior with solids for Carlos, Pierre, and Lorenzo and with liquids for Carlos, Fernando, and Lorenzo using proce- dures described by Bachmeyer et al. (2009).

Renewal Evaluation The feeder followed the general procedure

described above in addition to the specific pro- cedure described below. Only the child and the caregiver were in the simulated home setting, and no one entered the room during meals. The caregiver transitioned the child to the

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simulated home setting, without the therapist, in phases in which the caregiver was the feeder so the therapist would not be associated with the simulated home setting. Finally, the change from Context A reinforcement to Context B and the change from Context B to Context A extinction always occurred on the same day. We trained the caregiver to implement the

reinforcement procedures for Context A and the extinction procedures for Context B prior to the sessions by first having caregivers observe the therapist conduct most sessions of the functional analysis and function-based extinction interven- tion. For these observations, the caregiver entered the observation room after his or her child trans- itioned to the therapy room and remained in the observation room until the child transitioned to another location such that the child could not see the caregiver enter or leave the observation room. Next, we provided training in one-to-one meetings between the first author and the care- giver. These meetings occurred in a therapy room in the absence of the child. After describ- ing the procedures, one therapist modeled proto- col implementation by presenting bites or drinks to another therapist who played the role of a child. The caregiver then practiced the proce- dures by feeding a therapist who played the role of a child while the first author provided coaching and feedback. Role play continued until the caregiver implemented each protocol compo- nent at least twice with no errors. The caregiver wore a Bluetooth headset

through which the therapist provided ongoing coaching and feedback during Context A rein- forcement and Context B sessions to minimize the possibility that changes in rates of responding during the renewal test were affected by lapses in caregiver treatment integ- rity (St. Peter Pipkin, Vollmer, & Sloman, 2010). The therapist provided specific praise for correct performance, reminders for upcom- ing protocol components (e.g., mouth check in 5 s), and corrections for errors (e.g., provide specific praise), if necessary.

Context A reinforcement. Caregivers served as feeders for solids sessions with Carlos, Pierre, and Lorenzo and for liquids sessions with Car- los, Fernando, and Lorenzo in the simulated home settings described above. The feeder followed the general procedure and delivered functional reinforcement for 30 s if the child engaged in inappropriate mealtime behavior in a manner like that described for the functional analysis. Functional reinforcement was escape for Lorenzo (liquids); escape and attention for Carlos, Fernando, and Pierre; and escape, attention, and tangible for Lorenzo (solids). Before the caregiver and child transitioned to the simulated home setting, therapists prepared the materials for the meal (e.g., food) and placed them and the Bluetooth equipment and iPad in the room, opened the virtual room in the telehealth software, and tested the Bluetooth and telehealth equipment. Context B extinction. Therapists conducted

sessions in the standard clinic setting described above. The feeder conducted the general proce- dure and escape extinction for Lorenzo (liq- uids); escape and attention extinction for Carlos, Fernando, and Pierre; and escape, attention, and tangible extinction for Lorenzo (solids) based on the results of the child’s func- tional analysis. During escape extinction, the feeder kept the utensil touching the child’s lips until the child opened his mouth and allowed the feeder to deposit the bite or drink inside the mouth or until 10 min from the start of the session had elapsed. The feeder gently scraped the food on the child’s teeth with the spoon if the child did not close his mouth around the spoon when the feeder placed the spoon into the mouth. The feeder used the utensil to re-present expelled food or liquid, defined as any food or liquid larger than the size of a pea that exited the child’s mouth after entering the child’s mouth, by scooping up the food or liquid with the utensil as quickly as possible and placing it back in the mouth. If the child was expelling at the presentation

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interval for the next bite or drink, the feeder re-presented while prompting the child to, “Swallow your bite [drink]” approximately every 30 s until the bite or drink remained in the mouth for at least 3 s or the time-cap had been met. The feeder kept the utensil touching the child’s cheek and did not deposit the bite or drink if the child was coughing, gagging, or vomiting during the presentation until the child stopped coughing, gagging, or vomiting. Attention and tangible extinction consisted of the feeder no longer delivering attention or the tangible item when the child engaged in inap- propriate mealtime behavior. Context A extinction. The therapist prepared

session materials such as the child’s food and placed them in the room. Next, the caregiver transitioned the child to the therapy room as described above. Caregivers conducted function-based extinction as described for Con- text B but in the simulated home settings.

RESULTS

Figure 1 displays inappropriate mealtime behavior per minute for Carlos’ solids (top), Carlos’ liquids (middle), and Fernando’s liquids (bottom). During function-based reinforcement in Context A, inappropriate mealtime behavior was high and stable or increasing for Carlos’ solids (M = 101; range, 80 to 123), Carlos’ liq- uids (M = 95; range, 44 to 142), and Fernando’s liquids (M = 14; range, 0 to 50). During function-based extinction in Context B, inappropriate mealtime behavior was initially observed and then decreased to zero for Carlos’ solids (M = 32; range, 0 to 133) and liquids (M = 5, range, 0 to 29) and Fernando’s liquids (M = 5; range, 0 to 24). During the renewal test, inappropriate meal- time behavior immediately increased and then eventually decreased to zero for Carlos’ solids (M = 5; range, 0 to 37) and liquids (M = 4; range, 0 to 33). We observed a different pattern during the renewal test for Fernando’s liquids

(M = 20; range, 0 to 63). No inappropriate mealtime behavior occurred for three sessions, after which it increased and remained high and relatively stable during the last five sessions. Figure 2 displays percentage of acceptance

for Carlos’ solids (top), Carlos’ liquids (mid- dle), and Fernando’s liquids (bottom). During function-based reinforcement in Context A, percentage of acceptance for Carlos’ solids and liquids was at zero. Percentage acceptance for Fernando’s liquids was initially highly variable but became stable at zero for the last six ses- sions (M = 50%, range, 0% to 100%). During function-based extinction in Context B, per- centage of acceptance was initially low followed by an increase to high and stable levels for

Figure 1. Inappropriate mealtime behavior per minute for Carlos’ solids (top), Carlos’ liquids (middle), and Fernando’s liquids (bottom).

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Carlos’ solids (M = 54%; range, 0% to 100%), Carlos’ liquids (M = 75%; range, 0% to 100%), and Fernando’s liquids (M = 90%; range, 50% to 100%). During the renewal test, levels of acceptance initially decreased before increasing to high and stable levels for Carlos’ solids (M = 88%; range, 25% to 100%) and liquids (M = 82%; range, 25% to 100%). We observed high levels of acceptance for the first three sessions for Fernando’s liquids, followed by a decrease to zero (M = 22%; range, 0% to 100%). Figure 3 displays inappropriate mealtime

behavior per minute for Pierre’s solids (top), Lorenzo’s liquids (middle), and Lorenzo’s solids (bottom). During function-based reinforcement in Context A, inappropriate mealtime behavior

was high and stable for Pierre’s solids (M = 29; range, 14 to 50), Lorenzo’s liquids (M = 18; range, 3 to 56), and Lorenzo’s solids (M = 43; range, 6 to 60). During function-based extinc- tion in Context B, inappropriate mealtime behavior gradually decreased to zero for Pierre’s solids (M = 3; range, 0 to 23), Lorenzo’s liquids (M = 4; range, 0 to 15), and Lorenzo’s solids (M = 6; range, 0 to 44). During the renewal test, inappropriate mealtime behavior increased for Pierre’s solids (M = 9; range, 0 to 31), Lorenzo’s liquids (M = 5; range, 0 to 48), and Lorenzo’s solids (M = 18; range, 6 to 42). How- ever, inappropriate mealtime behavior eventually decreased to zero for Lorenzo’s liquids. Figure 4 displays percentage of acceptance

for Pierre’s solids (top), Lorenzo’s liquids

Figure 2. Percentage of acceptance for Carlos’ solids (top), Carlos’ liquids (middle), and Fernando’s liquids (bottom).

Figure 3. Inappropriate mealtime behavior per minute for Pierre’s solids (top), Lorenzo’s liquids (mid- dle), and Lorenzo’s solids (bottom).

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(middle), and Lorenzo’s solids (bottom). Dur- ing function-based reinforcement in Context A, percentage of acceptance was low and stable for Pierre’s solids (M = 1%; range, 0% to 25%), Lorenzo’s liquids (M = 0%), and Lorenzo’s solids (M = 0%). During function-based extinc- tion in Context B, percentage of acceptance gradually increased to high and stable levels for Pierre’s solids (M = 89%; range, 0% to 100%), Lorenzo’s liquids (M = 50%; range, 0% to 100%), and Lorenzo’s solids (M = 47%; range, 0% to 100%). During the renewal test, per- centage of acceptance initially decreased for Pierre’s solids (M = 75%; range, 25% to 100%), Lorenzo’s liquids (M = 53%; range, 0% to 100%), and Lorenzo’s solids (M = 19%; range, 0% to 50%). This initial decrease was

followed by variable levels of acceptance for Pierre’s and Lorenzo’s solids and by gradually increasing levels of acceptance for Lorenzo’s liquids. We calculated proportion of baseline to

allow researchers to make relative comparisons across studies that may not be possible with absolute measures such as the response rate we used in the current study. We calculated the proportion of baseline rates during extinction by dividing the rate of inappropriate mealtime behavior in the last session of function-based extinction in Context B by the mean of inap- propriate mealtime behavior during function- based reinforcement in Context A. Next, we calculated the proportion of baseline rates dur- ing the renewal test by dividing the first 21 ses- sions of function-based extinction in Context A by the mean of inappropriate mealtime behav- ior during function-based reinforcement in Context A. We used 21 to equate the number of function-based extinction sessions in Con- text A across participants because that was the fewest number of those sessions for any partici- pant. The proportion of baseline response rates was between 0 and 4.6 across children. See Supporting Information for individual partici- pant data on the proportion of baseline response rates.

DISCUSSION

Results of basic and translational research suggest that operant renewal is a reliable phe- nomenon when context changes occur during implementation of extinction. These context changes parallel what may occur in clinical set- tings when professionals attempt to transfer an intervention from one setting, such as a clinic, to another setting, such as the home. Thus, renewal serves as a paradigm for studying treat- ment relapse (e.g., Bouton, Todd, & León, 2014; Bouton et al., 2011; Kelley et al., 2015; Podlesnik et al., 2017). Clinicians have long recognized the problems associated with

Figure 4. Percentage of acceptance for Pierre’s solids (top), Lorenzo’s liquids (middle), and Lorenzo’s solids (bottom).

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treatment relapse, with researchers reporting rates as high as 80% for some behavioral-health disorders (Sahakian, 1983). Relapse is particu- larly concerning for children with severe feed- ing disorders given the significant negative consequences of inadequate calories, hydration, and nutrition (Freedman et al., 1999). To our knowledge, this is one of the first demonstra- tions of operant renewal for a socially signifi- cant problem, pediatric feeding disorders. Podlesnik et al. (2017) noted that context

typically refers to global features of the environ- ment such as visual, olfactory, and tactile stim- uli. In the current study, we defined context based on the feeder, the location, and the con- tent of the room, much like the approach described by Saini, Sullivan, Baxter, DeRosa, and Roane (2018). In the A phase of our renewal evaluation, caregivers delivered func- tional reinforcement for inappropriate mealtime behavior in a simulated home setting. We used a simulated rather than the actual home because families lived more than 50 miles from our clinic, so long-term in-home assessment and intervention was not practical. The B phase replicated our clinical practice in which thera- pists implemented function-based extinction of inappropriate mealtime behavior in our clinic. Finally, the caregiver implemented function- based extinction of inappropriate mealtime behavior in the simulated home setting in the renewal test. Assessing a single context change (e.g., from

a therapist to caregiver as feeder in the clinic) would have been a more parsimonious demon- stration of renewal. However, we wanted to assess renewal in the situation that caregivers report as most challenging for them and that we find most challenging to address, which is when renewal occurs in the home when the caregiver feeds. The caregiver and child are in clinic Monday through Friday from approxi- mately 9:00 am to 5:00 pm in the day- treatment program, and staff are physically pre- sent to support the caregiver. If renewal occurs,

we have many opportunities to observe care- giver and child behavior and modify the inter- vention, if necessary. By contrast, the caregiver and child attend the outpatient clinic via telehealth once or twice a week for 30 to 60 min per appointment. If renewal occurs during the outpatient program, staff are not physically present, and we have less empirical data on which we can base intervention deci- sions. Therefore, we chose to conduct the renewal test with the combination of contextual changes that we judged to be most meaningful to us and to families for promoting long-term maintenance of caregiver and child behavior. Rosas, Todd, and Bouton (2013) suggested

that context affects renewal, in part, because context provides information about the arranged contingencies. Results of our direct observations of caregiver-fed meals prior to the functional analysis were consistent with those of descriptive studies (Borrero et al., 2010; Piazza, Fisher, et al., 2003) and showed that caregivers delivered potential reinforcers for inappropriate mealtime behavior such as escape from bites or drinks, attention, and tangible items. The occurrence of renewal when we ret- urned the child to the simulated home setting with the caregiver feeding should not be sur- prising when we consider responding from the standpoint of discriminative control, because we established the caregiver and the simulated home setting as a signal for reinforcement of inappropriate mealtime behavior in the A phase. An alternative explanation of the findings is

that the child’s history of caregiver-delivered reinforcement of inappropriate mealtime behav- ior was responsible for the behavior change in the renewal test. Todd, Winterbauer, and Bouton (2012) showed that longer acquisition periods, which we could conceptualize as rein- forcement history, were associated with more renewal. Children in the current study had received reinforcement for inappropriate meal- time behavior from their caregivers for at least

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2 years before the study began. Thus, a change in feeder may have been sufficient to observe renewal as the caregiver’s presence may have been the most salient cue for reinforcement availability (Saini et al., 2018). Caregiver intervention integrity is another

factor that may have affected the increases in inappropriate mealtime behavior during the renewal test, because caregiver intervention integrity was lower than that of therapists (M = 94% vs 97%). Some researchers have used 85% as an acceptable level of caregiver intervention integrity (e.g., Marcus, Swanson, & Vollmer, 2001); however, the necessary level of intervention integrity to obtain treatment effects likely varies depending on the indepen- dent variable(s) and on the systems used to measure integrity. To evaluate further the effects of implementation integrity on child behavior, we examined the data to determine if errors were more common in the first meal of the renewal test relative to subsequent meals. This meal included eight, nine, ten, six, five, and four sessions for Carlos’ solids, Carlos’ liq- uids, Fernando’s liquids, Pierre’s solids, Lorenzo’s liquids, and Lorenzo’s solids, respec- tively. None of the caregivers made any errors in the first meal, except for Carlos’s mother whose intervention integrity was 93% for Ses- sion 5 of liquids. Thus, initial increases in inap- propriate mealtime behavior during the renewal test were not a function of intervention errors. It is possible, however, that inappropriate meal- time behavior can maintain on thin reinforce- ment schedules, which might explain the persistence we observed for some children. Future research should assess the implications of changes in context and intervention integrity during mealtimes. We also compared the patterns of

responding during the renewal test to those in other studies. Results of the renewal test for Carlos’ solids and liquids and Lorenzo’s liquids were like those of Kelley et al. (2015), in which previously extinguished behavior returned

immediately and temporarily. By contrast, renewal occurred in the fourth session of the renewal test for Fernando’s liquids. Recall that we conducted multiple sessions in each 40-min meal. Thus, even though renewal did not occur in the first session, it did occur in the first meal of the renewal test. Unlike other participants, inappropriate mealtime behavior persisted for Pierre and Lorenzo’s solids and Fernando’s liq- uids across the 63, 21, and 25 sessions of the renewal test, respectively. We could not find basic studies that demonstrated comparable persistence, and we do not know if inappropri- ate mealtime behavior would have decreased had we continued function-based extinction. Caregivers implemented extinction across just 2 to 4 days. As in other studies (e.g., Kelley et al. 2018; Saini et al., 2018), our renewal test phase was brief because the purpose was to measure responding immediately after a return to a previous context. The duration of extinc- tion required to decrease inappropriate meal- time behavior to previous levels could be a topic for future investigations. Taken together, results of current and previ-

ous studies suggest that we should anticipate renewal during intervention for a child with a feeding disorder. More importantly, we should assess strategies for mitigating renewal. An obvious renewal-mitigation strategy is for the caregiver rather than a therapist to implement function-based extinction initially. Werle, Mur- phy, and Budd (1993), Anderson and McMil- lan (2001), and Luiselli, Ricciardi, and Gilligan (2005) reported that caregivers could serve as the initial change agents and implement pediat- ric feeding disorders interventions with high integrity. Future studies should evaluate the generality of this finding and its effects on renewal. Alternatively, we could measure the magnitude of renewal in a series of contexts after we pair the caregiver with the clinic thera- pist during the intervention. Another renewal-mitigation strategy is to

implement the intervention in the multiple

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contexts in which the child is likely to eat, such as the home or school. For example, Gunther et al. (1998) showed that rats exposed to extinction in three contexts exhibited less renewal than rats exposed to extinction in one context. If we train sufficient exemplars, we might increase the probability that generaliza- tion will occur to contexts not exposed to inter- vention (Stokes & Baer, 1977). When intervention in the home is not practical, increasing the similarity between contexts may be an alternative, as context similarity is another method to mitigate renewal (Podlesnik et al., 2017; Todd et al., 2012). For example, caregivers could bring personal items such as the child’s highchair to the clinic to enhance context similarity. We do not know, however, which aspects of a context control behavior. Identification of those components could be helpful for programming similarity between contexts. We completed the current study by the third

(Carlos, Fernando) and fourth (Pierre, Lorenzo) week of each child’s day-treatment admission. After the renewal evaluation, we provided Fernando, Pierre, and Lorenzo with continuous access to tangible items, which resulted in a reduction of inappropriate mealtime behavior (Reed et al., 2004) and an increase in accep- tance. We discharged Pierre before he com- pleted the program because he had allergic reactions as we introduced new foods. We rec- ommended that he return to the program after allergy testing. We continued to progress the other participants to age-typical feeding for the remainder of their admission in a variety of ways (e.g., increasing the rate of bite presenta- tion, volume, and bolus size). We did not sys- tematically evaluate whether renewal occurred during these context changes. We then trans- itioned participants to the outpatient program. Future research should incorporate a renewal paradigm such as ABA, ABC, or AAC renewal to systematically study other types of contextual changes and long-term outcomes of behavior-

analytic interventions for pediatric feeding disorders. Results of the current study provide another

demonstration that extinction is an effective intervention for decreasing inappropriate meal- time behavior and increasing acceptance when a clinic therapist serves as feeder. These results also show that the effects of extinction are spe- cific to the context in which it occurs (Bouton et al., 2011). Failure to account for renewal in intervention for pediatric feeding disorders may decrease the likelihood the child will continue to eat and drink over the long term. Pediatric feeding disorders can have devastating physical, psychological, and financial consequences for the child, the child’s family, and society (Freedman et al., 1999; Graves & Ware, 1990; Greer, Gulotta, Masler, & Laud, 2007; Ludwig et al., 1999; Singer, Song, Hill, & Jaffe, 1990). Therefore, it is imperative that behavior ana- lysts conduct research that will refine our abil- ity to deliver long-lasting interventions.

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Received December 11, 2017 Final acceptance August 16, 2019 Action Editor, Dorothea Lerman

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