Clinical Case Studies http://ccs.sagepub.

com/

Feeding Therapy in a Child With Autistic Disorder: Sequential Food Presentation

Alison M. Kozlowski, Johnny L. Matson, Jill C. Fodstad and Brittany N. Moree Clinical Case Studies 2011 10: 236 originally published online 17 April 2011 DOI: 10.1177/1534650111405189 The online version of this article can be found at: http://ccs.sagepub.com/content/10/3/236

Published by:
http://www.sagepublications.com

Additional services and information for Clinical Case Studies can be found at: Email Alerts: http://ccs.sagepub.com/cgi/alerts Subscriptions: http://ccs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://ccs.sagepub.com/content/10/3/236.refs.html

>> Version of Record - May 9, 2011 Proof - Apr 17, 2011 What is This?

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

405189

CCSXXX10.1177/1534650111405189Kozlowski et al.Clinical Case Studies

Feeding Therapy in a Child With Autistic Disorder: Sequential Food Presentation

Alison M. Kozlowski1, Johnny L. Matson1, Jill C. Fodstad1, and Brittany N. Moree1

Clinical Case Studies 10(3) 236 246 The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1534650111405189 http://ccs.sagepub.com

Abstract The authors describe a feeding intervention for a 9-year-old male diagnosed with autistic disorder and mild mental retardation (also known as intellectual disability) who experienced food refusal related to food selectivity. Based on the results of a functional behavioral assessment, food refusal was found to be maintained by escape and tangible functions. Therefore, an intervention using escape extinction (i.e., nonremoval of nonpreferred foods with physical guidance as a secondary procedure), positive reinforcement (i.e., preferred foods and toys), and sequential food presentation was implemented. The child was successful in eating many novel foods both within the clinic and home environments. A 1-year follow-up found the effects of treatment to be maintained with significant increases in number of foods eaten and significant decreases in mealtime-related behavioral challenges. The treatment implications, recommendations to clinicians, and areas of future research are discussed. Keywords ASD, autism, food refusal, food selectivity

1 Theoretical and Research Basis for Treatment

Individuals with autism spectrum disorders (ASDs) present with a variety of challenges, including impairments in social skills, communication patterns, and restricted and repetitive interests and behaviors (American Psychiatric Association, 2000; Bhaumik et al., 2010; Fernell & Gillberg, 2010; Matson, Boisjoli, & Dempsey, 2009; Matson, Dempsey, & Fodstad, 2009). In line with symptoms related to restricted interests and behaviors, many of these individuals also display feeding problem behaviors, such as food refusal and food selectivity. Although feeding problem behaviors occur quite frequently among children who are typically developing (Kodak & Piazza, 2008), and the feeding difficulties that individuals with ASD experience tend to be similar in nature to those experienced by typically developing individuals (Ledford & Gast, 2006), such feeding difficulties arise at significantly higher rates in individuals with ASD compared with those who are both typically and atypically developing without an ASD diagnosis, with prevalence rates as high as 90% (Bandini et al., 2010; DeMeyer, 1979; Fodstad & Matson, 2008; Ledford &
1

Louisiana State University, Baton Rouge

Corresponding Author: Johnny L. Matson, Louisiana State University, Baton Rouge, LA 70803, USA Email:johnmatson@aol.com

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Kozlowski et al.

237

Gast, 2006; Schreck & Williams, 2006; Schreck, Williams, & Smith, 2004; Williams, Field, & Seiverling, 2010). For example, Matson, Fodstad, and Dempsey (2009) found that 75.89% of children with ASD in their sample would only eat certain foods (i.e., food selective), 75.89% preferred foods of a certain texture and/or smell, and 35.71% attempted to ingest inedible items. However, no significant differences were found between different ASD groups, such as when children with autistic disorder were compared with those with pervasive developmental disorder not otherwise specified. Similarly, Schreck and Williams (2006) reported that 72% of their sample of children with ASD engaged in food selectivity, whereas 57% displayed food refusal. However, according to parent report, food refusal was not related to preference of foods of a certain texture, which was a common difficulty in children with ASD noted by Matson, Fodstad, et al. (2009), but rather due to food presentation (e.g., particular utensils and foods touching). Bandini and colleagues (2010) found that children with ASD aged 3 to 11 years refused an average of 41.7% of foods offered compared with typically developing children who refused an average of 18.9% of foods offered. The presence of feeding problem behaviors can pose a significant challenge and can place undue stress on caregivers (Kodak & Piazza, 2008; Leung, Lau, Chan, Lau, & Chui, 2010). In addition to the emphasis the caregiver must place on feeding times within the household and the management of behavior problems occurring during this time, a variety of severe consequences may occur as a result of feeding problems, including, but not limited to, malnutrition, dehydration, learning problems, and death. For example, Bandini and colleagues (2010) found that children with ASD displayed significantly more nutrition inadequacy compared with typically developing children within their study sample. Due to the severe consequences that may occur as a result of feeding problem behaviors, the treatment of such difficulties is of great importance. Behavioral interventions are most commonly implemented, specifically those based in applied behavior analysis (Kodak & Piazza, 2008; Matson & Fodstad, 2009). Currently, the most empirically supported treatment for food refusal involves escape extinction (Ahearn, Kerwin, Eicher, Shantz, & Swearingin, 1996; Kodak & Piazza, 2008; Piazza, Patel, Gulotta, Sevin, & Layer, 2003). This treatment is based on the hypothesis, typically supported through a functional behavioral assessment, that the food refusal behavior is reinforced by the individuals ability to escape from eating foods by engaging in challenging behavior. In many cases, such as the case contained within this article, the individual is allowed to avoid eating the foods and given alternative choices (i.e., preferred foods). Therefore, implementing procedures that do not allow the individual to escape from eating the nonpreferred food have been repeatedly shown to decrease food refusal. Specifically, two types of extinction, nonremoval of the spoon (i.e., the nonpreferred food is held in front of the individuals mouth until the bite is taken) and physical guidance (i.e., the individual is physically assisted in opening his or her mouth and taking the bite via a jaw prompt), are the most commonly used procedures for feeding treatment (Ledford & Gast, 2006). Furthermore, combining escape extinction procedures with reinforcement procedures often increases the effectiveness of treatment (Kodak & Piazza, 2008). The use of simultaneous or immediate sequential reinforcers, such as preferred foods paired with nonpreferred foods as well as delayed sequential reinforcers, such as access to a preferred toy or activity on completion of a treatment step (e.g., one bite of nonpreferred food and three bites of nonpreferred food), are often included as a component of feeding treatment programs (Didden, Seys, & Schouwink, 1999; Luiselli, 1994). Motivation for treatment is often, especially, low for children with ASD as they often lack insight for the need to acquire new skills (Koegel, Koegel, Vernon, & Brookman-Frazee, 2010), and therefore, the use of external reinforcers can increase compliance and further engage the child in the treatment process. Preferred and nonpreferred foods can be presented either simultaneously or sequentially when treating food refusal. The simultaneous procedure involves combining the nonpreferred with the

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

238

Clinical Case Studies 10(3)

preferred food by either placing both edibles on a spoon/fork or mixing liquids (Ahearn, 2003; Kern & Marder, 1996; Luiselli, Ricciardi, & Gilligan, 2005; Piazza et al., 2002). When using this method, it is also common for the ratio of nonpreferred to preferred food to gradually increase over time to increase acceptance of the nonpreferred food. Sequential food presentation requires the individual to consume the nonpreferred food prior to receiving the preferred food (Najdowski, Wallace, Doney, & Ghezzi, 2003; Piazza et al., 2002). To date, the majority of research supports the simultaneous presentation approach (Ahearn, 2003; Kern & Marder, 1996, Luiselli et al., 2005), and some believe this approach to be superior over sequential presentation (Piazza et al., 2002). However, though effective, this method may be more difficult to implement and generalize to the home environment, which is often the goal of feeding therapy. Therefore, the current study demonstrates a sequential presentation approach of feeding therapy incorporating both escape extinction and positive reinforcement.

2 Case Introduction
William (a pseudonym) was a 9-year-old White male diagnosed with autistic disorder and mild mental retardation (also known as intellectual disability). William achieved an abbreviated IQ of 50 on the Stanford-Binet Intelligence Scales, Fifth Edition, placing him within the mild to moderate range of intellectual disability. Adaptively, William functioned in the low range according to the Vineland Adaptive Behavior Scales, Second Edition with an adaptive behavior composite standard score of 65. He could speak in simple sentences, print words from memory, bathe and dress himself, and recognize the likes and dislikes of others (e.g., verbally express likes and dislikes of family and close others). However, he was unable to follow multipart instructions, complete household chores, or demonstrate friendship-seeking behavior with other same-aged peers (e.g., approach and interaction initiation behaviors). His scores on the Childhood Autism Rating Scale and the Autism Diagnostic InterviewRevised indicated that Williams behavioral presentation was consistent with a diagnosis of autistic disorder. He demonstrated deficits in communication and social skills, and he frequently engaged in stereotypic behaviors. William lived at home with his biological mother, father, and younger brother. He was homeschooled by his mother. At the time of the present study, he was prescribed Metadate (30 mg) by his neurologist to treat symptoms of inattention.

3 Presenting Complaints
William was referred for intervention by his mother due to feeding difficulties and associated problem behaviors. Food selectivity and food refusal were the focus of the current study and intervention. Food selectivity was defined as eating only a limited number of preferred foods (e.g., chicken nuggets, French fries, French toast, and candy), and food refusal was defined as refusing to eat any other food when requested to do so. If William was asked to eat food items other than his preferred foods, he would often engage in problem behaviors and/or expel the nonpreferred food items from his mouth. More specifically, William demonstrated challenging behaviors, such as verbal outbursts and face slapping. Verbal outbursts were defined as whining, crying, and verbally protesting when asked to do something that he did not want to do. Face slapping was defined as William hitting his face with one or two open palms. These problem behaviors lasted approximately 10 min each time they occurred. As such, not only were Williams behaviors of food selectivity and food refusal increasing his risk of malnutrition, but they were also bringing about other challenging behaviors and causing significant hardship on Williams caregivers.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Kozlowski et al.

239

4 History
William was born as a result of a full-term pregnancy without complications. He met most of his developmental milestones within normal limits; however, his communication was delayed as he did not speak single words until age 2 or short phrases until age 4. He also was not toilet trained until age 4. At age 3, William was diagnosed with autistic disorder as well as attention deficit disorder (based on prior diagnostic criteria), by his neurologist. His mother reported that he exhibited stereotypic behaviors and lack of social reciprocity beyond his communication delays as well as a history of problem behaviors. William received speech and occupational services throughout preschool and early elementary school; however, at the time of the study, he was homeschooled by his mother and no longer received therapy services.

5 Assessment
The frequency and severity of Williams food refusal was assessed through administration of the Screening Tool of Feeding Problems (STEP; Kuhn & Matson, 2002; Matson & Kuhn, 2001) and the Brief Autism Mealtime Behavior Inventory (BAMBI; Lukens & Linscheid, 2008), both of which have acceptable reliability and validity. According to the STEP, William presented with significant difficulties related to both food selectivity and food refusal. Items endorsed indicated that William could not feed himself independently, displayed problem behaviors during mealtimes, only ate selected food types, continued to eat as long as food was available, spit out food if he did not like it, ate a large amount of food in a short time period, pushed away food or attempted to leave the area when food was offered, only ate foods of a certain temperature, and only liked foods of a certain texture. All of these behaviors occurred more than 10 times during the past month with the exception of spitting out food before swallowing and only eating foods of a certain temperature, both of which occurred between 1 and 10 times during the past month. BAMBI data were consistent with those of the STEP, with elevations on all three subscales: Limited Variety (total score = 27/35), Food Refusal (total score = 15/25), and Features of Autism (total score = 17/25). In an effort to determine the variables maintaining Williams food refusal behavior, a functional behavioral assessment was conducted (Didden, 2007; Matson, Bamburg, Cherry, & Paclawskyj, 1999). Both direct and indirect methods of functional behavioral assessment were used, such as direct observations within the clinic setting, administration of the Questions About Behavioral Function Scale (QABF; Applegate, Matson, & Cherry, 1999; Matson et al., 1999; Nicholson, Konstantinidi, & Furniss, 2006; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2000, 2001; Singh et al., 2009), and a clinical interview using the Functional Assessment Interview (FAI; ONeill et al., 1997). Williams mother served as the informant for both the QABF and FAI. On the QABF, Williams mothers responses were elevated on the Escape and Tangible subscales, suggesting that Williams food refusal was maintained by his ability to avoid ingesting the nonpreferred food items and also by him receiving tangibles (i.e., alternative preferred foods) once he had refused to eat the nonpreferred foods. Information gathered during a clinical interview using the FAI further supported these functions. When presented with nonpreferred food items, William would turn his head, often engaging in verbal outbursts and occasional face slapping, and spit the food out of his mouth if it were to pass across his lips. William was more likely to engage in these behaviors during dinner meals and less likely during breakfast meals, which was hypothesized to be due to some of Williams preferred foods being offered more frequently during breakfast (e.g., French toast). Furthermore, if William did engage in food refusal during mealtimes, Williams mother reported that he was always given other, preferred, food items so that he consumed food throughout the day.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

240

Clinical Case Studies 10(3)

To determine which nonpreferred foods to introduce to William during treatment, the therapist interviewed Williams mother. A list containing a variety of foods, which Williams mother stated he did not currently eat but she would like for him to eat (e.g., foods she frequently prepared for the family), was formulated. Subsequently, Williams mother was asked to rank the items from those that William would be most likely to eat to those he would be least likely to eat.

6 Case Conceptualization
Based on the results of the assessment, food refusal behavior was identified as a significant challenge for William and determined to be highly related to food selectivity. William engaged in food refusal whenever nonpreferred foods were presented to him. Engaging in this behavior always resulted in William not having to eat the nonpreferred foods that had been presented to him. Instead, preferred food items that William selectively ate were always provided afterward to ensure that he ate a meal. Therefore, although William frequently engaged in food refusal, he only did so when foods outside of his preferred foods were presented. As previously mentioned, the functional behavioral assessment suggested that food refusal served both escape and tangible functions (i.e., William was able to both escape the nonpreferred foods and gain access to preferred foods by engaging in the behavior). Therefore, an escape extinction procedure combined with positive reinforcement was proposed based on literature supporting its effectiveness (Didden et al., 1999; Luiselli, 1994). Rather than choosing either nonremoval of nonpreferred foods or physical guidance, the strategies were combined within the treatment procedures so that both were used simultaneously (as described below). Both forms of escape extinction have demonstrated efficacy (Ledford & Gast, 2006); however, due to nonremoval of nonpreferred foods being less invasive than physical guidance, this served as the primary treatment method.

7 Course of Treatment and Assessment of Progress

Treatment was provided in a clinic setting with two therapists present. The lead therapist implemented the treatment while a cotherapist assisted the lead therapist and collected data for all sessions. Both therapists were doctoral-level clinical psychology students; the lead therapist was a masters-level clinician with 2 years of experience in an intensive day treatment feeding program whereas the cotherapist was a bachelors-level clinician. The primary target variables included acceptance of nonpreferred food within a 5-s interval, the absence of challenging behaviors, and the reduction of gagging response. These variables are subsequently discussed in detail as part of the treatment procedure. The treatment procedure consisted of 10-min feeding sessions during the 1-hr therapy session with each feeding session followed by a 10-min break during which William was permitted to play with toys in the clinic. During each 1-hr therapy session, two to three 10-min feeding sessions occurred. The differing number of feeding sessions during each therapy session was due to variability in the amount of time spent at the beginning of each session reviewing Williams out-of-clinic behavior since his last therapy session. At the beginning of each feeding session, William was given one bite of a preferred food. Immediately following swallowing of the preferred food, introduction of nonpreferred foods ensued. When William was presented with a nonpreferred food, the edible was placed on a spoon or fork, and the lead therapist held the utensil directly in front of Williams mouth, at which time he was verbally instructed to Take a bite. William was then given 30 s to open his mouth and allow the therapist to place the food into his mouth. If William accepted the nonpreferred food within 5 s of its presentation, he received verbal praise. If William did not comply with the direction to eat the nonpreferred food (i.e., he did not open his mouth) within 30 s of the verbal direction being given, the lead therapist continued delivering verbal directions to take a bite every

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Kozlowski et al.

241

30 s until William complied or 5 min had passed, whichever occurred first. If William had still not opened his mouth after 5 min had elapsed, a jaw-prompt procedure was proposed to assist William in eating the bite of food. Jaw-prompt procedures were to consist of the lead therapist placing her fingers on both sides of Williams face at his mandible joint. A verbal prompt would then be given for William to take a bite, and, if necessary, minimal pressure would be applied to his jaw to assist him with opening his mouth so the lead therapist could place the nonpreferred food into his mouth. However, it should be noted that although this jaw-prompt procedure was documented as part of Williams feeding therapy plan, it was never required. It was also part of Williams feeding therapy plan that if William expelled the nonpreferred food from his mouth at any time, he was required to follow the aforementioned procedure in placing a new equal-sized portion of nonpreferred food into his mouth. This step was also unnecessary during the course of treatment. After William had successfully accepted the therapist placing a nonpreferred food item into his mouth, he was required to swallow the food within 30 s. Completion of this step was verified by verbally asking William to open his mouth to show the lead therapist that he had swallowed the food. The food was considered to have been successfully swallowed if less than a pea-sized amount was visible in Williams mouth. If William successfully swallowed the nonpreferred food within 5 s of accepting it, he was provided with verbal praise and a preferred toy. The preferred toy was one which William identified at the beginning of each therapy session as the item he would like to earn throughout the feeding sessions. If William had not succeeded in swallowing the food, he was given verbal directives every 30 s until he did so. Nonpreferred food items were introduced one by one each feeding session according to the food hierarchy described within the previous section. For each accepted and swallowed bite of nonpreferred food, William was originally given one bite of preferred food. The frequency of the delivery of preferred food items following bites of nonpreferred food was gradually faded to delivery of a preferred food item following three bites of nonpreferred food. This was done over the course of each therapy session and was based on the lead therapists impression of Williams timeliness to accept bites of nonpreferred food items, the absence of challenging behaviors (e.g., verbal outbursts, face slapping) when nonpreferred food items were presented, and the absence or reduction in severity of gagging. Although these three criteria were put in place, it should be noted that a strict fading schedule with consecutive trials of success was not implemented and that fading occurred based on general impressions of the lead therapist, and over the course of treatment, the fading schedule actually became a variable interval schedule to make the feeding sessions easily replicable in the home environment during mealtimes. William was considered successful at eating a nonpreferred food item once he had completed one session with 80% accuracy or higher. At this time, a more difficult food would be introduced along the food hierarchy in the next session. Williams progress was tracked according to the percentage of nonpreferred food bites accepted and swallowed during each session. Data were collected using a paper-and-pencil data sheet developed specifically for the therapy sessions. A plus or minus sign was used to indicate whether William accepted and/or swallowed each bite of food. There were additional columns to denote the number of verbal prompts needed if William did not accept/swallow the food immediately and whether a jaw prompt was necessary. Although William did occasionally gag on the food once it was accepted, he accepted and swallowed all foods 100% of the time across all feeding sessions within 5 s of them being presented. Furthermore, he was observed to gag less frequently as treatment progressed. After a few months of feeding treatment, consisting of 14 total feeding sessions, William was able to eat several foods that he had previously been unable to eat. In addition, parental report based on discussions during the beginning of each therapy session indicated that he was also accepting and swallowing these foods in the home environment.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

242

Clinical Case Studies 10(3)

8 Complicating Factors
Because many of the edibles provided for treatment were brought into the therapy session by Williams mother, it was sometimes necessary to conduct more than one feeding session on the same nonpreferred food despite Williams success at eating it. This procedure was followed if other nonpreferred foods were unavailable. As such, the introduction of nonpreferred foods did not occur as systematically as planned. Although this may have slightly hindered Williams progression of eating nonpreferred foods, it also incorporated maintenance of nonpreferred foods into Williams feeding program. Furthermore, it is not believed that this deviation from the treatment plan severely affected Williams acceptance of nonpreferred foods. In addition, although two therapists were present during all treatment sessions, data were only collected by one of the therapists to ensure treatment integrity. Therefore, formal interobserver agreeability was unable to be calculated. However, both therapists were present at all times and agreed on the delivery of reinforcement, thereby providing support for reliability of data.

9 Access and Barriers to Care

When implementing feeding intervention protocols for outpatient individuals, considerations, such as treatment and material cost, effects and ease of implementation with existing treatment, and access to properly trained individuals, must be examined. Williams feeding therapy was incorporated into his regular treatment program at an adjusted income clinic. Costs of materials (food supplies and reinforcers) were supplemented where necessary, and clinicians were appropriately trained to administer the described feeding therapy protocol. In addition, his mother provided consent on publication of the results of this treatment.

10 Follow-Up
Williams mother was contacted approximately 1 year after termination of treatment for a followup assessment. At that time, she reported that William was more compliant at mealtime, no longer exhibited tantrums (e.g., verbal outbursts and face slapping) when presented with nonpreferred foods, and was eating a larger variety of food each day. She reported that she continued the expansion of Williams food intake by having him try at least one bite of new or nonpreferred food items each time he is presented with them. According to his mother, at the time of follow-up, William would try the new foods on request without protest. She also reported that the frequency of Williams gagging response decreased to less than once per week and that he no longer regurgitated nonpreferred food. Examples of new food items include broccoli, rice, peas, carrots, and some meats that are not fried. He still exhibited trouble with foods that are difficult to chew (e.g., steak) and appeared to dislike certain textures (e.g., oatmeal and fruits). Results of the STEP and BAMBI at the time of the 1-year follow-up also demonstrated a decrease in Williams mealtime-related challenging behaviors, which often co-occur (Farmer & Aman, 2009). Only four items were endorsed as occurring on the STEP (i.e., problem behaviors increasing during mealtimes, only eating selected types of food, continuing to eat as long as food is available, and eating foods of only certain textures), all of which were reported to occur less than 10 times per month. All of these behaviors showed a reduction in comparison to the STEP administered prior to treatment, except for eating foods of only certain textures, which remained the same. All other behaviors that had been documented on the STEP prior to beginning treatment were no longer endorsed as occurring, indicating that William had made significant progress with acceptance of a variety of foods. With respect to the BAMBI, many decreases were seen in endorsements along all three subscales: Limited Variety (total score = 21/35), Food Refusal

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Kozlowski et al.

243

(total score = 8/25), and Features of Autism (total score = 7/25). This was a 32%, 47%, and 59% decrease in symptom endorsements for each of the three subscales, respectively. These results indicated that William experienced a significant decrease in food selectivity, food refusal, and symptoms of autism related to food selectivity/refusal.

11 Treatment Implications of the Case

This case provides further support for the use of sequential food presentation in an escape extinction plus positive reinforcement treatment for food refusal. Although simultaneous food presentation has been the most studied and empirically supported method thus far, this strategy can be difficult to implement outside of clinic settings and thus hinder generalization to home environments and parent training. However, sequential food presentation provides an avenue for parents to easily implement treatment at home so as to increase the effects of treatment. In addition, Schreck and Williams (2006) found that many individuals engaging in food refusal behavior may do so based on food presentation, with foods touching being associated with food refusal. Therefore, although simultaneous food presentation has been favored over sequential presentation in the current literature, the choice of which presentation to integrate into food refusal treatment should take into consideration whether food refusal is related to the presentation of food. Given the large focus on using the least restrictive procedure necessary when implementing treatment interventions, the current study illustrates that physical guidance and intervention are not always necessary during food refusal treatment. Although a physically restrictive procedure was proposed as a secondary prompt within the current treatment plan, this secondary approach was not necessary. It may be that the combination of edible and tangible (i.e., toys) reinforcement being added to the nonremoval of the spoon escape extinction procedure reduced the need for physical guidance. Although physical guidance may result in a quicker response to treatment, its use should be limited and does not need to occur when other, less restrictive interventions are available and effective.

12 Recommendations to Clinicians and Students

Based on the findings within this case study and the aforementioned treatment implications, it is recommended that clinicians conduct a comprehensive functional behavioral assessment prior to treatment implementation (Huete & Kurtz, 2010; Kodak, Fisher, Kelley, & Kisamore, 2009; Strachan et al., 2009; Weeden, Mahoney, & Poling, 2010). In addition to identifying the maintaining variable(s) of food refusal behavior, this assessment should also determine related factors to the food refusal, such as food presentation. This information can then be used to determine whether a sequential or simultaneous food presentation approach may be more appropriate based on the individual. Future research should aim to further assess the effectiveness of sequential versus simultaneous food presentation in food refusal treatments relative to the presence of difficulties with actual food presentation (e.g., being distressed over foods touching). In addition, although two types of escape extinction are currently used with relatively equal frequency at the moment (i.e., nonremoval of spoon and physical guidance), the least restrictive procedure should be used (Devlin, Leader, & Healy, 2009). Comparisons between the effectiveness of each procedure should be conducted to determine the necessity of more restrictive procedures, such as those using physical interventions, in food refusal treatment. In the meantime, treatments should follow a hierarchy of least restrictive to most restrictive interventions to cause the least amount of intrusion upon the client (Williams, 2010).

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

244 Declaration of Conflicting Interests

Clinical Case Studies 10(3)

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

References
Ahearn, W. H. (2003). Using simultaneous presentation to increase vegetable consumption in a mildly selective child with autism. Journal of Applied Behavior Analysis, 36, 361-365. Ahearn, W. H., Kerwin, M. E., Eicher, P. S., Shantz, J., & Swearingin, W. (1996). An alternating treatments comparison of two intensive interventions for food refusal. Journal of Applied Behavior Analysis, 29, 321-332. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Applegate, H., Matson, J. L., & Cherry, K. E. (1999). An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions About Behavioral Function Scale (QABF). Research in Developmental Disabilities, 20, 229-237. Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., & Must, A. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. Journal of Pediatrics, 157, 259-264. Bhaumik, S., Tyrer, F., Barrett, M., Tin, N., McGrother, C. W., & Kiani, R. (2010). The relationship between carers report of autistic traits and clinical diagnoses of autism spectrum disorders in adults with intellectual disability. Research in Developmental Disabilities, 31, 705-712. DeMeyer, M. K. (1979). Parents and children in autism. New York, NY: John Wiley. Devlin, S., Leader, G., & Healy, O. (2009). Comparison of behavioral intervention and sensory-integration therapy in the treatment of self-injurious behavior. Research in Autism Spectrum Disorders, 3, 223-231. Didden, R. (2007). Functional analysis methodology in developmental disabilities. In P. Sturmey (Ed.), Functional analysis in clinical treatment (pp. 65-86). San Diego, CA: Elsevier Academic Press. Didden, R., Seys, D., & Schouwink, D. (1999). Treatment of chronic food refusal in a young developmentally disabled child. Behavioral Interventions, 14, 213-222. Farmer, A., & Aman, M. G. (2009). Development of the Childrens Scale of Hostility and Aggression: Reactive/Proactive (C-SHARP). Research in Developmental Disabilities, 30, 1155-1167. Fernell, E., & Gillberg, C. (2010). Autism spectrum disorder in Stockholm preschoolers. Research in Developmental Disabilities, 31, 680-685. Fodstad, J. C., & Matson, J. L. (2008). A comparison of feeding and mealtime problems in adults with intellectual disabilities with and without autism. Journal of Developmental and Physical Disabilities, 20, 541-550. Huete, J. M., & Kurtz, P. F. (2010). Therapist effects on functional assessment outcomes with young children. Research in Developmental Disabilities, 31, 804-810. Kern, L., & Marder, T. J. (1996). A comparison of simultaneous and delayed reinforcement as treatments for food selectivity. Journal of Applied Behavior Analysis, 29, 243-246. Kodak, T., Fisher, W. W., Kelley, M. E., & Kisamore, A. (2009). Comparing preference assessments: Selection- versus duration-based preference assessment procedures. Research in Developmental Disabilities, 30, 1068-1077. Kodak, T., & Piazza, C. C. (2008). Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child and Adolescent Psychiatric Clinic of North America, 17, 887-905.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

Kozlowski et al.

245

Koegel, R. L., Koegel, L. K., Vernon, T. W., & Brookman-Frazee, L. I. (2010). Empirically supported pivotal response treatment for children with autism spectrum disorders. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 327-344). New York, NY: Guilford Press. Kuhn, D. E., & Matson, J. L. (2002). A validity study of the screening tool of feeding problems (STEP). Journal of Intellectual & Developmental Disabilities, 27, 161-167. Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental Disabilities, 21, 153-166. Leung, C., Lau, J., Chan, G., Lau, B., & Chui, M. (2010). Development and validation of a questionnaire to measure the service needs of families with children with developmental disabilities. Research in Developmental Disabilities, 31, 664-671. Luiselli, J. K. (1994). Oral feeding treatment of children with chronic food refusal and multiple developmental disabilities. American Journal on Mental Retardation, 98, 646-655. Luiselli, J. K., Ricciardi, J. N., & Gilligan, D. (2005). Liquid fading to establish milk consumption by a child with autism. Behavioral Interventions, 20, 155-163. Lukens, C. T., & Linscheid, T. R. (2008). Development and validation of an inventory to assess mealtime behavior problems in children with autism. Journal of Autism and Developmental Disorders, 38, 342-352. Matson, J. L., Bamburg, J. W., Cherry, K. E., & Paclawskyj, T. R. (1999). A validity study on the Questions About Behavioral Function (QABF) Scale: Predicting treatment success for self-injury, aggression, and stereotypies. Research in Developmental Disabilities, 20, 163-175. Matson, J. L., Boisjoli, J. A., & Dempsey, T. (2009). Factor structure of the Autism Spectrum DisordersDiagnostic for Children (ASD-DC). Journal of Developmental and Physical Disabilities, 21, 195-211. Matson, J. L., Dempsey, T., & Fodstad, J. C. (2009). Stereotypies and repetitive behaviors in infants with autism and pervasive developmental disorder. Developmental Neurorehabilitation, 12, 122-127. Matson, J. L., & Fodstad, J. C. (2009). The treatment of food selectivity and other feeding problems in children with autism spectrum disorders. Research in Autism Spectrum Disorders, 3, 455-461. Matson, J. L., Fodstad, J. C., & Dempsey, T. (2009). The relationship of childrens feeding problems to core symptoms of autism and PDD-NOS. Research in Autism Spectrum Disorders, 3, 759-766. Matson, J. L., & Kuhn, D. E. (2001). Identifying feeding problems in mentally retarded persons: Development and reliability of the screening tool of feeding problems (STEP). Research in Developmental Disabilities, 22, 165-172. Najdowski, A. C., Wallace, M. D., Doney, J. K., & Ghezzi, P. M. (2003). Parental assessment and treatment of food selectivity in natural settings. Journal of Applied Behavior Analysis, 36, 383-386. Nicholson, J., Konstantinidi, E., & Furniss, F. (2006). On some psychometric properties of the Questions About Behavioral Function (QABF) Scale. Research in Developmental Disabilities, 27, 337-352. ONeill, R. E., Horner, R. H., Albin, R. W., Sprague, J. R., Storey, K., & Newton, J. S. (1997). Functional assessment and program development for problem behavior: A practical handbook. Pacific Grove, OR: Brooks/Cole. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2000). Questions About Behavioral Function (QABF): A behavioral checklist for functional assessment of aberrant behavior. Research in Developmental Disabilities, 21, 223-229. Paclawskyj, T. R., Matson, J. L., Rush, K. S., Smalls, Y., & Vollmer, T. R. (2001). Assessment of the convergent validity of the Questions About Behavioral Function scale with analogue functional analysis and the Motivation Assessment Scale. Journal of Intellectual Disability Research, 45, 484-494. Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309-324.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011

246

Clinical Case Studies 10(3)

Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D., & Lancaster, B. M. (2002). An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity. Journal of Applied Behavior Analysis, 35, 259-270. Schreck, K. A., & Williams, K. (2006). Food preferences and factors influencing food selectivity for children with autism spectrum disorders. Research in Developmental Disabilities, 27, 353-363. Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of eating behaviors between children with and without autism. Journal of Autism and Developmental Disorders, 34, 433-438. Singh, A. N., Matson, J. L., Mouttapa, M., Pella, R. D., Hill, B. D., & Thorson, R. (2009). A critical items analysis of the QABF: Development of a short form assessment instrument. Research in Developmental Disabilities, 30, 782-792. Strachan, R., Shaw, R., Burrow, C., Horsler, K., Allen, D., & Oliver, C. (2009). Experimental functional analysis of aggression in children with Angelman syndrome. Research in Developmental Disabilities, 30, 1095-1106. Weeden, M., Mahoney, A., & Poling, A. (2010). Self-injurious behavior and functional analysis: Where are the descriptions of participant protections? Research in Developmental Disabilities, 31, 299-303. Williams, D. E. (2010). Reducing and eliminating restraint of people with developmental disabilities and severe behavior disorders: An overview of recent research. Research in Developmental Disabilities, 31, 1142-1148. Williams, K. E., Field, D. C., & Seiverling, L. (2010). Food refusal in children: A review of the literature. Research in Developmental Disabilities, 31, 625-633.

Bios
Alison M. Kozlowski is a doctoral student in clinical psychology at Louisiana State University. Her research interests include autism spectrum disorders, developmental disabilities, challenging behaviors, and communication training. Johnny L. Matson is professor and distinguished research master in the Department of Psychology at Louisiana State University. His research interests are in developmental disabilities and autism spectrum disorders. He is the author of more than 600 publications, including 38 books. Jill C. Fodstad is a doctoral student in clinical psychology at Louisiana State University. Her research interests include autism spectrum disorders, developmental disabilities, and challenging behaviors. Brittany N. Moree is a doctoral student in clinical psychology at Louisiana State University. Her research interests include childhood anxiety disorders and the presence of such disorders within children with autism spectrum disorders.

Downloaded from ccs.sagepub.com by Andreea Nicoleta Nicolae on October 12, 2011