MARCUS INSTITUTE AND JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE AND AMANDA J. OBERDORFF MARCUS INSTITUTE

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1 JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2003, 36, NUMBER 1(SPRING 2003) ACQUISITION OF CUP DRINKING USING PREVIOUSLY REFUSED FOODS AS POSITIVE AND NEGATIVE REINFORCEMENT MICHAEL E. KELLEY, CATHLEEN C. PIAZZA, AND WAYNE W. FISHER MARCUS INSTITUTE AND JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE AND AMANDA J. OBERDORFF MARCUS INSTITUTE We used previously refused foods as positive and negative reinforcement in the acquisition of cup drinking. Cup drinking increased with positive and negative reinforcement, both alone and in combination (without escape extinction), indicating that treatment of food refusal can establish some foods as appetitive stimuli whereas others remain aversive. DESCRIPTORS: acquisition, food refusal, liquid refusal, negative reinforcement, positive reinforcement Negative reinforcement in the form of escape from eating has been hypothesized to be a primary contributing factor in the maintenance of feeding problems (Iwata, 1987). Nevertheless, treatments for feeding problems have combined strategies based on both positive and negative reinforcement, and the conditions under which positive or negative reinforcement is effective in treatment of feeding problems have not been well studied. Riordan, Iwata, Finney, Wohl, and Stanley (1984) increased consumption of nonpreferred foods using preferred foods as positive reinforcement in children with food selectivity. However, the effectiveness of the reinforcement procedure in the absence of escape extinction is difficult to evaluate, because problem behaviors produced escape This investigation was supported in part by Grants 1 K24 HD and 5 R01 HD from the Department of Health and Human Services, the National Institute of Child Health and Human Development. Requests for reprints should be addressed to Cathleen C. Piazza, Marcus Behavior Center, 1920 Briarcliff Road, Atlanta, Georgia during baseline but were ignored during treatment. Positive and negative reinforcement have been examined as treatment for other escape-maintained problem behavior. For example, Lalli et al. (1999) showed that levels of compliance were higher and levels of problem behavior were lower when compliance produced an edible item (positive reinforcement) relative to a break (negative reinforcement) even though destructive behavior continued to produce escape. These results suggested that, in the absence of escape extinction, positive reinforcement may sometimes be more effective (for reinforcing acquisition of an alternative response) than negative reinforcement, particularly when the quality of the positive reinforcer is relatively high (Hoch, McComas, Thompson, & Paone, 2002). The purpose of the current study was to evaluate the separate and combined effects of positive and negative reinforcement on the acquisition of cup drinking in the absence of escape extinction. We used foods that the participant had refused previously as positive and negative reinforcement. 89

2 90 MICHAEL E. KELLEY et al. METHOD Al, a 3-year-old typically developing boy, had been admitted to a day treatment program for treatment of food refusal and bottle dependence. At admission, Al received 100% of his nutritional needs via bottle feedings and refused all solid foods (including peaches and carrots) and liquids from a cup. We treated Al s food refusal using fading, noncontingent reinforcement, and escape extinction prior to the current study (Al s food-refusal data are part of an ongoing investigation on stimulus fading). At the time of the study, Al ate three meals per day selected from 15 jarred baby foods (three to four types of food per food group). The purpose of the current analysis was to increase Al s consumption of liquid from a cup. Frequencies of choices and consumption were recorded and were converted to percentages of trials on which the behaviors occurred. A choice was defined as Al pointing to a card. Consumption was defined as a trial in which food or liquid was accepted and not expelled prior to the beginning of the next trial. A second observer independently coded 100% and 31% of preference assessment and treatment sessions, respectively. Mean exact agreement was 100% for choice during the preference assessments and 95.6% for consumption during the treatment analysis. Six to 12 5-min sessions were conducted, 5 days per week, in a room containing chairs, a table, and materials relevant to the sessions. The study consisted of (a) a pairedstimulus preference assessment (Fisher et al., 1992) of 15 foods; (b) a second preference assessment comparing peaches, carrots, and a 30-s break; and (c) a treatment analysis. Results of the first preference assessment indicated that peaches and carrots were the most and least preferred foods, respectively. During the first phase of the second preference assessment, we presented three cards concurrently (one depicting peaches, one depicting carrots, and one depicting a break) and prompted Al to choose a card using three-step prompting (he always selected a card following the verbal prompt). During the second phase, we presented two cards concurrently (carrots and break) and prompted him to choose. If Al chose a food item (e.g., carrots), that food was presented on a spoon 2.5 cm in front of his mouth and was held there until he opened his mouth and accepted the bite (i.e., nonremoval of the spoon). If Al chose the break card, he received a 30-s break from the cards and food. Each session consisted of 10 trials. The purpose of this assessment was to identify Al s preferences for peaches, carrots, and a break from eating. We used the results of the preference assessments to develop a treatment to increase cup drinking. In baseline, the therapist presented 7.5 ml of liquid in a cup and a verbal prompt ( Take a drink ) on a fixed-time (FT) 30-s schedule. Praise was delivered if Al either accepted or consumed the drink. No differential consequences were provided for expulsion, vomiting, or the absence of a response (i.e., bite presentation continued on an FT 30-s schedule). If Al engaged in any inappropriate behaviors (e.g., head turns, bats, blocks) during the presentation, the cup was removed for 30 s (i.e., escape from drinking), after which the next trial was initiated. Procedures in treatment were identical to baseline with the following additions. One level spoon of peaches was delivered following consumption of the drink during the positive reinforcement condition (Sr ). One level spoon of carrots was delivered if Al engaged in inappropriate behavior or failed to consume the drink within 30 s of presentation during the negative reinforcement condition (Sr ). Both contingencies were in effect during the positive and negative reinforcement condition (Sr /Sr ). The nonremoval-of-the-spoon procedure described

3 CUP DRINKING 91 Figure 1. The percentage of trials each stimulus was chosen during the first (paired-stimulus) preference assessment (top panel) and the percentage of trials chosen for peaches, carrots, and a break during the second preference assessment (bottom panel). above was used to present the peaches and carrots. Multiple baseline and multielement designs were used to evaluate the treatment effects. RESULTS AND DISCUSSION Results of the first preference assessment (top panel of Figure 1) showed that peaches were chosen and consumed on 100% of trials, whereas carrots were chosen infrequently and were rarely consumed. Results of the second preference assessment (bottom panel of Figure 1) showed that Al chose peaches over carrots and a break from eating on 100% of trials in Phase 1, and that he chose a break over carrots on 93.3% of trials in

4 92 MICHAEL E. KELLEY et al. Figure 2. The percentage of trials in which Al consumed orange juice (top panel), water (middle panel), and chocolate Carnation instant breakfast (bottom panel) during baseline and treatment. Phase 2. Based on these results, we predicted that contingent access to peaches and contingent avoidance of carrots might function as positive and negative reinforcement, respectively. Al s baseline consumption during the treatment analysis (Figure 2) was 0%, 44.6%, and 12.5% across the three beverages, respectively. Mean consumption was near 100% for all three beverages across all three treatment conditions. These results are unique because previously refused food items were used either as positive (peaches) or negative (carrots) reinforcement to increase cup drinking. Although treatment of Al s food refusal prior to this study increased acceptance of both peaches and carrots from 0% during baseline to 100%, the results of the preference assessments suggested that one previously refused food (peaches) became an appetitive stimulus and another food (carrots) remained an aversive stimulus. These data also are important because both positive and negative reinforcement were used effectively in the absence of escape extinction. That is, inappropriate behaviors occasioned by presentation of the cup resulted in a 30-s break from drinking during all baseline and treatment sessions. In the

5 CUP DRINKING 93 Sr condition, this escape from drinking contingency was in direct competition with the food item (peaches) predicted to function as positive reinforcement based on the results of the second preference assessment. In the Sr condition, the escape from drinking contingency was in direct competition with a different negative reinforcement contingency ( avoidance of eating carrots ). In our study, both contingencies (access to peaches or avoidance of carrots) increased drinking, either alone or in combination. One limitation of the current findings is that cup drinking increased to 100% in all conditions after Al contacted the treatment contingencies in one condition (Sr /Sr ), leaving open the possibility that the effects of the combined treatment carried over to the conditions in which Sr and Sr were implemented alone. A second limitation is that the generality of these findings remains uncertain and requires further investigation with feeding problems. REFERENCES 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, Hoch, H., McComas, J. J., Thompson, A. L., & Paone, D. (2002). Concurrent reinforcement schedules: Behavior change and maintenance without extinction. Journal of Applied Behavior Analysis, 35, Iwata, B. A. (1987). Negative reinforcement in applied behavior analysis: An emerging technology. Journal of Applied Behavior Analysis, 20, Lalli, J. S., Vollmer, T. R., Progar, P. R., Wright, C., Borrero, J., Daniel, D., et al. (1999). Competition between positive and negative reinforcement in the treatment of escape behavior. Journal of Applied Behavior Analysis, 32, 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 Applied Behavior Analysis, 17, Received May 8, 2002 Final acceptance November 17, 2002 Action Editor, Brian Iwata