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Food refusal in children: A review of the literature

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Research in Developmental Disabilities xxx (2010) xxx–xxx

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review

Food refusal in children: A review of the literature

Keith E. Williams a,*, Douglas G. Field a, Laura Seiverling b
a
Penn State Hershey Medical Center, 905 W. Governor Road, Hershey, PA 17033, United States
b
The Graduate Center and Queens College, City University of New York, United States

A R T I C L E I N F O A B S T R A C T

Article history: Food refusal is a severe feeding problem in which children refuse to eat all or most foods
Received 14 November 2009 presented and exhibit problems with growth. This review discusses the definition,
Received in revised form 24 December 2009 etiology, and interventions pertaining to food refusal. The interventions utilized for food
Accepted 11 January 2010
refusal typically consist of several treatment components. These treatment components
are reviewed and implications for future interventions are discussed.
Keywords:
ß 2010 Elsevier Ltd. All rights reserved.
Food refusal
Feeding disorders
Behavioral interventions

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. Etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4. Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

1. Introduction

Childhood feeding problems constitute a broad spectrum, ranging from milder issues that do not involve considerable
health risks to significant problems involving malnutrition and the need for supplemental tube feeding. Children with the
most significant feeding problems are often described as having food refusal. This article provides a review of the literature,
discussing the definition, etiology, and interventions pertaining to food refusal. As will be discussed, food refusal has been
defined broadly. For purposes of this literature review, food refusal was defined as a child’s refusal to eat all or most foods
presented, resulting in the child either failing to meet caloric needs or dependent on supplemental tube feeds. Articles in
which the participants did not meet this definition were excluded. The authors searched Medline and Psychinfo from 1979 to
2008 using the key words, ‘‘food refusal’’ and ‘‘children’’ to obtain both descriptive studies of children with food refusal and
studies that described interventions for the treatment of food refusal. To ensure a more complete review, these databases
were again searched using the key words, ‘‘feeding problems’’ and ‘‘children’’. For this review, 38 intervention studies were
identified whose participants met the definition of food refusal given previously.

* Corresponding author. Tel.: +1 717 531 7117; fax: +1 717 531 0720.
E-mail address: feedingprogram@hmc.psu.edu (K.E. Williams).

0891-4222/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2010.01.001

Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in
Developmental Disabilities (2010), doi:10.1016/j.ridd.2010.01.001
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2. Definition

Food refusal has been described and defined in a variety of ways. It has been described as a general term that embraces a
wide range of a child’s feeding problems (Douglas, 2002) and alternatively as a more specific type of feeding problem, defined
as a child’s refusal to eat all or most foods presented, resulting in the child’s failure to meet his or her caloric or nutritional
needs (Field, Garland, & Williams, 2003). Food refusal has also been defined both in terms of decreased appetite (Stainano,
2003) and the specific behaviors often associated with the refusal of food such as head turning and mouth closure contingent
upon the presentation of food, spitting out food, dawdling, gagging, and even vomiting (Lindberg, Bolin, & Hagekull, 1994).
These variations in the definition of food refusal reflect the more general state of the field, where, to date, there is little
consensus on defining childhood feeding disorders and no universally accepted classification system for childhood feeding
disorders (Kedesdy & Budd, 1998).
The term, food refusal, seems to imply that the child controls his or her intake. The literature, however, suggests that food
refusal is not simply a volitional issue but rather a complex feeding problem whose development and maintenance involves
multiple factors.

3. Etiology

Feeding is a complex process and problems with any stage in the process can result in feeding disorders. It has been
suggested that feeding disorders in children are heterogeneous and may include a range of problems including medical, oral-
motor, and behavioral (Piazza, 2008). This is especially true for food refusal. A small, but growing body of work has described
a wide variety of etiological factors among children with food refusal. In a sample of 349 children with feeding problems
evaluated at a hospital-based feeding program, food refusal was found in 117 (34%) children (Field et al., 2003). Among those
diagnosed with food refusal, only one, a child with autism, did not have a comorbid medical diagnosis. While the most
common medical diagnosis found among the children with food refusal was gastroesophageal reflux (69%), other diagnoses
such as cardiopulmonary conditions (33%), neurological conditions (25%), food allergies (15%), anatomical anomalies (14%),
and delayed gastric emptying (6%) were also reported. In a subsequent study from the same feeding clinic described by Field
et al., there were 43 children diagnosed with food refusal in a sample of 234 children with feeding problems. Among the
children with food refusal, gastroesophageal reflux was found in 53% of the children, while neurological conditions and
cardiorespiratory disease were each found in 30% of children (Williams, Riegel, & Kerwin, 2009). In a sample of 72 children
dependent upon tube feedings treated at another feeding program, medical conditions were prevalent, with 83% having
oropharygeal or gastrointestinal abnormalities and 64% having cardiac, pulmonary, neurological, or genetic conditions
(Greer, Gulotta, Masler, & Laud, 2007).
Other studies have suggested medical conditions, especially disorders of the gastrointestinal tract, are related to food
refusal. Although the study did not use the term food refusal, Dellert, Hyams, Treem, and Geertsma (1993) conducted a study
of infants with gastroesophageal reflux and found a subgroup of typically developing infants who developed feeding
resistance to the point of failing to thrive and requiring supplement tube feeds. Another study which compared a sample of
infants with gastroesophageal reflux disease (GERD) to infants without reflux found the children with GERD had more food
refusal and more problems with swallowing (Mathisen, Worrall, Masel, Wall, & Shepherd, 1999). Food allergies were
diagnosed in two boys hospitalized for protein-energy malnutrition and food refusal (Fortunato & Sheimann, 2008). In both
cases, the boys refused an ever increasing number of foods until they were eating nutritionally deficient diets resulting in
numerous medical sequelae stemming from malnutrition. Gastrointestinal motility and sensory abnormalities were found
in a sample of 14 children with food refusal dependent upon tube feedings who all had retching or vomiting that persisted
after anti-reflux surgery (Zangen et al., 2003). The authors suggested that gastrointestinal motor or sensory disturbances
could lead to persistent feeding problems.
Food refusal secondary to anatomical anomalies has also been reported by several studies. Three children who exhibited
food refusal each had multiple anatomical anomalies including defects of the sternum, stenosis of the trachea, and cleft
palate (DeMoor, Didden, & Tolboom, 2005). A girl who presented with food refusal since 1 year of age was found to have a
duodenal web (Karnsakul, Gillespie, Cannon, & Kumar, 2009). Field et al. (2003) reported 14% of the children with food
refusal in their sample had anatomical anomalies and these anomalies included tracheoesophageal fistula, cleft palate, and
microgastria.
In the 38 intervention studies reviewed, there were 218 participants who received treatment (the control group of one
study was excluded). Of all participants, 212 had some form of medical issue. Of these participants with medical issues, 116
(55%) had gastrointestinal disorders (e.g. gastroesophageal reflux) and 131 (62%) had a non-gastrointestinal medical
disorder (e.g. bronchopulmonary dysplasia, seizure disorder).
The prevalence of feeding problems more generally has been found to be high among children with developmental
disabilities, with rates ranging as high as 35% (Dahl & Sundelin, 1986; Palmer & Horn, 1978). This is not surprising
given the frequency of medical conditions, especially gastrointestinal problems found among children with
developmental disabilities (Sullivan, 2008). In many of the studies examined for this review, the children who were
identified with food refusal were also diagnosed with a developmental disability. In a sample of 20 infants with
growth failure and poor feeding (e.g. turning away from feeding, crying during meals), 12 of the infants were
diagnosed with developmental disabilities (Gremse, Lytle, Sacks, & Balistreri, 1998). Developmental status was

Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in
Developmental Disabilities (2010), doi:10.1016/j.ridd.2010.01.001
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described in 34 of the 38 intervention studies reviewed and 139 of 178 children were found to have developmental
disabilities.

4. Intervention

The majority of the interventions for food refusal were implemented in either inpatient (57%) or day treatment (24%)
setting, which speaks to the severity of food refusal as a subtype of childhood feeding disorder. While the medical and
nutritional issues that are commonly comorbid with food refusal may require monitoring in a more controlled environment
such as an inpatient unit or day hospital program, studies have described the treatment of food refusal in outpatient
(Chamberlin, Henry, Roberts, Sapford, & Courtney, 1991; DeMoor, Didden, & Korzilius, 2007) and home (Luiselli, 2000;
O’Reilly & Lancioni, 2001) settings.
All of the 38 studies described interventions involving multiple treatment components and each of these studies
described at least one or more behavioral components. These 38 studies are listed in Appendix A along with a summary of
treatment procedures and participant demographics. Several of the same components described in the interventions were
reported in multiple studies. While the effectiveness of individual treatment components is not yet well understood, the
body of research investigating the effectiveness of these components through component analyses and other techniques
continues to grow.
As discussed previously, there are multiple biological conditions that may contribute to the development or
maintenance of food refusal. Gastrointestinal conditions such as gastroesophageal reflux or motility problems were cited
as examples. Despite that the majority of the intervention studies involve patients with biological conditions, the primary
focus of most food refusal intervention articles was to describe the behavioral components included in the intervention.
Thus, the medical management of these conditions, while often mentioned, was not provided in detail in most of these
studies. One notable exception was a study which examined the medical and nutritional management of a sample of 14
children with gastrointestinal motility and sensory abnormalities who had failed feeding therapy and prior medical
management of their food refusal (Zangen et al., 2003). Forty-three percent of these children began to eat orally after their
gastrointestinal abnormalities were identified and treated with medications for visceral pain or motility disorders. This
study mentioned behavioral and psychological interventions, but did not report the role of these interventions in the
resolution of the food refusal. It did, however, illustrate possible utility of medical management in the treatment of food
refusal. While the vast majority of children with food refusal do have one or more medical problems, the extent of the
medical treatment received by these children is not known and the role of medical management in the treatment of food
refusal is still unclear.
Parents are commonly advised not to reward children for eating (Birch, Marlin, & Rotter, 1984; Melanson, 2006) While
this advice may be appropriate for the majority of the pediatric population, children with food refusal who have, for reasons
discussed previously, a conditioned aversion to eating and limited motivation to eat, may be an exception to this oft used
guideline. Positive reinforcement was the most common component described in these intervention studies. In several
studies, it was stated that reinforcement could help teach children with food refusal that eating, an activity previously
associated with discomfort or even pain, is now associated with enjoyable objects or activities. Reportedly used in 37 of 38
intervention studies, reinforcement was used in a variety of ways. In one study, two children were provided praise and
access to toys after accepting bites of food (Hoch, Babbitt, Coe, Krell, & Hackbert, 1994), while in another study a child was
provided with toys during a post-meal ‘‘reward time’’, with the length of the reward time depending upon the number of
bites eaten during the meal (Luiselli, 2000). Although many of the studies used non-food reinforcers, some studies used
preferred foods as reinforcement. In an early study involving a 2-year-old girl with a complex medical history, the
consumption of solid foods, a behavior which seldom occurred, was reinforced with access to liquids, which the child
readily drank (Hatcher, 1979). One study described sensory reinforcement in the form of swinging and light provided to a
young girl with hearing and visual impairments for acceptance of food (Luiselli & Gleason, 1987). Many of the studies
stressed that the specific foods, objects, or activities used as reinforcers were specific to the individual undergoing
treatment. Studies used reinforcers that were empirically derived through standardized preference and reinforcer
assessments (Hoch et al., 1994), identified by caregiver report (Gutentag & Hammer, 2000), or determined through direct
observation (Luiselli & Gleason, 1987).
Numerous studies described children with food refusal attempting to avoid, or at least delay, eating through the use of a
variety of behaviors such as crying, tantrums, excessive talking, throwing food, and even negotiation. Caregiver responses
to such behaviors included coaxing, pleading, or yelling to induce their children to eat. These caregiver tactics were
described as being unsuccessful at decreasing these inappropriate child behaviors because these caregivers’ actions,
unintentionally, provided attention for their children’s refusal behaviors. While 21 of the 38 intervention studies
specifically mentioned purposefully ignoring a child’s inappropriate mealtime behavior, it is probable that ignoring was
used in more studies, but was not expressly described as a treatment procedure. Ignoring was often paired with providing
attention contingent upon the child exhibiting appropriate mealtime behaviors such as eating, sitting quietly, or using
utensils.
If the purpose of a child’s inappropriate mealtime behavior was to gain attention, the ignoring component described in
most studies would have been sufficient to eliminate these behaviors, as it is well established in the behavioral literature that
when a specific behavior is no longer reinforced, it extinguishes over time. However, the intervention studies have

Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in
Developmental Disabilities (2010), doi:10.1016/j.ridd.2010.01.001
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hypothesized that many children with food refusal have learned that inappropriate behaviors such as tantrums, leaving the
table, or throwing food result in their caregivers terminating the meal and thus allowing them to avoid eating. Escape
prevention has been used as a treatment component to eliminate the child’s ability to avoid eating and was described in 23 of
38 intervention studies included in this review. Variations of escape prevention depicted in the literature range in
intrusiveness from a study that describes the child being returned to his chair contingent upon leaving during mealtime
(O’Reilly & Lancioni, 2001) to a pair of early studies that mention ‘‘forced feeding’’ and restraint in the form of the child being
held during the feeding session (Blackman & Nelson, 1985; Blackman & Nelson, 1987). Most of the studies which describe
escape prevention use either physical guidance or nonremoval of the spoon. Physical guidance has been described as a
therapist physically guiding the mouth open by applying gentle pressure to the mandibular junction of the jaw contingent
upon the child refusing to accept a bite within a specified period of time (Ahearn, Kerwin, Eicher, Shantz, & Swearingin,
1996). Nonremoval of the spoon has been described as the presentation of food or drink to the child’s lip until the bite or
drink is accepted with the ignoring or blocking of all inappropriate behaviors (Hoch et al., 1994). The effectiveness of these
two procedures has been compared and both were found to increase food acceptance (Ahearn et al., 1996). One of the clear
reasons for the widespread use of escape prevention among children with food refusal is the proven success of the procedure
in increasing acceptance of food. Several studies found that positive reinforcement alone was insufficient to increase food
acceptance and acceptance did not increase until the introduction of escape prevention (Hoch et al., 1994; Piazza, Patel,
Gulotta, Sevin, & Layer, 2003). While escape prevention alone has been found to be sufficient to increase food acceptance, it
was found that combining escape prevention and reinforcement results in lower rates of inappropriate behaviors (Piazza
et al., 2003; Reed et al., 2004). Despite it effectiveness, escape prevention must be used with care and implemented as part of
an intervention developed by a therapist experienced in the behavioral treatment. Escape prevention, like all extinction
procedures, can cause negative side-effects such as crying, tantrums, spitting out food, and other inappropriate behaviors.
While these behaviors extinguish over time, persons who are implementing the feeding intervention must understand why
they occur and how to address them.
Expulsion or spitting out food is another behavior that is frequently exhibited by children with food refusal and this
behavior was reported in multiple studies. One procedure that has been used to reduce this behavior has been called
representation, which involves replacing food that has been expelled back into the child’s mouth, teaching the child that
spitting out food does not allow the child to avoid eating (Coe et al., 1997). Also an extinction procedure, representation was
reported as a treatment component in 12 of the 38 intervention studies. In every study in which representation was used, the
intervention package also included one of the variations of escape prevention just described.
Stimulus fading involves systematic changes in the stimulus, which, in the case of food refusal, is the food. One study
found decreasing the amount of food offered on the spoon increased the probability that the child would accept the bite
(Kerwin, Ahearn, Eicher, & Burd, 1995). A child who ate only lower textures was taught to accept higher textures by
systematically increasing the texture of the food (Luiselli & Gleason, 1987). Packing or holding food in the mouth is a
behavior commonly reported in children with food refusal. This behavior was also addressed through the use of texture
fading has also been used as a method for reducing packing (Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005). Another
variation of stimulus fading involved blending preferred and novel foods (Mueller, Piazza, Patel, Kelley, & Pruett, 2004). In
this study, foods were blended at ratios of 10% novel/90% preferred and 20% novel/80% preferred. The results showed
consumption of the blended foods increased the probability that novel foods would later be eaten without being blended.
Some variation of stimulus fading was described in 10 of the intervention studies.
It has been suggested that the motivation to eat is directly related to deprivation of calories making appetite
manipulation an important treatment component for food refusal (Linscheid, 2006). Ten children dependent upon tube
feeding were treated using an intervention combining hunger provocation, which involved rapidly eliminating tube feeds,
and positive reinforcement (Kindermann et al., 2008). At 6-month follow-up, eight of these ten children remained off tube
feedings. Only two other studies that utilized multicomponent interventions for food refusal specifically mentioned
appetite manipulation (DeMoor, Didden, & Korzilius, 2007; Gibbons, Williams, & Riegel, 2007), however it is not known
how tube feedings were reduced in most studies even though the elimination of tube feedings was listed as an outcome in
many studies.
A handful of studies have included treatment components to address behaviors that co-occur with food refusal. The
absence of swallowing was addressed by an intervention which involved a prompting procedure that included an eliciting
stimulus consisting of touching the right posterior portion of the tongue to elicit a swallow (Lamm & Greer, 1988). In a child
whose tongue thrust interfered with swallowing, the tongue thrust was eliminated by placing food on the tongue with a rub-
tipped brush which prevented the tongue thrust. This procedure was faded and the brush replaced with a spoon as the
tongue thrust was eliminated (Gibbons, Williams, & Riegel, 2007). It was previously mentioned that packing was addressed
through the use of stimulus fading in the form of reducing food texture (Patel et al., 2005). Redistribution or moving the food
around in the mouth contingent upon packing was also found to reduce packing and increase consumption in four children
with food refusal (Gulotta, Piazza, Patel, & Layer, 2005).

5. Conclusion

The goal of this review was to examine etiology and treatment of children with a specific severe feeding problem. To
meet this goal, only studies describing children with food refusal, defined as a child’s refusal to eat all or most foods

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presented which resulted in either the failure to meet caloric needs or dependence on supplemental tube feeds, were
included. It should be noted that most studies that used the term, food refusal, did in fact describe participants that met this
definition with only a handful of studies excluded because the participants were selective eaters who had no apparent
problems with nutrition.
Even though all of the studies in this review included participants who met the same definition of food refusal, there was
still a wide range in the complexity of the children’s medical and developmental histories. Some studies included children
with both developmental delays and significant medical issues, with the children receiving tube feedings or even central
intravenous nutrition (e.g. DeMoor et al., 2007; Handen, Mandell, & Russo, 1986). Other studies included only young children
dependent upon nasogastric tube feedings who were without anatomical, neurological, or functional conditions (e.g.
Kindermann et al., 2008). This variation in the severity of the children’s feeding and medical problems makes it difficult to
determine if an intervention that was successfully implemented in one study would have produced the same level of success
utilizing children with different characteristics or learning histories.
Several large descriptive studies of children with food refusal described children who had one or more medical conditions
that were hypothesized to be associated with their feeding problems. These same medical conditions were also found in the
descriptions of the participants of the 38 intervention studies, leading one to the conclusion that medical problems,
especially gastrointestinal problems, are predominant in the population of children with food refusal. Despite this finding,
the role of medical management in the treatment of food refusal is still not clear. While several intervention studies
mentioned the importance of treating the medical conditions that were comorbid with the child’s food refusal, in the studies
reviewed, it was not always clear how medical conditions were managed or that these conditions were managed sufficiently.
This is significant as these medical conditions were mentioned in some studies as a reason why some children were not
successfully weaned from supplemental tube feedings. Given that feeding disorders have been termed biobehavioral
problems (Kedesdy & Budd, 1998), a more complete description of the medical treatment provided to children with food
refusal should become a standard component of the intervention literature. This may provide a better guide for integrating
medical and behavioral interventions.
It is not yet possible to directly compare the effectiveness of the various intervention packages described in these studies
since the necessary research has not been conducted. The sole exception is a study which randomized children with food
refusal into either a treatment group involving a behavioral treatment package or a treatment group involving nutrition
education and meal schedules only (Benoit, Wang, & Zlotkin, 2000). While this study did show the advantage of behavioral
intervention relative to only nutritional advice, further research will need to compare the effectiveness of the various
behavioral treatment packages commonly used. Although research has shown that escape prevention was an active
treatment variable in most behavioral intervention packages (Cooper et al., 1995) and thus may be viewed as a critical and
perhaps essential treatment component in ameliorating food refusal, there is little research examining the effectiveness of
the individual components included in these intervention packages beyond reinforcement and escape prevention.
Stimulus fading has also been shown to be an effective adjunct to escape prevention. Manipulating the bite size, fading
texture of the food, and blending preferred and novel foods were all previously described as variations of stimulus fading
utilized with children with food refusal. Future interventions could utilize not only these methods, but also other forms of
stimulus fading which may make the act of eating less aversive due to presentation of small bites and gradually changing
bite size and texture. If a child views eating as less aversive, this could in turn, improve eating and decrease inappropriate
behavior.
While the use of stimulus fading to reduce response effort should certainly be considered when designing interventions,
other treatment components receiving increasing attention addresses the children’s motivation to eat. Appetite
manipulation, which involved the elimination of tube feedings, and reinforcement of food consumption has been shown
to be effective in one study (Kindermann et al., 2008). While this study did not involve the use of escape prevention, it is not
clear if the outcome obtained with the young children in this study who had limited medical and developmental problems
could be replicated with older children with a longer history of feeding problems. It may be the case that there is a continuum
of severity even within the group of children defined as having food refusal, with only a subgroup requiring escape
prevention. While the use of appetite manipulation, escape prevention, and other components have been described in
successful treatment of a 6-year-old with long-standing food refusal (Gibbons et al., 2007), the combination of these
components has, to date, not been widely used. A combination of appetite manipulation, escape prevention, and stimulus
fading may prove to be not only an effective treatment for food refusal, but this combination may also decrease the duration
of treatment.
In the intervention studies reviewed, there were 190 participants who were receiving some form of supplemental
feedings. Of these children, 113 (59%) were described as being weaned from these feedings. As we learn more about both the
effectiveness of various interventions and the variables involved in the development and maintenance of food refusal, the
percentage of children who are successfully weaned from tube feeding should increase, and hopefully, more children will be
successfully treated prior to the need for supplemental tube feedings.

Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in
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Appendix A
Developmental Disabilities (2010), doi:10.1016/j.ridd.2010.01.001
Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in

The behavioral procedures and participant demographics in the food refusal intervention studies.
Study Intervention procedures Participants and ages % with % with
medical developmental
problems delays

1. Hatcher (1979) Premack Principle 2-year-old girl 100% 100%

2. Riordan, Iwata, Finney, Wohl, Differential reinforcement, planned ignoring, simultaneous 4 children, 16–40 months of age 100% 100%
and Stanley (1984) presentation, physical guidance
3. Blackman and Nelson (1985) Forced oral feeding, differential reinforcement 9 children, aged 4–40 months 89% 89%
4. Handen et al. (1986) Demand fading, short meal duration, contingent access 7 children, aged 10–66 months 100% Unknown
to reinforcers, time out, planned ignoring

K.E. Williams et al. / Research in Developmental Disabilities xxx (2010) xxx–xxx

5. Blackman and Nelson (1987) Forced oral feeding, escape extinction, differential rein- 11 children, aged 10–29 months 91% 73%
forcement,
demand fading, texture fading
6. Luiselli and Gleason (1987) Texture fading, sensory stimulation, contingent reinforce- 4-year-old girl 100% 100%
ment
7. Lamm and Greer (1988) Graduated prompts, eliciting stimulus, positive reinforce- 3 children, aged 10–13 months 100% 100%
ment
8. Dunbar, Jarvis, and Breyer (1990) Positive reinforcement, planned ignoring, verbal repri- 3 children, aged 18–48 months 100% 67%
mand,
shaping, play facilitation
9. Chamberlin et al. (1991) Group program providing nutrition and behavior manage- 6 children, aged 12–27 months 100% Unknown
ment
information
10. Hoch et al. (1994) Positive reinforcement, escape extinction, planned ignoring 2 children, aged 25 and 41 months 100% 50%
11. Cooper et al. (1995) Contingent attention, escape extinction, representation, 4 children, aged 1 year 8 months to 6 years 2 months 100% 100%
noncontingent access to toys, choice procedure
12. Hoch, Babbitt, Coe, Duncan, Positive reinforcement, escape extinction, representation, 3.5-year-old girl 100% 100%
and Trusty (1995) swallow induction
13. Kerwin et al. (1995) Differential reinforcement of incompatible behavior, escape 3 children, aged 2.5–5 years 100% Unknown
extinction, planned ignoring, representation
14. Ahearn et al. (1996) Positive reinforcement, escape extinction, representation 3 children, aged 33–42 months 67% 67%
15. Coe et al. (1997) Differential reinforcement, escape extinction, representa- 5-year-old boy and a 2-year-old girl 100% 50%
tion
16. Foy et al. (1997) Physical restraint, praise, tube feed reduction, planned 19 children, aged 9–51 months 100% 53%
ignoring
17. Freeman and Piazza (1998) Stimulus fading, positive reinforcement, escape extinction, 6-year-old girl 100% 100%
planned ignoring
18. Didden, Seys, and Schouwink (1999) Positive reinforcement, escape extinction, shaping, planned 1.5-year-old girl 100% 100%
ignoring
a
19. Benoit et al. (2000) Escape extinction, other behavioral procedures used but 32 children, aged 4–36 months 100% 100%
not specified
20. Gutentag and Hammer (2000) Positive reinforcement, planned ignoring, texture fading 3-year-old girl 100% 100%
21. Luiselli (2000) Demand fading, visual cues, positive reinforcement 3-year-old boy 100% 0%
22. Kahng, Tarbox, and Wilke (2001) Differential reinforcement, response cost, planned ignoring 5-year-old boy 0% 100%
23. O’Reilly & Lancioni (2001) Planned ignoring, positive reinforcement, escape extinction 5-year-old girl 100% 100%
24. Patel, Piazza, Martinez, Volkert, Differential reinforcement, escape extinction, planned 3 children, aged 2–3 years 100% 100%
and Santana (2002) ignoring
25. Dawson et al. (2003) High-p instructional sequence, escape extinction, planned 3-year-old girl 100% 100%
ignoring, representation
 RIDD-860; No. of Pages 9
G Model
26. Piazza et al. (2003) Differential reinforcement, escape extinction, planned 4 children, aged 23 months to 4 years 100% 50%
Developmental Disabilities (2010), doi:10.1016/j.ridd.2010.01.001
Please cite this article in press as: Williams, K. E, et al. Food refusal in children: A review of the literature. Research in

ignoring
27. Zangen et al. (2003) Drip feeding, medication for motility, visceral pain and 14 children, aged 1.5–6 years 100% Unknown
non-specific arousal, unspecified cognitive-behavioral ther-
apy
28. Mueller, Patel, Kelly, Blending together preferred and novel foods, differential 2 children, aged 3–4 years 100% 100%
and Pruett (2004) reinforcement or noncontingent reinforcement, escape
extinction, planned ignoring
29. Reed et al. (2004) Noncontingent reinforcement, escape extinction, 4 children, aged 15 months to 4 years 75% 50%
representation, planned ignoring
30. Gulotta et al. (2005) Food redistribution, escape extinction, representation, 4 children, aged 2–5 years 100% 75%
positive reinforcement, planned ignoring
31. Patel et al. (2005) Positive reinforcement, escape extinction, representation, 3 children, aged 3–4 years 100% 100%
planned ignoring, texture fading

K.E. Williams et al. / Research in Developmental Disabilities xxx (2010) xxx–xxx

32 DeMoor et al. (2005) Texture fading, demand fading, positive reinforcement, 3 children, aged 1 year 6 months to 6 years 8 months 100% 100%
planned ignoring
33 Clawson, Palinski, and Elliott (2006) Oral-motor exercises, positive reinforcement, escape ex- 3 children, aged 15–42 months 100% 100%
tinction,
response cost, representation
34. DeMoor et al. (2007) Stimulus fading, positive reinforcement, verbal reprimand, 5 children, aged 2.5–3.3 years 100% 100%
time out, escape extinction, planned ignoring, appetite
manipulation
35. Gibbons et al. (2007) Positive reinforcement, planned ignoring, representation, 6-year-old girl 100% 100%
escape extinction, tongue thrust reduction
36. Williams, Riegel, Gibbons, Positive reinforcement, escape extinction, representation, 46 children, aged 16–133 months 100% 59%
and Field (2007) swallow induction, texture fading, response cost, token
economy, exit criterion
37. Kindermann et al. (2008) Positive reinforcement, appetite manipulation 10 children, aged 9–21 months 100% Unknown
38. Casey et al. (2008) Enriched environment, behavioral momentum, differential 8-year-old boy Unknown 100%
reinforcement, functional communication training, escape
extinction, contingent restraint, exit criterion
a
Benoit et al. used a group design with a behavioral treatment group and a nutrition counseling only group. The participant demographics for the behavioral treatment group were included.

7
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8 K.E. Williams et al. / Research in Developmental Disabilities xxx (2010) xxx–xxx

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*
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