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: william.sharp@choa.org

D. L. Jaquess

e-mail: David.Jaquess@choa.org

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

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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

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356 Clin Child Fam Psychol Rev (2010) 13:348–365

123

Ta

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Clin Child Fam Psychol Rev (2010) 13:348–365 357

123

Ta

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n39

91

28

25

%O

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s(n

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aS

tudie

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volv

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mult

iple

par

tici

pan

tsre

ceiv

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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.

References

Ahearn, W. H. (2003). Using simultaneous presentation to increase

vegetable consumption in a mildly selective child with autism.

Journal of Applied Behavior Analysis, 36, 361–365.

Ahearn, W. H., Castine, T., Nault, K., & Green, G. (2001). An

assessment of food acceptance in children with autism or

pervasive developmental disorder-not otherwise specified. Jour-nal of Autism and Developmental Disorders, 31(5), 505–511.

Ahearn, W. H., Kerwin, M. E., Eicher, P., & Lukens, C. T. (1996a).

An ABAC comparison of two of two intensive intervention for

food refusal. Behavior Modification, 35, 385–405.

Ahearn, W. H., Kerwin, M. E., Eicher, P., Shantz, J., & Swearingin,

W. (1996b). An alternating treatments comparison of two

intensive interventions for food refusal. Journal of AppliedBehavior Analysis, 29, 321–332.

Allison, D. B., Faith, M. S., & Franklin, R. D. (1995). Antecedent

exercise in the treatment of disruptive behavior: A meta-analytic

review. Clinical Psychology: Science and Practice, 2, 279–303.

Amaniti, M., Ambruzzi, A. M., Lucarelli, L., Cimino, S., &

D’Olimpio, F. (2004). Malnutrition and dysfunctional mother-

child feeding interactions: Clinical assessment and research

implications. Journal of the American College of Nutrition, 23,

259–271.

Anderson, C. M., & McMillan, K. (2001). Parental use of escape

extinction and differential reinforcement to treat food selectivity.

Journal of Applied Behavior Analysis, 34, 511–515.

Arvedson, J. C. (2008). Assessment of pediatric dysphagia and

feeding disorders: Clinical and instrumental approaches. Devel-opmental Disabilities Research Reviews, 14, 118–127.

Association, American Psychiatric. (2000). Diagnostic and statisticalmanual of mental disorders (4th ed.). Washington, DC: Amer-

ican Psychiatric Association.

Babbitt, R. L., Hoch, T. A., Coe, D. A., Cataldo, M. F., Kelly, K. J.,

Stackhouse, C., et al. (1994). Behavioral assessment and

treatment of pediatric feeding disorders. Developmental andBehavioral Pediatrics, 15, 278–291.

Benoit, D. (1993). Failure to thrive and feeding disorders. In

C. H. Zeanah (Ed.), Handbook of Infant Mental Health(pp. 317–331). New York: Guilford.

Benoit, D., Wang, E., & Zlotkin, S. (2000). Discontinuation of

esterostromy tube feeding by behavioral treatment in early

childhood: A randomized controlled trial. Journal of Pediatrics,137, 498–503.

Berger-Gross, P., Coletti, D. J., Hirschkorn, K., Terranova, E., &

Simpser, E. F. (2004). The effectiveness of risperidone in the

treatment of three children with feeding disorders. Journal ofChild and Adolescent Psychopharmacology, 14, 621–627.

Bowers, L. (2002). An audit of referrals of children with autistic

spectrum disorder to the dietetic Service. Journal of HumanNutrition & Dietetics, 15, 141–144.

Busk, P. L., & Serlin, R. C. (1992). Meta-analysis for single-case

research. In T. R. Kratochwill & J. R. Levin (Eds.), Single-caseresearch and analysis: New directions for psychology andeducation (pp. 187–212). Hillsdale, NJ: Lawrence Erlbaum

Associates.

Campbell, J. M. (2003). Efficacy of behavioral interventions for

reducing problem behavior in persons with autism: A quantita-

tive synthesis of single-case research. Research in Developmen-tal Disabilities, 8, 165–178.

Campbell, J. M. (2004). Statistical comparison of four effect sizes for

single-subject designs. Behavior Modification, 28, 234–246.

Casey, S. D., Cooper-Brown, L. J., Wacker, D. P., & Rankin, B. E.

(2006). The use of descriptive analysis to identify and

362 Clin Child Fam Psychol Rev (2010) 13:348–365

123

manipulate schedules of reinforcement in the treatment of food

refusal. Journal of Behavioral Education, 15(1), 41–52.

Casey, S. D., Perrin, C. J., Lesser, A. D., Perrin, S. H., Casey, C. L., &

Reed, G. K. (2009). Using descriptive assessment in the

treatment of bite acceptance and food refusal. Behavior Mod-ification, 33(5), 537–558.

Chatoor, I. (2002). Feeding disorders in infants and toddlers:

Diagnosis and treatment. Child and Adolescent PsychiatricClinics of North America, 11, 163–183.

Coe, D. A., Babbitt, R. L., Williams, K. E., Hajimihalis, C., Snyder,

A. M., Ballard, C., et al. (1997). Use of extinction and

reinforcement to increase food consumption and reduce expul-

sion. Journal of Applied Behavior Analysis, 30, 581–583.

Cohen, J. (1988). Statistical power analysis for the behavioralsciences (2nd ed.). Hillsdale, NJ: Erlbaum.

Collins, M. S., Kyle, R., Smith, S., Laverty, A., Roberts, S., & Eaton-

Evans, J. (2003). Coping with the unusual family diet: Eating

behavior and food choices of children with Down’s syndrome,

autistic spectrum disorders or chi du chat syndrome and

comparison groups of siblings. Journal of Learning Disabilities,7, 137–155.

Cooper, L. J., Wacker, D. P., Brown, K., McComas, J. J., Peck, S. M.,

Drew, J., et al. (1999). Use of concurrent operants paradigm to

evaluate positive reinforcers during treatment of food refusal.

Behavior Modification, 23, 3–40.

Cooper, L. J., Wacker, D. P., McComas, J. J., Brown, K., Pack, S. M.,

Richman, D., et al. (1995). Use of component analyses to

identify active variables in treatment packages for children with

feeding disorders. Journal of Applied Behavior Analysis, 28,

139–153.

Cornish, E. (1998). A balanced approach towards healthy eating in

autism. Journal of Human Nutrition & Dietetics, 11, 501–509.

Cornish, E. (2002). Gluten and casein free diets in autism: A study of

the effects on food choice and nutrition. Journal of HumanNutrition & Dietetics, 15, 261–269.

Dahl, M., & Sunderlin, C. (1986). Early feeding problems in an

affluent society. 1. Categories and clinical signs. Acta PaediaticScandinavia, 75, 370–379.

Davies, W. H., Satter, E., Berlin, K. S., Sato, A. F., Silverman, A. H.,

Fischer, E. A., et al. (2006). Reconceptualizing feeding and

feeding disorders in interpersonal context: The case for a

relational disorder. Journal of Family Psychology, 20, 409–417.

Dawson, J., Piazza, C. C., Sevin, B., Gulotta, C., Lerman, D., &

Kelly, M. L. (2003). Use of the high-probability instructional

sequence and escape extinction in a child with food refusal.

Journal of Applied Behavior Analysis, 36, 105–108.

DeMoor, J., Didden, R., & Korzilius, H. (2007). Behavioral

treatment of severe food refusal in five toddlers with develop-

mental disabilities. Childcare, Health, and Development, 33,

670–676.

Didden, R., Seys, D., & Schouwink, D. (1999). Treatment of chronic

food refusal in a young developmentally disabled child. Behav-ioral Interventions, 14, 213–222.

Duker, P. C. (1981). Treatment of food refusal by the overcorrective

functional movement training method. Journal of BehaviorTherapy and Experimental Psychiatry, 12, 337–340.

Faith, M. S., Allison, D. B., & Gorman, B. S. (1996). Meta-analysis of

single-case research. In R. D. Franklin, D. B. Allison, &

B. S. Gorman (Eds.), Design and analysis of single-caseresearch (pp. 245–277). Hillsdale, NJ: Lawrence Erlbaum.

Farrow, C. V., & Blissett, J. (2008). Controlling feeding practices:

Cause or consequence of early child weight? Pediatrics, 121,

164–169.

Field, D., Garland, M., & Williams, K. (2003). Correlates of specific

childhood feeding problems. Journal of Pediatrics and ChildHealth, 39, 299–304.

Finney, J. W. (1986). Preventing common feeding problems in infants

and young children. Pediatric Clinics of North America, 33,

775–798.

Fisher, W. W., Piazza, C. C., Bowman, L. G., Hagopian, L. P.,Owens, J. C., & Slevin, I. (1992). A comparison of two

approaches for identifying reinforcers for persons with severe

and profound disabilities. Journal of Applied Behavior Analysis,25, 491–498.

Freeman, K. A., & Piazza, C. C. (1998). Combining stimulus fading,

reinforcement, and extinction to treat food refusal. Journal ofApplied Behavior Analysis, 31, 691–694.

Gentry, J. A., & Luiselli, J. K. (2008). Treating a child’s selective

eating through parent implemented feeding intervention in the

home setting. Journal of Developmental and Physical Disabil-ities, 20, 63–70.

Greer, R. D., Dorow, L., Williams, G., & McCorkle, N. (1991). Peer-

mediated procedures to induce swallowing and food acceptance

in young children. Journal of Applied Behavior Analysis, 24,

783–790.

Greer, A. J., Gulotta, C. S., Masler, E. A., & Laud, R. B. (2009).

Caregiver stress and outcomes of children with pediatric feeding

disorders treated in an intensive interdisciplinary program.

Journal of Pediatric Psychology, 33, 520–536.

Gulotta, C. S., Piazza, C. C., Patel, M. R., & Layer, S. A. (2005).

Using food re-distribution to reduce packing in children with

severe food refusal. Journal of Applied Behavior Analysis, 38,

39–50.

Hagopian, L. P., Farrell, D. A., & Amari, A. (1996). Treating total

liquid refusal with backward chaining and fading. Journal ofApplied Behavior Analysis, 29, 573–575.

Herzinger, C. V., & Campbell, J. M. (2007). Comparing functional

assessment methodologies: A quantitative synthesis. Journal ofAutism and Developmental Disorders, 37, 1430–1445.

Hoch, T. A., Babbitt, R. A., Coe, D. A., Krell, D. M., & Hackbert, L.

(1994). Contingency contracting: Combining positive reinforce-

ment and escape extinction procedures to treat persistent food

refusal. Behavior Modification, 18, 106–128.

Hoch, T. A., Babbitt, R. L., Farrar-Schneider, D., Berkowitz, M. J.,

Owens, J. C., Knight, T. L., et al. (2001). Empirical examination

of a multicomponent treatment for pediatric food refusal.

Education and Treatment of Children, 24, 176–198.

Johnson, C. R., & Babbitt, R. L. (1993). Antecedent manipulation in

the treatment of primary solid food refusal. Behavior Modifica-tion, 17, 510–521.

Kahng, S., Boscoe, J. H., & Byrne, S. (2003). The use of an escape

contingency and a token economy to increase food acceptance.

Journal of Applied Behavior Analysis, 36, 349–353.

Kahng, S., Tarbox, J., & Wilke, A. E. (2001). Use of multicomponent

treatment for food refusal. Journal of Applied Behavior Analysis,34, 93–96.

Kern, L., & Marder, T. J. (1996). A comparison of simultaneous and

delayed reinforcement as treatment for food selectivity. Journalof Applied Behavior Analysis, 29, 243–246.

Kerwin, M. E. (1999). Empirically supported treatments in pediatric

psychology: Severe feeding problems. Journal of PediatricPsychology, 24, 193–214.

Kerwin, M. E., Ahearn, W. H., Eicher, P. S., & Burd, D. M. (1995).

The costs of eating: A behavioral economic analysis of food

refusal. Journal of Applied Behavior Analysis, 28, 245–260.

Kindermann, A., Kneepkens, C. M. F., Stok, A., van Dijk,

E. M., Engels, M., & Douwes, A. C. (2008). Discontinuation

of tube feeding in young children by hunger provocation.

Journal of Pediatric Gastroenterology and Nutrition, 47, 87–91.

Lamm, N., & Greer, R. D. (1988). Induction and maintenance of

swallowing responses in infants with dysphagia. Journal ofApplied Behavior Analysis, 21, 143–156.

Clin Child Fam Psychol Rev (2010) 13:348–365 363

123

Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children

with autism spectrum disorders: A review. Focus on Autism andOther Developmental Disabilities, 21, 153–166.

Levin, L., & Carr, E. G. (2001). Food selectivity and problem

behavior in children with developmental disabilities analysis and

intervention. Behavior Modification, 25, 443–470.

Lindberg, L., Bohlin, G., & Hagekull, B. (1991). Early feeding

problems in a normal population. International Journal of EatingDisorders, 10, 395–405.

Linscheid, T. R. (2006). Behavioral treatments for pediatric feeding

disorders. Behavior Modification, 30, 6–23.

Luiselli, J. K. (1994). Oral feeding treatment of children with chronic

food refusal and multiple developmental disabilities. AmericanJournal of Mental Retardation, 98, 646–655.

Luiselli, J. K. (2000). Cueing, demand fading, and positive reinforce-

ment to establish self-feeding and oral consumption in a child

with chronic food refusal. Behavior Modification, 24, 350–360.

Luiselli, J. K., Evans, T. P., & Boyce, D. A. (1985). Contingency

management of food selectivity and oppositional eating in a

multiply handicapped child. Journal of Clinical Child Psychol-ogy, 14, 153–156.

Luiselli, J. K., & Gleason, D. J. (1987). Combining sensory

reinforcement and texture-fading procedures to overcome

chronic food refusal. Journal of Behavioral Therapy andExperimental Psychiatry, 18, 149–155.

Manikam, R., & Perman, J. (2000). Pediatric feeding disorders.

Journal of Clinical Gastroenterology, 30, 34–46.

Mayes, L., & Volkmar, F. (1993). Nosology of eating and growth

disorders in early childhood. Child and Adolescent PsychiatricClinics of North America, 2, 15–25.

McCartney, E. J., Anderson, C. M., & English, C. L. (2005). Effect of

brief clinic-based training on the ability of caregivers to

implement escape extinction. Journal of Positive BehaviorInterventions, 7, 18–32.

Mueller, M. M., Piazza, C. C., Patel, M. R., Kelley, M. E., & Pruett,

A. E. (2004). Increasing variety of foods consumed by blending

non-preferred foods into preferred foods. Journal of AppliedBehavior Analysis, 37, 159–170.

Munk, D. D., & Repp, A. C. (1994). Behavioral assessment of feeding

problems of individuals with severe disabilities. Journal ofApplied Behavior Analysis, 27, 241–250.

Najdowski, A. C., Wallace, M. D., Doney, J. K., & Ghezzi, P. M.

(2003). Parental assessment and treatment of food selectivity in

natural settings. Journal of Applied Behavior Analysis, 36,

383–386.

Najdowski, A. C., Wallace, M. D., Reagon, K., Penrod, B., Higbee,

T. S., & Tarbox, J. (2010). Utilizing a home-based parent

training approach in the treatment of food selectivity. BehavioralInterventions, 25, 89–107.

O’Reilly, M. F., & Lancioni, G. (2001). Treating food refusal in a

child with Williams syndrome using the parent as therapist in the

home setting. Journal of Intellectual Disability Research, 45,

41–46.

Palmer, S., & Horn, S. (1978). Feeding problems in children. In

S. Palmer & S. Ekvall (Eds.), Pediatric nutrition in develop-mental disabilities (pp. 107–129). Springfield, IL: Charles

Thomas. (Ch 13).

Palmer, S., Thompson, R. J., & Linscheid, T. R. (1975). Applied

behavior analysis in the treatment of childhood feeding prob-

lems. Developmental, Medical and Child Neurology, 17,

333–339.

Parker, R. I., & Vannest, K. (2009). An improved effect size for

single-case research: Nonoverlap of all pairs. Behavior Therapy,40, 357–367.

Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana,

C. M. (2002a). An evaluation of two differential reinforcement

procedures with escape extinction to treat food refusal. Journalof Applied Behavior Analysis, 35, 363–374.

Patel, M. R., Piazza, C. C., Santana, C. M., & Volkert, V. M. (2002b).

An evaluation of food type and texture in the treatment of a

feeding problem. Journal of Applied Behavior Analysis, 35,

183–186.

Patel, M., Reed, G. K., Piazza, C. C., Mueller, M., Bachmeyer, M. H.,

& Layer, S. A. (2007). Use of a high-probability instructional

sequence to increase compliance to feeding demands in the

absence of escape extinction. Behavioral Interventions, 22,

305–310.

Pentiuk, S. P., Mill, C. K., & Kaul, A. (2007). Eosinophilic

esophagitis in infants and toddlers. Dysphagia, 22, 44–48.

Piazza, C. C., Fisher, W. W., Brown, K. A., Shore, B. A., Patel, M. R.,

Katz, R. M., et al. (2003a). Functional analysis of inappropriate

mealtime behaviors. Journal of Applied Behavior Analysis, 36,

187–204.

Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S.

A. (2003b). On the relative contributions of positive reinforce-

ment and escape extinction n the treatment of food refusal.

Journal of Applied Behavior Analysis, 36, 309–324.

Piazza, C. C., Patel, M. R., Santana, C. M., Goh, H. L., Delia, M. D.,

& Lancaster, B. M. (2002). An evaluation of simultaneous and

sequential presentation of preferred and non-preferred food to

treat food selectivity. Journal of Applied Behavior Analysis, 35,

259–270.

Reau, N. R., Senturia, Y. D., Lebailly, S. A., & Christoffell, K. K.

(1996). Infant and toddler feeding patterns and problems:

Normative data and a new direction. Journal of Developmentaland Behavioral Pediatrics, 17, 149–153.

Reed, G. K., Dolezal, D. N., Cooper-Brown, L. J., & Wacker, D. P.

(2005). The effects of sleep disruption on the treatment of a

feeding disorder. Journal of Applied Behavior Analysis, 38,

243–245.

Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Backmeyer,

M. H., Bethke, S. D., et al. (2004). On the relative contributions

of non-contingent reinforcement and escape extinction in the

treatment of food refusal. Journal of Applied Behavior Analysis,37, 27–42.

Riordan, M. M., Iwata, B. A., Finney, J. W., Wohl, M. K., & Stanley,

A. E. (1984). Behavioral assessment and treatment of chronic

food refusal in handicapped children. Journal of AppliedBehavior Analysis, 17, 327–341.

Riordan, M. M., Iwata, B. A., Wohl, M. K., & Finney, J. W. (1980).

Behavioral treatment of food refusal and selectivity in develop-

mentally disabled children. Applied Research in Mental Retar-dation, 1, 95–112.

Sanders, M. R., Patel, R. K., Le Grice, B., & Shepherd, R. W. (1993).

Children with persistent feeding difficulties: An observational

analysis of the feeding interaction of problem and non-problem

eaters. Health Psychology, 12, 64–73.

Schreck, K. A., Williams, K., & Smith, A. F. (2004). A comparison of

eating behavior between children with and without autism.

Journal of Autism and Developmental Disabilities, 34, 433–438.

Scruggs, T. E., & Mastropieri, M. A. (1998). Summarizing single-

subject research: Issues and applications. Behavior Modification,22, 221–242.

Scruggs, T. E., Mastropieri, M. A., & Castro, G. (1987). The

quantitative synthesis of single-subject research: Issues and

applications. Remedial and Special Education, 8(2), 24–52.

Sevin, B., Gulotta, C., Sierp, B., Rosica, L. A., & Miller, L. J. (2002).

Analysis of response covariation among multiple topographies of

food refusal. Journal of Applied Behavior Analysis, 35, 65–68.

Sisson, K. A., & Van Hasselt, V. B. (1989). Feeding disorders. In

J. K. Luiselli (Ed.), Behavioral medicine and developmentaldisabilities (pp. 45–73). NewYork: Springer.

364 Clin Child Fam Psychol Rev (2010) 13:348–365

123

Stark, L. J., Mulvihill, M. M., Powers, S. W., Jelalian, E., Keating, K.,

Creveling, S., et al. (1996). Behavioral intervention to improve

caloric intake of children with cystic fibrosis: Treatment versus

wait list control. Journal of Pediatric Gastroenterology andNutrition, 22, 240–253.

Tarbox, J., Schiff, A., & Najdowski, A. C. (2010). Parent-imple-

mented procedural modification of escape extinction in the

treatment of food selectivity in a young child with autism.

Education and Treatment of Children, 33(3), 223–234.

Task Force on Promotion and Dissemination of Psychological

Procedures (1995). Training in and dissemination of empiri-

cally-validated psychological treatments: Report and recommen-

dations. Clinical Psychologist, 48, 3–23.

Turner, K. M., Sanders, M. R., & Wall, C. R. (1994). Behavioral

parent training versus dietary education in the treatment of

children with persistent feeding difficulties. Behavior Change,11, 242–258.

Werle, M. A., Murphy, T. B., & Budd, K. S. (1993). Treating chronic

food refusal in young children: Home based parent training.

Journal of Applied Behavior Analysis, 26, 421–433.

Wilder, D. A., Normand, M., & Atwell, J. (2005). Non-contingent

reinforcement as treatment for food refusal and associated self-

injury. Journal of Applied Behavior Analysis, 38, 549–553.

Williams, K. E., Field, D. G., & Seiverling, L. (2010). Food refusal in

children: A review of the literature. Research in DevelopmentalDisabilities, 31, 625–633.

Williams, K. E., Riegel, K., Gibbons, B., & Field, D. G. (2007).

Intensive behavioral treatment for severe feeding problems: A

cost-effective alternative to tube feedings? Journal of Develop-mental and Physical Disabilities, 19, 227–235.

Wood, B. K., Wolery, M., & Kaiser, A. P. (2009). Treatment of food

selectivity in a young child with autism. Focus on Autism andOther Developmental Disabilities, 24(3), 169–177.

World Health Organization. (2009). International classification of

disease. In 9th revision clinical modification. Retrieved 11/27/09

from http://www.cdc.gov/nchs/icd/icd9cm.htm.

Clin Child Fam Psychol Rev (2010) 13:348–365 365

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