Student Name
Article reviewed- full citation
Brief description of article
In 2-3 bullet points
3 behavioral procedures found in article
7 dimensions of ABA
How article achieved 7 dimensions of ABA
ARTICLE REVIEW
Students will read one article from the Journal of Applied Behavior Analysis during the
course of the semester. Research articles may be found at
https://www.ncbi.nlm.nih.gov/pmc/journals/309/ or from the instructor’s personal library.
Additional guidelines for completing the review will be provided to students. Students
should read the article, paying particular attention to the methods/procedures section of
the article. In at least 3 FULL pages, students will analyze the procedures used in the
journal article, outlining each of the specific points in the article that correspond with the
appropriate section in the textbook (Mayer et al.). That is, students will show how the
procedures outlined in the text are utilized in the procedures outlined in the article,
making specific reference to sections/pages in the text. Reviews should be typed,
double spaced, in 12 point font, with no more than 1 inch margins. At the top of the
page, please put only your name; do not include the date, the class, the professor’s
name, the name of the assignment, etc. Students should also upload a copy of the
entire article used for their review to Canvas with the article review assignment. Points
will be deducted for reviews not following this format. Presentation of the article
analysis is also a component of the grade for this assignment. This assignment must
be submitted online, through Canvas, by 5:59pm on the due date.
Required information
Points Available
Student chooses an appropriate article from
JABA and behavior analysis in scope
1
Student chooses 3 principles of behavior
analysis reflected in article and explains how
these principles are supported
5
Points Awarded
Student demonstrates how 7 dimensions of 25
applied behavior analysis are shown in the
article reviewed
APA style properly followed, appropriate
citations, proper grammar and spelling
3
Presentation of article analysis to class
6
Total: 40
Total
JOURNAL OF APPLIED BEHAVIOR ANALYSIS
2012, 45, 527–537
NUMBER
3 (FALL 2012)
AN EVALUATION OF A PROGRESSIVE HIGH-PROBABILITY
INSTRUCTIONAL SEQUENCE COMBINED WITH LOW-PROBABILITY
DEMAND FADING IN THE TREATMENT OF FOOD SELECTIVITY
BECKY PENROD, LAURA GARDELLA,
AND JONATHAN
FERNAND
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
Few studies have examined the effects of the high-probability instructional sequence in the
treatment of food selectivity, and results of these studies have been mixed (e.g., Dawson et al.,
2003; Patel et al., 2007). The present study extended previous research on the high-probability
instructional sequence by combining this procedure with low-probability demand fading with 2
boys with autism (9 and 10 years old) who had a history of food selectivity and engaged in active
food refusal behaviors when presented with novel foods. Response requirements were faded
gradually from responses the child would tolerate (e.g., touching the food) to the final
requirement of chewing and swallowing the food. The antecedent-based intervention was
implemented in the absence of escape extinction and was effective in increasing food
consumption for both participants. Possible mechanisms responsible for the effectiveness of the
intervention are discussed along with directions for future research.
Key words: food selectivity, noncompliance, high-p instructional sequence, demand fading
Food selectivity has been conceptualized as a
form of noncompliance in which the child
refuses to eat a sufficient variety of food
(Dawson et al., 2003). Selective food preferences may result in inadequate daily nutritional
intake even though the child may maintain his
or her weight by eating a sufficient quantity of
preferred foods. Furthermore, children with an
autism spectrum disorder (ASD) may be
especially at risk for developing abnormal eating
behaviors of this type (Ahearn, Castine, Nault,
& Green, 2001). Several authors have suggested
that feeding problems result from a combination of environmental, behavioral, and physical
factors (Ahearn, Kerwin, Eicher, & Lukens,
2001; Freeman & Piazza, 1998).
Although the etiology of feeding disorders
varies across children, feeding problems often
The research presented in this article was completed
in partial fulfillment of thesis requirements for the MA
degree by the second author. We thank Caio Miguel for
his comments on a previous version of this manuscript
and Shu Wing Fu for her assistance in conducting this
project.
Address correspondence to Becky Penrod, Department of Psychology, California State University,
Sacramento, 6000 J Street, Sacramento, California
95819 (e-mail: penrodb@csus.edu).
doi: 10.1901/jaba.2012.45-527
persist as a result of environmental factors.
Research has suggested that reinforcement plays
a large role in the development and maintenance
of inappropriate mealtime behaviors (Freeman &
Piazza, 1998; Kern & Marder, 1996). For
example, refusing food may be positively reinforced when parents offer their child a reward
contingent on refusal behaviors rather than setting
up a contingency prior to presenting the meal
(e.g., a parent might tell the child ‘‘If you eat your
apple, you can watch a video’’). Alternatively,
inappropriate mealtime behavior may be negatively reinforced when the child is allowed to leave
the meal early contingent on such behaviors.
When attempts to introduce new foods to the
child are met with resistance, noncompliance, or
tantrums, Kern and Marder (1996) noted that
many parents often resort to offering the child a
preferred food to abate the negative behavior.
Based on this learning history, parents of selective
eaters may stop introducing new foods and
provide their children with only preferred foods
to avoid these negative mealtime behaviors.
Although complete food refusal requires
intensive, and often invasive, treatment procedures provided by a team of experienced medical
professionals, research suggests that less intrusive
527
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BECKY PENROD et al.
treatment procedures may be effective for
children who struggle with food selectivity
(Bachmeyer, 2009; Patel et al., 2007). As
mentioned previously, food selectivity has been
conceptualized as a form of noncompliance
(Dawson et al., 2003); therefore, the focus of
the current study was to evaluate two antecedent
interventions that have been previously shown to
be effective in increasing compliance. Specifically, the current study examined a high-probability
(high-p) instructional sequence and demand
fading. Instructions with a higher probability
of compliance were issued prior to an instruction
with a lower probability of compliance, and the
difficulty of low-probability (low-p) instructions
was increased gradually until the terminal
response requirement was met.
Although research has demonstrated the
effectiveness of the high-p instructional sequence for increasing compliance (e.g., Mace
et al., 1988), few studies have evaluated the
effects of the high-p instructional sequence for
the treatment of noncompliance in the form of
food selectivity. Dawson et al. (2003) evaluated
the effects of the high-p sequence alone and
combined with escape extinction (EE) relative
to EE alone in a young girl with a history of
food refusal and gastrostomy-tube dependence.
Results showed that the high-p instructional
sequence was ineffective when escape was
delivered contingent on noncompliance. Acceptance occurred only during the conditions in
which EE was implemented, regardless of the
delivery of high-p instructions. The authors
suggested that the high-p sequence was ineffective without an EE component because the
positive reinforcement available for compliance
did not compete with the negative reinforcement provided for escape behavior. However, a
potential limitation of this study was that highp instructions required simple fine motor
responses that were not related to eating, and
the low-p instructions required multiple responses (i.e., opening the mouth, chewing the
food, swallowing, and retaining the food).
Patel et al. (2007) further evaluated the
effects of high-p instructional sequences without EE in the treatment of feeding-related
noncompliance. Prior to treatment, a compliance assessment was conducted to demonstrate
that the child’s acceptance of an empty spoon
was a high-p response. The effects of the high-p
sequence were evaluated using an ABAB
reversal design. In Phase A, the therapist
presented low-p instructions every 30 s; the
therapist placed a spoonful of food in a bowl in
front of the participant and delivered up to two
verbal instructions to take a bite before
removing the bite. Verbal praise and light
physical touch (e.g., high fives) were provided
contingent on compliance. A 20-s escape period
was provided contingent on inappropriate
behavior (e.g., turning head, spitting). The
procedures in Phase B were identical to those in
Phase A, except the therapist presented an
empty spoon three times rapidly (i.e., high-p
instruction) before presenting the low-p instruction. Results showed zero compliance
when the low-p instructions were presented in
isolation and 100% compliance when the highp sequence preceded the low-p instruction.
Furthermore, the child’s mother was taught to
implement the intervention during mealtimes
following treatment. Unlike Dawson et al.
(2003), the high-p and low-p responses in this
study were topographically similar (both involved accepting a spoon); in addition, the
participant in this study engaged in what the
authors referred to as passive refusal (i.e., not
responding to bite presentations in the absence
of problem behavior) whereas the participant in
Dawson et al. displayed active refusal (noncompliance that co-occurred with problem
behavior). These discrepancies may account
for why the high-p sequence was found to be
effective in Patel et al. but not in Dawson et al.
Demand fading, in which the number of
requests to take a bite is increased gradually
(also known as bite fading), is another
antecedent intervention that has been shown
to be effective in the treatment of feeding
PROGRESSIVE HIGH-P SEQUENCE
difficulties. Najdowski, Wallace, Doney, and
Ghezzi (2003) evaluated a large magnitude of
reinforcement for the acceptance of bites in
conjunction with bite fading and EE. Initially,
an entire plate of high-preference food was
provided when the child accepted one bite of
nonpreferred food; with each increase in bite
requirement, the magnitude of reinforcement
was decreased until the child reached his
terminal bite requirement and the plate of
high-preference foods was faded completely.
Penrod, Wallace, Reagon, Betz, and Higbee
(2010) extended Najdowski et al. (2003) by
further evaluating the effects of bite fading as
one component of treatment in a sequential
component analysis. For two participants,
results were similar to those of Najdowski et
al.; food consumption increased when bite
fading was implemented in conjunction with
a large reinforcer and EE. However, for one
participant, bite fading combined with a large
reinforcer was effective in increasing food
consumption without the use of EE.
Although results of studies evaluating the
high-p instructional sequence and bite fading are
promising, these antecedent interventions may
be germane to some children only. For children
who may not tolerate even being in the presence
of certain foods or engage in active refusal, these
procedures may not be effective when implemented in the absence of EE. Therefore, the
purpose of the current study was to extend
previous research by evaluating the high-p
instructional sequence and demand fading in
the treatment of food selectivity in two boys
who exhibited active refusal. The effectiveness of
the high-p instructional sequence was evaluated
when combined with demand fading in which
response requirements consisted of graduated
approximations to the final response requirement of consumption. More specifically, the
difficulty of the low-p instructions was increased
gradually. High-p instructions that required
physical contact with the target foods (e.g.,
touching the food, smelling the food) preceded
low-p instructions, which involved increasingly
529
closer approximations to the terminal desired
response of chewing and swallowing the food
(similar to a shaping procedure).
METHOD
Participants and Setting
Two children, both with a diagnosis of ASD
and a history of food selectivity, participated.
Cole was a 9-year-old boy, and Colin was a 10year-old boy. Participants were recruited from
the Autism Center for Excellence at California
State University, Sacramento (CSUS). Children
selected as participants were required to have at
least an imitative repertoire (i.e., the ability to
copy or mimic another person’s actions) and
some listener skills (e.g., the ability to follow
one-step instructions). The children also had to
have a limited food repertoire within at least
one primary food group (i.e., fruit or vegetable,
protein, dairy, and starch), and they had to be
resistant to trying new foods. Parents were
asked to complete the Behavioral Feeding
Assessment Parent Interview to identify potential participants (Budd et al., 1992). Parents
also were interviewed to identify 12 foods that
their children did not prefer from one or more
of the food groups listed above. Prior to the
start of the study, Cole’s food repertoire was
limited to dairy, starches, and some proteins
(e.g., grilled cheese sandwiches, waffles, and
hamburgers). Colin’s food repertoire was
limited to starches and proteins (e.g., pancakes,
bacon, and hot dogs). Both participants
engaged in gagging, spitting, or vomiting when
presented with novel foods.
All treatment sessions took place in the
pediatric behavior research laboratory (measuring approximately 3.7 m by 4.6 m) on the
CSUS campus. The treatment room was
equipped with a table, chairs, and items
relevant to the feeding session (e.g., preferred
and nonpreferred foods, napkins, utensils).
Two to four consecutive sessions (i.e., alternating baseline and treatment sessions described
below), with 5-min breaks in between, were
conducted 2 to 3 days per week. Sessions were
trial based (described below) rather than time
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BECKY PENROD et al.
based, but were approximately 10 min in
duration; on average, four sessions were
completed within approximately 60 min (including breaks between sessions and time for
setup and cleanup).
Design and Response Measurement
A multielement design was used that alternated between two food groups, one associated
with baseline and the other associated with
treatment. The dependent variable was the
percentage of bites consumed as well as the
percentage of compliance with low-p instructions. Bite consumption was defined as a clean
mouth after 5 s of food acceptance, and
compliance was defined as the participant
following through with an instruction after
the first or second prompt (further described
below). Data on both child and therapist
behaviors were recorded on a trial-by-trial basis
using prepared data sheets. Child behaviors
included consumption and compliance, and
therapist behaviors included prompting and
reinforcer delivery. Percentage of bites consumed was calculated by dividing the total
number of bites consumed by 12 (the total
number of trials [each trial consisted of two
high-p instructions and one low-p instruction]
presented during the session) and converting
the result to a percentage. Percentage of
compliance was calculated by dividing instances
of compliance with the low-p instruction by 12
(the total number of low-p instructions issued
within one session) and converting the result to
a percentage. Data were analyzed by graphing
the percentage of compliance with low-p
instructions as well as the percentage of bites
consumed for each session.
Procedural integrity data were collected on
all trials for therapist prompting and reinforcer
delivery and were calculated as the total number
of correct implementations divided by the sum
of correct plus incorrect implementations; the
result was converted to a percentage. Procedural
integrity for prompting averaged 100% and
99% (range, 97% to 100%) for Cole and
Colin, respectively. Procedural integrity for
reinforcer delivery was 94% (range, 92% to
100%) and 99% (range, 97% to 100%) for
Cole and Colin, respectively.
Two independent observers collected interobserver agreement data for compliance with
low-p requests, bites consumed, and procedural
integrity measures for 36% of Cole’s sessions
and 52% of Colin’s sessions. Interobserver
agreement was calculated by dividing the total
number of agreements by the sum of agreements plus disagreements and converting the
result to a percentage. Agreement for compliance to low-p requests was defined as both
observers scoring the same behavior (compliance following the first prompt, compliance
following the second prompt, or noncompliance) for each trial. Agreement for bites
consumed was defined as both observers
marking the trial in the same way (either by
marking a plus to indicate the child swallowed
[defined as a clean mouth following acceptance]
or by marking a minus to indicate noncompliance). Agreement for procedural integrity was
defined as both observers marking the trial in
the same way for both procedural integrity
measures (marking either a plus or a minus to
indicate correct or incorrect implementation of
therapist prompting and reinforcer delivery;
observers had to agree on both measures in
order for the trial to count as an agreement).
Interobserver agreement was 100% for compliance with low-p requests, 100% for bites
consumed, and 99% (range, 94% to 100%)
for procedural integrity across both participants.
Pretreatment Preference Assessment
Prior to the start of treatment, parents were
asked to choose two nonpreferred foods from
each food group. Four foods were targeted
during treatment, and four foods were used for
baseline measures. A single-stimulus preference
assessment (Pace, Ivancic, Edwards, Iwata, &
Page, 1985) was conducted to ensure that foods
chosen by the parent were truly nonpreferred by
the participant. Prior to the assessment, the
participant was prompted to sample each food.
Each trial consisted of presenting one food item
PROGRESSIVE HIGH-P SEQUENCE
to the participant for 5 s. If he approached the
food (e.g., reached toward the food and
touched it) within the time allowed, that item
was made available for an additional 5 s. If he
failed to approach the food within 5 s, he was
prompted to ‘‘try the food.’’ If he refused the
food item during the next 5 s, the food was
removed and the next trial began. For both
participants, each of the foods included in
baseline and treatment were never approached
and consumed. Each food included in the
assessment was presented a total of three times.
Following the single-stimulus preference
assessment, a paired-choice preference assessment (Fisher et al., 1992) was conducted to
evaluate relative preferences for high-preference
(HP) foods that could be used as responsedependent reinforcement throughout each
phase. Seven items identified as preferred by
the participants’ parents were presented in
pairs, and the participant was prompted to
‘‘pick one.’’ The assessment continued until
each food had been paired with every other
food once, and the two to three food items
selected and consumed most often were
delivered contingent on compliance during
each phase. Parents were asked to restrict access
to the chosen HP food outside the treatment
sessions.
Baseline
During the initial baseline, the food group
for treatment (Group A) and the food group
for baseline (Group B) were alternated, with
each session consisting of 12 trials (i.e., four
foods each presented three times). Foods were
presented in small bite-sized pieces (e.g., a
cucumber cut into six equal pieces). In
addition, each condition was associated with
a different therapist. One bite of food at a time
was placed in front of the participant. If he did
not take a bite of food within 5 s of the
presentation, the therapist delivered a verbal
instruction (e.g., ‘‘Colin, take a bite’’). If the
participant failed to take a bite within 5 s of
the first verbal instruction, the therapist
delivered another verbal instruction. If he did
not take a bite within 5 s of the second verbal
531
instruction, the therapist removed the bite and
presented the next bite approximately 20 s
later. The therapist ignored food refusal (i.e.,
made neither eye contact with the child nor
any statements about the refusal behavior),
removed the bite of food, and began the next
trial approximately 20 s later. Food refusal was
defined as the participant vocally refusing the
food at any time after it was placed in front of
him (e.g., by saying ‘‘no’’), gagging either with
or without food in the mouth (i.e., making a
choking noise or thrusting the tongue forward
as if to expel or vomit food), food expulsion
(i.e., spitting food out after accepting it past
the plane of the lips), or vomiting (either
before or after a bite presentation). The
participant received praise contingent on
compliance following the first or second
instruction.
Instructional Procedure
Responses observed during the initial baseline determined the starting phase for each
participant. For example, if during baseline, the
participant licked the food after being instructed to ‘‘take a bite,’’ this was the starting phase at
the onset of treatment. The initial low-p
instruction for Colin was ‘‘kiss the food,’’ and
the initial low-p instruction for Cole was
‘‘balance the food on your tongue.’’ It should
be noted that, in baseline, the only instruction
presented was to ‘‘take a bite.’’
To establish a motivating operation for
compliance, the participant was permitted 10 s
of noncontingent access to the HP food at the
start of the session. Each session consisted of 12
trials with three instructions for each of four
targeted foods. Each instruction was issued in
conjunction with a model prompt (e.g., ‘‘Touch
the food’’ [while the therapist touched the food]
or ‘‘Do this’’ [while touching the food]; ‘‘Eat
your watermelon’’ [while the therapist demonstrated chewing and swallowing a bite of
watermelon]). Both high-p and low-p instructions were issued with model prompts. If
compliance did not occur after the first
instruction, the therapist repeated the instruction; if compliance still did not occur, the
532
BECKY PENROD et al.
therapist removed the bite of food and presented
the next target food approximately 20 s later.
Further, the same procedures described in
baseline were followed for refusal. Compliance
with the first two high-p instructions resulted in
praise from the therapist, and compliance with
the last instruction (low-p) resulted in praise plus
a small portion (two to three small bites) of the
HP food. Low-p instructions were issued
immediately after the delivery of high-p instructions. The criterion for moving from one phase
to the next was at least three consecutive sessions
with 100% compliance with all instructions;
however, if the participant engaged in food
refusal (specifically, gagging or vomiting), phase
changes were postponed until food refusal no
longer occurred.
It should be noted that previous low-p
instructions were issued as high-p instructions
as low-p instructions were faded in. For example,
two high-p instructions, ‘‘touch the food’’ and
‘‘smell the food,’’ might be issued prior to the
delivery of the low-p instruction, ‘‘kiss the food’’;
once the child consistently complied with the
low-p instruction, ‘‘kiss the food,’’ in the absence
of food refusal for at least three consecutive
sessions, the next low-p instruction would be
introduced in a subsequent phase and the first
high-p instruction from the previous phase
would be dropped. Instructions were presented
in the same sequence such that the previous lowp instruction would be issued as the second highp instruction (i.e., ‘‘smell the food,’’ ‘‘kiss the
food’’ [previous low-p instruction], and ‘‘lick the
food’’ [new low-p instruction]). The instructional sequence introduced across phases was as
follows: (a) touch the food, (b) smell the food, (c)
kiss the food (initial low-p instruction for Colin),
(d) lick the food, (e) balance the food on tongue
(initial low-p instruction for Cole), (f) bite the
food into two pieces, (g) eat one of the pieces, (h)
chew the food (i.e., one of the pieces) into little
pieces (this was a remedial phase added for both
participants after an unsuccessful transition to
eating one of the pieces; they were required to
chew the food until the therapist indicated it was
safe to swallow, at which point the participant
spit out the chewed food), and finally (i) swallow
the chewed food (both pieces). The initial low-p
instruction for Cole was to balance the food on
his tongue, which was preceded by the instruction to kiss the food and lick the food; hence,
Cole was never given the first two instructions
listed above (touch the food and smell the food).
It should be noted that the demand fading steps
were not selected based on a standard instructional sequence but rather on the primary
investigator’s previous clinical experience.
Once participants reached 100% compliance
with eating each bite of the target foods for
three sessions in a row, the therapist increased
the bite requirement to six bites of each target
food (a total of 24 bites of food per session). At
this point, high-p instructions no longer
preceded the terminal low-p instruction to
consume each bite of food. It was observed
that both participants immediately began eating
the target foods as soon as they were presented;
therefore, it was decided that the high-p
instructions were no longer necessary. The
criterion for completion of treatment was three
sessions of eating six bites of each of the target
foods in the absence of refusal. Next, treatment
sessions for Group A foods were alternated
between the therapist and the research assistant
who had been associated previously with
baseline to ensure that compliance was not
trainer specific and was, instead, under control
of the treatment procedures.
Posttreatment Assessment
A posttreatment preference assessment was
conducted with the baseline foods (Group B)
to determine the extent to which accepting and
swallowing generalized to other nonpreferred
foods that were not specifically targeted during
treatment. The single-stimulus preference
assessment and procedures used during the
pretreatment preference assessment were conducted as described previously. Each food was
presented to the participant for 5 s. If he
approached the food, it was made available for
an additional 5 s; however, if he did not
PROGRESSIVE HIGH-P SEQUENCE
533
Figure 1. Percentage of compliance (top) and percentage of bites consumed (bottom) for Cole during baseline and
treatment.
approach the food within the time allowed, the
therapist presented the high-p and low-p
instructions until the participant stopped
complying.
Follow-up
Follow-up sessions were scheduled after
completion of the treatment sessions as an
additional evaluation of generalization and
maintenance outside the experimental setting.
Follow-up sessions were conducted at the
participant’s home with the experimenter and
parent present, and the parent was taught to
implement the treatment procedure with the
baseline foods (Group B). The starting instruc-
tion for baseline foods was determined by the
level of compliance observed with the low-p
instructions during the posttreatment preference assessment. Follow-up sessions occurred 3,
6, and 12 weeks after completion of treatment.
RESULTS
Figure 1 (top) depicts Cole’s compliance to
low-p requests across baseline and treatment
phases. Compliance remained at zero during
baseline when the low-p instruction (i.e., take a
bite) was presented in isolation and increased
only when demand fading was employed in
534
BECKY PENROD et al.
Figure 2. Percentage of compliance (top) and percentage of bites consumed (bottom) for Colin during baseline and
treatment.
combination with the high-p sequence preceding low-p instructions. Compliance decreased
when the therapist presented the low-p instruction to eat one of the pieces of food; therefore, a
subsequent remedial phase was added in which
the therapist instructed Cole to chew the bite of
food into little pieces. When the remedial phase
was introduced, compliance returned to 100%
and remained high for the remainder of
treatment sessions. Once Cole was chewing
and swallowing each of the four target foods,
the therapist associated with baseline alternated
conducting treatment sessions with the experimenter (with the same Group A foods);
compliance and bite consumption (Figure 1)
remained at 100% with this therapist, demon-
strating that the increase in consumption was
not trainer specific.
Figure 1 (bottom) depicts Cole’s bite
consumption across phases. During the first
two phases following baseline, Cole was not
required to consume any of the food. In the
third phase, when the low-p instruction to ‘‘eat
one of the pieces’’ was introduced, consumption increased to and remained at 25%. With
the introduction of the remedial phase (low-p
instruction to chew the food into little pieces),
bite consumption decreased to zero until Cole
was instructed to swallow the chewed pieces.
Once this phase was introduced, bites consumed increased to 100% within two treatment
sessions.
PROGRESSIVE HIGH-P SEQUENCE
Figure 2 (top) depicts Colin’s compliance to
low-p instructions across both baseline and
treatment phases. Compliance remained at zero
during baseline sessions and increased only
when demand fading was employed in combination with the high-p sequence preceding lowp instructions. Compliance decreased when the
therapist presented the low-p instruction to eat
one of the pieces of food; therefore, a remedial
phase was implemented in which the therapist
instructed Colin to chew the bite of food into
little pieces. When the remedial phase was
introduced, compliance returned to 100% and
remained high for the remainder of treatment
sessions. Similar to Cole, once Colin was
chewing and swallowing each of the four target
foods, the therapist associated with baseline also
conducted treatment sessions (with the same
Group A foods); compliance and bite consumption (Figure 2) remained at 100% with
this therapist, demonstrating that the increase
in consumption was not trainer specific.
Figure 2 (bottom) depicts Colin’s bite
consumption across phases. He was not required to consume any of the food until Session
54, when consumption increased to 42%;
however, with the introduction of the remedial
phase (low-p instruction to chew the food into
little pieces), bite consumption decreased to
zero until he was instructed to swallow the
chewed pieces. Once this phase was introduced,
bites consumed increased to and remained at
100% within two treatment sessions.
Although data on the frequency of specific
refusal behaviors were not collected, anecdotally, both boys primarily engaged in vocal
protests during baseline. During treatment,
when compliance was at 100%, refusal generally did not occur. For both participants, when
the instruction to eat one of the pieces was
introduced, compliance dramatically decreased
and there was a concomitant increase in refusal;
during this phase, gagging and, on occasion,
vomiting were observed in conjunction with
vocal protests.
535
Prior to completion of treatment, bite
requirements were expanded systematically by
increasing the volume of food required for
consumption prior to receiving reinforcement.
At the end of treatment, Cole was eating one
slice of watermelon, six kernels of corn, two
strawberries, and one slice of cucumber per
session. Colin was eating nine bites of chicken,
nine noodles, four baby carrots, and nine bites
of banana per session. For both participants, two
treatment sessions were conducted each day.
During the posttreatment assessment with
Group B foods, neither participant consumed
any of the foods presented, suggesting that
preference for and generalization to nontargeted
foods did not occur. Therefore, each food in
this group was presented to the child following
the aforementioned instructional sequence. The
first instruction at which compliance no longer
occurred was the starting point for parent
training. The starting instructions for Cole and
Colin were ‘‘balance food on tongue’’ and ‘‘lick
the food,’’ respectively. During three follow-up
visits, both Cole’s and Colin’s mothers were
taught to implement treatment during mealtimes at home. Compliance and bite consumption for both participants remained at 100%
during parent implementation of treatment.
DISCUSSION
This study sought to examine the effects of a
proactive feeding intervention that used high-p
instructional sequences in combination with
low-p demand fading in the absence of EE.
Results corroborated those of Patel et al.
(2007), suggesting that antecedent-based treatments may increase food consumption in the
absence of EE or physical guidance. The study
also extends previous research on the high-p
instructional sequence. The feeding intervention increased consumption for both Cole and
Colin despite active refusal (e.g., spitting,
gagging, and vomiting), which had not been
observed by Patel et al. Active refusal was
observed by Dawson et al. (2003), and the
536
BECKY PENROD et al.
high-p instructional sequence was not effective
in increasing food consumption in the absence
of EE. This led the authors to suggest that
antecedent-based treatments are ineffective
when escape is provided for refusal.
As noted previously, a possible reason for the
discrepant results between Dawson et al. (2003)
and Patel et al. (2007) is that the high-p
instructional sequence used in Dawson et al.
involved motor responses that were not related
to eating, whereas the low-p response was a
more complex behavior that involved multiple
steps associated with eating (i.e., opening the
mouth, chewing the food, and swallowing). As
in Patel et al., our high-p and low-p instructions
were both related to eating; however, our high-p
responses required physical contact with the
target foods. In addition, demand fading was
implemented in conjunction with the high-p
instructional sequence; specifically, high-p and
low-p instructions built on each other as the
participants moved across phases. With the
introduction of each low-p instruction, a closer
approximation to the terminal response of
chewing and swallowing was required. This
may have been a contributing factor to the
acquisition of eating observed in the current
study. In other words, it is possible that the
procedure responsible for the increase in food
consumption was the demand fading component and not the high-p instructional sequence.
Future research should evaluate the relative
effects of demand fading alone and in combination with the high-p instructional sequence.
An important finding of the current study
was that the increase in food consumption was
maintained across people and environments.
Cole’s compliance and consumption remained
at 100% when his mother was taught to
implement the treatment procedure at home.
This is promising given that there are more
opportunities to conduct treatment sessions
throughout the day when at home (e.g., at each
mealtime), whereas the number of treatment
sessions per day may be limited in a clinical
setting. In addition, because this feeding
intervention did not require EE and was not
time consuming, teachers or clinicians may be
successful in implementing this treatment in a
school setting, again increasing the child’s
opportunity to contact novel foods.
Although this study adds to the literature on
the use of the high-p instructional sequence in
the treatment of food selectivity, several
limitations should be addressed in future
research. First, the hierarchy of instructions
was selected somewhat arbitrarily. The starting
phase for treatment was based on behaviors
observed in baseline following the instruction to
‘‘take a bite’’; however, the escape contingency
for noncompliance may have prevented opportunities to observe other behaviors. It is possible
that participants may have complied with later
steps in the hierarchy of instructions in spite of
noncompliance with earlier steps; future research should conduct a compliance assessment
for each step prior to selecting the starting phase
for treatment. In addition, the last fading step
was not probed prior to advancing phases;
therefore, some of the fading steps may not
have been needed.
The total quantity of food consumed during
treatment sessions may seem negligible given
the number of sessions to complete treatment.
Participants were given only a limited amount
of food. Initially, 12 small bites were presented
(three bites of four different foods) during each
session. Although the bite requirement was
increased from 12 bites to 24 bites (six bites of
four different foods) per session, the size of the
bites was not increased. It is possible that
participants would have consumed a greater
quantity of food if given the opportunity. The
bite sizes were not increased to avoid the
possibility of satiation because more than one
treatment session was conducted per day.
Other limitations include procedural differences across baseline and treatment conditions
that make it difficult to draw definitive
conclusions regarding the procedures responsible for increased compliance and food consumption. One procedural difference was that
PROGRESSIVE HIGH-P SEQUENCE
only vocal instructions were presented in
baseline whereas in treatment, both high-p
and low-p instructions were delivered in
conjunction with a model prompt; thus, it is
possible that modeling may have played a role
in the increase in food consumption observed
during treatment. In addition, HP foods were
delivered for compliance with low-p instructions in treatment but only social praise was
delivered contingent on compliance during
baseline. Thus, it is possible that the increase
in compliance and food consumption during
treatment was a result of reinforcement in the
form of HP foods.
Finally, a possible mechanism of behavior
change may have been repeated exposure to novel
foods. Participants had greater exposure to the
treatment foods during treatment than during
baseline. Specifically, during baseline, foods were
presented directly in front of the participant.
Contingent on refusal, the foods were removed
and placed off to the side such that they were only
peripherally visible. In treatment, foods also were
removed and placed off to the side contingent on
refusal; however, the foods remained directly in
front of the participant after compliance with
both high-p and low-p instructions. Given that
compliance never occurred in baseline, one might
argue that the participants had more direct
exposure to the treatment foods. Furthermore,
during treatment, participants were asked to
engage in behaviors that simulated aspects of
eating the food, which may have desensitized
them to the actual behavior of eating rather than
just tolerating being in the presence of the food.
Anecdotal observations, however, indicated that
participants often played with the baseline foods
(e.g., touching, rolling, picking apart), which
suggests that they were no less desensitized to the
treatment foods than they were to the baseline
foods.
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Received June 22, 2011
Final acceptance January 20, 2012
Action Editor, Jennifer Zarcone
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