A translational evaluation of renewal of inappropriate mealtimebehavior

VIVIAN F. IBAÑEZ, CATHLEEN C. PIAZZA AND KATHRYN M. PETERSON

UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

The term renewal describes the recurrence of previously extinguished behavior that occurs whenthe intervention context changes. Renewal has important clinical relevance as a paradigm forstudying treatment relapse because context changes are necessary for generalization and mainte-nance of most intervention outcomes. The effects of context changes are particularly importantduring intervention for pediatric feeding disorders because children eat in a variety of contexts,and extinction is an empirically supported and often necessary intervention. Therefore, we usedan ABA arrangement to test for renewal during intervention with 3 children diagnosed with afeeding disorder. The A phase was functional reinforcement of inappropriate mealtime behaviorin a simulated home setting with the child’s caregiver as feeder, B was function-based extinctionin a standard clinic setting with a therapist as feeder, and the return to the A phase wasfunction-based extinction in a simulated home setting with caregiver as feeder. Returning toContext A resulted in renewal of inappropriate mealtime behavior across children, despite thecaregivers’ continued implementation of function-based extinction with high levels of integrity.Key words: feeding disorder, inappropriate mealtime behavior, generalization, maintenance,

pediatric feeding disorders, renewal, translational, treatment integrity

Researchers have identified context as one fac-tor that may influence generalization and long-term maintenance of intervention outcomes(e.g., Kelley, Liddon, Ribeiro, Greif, & Podlesnik,2015; Stokes & Baer, 1977). Researchers describecontext as the exteroceptive stimuli associatedwith learning, such as an experimental chamber, acolor, or an odor (e.g., Kincaid, Lattal, & Spence,2015), and contextual control as the conditionunder which learning occurs (Podlesnik, Kelley,Jimenez-Gomez, & Bouton, 2017). For example,Bouton and Bolles (1979) trained rats in ContextA and extinguished responding in Context B,and associated each context with different

exteroceptive stimuli. When Bouton and Bollesreturned the rats to Context A and continuedextinction, the trained response returned, whichBouton and Bolles referred to as the renewal effect.Results of Bouton and Bolles (1979) suggest

that learning was specific to the context in whichit occurred, and numerous researchers havedemonstrated renewal of extinguished behavior in -respondent- (e.g., Bouton & King, 1983;Bouton & Peck, 1989; Bouton & Swartzentruber,1989; Gunther, Denniston, & Miller, 1998;Nakajima, Tanaka, Urushihara, & Imada, 2000;Rauhut, Thomas, & Ayres, 2001) and operant-(Trask, Schepers, & Bouton, 2015) conditioningarrangements. In fact, Bouton, Todd, Vurbic, andWinterbauer (2011) suggested that operant extinc-tion is relatively specific to the context in whichthe organism learns that the response no longerproduces reinforcement.Renewal has important clinical relevance as a

paradigm for studying treatment relapse.Relapse, when previously extinguished undesir-able behavior returns (Mace & Critchfield,2010), is a common problem among individuals

This study was based on a dissertation submitted inpartial fulfillment of the first author’s doctoral degree fromthe University of Nebraska Medical Center. We thankWayne W. Fisher and Brian D. Greer for their helpfulguidance throughout the study. We also thank JaimeG. Crowley, Tara J. Johnson, Caitlin A. Kirkwood, HollyM. Ney, Jocelin L. Merciez, and Ryan C. Ortega, fortheir assistance in completing this study.Vivian Ibañez is now at the University of Florida.Address correspondence to: Vivian Ibañez (vibanez@ufl.

edu) or Cathleen Piazza ([email protected])doi: 10.1002/jaba.647

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2019, 52, 1005–1020 NUMBER 4 (FALL)

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with behavioral-health disorders that negativelyimpacts the long-term effectiveness of interven-tion. Results of renewal studies suggest thatextinguished behavior will return or relapse inthe absence of a change in implemented contin-gencies simply by changing the context in whichextinction occurs. Researchers have used a three-phase arrangement (ABA, ABC, or AAC) tostudy renewal, in which a reinforcement phasein Context A is followed by two phases ofextinction in either Contexts B and A in ABArenewal, in Contexts B and C in ABC renewal,or in Contexts A and C in AAC renewal. Thefocus of these arrangements is the pattern ofresponding associated with the context changes.For example, Kelley et al. (2015) conducted atranslational study in which researchers providedreinforcement to participants for task comple-tion in Context A, extinguished task completionin Context B, and continued extinction inContext A. Although task completion decreasedto zero during extinction in Context B,responding increased during extinction in thereturn to Context A. Researchers also havedemonstrated renewal with ABC and AACarrangements, but the ABA arrangement pro-duces the most robust demonstrations ofrenewal (Podlesnik et al., 2017).Despite the clinical relevance of renewal to

behavioral-health disorders, few studies haveevaluated operant renewal with a socially signif-icant problem like pediatric feeding disorders.Pediatric feeding disorders are an excellent sub-ject for a variety of reasons. Basic studies showthat context changes during extinction reliablyproduce renewal. Clinical studies on pediatricfeeding disorders show that extinction is anempirically supported and often necessary inter-vention component (Volkert & Piazza, 2012).In addition, researchers have conducted mostfeeding intervention studies in clinic settingswith highly trained therapists (e.g., Ahearn,Kerwin, Eicher, Shantz, & Swearingin, 1996;Babbitt, Hoch, & Coe, 1994; Gulotta, Piazza,Patel, & Layer, 2005; Kadey, Piazza, Rivas, &

Zeleny, 2013; Patel, Piazza, Layer, Coleman, &Swartzwelder, 2005; Piazza, Fisher, et al.,2003; Volkert, Vaz, Piazza, Frese, & Barnett,2011; Wilkins, Piazza, Groff, & Vaz, 2011),who then train caregivers to implement inter-vention. Even if the caregiver serves as the ini-tial change agent (Seiverling, Williams,Sturmey, & Hart, 2012; Tarbox, Schiff, &Najdowski, 2010), children feed in many con-texts, and teachers, relatives, or day-care pro-viders also may implement intervention.Although these factors suggest that we shouldexpect renewal to occur, only one study hasevaluated renewal systematically during inter-vention for pediatric feeding disorders (Kelley,Jimenez-Gomez, Podlesnik, & Morgan. 2018).Not only is the study of renewal in children

with feeding disorders relevant for the reasonscited above, it is particularly important for chil-dren with severe feeding problems, like thosewe admit to our day-treatment program. Thesechildren often have complex medical problemsand oral-motor-skill deficits that may compro-mise their health and safety during oral feeding.Thus, these children warrant initial interven-tion in a setting where professionals can closelymonitor the child. For this reason, trained ther-apists implement intervention initially with ourday-treatment patients. Using therapists aschange agents also allows us to ensure highlevels of integrity during initial interventionand to determine whether the intervention isefficacious before we ask caregivers to imple-ment it. After we demonstrate intervention effi-cacy, we train caregivers, generalize theintervention to the home and other settings(e.g., daycare), discharge the child from theday-treatment program, and admit the child tothe outpatient program. When caregiversimplement the intervention in the home afterdischarge from the day-treatment program,they sometimes observe relapse. This relapse isparticularly frustrating for caregivers if they areimplementing the intervention with high integ-rity. Our experience is that caregivers are more

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likely to discontinue or change the interven-tion, drop out of therapy, or both duringperiods of relapse. Relapse is particularly con-cerning for children with severe feeding disor-ders because inadequate calories, hydration,and nutrition can have short- and long-termnegative effects on behavior, development, andhealth (Freedman, Dietz, Srinivasan, & Beren-son, 1999). Therefore, a better understandingof relapse, with the long-term goal of mitigat-ing it, is critical for the treatment of severefeeding disorders.To that end, we tested for ABA renewal in

the current study, in which A was functionalreinforcement of inappropriate mealtimebehavior in a simulated home setting with thechild’s caregiver as the feeder, B was function-based extinction of inappropriate mealtimebehavior in a standard clinic setting with aclinic therapist as feeder, and a return to Awas function-based extinction in the simulatedhome setting with the child’s caregiver as thefeeder.

METHOD

ParticipantsParticipants were patients in an intensive

day-treatment feeding program Mondaythrough Friday from about 9:00 am to about5:00 pm. Carlos was a 3-year-old boy whosediagnoses included autism spectrum disorder,apraxia, global developmental delays, and foodselectivity. At the time of admission, Carlosreportedly received 100%, 209%, and 46% ofhis daily calories, protein, and fluids, respec-tively, via 8-oz sippy-cup feedings of Pediasurewith Fiber at 7:30 a.m., 12:00 p.m., and5:30 p.m., and via McDonald’s chicken nug-gets, graham crackers, Kellogg’s Eggo BitesChocolatey Chip Pancakes, and Idahoan FourCheese mashed potatoes. Our program’s regis-tered dietician estimated that Carlos’ intake ofnutrients was adequate only due to his con-sumption of Pediasure with Fiber. Carlos’

caregiver was the referral source. Fernando wasa 3-year-old boy whose diagnoses included bot-tle dependence; food refusal; allergies to soy,dairy, and gluten; colitis; chronic diarrhea;speech delays; and a history of pneumonia. Atthe time of admission, Fernando reportedlyreceived 78%, 146%, and 66% of his daily cal-ories, protein, and fluids, respectively, via 8-ozsippy-cup feedings of Elecare Jr. mixed withalmond milk at 8:00 a.m., 12:00 p.m., 6:00 p.m., and 7:00 p.m., and via small amounts ofcrackers, fruit snacks, and applesauce. Our pro-gram’s registered dietician estimated thatFernando’s mean intake was low in vitamins Dand K, pantothenic acid, phosphorous, andpotassium. Fernando’s pediatrician referred himfor bottle dependence and food refusal. Pierrewas a 4-year-old boy whose diagnoses includedgastrostomy-tube dependence; gastroesophagealreflux disease and a history of vomiting, whichresulted in a Nissen Fundoplication; tetralogyof fallot; and pulmonary atresia. At the time ofadmission, Pierre reportedly received 71%,137%, and 102% of his daily calories, protein,and fluids, respectively, via 3.5-oz gastrostomy-tube feedings of a caregiver-prepared blended-food diet every 30 min from 7:30 a.m. to9:00 p.m., delivered via gravity at 100 mL perhour. Our program’s registered dietician esti-mated that Pierre’s mean intake met 100% ofhis nutritional needs only due to gastrostomy-tube feedings of a blended-food diet, and thathis growth was inadequate. Pierre’s pediatricianreferred him for gastrostomy-tube dependence.Lorenzo was a 2-year-old boy whose diagnosesincluded gastrostomy-tube dependence,vomiting, failure to thrive, gastroesophagealreflux disease, hypercalcemia, developmentaldelays, and a history of prematurity. At thetime of admission, Lorenzo reportedly received100%, 148%, and 54% of his daily calories,protein, and fluids, respectively, via 5-ozgastrostomy-tube feedings of Pediasure 1.5 at8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., delivered via pump at 200 mL per hour.

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Our program’s registered dietician estimatedthat Lorenzo’s intake of nutrients was adequateonly due to his consumption of Pediasure1.5. Lorenzo’s pediatrician referred him forgastrostomy-tube dependence.Before the current study, each child partici-

pated in an interdisciplinary evaluation conductedby a dietitian, a pediatric gastroenterologist, mas-ter’s and bachelor’s level feeders with specializedtraining in feeding and behavior analysis, a psy-chologist, and a speech and language pathologistto confirm the safety of oral feeding.

FeedersClinic therapists conducted sessions during

the functional analysis and during the B phaseof the renewal analysis in the solids and liquidsstandard clinic settings. Caregivers who con-ducted sessions in the A phases of the analysiswere the participants’ biological mothers.

Settings and MaterialsWe conducted sessions in three settings in a

university-based tertiary care facility. Settingscontained utensils, food trays, a scale, andtimers. The solids and liquids standard clinic set-tings were 4-m x 4-m therapy rooms in a pedi-atric feeding disorders clinic. These roomscontained one-way observation windows, arectangular table, a sanitizer dispenser on thewall, and a chair. The solids simulated home set-ting was in a semiprivate area of an early inter-vention clinic. This room contained a squaretable with a red table cloth, a table lamp, acompact refrigerator, a coffee maker, a smallpantry shelf containing a variety of foods(e.g., chips, applesauce), a variety of home dec-orations (e.g., a framed photo of a family, abowl of plastic fruit, a painting hung on thewall, artificial flowers in a vase), striped curtainsthat covered two freestanding room partitions,and a chair. The liquids simulated home settingwas in a kitchen of a recreational therapy pro-gram. This room contained a large table with

chairs, materials in a typical kitchen (e.g., full-size refrigerator, toaster, stove, blender, standmixer, a counter with snacks, pots, pans), and achair. Carlos sat in a Special Tomato Soft-Touch sitter that we secured to a regular chair.Fernando and Lorenzo sat in a high chair. Pie-rre sat in a booster seat.We asked the caregiver to select eight target

foods from a list provided by the first authorthat the child did not eat currently, but thatthe caregiver wanted the child to eat. Generally,we targeted two foods from each of the foodgroups of fruits, proteins, starches, and vegeta-bles, or foods from the food group(s) that con-tained nutrients for which the child’s diet wasdeficient per our program’s dietitian. We alsoincorporated dietary recommendations fromother professionals, such as the child’s physi-cian, when appropriate. The feeder presentedthe foods at a pureed texture, which is tablefood blended in a blender until smooth withliquid added as needed. The bolus size was alevel small maroon spoon for all children. Thecaregiver also selected a liquid such as Pediasureor milk that the child did not currently con-sume orally and that was calorically and nutri-tionally appropriate for the child per ourprogram dietitian. The feeder presented 2 cc ofliquids in a pink cut-out cup.

Dependent Variables, Reliability, andProcedural IntegrityTrained observers sat in a room with one-way

observation windows adjacent to the therapyroom during standard clinic-setting sessions andin an unoccupied therapy room or a private officein the clinic during simulated home-setting ses-sions. Observers used Vidyo, a HIPAA-complianttelehealth video conferencing platform, to watchsimulated home-setting sessions on iPads, one ofwhich was in the simulated home setting and oneof which was in the room with the observer.Observers used laptop computers to collect datausing the DataPal 1.0 program.

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Observers scored inappropriate mealtimebehavior when the utensil was in arm’s reach ofthe child and the child turned his head 45� orgreater away from the utensil during a bite ordrink presentation; used his hand to contactthe utensil, food or drink, or the feeder’s handor arm anywhere from the elbow down whilethe feeder was presenting the bite or drink;threw food, liquids, or utensils; or blocked hismouth with his hand, bib, or toys. Observersscored acceptance when the child opened hismouth in the absence of inappropriate meal-time behavior or leaned forward and openedhis mouth while engaging in negative vocaliza-tions such that the feeder deposited the entirebite except for food or drink of pea size orsmaller, within 5 s of presentation. A presenta-tion occurred when the feeder touched themidline of the child’s lips with the utensil.Observers recorded whether acceptance

occurred during each bite presentation and fre-quency of inappropriate mealtime behavior.We converted acceptance to a percentage afterdividing the number of acceptances by thenumber of bite or drink presentations. Weconverted the frequency of inappropriate meal-time behavior to responses per minute bydividing the number of inappropriate mealtimebehaviors during the session by the durationthe utensil or bite was in arm’s reach.At least one observer scored feeder proce-

dural integrity for correct context, correct uten-sil presentation, incorrect praise, and incorrectattention during 87% of sessions. Observerswrote a yes or a no on an excel spreadsheet toindicate whether the feeder conducted the ses-sion in the correct context, as described above.We converted correct context to a percentageby dividing the instances of correct context bythe total number of sessions. Mean correct con-text was 100% across participants.Observers scored duration of correct utensil

presentation by pressing a key on the data-collection program that activated a timer whenthe feeder met the criterion for correct spoon

presentation and pressed the key, whichdeactivated the timer, if the feeder did not meetthe criterion for 3 s or more. Observers scoredcorrect utensil presentation when the feeder(a) presented the utensil to the child’s lips;(b) removed the utensil after the bite or drinkentered the child’s mouth; and (c) presented thenext bite or drink approximately 30 s after theprevious bite or drink entered the child’s mouth,except as indicated below. Observers scored cor-rect utensil presentation during function-basedextinction when the feeder (a) held the utensiltouching the child’s lips until the child openedhis or her mouth and allowed the feeder todeposit the bite or drink; (b) left the utensiltouching the child’s lips if the bite of food ordrink did not remain on the utensil and thefeeder needed to obtain another bite or drink;(c) deposited the bite or drink when the childopened his or her mouth; (d) held the utensil tothe side of the child’s lips if the child vomited,coughed, or gagged while the feeder was holdingthe utensil at the child’s lips; (e) scooped upexpelled food or liquid within 3 s of expulsion(any food or liquid larger than a pea passed theplane of the lips after the feeder deposited the biteor drink) and placed the utensil with the bite ordrink back to the child’s lips. Observers alsoscored correct utensil presentation duringfunction-based extinction if the child was engag-ing in expulsion when it was time for the feederto present the next bite or drink and the feederpresented the next bite or drink when theexpelled food or liquid remained in the child’smouth for 3 s. The criterion for correct utensilpresentation was relatively conservative because(a) the feeder had to keep the utensil touchingthe child’s lips, which can be difficult during ini-tial escape-extinction sessions; and (b) observersstopped the correct utensil placement timer forany 3-s deviation from the protocol. Weconverted duration of correct utensil presentationto a percentage after dividing the duration of cor-rect utensil presentation by the session duration.Mean correct utensil presentation was 98%

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(range, 97% to 100%) and 94% (range, 93%to 100%) across therapists and caregivers,respectively.Observers scored the occurrence of incorrect

attention during function-based extinction eachtime the feeder provided attention (e.g., repri-mands, coaxes) within 3 s of inappropriate meal-time behavior (Borrero, Woods, Borrero,Masler, & Lesser, 2010). We divided the occur-rences of incorrect attention by the number ofinappropriate mealtime behaviors and convertedthe ratio to a percentage. Mean incorrect atten-tion was 0% and 3% (range, 0% to 5%) acrosstherapists and caregivers, respectively.Observers scored incorrect praise if the

feeder did not provide behavior-specific praisewithin 5 s of acceptance and mouth clean, pro-vided praise when bites or drinks entered themouth after 5 s, or when there was food or liq-uid larger than the size of a pea in the mouthat the time of mouth check. We convertedincorrect praise to a percentage after dividingthe instances of incorrect praise by the totalopportunities to provide correct and incorrectpraise. Feeders provided incorrect praise duringa mean of 0% and 4% (range, 0% to 6%) ofopportunities across therapists and caregivers,respectively.A second observer simultaneously, but inde-

pendently, scored a mean of 87% of sessions.We trained observers before the study to collectdata with greater than 85% interobserver agree-ment for three consecutive sessions. The Dat-aPal Reli 1.0 software calculated interobserveragreement by partitioning each session into10-s intervals. DataPal calculated total agree-ment coefficients for acceptance, correct utensilpresentation, incorrect attention, and incorrectpraise by dividing the number of agreements(defined as both observers scoring or notscoring an occurrence of the behavior in theinterval) by the total number of agreementsplus disagreements and converting this ratioto a percentage. Mean interobserver agreementacross participants was 98% (range, 93% to

100%) for acceptance, 95% (range, 92% to98%) for correct utensil placement, 97%(range, 95% to 98%) for incorrect attention,and 98% (range, 96% to 99%) for incorrectpraise. We calculated interobserver agreementfor correct context by dividing the smallernumber by the larger number and convertingthe ratio to a percentage. Mean interobserveragreement across participants was 100% forcorrect context. DataPal calculated exact agree-ment coefficients for inappropriate mealtimebehavior by dividing the number of exactagreements (defined as observers scoring thesame frequency of the behavior in the interval)by the number of exact agreements plus dis-agreements and converting this ratio to a per-centage. Mean interobserver agreement acrossparticipants was 93% (range, 92% to 96%) forinappropriate mealtime behavior.

Experimental DesignWe used a pairwise design (Bachmeyer

et al., 2009; Iwata, Duncan, Zarcone,Lerman, & Shore, 1994) for the functionalanalysis to compare levels of inappropriatemealtime behavior in the test (escape, atten-tion, tangible) versus the control conditions.For the renewal evaluation, we used a three-phase arrangement (i.e., ABA) embedded in anonconcurrent multiple baseline design acrossparticipants during solids and liquids sessions.During Context A, the child’s caregiver deliv-ered functional reinforcement contingent oninappropriate mealtime behavior in a simulatedhome setting. During Context B, the clinictherapist conducted function-based extinctionin a standard therapy room. During a return toContext A, the child’s caregiver conductedfunction-based extinction in the simulatedhome setting.

General ProcedureEach child followed an individualized sched-

ule of five 40-min meals a day with at least

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40 min between the end of one meal and thebeginning of the next. The feeder presentedsolids in some meals and liquids in other meals,but did not present solids and liquids togetherin the same meal. The feeder conducted multi-ple four-bite or four-drink sessions in eachmeal. The number of sessions per mealdepended on the duration of each sessionwithin the meal (i.e., the duration of a singlesession depended on the child’s behavior).There were approximately 1-min breaksbetween sessions, during which feeders andobservers prepared for the next session(e.g., recorded gram consumption, set up data-collection computer program).Before each meal with solid food, the feeder

randomly selected one caregiver-selected foodfrom each of the food groups of fruit, protein,starch, and vegetable, to present during the ses-sions. The feeder randomly selected the orderin which to present the four foods before eachsession. The feeder used the same foods andpresented them in the same order when he orshe alternated between conditions (i.e., pairwisefunctional analysis). The feeder presented everycaregiver-selected food in each phase and inevery condition to control for potential differ-ences in the child’s behavior as a function offood type (Patel, Piazza, Santana, &Volkert, 2002).The feeder presented a bite or drink by

touching the child’s lips with the utensil andsaying, “Take a bite (drink).” The feeder pres-ented a bite or drink approximately 30 s afterthey had presented or deposited the previousbite or drink, depending on the child’s behavior.Contingent on food acceptance, the feeder pro-vided praise and activated a timer for 30 s. Thefeeder conducted a mouth check when 30 selapsed by saying, “Show me, Ahh” whilemodeling an open mouth. The feeder inserted arubber-coated baby spoon between the child’slips and turned it 90� if the child did notopen his mouth within 3 s of the verbal andmodel prompt. The feeder provided praise

(e.g., “Great job swallowing your bite!”) formouth clean, defined as no food or liquid in themouth larger than the size of a pea. The feederdelivered a verbal prompt to “Swallow your bite(drink)” if any food or liquid larger than the sizeof a pea was in the child’s mouth at the 30-scheck. The feeder conducted a mouth checkevery 30 s until no food or liquid larger than thesize of a pea was in the mouth or until 10 minhad elapsed from the start of the session if thechild had food or liquid larger than the size of apea in their mouth during the mouth check forthe fourth bite or drink. However, observers didnot score mouth clean or pack for these subse-quent mouth checks. The feeder provided nodifferential consequence for coughing, gagging,or vomiting.

Functional AnalysisWe asked each caregiver to feed her child as

she would at home before we conducted thefunctional analysis, and we used our directobservations of caregiver-fed meals and care-giver report to inform the conditions of eachchild’s functional analysis. For example, a ther-apist conducted escape, attention, and tangibleconditions if we observed that the caregiverdelivered escape, attention, and a tangible afterinappropriate mealtime behavior, but onlyescape and attention conditions if we observedthe caregiver deliver escape and attention. Atherapist conducted a functional analysis ofinappropriate mealtime behavior with solids forCarlos, Pierre, and Lorenzo and with liquidsfor Carlos, Fernando, and Lorenzo using proce-dures described by Bachmeyer et al. (2009).

Renewal EvaluationThe feeder followed the general procedure

described above in addition to the specific pro-cedure described below. Only the child and thecaregiver were in the simulated home setting,and no one entered the room during meals.The caregiver transitioned the child to the

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simulated home setting, without the therapist,in phases in which the caregiver was the feederso the therapist would not be associated withthe simulated home setting. Finally, the changefrom Context A reinforcement to Context Band the change from Context B to Context Aextinction always occurred on the same day.We trained the caregiver to implement the

reinforcement procedures for Context A and theextinction procedures for Context B prior to thesessions by first having caregivers observe thetherapist conduct most sessions of the functionalanalysis and function-based extinction interven-tion. For these observations, the caregiver enteredthe observation room after his or her child trans-itioned to the therapy room and remained in theobservation room until the child transitioned toanother location such that the child could notsee the caregiver enter or leave the observationroom. Next, we provided training in one-to-onemeetings between the first author and the care-giver. These meetings occurred in a therapyroom in the absence of the child. After describ-ing the procedures, one therapist modeled proto-col implementation by presenting bites or drinksto another therapist who played the role of achild. The caregiver then practiced the proce-dures by feeding a therapist who played the roleof a child while the first author providedcoaching and feedback. Role play continued untilthe caregiver implemented each protocol compo-nent at least twice with no errors.The caregiver wore a Bluetooth headset

through which the therapist provided ongoingcoaching and feedback during Context A rein-forcement and Context B sessions to minimizethe possibility that changes in rates ofresponding during the renewal test wereaffected by lapses in caregiver treatment integ-rity (St. Peter Pipkin, Vollmer, & Sloman,2010). The therapist provided specific praisefor correct performance, reminders for upcom-ing protocol components (e.g., mouth check in5 s), and corrections for errors (e.g., providespecific praise), if necessary.

Context A reinforcement. Caregivers served asfeeders for solids sessions with Carlos, Pierre,and Lorenzo and for liquids sessions with Car-los, Fernando, and Lorenzo in the simulatedhome settings described above. The feederfollowed the general procedure and deliveredfunctional reinforcement for 30 s if the childengaged in inappropriate mealtime behavior ina manner like that described for the functionalanalysis. Functional reinforcement was escapefor Lorenzo (liquids); escape and attention forCarlos, Fernando, and Pierre; and escape,attention, and tangible for Lorenzo (solids).Before the caregiver and child transitioned tothe simulated home setting, therapists preparedthe materials for the meal (e.g., food) andplaced them and the Bluetooth equipment andiPad in the room, opened the virtual room inthe telehealth software, and tested theBluetooth and telehealth equipment.Context B extinction. Therapists conducted

sessions in the standard clinic setting describedabove. The feeder conducted the general proce-dure and escape extinction for Lorenzo (liq-uids); escape and attention extinction forCarlos, Fernando, and Pierre; and escape,attention, and tangible extinction for Lorenzo(solids) based on the results of the child’s func-tional analysis. During escape extinction, thefeeder kept the utensil touching the child’s lipsuntil the child opened his mouth and allowedthe feeder to deposit the bite or drink insidethe mouth or until 10 min from the start ofthe session had elapsed. The feeder gentlyscraped the food on the child’s teeth with thespoon if the child did not close his moutharound the spoon when the feeder placed thespoon into the mouth. The feeder used theutensil to re-present expelled food or liquid,defined as any food or liquid larger than thesize of a pea that exited the child’s mouth afterentering the child’s mouth, by scooping up thefood or liquid with the utensil as quickly aspossible and placing it back in the mouth. Ifthe child was expelling at the presentation

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interval for the next bite or drink, the feederre-presented while prompting the child to,“Swallow your bite [drink]” approximatelyevery 30 s until the bite or drink remained inthe mouth for at least 3 s or the time-cap hadbeen met. The feeder kept the utensil touchingthe child’s cheek and did not deposit the biteor drink if the child was coughing, gagging, orvomiting during the presentation until thechild stopped coughing, gagging, or vomiting.Attention and tangible extinction consisted ofthe feeder no longer delivering attention or thetangible item when the child engaged in inap-propriate mealtime behavior.Context A extinction. The therapist prepared

session materials such as the child’s food andplaced them in the room. Next, the caregivertransitioned the child to the therapy room asdescribed above. Caregivers conductedfunction-based extinction as described for Con-text B but in the simulated home settings.

RESULTS

Figure 1 displays inappropriate mealtimebehavior per minute for Carlos’ solids (top),Carlos’ liquids (middle), and Fernando’s liquids(bottom). During function-based reinforcementin Context A, inappropriate mealtime behaviorwas high and stable or increasing for Carlos’solids (M = 101; range, 80 to 123), Carlos’ liq-uids (M = 95; range, 44 to 142), andFernando’s liquids (M = 14; range, 0 to 50).During function-based extinction inContext B, inappropriate mealtime behaviorwas initially observed and then decreased tozero for Carlos’ solids (M = 32; range, 0 to133) and liquids (M = 5, range, 0 to 29) andFernando’s liquids (M = 5; range, 0 to 24).During the renewal test, inappropriate meal-time behavior immediately increased and theneventually decreased to zero for Carlos’ solids(M = 5; range, 0 to 37) and liquids (M = 4;range, 0 to 33). We observed a different patternduring the renewal test for Fernando’s liquids

(M = 20; range, 0 to 63). No inappropriatemealtime behavior occurred for three sessions,after which it increased and remained high andrelatively stable during the last five sessions.Figure 2 displays percentage of acceptance

for Carlos’ solids (top), Carlos’ liquids (mid-dle), and Fernando’s liquids (bottom). Duringfunction-based reinforcement in Context A,percentage of acceptance for Carlos’ solids andliquids was at zero. Percentage acceptance forFernando’s liquids was initially highly variablebut became stable at zero for the last six ses-sions (M = 50%, range, 0% to 100%). Duringfunction-based extinction in Context B, per-centage of acceptance was initially low followedby an increase to high and stable levels for

Figure 1. Inappropriate mealtime behavior perminute for Carlos’ solids (top), Carlos’ liquids (middle),and Fernando’s liquids (bottom).

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Carlos’ solids (M = 54%; range, 0% to 100%),Carlos’ liquids (M = 75%; range, 0% to100%), and Fernando’s liquids (M = 90%;range, 50% to 100%). During the renewal test,levels of acceptance initially decreased beforeincreasing to high and stable levels for Carlos’solids (M = 88%; range, 25% to 100%) andliquids (M = 82%; range, 25% to 100%). Weobserved high levels of acceptance for the firstthree sessions for Fernando’s liquids, followedby a decrease to zero (M = 22%; range, 0%to 100%).Figure 3 displays inappropriate mealtime

behavior per minute for Pierre’s solids (top),Lorenzo’s liquids (middle), and Lorenzo’s solids(bottom). During function-based reinforcementin Context A, inappropriate mealtime behavior

was high and stable for Pierre’s solids (M = 29;range, 14 to 50), Lorenzo’s liquids (M = 18;range, 3 to 56), and Lorenzo’s solids (M = 43;range, 6 to 60). During function-based extinc-tion in Context B, inappropriate mealtimebehavior gradually decreased to zero for Pierre’ssolids (M = 3; range, 0 to 23), Lorenzo’s liquids(M = 4; range, 0 to 15), and Lorenzo’s solids(M = 6; range, 0 to 44). During the renewaltest, inappropriate mealtime behavior increasedfor Pierre’s solids (M = 9; range, 0 to 31),Lorenzo’s liquids (M = 5; range, 0 to 48), andLorenzo’s solids (M = 18; range, 6 to 42). How-ever, inappropriate mealtime behavior eventuallydecreased to zero for Lorenzo’s liquids.Figure 4 displays percentage of acceptance

for Pierre’s solids (top), Lorenzo’s liquids

Figure 2. Percentage of acceptance for Carlos’ solids(top), Carlos’ liquids (middle), and Fernando’s liquids(bottom).

Figure 3. Inappropriate mealtime behavior perminute for Pierre’s solids (top), Lorenzo’s liquids (mid-dle), and Lorenzo’s solids (bottom).

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(middle), and Lorenzo’s solids (bottom). Dur-ing function-based reinforcement in Context A,percentage of acceptance was low and stable forPierre’s solids (M = 1%; range, 0% to 25%),Lorenzo’s liquids (M = 0%), and Lorenzo’ssolids (M = 0%). During function-based extinc-tion in Context B, percentage of acceptancegradually increased to high and stable levels forPierre’s solids (M = 89%; range, 0% to 100%),Lorenzo’s liquids (M = 50%; range, 0% to100%), and Lorenzo’s solids (M = 47%; range,0% to 100%). During the renewal test, per-centage of acceptance initially decreased forPierre’s solids (M = 75%; range, 25% to100%), Lorenzo’s liquids (M = 53%; range,0% to 100%), and Lorenzo’s solids (M = 19%;range, 0% to 50%). This initial decrease was

followed by variable levels of acceptance forPierre’s and Lorenzo’s solids and by graduallyincreasing levels of acceptance for Lorenzo’sliquids.We calculated proportion of baseline to

allow researchers to make relative comparisonsacross studies that may not be possible withabsolute measures such as the response rate weused in the current study. We calculated theproportion of baseline rates during extinctionby dividing the rate of inappropriate mealtimebehavior in the last session of function-basedextinction in Context B by the mean of inap-propriate mealtime behavior during function-based reinforcement in Context A. Next, wecalculated the proportion of baseline rates dur-ing the renewal test by dividing the first 21 ses-sions of function-based extinction in Context Aby the mean of inappropriate mealtime behav-ior during function-based reinforcement inContext A. We used 21 to equate the numberof function-based extinction sessions in Con-text A across participants because that was thefewest number of those sessions for any partici-pant. The proportion of baseline response rateswas between 0 and 4.6 across children. SeeSupporting Information for individual partici-pant data on the proportion of baselineresponse rates.

DISCUSSION

Results of basic and translational researchsuggest that operant renewal is a reliable phe-nomenon when context changes occur duringimplementation of extinction. These contextchanges parallel what may occur in clinical set-tings when professionals attempt to transfer anintervention from one setting, such as a clinic,to another setting, such as the home. Thus,renewal serves as a paradigm for studying treat-ment relapse (e.g., Bouton, Todd, & León,2014; Bouton et al., 2011; Kelley et al., 2015;Podlesnik et al., 2017). Clinicians have longrecognized the problems associated with

Figure 4. Percentage of acceptance for Pierre’s solids(top), Lorenzo’s liquids (middle), and Lorenzo’s solids(bottom).

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treatment relapse, with researchers reportingrates as high as 80% for some behavioral-healthdisorders (Sahakian, 1983). Relapse is particu-larly concerning for children with severe feed-ing disorders given the significant negativeconsequences of inadequate calories, hydration,and nutrition (Freedman et al., 1999). To ourknowledge, this is one of the first demonstra-tions of operant renewal for a socially signifi-cant problem, pediatric feeding disorders.Podlesnik et al. (2017) noted that context

typically refers to global features of the environ-ment such as visual, olfactory, and tactile stim-uli. In the current study, we defined contextbased on the feeder, the location, and the con-tent of the room, much like the approachdescribed by Saini, Sullivan, Baxter, DeRosa,and Roane (2018). In the A phase of ourrenewal evaluation, caregivers delivered func-tional reinforcement for inappropriate mealtimebehavior in a simulated home setting. We useda simulated rather than the actual homebecause families lived more than 50 miles fromour clinic, so long-term in-home assessmentand intervention was not practical. The B phasereplicated our clinical practice in which thera-pists implemented function-based extinction ofinappropriate mealtime behavior in our clinic.Finally, the caregiver implemented function-based extinction of inappropriate mealtimebehavior in the simulated home setting in therenewal test.Assessing a single context change (e.g., from

a therapist to caregiver as feeder in the clinic)would have been a more parsimonious demon-stration of renewal. However, we wanted toassess renewal in the situation that caregiversreport as most challenging for them and thatwe find most challenging to address, which iswhen renewal occurs in the home when thecaregiver feeds. The caregiver and child are inclinic Monday through Friday from approxi-mately 9:00 am to 5:00 pm in the day-treatment program, and staff are physically pre-sent to support the caregiver. If renewal occurs,

we have many opportunities to observe care-giver and child behavior and modify the inter-vention, if necessary. By contrast, the caregiverand child attend the outpatient clinic viatelehealth once or twice a week for 30 to60 min per appointment. If renewal occursduring the outpatient program, staff are notphysically present, and we have less empiricaldata on which we can base intervention deci-sions. Therefore, we chose to conduct therenewal test with the combination of contextualchanges that we judged to be most meaningfulto us and to families for promoting long-termmaintenance of caregiver and child behavior.Rosas, Todd, and Bouton (2013) suggested

that context affects renewal, in part, becausecontext provides information about thearranged contingencies. Results of our directobservations of caregiver-fed meals prior to thefunctional analysis were consistent with thoseof descriptive studies (Borrero et al., 2010;Piazza, Fisher, et al., 2003) and showed thatcaregivers delivered potential reinforcers forinappropriate mealtime behavior such as escapefrom bites or drinks, attention, and tangibleitems. The occurrence of renewal when we ret-urned the child to the simulated home settingwith the caregiver feeding should not be sur-prising when we consider responding from thestandpoint of discriminative control, becausewe established the caregiver and the simulatedhome setting as a signal for reinforcement ofinappropriate mealtime behavior in the Aphase.An alternative explanation of the findings is

that the child’s history of caregiver-deliveredreinforcement of inappropriate mealtime behav-ior was responsible for the behavior change inthe renewal test. Todd, Winterbauer, andBouton (2012) showed that longer acquisitionperiods, which we could conceptualize as rein-forcement history, were associated with morerenewal. Children in the current study hadreceived reinforcement for inappropriate meal-time behavior from their caregivers for at least

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2 years before the study began. Thus, a changein feeder may have been sufficient to observerenewal as the caregiver’s presence may havebeen the most salient cue for reinforcementavailability (Saini et al., 2018).Caregiver intervention integrity is another

factor that may have affected the increases ininappropriate mealtime behavior during therenewal test, because caregiver interventionintegrity was lower than that of therapists(M = 94% vs 97%). Some researchers haveused 85% as an acceptable level of caregiverintervention integrity (e.g., Marcus, Swanson, &Vollmer, 2001); however, the necessary level ofintervention integrity to obtain treatmenteffects likely varies depending on the indepen-dent variable(s) and on the systems used tomeasure integrity. To evaluate further theeffects of implementation integrity on childbehavior, we examined the data to determine iferrors were more common in the first meal ofthe renewal test relative to subsequent meals.This meal included eight, nine, ten, six, five,and four sessions for Carlos’ solids, Carlos’ liq-uids, Fernando’s liquids, Pierre’s solids,Lorenzo’s liquids, and Lorenzo’s solids, respec-tively. None of the caregivers made any errorsin the first meal, except for Carlos’s motherwhose intervention integrity was 93% for Ses-sion 5 of liquids. Thus, initial increases in inap-propriate mealtime behavior during the renewaltest were not a function of intervention errors.It is possible, however, that inappropriate meal-time behavior can maintain on thin reinforce-ment schedules, which might explain thepersistence we observed for some children.Future research should assess the implicationsof changes in context and intervention integrityduring mealtimes.We also compared the patterns of

responding during the renewal test to those inother studies. Results of the renewal test forCarlos’ solids and liquids and Lorenzo’s liquidswere like those of Kelley et al. (2015), in whichpreviously extinguished behavior returned

immediately and temporarily. By contrast,renewal occurred in the fourth session of therenewal test for Fernando’s liquids. Recall thatwe conducted multiple sessions in each 40-minmeal. Thus, even though renewal did not occurin the first session, it did occur in the first mealof the renewal test. Unlike other participants,inappropriate mealtime behavior persisted forPierre and Lorenzo’s solids and Fernando’s liq-uids across the 63, 21, and 25 sessions of therenewal test, respectively. We could not findbasic studies that demonstrated comparablepersistence, and we do not know if inappropri-ate mealtime behavior would have decreasedhad we continued function-based extinction.Caregivers implemented extinction across just2 to 4 days. As in other studies (e.g., Kelleyet al. 2018; Saini et al., 2018), our renewal testphase was brief because the purpose was tomeasure responding immediately after a returnto a previous context. The duration of extinc-tion required to decrease inappropriate meal-time behavior to previous levels could be atopic for future investigations.Taken together, results of current and previ-

ous studies suggest that we should anticipaterenewal during intervention for a child with afeeding disorder. More importantly, we shouldassess strategies for mitigating renewal. Anobvious renewal-mitigation strategy is for thecaregiver rather than a therapist to implementfunction-based extinction initially. Werle, Mur-phy, and Budd (1993), Anderson and McMil-lan (2001), and Luiselli, Ricciardi, and Gilligan(2005) reported that caregivers could serve asthe initial change agents and implement pediat-ric feeding disorders interventions with highintegrity. Future studies should evaluate thegenerality of this finding and its effects onrenewal. Alternatively, we could measure themagnitude of renewal in a series of contextsafter we pair the caregiver with the clinic thera-pist during the intervention.Another renewal-mitigation strategy is to

implement the intervention in the multiple

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contexts in which the child is likely to eat, suchas the home or school. For example, Guntheret al. (1998) showed that rats exposed toextinction in three contexts exhibited lessrenewal than rats exposed to extinction in onecontext. If we train sufficient exemplars, wemight increase the probability that generaliza-tion will occur to contexts not exposed to inter-vention (Stokes & Baer, 1977). Whenintervention in the home is not practical,increasing the similarity between contexts maybe an alternative, as context similarity isanother method to mitigate renewal (Podlesniket al., 2017; Todd et al., 2012). For example,caregivers could bring personal items such asthe child’s highchair to the clinic to enhancecontext similarity. We do not know, however,which aspects of a context control behavior.Identification of those components could behelpful for programming similarity betweencontexts.We completed the current study by the third

(Carlos, Fernando) and fourth (Pierre, Lorenzo)week of each child’s day-treatment admission.After the renewal evaluation, we providedFernando, Pierre, and Lorenzo with continuousaccess to tangible items, which resulted in areduction of inappropriate mealtime behavior(Reed et al., 2004) and an increase in accep-tance. We discharged Pierre before he com-pleted the program because he had allergicreactions as we introduced new foods. We rec-ommended that he return to the program afterallergy testing. We continued to progress theother participants to age-typical feeding for theremainder of their admission in a variety ofways (e.g., increasing the rate of bite presenta-tion, volume, and bolus size). We did not sys-tematically evaluate whether renewal occurredduring these context changes. We then trans-itioned participants to the outpatient program.Future research should incorporate a renewalparadigm such as ABA, ABC, or AAC renewalto systematically study other types of contextualchanges and long-term outcomes of behavior-

analytic interventions for pediatric feedingdisorders.Results of the current study provide another

demonstration that extinction is an effectiveintervention for decreasing inappropriate meal-time behavior and increasing acceptance whena clinic therapist serves as feeder. These resultsalso show that the effects of extinction are spe-cific to the context in which it occurs (Boutonet al., 2011). Failure to account for renewal inintervention for pediatric feeding disorders maydecrease the likelihood the child will continueto eat and drink over the long term. Pediatricfeeding disorders can have devastating physical,psychological, and financial consequences forthe child, the child’s family, and society(Freedman et al., 1999; Graves & Ware, 1990;Greer, Gulotta, Masler, & Laud, 2007; Ludwiget al., 1999; Singer, Song, Hill, & Jaffe, 1990).Therefore, it is imperative that behavior ana-lysts conduct research that will refine our abil-ity to deliver long-lasting interventions.

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Received December 11, 2017Final acceptance August 16, 2019Action Editor, Dorothea Lerman

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