Title: Behavioral assessment and treatment of pediatric feeding disorders

Abstract: Provides an overview of the pediatric behavioral feeding literature and the basic assessment and treatment procedures used by an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach that incorporates behavioral procedures. (PsycINFO Database Record (c) 2004 APA, all rights reserved)
(1994). Journal of Developmental and Behavioral Pediatrics, 15 (4), 278-291.

Title: A hospital and home based behavioral intervention for a child with chronic food refusal and gastrostomy tube dependence

Abstract: There is a growing body of evidence supporting the efficacy of behavioral interventions for increasing oral consumption in individuals with chronic food refusal. Although several studies have reported on interventions carried out in hospital or clinic settings, few investigations have described the long-term effects of treatment in the individual's natural environment. In this case study, we developed a treatment package for increasing oral intake of a child (aged 8 yrs) with chronic food refusal during her admission to an inpatient behavioral unit. After discharge, a home-based intervention was continued for 18 mo during which time oral intake was further increased while gastrostomy tube feedings were decreased and eventually eliminated. Results suggest that a combination of hospital- and home-based interventions may be beneficial for some patients with chronic food refusal. (PsycINFO Database Record (c) 2004 APA, all rights reserved)
(2001). Journal of Developmental and Physical Disabilities, 13 (4), 407-418.

Title: Mealtime behaviors of young children: A comparison of normative and clinical data

Abstract: Compared the behavior of healthy young children around feeding and mealtimes to the behavior of two clinical groups, children referred for feeding problems, without related medical issues and those with medical issues associated with the feeding problems. Using the Behavioral Pediatrics Feeding Assessment Scale, data were obtained for 96 healthy children between the ages of 9 months to 7 years, and descriptive information was presented in the paper on these normal mealtime behaviors. In comparing this normative data to similar data obtained from the clinical groups, the authors' primary purpose was to investigate whether children with feeding problems engage in fundamentally different behaviors (maladaptive) or similar behaviors, but at an increased frequency to normal children. Factor analysis identified five common patterns of behavior across the three groups. The difference in parental report of feeding difficulties between healthy and clinical groups appears to reflect the frequency in which the child with feeding difficulties engages in the problematic behavior, rather than fundamental differences in behaviors exhibited during mealtimes. (PsycINFO Database Record (c) 2004 APA, all rights reserved)
(2001). Journal of Developmental and Physical Disabilities, 22(5), 279-286.

Title: An interdisciplinary team approach to the management of pediatric feeding and swallowing disorders

Abstract: Children with complex feeding problems frequently are involved with many health care services given the multiple medical and developmental issues impacting on feeding progress. The key to providing well-coordinated clinical services for these patients is to use an interdisciplinary team approach. In this article, the authors describe a model of interdisciplinary team care for medically complex children with chronic feeding, swallowing, nutrition, and growth problems. A description of the functional roles of each of the disciplines represented on the team (nursing, nutrition, speech pathology, occupational therapy, psychology, and gastroenterology) is provided. (PsycINFO Database Record (c) 2004 APA, all rights reserved)
(2001). Children's Health Care, 30(3), 201-218.

Title: Functional assessment and treatment of mealtime behavior problems

Abstract: Utilized descriptive assessment methods to develop hypotheses regarding the function of mealtime behavior problems for 3 typically developing children (aged 2-6 yrs). Functional treatment was evaluated in the natural setting with caregivers as change agents. Overall, results of the descriptive assessment suggested that each child's problem behavior was maintained by escape and, to a lesser extent, attention. In addition, this study suggests that direct observation is more reliable than a behavioral interview or questionnaire in acquiring the information necessary to develop hypotheses on factors maintaining a child's mealtime behavior problems. Finally, a functional treatment package consisting of extinction, stimulus fading, and reinforcement of appropriate eating behaviors implemented by the caregivers was effective in decreasing the mealtime behavior problems for 2 of the children who continued in the study, thus providing support for the hypotheses developed from the assessment. (PsycINFO Database Record (c) 2004 APA, all rights reserved)
(2001). Journal of Positive Behavior Intervetions, 3(4), 211-224.

Abstract: We compared two treatment packages involving negative reinforcement contingencies for 3 children with chronic food refusal. One involved physically guiding the child to accept food contingent on noncompliance, whereas the other involved nonremoval of the spoon until the child accepted the presented food. Subsequent to baseline, an alternating treatments comparison was implemented in a multiple baseline design across subjects. After each child had been exposed to at least nine sessions of each treatment condition and percentage of bites accepted had increased to at least 80%, the child's caregivers selected the preferred treatment package. The results indicated that both treatments were effective in establishing food acceptance. However, physical guidance was associated with fewer corollary behaviors, shorter meal durations, and parental preference. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(1996). Journal of Applied Behavioral Analysis, 29(3), 321-332.

Abstract: Pediatric feeding disorders are estimated to occur in as many as one in every four infants and children, and when serious can require numerous, costly and sustained interventions. For over a decade research has cumulated evidence on the contributions of Behavior Analysis in understanding and remediating some types of pediatric feeding disorders. The systematic use of this body of evidence in conjunction with other approaches (medical, nutrition, occupational therapy, physical therapy, and so forth) is being carried out on an inpatient treatment unit at the Kennedy Krieger Institute. Key aspects are described here, including direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training. The results based on case studies and overall program evaluation indicate that medically complicated, severe feeding disorders can be treated successfully in a few months with a multidisciplinary approach which incorporates behavioral procedures. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(1994).Journal of Developmental and Behavioral Pediatrics, 15(4), 278-291.

Abstract: Swallow induction has been used to shape swallowing behavior in dysphagic children and to accelerate swallowing in nondysphagic children with profound mental retardation who display primitive swallows. Swallow induction may be considered a type of prompt. This project coupled swallow induction with a modified delayed prompting paradigm to establish eating in a 3.5-year-old girl. Coupling these procedures produced prompt swallowing and established oral consumption. Follow-ups at 1, 2, 6 and 12 months demonstrated maintenance and further improvement of the newly acquired feeding skills. Implications for treatment and further research are discussed. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(1995). Journal of Behavior Therapy and Experimental Psychiatry, 26(1), 41-50.

Abstract: Gastroesophageal reflux (GER) is the movement of gastric contents retrograde into the esophagus. Sometimes the refluxate is seen as emesis, but often reflux is "silent," meaning that there are no discrete symptoms during an episode. In adults, the most common symptom of GER is heartburn, whereas in infancy excessive crying and malaise are symptoms that prompt investigation for GER, with or without esophagitis. Symptoms of esophagitis in infancy may include arching (hyperextension) of the torso and refusal of feedings. Tube feedings may be required to treat infants with failure to thrive who refuse oral feedings. Paradoxically, tube feedings increase the number of GER episodes. A hypothetical explanation for refusal of food in infancy is that pain with swallowing (odynophagia) or heartburn are consequences of peptic esophagitis. As a result, infants will learn to refuse food if it hurts or if they fear that it will hurt to eat. Another possible mechanism is visceral hyperalgesia, a neuropathic condition in which prior experience changes sensory nerves so that previously innocuous stimuli are perceived as painful. Some infants may have especially sensitive sensory nerves in the upper gastrointestinal tract, which predisposes visceral hyperalgesia to develop. Thus pain occurs from luminal distension or acid reflux in the absence of tissue damage. The evaluation of babies who won't eat includes a careful history and physical examination to exclude the possibility of chronic systemic illness. Refusal to feed is an unusual manifestation of a common condition: GER disease. The initial tests for GER usually include a barium swallow study to assess the upper gastrointestinal anatomy, endoscopy and esophageal biopsy to assess esophagitis, and an intraesophageal pH study, which is useful in "silent" reflux to quantitate the duration of esophageal acid exposure and to correlate discrete symptom episodes with periods of reflux. The treatment of infants and toddlers who refuse to eat because of pain resulting from visceral hyperalgesia or reflux esophagitis involves removing the pain associated with eating and making eating a pleasurable experience. Treatment for esophagitis may include maintaining an upright posture after meals and thickened feeds, medication to improve gastrointestinal motility or to decrease acid secretion, or fundoplication. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(1994). The Journal of Pediatrics, 125(6), S103-S109.

Abstract: Consumption of solids and liquids occurs as a chain of behaviors that may include accepting, swallowing, and retaining the food or drink. In the current investigation, we evaluated the relative effectiveness of differential reinforcement of the first behavior in the chain (acceptance) versus differential reinforcement for the terminal behavior in the chain (mouth clean). Three children who had been diagnosed with a feeding disorder participated. Acceptance remained at zero when differential reinforcement contingencies were implemented for acceptance or mouth clean. Acceptance and mouth clean increased for all 3 participants once escape extinction was added to the differential reinforcement procedures, independent of whether reinforcement was provided for acceptance or for mouth clean. Maintenance was observed in 2 children when escape extinction was removed from the treatment package. The mechanism by which consumption increased is discussed in relation to positive and negative reinforcement contingencies. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(2002). Journal off Applied Behavioral Analysis, 35(4), 363-374.

Abstract: An evaluation of food type and texture indicated that both variables affected the expulsions of a 3-year-old with feeding problems. The results of the evaluation were used to prescribe a treatment (reducing the texture of one food type) that reduced expulsion. (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(2002). Journal of Applied Behavioral Analysis, 35(2), 183-186.

Abstract: In the current investigation, we compared two methods of food presentation (simultaneous vs. sequential) to increase consumption of nonpreferred food for 3 children with food selectivity. In the simultaneous condition, preferred foods were presented at the same time as nonpreferred food (e.g., a piece of broccoli was presented on a chip). In the sequential condition, acceptance of the nonpreferred food resulted in presentation of the preferred food. Increases in consumption occurred immediately during the simultaneous condition for 2 of the 3 participants. For 1 participant, increases in consumption occurred in the simultaneous condition relative to the sequential condition, but only after physical guidance and re-presentation were added to treatment. Finally, consumption increased for 1 participant in the sequential condition, but only after several sessions. These results are discussed in terms of possible mechanisms that may alter preferences for food (i.e., establishing operations, flavor-flavor conditioning). (PsycINFO Database Record (c) 2007 APA, all rights reserved)
(2002). Journal of Applied Behavioral Analysis, 35(3), 259-270.

• Linscheid, T. R. (2006). Behavioral Treatments for Pediatric Feeding Disorders. Behavior Modification, 30, 6-23.
• Linscheid, T. R., Tarnowski, K. J., Rasnake, L. K., and Brams, J. S. (1987). Behavioral Treatment of Food Refusal in a Child with Short-Gut Syndrome. Journal of Pediatric Psychology, 12, 451-459.
• Linscheid, T. R., Oliver, J., Blyler, E., Palmer, S. (1978). Brief Hospitalization for the Behavioral Treatment of Feeding Problems in the Developmentally Disabled. Journal of Pediatric Psychology, 3, 72-76.