Escape extinction has been coupled with positive reinforcement, non-contingent reinforcement, and punishment (re-presentation of food on Nuk brush after food expulsions). There have been few studies on food acceptance relating to choice. This study aims to examine the effects of using an escape extinction procedure and a choice procedure to increase acceptance to a variety of non-preferred foods, while decreasing refusal behaviors.

The random presentation of non-preferred food items in three other case studies conducted at the Los Altos Feeding Clinic has resulted in faster acquisition to non-preferred foods in picky eaters. In this procedure food items were not only randomized within session, but also between sessions. This randomized procedure was also utilized in the current study.

The inclusion of choice in the current feeding protocol was the ability to exclude one food or consume all foods. All foods presented were identified as non-preferred and were shown to the child prior to the session.

The participant was a 4-year-old male who has consumed a limited variety since he was 11-months-old. At the time of treatment, he would only consume macaroni and cheese, grilled cheese sandwiches, vanilla yogurt, PopTarts, candy, milk and Pediasure. He refused to consume all other foods, including meats, vegetables and fruits. The participant was born 5 weeks premature and has no current medical issues. He has been tested for food allergies and physicians following him have decided not to pursue further medical testing. As a result he was referred to an occupational therapist, speech therapist and general psychologist. All were seen once per week. His mother reports that none of those therapists were able to add non-preferred foods. Refusal behaviors exhibited during presentation of non-preferred foods include gagging, vomiting, crying and throwing food and feeding utensils.

The participant did not eat any solid foods for three hours and did not drink any liquid for one hour prior to each meal.

Three non-preferred foods in puree texture were introduced. The food was presented using an escape extinction procedure in which the spoon was not removed from the top lip until the bite was taken or the session time cap had elapsed (30 minutes). If the bite was taken there was a 20 second interval before the next bite was presented. All combined inappropriate behavior (e.g. crying, head turns, or hitting the spoon) were put on extinction.  The feeding therapist fed the child while the mother watched from the next room (the child could not see the mother). Vomiting occurred during presentation of two of the three foods.

1/10/11 Session 1: 112 grams of pureed peaches, 112 grams of pureed green beans, 112 grams of pureed beef were presented. 88 grams of peaches were consumed. Emesis occurred after the participant ate both the green beans and the beef. The meal lasted 15 minutes.

All variables remained the same as in baseline conditions, except that a choice was given before each meal to omit one food or consume all foods.

1/12/11 Session 2: The participant was presented pureed beef, blended fruits with oatmeal, and pureed green beans, and chose to omit green beans. 112 grams of pureed beef were presented. 110 grams were consumed. 112 grams of blended fruits with oatmeal were presented 110 grams consumed. The meal lasted 10 minutes and 7 seconds.

1/14/11 Session 3: The participant was presented pureed turkey and rice, pureed green beans, and pureed apples and blueberries, and chose to omit apples and blueberries. 140 grams of pureed turkey and rice were presented. 137 grams were consumed. 140 grams of pureed green beans were presented. 135 grams were consumed. 140 grams of low fat organic milk were presented. 140 grams were consumed. The meal lasted 10 minutes and 12 seconds.

1/17/11 Session 4: The participant was presented pureed ham, pureed apples and blueberries, pureed corn, and pureed sweet potatoes, and chose to omit apples and blueberries. 84 grams of pureed ham were presented. 81 grams were consumed. 84 grams of pureed sweet corn casserole were presented. 81 grams were consumed. 84 grams of pureed sweet potatoes were presented. 81 grams were consumed. 140 grams of low fat organic milk were presented. 140 grams were consumed. The meal lasted 6 minutes and 56 seconds.

Return to baseline conditions.

1/19/11 Session 5: 84 grams of pureed vegetables and chicken were presented. 40 grams were consumed and there were 31 grams of emesis. 84 grams of vanilla custard with bananas were presented. 71 grams were consumed. 84 grams of pureed squash were presented. 78 grams were consumed. 84 grams of pureed turkey were presented. 78 grams were consumed. 140 grams of low fat organic milk were presented. 140 grams were consumed. The meal lasted 9 minutes and 48 seconds.

1/21/11 Session 6: 84 grams of organic pasta dinner puree were presented. 79 grams were consumed. 84 grams of chicken and rice puree were presented. 75 grams were consumed. 84 grams of pureed green beans were presented. 81 grams were consumed. 84 grams of pureed mango were presented. 80 grams were consumed. 140 grams of low fat organic milk were presented. 140 grams were consumed. The meal lasted 11 minutes and 46 seconds.

1/24/11 Session 7: 84 grams of pureed chicken were presented. 79 grams were consumed. 84 grams of pureed sweet potatoes were presented. 79 grams were consumed. 84 grams of pureed macaroni and beef with vegetables were presented. 81 grams were consumed. 84 grams of pureed bananas, apples and pears were presented. 82 grams were consumed. 140 grams of low fat milk were presented. 140 grams were consumed. The meal lasted 10 minutes and 7 seconds.

Table texture foods in bite-sized pieces were presented. Baseline conditions continued because the effects of treatment remained in that refusal behaviors remained at a low rate or were non-existent during these sessions.

1/26/11 Session 8: Tomatoes, turkey, avocado, cucumber, pureed bananas, mango smoothie and organic milk were presented. 4 bites of tomato, 4 bites of turkey, 4 bites of avocado, 4 bites of cucumber, 99 grams of bananas, 99 grams of mango smoothie, and the entire 140 grams of milk were consumed.

1/28/11 Session 9: Pears, white mushrooms, blueberries, beef ravioli in tomato meat sauce, smoked salmon, Hawaiian Delight smoothie and 140 grams of low fat milk were presented. 4 bites of pears, 4 bites of mushrooms, 4 bites of ravioli, 19 bites of smoked salmon, 99 grams of Hawaiian Delight smoothie and all of the milk were consumed. The meal lasted 15 minutes.

1/31/11 Session 10: Green bell peppers, beets, pineapple, mashed potatoes, flat fillet, mango smoothie and 140 grams of low fat milk were presented. 4 bites of bell pepper, 4 bites of beets, 4 bites of pineapple, 4 bites of mashed potato, 4 bites of flat fillet, 99 grams of mango smoothie and all of the milk were consumed for a total of 437 grams. The meal lasted 21 minutes and 25 seconds.

2/2/11 Session 11: Green beans, carrots, chicken nuggets, lasagna, strawberries, salmon, vanilla custard with bananas, pureed bananas with apples and 140 grams of low fat organic milk were presented. 4 bites of green beans, 4 bites of carrots, 15 bites of chicken nuggets, 4 bites of lasagna, 4 bites of strawberries, 5 bites of salmon, 198 grams of pudding, all of the bananas with apples and all of the milk were consumed for a total of 437 grams. The meal lasted 21 minutes and 16 seconds.

2/4/11 Session 12: Sardines in mustard, potatoes, cord, oranges, cauliflower, banana orange medley puree, vanilla custard pudding, and 140 grams of grape juice were presented. 4 bites of sardines, 4 bites of potato, 4 bites of corn, 4 bites of oranges, 4 bites of cauliflower, 198 grams of banana orange medley, 99 grams of pudding, and all of the grape juice were consumed. The meal lasted 15 minutes.

2/7/11 Session 13: Oysters in oil, apples, red bell pepper, broccoli, peanut butter and strawberry jelly stripes sandwich, ham, beefaroni, turkey breast, peach cobbler smoothie, vanilla custard and 140 grams of V8 vegetable juice were presented. 4 big bites of oysters, 4 big bites of apples, 4 big bites of red bell pepper, 4 big bites of broccoli, 4 big bites of peanut butter and jelly sandwich, 4 big bites of ham, 4 big bites of beefaroni, 198 grams of peach cobbler smoothie, 99 grams of vanilla custard, and all of the vegetable juice were consumes. The meal lasted 32 minutes and 45 seconds.

2/9/11 Session 14: Banana, leaf spinach, small shrimp, beef hamburger, egg beaters (cooked), brown rice, pepperoni pizza snack rolls, strawberry yogurt, pear and pineapple puree and 140 grams of V8 vegetable juice were presented. 4 big bites of banana, 4 big bites of leaf spinach, 4 big bites of shrimp, 4 big bites of hamburger, 4 big bites of egg beaters,  4 big bites of brown rice, 4 big bites of pepperoni pizza snack rolls, 1 container of yogurt, 198 grams of pear pineapple puree and all 140 grams of V8 vegetable juice were consumed. There was emesis after the second bite of spinach. The meal lasted 21 minutes and 57 seconds.

2/11/11 Session 15: Baby sweet corn, green peas, tofu vegetable lasagna, turkey sandwich with multi grain bread, cantaloupe, blueberry yogurt, brown mushrooms, maple brown sugar oatmeal, pureed bananas with apples and pears, and 140 grams of V8 vegetable juice were presented. 4 big bites of corn, 4 big bites of peas, 4 big bites of lasagna, 4 big bites of sandwich, 4 big bites of cantaloupe, 1 container of blueberry yogurt, 4 big bites of brown mushrooms, 4 big bites of oatmeal, 99 grams of pureed bananas, apples and pears, and all of the vegetable juice were consumed. The meal lasted 37 minutes and 20 seconds.

Parent Training:

2/14/11 Session 16: Cauliflower, crab, chicken breast, pear, beef ravioli, chicken Vienna sausage, mango smoothie and 140 grams of V8 vegetable juice were presented. 4 big bites of cauliflower, 4 big bites of crab, 4 big bites of chicken, 4 big bites of pear, 4 big bites of ravioli, 12 bites of chicken Vienna sausage, 99 grams of mango smoothie and 140 grams of vegetable juice were consumed. Emesis occurred with the crab. The meal lasted 21 minutes.

2/16/11 Session 17: Cucumber, ham, beets, pineapple, shrimp, egg beaters (cooked), peach cobbler smoothie, pureed pear and pineapple, and 140 grams of V8 vegetable juice were presented. 4 big bites of cucumber, 18 bites of ham, 4 bites of beets, 4 bites of pineapple, 4 bites of shrimp, 4 bites of egg beaters, 99 grams of peach smoothie, 198 grams of pear and pineapple, and all of the vegetable juice were consumed. The meal lasted 22 minutes.

Generalization and Further Parent Training

Mom was instructed to enter novel room with participant. He did not see the therapist. Food was already in the room and mother was instructed to begin the meal. Therapist monitored session remotely. 

Participant began to expel food (which had not occurred in any other sessions) and cry (which had not occurred since first session). There was no vomiting, but an abundance of other refusal behaviors occurred throughout the session.

After fifteen minutes of refusal with Mom alone in room with participant, the therapist entered the room and the meal stabilized with acceptance of the rest of the meal without any of the previously mentioned refusal. No other changes were made in the meal besides the therapist being present in the room. 

It is of significant note that mango has been a preferred food for the past twelve sessions. He has always verbalized liking the mango and asking for more, which was always given at the end of the session. All extra requested bites were always consumed without protocol. Mom has also mentioned that he is frequently requesting mango at home and consuming all that is presented.  Mango however was one of the foods refused during this session at the clinic.  

2/28/11 Session 22: Beef ravioli, sardines in water, scrambled eggs, mango, green bell pepper, bagel bites, 99 grams of mango smoothie, and 140 grams of V8 vegetable juice were presented. 4 bites of ravioli, 4 bites of sardines, 4 bites of eggs, 4 bites of mango, 4 bites of bell pepper, 4 bites of bagel bites, 99 grams of mango smoothie, and 140 grams of vegetable juice were consumed.

3/2/11 Session 23: Pineapple, green beans, chicken breast, mashed potatoes, oysters in oil, tomatoes, 99 grams of peach cobbler smoothie, and 140 grams of  V8 vegetable juice were presented. 4 bites of pineapple, 4 bites of green beans, 4 bites of chicken breast, 4 bites of mashed potatoes, 4 bites of oyster, 4 bites of tomato, 99 grams of smoothie and 140 grams of vegetable juice were consumed.

It was decided that the therapist needed to be faded out on a slower basis. The session was generalized again to a new context. The therapist remained in the room for the first ten minutes of the session and then left the room. The therapist continued to remotely monitor the session. One novel food was presented in the session (sardines in tomato sauce). More of the sardines were requested by the child after he had consumed the portion presented to him during the session. The entire volume of sardines presented subsequent to the session was consumed in the absence of protocol. All foods were consumed without refusal during the session.

3/4/11 Session 24: Pepperoni pizza snacks, corn, sardines in tomato sauce, mango, ham, peanut butter and strawberry jelly sandwich, 99 grams of mango smoothie and 140 grams of V8 vegetable juice were presented. 4 bites of pizza snacks, 4 bites of corn, 19 bites of sardines, 4 bites of mango, 4 bites of ham, 4 bites of sandwich, 99 grams of smoothie and 140 grams of vegetable juice were consumed.