JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2014, 47, 710–722 NUMBER 4 (WINTER)

ANALYSIS OF SELF-FEEDING IN CHILDREN WITH

FEEDING DISORDERS
KRISTI M. RIVAS, CATHLEEN C. PIAZZA, HENRY S. ROANE, VALERIE M. VOLKERT,
VICTORIA STEWART, HEATHER J. KADEY, AND REBECCA A. GROFF
UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

In the current investigation, we evaluated a method for increasing self-feeding with 3 children with a
history of food refusal. The children never (2 children) or rarely (1 child) self-fed bites of food when
the choice was between self-feeding and escape from eating. When the choice was between self-
feeding 1 bite of food or being fed an identical bite of food, self-feeding was low (2 children) or
variable (1 child). Levels of self-feeding increased for 2 children when the choice was between self-
feeding 1 bite of food or being fed multiple bites of the same food. For the 3rd child, self-feeding
increased when the choice was between self-feeding 1 bite of food or being fed multiple bites of a less
preferred food. The results showed that altering the contingencies associated with being fed
increased the probability of self-feeding, but the specific manipulations that produced self-feeding
were unique to each child.
Key words: choice, concurrent operants, feeding disorder, food refusal, food selectivity, pediatric
feeding disorders, response effort, self-feeding

Much is known about the developmental
progression of self-feeding skills in children who
eat typically (e.g., Carruth, Ziegler, Gordon, &
Hendricks, 2004). For example, before 7 months
of age, most children who eat typically are bottle
and spoon fed by a caregiver. The vast majority of
children who eat typically will use their hands to
grasp pieces of food by 7 to 11 months of age and
will eat with a spoon by 19 to 24 months, and this
progression will occur in the absence of formal-
ized intervention (Carruth & Skinner, 2002).
Surprisingly little is known, however, about the
emergence of self-feeding in children who have
been diagnosed with feeding disorders. That is,
does self-feeding emerge in children with feeding
disorders in the absence of formalized interven-
tion as it does in typically eating children, or is the
motivation to self-feed affected by their historical
avoidance of eating?
One way of answering this question is to
examine variables that affect the responding of
Address correspondence to Cathleen C. Piazza, Munroe-
Meyer Institute, University of Nebraska Medical Center,
985450 Nebraska Medical Center, Omaha, Nebraska 68198
(e-mail: cpiazza@unmc.edu).
doi: 10.1002/jaba.170
children with feeding disorders (e.g., Cooper
et al., 1999; Kerwin, Ahearn, Eicher, & Burd,
1995; Vaz, Volkert, & Piazza, 2011). For example,
Kerwin et al. (1995) evaluated the effects of
response effort on levels of acceptance and
consumption in children with feeding disorders.
In Study 1, the feeder presented the child with
varying amounts of food on a spoon, which was
conceptualized as the response-effort manipula-
tion, and acceptance resulted in access to toys and
praise. In general, as response effort increased with
increasing food volume, the probability of eating
decreased and the probability of refusal increased.
In Study 2, feeders used putative escape extinction
in the form of nonremoval of the spoon or
physical guidance to increase acceptance. Kerwin
et al. hypothesized that implementation of escape
extinction increased the aversiveness of refusal. As
the aversiveness of refusal increased, the probabil-
ity of refusal decreased, and the probability of
eating increased.
Vaz et al. (2011) applied the same conceptual
framework used by Kerwin et al. (1995) to
increase the self-feeding of one child with a
history of food selectivity. In baseline, the child
did not eat when he had the choice of feeding

710
 SELF-FEEDING 711

himself a target food or engaging in refusal METHOD

behavior. Following baseline, Vaz et al. identified Participants, Setting, and Materials
several low-preference foods, called avoidance
Three children who had been admitted to an
foods, which the feeder used in the treatment
outpatient pediatric feeding disorders program
manipulation. During treatment, self-feeding
participated. A goal of the admission was to
increased when the child had the choice of
increase self-feeding, which was the focus of the
feeding himself one bite of a target food or having
current investigation. Based on direct observation
the caregiver feed him one bite of the target food
and caregiver report, all children had the skills to
and five bites of an avoidance food.
self-feed, but none self-fed consistently at home
Vaz et al. (2011) conceptualized their manipu-
or in the clinic.
lation in terms of the response effort and quality of
The participants were Tina, Seth, and Brian for
reinforcement associated with responding. The
Experiment 1 and Brian for Experiment 2. Tina
response-effort manipulation was that self-feeding
was a 3-year-old girl who had been diagnosed
was associated with consumption of a single bite of
with status post short-gut syndrome secondary to
food and being fed was associated with consump-
gastroschisis, which resulted in a small-bowel
tion of six bites of food. Consistent with Kerwin
transplant. Before admission, she was 100%
et al. (1995), Vaz et al. hypothesized that the larger
dependent on gastrostomy (G-) tube feeding and
volume of food was more effortful to consume
parenteral nutrition; she consumed nothing by
because it required more responses. The qualitative
mouth. Seth was a 3-year-old boy who had been
manipulation was that self-feeding was associated
diagnosed with gastroesophageal reflux disease
with consumption of the relatively more preferred
and failure to thrive. Before admission, he was
target food and being fed was associated with the
100% dependent on G-tube feeding; he con-
relatively less preferred avoidance food. The
sumed nothing by mouth. Brian was a 2.5-year-
limitation of Vaz et al. was that the necessity of
old boy who had been diagnosed with pervasive
both the response-effort and quality manipulations
developmental disorder not otherwise specified
to increase self-feeding was unclear.
and no other significant medical history. Before
In the current investigation, we extended the
admission, he consumed most types of Stage 2
results of Kerwin et al. (1995) and Vaz et al.
and 3 jarred baby foods except vegetables. He
(2011) by evaluating a method for increasing self-
refused foods of any other texture. He received
feeding with three children with a history of food
100% of his liquids via baby bottle.
refusal. Before this investigation, we treated these
Sessions for Tina and Seth were conducted in
children’s feeding problems with nonremoval of
the clinic in rooms (4 m by 4 m) with one-way
the spoon with the caregiver feeding the child.
observation panels and sound monitoring. Ses-
Next, we gave each child the opportunity to
sions for Brian were conducted in the home, and
self-feed or to escape eating, and all children
sessions were observed via telehealth. Materials
frequently chose to escape eating and infrequent-
included utensils, bowls, seating equipment, food
ly chose to self-feed. We then eliminated escape
trays, gloves, timers, and laptop computers.
from eating and gave the child a choice between
being fed and self-feeding. Under this arrange-
ment, the children did not self-feed consistently. Response Measurement and Reliability
We then manipulated the number of bites (Study Observers used laptop computers to score self-
1) or the number of bites and type of food (Study fed acceptance for each bite presentation when the
2) associated with being fed until the child’s child picked up the spoon of food and placed
responding shifted from preference for being fed the entire bite past the plane of the lips and into
to preference for self-feeding. the mouth within 5 s (Tina) or 30 s (Seth and
712 KRISTI M. RIVAS et al.
Brian) of the initial presentation. We decreased
the time requirement for self-fed acceptance for
Tina because we observed that Seth and Brian
sometimes waited until the end of the 30-s
interval to self-feed the bite. Therefore, we
shortened the latency for Tina to decrease the
interpresentation interval and prevent long
pauses in this interval, which made the meal
more efficient. (We conducted the self-feeding
analysis with Seth and Brian before we conducted
it with Tina.) Observers scored a presentation
when the caregiver placed a bowl with the spoon
of food in front of the child. Data for self-fed
acceptance were converted to a percentage after
dividing occurrences of self-fed acceptance by
number of presentations.
During the food preference assessment (Brian
only), observers scored consumption when Brian
had no food larger than a pea in his mouth 30 s
after the entire bite entered the mouth, unless the
absence of food in the mouth was due to
expulsion (spitting out the food). Observers
scored avoidance when Brian contacted the
feeder’s hand or arm or the spoon, covered his
mouth, or engaged in negative vocalizations such
as screaming, crying, or saying “get it away” while
the feeder presented the bite.
Two observers recorded data simultaneously
but independently during 75%, 24%, and 45%
of self-feeding sessions for Tina, Seth, and Brian,
respectively, and 100% of stimulus preference
assessment trials for Brian. We calculated occur-
rence agreement as occurrence agreements (both
observers scored a self-fed acceptance) divided
by occurrence agreements plus disagreements
(one observer scored and the other did not score a
self-fed acceptance) and converted this ratio to a
percentage. We calculated nonoccurrence agree-
ment as nonoccurrence agreements (both ob-
servers did not score a self-fed acceptance) divided
by nonoccurrence agreements plus disagreements
and converted this ratio to a percentage. We
calculated total agreement as agreements divided
by agreements plus disagreements and converted
the ratio to a percentage. For self-fed acceptance,
occurrence agreement was 87%, 87%, and 98%;
nonoccurrence agreement was 83%, 88%, and
98%; and total agreement was 92%, 93%, and
99% for Tina, Seth, and Brian, respectively. For
the stimulus preference assessment, we calculated
agreement as occurrence (both observers scored
the behavior during the trial) plus nonoccurrence
(both observers did not score the behavior during
a trial) agreements divided by occurrence plus
nonoccurrence agreements plus disagreements
and converted this ratio to a percentage. Mean
interobserver agreement was 97% for consump-
tion and 100% for avoidance for Brian during the
stimulus preference assessment.
General Procedure
Tina’s and Seth’s mothers and Brian’s paternal
grandmother served as feeders and are henceforth
referred to as caregivers. Before this analysis,
children received feeding treatment in intensive
outpatient and outpatient clinics (Tina and
Brian) and day-treatment and outpatient clinics
(Seth) for 10, 7, and 4.5 months for Tina, Seth,
and Brian, respectively. As a result, we had
conducted caregiver training on feeding protocol
implementation for approximately 174, 45, and
74 hr with the caregivers of Tina, Seth, and Brian,
respectively, before the initiation of the self-
feeding analysis.
Caregivers selected target foods before the start
of the analysis from a list of 68 possible foods.
Target foods were the focus of the self-feeding
analysis; that is, they were the foods that the
caregiver wanted the child to self-feed. The target
foods were carrots, chicken nuggets, green beans,
hot dogs, mashed potatoes, sweet potatoes, and
tuna for Tina; bread, broccoli and cheese, carrots,
cheese, chicken, green beans, hot dogs, mashed
potatoes, peaches, pears, and waffles for Seth;
and baked beans, baked potato, bananas, carrots,
chicken, corn, green beans, macaroni and cheese,
mandarin oranges, mashed potatoes, peaches,
pears, rice, scrambled eggs, soup beans, and
spaghetti in Study 1 and the same foods except for
scrambled eggs in Study 2 for Brian.
 SELF-FEEDING
Children participated in weekly 1- to 1.5-hr
appointments. During each appointment, care-
givers conducted multiple five-bite sessions with
brief breaks between sessions. The mean number
of self-feeding sessions conducted per appoint-
ment was 4.4 for Tina, 3.8 for Seth, and 8.8 for
Brian. Before each appointment, the therapist
who coordinated the treatment selected at least
four foods from the list of caregiver-identified
target foods to present during sessions. The
therapist ensured that the caregiver presented
every target food in each phase of the analysis
with approximately equal numbers of presenta-
tions of each food within the phase. The therapist
told the caregivers which foods to bring to the
appointment. For Tina, the caregiver presented
the same four target foods in each session, with at
least one food from the food groups of protein,
starch, and vegetable (e.g., chicken, potatoes,
green beans, tuna) because she could not eat fruit
due to her medical condition. For Seth and
Brian, one target food from the food groups of
protein, starch, fruit, and vegetable (e.g., chicken,
potatoes, peaches, green beans) were presented.
The caregiver presented target foods in a
random order across sessions. The texture of
presented food was pureed table food for Tina
and Seth and finely chopped table food for Brian.
The bolus volume for target and avoidance foods
(Brian only) was 1.75 cc on a small Maroon
spoon for Tina, 2 cc on a toddler spoon for Seth,
and 4 cc on a toddler spoon for Brian. These were
the textures, utensils, and bolus sizes we had
presented in the previous treatment of the child’s
feeding problem.
Before the start of sessions, the caregiver
explained the contingencies to the child (e.g., “If
you take your bite, I will say, ‘good job.’ If you
don’t take your bite, I will feed you two bites of
the same food.”). Explanation of the contingen-
cies occurred once per appointment unless the
contingencies changed during the appointment.
In this case, the caregiver explained the new
contingencies to the child before beginning
sessions with the changed contingencies. During
713
each five-bite session, the caregiver presented
three of the foods once and one of the foods twice,
one bite at a time. The caregiver presented the
bite by placing a spoon with food in a bowl on a
table or tray in front of the child accompanied by
a prompt to “take a bite” approximately every 30 s
if the child did not self-feed the bite or 30 s after
the previous bite entered the child’s mouth. The
caregiver delivered praise (e.g., “Good job taking
your bite”) after self-fed acceptance. After the bite
entered the child’s mouth, the caregiver activated
a timer for 30 s. When the 30-s interval elapsed,
the caregiver implemented a mouth check by
saying “show me” while modeling an open mouth.
If the child did not open his or her mouth in
response to the verbal and model prompt, the
caregiver used a rubber-coated baby spoon to
prompt the child to open his or her mouth by
inserting the spoon just past the plane of the
child’s lips and turning the spoon 90°. The
caregiver delivered praise (e.g., “Good job
swallowing your bite”) if no food larger than a
pea was in the child’s mouth after the first 30-s
check for each bite and then presented the next
bite. The caregiver did not provide praise if the
absence of food was due to expulsion. The
caregiver delivered a prompt to “finish swallowing
your bite” if the child had food larger than a pea in
his or her mouth at the 30-s check and then
immediately presented the next bite. If the child
was packing, which was defined as food larger than
a pea in the mouth at the 30-s check, the caregiver
conducted checks after the caregiver had presented
the last (fifth) bite of the session and prompted the
child to swallow every 30 s until no food larger
than a pea remained in the child’s mouth.
General baseline procedure. The purpose of
the baseline was to establish levels of self-fed
acceptance when the child had the choice of self-
feeding or refusing the bite of target food. The
caregiver followed the general procedure. If the
child did not self-feed the bite, the bowl remained
on the table or tray for 30 s. After 30 s, the
caregiver removed the bowl and presented the
next bite.
714 KRISTI M. RIVAS et al.
General treatment procedure. The caregiver
followed the general procedure with the following
modifications. If the child did not self-feed the
bite, the caregiver used nonremoval of the spoon
with re-presentation of expelled bites (Hoch,
Babbitt, Coe, Krell, & Hackbert, 1994) to feed
the number and type of foods specified by the
arranged contingency described below. During
nonremoval of the spoon, the caregiver held the
spoon at the child’s lips until she could deposit
the bite into the child’s mouth. In conditions in
which the caregiver fed the child multiple bites
consecutively, she fed the child the bite that was
in the bowl in front of the child and the additional
bites from a bowl of identical target food located
on a table next to her. She fed the bites one after
the other and activated the mouth-check timer
after the prescribed number and type of bites had
entered the child’s mouth.
The caregiver re-presented expelled bites each
time an expulsion occurred. During re-presenta-
tion, the caregiver used the spoon to scoop up the
expelled food from the child’s face or bib and
placed it back into the child’s mouth using the
nonremoval procedure. If the caregiver could not
re-present the bite that had been in the child’s
mouth (e.g., it fell on the floor), the caregiver
obtained food from the bowl for the re-
presentation. If the caregiver had to re-present
food from the bowl, she estimated the amount of
food that the child expelled and re-presented the
estimated amount. If the child expelled more
than one food type (e.g., tuna and peas at the
same time), the caregiver obtained a small
amount of each food type from the bowls until
the total bolus equaled the estimated amount of
food that had been expelled.
The caregiver continued to re-present the
expelled bite until the child swallowed. Tina and
Brian did not expel during the self-feeding
analysis. Seth expelled six times in Session 12
and once in Session 30. Thus, re-presentation did
not affect session length or prevent the caregiver
from presenting the next bite on 99% of
presented bites for Seth.
Design
For the treatment-condition labels, we use the
acronyms TF and AF to represent the words
target food and avoidance food, respectively. Each
label contains two acronyms with accompanying
numbers to the left and right of a colon (e.g.,
1TF:3TF). The label to the left of the colon is
always 1TF, indicating that the caregiver pre-
sented the child with one bite of target food to
self-feed. The label to the right indicates the
number of bites and type of food the caregiver fed
to the child if the child did not self-feed. For
example, in the 1TF:2AF condition, the caregiver
presented the child with one bite of the target
food (1TF), and if the child did not self-feed the
bite of target food, the caregiver fed the child two
bites of the avoidance food (2AF). In Study 1, we
evaluated the effectiveness of treatment in an
ABCAC design for Tina, an ABCDAD design for
Seth, and an ABCDEF design for Brian. The
baseline was A, B was 1 TF:1TF, C was 1TF:2TF,
D was 1TF:3TF, E was 1TF:4TF, and F was
1TF:5TF. In Study 2, we evaluated the effective-
ness of treatment in an ABCDEAE design for
Brian. The baseline was A, B was 1TF:1AF, C was
1TF:2AF, D was 1TF:3AF, and E was 1TF:4AF.
STUDY 1: BITE-NUMBER
MANIPULATION WITH TARGET FOOD
Baseline. The caregiver followed the general
baseline procedure.
Bite-number manipulation with target food.
The caregiver followed the general treatment
procedure. If the child did not self-feed the bite of
target food independently, the caregiver fed
the child the prescribed number of bites of
the identical target food. For example, in the
1TF:2TF condition, if the child did not accept
the bite of chicken independently, the caregiver
fed the child two bites of chicken. If the child’s
self-fed acceptance did not increase across
sessions based on visual inspection of the data,
the number of caregiver-fed bites increased from
phase to phase until the child began self-feeding
 SELF-FEEDING
consistently, or we reached a maximum of
1TF:5TF. We did not go beyond 1TF:5TF
because the amount of food that the child would
have consumed at higher ratios would have been
unacceptably large.
Mean session length in minutes was 4.3 for
baseline, 4.7 for 1TF:1TF, and 3.7 for 1TF:2TF
for Tina; 4.3 for baseline, 3.9 for 1TF:1TF, 4.8
for 1TF:2TF, and 4.0 for 1TF:3TF for Seth; and
4.3 for baseline, 4.3 for 1TF:1TF, 4.2 for
1TF:2TF, 4.5 for 1TF:3TF, 5.4 for 1TF:4TF,
and 5.9 for 1TF:5TF for Brian. Mean target-bite
presentation per minute was 1.2 for baseline, 1.1
for 1TF:1TF, and 1.3 for 1TF:2TF for Tina; 1.9
for baseline, 1.3 for 1TF:1TF, 1.0 for 1TF:2TF,
and 1.4 for 1TF:3TF for Seth; and 1.2 for
baseline, 1.2 for 1TF:1TF, 1.2 for 1TF:2TF, 1.1
for 1TF:3TF, 0.94 for 1TF:4TF, and 0.84 for
1TF:5TF for Brian. These data suggest that the
caregiver was able to present target bites and the
child accepted caregiver-fed bites at approximate-
ly the same rate across conditions for Tina and
Seth. For Brian, presentation of target bites was
delayed slightly relative to baseline during the
1TF:4TF and 1TF:5TF conditions.
Results and Discussion
The results for percentage of self-fed accep-
tance for Tina (top), Seth (middle), and Brian
(bottom) appear in Figure 1. During baseline,
Tina infrequently and Seth and Brian never self-
fed bites. The probability of self-fed acceptance
increased when the ratio of self-fed to caregiver-
fed bites was 1:2 for Tina and 1:3 for Seth. Brian’s
self-feeding never increased to clinically accept-
able levels.
Kerwin et al. (1995) increased volume of food by
increasing bite size, the response-effort manipula-
tion, and observed decreases in acceptance. We
extended Kerwin et al. in that we increased volume
by increasing bite number to decrease one response
and increase an alternative response. These results
are consistent with basic studies on response effort
in that increasing response effort for one behavior
shifted responding to an alternative behavior
715
(Miller, 1968; Perone & Baron, 1980). In the
investigations by Miller and Perone and Baron, at
least one of the response choices was arbitrary (e.g.,
pulling a knob). Those investigations focused on
describing the basic effects of alterations of effort on
responding, which suggested that effortful respond-
ing is aversive. By contrast, the current investigation
focused on applying those basic findings to the
socially important behavior of self-feeding. Similar-
ly, Patel, Piazza, Layer, Coleman, and Swartzwelder
(2005) showed that as texture decreased, packing
decreased and vice versa. Patel et al. hypothesized
that participants lacked the oral motor skills to
manipulate higher textures of food; therefore,
decreasing the texture of presented food decreased
the response effort associated with eating.
Although the probability of self-feeding increased
for Tina and Seth as the number of caregiver-fed
bites increased, Brian did not self-feed consistently,
even when the ratio of self-fed to caregiver-fed bites
was 1:5. These results suggest that response-effort
manipulations may increase self-feeding in some
children with feeding disorders, but not others.
STUDY 2: BITE-NUMBER AND FOOD-
TYPE MANIPULATION
The purpose of Study 2 was to examine an
adjunctive method of increasing self-feeding for
Brian. First, we identified a low-preference food
(the avoidance food). Next, we increased the ratio
of self-fed to caregiver-fed bites as in Study 1, but
the caregiver-fed bites were presentations of the
avoidance food instead of the target food.
Stimulus preference assessment. The purpose of
this assessment was to identify an avoidance
food to use in treatment. We conducted a paired-
stimulus preference assessment based on Fisher
et al. (1992) to determine Brian’s relative
preference for the 16 foods we used in Study 1.
We used the general procedure described above
with the following modifications. The caregiver
presented two different foods by placing two
bowls with one bite of food on a spoon in each
bowl on the tray in front of Brian with the
716 KRISTI M. RIVAS et al.

Baseline 1 TF:1 TF 1 TF:2 TF BL 1 TF:2 TF

100 (BL)
PERCENTAGE OF BITES WITH
SELF-FED ACCEPTANCE

80

60

40

20
TINA
0
0 10 20 30 40 50 60 70 80 90 100 110 120

1 TF: 1 TF: 1 Target Food (TF):3 TF BL 1 TF:3 TF

BL 1 TF 2 TF
100
PERCENTAGE OF BITES WITH
SELF-FED ACCEPTANCE

80

60

40

20
SETH

0
0
0 5 10 15 20 25 30 35 40 45 50 55 60

BL 1 TF:1 TF 1 TF:2 TF 1 TF:3 TF 1 TF: 1 TF:

4 TF 5 TF
100
PERCENTAGE OF BITES WITH
SELF-FED ACCEPTANCE

80

60
BRIAN

40

20

0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
SESSION

Figure 1. Percentage of bites with self-fed acceptance for Tina (top), Seth (middle), and Brian (bottom) during Study 1.

prompt to “pick one.” The caregiver presented bowl of the nonchosen food, presented the
each food with every other food and selected the chosen food by touching the spoon to Brian’s lips
order of pairings randomly. If Brian chose a food, for 30 s, and deposited the bite if Brian opened
the caregiver provided brief praise, removed the his mouth during the 30-s interval. The caregiver
 SELF-FEEDING
did not re-present expelled bites. If Brian did not
choose or accept a bite during the 30-s interval,
the caregiver removed the bowls and presented
the next pair of foods. The results of the
preference assessment identified scrambled eggs
as the least preferred food for Brian. Thereafter,
the caregiver presented scrambled eggs only in
the avoidance procedure and did not present
scrambled eggs in the rotation of target foods in
baseline or treatment.
Baseline. The procedure was identical to that
of Study 1, except the caregiver did not present
scrambled eggs.
Bite-number and food-type manipulation. The
procedure was similar to that of Study 1, except
when Brian did not self-feed the bite, the caregiver
fed him the prescribed number of bites of avoidance
food. To illustrate, in the 1TF:3AF condition, the
caregiver presented a bite of mashed potatoes. If
Brian did not self-feed the bite of mashed potatoes,
the caregiver removed the bowl of mashed potatoes
and fed him three bites of scrambled eggs. Mean
session length in minutes across phases was 4.2 for
baseline, 5.1 for 1TF:1AF, 5.3 for 1TF:2AF, 5.3 for
1TF:3AF, and 4.9 for 1TF:4AF. Mean target-bite
presentation per minute was 1.2 in baseline, 0.99
for 1TF:1AF, 0.94 for 1TF:2AF, 0.96 for 1TF:3AF,
and 1.1 for 1TF:4AF, suggesting that the caregiver
was able to present target bites and Brian accepted
caregiver-fed bites at approximately the same rate
across conditions.
Results and Discussion
The top panel of Figure 2 shows the percentage
of consumption (solid bars) and avoidance
(dotted bars) during the preference assessment,
and the bottom panel shows the percentage of
self-fed acceptance during the self-feeding analy-
sis. During the preference assessment, Brian did
not consume four foods (chicken, scrambled
eggs, creamed corn, baked potato), which
suggested that these foods were less preferred
than the foods he consumed more frequently
during the assessment. We examined the avoid-
ance data to further discriminate Brian’s prefer-
717
ence for the four less preferred foods. Of the four
foods that Brian never consumed, he engaged in
the highest levels of avoidance behavior (20% of
trials) with the scrambled eggs; therefore, we
chose scrambled eggs as the avoidance food.
During baseline of the self-feeding analysis,
Brian infrequently self-fed target bites. He
engaged in steadily increasing levels of self-fed
acceptance when the ratio of self-fed target bites
to caregiver-fed avoidance bites was 1:4.
When effort manipulations alone were not
effective for Brian in Study 1, we evaluated his
relative preferences for the target foods and
identified his least preferred food. An alternative
method for identifying avoidance foods would be
to use caregiver report regarding foods the child
had avoided in the past or to use foods that are
consumed less often by the general population.
Consistent with Vaz et al. (2011), we conceptu-
alized presentation of the least preferred food as a
quality manipulation. When we altered effort and
quality of caregiver-fed bites, responding shifted
to self-feeding when being fed was associated with
presentation of four bites of the avoidance food.
These data replicate other studies that show
that manipulations of the parameters associated
with responding can be an effective method for
changing behavior. For example, Athens and
Vollmer (2010) evaluated the effects of alterations
of duration of, quality of, and delay to reinforce-
ment, and a combination of these parameters
during differential-reinforcement-of-alternative-
behavior schedules. Although the various manip-
ulations in isolation produced some changes in
behavior, the greatest changes occurred when
multiple manipulations occurred simultaneously.
Similarly, the greatest and most consistent changes
in behavior for Brian occurred when the caregiver
manipulated both the response effort and the
quality of food associated with being fed.
GENERAL DISCUSSION
These results are important for a number of
reasons. First, the results suggest that a history of a
718 KRISTI M. RIVAS et al.

100
CONSUMPTION
90
AVOIDANCE
PERCENTAGE OF TRIALS

80
70
60
50
40 BRIAN
30
20
10
0 Mac & Banana Baked Pears Peaches Spaghetti Mandarin Carrots Mashed Rice Green Tuna Chicken Scrambled Creamed Baked
Cheese Beans Oranges Potatoes Beans Eggs Corn Potato

FOODS
1 Target Food (TF):
1 TF: 1 TF: 4 AF Baseline (BL) 1 TF: 4 Avoidance Food (AF)
1 TF: 3 AF
BL 1 AF 2 AF

100
PERCENTAGE OF BITES WITH

90
SELF-FED ACCEPTANCE

80
70
60
50
40
30
20
10 BRIAN
0
0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180
SESSION

Figure 2. Percentage of trials with consumption (solid bars) and avoidance (dotted bars) by food during the stimulus
preference assessment (top) and percentage of bites with self-fed acceptance (bottom) for Brian in Study 2.

feeding disorder may be associated with refusal to children in this investigation was similar to our
self-feed in an age-typical manner, at least for the clinical experience that many children with severe
participants in the current investigation. The feeding disorders do not exhibit age-typical self-
children were at or beyond the age (19 to 24 feeding without intervention. The data from the
months) at which self-feeding is expected to current study suggest that this refusal may be a
emerge, yet none exhibited consistent self- function of a motivational deficit.
feeding behavior. At home, they rarely or never The results of the current investigation extend
self-fed by caregiver report, and in the clinic, self- those of Kerwin et al. (1995) and Vaz et al.
feeding was inconsistent. The failure to self-feed (2011). As Kerwin et al. noted, a history of
did not appear to be due to motor limitations, medical problems, oral-motor problems, or both,
because we had observed the children self-feed in and escape from bite presentations may bias the
the past and they were able to self-feed without responding of children with feeding problems in
assistance during treatment. The behavior of the favor of refusal. The data from the current
 SELF-FEEDING
investigation are consistent with Kerwin et al. in
that participants more often refused to eat when
given the choice between escape from eating and
self-feeding in baseline. The children also chose
to be fed either more often (Seth and Brian) or at
least some of the time (Tina) when given the
choice between being fed and self-feeding the
identical bite of food in the 1TF:1TF condition.
Recall that Vaz et al. used a combination of
effort and quality manipulations to increase self-
feeding. However, it was not clear whether
both were necessary. The results from the current
investigation suggest that different manipulations
may be necessary to alter the behavior of different
children. Nevertheless, these data provide a
model for how contingencies may be manipulat-
ed to increase self-feeding.
The model we used was one in which the first
manipulation was to increase the response effort
associated with being fed via systematic increases
in the ratio of caregiver-fed to self-fed bites of the
same food. If the response-effort manipulation
was ineffective, we then manipulated both the
effort and quality of food associated with being
fed. Although we used the model of response
effort followed by effort and quality manipu-
lations, other sequences or types of manipulations
could be the focus of future research.
One unanswered question is why different
manipulations were effective for different chil-
dren. Recall that of the three children, we used
the largest bolus size and a higher texture of food
with Brian; thus, eating for him may have been
even more effortful than for Tina and Seth. That
may be one reason Brian required manipulations
of response effort and food quality to increase
self-feeding, and this could be a topic for future
investigations. An alternative explanation is that
Brian had received the least amount of feeding
therapy of the three participants before the start
of this study. Interestingly, the number and type
of manipulations necessary to increase self-
feeding were inversely correlated with the
duration of feeding therapy. Of the three
children, Tina began self-feeding with the fewest
719
manipulations, and she had participated in
feeding therapy for the longest time. Brian began
self-feeding with the most manipulations, and
he had participated in feeding therapy for the
shortest time. However, it is not clear whether
length of feeding therapy had any impact on the
self-feeding manipulation.
These results are also important because there
have been surprisingly few investigations on
increasing self-feeding in children with underlying
feeding disorders. The majority of investigations
on self-feeding have involved participants with
disabilities who required training to master the
specific skills associated with self-feeding (Collins,
Gast, Wolery, Holcombe, & Leatherby, 1991;
Leibowitz & Holcer, 1974; Luiselli, 1991, 1993;
Piazza, Anderson, & Fisher, 1993; Richman,
Sonderby, & Kahn, 1980; Sisson & Dixon, 1986;
Stimbert, Minor, & McCoy, 1977; Thompson,
1977). Self-feeding is a behavior that is important
for the child’s socialization (i.e., for the child to be
similar to same-aged peers) and is valued by
caregivers (Schulze, Harwood, & Schoelmerich,
2001). If refusal to self-feed is, in fact, a chronic
problem for children with feeding problems, then
investigations like the current study and those of
Luiselli (2000) and Vaz et al. (2011) are important
in providing clinicians with the necessary tools to
address the problem.
The data from the current investigation also
are important because few studies have been
conducted using negative reinforcement and
both response-effort and quality manipulations
to increase a desirable behavior. Manipulations in
the majority of studies have focused on increasing
response effort of an inappropriate behavior to
decrease that inappropriate behavior (e.g., self-
injury; Hanley, Piazza, Keeney, Blakeley-Smith,
& Worsdell, 1998; Van Houten, 1993), to shift
responding from an inappropriate to a more
desirable behavior in the context of concurrent
reinforcement schedules for both behaviors (e.g.,
self-injury and toy play; Shore, Iwata, DeLeon,
Kahng, & Smith, 1997), or to test the efficacy
of different stimuli as reinforcement during
720 KRISTI M. RIVAS et al.
progressive-ratio schedules of reinforcement (e.g.,
Glover, Roane, Kadey, & Grow, 2008).
Some limitations of the study are that we did
not evaluate a positive reinforcement procedure
for self-feeding before our manipulations. Al-
though a number of studies have shown that
reinforcement for acceptance and swallowing
may be an effective treatment for food refusal
(e.g., Stark, Bowen, Tyc, Evans, & Passero, 1990;
Stark et al., 1993; Turner, Sanders, & Wall,
1994), more recent studies have demonstrated
that putative escape extinction may be a necessary
component of treatment for some children (e.g.,
Bachmeyer et al., 2009; LaRue et al., 2011;
Piazza, Patel, Gulotta, Sevin, & Layer, 2003;
Reed et al., 2004). In fact, all of the children in
the current investigation required an escape
extinction component in the initial treatment
of their feeding problem that was conducted
before the current investigation. Therefore, we
hypothesized that these children were not likely
to respond to reinforcement procedures for self-
feeding. As Kerwin et al. (1995) noted, positive
reinforcement may be a “luxury” that some
children with feeding disorders are willing to
forgo if the cost of that luxury is consumption.
Said another way, many children with feeding
problems would choose not to eat rather than eat
and access highly preferred stimuli, and it often is
difficult to identify preferred stimuli that
compete with escape from eating (Piazza et al.,
2003). Nevertheless, this hypothesis is specula-
tive, and future investigators might explore the
use of positive reinforcement or a combination
of positive reinforcement, response-effort, and
quality manipulations to increase self-feeding.
A second limitation is that the data were variable
during many of the phases. The caregiver presented
four target foods in each session, and it is possible
that this variability was due to the child’s relative
preferences for individual target foods. However,
we did not conduct a preference assessment of
foods for children in Study 1, and we did not
examine responding to individual foods. This
could be a topic for future investigations.
Another limitation is that the initial treatments
implemented before the current study to establish
consumption occurred in the context of a
caregiver feeding the child. It is possible that
this history of being fed during initial treatment
biased the children toward being fed and reduced
the probability that they would self-feed. We first
treated the children in the context of being fed
because we hypothesized that being fed was less
effortful than self-feeding and that reducing the
effort of eating was important for establishing
consumption. It is not clear whether the method
by which initial acceptance is established in
children with feeding disorders affects the
subsequent probability of self-feeding, but this
could be a topic to explore in future research.
In conclusion, we evaluated a method to
increase self-feeding by three children with a
history of food refusal. We showed that these
children often preferred to be fed when given a
choice between being fed by a caregiver or self-
feeding. We then manipulated the response effort
or response effort and quality of food fed by the
caregiver. The results showed that altering the
contingencies associated with being fed increased
the probability of self-feeding. Even though the
specific manipulations that produced self-feeding
were unique to each child, this study provides a
general model for manipulating concurrent
contingencies to increase self-feeding.
REFERENCES
Athens, E. S., & Vollmer, T. R. (2010). An investigation of
differential reinforcement of alternative behavior
without extinction. Journal of Applied Behavior Analysis,
43, 569–589. doi: 10.1901/jaba.2010.43-569
Bachmeyer, M. H., Piazza, C. C., Fredrick, L. D., Reed,
G. K., Rivas, K. D., & Kadey, H. J. (2009). Functional
analysis and treatment of multiply controlled inappro-
priate mealtime behavior. Journal of Applied Behavior
Analysis, 42, 641–658. doi: 10.1901/jaba.2009.42-641
Carruth, B. R., & Skinner, J. D. (2002). Feeding behaviors
and other motor development in healthy children (2-24
months). Journal of the American College of Nutrition,
21, 88–96. doi: 10.1080/07315724.2002.10719199
Carruth, B. R., Ziegler, P. J., Gordon, A., & Hendricks, K.
(2004). Developmental milestones and self-feeding
 SELF-FEEDING
behaviors in infants and toddlers. Journal of the
American Dietetic Association, 104, 51–56. doi:
10.1016/j.jada.2003.10.019
Collins, B. C., Gast, D. L., Wolery, M., Holcombe, A., &
Leatherby, J. G. (1991). Using constant time delay to
teach self-feeding to young students with severe/
profound handicaps: Evidence of limited effectiveness.
Journal of Developmental and Physical Disabilities, 3,
157–179. doi: 10.1007/BF01045931
Cooper, L. J., Wacker, D. P., Brown, K., McComas, J. J., Peck,
S. M., Drew, J., … Kayser, K. (1999). Use of a concurrent
operants paradigm to evaluate positive reinforcers during
treatment food refusal. Behavior Modification, 23, 3–40.
doi: 10.1177/0145445599231001
Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P.,
Owens, J. C., & Slevin, I. (1992). A comparison of two
approaches for identifying reinforcers for persons with
severe and profound disabilities. Journal of Applied
Behavior Analysis, 25, 491–498. doi: 10.1901/
jaba.1992.25-491
Glover, A. C., Roane, H. S., Kadey, H. J., & Grow, L. L.
(2008). Preference for reinforcers under progressive-
and fixed-ratio schedules: A comparison of single and
concurrent arrangements. Journal of Applied Behavior
Analysis, 41, 163–176. doi: 10.1901/jaba.2008.41-163
Hanley, G. P., Piazza, C. C., Keeney, K. M., Blakeley-Smith,
A. B., & Worsdell, A. S. (1998). Effects of wrist weights
on self-injurious and adaptive behaviors. Journal of
Applied Behavior Analysis, 31, 307–310. doi: 10.1901/
jaba.1998.31-307
Hoch, T. A., Babbitt, R. L., Coe, D. A., Krell, D. M., &
Hackbert, L. (1994). Contingency contacting: Com-
bining positive reinforcement and escape extinction
procedures to treat persistent food refusal. Behavior
Modification, 18, 106–128. doi: 10.1177/
01454455940181007
Kerwin, M. E., Ahearn, W. H., Eicher, P. S., & Burd, D. M.
(1995). The costs of eating: A behavioral economic
analysis of food refusal. Journal of Applied Behavior
Analysis, 28, 245–260. doi: 10.1901/jaba.1995.28-245
LaRue, R. H., Stewart, V., Piazza, C. C., Volkert, V. M.,
Patel, M. R., & Zeleny, J. (2011). Escape as
reinforcement and escape extinction in the treatment
of feeding problems. Journal of Applied Behavior
Analysis, 44, 719–735. doi: 10.1901/jaba.2011.44-719
Leibowitz, J. M., & Holcer, P. (1974). Building and
maintaining self-feeding skills in a retarded child.
American Journal of Occupational Therapy, 28, 545–
548.
Luiselli, J. K. (1991). Acquisition of self-feeding in a child
with Lowe’s syndrome. Journal of Developmental and
Physical Disabilities, 3, 181–189. doi: 10.1007/
BF01045932
Luiselli, J. K. (1993). Training self-feeding skills in children
who are deaf and blind. Behavior Modification, 17, 457–
473. doi: 10.1177/01454455930174003
Luiselli, J. K. (2000). Cueing, demand fading, and positive
reinforcement to establish self-feeding and oral con-
721
sumption in a child with chronic food refusal. Behavior
Modification, 24, 348–358. doi: 10.1177/
0145445500243003
Miller, L. K. (1968). Escape from an effortful situation.
Journal of the Experimental Analysis of Behavior, 11,
619–627. doi: 10.1901/jeab.1968.11-619
Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., &
Swartzwelder, D. M. (2005). A systematic evaluation of
food textures to decrease packing and increase oral
intake in children with pediatric feeding disorders.
Journal of Applied Behavior Analysis, 38, 89–100. doi:
10.1901/jaba.2005.161-02
Perone, M., & Baron, A. (1980). Reinforcement of human
observing behavior by a stimulus correlated with
extinction or increased effort. Journal of the Experimen-
tal Analysis of Behavior, 34, 239–261. doi: 10.1901/
jeab.1980.34-239
Piazza, C. C., Anderson, C., & Fisher, W. (1993). Teaching
self-feeding skills to patients with Rett syndrome.
Developmental Medicine and Child Neurology, 35, 991–
996. doi: 10.1111/j.1469-8749.1993.tb11581.x
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. doi: 10.1901/jaba.2003.36-309
Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A.,
Bachmeyer, M. H., Bethke, S. D., & Gutshall, K. A.
(2004). On the relative contributions of noncontingent
reinforcement and escape extinction in the treatment of
food refusal. Journal of Applied Behavior Analysis, 37,
27–42. doi.10.1901/jaba.2004.37-27
Richman, J. S., Sonderby, T., & Kahn, J. V. (1980).
Prerequisite vs. in vivo acquisition of self-feeding skill.
Behaviour Research and Therapy, 18, 327–332. doi:
10.1016/0005-7967(80)90091-1
Schulze, P. A., Harwood, R. L., & Schoelmerich, A. (2001).
Feeding practices and expectations among middle-class
Anglo and Puerto Rican mothers of 12-month-old
infants. Journal of Cross-Cultural Psychology, 32, 397–
406. doi: 10.1177/0022022101032004002
Shore, B. A., Iwata, B. A., DeLeon, I. G., Kahng, S., & Smith,
R. G. (1997). An analysis of reinforcer substitutability
using object manipulation and self-injury as competing
responses. Journal of Applied Behavior Analysis, 30, 21–41.
doi: 10.1901/jaba.1997.30-21
Sisson, L. A., & Dixon, M. J. (1986). A behavioral approach
to the training and assessment of feeding skills in
multihandicapped children. Applied Research in Mental
Retardation, 7, 149–163. doi: 10.1016/0270-3092(86)
90002-0
Stark, L. J., Bowen, A. M., Tyc, V. L., Evans, S., & Passero,
M. A. (1990). A behavioral approach to increasing
calorie consumption in children with cystic fibrosis.
Journal of Pediatric Psychology, 15, 309–326. doi:
10.1093/jpepsy/15.3.309
Stark, L. J., Knapp, L. G., Bowen, A. M., Powers, S. W.,
Jelalian, E., Evans, S., … Hovell, M. (1993). Increasing
722 KRISTI M. RIVAS et al.
calorie consumption in children with cystic fibrosis:
Replication with 2-year follow-up. Journal of Applied
Behavior Analysis, 26, 435–450. doi: 10.1901/
jaba.1993.26-435
Stimbert, V. E., Minor, J. W., & McCoy, J. F. (1977).
Intensive feeding training with retarded children.
Behavior Modification, 1, 517–530. doi: 10.1177/
014544557714005
Thompson, R. J., Jr. (1977). Applied behavior analysis in the
treatment of mealtime tantrums and delay in self-
feeding in a multi-handicapped child. Journal of Clinical
Child and Adolescent Psychology, 6, 52–54. doi:
10.1080/15374417709532784
Turner, K. M. T., Sanders, M. R., & Wall, C. R. (1994).
Behavioural parent training versus dietary education in
the treatment of children with persistent feeding
difficulties. Behavior Change, 11, 242–258.
Van Houten, R. (1993). The use of wrist weights to reduce
self-injury maintained by sensory reinforcement.
Journal of Applied Behavior Analysis, 26, 197–203.
doi: 10.1901/jaba.1993.26-197
Vaz, P. C. M., Volkert, V. M., & Piazza, C. C. (2011). Using
negative reinforcement to increase self-feeding in a child
with food selectivity. Journal of Applied Behavior
Analysis, 44, 915–920. doi: 10.1901/jaba.2011.44-915
Received December 15, 2011
Final acceptance May 5, 2014
Action Editor, MaryLou Kerwin
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