pediatric feeding
TRANSCRIPT
Pediatric Feeding Disorders: A Quantitative Synthesisof Treatment Outcomes
William G. Sharp • David L. Jaquess •
Jane F. Morton • Caitlin V. Herzinger
Published online: 16 September 2010
� Springer Science+Business Media, LLC 2010
Abstract A systematic review of the literature regarding
treatment of pediatric feeding disorders was conducted.
Articles in peer-reviewed scientific journals (1970–2010)
evaluating treatment of severe food refusal or selectivity
were identified. Studies demonstrating strict experimental
control were selected and analyzed. Forty-eight single-case
research studies reporting outcomes for 96 participants
were included in the review. Most children presented with
complex medical and developmental concerns and were
treated at multidisciplinary feeding disorders programs.
All studies involved behavioral intervention; no well-
controlled studies evaluating feeding interventions by other
theoretical perspectives or clinical disciplines met inclu-
sion criteria. Results indicated that behavioral intervention
was associated with significant improvements in feeding
behavior. Clinical and research implications are discussed,
including movement toward the identification of key
behavioral antecedents and consequences that promote
appropriate mealtime performance, as well as the need to
better document outcomes beyond behavioral improve-
ments, such as changes in anthropometric parameters,
generalization of treatment gains to caregivers, and
improvements in nutritional status.
Keywords Autism spectrum disorders � Behavioral
intervention � Evidence-based treatment � Failure to thrive �Feeding � Feeding disorders � Mealtime problems
Introduction
Eating is an essential human activity, necessary to sustain
life and ensure growth, but it also is a common challenge
for children and a source of stress for caregivers. Up to
40% of toddlers and early school-age children experience
some mealtime difficulties (Manikam and Perman 2000;
Mayes and Volkmar 1993). Issues include ‘‘picky’’ eating
patterns, strong food preferences, behaviors aimed at end-
ing meals prematurely (e.g., whining, crying, pushing food
away), and/or fluctuating hunger (Reau et al. 1996). Mild
difficulties typically resolve spontaneously or with low
intensity interventions, such as caregiver education in food
preparation/presentation, and/or nutritional guidance
(Greer et al. 2009; Kerwin 1999). Between 3 and 10% of
children, however, develop chronic feeding issues
exceeding ordinary developmental variation and possibly
associated with a number of negative medical and devel-
opmental outcomes (Kerwin 1999). These include growth
retardation, malnutrition, developmental and psychological
deficits, poor academic achievement, social difficulties,
invasive medical procedures (e.g., placement of a feeding
tube), or death (Benoit 1993; Chatoor 2002; Finney 1986).
Feeding problems of this magnitude are characterized as
‘‘feeding disorders’’ due to their chronic and more severe
course, often involving the complex interplay among
biological, psychological, and social factors and requiring
intensive intervention to avoid long-term medical and
developmental sequelae (Babbitt et al. 1994; Lindberg
et al. 1991; Sanders et al. 1993).
W. G. Sharp (&) � D. L. Jaquess � J. F. Morton �C. V. Herzinger
Marcus Autism Center, Atlanta, GA, USA
e-mail: [email protected]
D. L. Jaquess
e-mail: [email protected]
W. G. Sharp � D. L. Jaquess � J. F. Morton
Emory University School of Medicine, Atlanta, GA, USA
123
Clin Child Fam Psychol Rev (2010) 13:348–365
DOI 10.1007/s10567-010-0079-7
The process of assessing and treating severe feeding
disorders is complicated by a number of interrelated factors.
The psychiatric diagnosis of ‘‘Feeding Disorder of Infancy
or Early Childhood’’ is non-specific, encompassing children
who fail to eat a sufficient quantity and/or variety of food
resulting in chronic malnutrition, poor weight gain and/or
weight loss before age 6 years in the absence of an active
organic complaint (American Psychiatric Association
2000). The medical diagnosis for these disorders ‘‘Feeding
Difficulties and Mismanagement’’ is similarly broad,
(World Health Organization 2009). Children meeting these
criteria represent a heterogeneous group with numerous
etiological pathways. A variety of organic factors that lead
to difficult or painful eating may precipitate or play a role in
the development of feeding concerns. These include (1)
metabolic abnormalities or defects in absorption that
accompany conditions such as cystic fibrosis, mitochondrial
disease, short bowel syndrome, or lactose intolerance; (2)
gastrointestinal issues involving persistent emesis and/or
diarrhea (e.g., gastroesophageal reflux, gastroenteritis,
dysmotility), (3) structural or anatomical defects (e..g,
bronchopulmonary dysplasia, malrotated intestine, micro-
gnathia), (4) oral motor deficits (dysphagia), and 5) hyper-
sensitivity to food tastes, smells, and textures (Arvedson
2008; Babbitt et al. 1994; Sanders et al. 1993). Children
with no known organic factors, however, also develop
severe feeding problems, suggesting that additional causal
factors result in maladaptive feeding patterns.
Children with developmental disabilities are also at high
risk for developing feeding disorders (Babbitt et al. 1994).
Approximately one-third of all children with develop-
mental disabilities experience a clinically significant
feeding concern (Dahl and Sunderlin 1986; Palmer and
Horn 1978; Palmer et al. 1975). Common issues include
lack of independent self-feeding skills, disruptive mealtime
behaviors, and/or limited intake related to food selectivity
(Munk and Repp 1994; Sisson and Van Hasselt 1989).
Prevalence estimates have been reported to be much higher
among certain subgroups. For example, up to 89% of
children with autism spectrum disorders (ASD) display
strong preferences for certain foods (by type, texture, color,
or packaging), consume a narrower range and quantity of
food when compared with peers, and/or display elevated
rates of disruptive behavior when presented with non-pre-
ferred food (Ahearn et al. 2001; Bowers 2002; Collins,
et al. 2003; Cornish 1998, 2002; Field et al. 2003; Schreck
et al. 2004). In past reports, the emergence and mainte-
nance of severe feeding problems in ASD often has no
identifiable organic factors or gastrointestinal etiology,
leading to the hypothesis that aberrant feeding habits
among those with ASD may be a manifestation of
restricted interests, behavioral rigidity, and/or persevera-
tion (Ledford and Gast 2006).
Significant feeding disturbances have also been reported
among children with no clear physiological precursor or
developmental issues and may continue in children whose
organic issues are resolved. Causal factors in these cases are
believed to include disrupted family functioning and mal-
adaptive patterns of reinforcement (Babbitt et al. 1994).
Potentially problematic feeding practices include lack of
structure conducive to eating (e.g., unrestrained access to
food; irregular mealtimes), exposure to developmentally
inappropriate textures, and/or parental modeling of inap-
propriate eating habits (Sanders et al. 1993). Many long-
standing feeding problems involve learned behaviors whose
function is to escape unpleasant feeding experiences and/or
gain attention from caregivers (Piazza, Fisher et al. 2003).
Behavioral mismanagement in the form of positive rein-
forcement (e.g., caregiver attention for inappropriate
behaviors) and negative reinforcement (e.g., removing food
and/or ending meals due to problem behaviors) may inad-
vertently shape and strengthen problem behaviors. When a
caregiver inadvertently reinforces problem behaviors, those
behaviors tend to become more frequent or intense, which, in
turn, may lead to greater efforts to manage problem behav-
iors. The resulting coercive cycle often terminates only after
the child or caregiver withdraws from the feeding situation or
stops responding altogether. At the familial and inter-sys-
temic levels of analysis, critical developmental experiences
are circumvented or severely disrupted (Davies et al. 2006).
Without direct intervention, this pattern is likely to increase
in frequency and severity over time (Lindberg et al. 1991).
Given this breadth of diagnostic inclusion and possible
etiological pathways, feeding disorders often include more
than one causal factor and involve a wide range of topog-
raphies. Typical consumption involves a number of suc-
cessive steps: bringing a bite to the lips, accepting food into
the mouth, chewing and forming a bolus, and swallowing
(Gulotta et al. 2005). When this process is interrupted,
problems may arise at different points along this chain of
consumption, which further complicates the diagnostic and
intervention picture (Riordan et al. 1980; Sevin et al. 2002).
For example, some children display disruptive behaviors
(e.g., head turning, batting at the spoon) that interfere with
accepting a bite into the mouth, while other children fail to
consume an adequate volume of food due to packing or
expelling bites. In addition, treatment resolving refusal at
one point along the chain of consumption (e.g., acceptance)
can lead to a collateral increase in topographies of food
refusal further down the chain (e.g., expulsions, packing)
after a child is accepting bites without difficulty (Gulotta
et al. 2005). This presents a unique challenge for caregivers
and professionals addressing feeding concerns, with the
goal of an intervention often shifting over time.
The multifaceted and mercurial nature of severe feeding
problems combined with their complex biopsychosocial
Clin Child Fam Psychol Rev (2010) 13:348–365 349
123
etiology intensifies the need to identify evidence-based
treatments. Although numerous researchers have docu-
mented treatment outcomes for feeding disorders, few
attempts have been made to summarize or evaluate this body
of evidence (see Kerwin 1999; Ledford and Gast 2006;
Williams et al. 2010). Kerwin conducted the first compre-
hensive literature review in this area, summarizing studies
published between 1970 and 1997. Twenty-nine studies were
identified as meeting the methodological criteria of the Task
Force on Promotion and Dissemination of Psychological
Procedures (1995) of the American Psychological Associa-
tion, all of which involved behavioral intervention. Differ-
ential reinforcement (DRA) contingent upon appropriate
eating behaviors, ignoring inappropriate response, and
physically guiding appropriate feeding responses were
identified as effective interventions. DRA of acceptance in
combination with escape extinction (EE) procedures target-
ing avoidance of food in the form of non-removal of the spoon
(NRS, e.g., Ahearn et al. 1996a, b) or swallow elicitation
(e.g., Hagopian et al. 1996) was identified as a promising
intervention. Kerwin acknowledged that non-behavioral
interventions may be effective in treating feeding problems
but noted the need for well-controlled studies by other theo-
retical perspectives or disciplines. In addition, the review
highlighted the need to investigate the setting in which
evidence-based treatments are developed and evaluated.
Subsequent less comprehensive literature reviews by
Ledford and Gast (2006) and Williams et al. (2010) added
support for the effectiveness of behavioral intervention to
address chronic feeding concerns. Ledford and Gast
focused specifically on the treatment of children with ASD
and feeding difficulties, reviewing studies with experi-
mental control published between 1994 and 2000. Nine
single-case design studies were identified, all involving one
or more behavioral elements to address severe food
selectivity. In each case, the use of behavioral intervention
was associated with significant improvements in the variety
and/or quantity of food consumed. Strategies included
DRA, simultaneous and/or sequential presentation of pre-
ferred and non-preferred food, EE, and stimulus fading
(Ahearn 2003; Najdowski et al. 2003; Piazza et al. 2002).
More recently, Williams et al. (2010) identified 38 inter-
vention studies (published between 1979 and 2008) tar-
geting children with food refusal, defined as refusing to eat
all or most foods resulting in a failure to meet caloric needs
or reliance on supplemental tube feedings. In all 38 studies,
improvements in oral intake were reported, with more than
half of the children who received some form of supple-
mental tube feeds being described as weaned from these
feedings. Treatments were primarily multidisciplinary and
involved one or more behavioral interventions incorporated
into larger treatment packages at inpatient (57%) or day
treatment (24%) feeding programs. Common treatment
elements included DRA, EE, and stimulus fading. While
providing an updated survey the literature, Williams and
colleagues did not screen the studies in terms of method-
ological rigor or experimental control.
Kerwin’s (1999) work and subsequent reviews provided
an important springboard for research focusing on the spe-
cific etiological factors associated with feeding problems
and treatments effecting their remediation, while also laying
the groundwork for an updated quantitative review of the
literature. The past decade has seen a significant increase in
the number of studies focusing on the analysis and treatment
of severe feeding disorders, yielding important data
regarding key treatment elements and outcomes. In addition,
statistical procedures for estimating and combining the size
of treatment outcomes for both group and single-case studies
have also been developed and refined (Busk and Serlin
1992). With these advances in place, the current review
seeks to: (1) survey the medical, habilitative, and psycho-
logical literature, focusing on identifying studies using strict
methodological rigor and experimental control to investigate
interventions aimed at improving intake among children
with severe feeding disorders; (2) determine the overall
effect size of identified treatments using statistical proce-
dures for synthesizing outcome data; and (3) describe the
treatment elements, population, and settings associated with
significant improvements in feeding patterns.
Method
Study Identification and Eligibility Criteria
Studies investigating the treatment of pediatric feeding
disorders were identified through searches of the MedLine
and PsychINFO databases. The search parameters included
combinations of the following key words: feeding, food
refusal, feeding disorder, pediatric feeding disorders,
treatment, intervention, behavioral, psychosocial, family
therapy, psychodynamic, pediatric dysphagia, oral motor,
and nutrition. These search terms were expressly selected in
order to capture all experiments demonstrating efficacy of
treatments across possible disciplines or theoretical for-
mulations providing feeding therapy. In addition, references
in identified articles were evaluated for possible inclusion.
The central inclusion criterion for the review was the
use of an experimental design to investigate treatment
outcomes, including the use of a control group with group
designs or experimental single-case research methodology
(e.g., changing criterion, reversal, alternating treatments,
multiple baseline). This excluded group designs without
randomization to a control condition and single-case
studies using simple AB designs if no additional experi-
mental elements were incorporated into the study to control
350 Clin Child Fam Psychol Rev (2010) 13:348–365
123
for alternative hypotheses. In addition, studies needed to
meet the following criteria:
1. The article was published in an English language peer-
reviewed journal between January 1970 and June
2010.
2. The study evaluated the effects of an intervention
aimed at treating children (birth to 18 years of age)
presenting with severe feeding disorders characterized
by chronic food refusal, tube/bottle dependence, food
selectivity, and/or poor oral intake.
3. The intervention aimed at improving solid food intake,
not liquids. Studies focusing only on reducing problem
behaviors (e.g., expulsions; packing) or analyzing the
function of refusal behaviors, including descriptive and
functional analysis, were excluded if this was the sole
purpose of the study, and no data on intake during
treatment were presented. Studies evaluating the
impact of antecedent manipulations (e.g., food texture;
presentation methods) on refusal behaviors were also
excluded if the analysis did not focus on changes in
intake from baseline levels.
4. The dependent variable(s) was a measure of food
intake (e.g., acceptance; swallowing; grams).
5. Children meeting the Diagnostic and Statistical Man-
ual-IV (DSM-IV-TR; American Psychiatric Associa-
tion 2000) criteria for anorexia nervosa, bulimia
nervosa, binge-eating disorder, or eating disorder not
otherwise specified were excluded from the review.
Articles describing children with rumination, pica,
vomiting, rapid and/or messy eating, poor table
manners, lack of utensil use, and/or lack of self-
feeding skills were excluded from the review unless
these behaviors interfered with appropriate nutritional
intake and/or promoted tube dependence.
Studies involving both group and single-case designs
were initially considered for inclusion in the meta-analysis;
however, since only three studies with group design
involved experimental control (i.e., Benoit et al. 2000;
Stark et al. 1996, Turner et al. 1994), those studies were
reviewed separately. The present meta-analysis focused on
combining findings from studies involving single-case
designs. Other group studies consisted of program evalu-
ations that lacked experimental control or involved a single
demonstration of positive outcomes (e.g., Berger-Gross
et al. 2004; Greer et al. 2009; Kindermann et al. 2008;
Williams et al. 2007). Outcomes from group studies will be
discussed below in relation to the results of the meta-
analysis.
In order to provide data appropriate for single-case
meta-analytic procedures (described below), three addi-
tional criteria were used to select single-case articles for
inclusion in the analysis: (a) The effect of the intervention
was empirically measured and graphically illustrated with
clearly identifiable baseline and treatment phases for each
participant. Repeated data points, not mean scores or
trends/lines, had to be reported; (b) Reliability data (e.g.,
interobserver agreement) was provided in the article and
reached at least 80% for each dependent measure; and (c) If
an article included multiple participants or studies, only
partially meeting inclusion criteria, only those participants
or components that met criteria were included in the
review.
Quantifying Treatment Outcomes of Feeding
Interventions
A quantitative synthesis of findings from single-case
research relies on the availability of graphs published in
articles and involves quantifying data points for the anal-
ysis, rather than relying solely on visual inspection to
determine treatment effectiveness (Busk and Serlin 1992).
Several commonly used metrics for quantifying treatment
outcomes include mean baseline reduction (MBLR), stan-
dard mean difference (SMD), percentage of non-overlap-
ping data (PND), and/or percentage of zero data (PZD; see
Campbell 2003 for review). These metrics provide overall
estimates of treatment effectiveness but are not considered
traditional effect size measures because the relative
standing of the average treatment point within a population
distribution is not reported (Herzinger and Campbell 2007).
Regression-based approaches, such as d (Cohen 1988),
have also been developed. Recent studies indicate that
MBLR, SMD, PND, PZD, and regression-based measures
are comparable in detecting treatment effects in single-case
meta-analysis (Campbell 2004).
PND was selected as the non-regression metric in this
analysis. This statistic involves determining the percentage
of treatment data not overlapping with baseline data. Cal-
culations involved dividing the number of treatment data
points exceeding the highest baseline data point by the total
number of data points in the treatment phase and multi-
plying this value by 100 (Scruggs et al. 1987). Possible
scores range from 0 to 100%, with higher scores reflecting
more effective treatments. To address the influences of
outliers, the stringent conventions set forth by Scruggs
et al. were adopted, with a PND score recorded as zero
when a single baseline data point reached ceiling level on
the dependent variable of interest.
A number of considerations guided the selection of
PND. The primary focus was to quantify results of treat-
ments aimed at increasing appropriate intake of food,
which eliminated measures designed to quantify results of
studies involving behavioral reduction (e.g., PZD, MBLR).
In addition, some effect size measures (e.g., MBLR, SMD)
Clin Child Fam Psychol Rev (2010) 13:348–365 351
123
require variability in the baseline and/or treatment phase(s)
in order to complete the calculation and/or lack conven-
tions for addressing floor or ceiling levels. Many studies in
this review involved no variability during baseline and/or
treatment phases (e.g., no acceptance of food before
intervention). Finally, standards are available for evaluat-
ing and easily communicating treatment effectiveness
(Scruggs and Mastropieri 1998); PND scores below 50%
represent ‘‘ineffective’’ treatments, scores between 50 and
70% reflect ‘‘questionable’’ treatments, scores from 70 to
90% are associated with ‘‘effective’’ treatments, and scores
above 90% reflect ‘‘highly effective’’ treatments.
Non-overlap of all pairs (NAP), a recently developed
index of data overlap in single-case research, was selected
as a confirmatory measure of treatment outcomes (Parker
and Vannest 2009). Although less established in the liter-
ature, NAP holds some advantages over PND. NAP
represents a variation of an established effect size known in
various forms as area under the curve (AUC), the common
language effect size (CL), and Mann–Whitney’s U,
producing a non-parametric distribution that permits
questions regarding the probability a score drawn at ran-
dom from treatment to exceed or overlap that of a score
drawn from baseline. Each baseline data point is compared
with each treatment phase data point, with the total number
of possible overlapping pairs (Total N) representing the
number of data points in baseline multiplied by the number
of points in treatment (N baseline 9 N treatment). NAP is
calculated by dividing the number of pairs that do not
overlap by the total number of possible pairs. Possible
scores range from 0 to 1 (higher scores reflecting more
effective treatments). The result yields a nomothetic effect
size that can be interpreted in relation to effect sizes that
have gained wide acceptance in large-scale group studies,
with formulas available for estimating Cohen’s d and R
squared from NAP (Parker and Vannest 2009).
Variables Coded, Data Extraction, and Reliability
Data were extracted from articles using a two-phase
system. An initial screening of all articles identified through
the literature search was conducted to determine eligibility
and extract descriptive information. Six researchers were
trained to collect information regarding participant demo-
graphic variables, intervention targets, study descriptors,
and treatment techniques/protocols. Characteristics in each
of these categories were coded using a system modeled after
previous single-case reviews (Herzinger and Campbell
2007) and involved a checklist system for recording vari-
ables (available upon request from the first author).
Demographic information included age, gender, develop-
mental concerns (e.g., autism spectrum disorders, mental
retardation), medical issues (e.g., gastroesophageal reflux,
food allergies), and feeding concerns (e.g., food selectivity;
tube dependence). The study’s primary intervention target
(e.g., acceptance, swallowing) was recorded, and variations
in operational definitions were noted.
Study descriptors included journal, year of publication,
experimental design, number of participants, and reliability
of observation. Experimental designs coded included non-
experimental, reversal, multiple treatment reversal, multi-
ple baselines, alternating treatments, changing criteria or
some combination of these methods. Intervention data
coded included type of intervention, treatment setting, and
follow-up data. Treatment techniques were coded as
involving (a) extinction-based procedures (e.g., NRS,
physical guidance [PG], non-removal of food/ignoring
disruptions), (b) reinforcement procedures (e.g., differen-
tial reinforcement), (c) enriched feeding environments
involving non-contingent access (NCA) to preferred items/
attention, (d) antecedent manipulations (e.g., texture, bite
size), and (e) combinations of these techniques. If rein-
forcement was implemented, the density of the reinforce-
ment schedule (e.g., continuous, fixed ratio) was also
included if available. The treatment setting (e.g., school,
outpatient, day treatment, inpatient) and primary therapist
(e.g., parent, teacher, trained therapist) were also identified
for each study. The unit of measurement, in terms of days,
weeks, and/or treatment sessions, was documented and, if
conducted, the type of contact (e.g., phone, clinic visit),
time frame, and stability at follow-up were recorded.
The second phase of data extraction involved converting
raw data displayed in the primary articles to a standardized
metric by measuring with a ruler the distance between the
horizontal (X) axis and the bottom of each data point in
millimeters. Similar data conversion procedures have been
shown to have a high degree of inter-rater reliability in
previous meta-analyses (Allison et al. 1995; Campbell
2003). Decision rules were established for selecting which
data to include in the calculation for PND and NAP.
Reviewed articles varied in the number of participants,
outcomes measured and/or experimental design (e.g.,
ABAB, ABAC, multi-element). When more than one par-
ticipant and/or feeding related behavior was included in a
study and separate data points were graphically illustrated,
outcomes were documented for each behavior of each
participant. Implemented in previous research (e.g., Herz-
inger and Campbell 2007), this allows all available data
across participants and outcomes to be included in the
analysis. Because treatment effects were evaluated sepa-
rately for each dependent variable across studies, this
procedure does not inflate the impact of data from a par-
ticular study; in addition, it eliminates potential bias in
selecting which variable should be included in the review.
When a design involved multiple phases, only the first
baseline phase and the last treatment phase were included,
352 Clin Child Fam Psychol Rev (2010) 13:348–365
123
as recommended by Faith et al. (1996) and applied in
similar review studies (e.g., Campbell 2003). In studies
involving multi-element designs conducted across baseline
and treatment phases, a single effect size was calculated
only if both treatment paths were presented in the baseline
and final treatment phases. This allowed analysis of overall
treatment effect rather than breaking down individual
treatment elements. PND and NAP were calculated using
all data points in the first baseline and last treatment pha-
ses, allowing for common outcome metrics to be generated
for all studies.
Twenty-seven percent of the articles (n = 13) in this
analysis were randomly selected for independent coding by
two trained staff to calculate inter-rater reliability. These
articles involved 23 different participants (24% of all par-
ticipants) contributing data for 32 separate dependent
variables (29% of all outcomes). For descriptive informa-
tion extracted during the review process, inter-rater
agreement was calculated through the percent agreement
method: # agreements/(# agreements ? # disagree-
ments) 9 100, as well as the Kappa statistic. The mean
inter-rater agreement across all variables was 94.1% (range
87.5–100%) with a corresponding Kappa of .8 (range .7 to
.99). For quantitative information extracted via ruler, reli-
ability was calculated on all individual data points using
Spearman’s q. The overall inter-rater reliability for quan-
titative data was q = .942. Inter-rater agreement for both
qualitative and quantitative exceeded the 80% acceptable
standard of agreement widely adopted and recommended
during quantitative synthesis of single-case research (e.g.,
Campbell 2003). To further ensure the accuracy, the first
author conducted a second review of all articles included in
the study, focusing on potential areas of discrepancy
highlighted by the inter-rater analysis and consensus with
the second author was reached in cases of ambiguity.
Results
Characteristics of Studies and Participants
The search yielded 48 studies meeting inclusion criteria out
of a pool of 124 possible articles, resulting in 96 partici-
pants included in the summary. Table 1 presents descrip-
tive and experimental characteristics of the identified
studies. More than half of the studies were published after
2000, indicating a recent increase in studies employing a
high degree of experimental control to investigate the
treatment of severe feeding problems. Interestingly, only 9
of the 29 studies identified by Kerwin (1999) were included
in the present review. The other 20 studies did not meet the
present inclusion criteria because they focused on inde-
pendent feeding skills or healthy eating habits (n = 11) or
liquid intake (n = 1), did not present individual data points
and/or reliability data (n = 6), or analyzed treatment out-
comes using a group design (n = 3). Studies meeting
inclusion criteria were published in 14 journals, with the
Table 1 Description of studies and experimental characteristics
Characteristic n %
Journal title
Journal of Applied Behavior Analysis 25 52.1
Behavior Modification 7 14.6
Behavioral Interventions 3 6.3
Journal of Behavioral Therapy and Experimental Psychiatry 2 4.2
Education and Treatment of Children 2 4.2
American Journal of Mental Retardation 1 2.1
Applied Research in Mental Retardation 1 2.1
Childcare, Health, and Development 1 2.1
Focus on Autism and Other Developmental Disabilities 1 2.1
Journal of Clinical Child Psychology 1 2.1
Journal of Behavioral Education 1 2.1
Journal of Developmental and Physical Disabilities 1 2.1
Journal of Intellectual Disability Research 1 2.1
Journal of Positive Behavior Interventions 1 2.1
Total studies 48
Number of participants contributed per study
1 25 52.1
2 7 14.5
3 8 16.7
4 7 14.6
5 1 2.1
Total participants 96
Study breakdown (n = 48)
Year published
2000–2010 29 60.4
1990–1999 13 27.1
1980–1989 6 12.5
Primary experimental design
Reversal 20 41.7
Multiple baseline 11 22.9
Changing criterion 7 14.6
Multielement and reversal 5 10.4
Multielement 2 4.2
Multielement and multiple baseline 2 4.2
Multiple baseline and reversal 1 2.0
Unit of measurement reported for data collection
Sessions 28 58.3
Meals 11 22.9
Days 7 14.6
Weeks 2 4.2
Inter-rater reliability of observations by study: M = 96.7;
SD = 3.5; range = 85–100
% Calculated based on total sample n = 82
Clin Child Fam Psychol Rev (2010) 13:348–365 353
123
Journal of Applied Behavior Analysis contributing the
largest number of articles (52.1%). All studies recorded
discreet behaviors through direct observation. Inter-rater
reliability of overall observations exceeded the inclusion
criterion of 80% agreement, with an average of 96.7%
across all studies.
Participant characteristics are presented in Table 2. The
mean age of participants was 4 years; however, the sample
captured a wide age range (10 months to 14 years).
Feeding tube dependence was the most prevalent feeding
concern (44.8% of participants), followed by food selec-
tivity (31.3%), bottle/liquid dependence (15.6%), and poor
oral intake (8.3%). Only a small subgroup of participants
(10.5%) were described as ‘‘typically developing’’, with
most cases (65.6%) identified as having a developmental
issue in addition to a feeding disorder. Developmental
concerns were most often described as global develop-
mental delays (31.2%), followed by, ASD (23.7%), intel-
lectual disability (21.5%), and language/speech issues
(9.7%). Consistent with the literature to date, 90.9% of
children with ASD (20 of 22 cases) presented with food
selectivity rather than food refusal, X2(1, N = 22) = 14.7,
p \ .0001, representing the majority (67%) of participants
identified as food selective. Medical concerns were com-
mon, with 67.7% of the sample having at least one reported
medical concern. Forty of the sixty-five children (61.5%)
presented with multiple medical issues, suggesting severe
feeding problems often co-occur with complex medical
histories. A significant number of children with feeding
tube dependence (42 out of 43) had one or more medical
issues, X2(1, N = 43) = 36.1, p \ .0001. In contrast, only
5 of the 22 children with ASD also had medical issues
reported.
Intervention Characteristics
All of the studies meeting inclusion criteria emphasized
behavioral interventions. While a few articles described
conceptualization or treatment approaches through family
therapy, psychodynamic, sensory therapy or oral motor
therapy, no actual outcomes of treatment effectiveness
were included in these articles. A few articles described
medication interventions in pre- post-treatment studies for
small groups of patients; however, none of them included a
control group. Among the behavioral interventions
reviewed, EE was the most widely applied intervention,
with 83.3% of the treatments involving some form of this
procedure. NRS, which involves keeping a bite at the lips
and ignoring problem behaviors until acceptance occurs,
was used is 47.9% of the studies, whereas PG, or the use of
a prompt to open the mouth if a bite was not initially
accepted, was used in 20.8% of studies. Although often not
explicitly described by their authors as EE, a quarter of the
studies (25%) involved treatments in which children were
asked to feed themselves and refusal behaviors were placed
on extinction with a less intrusive level of prompting (i.e.,
‘‘non-removal of the food’’ by ignoring disruptive behav-
iors plus redirecting a child back to the table in response to
leaving plus not removing the food for a set amount of
time). DRA was also a common treatment element, with
reinforcement of acceptance or swallowing cited in 77.1%
of studies. A smaller number of studies (10.4%) involved
Table 2 Description of participants
Characteristic n %
Age (in months) M = 48.06; SD = 30.47;
range 10–168
Gender
Male 62 64.6
Female 34 35.4
Total 96
Feeding concerns
Feeding tube 43 44.8
Food selectivity 30 31.3
Bottle/liquid dependence 15 15.6
Poor oral intake 8 8.3
Developmental issues
Reported 63 65.6
Not reported 23 23.9
‘‘Typically developing’’ 10 10.5
Breakdown of developmental issuesa
Developmental delay 29 31.2
Autism spectrum disorder 22 23.7
Mental retardation 20 21.5
Speech/language delay 9 9.7
Other 4 4.3
Medical issues
Reported 65 67.7
Not reported 31 32.3
Breakdown of medical issuesa
Failure to thrive 25 26.0
Gastroesophageal reflux 21 22.8
Gastrointestinal problems 14 15.2
Anatomical abnormalities 10 10.9
Genetic disorder 10 10.9
Pulmonary disorder/dysfunction 7 7.6
CNS disorder/malformation 6 6.5
Prematurity 4 4.3
Food allergies 3 3.3
Cardiac impairment 2 2.2
Other 11 12.0
a Subheadings may not add up to 100% due to multiple medical or
developmental issues per participant
% Calculated based on total sample, n = 92
354 Clin Child Fam Psychol Rev (2010) 13:348–365
123
procedures aimed at enriching the feeding environment by
providing access to social attention and preferred tangible
objects throughout the meal session regardless of a child’s
feeding behavior. Although often referred to as ‘‘non-
contingent reinforcement,’’ the present review uses the
more precise term ‘‘non-contingent access to preferred
items’’ (NCA). Items selected for use during DRA or NCA
procedures included preferred toys and activities, as well as
highly preferred foods. Empirical procedures for identify-
ing highly preferred leisure items, such as paired choice
preference assessments (e.g., Fisher et al. 1992), were cited
in 17 studies (45.9%) implementing DRA and NCA pro-
cedures. Less common (10.4% of studies) were punish-
ment-based procedures (e.g., response cost; time-out). In
addition to consequence-based procedures, antecedent
manipulations, including modifying food texture, spoon
volume, and/or number of bites per meal, were cited in
47.8% of studies. Forty-three studies (89.6%) incorporated
more than one element in a ‘‘treatment package’’. The most
common packages involved EE and DRA (17 studies) or
EE, DRA and antecedent manipulations (13 studies).
Treatment settings included hospital inpatient units
(43.8% of studies), followed by home/school (29.2%), day
treatment programs (16.7%), outpatient clinics (10.4%),
and residential facilities (6.3%). While most participants
(60.4%) received treatment in an inpatient or day treatment
setting, there was a notable trend in terms of the setting
in which certain feeding issues were addressed. A sig-
nificant proportion of children with tube (69.7%;
X2[3, N = 43] = 47.14, p \ .0001) and bottle dependence
(87%; X2[2, N = 15] = 19.2, p \ .0001) were treated at
inpatient or day treatment facilities. In contrast, no sig-
nificant difference in treatment setting was detected for
children treated for food selectivity (inpatient/day treat-
ment: n = 8; home/school: n = 15; outpatient: n = 5;
residential facility: n = 2).
Trained therapists were identified as treatment providers
in 81.3% of studies, with fewer outcomes documented with
parents or teachers serving as primary interventionist from
the onset of the study. Length of intervention, derived from
the horizontal axis of treatment graphs, was most often
presented as 5 or 10 bites sessions (58.3% of studies),
followed by meals (22.9%), and days (14.5%). Two studies
presented data in terms of weeks. The average number of
sessions was 76 (SD = 45), number of meals was 76
(SD = 37), days in treatment was 47 (SD = 11), and
weeks in treatment was 26 (SD = 20). Although the
process was implied in most articles, only 58.3% of studies
documented systematic training to generalize treatment
gains to caregivers. Follow-up was reported in 52.1% of
the studies, all of which reported sustained or improved
feeding outcomes. Table 3 presents a detailed breakdown
of the intervention characteristics by study.
Dependent Variables
Acceptance of food into the mouth was the most frequent
measure of food intake (72.9% of studies), although studies
varied with regard to how acceptance was operationally
defined (see Table 4). The definition often included a time
limit for the bite to pass the lips after the initial presenta-
tion for acceptance to be scored (e.g., 5 s acceptance).
Acceptance was typically presented as a percentage of total
bites entering the mouth during a session or meal (60.4% of
studies); less common (12.5%) were studies presenting
frequency data (e.g., number of bites accepted; number
bites accepted per minute). To increase the consistency
among outcome measures, studies that presented both the
number of bites accepted and bites refused per session/
meal were converted to a percentage of bites accepted if
these values equaled the total number of bite presented.
Swallowing of bites was a less frequent measure of food
intake (27.1% of studies). Swallowing was typically
assessed by having the feeder examine the inside of the
child’s mouth. Similar to acceptance, many definitions
included an element of time, such as rapid swallowing
defined as swallowing before 30 s (i.e., mouth cleans).
Outcomes were most often presented as percentage of bites
swallowed per session or meal, representing 22.9% of
studies; only two studies presenting frequency data for this
variable. As with frequency of acceptance, data were
converted to percentages where possible. Finally, six
studies presented data on the total volume of food con-
sumed measured in grams or cubic centimeters.
The decision rules adopted for this review allowed
results for a single participant to contribute to more than one
dependent measure. Only six studies, however, presented
data on two measures of food intake (i.e., four with per-
centage acceptance and swallowing; one with percentage
acceptance and grams and one with number of bites
accepted and grams). This resulted in 14 participants
(14.6% of the sample) contributing to more than one effect
size calculation, resulting in a total of 109 effect size esti-
mates across the three categories of dependent measures.
Treatment Outcomes
The overall mean PND for all outcome measures was
87.95% (SD = 29.54%), with a range of 0–100% (See
Table 4). This falls in the effective range of treatment
outcomes based on Scruggs and Mastropieri (1998) crite-
ria. PND scores were high across dependent variables
(range 81.75–98.85%), with all values falling in the
effective to very effective ranges. PND scores were con-
sistent across measures of acceptance (Percentage Data:
M = 87.87%; Frequency Data: M = 88.8%), falling in the
effective treatment range, based on established standards.
Clin Child Fam Psychol Rev (2010) 13:348–365 355
123
Ta
ble
3In
terv
enti
on
char
acte
rist
ics
by
stu
dy
Stu
dy
Tre
atm
ent
elem
ents
Set
ting
Exti
nct
ion
Non-
rem
oval
of
the
spoon
Physi
cal
guid
ance
Ignori
ng/n
on-
rem
oval
of
pla
te/
food
Dif
fere
nti
al
rein
forc
emen
t
Non-
conti
ngen
t
acce
ss
Ante
ceden
t
man
ipula
tion/
fadin
g
Punis
hm
ent
Oth
erIn
pat
ient
Day
trea
tmen
t
Outp
atie
nt
Hom
e/
school
Gro
up
hom
e/
resi
den
tial
faci
lity
Ahea
rn(2
003
)X
X
Ahea
rnet
al.
(1996a)
Xx
xX
X
Ahea
rnet
al.
(1996b
)X
xx
XX
Ander
son
and
McM
illa
n(2
001
)X
xX
X
Cas
eyet
al.
(2006
)X
xX
X
Cas
eyet
al.
(2009
)X
xX
X
Coe
etal
.(1
997
)X
xX
X
Cooper
etal
.(1
999
)X
xX
XX
Cooper
etal
.(1
995
)X
xX
XX
Daw
son
etal
.(2
003
)X
xX
DeM
oor
etal
.(2
007
)X
xX
XX
X
Did
den
etal
.(1
999
)X
xX
XX
Duker
(1981
)X
xX
X
Fre
eman
and
Pia
zza
(1998
)X
xX
X
Gen
try
and
Luis
elli
(2008
)X
xX
X
Gre
eret
al.
(1991
)X
XX
Hoch
etal
.(1
994
)X
xX
X
Hoch
etal
.(2
001
)X
xX
X
Johnso
nan
dB
abbit
t(1
993
)X
xX
XX
Kah
ng
etal
.(2
003
)X
xx
XX
X
Kah
ng
etal
.(2
001
)X
XX
Ker
nan
dM
arder
(1996)
Xx
XX
Ker
win
etal
.(1
995
)X
xx
XX
Lam
man
dG
reer
(1988
)aX
XX
XX
X
Lev
inan
dC
arr
(2001
)X
XX
Luis
elli
(1994
)X
X
Luis
elli
(2000
)X
xX
XX
Luis
elli
etal
.(1
985)
Xx
XX
Luis
elli
and
Gle
ason
(1987
)X
xX
XX
McC
artn
eyet
al.
(2005
)X
xX
XX
Muel
ler
etal
.(2
004
)X
xX
XX
X
Naj
dow
ski
etal
.(2
003
)X
xX
XX
Naj
dow
ski
etal
.(2
010
)X
xX
XX
X
O’R
eill
yan
dL
anci
oni
(2001
)X
xX
X
Pat
elet
al.
(2002
)X
xX
X
Pat
elet
al.
(2002
)X
xX
XX
356 Clin Child Fam Psychol Rev (2010) 13:348–365
123
Ta
ble
3co
nti
nu
ed
Stu
dy
Tre
atm
ent
elem
ents
Set
ting
Exti
nct
ion
Non-
rem
oval
of
the
spoon
Physi
cal
guid
ance
Ignori
ng/n
on-
rem
oval
of
pla
te/
food
Dif
fere
nti
al
rein
forc
emen
t
Non-
conti
ngen
t
acce
ss
Ante
ceden
t
man
ipula
tion/
fadin
g
Punis
hm
ent
Oth
erIn
pat
ient
Day
trea
tmen
t
Outp
atie
nt
Hom
e/
school
Gro
up
hom
e/
resi
den
tial
faci
lity
Pat
elet
al.
(2007
)X
XX
Pia
zza
etal
.(2
003)a
Xx
xX
XX
Pia
zza
etal
.(2
002)a
Xx
XX
X
Ree
det
al.
(2005
)X
xX
X
Ree
det
al.
(2004
)X
xX
X
Rio
rdan
etal
.(1
984
)X
xX
XX
Rio
rdan
etal
.(1
980
)X
xX
XX
Sev
inet
al.
(2002
)X
xX
Tar
box
etal
.(2
010
)X
xX
X
Wer
leet
al.
(1993)
Xx
XX
X
Wil
der
etal
.(2
005
)X
X
Wood
etal
.(2
009
)X
xX
XX
n40
23
10
12
37
522
52
21
85
14
3
%O
fto
tal
studie
s(n
=48)
83.3
47.9
20.8
25.0
77.1
10.4
45.8
10.4
4.2
43.8
16.7
10.4
29.2
6.3
Stu
dy
Pri
mar
yth
erap
ist
Gen
eral
izat
ion
Tra
ined
ther
apis
tP
aren
tT
each
erF
oll
ow
-up
report
ed(Y
/N)
Par
ent
trai
nin
gre
port
ed(Y
/N)
Ahea
rn(2
003
)X
X
Ahea
rnet
al.
(1996a)
XX
Ahea
rnet
al.
(1996b
)X
XX
Ander
son
and
McM
illa
n(2
001)
XX
Cas
eyet
al.
(2006
)X
X
Cas
eyet
al.
(2009
)X
XX
Coe
etal
.(1
997
)X
Cooper
etal
.(1
999
)X
XX
Cooper
etal
.(1
995
)X
XX
X
Daw
son
etal
.(2
003
)X
DeM
oor
etal
.(2
007
)X
XX
Did
den
etal
.(1
999
)X
XX
Duker
(1981
)X
X
Fre
eman
and
Pia
zza
(1998
)X
Gen
try
and
Luis
elli
(2008
)X
X
Gre
eret
al.
(1991
)X
Hoch
etal
.(1
994
)X
XX
Hoch
etal
.(2
001
)X
X
Clin Child Fam Psychol Rev (2010) 13:348–365 357
123
Ta
ble
3co
nti
nu
ed
Stu
dy
Pri
mar
yth
erap
ist
Gen
eral
izat
ion
Tra
ined
ther
apis
tP
aren
tT
each
erF
oll
ow
-up
report
ed(Y
/N)
Par
ent
trai
nin
gre
port
ed(Y
/N)
Johnso
nan
dB
abbit
t(1
993
)X
Kah
ng
etal
.(2
003
)X
X
Kah
ng
etal
.(2
001
)X
X
Ker
nan
dM
arder
(1996)
XX
Ker
win
etal
.(1
995
)X
X
Lam
man
dG
reer
(1988)a
XX
X
Lev
inan
dC
arr
(2001
)X
Luis
elli
(1994
)X
XX
Luis
elli
(2000
)X
XX
Luis
elli
etal
.(1
985)
XX
X
Luis
elli
and
Gle
ason
(1987
)X
X
McC
artn
eyet
al.
(2005
)X
XX
Muel
ler
etal
.(2
004
)X
X
Naj
dow
ski
etal
.(2
003
)X
XX
Naj
dow
ski
etal
.(2
010
)X
XX
O’R
eill
yan
dL
anci
oni
(2001
)X
XX
Pat
elet
al.
(2002
)X
Pat
elet
al.
(2002
)X
Pat
elet
al.
(2007
)X
XX
Pia
zza
etal
.(2
003)a
XX
X
Pia
zza
etal
.(2
002)a
X
Ree
det
al.
(2005
)X
Ree
det
al.
(2004
)X
Rio
rdan
etal
.(1
984
)X
XX
Rio
rdan
etal
.(1
980
)X
X
Sev
inet
al.
(2002
)X
Tar
box
etal
.(2
010
)X
XX
Wer
leet
al.
(1993)
XX
Wil
der
etal
.(2
005
)X
Wood
etal
.(2
009
)X
n39
91
28
25
%O
fto
tal
studie
s(n
=48)
81.3
18.8
2.1
58.3
52.1
aS
tudie
sin
volv
ing
mult
iple
par
tici
pan
tsre
ceiv
ing
trea
tmen
tin
dif
fere
nt
sett
ings
358 Clin Child Fam Psychol Rev (2010) 13:348–365
123
PND scores regarding swallowing varied slightly according
to whether percentage (M = 81.75) or frequency data
(M = 98.85) were reported, falling in the effective and
highly effect ranges, respectively. Studies reporting vol-
ume of food consumed during meals had a mean PND of
95.80%, which falls in the highly effective range.
NAP values reflected similar levels of improved per-
formance, with an overall mean NAP score of .96
(SD = .12; range of .29 to 1). The size of the treatment
effect was large for overall outcomes (d = 2.46), with all
values across measures of acceptance reflecting large
treatment effects by conventional standards (range
d = 1.81–2.89). No subgroup differences in effectiveness
were detected in terms of feeding concern and treatment
setting. However, the high degree of heterogeneity among
the sample in terms of outcome measures, presenting
problem, and the aforementioned trend for different types
of feeding issues addressed in settings with varying
intensity levels may represent an uncontrolled bias in this
analysis. Treatment elements were not evaluated separately
due to lack of sufficient studies with single treatment
packages appropriate for this level of component analysis.
Medical and Nutritional Outcomes
Outcomes beyond behavioral change were not consistently
documented. Tube reductions were reported in 25 of 43
children (58.1%) reliant on this method for their nutritional
needs. In the remaining 14 cases, although improved intake
was implied, specific volume reductions associated with
treatment were not specified. Of the 25 cases reporting on
tube feedings, they were eliminated in 16 cases (64%) and
reduced by an average of 57.1% (range 42–60%) in 7
cases. Two cases involved a specific volume of tube
reduction per day (e.g., 6 oz), but improvement was not
translated into a percentage of daily needs. Less outcome
data were available for bottle/liquid dependence, poor oral
intake, or food selectivity. Five of the fifteen cases (33%)
involving bottle/liquid dependence provided data regarding
improved intake, all noting discontinuation of bottle feed-
ing. Only one case (12.5%) involving poor oral intake
provided data regarding consumption following treatment,
with a 50% improvement reported. Improvements in die-
tary variety were reported in 75 out of the 96 cases
(78.1%), with children most often described as consuming
of foods from ‘‘all food groups’’ following treatment (30 of
75 cases; 40%). A specific number of foods targeted were
reported in 26 of 75 cases (34.7%), with 16 foods repre-
senting the modal number introduced during treatment. The
remaining 19 participants were described as improving
their nutritional status, but no dietary details were pro-
vided. Finally, data regarding anthropometric parameters
were reported in 23 of the 96 cases (23.9%). Change in
weight from pre-treatment levels was reported for 19
children, with an average increase of 1.67 kg (range
0–5.4 kg); average weight gain per day was presented for
four children (M = 39.25 g/day; range 11–58 g).
Discussion
Findings from this review provide further support for the
use of behavioral intervention in the treatment of severe
feeding disorders. The identified studies represent an
experimentally sound body of literature demonstrating
significant improvements in mealtime behaviors among a
sample of 96 children. The majority of studies included
were published since Kerwin (1999) first reviewed the
literature, highlighting the growth of research in this area.
Findings also reflect a noticeable increase in the use of
extinction-based procedures, such as NRS and PG, when
compared with Kerwin’s findings. This likely reflects the
current review’s focus on more severe feeding issues, as
well as refinements in the behavioral technology used to
address chronic feeding concerns. Refinements in treatment
appear, in part, guided by descriptive assessments and
Table 4 PND, NAP, and effect size values by dependent variable
Dependent variable # Contributing
studies (%)
# Contributing
participants (%)
Mean PND (Standard
deviation) n = 109aMean NAP (Standard
deviation) n = 109aEffect size
(d) n = 106a
Acceptance (Percent) n = 29 (60.4%) n = 54 (56.3%) 87.87 (31.63) .97 (.09) 2.598
Acceptance (Frequency) n = 6 (12.5%) n = 17 (17.7%) 88.8 (24.8) .98 (.04) 2.698
Swallowing (Percent) n = 11 (22.9%) n = 22 (22.9%) 81.75 (36.04) .91 (.20) 1.81
Swallowing (Frequency) n = 2 (4.2%) n = 7 (7.3%) 98.85 (3.27) .98 (.03) 2.88
Volume n = 6 (12.5%) n = 9 (9.4%) 95.40 (5.5) .97 (.03) 2.89
Total n = 54 n = 109a 87.95 (29.54) .96 (.12) 2.46
PND percent of non-overlapping data, NAP non-overlap of all pairsa Data for some participants contributed to more than one dependent variable
Clin Child Fam Psychol Rev (2010) 13:348–365 359
123
functional analyses (e.g., Piazza et al. 2003) indicating that
negative reinforcement (i.e., escape from feeding demands)
often maintains inappropriate mealtime behaviors. In
addition, several studies (e.g., Hoch et al. 2001; Piazza
et al. 2003; Reed et al. 2004) comparing the relative con-
tribution of different treatment elements (e.g., EE, DRA,
NCA) have demonstrated the importance of EE in elimi-
nating disruptive behaviors that preclude food acceptance.
As long as escape contingencies persist, these children do
not eat and thus lack exposure to the sensory experience of
food and the opportunity to contact the primary and sec-
ondary reinforcement contingent upon eating (Hoch et al.
2001). Despite support for using EE, it should be noted that
milder levels of feeding difficulty (not the focus of the
present review) may respond to less intrusive interventions,
and extinction-based procedures may be contraindicated in
these cases (Farrow and Blissett 2008).
While EE represented a common intervention, most
studies incorporated additional behavioral elements into
larger packages, which may afford additional treatment
benefits. Packages involving DRA (e.g., Piazza et al. 2003)
or NCA (e.g., Reed et al. 2004) have been associated with
reduced rates of negative behaviors (e.g., crying, disrup-
tions) during extinction bursts. For example, Reed et al.
reported that, although extinction was necessary to increase
and maintain food acceptance, the addition of NCA was
associated with decreased rates of inappropriate behavior
and crying in some cases. Evidence also supports the
potential role of antecedent manipulations (e.g., texture,
bite size, utensil) as an avenue for modifying the feeding
demands during treatment and/or accommodating possible
oral motor skill deficits. For example, Kerwin et al. (1995)
reported an inverse relationship between appropriate
mealtime behaviors and increasing bite sizes, suggesting
that beginning treatment with smaller bite sizes may
decrease possible negative side effects associated with
introduction of food. The use of antecedent manipulations
and/or rich reinforcement schedules along with EE suggest
movement in the field toward highly specific treatment
packages that balance addressing the operant function of
food refusal with maintaining the least restrictive envi-
ronment and ameliorating possible side effects associated
with extinction procedures.
The treatment context in which multi-component treat-
ment packages have been developed and evaluated is also
noteworthy. Most of this research was conducted at
intensive feeding programs involving inpatient or day
treatment admissions. This likely reflects the need for high
degrees of structure and supervision during intensive
treatment of severe feeding problems (Kerwin 1999),
especially with concurrent significant medical concerns. By
and large, treatment packages were implemented by trained
therapists under the guidance of a multidisciplinary team of
professionals. In addition to behavioral psychology, pro-
fessions cited as collaborating in treatment development and
evaluation included medicine, dietetics, speech/language
pathology, and/or occupational therapy. Given the general
acceptance that these disorders involve problems that cross
areas of expertise, a multidisciplinary approach, at a mini-
mum, provides safeguards against possible complications
with treatment (e.g., aspiration; metabolic concerns; severe
weight loss), while allowing design of treatment packages
unique to each child. Components besides behavioral treat-
ment, however, have not been evaluated in published reports,
suggesting the need to examine the relative contributions of
disciplines besides behavioral techniques in the context of
multidisciplinary treatment outcomes.
While the current review provides support for behavioral
treatment to address severe feeding disorders, there are
limitations to the evidence for these conclusions. The goal
of a feeding intervention is to achieve the closest approxi-
mation of age-appropriate mealtime behavior, including
both proximate behavior change and more distal nutritional
and medical goals. This entails replacing supplemental
feedings, in cases involving tube or bottle dependence, and/
or increasing dietary diversity among children with severe
food selectivity. Improvements in intake should be
accompanied by increased levels of appropriate mealtime
behaviors (e.g., acceptance, swallowing) and, to assure
external validity, treatment gains need to be generalized to
caregivers and transitioned into the home environment.
While this review suggests behavioral treatment is associ-
ated with significant improvements in mealtime behaviors,
it also reveals the need to better document outcomes in
other areas, including changes in tube dependence, food
variety, weight status, oral motor status, generalization of
treatment effects, and long-term follow-up. When docu-
mented, outcomes suggested improvements in these areas,
but more systematic evaluation is recommended. Suggested
refinements in future studies include documenting behav-
ioral (e.g., acceptance, swallowing), medical (e.g., weight,
tube reductions), physical (tongue control), and social (e.g.,
parent satisfaction; caregiver stress) data. Increased breadth
and standardization in outcome measures will expand the
knowledge base and strengthen conclusions from feeding
intervention studies.
The ‘‘file drawer problem’’ or the editorial practice of
publishing only those studies demonstrating positive out-
comes also represents a potential source of bias intrinsic to
comprehensive literature reviews. On the other hand, a
small number of randomized controlled studies supporting
behavioral intervention (Benoit et al. 2000; Stark et al.
1996, Turner et al. 1994) and recent program evaluations of
multidisciplinary feeding treatment programs (Greer et al.
2009; Williams et al. 2007) provide some evidence against
the general suppression of negative findings among single-
360 Clin Child Fam Psychol Rev (2010) 13:348–365
123
case reports analyzed in the present review. For example,
Benoit et al. randomly assigned a sample of 64 child/feeder
dyads involving children with tube dependence and food
refusal to either a treatment group involving behavioral
intervention (n = 32) or a treatment group involving
nutritional education (n = 32). Nutritional education
involved advice regarding volume and concentration of
oral feedings, feeding schedules and routine, and guidance
on reducing tube feeding; behavioral intervention included
identical nutritional guidance, as well as training on
behavioral techniques (e.g., EE in the form of NRS;
stimulus fading) to address refusal behaviors. At 8-week
follow-up, 15 (47%) of the 32 patients in the behavioral
intervention group were no longer dependant on tube
feedings, while no change in tube feeding status occurred
in the nutrition group (p = .0001). Stark et al. investigated
the use of behavioral intervention to increase caloric intake
and weight gain among a sample of five children with
cystic fibrosis (CF) compared with a waitlist control
involving four children with CF. Treatment included child
behavior management training focusing on differential
attention, contingency management, and implementation of
mealtime rules and consequences. Following treatment,
children in the behavioral intervention group experienced
significantly greater improvement in calories per meal and
weight gain compared with the waitlist control (p = .03).
Finally, Turner et al. compared the use of behavioral parent
training versus dietary education to address feeding prob-
lems in a sample of 20 children with feeding problems
lasting longer than 3 months. Both groups demonstrated
improvement in mealtime behaviors, while behavioral
parent training was associated with improved caregiver
attention during meals.
Comprehensive chart reviews have also documented
levels of treatment efficacy similar to those in this review,
while providing transparency regarding outcomes for all
children treated at multidisciplinary treatment programs.
For example, Greer et al. (2009) presented data on 121
children discharged from a pediatric feeding program after
receiving treatment for tube dependence (n = 72), liquid
dependence (n = 17) or food selectivity (n = 32). During
meals, behavioral protocols were systematically imple-
mented and involved antecedent and consequence manip-
ulations similar to the interventions described in this
review. Across all groups, significant improvements
(p \ .001) were reported across several measures of feed-
ing behavior, including acceptance, mouth cleans, oral
intake, and grams consumed. Treatment was also associ-
ated with significant declines (p \ .001) in caregivers
stress compared with pre-treatment values. Similarly, in a
study focusing on the treatment outcomes of 46 children
with complete tube dependence, Williams et al. (2007)
assessed the percent of the sample successfully removed
from supplemental tube feedings after discharge from a
day treatment program. Treatment was described as
involving intensive behavioral therapy with input from a
multidisciplinary team. At the year 2 follow-up, 74% of
the sample (n = 34) no longer received tube feedings; an
additional 17% (n = 8) received 50% or less of their
caloric needs by feeding tube. The authors also high-
lighted the cost-effectiveness of intensive feeding treat-
ment when compared with supplemental tube feedings; the
annual cost of tube feeding exceeded the cost of day
treatment in all but one case. The uniformly positive
outcomes across those studies, combined with the size of
the treatment effects reported in the present review
(medium to large by conventional standards), provide
convergent support for the efficacy of behavioral inter-
ventions in highly controlled settings. Prospective ran-
domized controlled trials would clearly strengthen this
conclusion, providing additional protection against possi-
ble publication bias while addressing possible threats to
internal validity (e.g., history, maturation).
It is noteworthy that no eligible studies from other
theoretical perspectives in psychology (e.g., family ther-
apy, psychodynamic therapy) or from other habilitative
disciplines were identified in the current literature search.
This void is particularly notable, given prior research
showing an association between parent–child interactions
and disrupted feeding (e.g., Amaniti et al. 2004) and
Kerwin’s (1999) call for such research a decade ago. While
it can be argued that behavioral intervention, with its focus
on repeated assessment of operationally defined behaviors,
lends itself more readily to the stringent methodological
criteria established for this review, this does not nullify the
importance of establishing an evidence base for other dis-
ciplines providing feeding therapy (e.g., medical, occupa-
tional therapy, speech therapy, dietetics). Even with the
methodological criteria of the review removed, there were
few descriptions of feeding interventions, let alone well-
controlled outcomes studies by other disciplines. The few
studies identified as evaluating non-behavioral treatment
approaches involved single demonstrations of effectiveness
without replication, often without experimental control.
For example, Linscheid (2006) described effective treat-
ment of feeding disorders as combining behavioral ele-
ments with hunger manipulations; however, only one
outcome study was located focusing on hunger provocation
as a mechanism of change. Specifically, Kindermann et al.
(2008) presented outcomes for 10 children treated for tube
dependence in a ‘‘multidisciplinary hunger provocation
program’’. Following inpatient admission, tube feedings
were systematically reduced. Concurrently, regularly
structured meals were conducted involving reinforcement
for acceptance without pressure or ‘‘forced feeding’’.
Kindermann reported that 8 of the 10 children were
Clin Child Fam Psychol Rev (2010) 13:348–365 361
123
successfully weaned from tube feedings, although the study
lacked a control group/condition, and a closer inspection of
age-adjusted weight for height (i.e., z-scores) at the
6-month follow-up suggests actual decline on that outcome
measure as a group.
Small groups of children have also been shown to
respond to medication intervention. Three children showed
enhanced response to a multidisciplinary feeding disorders
program when combined with the medication risperidone,
although the authors did not analyze contribution of sepa-
rate components of the program (Berger-Gross et al. 2004).
Treatments addressing pain-related organic conditions also
hold promise in avoiding longstanding feeding concerns
and/or precluding the need for further treatment. For
example, thirteen participants with eosinophilic esophagitis
showed improvement in feeding when treated with proton
pump inhibitors combined with fluticasone, although the
design did not allow experimental evaluation (Pentiuk et al.
2007). Clearly, more research is needed to delineate the
role of hunger manipulation in the treatment of feeding
disorders, as well as the impact of early intervention in
preventing long-term feeding concerns. Further, other
widely applied approaches to treatment, such as sensory
and oral motor therapies in speech and occupational ther-
apy, are candidates for empirical investigation to corrob-
orate anecdotal reports of effectiveness.
In conclusion, findings from the current review suggest
behavioral intervention remains the only treatment for
pediatric feeding disorders with well-documented empiri-
cal support. In addition to addressing the aforementioned
limitations in the research base, a remaining challenge
going forward is to assure that this technology is appro-
priately disseminated in order to promote appropriate
access to care. Increasing interdisciplinary collaboration
and communication through clinical collaboration, train-
ing, and research activities will help in this process and has
the potential to stimulate research focusing on other
treatment approaches. Expanding the number of interdis-
ciplinary inpatient and day treatment programs or devel-
oping additional treatment options across settings within
the medical community (e.g., organizing providers in a
geographic area along a clinical service line) would also
help fill a noticeable void in the current treatment com-
munity. Addressing potential reimbursement barriers and
the lack of clear treatment standards/recommendations
adopted by professional organizations (e.g., American
Psychological Association, American Academy of Pediat-
rics, North American Society for Pediatric Gastroenterol-
ogy, Hepatology, and Nutrition) could also help increase
treatment recognition and access. To achieve these ends,
continued systematic research in this important and grow-
ing area is critical.
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