405189 CCSXXX10.1177/1534650111405189Kozlowski et al.

Clinical Case Studies

Clinical Case Studies

Feeding Therapy in a Child 10(3) 236­–246

© The Author(s) 2011

With Autistic Disorder: 

Reprints and permission: http://www.
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DOI: 10.1177/1534650111405189
Sequential Food Presentation http://ccs.sagepub.com

Alison M. Kozlowski1, Johnny L. Matson1,

Jill C. Fodstad1, and Brittany N. Moree1

Abstract
The authors describe a feeding intervention for a 9-year-old male diagnosed with autistic disorder
and mild mental retardation (also known as intellectual disability) who experienced food refusal
related to food selectivity. Based on the results of a functional behavioral assessment, food refusal
was found to be maintained by escape and tangible functions. Therefore, an intervention using
escape extinction (i.e., nonremoval of nonpreferred foods with physical guidance as a secondary
procedure), positive reinforcement (i.e., preferred foods and toys), and sequential food presenta-
tion was implemented. The child was successful in eating many novel foods both within the clinic
and home environments. A 1-year follow-up found the effects of treatment to be maintained
with significant increases in number of foods eaten and significant decreases in mealtime-related
behavioral challenges. The treatment implications, recommendations to clinicians, and areas of
future research are discussed.

Keywords
ASD, autism, food refusal, food selectivity

1 Theoretical and Research Basis for Treatment

Individuals with autism spectrum disorders (ASDs) present with a variety of challenges, including
impairments in social skills, communication patterns, and restricted and repetitive interests and
behaviors (American Psychiatric Association, 2000; Bhaumik et al., 2010; Fernell & Gillberg,
2010; Matson, Boisjoli, & Dempsey, 2009; Matson, Dempsey, & Fodstad, 2009). In line with symp-
toms related to restricted interests and behaviors, many of these individuals also display feeding
problem behaviors, such as food refusal and food selectivity. Although feeding problem behav-
iors occur quite frequently among children who are typically developing (Kodak & Piazza, 2008),
and the feeding difficulties that individuals with ASD experience tend to be similar in nature
to those experienced by typically developing individuals (Ledford & Gast, 2006), such feeding
difficulties arise at significantly higher rates in individuals with ASD compared with those who
are both typically and atypically developing without an ASD diagnosis, with prevalence rates
as high as 90% (Bandini et al., 2010; DeMeyer, 1979; Fodstad & Matson, 2008; Ledford &

1
Louisiana State University, Baton Rouge

Corresponding Author:
Johnny L. Matson, Louisiana State University, Baton Rouge, LA 70803, USA
Email:johnmatson@aol.com

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Kozlowski et al. 237

Gast, 2006; Schreck & Williams, 2006; Schreck, Williams, & Smith, 2004; Williams, Field, &
Seiverling, 2010). For example, Matson, Fodstad, and Dempsey (2009) found that 75.89% of chil-
dren with ASD in their sample would only eat certain foods (i.e., food selective), 75.89% preferred
foods of a certain texture and/or smell, and 35.71% attempted to ingest inedible items. However, no
significant differences were found between different ASD groups, such as when children with autis-
tic disorder were compared with those with pervasive developmental disorder not otherwise speci-
fied. Similarly, Schreck and Williams (2006) reported that 72% of their sample of children with
ASD engaged in food selectivity, whereas 57% displayed food refusal. However, according to par-
ent report, food refusal was not related to preference of foods of a certain texture, which was a
common difficulty in children with ASD noted by Matson, Fodstad, et al. (2009), but rather due to
food presentation (e.g., particular utensils and foods touching). Bandini and colleagues (2010) found
that children with ASD aged 3 to 11 years refused an average of 41.7% of foods offered compared
with typically developing children who refused an average of 18.9% of foods offered.
The presence of feeding problem behaviors can pose a significant challenge and can place undue
stress on caregivers (Kodak & Piazza, 2008; Leung, Lau, Chan, Lau, & Chui, 2010). In addition to
the emphasis the caregiver must place on feeding times within the household and the management
of behavior problems occurring during this time, a variety of severe consequences may occur as a
result of feeding problems, including, but not limited to, malnutrition, dehydration, learning prob-
lems, and death. For example, Bandini and colleagues (2010) found that children with ASD displayed
significantly more nutrition inadequacy compared with typically developing children within their
study sample.
Due to the severe consequences that may occur as a result of feeding problem behaviors, the
treatment of such difficulties is of great importance. Behavioral interventions are most com-
monly implemented, specifically those based in applied behavior analysis (Kodak & Piazza,
2008; Matson & Fodstad, 2009). Currently, the most empirically supported treatment for food
refusal involves escape extinction (Ahearn, Kerwin, Eicher, Shantz, & Swearingin, 1996; Kodak &
Piazza, 2008; Piazza, Patel, Gulotta, Sevin, & Layer, 2003). This treatment is based on the
hypothesis, typically supported through a functional behavioral assessment, that the food refusal
behavior is reinforced by the individual’s ability to escape from eating foods by engaging in chal-
lenging behavior. In many cases, such as the case contained within this article, the individual is
allowed to avoid eating the foods and given alternative choices (i.e., preferred foods). Therefore,
implementing procedures that do not allow the individual to escape from eating the nonpreferred
food have been repeatedly shown to decrease food refusal. Specifically, two types of extinction,
nonremoval of the spoon (i.e., the nonpreferred food is held in front of the individual’s mouth
until the bite is taken) and physical guidance (i.e., the individual is physically assisted in opening
his or her mouth and taking the bite via a jaw prompt), are the most commonly used procedures
for feeding treatment (Ledford & Gast, 2006). Furthermore, combining escape extinction proce-
dures with reinforcement procedures often increases the effectiveness of treatment (Kodak &
Piazza, 2008). The use of simultaneous or immediate sequential reinforcers, such as preferred
foods paired with nonpreferred foods as well as delayed sequential reinforcers, such as access to
a preferred toy or activity on completion of a treatment step (e.g., one bite of nonpreferred food
and three bites of nonpreferred food), are often included as a component of feeding treatment
programs (Didden, Seys, & Schouwink, 1999; Luiselli, 1994). Motivation for treatment is often,
especially, low for children with ASD as they often lack insight for the need to acquire new skills
(Koegel, Koegel, Vernon, & Brookman-Frazee, 2010), and therefore, the use of external rein-
forcers can increase compliance and further engage the child in the treatment process.
Preferred and nonpreferred foods can be presented either simultaneously or sequentially when
treating food refusal. The simultaneous procedure involves combining the nonpreferred with the

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238 Clinical Case Studies 10(3)

preferred food by either placing both edibles on a spoon/fork or mixing liquids (Ahearn, 2003;
Kern & Marder, 1996; Luiselli, Ricciardi, & Gilligan, 2005; Piazza et al., 2002). When using this
method, it is also common for the ratio of nonpreferred to preferred food to gradually increase
over time to increase acceptance of the nonpreferred food. Sequential food presentation requires
the individual to consume the nonpreferred food prior to receiving the preferred food (Najdowski,
Wallace, Doney, & Ghezzi, 2003; Piazza et al., 2002). To date, the majority of research supports
the simultaneous presentation approach (Ahearn, 2003; Kern & Marder, 1996, Luiselli et al.,
2005), and some believe this approach to be superior over sequential presentation (Piazza et al.,
2002). However, though effective, this method may be more difficult to implement and general-
ize to the home environment, which is often the goal of feeding therapy. Therefore, the current
study demonstrates a sequential presentation approach of feeding therapy incorporating both
escape extinction and positive reinforcement.

2 Case Introduction
William (a pseudonym) was a 9-year-old White male diagnosed with autistic disorder and mild
mental retardation (also known as intellectual disability). William achieved an abbreviated IQ
of 50 on the Stanford-Binet Intelligence Scales, Fifth Edition, placing him within the mild to
moderate range of intellectual disability. Adaptively, William functioned in the low range accord-
ing to the Vineland Adaptive Behavior Scales, Second Edition with an adaptive behavior compos-
ite standard score of 65. He could speak in simple sentences, print words from memory, bathe and
dress himself, and recognize the likes and dislikes of others (e.g., verbally express likes and dis-
likes of family and close others). However, he was unable to follow multipart instructions, com-
plete household chores, or demonstrate friendship-seeking behavior with other same-aged peers
(e.g., approach and interaction initiation behaviors). His scores on the Childhood Autism Rating
Scale and the Autism Diagnostic Interview–Revised indicated that William’s behavioral presen-
tation was consistent with a diagnosis of autistic disorder. He demonstrated deficits in commu-
nication and social skills, and he frequently engaged in stereotypic behaviors. William lived at home
with his biological mother, father, and younger brother. He was homeschooled by his mother.
At the time of the present study, he was prescribed Metadate (30 mg) by his neurologist to
treat symptoms of inattention.

3 Presenting Complaints
William was referred for intervention by his mother due to feeding difficulties and associated
problem behaviors. Food selectivity and food refusal were the focus of the current study and
intervention. Food selectivity was defined as eating only a limited number of preferred foods
(e.g., chicken nuggets, French fries, French toast, and candy), and food refusal was defined as
refusing to eat any other food when requested to do so. If William was asked to eat food items
other than his preferred foods, he would often engage in problem behaviors and/or expel the
nonpreferred food items from his mouth. More specifically, William demonstrated challenging
behaviors, such as verbal outbursts and face slapping. Verbal outbursts were defined as whining,
crying, and verbally protesting when asked to do something that he did not want to do. Face slap-
ping was defined as William hitting his face with one or two open palms. These problem behav-
iors lasted approximately 10 min each time they occurred. As such, not only were William’s
behaviors of food selectivity and food refusal increasing his risk of malnutrition, but they were
also bringing about other challenging behaviors and causing significant hardship on William’s
caregivers.

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Kozlowski et al. 239

4 History
William was born as a result of a full-term pregnancy without complications. He met most of
his developmental milestones within normal limits; however, his communication was delayed as
he did not speak single words until age 2 or short phrases until age 4. He also was not toilet trained
until age 4. At age 3, William was diagnosed with autistic disorder as well as attention deficit
disorder (based on prior diagnostic criteria), by his neurologist. His mother reported that he exhib-
ited stereotypic behaviors and lack of social reciprocity beyond his communication delays as well
as a history of problem behaviors. William received speech and occupational services throughout
preschool and early elementary school; however, at the time of the study, he was homeschooled
by his mother and no longer received therapy services.

5 Assessment
The frequency and severity of William’s food refusal was assessed through administration of the
Screening Tool of Feeding Problems (STEP; Kuhn & Matson, 2002; Matson & Kuhn, 2001) and
the Brief Autism Mealtime Behavior Inventory (BAMBI; Lukens & Linscheid, 2008), both of
which have acceptable reliability and validity. According to the STEP, William presented with
significant difficulties related to both food selectivity and food refusal. Items endorsed indicated
that William could not feed himself independently, displayed problem behaviors during meal-
times, only ate selected food types, continued to eat as long as food was available, spit out food
if he did not like it, ate a large amount of food in a short time period, pushed away food or
attempted to leave the area when food was offered, only ate foods of a certain temperature, and
only liked foods of a certain texture. All of these behaviors occurred more than 10 times during
the past month with the exception of spitting out food before swallowing and only eating foods
of a certain temperature, both of which occurred between 1 and 10 times during the past month.
BAMBI data were consistent with those of the STEP, with elevations on all three subscales:
Limited Variety (total score = 27/35), Food Refusal (total score = 15/25), and Features of Autism
(total score = 17/25).
In an effort to determine the variables maintaining William’s food refusal behavior, a functional
behavioral assessment was conducted (Didden, 2007; Matson, Bamburg, Cherry, & Paclawskyj,
1999). Both direct and indirect methods of functional behavioral assessment were used, such as
direct observations within the clinic setting, administration of the Questions About Behavioral
Function Scale (QABF; Applegate, Matson, & Cherry, 1999; Matson et al., 1999; Nicholson,
Konstantinidi, & Furniss, 2006; Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2000, 2001; Singh
et al., 2009), and a clinical interview using the Functional Assessment Interview (FAI; O’Neill
et al., 1997). William’s mother served as the informant for both the QABF and FAI.
On the QABF, William’s mother’s responses were elevated on the Escape and Tangible sub-
scales, suggesting that William’s food refusal was maintained by his ability to avoid ingesting the
nonpreferred food items and also by him receiving tangibles (i.e., alternative preferred foods)
once he had refused to eat the nonpreferred foods. Information gathered during a clinical inter-
view using the FAI further supported these functions. When presented with nonpreferred food
items, William would turn his head, often engaging in verbal outbursts and occasional face slap-
ping, and spit the food out of his mouth if it were to pass across his lips. William was more likely
to engage in these behaviors during dinner meals and less likely during breakfast meals, which
was hypothesized to be due to some of William’s preferred foods being offered more frequently
during breakfast (e.g., French toast). Furthermore, if William did engage in food refusal during
mealtimes, William’s mother reported that he was always given other, preferred, food items so
that he consumed food throughout the day.

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240 Clinical Case Studies 10(3)

To determine which nonpreferred foods to introduce to William during treatment, the therapist
interviewed William’s mother. A list containing a variety of foods, which William’s mother stated
he did not currently eat but she would like for him to eat (e.g., foods she frequently prepared for
the family), was formulated. Subsequently, William’s mother was asked to rank the items from
those that William would be most likely to eat to those he would be least likely to eat.

6 Case Conceptualization
Based on the results of the assessment, food refusal behavior was identified as a significant chal-
lenge for William and determined to be highly related to food selectivity. William engaged in
food refusal whenever nonpreferred foods were presented to him. Engaging in this behavior
always resulted in William not having to eat the nonpreferred foods that had been presented to
him. Instead, preferred food items that William selectively ate were always provided afterward
to ensure that he ate a meal. Therefore, although William frequently engaged in food refusal, he
only did so when foods outside of his preferred foods were presented. As previously men-
tioned, the functional behavioral assessment suggested that food refusal served both escape
and tangible functions (i.e., William was able to both escape the nonpreferred foods and gain
access to preferred foods by engaging in the behavior). Therefore, an escape extinction pro-
cedure combined with positive reinforcement was proposed based on literature supporting its
effectiveness (Didden et al., 1999; Luiselli, 1994). Rather than choosing either nonremoval of
nonpreferred foods or physical guidance, the strategies were combined within the treatment pro-
cedures so that both were used simultaneously (as described below). Both forms of escape extinc-
tion have demonstrated efficacy (Ledford & Gast, 2006); however, due to nonremoval of nonpreferred
foods being less invasive than physical guidance, this served as the primary treatment method.

7 Course of Treatment and Assessment of Progress

Treatment was provided in a clinic setting with two therapists present. The lead therapist imple-
mented the treatment while a cotherapist assisted the lead therapist and collected data for all
sessions. Both therapists were doctoral-level clinical psychology students; the lead therapist was
a master’s-level clinician with 2 years of experience in an intensive day treatment feeding program
whereas the cotherapist was a bachelor’s-level clinician. The primary target variables included
acceptance of nonpreferred food within a 5-s interval, the absence of challenging behaviors, and
the reduction of gagging response. These variables are subsequently discussed in detail as part of
the treatment procedure. The treatment procedure consisted of 10-min feeding sessions during the
1-hr therapy session with each feeding session followed by a 10-min break during which William
was permitted to play with toys in the clinic. During each 1-hr therapy session, two to three
10-min feeding sessions occurred. The differing number of feeding sessions during each therapy
session was due to variability in the amount of time spent at the beginning of each session review-
ing William’s out-of-clinic behavior since his last therapy session.
At the beginning of each feeding session, William was given one bite of a preferred food.
Immediately following swallowing of the preferred food, introduction of nonpreferred foods
ensued. When William was presented with a nonpreferred food, the edible was placed on a spoon
or fork, and the lead therapist held the utensil directly in front of William’s mouth, at which time
he was verbally instructed to “Take a bite.” William was then given 30 s to open his mouth and
allow the therapist to place the food into his mouth. If William accepted the nonpreferred food
within 5 s of its presentation, he received verbal praise. If William did not comply with the
direction to eat the nonpreferred food (i.e., he did not open his mouth) within 30 s of the verbal
direction being given, the lead therapist continued delivering verbal directions to “take a bite” every

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Kozlowski et al. 241

30 s until William complied or 5 min had passed, whichever occurred first. If William had still
not opened his mouth after 5 min had elapsed, a jaw-prompt procedure was proposed to assist
William in eating the bite of food. Jaw-prompt procedures were to consist of the lead therapist
placing her fingers on both sides of William’s face at his mandible joint. A verbal prompt would
then be given for William to “take a bite,” and, if necessary, minimal pressure would be applied to
his jaw to assist him with opening his mouth so the lead therapist could place the nonpreferred
food into his mouth. However, it should be noted that although this jaw-prompt procedure was
documented as part of William’s feeding therapy plan, it was never required. It was also part of
William’s feeding therapy plan that if William expelled the nonpreferred food from his mouth at
any time, he was required to follow the aforementioned procedure in placing a new equal-sized
portion of nonpreferred food into his mouth. This step was also unnecessary during the course of
treatment.
After William had successfully accepted the therapist placing a nonpreferred food item into
his mouth, he was required to swallow the food within 30 s. Completion of this step was verified by
verbally asking William to open his mouth to show the lead therapist that he had swallowed the
food. The food was considered to have been successfully swallowed if less than a pea-sized
amount was visible in William’s mouth. If William successfully swallowed the nonpreferred
food within 5 s of accepting it, he was provided with verbal praise and a preferred toy. The pre-
ferred toy was one which William identified at the beginning of each therapy session as the item
he would like to earn throughout the feeding sessions. If William had not succeeded in swallowing
the food, he was given verbal directives every 30 s until he did so.
Nonpreferred food items were introduced one by one each feeding session according to the
food hierarchy described within the previous section. For each accepted and swallowed bite of
nonpreferred food, William was originally given one bite of preferred food. The frequency of the
delivery of preferred food items following bites of nonpreferred food was gradually faded to
delivery of a preferred food item following three bites of nonpreferred food. This was done over
the course of each therapy session and was based on the lead therapist’s impression of William’s
timeliness to accept bites of nonpreferred food items, the absence of challenging behaviors (e.g.,
verbal outbursts, face slapping) when nonpreferred food items were presented, and the absence
or reduction in severity of gagging. Although these three criteria were put in place, it should be
noted that a strict fading schedule with consecutive trials of success was not implemented and that
fading occurred based on general impressions of the lead therapist, and over the course of treatment,
the fading schedule actually became a variable interval schedule to make the feeding sessions
easily replicable in the home environment during mealtimes.
William was considered successful at eating a nonpreferred food item once he had completed
one session with 80% accuracy or higher. At this time, a more difficult food would be introduced
along the food hierarchy in the next session. William’s progress was tracked according to the
percentage of nonpreferred food bites accepted and swallowed during each session. Data were
collected using a paper-and-pencil data sheet developed specifically for the therapy sessions. A
plus or minus sign was used to indicate whether William accepted and/or swallowed each bite of
food. There were additional columns to denote the number of verbal prompts needed if William
did not accept/swallow the food immediately and whether a jaw prompt was necessary. Although
William did occasionally gag on the food once it was accepted, he accepted and swallowed all
foods 100% of the time across all feeding sessions within 5 s of them being presented. Furthermore,
he was observed to gag less frequently as treatment progressed. After a few months of feeding
treatment, consisting of 14 total feeding sessions, William was able to eat several foods that he
had previously been unable to eat. In addition, parental report based on discussions during the
beginning of each therapy session indicated that he was also accepting and swallowing these foods
in the home environment.

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242 Clinical Case Studies 10(3)

8 Complicating Factors
Because many of the edibles provided for treatment were brought into the therapy session by
William’s mother, it was sometimes necessary to conduct more than one feeding session on the
same nonpreferred food despite William’s success at eating it. This procedure was followed if
other nonpreferred foods were unavailable. As such, the introduction of nonpreferred foods did
not occur as systematically as planned. Although this may have slightly hindered William’s pro-
gression of eating nonpreferred foods, it also incorporated maintenance of nonpreferred foods
into William’s feeding program. Furthermore, it is not believed that this deviation from the treat-
ment plan severely affected William’s acceptance of nonpreferred foods.
In addition, although two therapists were present during all treatment sessions, data were only
collected by one of the therapists to ensure treatment integrity. Therefore, formal interobserver agree-
ability was unable to be calculated. However, both therapists were present at all times and agreed on
the delivery of reinforcement, thereby providing support for reliability of data.

9 Access and Barriers to Care

When implementing feeding intervention protocols for outpatient individuals, considerations, such
as treatment and material cost, effects and ease of implementation with existing treatment, and
access to properly trained individuals, must be examined. William’s feeding therapy was incor-
porated into his regular treatment program at an adjusted income clinic. Costs of materials (food
supplies and reinforcers) were supplemented where necessary, and clinicians were appropriately
trained to administer the described feeding therapy protocol. In addition, his mother provided
consent on publication of the results of this treatment.

10 Follow-Up
William’s mother was contacted approximately 1 year after termination of treatment for a follow-
up assessment. At that time, she reported that William was more compliant at mealtime, no
longer exhibited tantrums (e.g., verbal outbursts and face slapping) when presented with non-
preferred foods, and was eating a larger variety of food each day. She reported that she continued
the expansion of William’s food intake by having him try at least one bite of new or nonpreferred
food items each time he is presented with them. According to his mother, at the time of follow-up,
William would try the new foods on request without protest. She also reported that the frequency
of William’s gagging response decreased to less than once per week and that he no longer regur-
gitated nonpreferred food. Examples of new food items include broccoli, rice, peas, carrots, and
some meats that are not fried. He still exhibited trouble with foods that are difficult to chew
(e.g., steak) and appeared to dislike certain textures (e.g., oatmeal and fruits).
Results of the STEP and BAMBI at the time of the 1-year follow-up also demonstrated a
decrease in William’s mealtime-related challenging behaviors, which often co-occur (Farmer &
Aman, 2009). Only four items were endorsed as occurring on the STEP (i.e., problem behaviors
increasing during mealtimes, only eating selected types of food, continuing to eat as long as food
is available, and eating foods of only certain textures), all of which were reported to occur less
than 10 times per month. All of these behaviors showed a reduction in comparison to the STEP
administered prior to treatment, except for eating foods of only certain textures, which remained
the same. All other behaviors that had been documented on the STEP prior to beginning treat-
ment were no longer endorsed as occurring, indicating that William had made significant progress
with acceptance of a variety of foods. With respect to the BAMBI, many decreases were seen
in endorsements along all three subscales: Limited Variety (total score = 21/35), Food Refusal

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Kozlowski et al. 243

(total score = 8/25), and Features of Autism (total score = 7/25). This was a 32%, 47%, and 59%
decrease in symptom endorsements for each of the three subscales, respectively. These results indi-
cated that William experienced a significant decrease in food selectivity, food refusal, and symptoms
of autism related to food selectivity/refusal.

11 Treatment Implications of the Case

This case provides further support for the use of sequential food presentation in an escape
extinction plus positive reinforcement treatment for food refusal. Although simultaneous food
presentation has been the most studied and empirically supported method thus far, this strategy
can be difficult to implement outside of clinic settings and thus hinder generalization to home
environments and parent training. However, sequential food presentation provides an avenue for
parents to easily implement treatment at home so as to increase the effects of treatment. In addition,
Schreck and Williams (2006) found that many individuals engaging in food refusal behavior
may do so based on food presentation, with foods touching being associated with food
refusal. Therefore, although simultaneous food presentation has been favored over sequential
presentation in the current literature, the choice of which presentation to integrate into food
refusal treatment should take into consideration whether food refusal is related to the presentation
of food.
Given the large focus on using the least restrictive procedure necessary when implementing
treatment interventions, the current study illustrates that physical guidance and intervention are
not always necessary during food refusal treatment. Although a physically restrictive procedure
was proposed as a secondary prompt within the current treatment plan, this secondary approach
was not necessary. It may be that the combination of edible and tangible (i.e., toys) reinforcement
being added to the nonremoval of the spoon escape extinction procedure reduced the need for
physical guidance. Although physical guidance may result in a quicker response to treatment, its
use should be limited and does not need to occur when other, less restrictive interventions are
available and effective.

12 Recommendations to Clinicians and Students

Based on the findings within this case study and the aforementioned treatment implications,
it is recommended that clinicians conduct a comprehensive functional behavioral assessment
prior to treatment implementation (Huete & Kurtz, 2010; Kodak, Fisher, Kelley, & Kisamore,
2009; Strachan et al., 2009; Weeden, Mahoney, & Poling, 2010). In addition to identifying
the maintaining variable(s) of food refusal behavior, this assessment should also determine
related factors to the food refusal, such as food presentation. This information can then be
used to determine whether a sequential or simultaneous food presentation approach may
be more appropriate based on the individual. Future research should aim to further assess the
effectiveness of sequential versus simultaneous food presentation in food refusal treatments
relative to the presence of difficulties with actual food presentation (e.g., being distressed
over foods touching). In addition, although two types of escape extinction are currently used
with relatively equal frequency at the moment (i.e., nonremoval of spoon and physical guid-
ance), the least restrictive procedure should be used (Devlin, Leader, & Healy, 2009).
Comparisons between the effectiveness of each procedure should be conducted to determine
the necessity of more restrictive procedures, such as those using physical interventions, in
food refusal treatment. In the meantime, treatments should follow a hierarchy of least restric-
tive to most restrictive interventions to cause the least amount of intrusion upon the client
(Williams, 2010).

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244 Clinical Case Studies 10(3)

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Bios
Alison M. Kozlowski is a doctoral student in clinical psychology at Louisiana State University. Her research
interests include autism spectrum disorders, developmental disabilities, challenging behaviors, and com-
munication training.

Johnny L. Matson is professor and distinguished research master in the Department of Psychology at
Louisiana State University. His research interests are in developmental disabilities and autism spectrum
disorders. He is the author of more than 600 publications, including 38 books.

Jill C. Fodstad is a doctoral student in clinical psychology at Louisiana State University. Her research inter-
ests include autism spectrum disorders, developmental disabilities, and challenging behaviors.

Brittany N. Moree is a doctoral student in clinical psychology at Louisiana State University. Her research
interests include childhood anxiety disorders and the presence of such disorders within children with autism
spectrum disorders.

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