JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2019, 9999, 1–19 NUMBER 9999 ()

A comparison of functional analysis methods of inappropriate

mealtime behavior
MELANIE H. BACHMEYER, CAITLIN A. KIRKWOOD, AMANDA B. CRISCITO,
COURTNEY R. MAUZY IV AND DIANE P. BERTH
UNIVERSITY OF NORTH CAROLINA WILMINGTON

Investigators have evaluated two procedural variations for conducting a functional analysis of
inappropriate mealtime behavior exhibited by children with feeding problems. One method
involves prompting bites only in the escape condition (e.g., Najdowski et al., 2008). Another
method involves prompting bites across all conditions (e.g., Piazza et al., 2003). We assessed the
food refusal of 3 children diagnosed with a feeding disorder by comparing the two variations.
The two methods resulted in different outcomes for 2 of 3 children. Prompting bites only in
the escape condition identified a single function (i.e., escape). Prompting bites across all condi-
tions identified multiple functions (i.e., escape and attention). We then examined the relative
effects of extinction procedures (individually and in combination) to determine the validity of
each method. Results of the treatment evaluation suggested that the procedural variation that
failed to identify an attention function for 2 of 3 children produced false negative findings.
Key words: food refusal, functional analysis, pediatric feeding disorder

Investigators have demonstrated that the
results of a functional analysis of problem
behavior (e.g., Iwata, Dorsey, Slifer, Bauman, &
Richman, 1982/1994) can be used to develop
treatments that match the sources of reinforce-
ment maintaining problem behavior. These
function-based treatments are more effective
and efficient than those developed in the
absence of a functional analysis (Iwata, Pace,
et al., 1994). A functional analysis involves test
conditions that contain the variables (anteced-
ent and consequent events) whose influence is
being evaluated relative to a control condition
(Iwata & Dozier, 2008). Iwata, Dorsey, et al.
(1982/1994) described an initial set of test con-
ditions (contingent attention as a test for social
positive reinforcement, escape from demands as
a test for social negative reinforcement, and
We thank Catherine Durando, Jessica Keane, Billie
Klein, and Melissa Meglin for their assistance with data
collection.
Address correspondence to Melanie H. Bachmeyer in
the Department of Psychology at the University of North
Carolina Wilmington, Wilmington, North Carolina
28403 (e-mail: bachmeyerm@uncw.edu)
doi: 10.1002/jaba.556
© 2019 Society for the Experimental Analysis of Behavior
1
alone as a test for automatic reinforcement) and
a control condition to identify the function(s)
maintaining self-injurious behavior exhibited
by individuals with developmental disabilities.
Investigators have extended the initial proce-
dure described by Iwata, Dorsey, et al. to suit a
wide range of applications.
Investigators have evaluated two procedural
variations for conducting a functional analysis
of inappropriate mealtime behavior to treat
children with feeding disorders. Some
researchers have conducted functional analyses
similar to the procedures described by Iwata,
Dorsey, et al. (1982/1994) in which each test
condition is designed to involve a single and
different antecedent manipulation (Najdowski,
Wallace, Doney, & Ghezzi, 2003; Najdowski
et al., 2008). That is, the feeder in Najdowski
et al. (2003) and Najdowski et al. (2008) pres-
ented bites and/or drinks and verbal instruc-
tions to eat and/or drink only in the escape
condition. The feeder placed a plate of non-
preferred foods in front of the child at the start
of each control and nondemand test condition
but did not present bites or deliver additional
2 MELANIE H. BACHMEYER et al.
verbal instructions to “take a bite.” An alterna-
tive method involves arranging the same ante-
cedent event in all conditions (Bachmeyer
et al., 2009; Girolami & Scotti, 2001; Piazza
et al., 2003). That is, the feeder presented bites
and/or drinks and prompts to eat and/or drink
in all conditions. In both variations of the func-
tional analysis, the feeder delivered the conse-
quence of escape, attention, or tangible
following inappropriate mealtime behavior in
the relevant test conditions. The feeder deliv-
ered no differential consequences in the control
condition.
Bachmeyer et al. (2009) and Najdowski
et al. (2008) discussed the interpretative con-
cerns inherent in the design of the experimental
conditions of both functional analysis methods
for inappropriate mealtime behavior. When
bite and/or drink presentations and verbal
instructions to “take a bite and/or drink”
(i.e., the aversive stimuli) are included in all
functional analysis conditions, the interpretive
concern is that these stimuli may evoke inap-
propriate mealtime behavior across all condi-
tions (i.e., high and undifferentiated
responding), leading to inconclusive results or a
tendency for this method to falsely identify a
positive reinforcement function (Bachmeyer
et al., 2009; Najdowski et al., 2008). The
interpretive concern with not including bite
and/or drink presentations and verbal instruc-
tions to “take a bite and/or drink” in all condi-
tions is that the relevant discriminative stimuli
or motivating operations for inappropriate
mealtime behavior may not be present during
all conditions of the functional analysis
(Bachmeyer et al., 2009). That is, reinforce-
ment effects may be context specific and a
stimulus, such as attention, may function as a
reinforcer when the feeder prompts a child to
“take a bite and/or drink” during a meal but
not in other contexts, such as when the child is
left alone with food on the table or when a
caregiver’s attention is diverted during other
times (Bachmeyer et al., 2009). The prompts
to eat may serve as a motivating operation for
attention-maintained inappropriate mealtime
behavior. Thus, it may be important to include
bite and/or drink presentations and verbal
instructions to “take a bite and/or drink” across
all conditions to ensure the identification of
this potential functional relation.
Results of studies in which the feeder deliv-
ered prompts to “take a bite and/or drink” in all
conditions (Bachmeyer et al., 2009; Girolami &
Scotti, 2001; Piazza et al., 2003) have shown
that many participants’ inappropriate mealtime
behavior was maintained by multiple functions
(i.e., negative and positive reinforcement). By
contrast, all participants in studies in which the
feeder delivered prompts to “take a bite and/or
drink” only in the escape condition (Najdowski
et al., 2003; Najdowski et al., 2008) displayed
high rates of inappropriate mealtime behavior
only in the escape condition, suggesting all par-
ticipants’ inappropriate mealtime behaviors were
maintained exclusively by negative reinforce-
ment (escape from bites). It seems plausible that
the discrepancy in the findings between studies
using these two different methods is a result of
the procedural variations.
Failing to identify a positive reinforcement
function may result in a less effective treatment.
Falsely identifying a positive reinforcement
function may lead to the development of a less
efficient treatment that may be more compli-
cated than necessary. Thus, a direct comparison
of the validity of the two methods of a func-
tional analysis of inappropriate mealtime behav-
ior is important. In the current investigation,
we conducted functional analyses of the inap-
propriate mealtime behavior of three children
diagnosed with feeding disorders. We com-
pared experimental conditions with and with-
out bite presentations and prompts to eat. We
then examined the relative effects of extinction
procedures matched to the results of the func-
tional analysis (individually and in combina-
tion) to better evaluate the validity of each
method.
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
METHOD
Participants and Setting
Three children diagnosed with a feeding dis-
order participated. Levi was a typically develop-
ing, 6-year-old boy with a history of failure to
thrive (FTT), gastroesophageal reflux disease
(GERD), gastrostomy (G-) tube dependence,
asthma, hernia repair, tonsillectomy, and
adenoidectomy. His solid-food intake was a lim-
ited variety of table-texture foods including: hot
dogs, chicken nuggets, sausage biscuits, pizza,
spaghetti, macaroni and cheese, a variety of
fruits, and most junk foods (e.g., cake, cookies,
and candy), and he received approximately 75%
of his daily calorie needs orally via PediaSure®
at the beginning of this study. He was pre-
scribed Reglan® during this study. He received
previous feeding therapies from an occupational
therapist and a nutritionist. Ava was a typically
developing, 2-year-old girl with a history of con-
genital heart defect. She consumed a limited
quantity and variety of baby foods, and she
received approximately 80% of her daily calorie
needs via G-tube at the beginning of this study.
She received previous feeding therapies from an
occupational therapist and a nutritionist. Kam
was a typically developing, 5-year-old boy with
a history of FTT, GERD, scoliosis, neurofibro-
matosis Type I, and asthma. He consumed lim-
ited quantities of table-texture foods including a
variety of starches, yogurt, chicken nuggets, hot
dogs, and scrambled eggs, and he received
approximately 80% of his daily calorie needs via
G-tube at the beginning of this study. He was
prescribed Prevacid® during this study. He
received previous feeding therapies from a
speech and language pathologist, occupational
therapist, and nutritionist. Prior to participa-
tion, each child underwent a comprehensive
interdisciplinary evaluation. Medical causes for
ongoing feeding problems were ruled out and
each child was cleared as a safe oral feeder.
We conducted all sessions in rooms (1.83 m
x 2.59 m) equipped with one-way observation
3
and sound monitoring at a university-based
clinic. Materials included age- and size-
appropriate seating (highchair or Rifton® chair
with straps), food, utensils, latex gloves, timers,
and toys.
Response Measurement and Data Collection
Observers collected data on laptop com-
puters using an event-recording system. All ses-
sions were recorded on a video camera.
Observers recorded when the feeder presented
and removed the plate of food and bite presen-
tations. Bite presentation was defined during the
conditions with prompts when the feeder
placed a bite of food from the plate on the
spoon and placed the spoon on the plate in
front of Levi while simultaneously delivering a
verbal prompt to “take a bite” or placed the
spoon within 2.5 cm from Ava or Kam’s lips
while simultaneously delivering a verbal prompt
to “take a bite.” Observers scored inappropriate
mealtime behavior when the plate of food or the
bite on the spoon were within arm’s reach of
the child, and the child pushed the plate of
food, the utensil, or the feeder’s arm from
elbow to hand away; turned his or her head or
body 45 or greater away from the plate of
food or the spoon; covered his or her mouth
with his or her hand, arm, or a toy; or dis-
played vocal protests (e.g., saying “no” or mak-
ing other negative comments about the food).
Observers converted these data to responses per
minute (rpm) by dividing the number of occur-
rences of inappropriate mealtime behavior by
the total duration of time that the behavior
could have occurred (i.e., when the plate of
food or the bite on the spoon were within the
arm’s reach of the child). Observers scored
acceptance if Levi placed the bite of food in his
mouth within 5 s of presentation of the bite or
if Ava and Kam leaned forward and opened his
or her mouth, allowing the feeder to deposit
the entire bolus of food (except for an amount
smaller than the size of a pea) into the mouth
4 MELANIE H. BACHMEYER et al.
within 5 s of presentation of the bite, only in
the absence of inappropriate mealtime behav-
ior, negative vocalizations (e.g., crying, whin-
ing), gagging, and coughing. Observers
converted acceptance to a percentage by divid-
ing the number of occurrences of acceptance by
the number of bite presentations.
Interobserver Agreement
Two observers recorded child and feeder
behavior simultaneously but independently
during 60%, 35%, and 35% of functional anal-
ysis sessions and during 87%, 33%, and 49%
of treatment evaluation sessions for Levi, Ava,
and Kam, respectively. Interobserver agreement
was calculated by separating each session into
10-s intervals. Total agreement coefficients
were calculated for acceptance by dividing the
number of occurrence and nonoccurrence
agreements by the total number of agreements
plus disagreements and converting this ratio to
a percentage. Agreements occurred when both
observers recorded an occurrence or did not
record an occurrence of the behavior during
each 10-s interval. Disagreements occurred
when one observer recorded an occurrence and
the other observer did not score an occurrence
of the behavior during the 10-s interval. Exact
agreement coefficients were calculated for inap-
propriate mealtime behavior by dividing the
number of 10-s intervals during which both
observers scored the exact same number of
occurrences of an inappropriate mealtime
behavior by the number of 10-s intervals and
converting this ratio to a percentage. Agree-
ment for inappropriate mealtime behavior dur-
ing the functional analysis was 92% (range,
81% to 100%) for Levi, 95% (range, 82% to
100%) for Ava, and 93% (range, 80% to
100%) for Kam. Agreement for inappropriate
mealtime behavior during the treatment evalua-
tion was 92% (range, 81% to 100%) for Levi,
97% (range, 86% to 100%) for Ava, and 96%
(range, 82% to 100%) for Kam. Agreement for
acceptance during the treatment evaluation was
98% (range, 93% to 100%) for Levi, 97%
(range, 86% to 100%) for Ava, and 98%
(range, 90% to 100%) for Kam.
General Procedures
Trained therapists conducted two to three
session blocks during 3-hr visits occurring
4 days per week. Therapists conducted approxi-
mately two to six sessions in a session block
with each session block lasting 30 min or less
and with at least 30 min between the end of
one session block and the beginning of the
next. The feeder presented five bites or termi-
nated the session after 30 min even if she had
not presented all five bites in conditions with
prompts. We yoked the session duration of
conditions without prompts to the duration of
feeder-prompted bites during the conditions
with prompts to ensure that the opportunity
for responding was equivalent across conditions
with and without prompts. We used the dura-
tion of feeder-prompted bites during conditions
with prompts to determine the session duration
for the next session of the same condition with-
out prompts during the same or a subsequent
phase.
We selected two to four foods from the four
food groups of protein, starch, fruit, and vege-
table for a total of 8 to 16 foods. We selected
foods based on the recommendations of each
child’s parents and physician or dietician. Each
bite was a 1-cm by 1-cm piece of regular-
textured food for Levi and Kam or a level bolus
of a pureed food on a small maroon spoon for
Ava. We selected the texture of food based on
the individual child’s feeding history and cur-
rent oral-motor skills. In each session, there
were five bites of four foods, one from each
food group, resulting in one bite of three foods
and two bites of one food. We randomly
selected the foods for each session without
replacing foods from the list of each food group
until the feeder presented all foods within each
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
food group. All foods were presented in all
phases and conditions. The feeder placed a
plate with all five bites on the table at 7.62 cm
from the child at the beginning of the session.
In conditions with prompts, the feeder ran-
domly selected the order in which to prompt
the bites. All children displayed self-feeding
skills when presented with preferred foods dur-
ing initial observations. The feeder used a
three-step prompt sequence for Levi because his
caregivers typically provided him with an oppor-
tunity to feed himself when presenting non-
preferred foods. The feeder placed one of the
bites from the plate on a spoon, left the spoon
on the plate, and provided a verbal prompt to
take a bite. If he did not accept the bite within
5 s of the verbal prompt, the feeder provided a
gestural prompt (modeled picking up the spoon
and guiding it to his or her mouth while simul-
taneously saying, “Take a bite like this”). If he
did not accept the bite within 5 s of the gestural
prompt, the feeder used hand-over-hand guid-
ance to present the bite within 2.5 cm from his
mouth. The feeder presented bites to Ava and
Kam without an opportunity to feed themselves
because although their caregivers provided them
some opportunities to feed themselves non-
preferred foods, the caregivers typically did this
only in the absence of any prompts, and when
the caregivers prompted bites they were more
likely to present bites without giving the chil-
dren opportunities to feed themselves. The
feeder placed one of the bites from the plate on
a spoon and presented the spoon 2.5 cm from
the child’s mouth with a simultaneous verbal
prompt (“Take a bite”).
The feeder provided brief verbal praise
(e.g., “Good job taking your bite”) if the child
accepted the bite within 5 s of the bite presenta-
tion in conditions with prompts. After the child
accepted a bite, the feeder activated a timer for
30 s and checked the child’s mouth when the
timer sounded to determine if the child had
swallowed the bite. The feeder delivered brief
praise (e.g., “Good job swallowing your bite”) if
5
there was no food the size of a pea or larger in
the child’s mouth at the 30-s check. If food
larger than the size of a pea was in the child’s
mouth at the 30-s check, the feeder delivered a
brief verbal prompt (e.g., “Finish your bite”).
The feeder immediately presented the next bite
after he or she prompted the child to “finish
your bite.” The feeder immediately provided
brief praise if the child showed that he or she
had swallowed before the mouth check. The
feeder waited to present the next bite until 30 s
after the previous bite had entered the child’s
mouth. If the feeder presented all five bites and
food larger than the size of a pea was in the chi-
ld’s mouth at the 30-s check, the feeder repeated
the verbal prompt to “finish your bite” every
30 s until no food larger than the size of a pea
was in the child’s mouth. The feeder would
have terminated the session at 30 min and
scooped out the remaining food if the child was
still packing at 30 min, but this never occurred.
The feeder would have ignored vomiting and
continued with the programmed procedure, but
this never occurred.
No child placed a bite in his or her mouth
during the conditions without prompts. How-
ever, the procedures indicated the feeder would
have provided brief verbal praise and activated
a timer for 30 s any time a bite passed the
plane of the child’s lips to determine if the
child had swallowed the bite when the timer
sounded. The feeder would have delivered brief
praise (e.g., “Good job swallowing your bite”)
if there was no food the size of a pea or larger
in the child’s mouth at the 30-s check. If food
larger than the size of a pea was in the child’s
mouth at the 30-s check, the feeder would have
delivered a brief verbal prompt to “finish your
bite” every 30 s until the child’s mouth was
clear or the session expired. The feeder would
have scooped out the remaining food if the
child was still packing when the session
expired. If the child would have vomited, the
feeder would have ignored vomiting and con-
tinued with the programmed procedure.
6 MELANIE H. BACHMEYER et al.
The feeder briefly described the contingencies
for appropriate and inappropriate mealtime
behavior for that condition the first time he or
she conducted a session within a session block.
For example, before the escape condition, the
feeder said, “If you take your bite quickly, I am
going to say, ‘Good job taking your bite.’ If you
push the bite away, turn your head, or cover
your mouth, I’m going to take the bite away.”
The feeder presented a colored card assigned to
the specific condition on the highchair tray or
table in front of the child to potentially aid dis-
crimination between conditions. The feeder
presented only the colored card when repeating
the same condition within a session block. We
did not evaluate whether the cards exerted stim-
ulus control over the child’s behavior because
that was not the aim of this study.
Functional Analysis Design
We conducted a functional analysis using a
combined reversal and multielement (ABABCBC
for Levi and Ava, CBCBABA for Kam) design.
Phase A was the escape condition. Phase B was a
multielement comparison of control conditions
with and without prompts. Phase C for Levi was
a multielement comparison of a contingent atten-
tion condition with prompts and a diverted plus
contingent attention condition without prompts.
Phase C for Ava and Kam was a multielement
comparison of contingent attention conditions
with and without prompts and a diverted plus
contingent attention without prompts condition.
We randomly selected the order of the test condi-
tions. We did not conduct a tangible condition
because although we did observe caregivers using
highly preferred toys during meals, we never
observed them providing access to those items
contingent on inappropriate mealtime behavior.
Functional Analysis Procedures
The feeder placed a plate with five bites of
food on the table at 7.62 cm from the child at
the beginning of the session. A large maroon
spoon was available for Levi and Kam and a
small maroon spoon was available for Ava in
conditions without prompts. The feeder used
the same spoons in conditions with prompts and
randomly selected the order in which to prompt
the bites. The feeder sat next to the child in all
conditions except for the diverted plus contin-
gent attention condition. The feeder did not re-
present expelled bites. If the child pushed the
plate away from its initial position on the table,
the feeder repositioned the plate in its initial
position near the child during the control, con-
tingent attention, and diverted plus contingent
attention conditions with and without prompts.
The feeder followed the general procedures with
the modifications described for each condition.
Escape (ESC). The feeder immediately
removed the bite and plate of food for 30 s fol-
lowing inappropriate mealtime behavior. If the
child did not display inappropriate mealtime
behavior, the bite remained stationary at 2.5 cm
from the child’s lips and the plate of food
remained stationary on the table at 7.62 cm from
the child until the feeder placed the bite into the
child’s mouth or the 30-s interval expired. The
feeder did not provide attention during the 30-s
interval and no toys were available. The feeder
prompted the child to “take a bite” after the 30-s
escape interval if the child engaged in inappropri-
ate mealtime behavior, 30 s after the previous bite
presentation if the child did not engage in inap-
propriate mealtime behavior and the bite did not
enter the child’s mouth, or after the mouth check
if the bite entered the child’s mouth and the child
did not spit it out.
Control, no prompts (CTRL-NP). The feeder
provided highly preferred toys identified via a
paired-choice preference assessment (Fisher et al.,
1992) and interacted with the child in the form of
singing, playing, and telling stories throughout the
entire session. The feeder provided no prompts to
eat and the plate of food with a spoon remained
stationary on the table at 7.62 cm from the child.
The feeder provided no differential consequences
following inappropriate mealtime behavior.
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
Control with prompts (CTRL-P). The feeder
provided highly preferred toys and interacted
with the child in the form of singing, playing,
and telling stories throughout the entire session
as in the control condition without prompts.
The feeder prompted the child to “take a bite”
30 s after the previous bite presentation if the
bite did not enter the child’s mouth or after
the mouth check if the bite entered the child’s
mouth and the child did not spit it out. The
bite remained stationary at 2.5 cm from the
child’s lips and the plate of food remained sta-
tionary on the table 7.62 cm from the child
until the feeder placed the bite into the child’s
mouth or the 30-s interval expired.
Diverted attention, no prompts (D-ATTN-
NP). The feeder left the table to wash dishes at
the sink adjacent to the session room after plac-
ing the plate of food on the table at 7.62 cm
from the child, replicating the procedures
described by Najdowski et al. (2008). The ses-
sion room door remained open so that the
feeder and child were in each other’s view. The
feeder provided no prompts to eat and the plate
of food with a spoon remained stationary on
the table at 7.62 cm from the child. The feeder
returned and provided 30 s of brief attention
in the form of comforting (e.g., “You are
okay”) or reprimands (e.g., “Don’t throw your
peas”) following inappropriate mealtime behav-
ior. The feeder used a script to deliver attention
to ensure that he or she provided the same type
of attention across all conditions. No toys were
available.
Attention, no prompts (ATTN-NP) for Ava
and Kam. Procedures were the same as the div-
erted attention without prompts condition
except that the feeder remained seated at the
table next to the child throughout the entire
session. We conducted this condition with Ava
and Kam to examine whether differential
responding observed in the attention conditions
was due only to the presence or absence of pro-
mpts to eat and not the presence or absence of
the feeder.
7
Attention with prompts (ATTN-P). The
feeder delivered attention following inappropri-
ate mealtime behavior as described for the div-
erted attention, no prompts condition. The
feeder prompted the child to “take a bite” 30 s
after the previous bite presentation if the bite
did not enter the child’s mouth or after the
mouth check if the bite entered the child’s
mouth and the child did not spit it out. The
bite remained stationary 2.5 cm from the chi-
ld’s lips and the plate of food remained station-
ary on the table at 7.62 cm from the child
until the feeder placed the bite into the child’s
mouth or the 30-s interval expired.
Treatment Evaluation Design
We used a combined multielement and
reversal (ABCDCDACD) design to examine
the effects of an intervention matched to the
results of each functional analysis method for
Levi. Phase A was an escape and attention base-
line. Phase B was a multielement comparison
of an intervention matched to only an escape
function (i.e., escape extinction plus attention)
and an intervention matched to multiple func-
tions (i.e., escape extinction and attention
extinction). Phase C was escape extinction and
attention in isolation. Phase D was escape
extinction and attention extinction in isolation.
We used a combined multielement and reversal
design (ABABCBC) to examine the effects of
extinction procedures matched to escape and
attention individually and in combination for
Ava and Kam. Phase A was an escape and
attention baseline. Phase B was a multielement
comparison of an intervention matched to only
an escape function (i.e., escape extinction plus
attention) and an intervention matched to only
an attention function (i.e., attention extinction
plus escape). Phase C was escape extinction and
attention extinction. We examined the relative
effects of the additional intervention matched
only to an attention function (i.e., attention
extinction plus escape) with Ava and Kam to
8 MELANIE H. BACHMEYER et al.
further examine the validity of the functional
analysis results suggesting that their inappropri-
ate mealtime behavior was maintained by both
escape and attention.
Treatment Evaluation Procedures
The procedure for presenting bites and
responding to acceptance, mouth clean, and
packs was identical to that described in the gen-
eral procedure for conditions with prompts in
the functional analysis. The feeder placed a
plate with all five bites in front of the child at
the beginning of the session and randomly
selected the order in which to prompt the bites.
Escape and attention baseline (ESC + ATTN).
The feeder immediately removed the bite and
delivered attention as described for the contin-
gent attention condition of the functional anal-
ysis for 30 s following inappropriate mealtime
behavior. If the child did not display inappro-
priate mealtime behavior and did not accept
the bite, the feeder continued the three-step
prompt sequence for Levi and the bite
remained stationary in its original presentation
position in space until the bite entered the chi-
ld’s mouth or the 30-s interval expired for all
children. The feeder did not re-present expelled
bites. The feeder prompted the child to “take a
bite” after the 30-s escape and attention inter-
val if the child engaged in inappropriate meal-
time behavior, 30 s after the previous bite
presentation if the child did not engage in inap-
propriate mealtime behavior, 30 s after the pre-
vious bite presentation if the child did not
engage in inappropriate mealtime behavior and
the bite did not enter the child’s mouth, or
after the mouth check if the bite entered the
child’s mouth and the child did not spit it out.
Escape extinction plus attention (EE +
ATTN). The feeder held the bite at the child’s
lips if Levi did not place the bite in his mouth
after the verbal or gestural prompt or if Ava
and Kam did not accept the bite within 5 s.
The feeder blocked inappropriate mealtime
behavior (i.e., used a hand or arm to prevent
the child from hitting or pushing the spoon or
turning his or her head away from the spoon)
if that behavior interfered with the feeder’s abil-
ity to hold the spoon at the child’s lips. The
feeder deposited the bite into the child’s mouth
when the mouth was open in the absence of
coughing and gagging. The feeder re-presented
expelled bites (i.e., scooped up the bite and
held it at the child’s lips until the feeder could
deposit the bite into the mouth). The feeder
delivered 30 s of attention as described for the
contingent attention condition of the func-
tional analysis following inappropriate mealtime
behavior. The feeder prompted the child to
“take a bite” after the mouth check for the
previous bite.
Attention extinction plus escape (AE + ESC)
for Ava and Kam. The feeder immediately
removed the bite for 30 s following inappropri-
ate mealtime behavior but did not provide
attention. If the child did not display inappro-
priate mealtime behavior and did not accept the
bite, the bite remained stationary in its original
presentation position (following the physical
prompt for Levi) until the 30-s interval expired.
The feeder did not re-present expelled bites.
The feeder prompted the child to “take a bite”
after the 30-s escape interval if the child engaged
in inappropriate mealtime behavior, 30 s after
the previous bite presentation if the child did
not engage in inappropriate mealtime behavior
and the bite did not enter the child’s mouth, or
after the mouth check if the bite entered the
child’s mouth and the child did not spit it out.
Escape extinction and attention extinction
(EE + AE). We discontinued the delivery of
attention following inappropriate mealtime
behavior. All other procedures were identical to
the escape extinction plus attention condition.
Procedural Integrity
Trained observers scored the correct imple-
mentation of prompts and consequences.
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
During conditions with prompts, observers
scored correct implementation for each bite
presentation when the feeder delivered all ante-
cedents and consequences correctly within 3 s
before or after the programmed implementa-
tion. Observers scored correct antecedents
when the feeder presented the plate of food on
the table in front of the child at the beginning
of the session; repositioned the plate in front of
the child if the child pushed the plate away
from its initial position in all conditions with
prompts, except the escape condition;
proceeded through the three-step prompting
sequence (verbal, gestural, and physical pro-
mpts) if Levi did not place the bite in his
mouth within 5 s of the previous prompt or
presented the spoon 2.5 cm from Ava or Kam’s
mouth with a simultaneous verbal prompt;
checked for a mouth clean 30 s after the bite
was placed in the child’s mouth; and when the
feeder provided access to highly preferred toys
and interacted with the child continuously dur-
ing the control condition. Observers scored
correct consequences during conditions with
prompts when the feeder delivered brief verbal
praise only after Levi placed the bite in his
mouth following a verbal prompt or only when
the bite was placed in Ava or Kam’s mouth
within 5 s of presentation; delivered brief praise
when the child’s mouth was clean following the
check; delivered a verbal prompt to “finish the
bite” and immediately presented the next bite
if the child packed the bite (was holding more
than a pea size of food in mouth); removed the
bite and plate following inappropriate mealtime
behavior in escape conditions; delivered
scripted attention following inappropriate meal-
time behavior in attention conditions; blocked
inappropriate mealtime behavior during escape
extinction conditions; and withheld attention
following inappropriate mealtime behavior in
control, escape, and attention extinction condi-
tions. The percentage of bites with correct
implementation of antecedents and conse-
quences was calculated by dividing the number
9
of correctly implemented bite presentations by
the total number of bite presentations.
During conditions without prompts,
observers scored correct implementation for the
entire session when the feeder delivered all
antecedents and consequences correctly within
3 s before or after the programmed implemen-
tation. During conditions without prompts,
observers scored correct antecedents for the
entire session when the feeder placed the plate
of bites and a spoon in front of the child and
withheld verbal, gestural, and physical prompts
of bite presentations, repositioned the plate in
front of the child each time the child pushed
the plate away from its initial position, and
provided access to highly preferred toys and
interacted with the child continuously during
the control condition. Observers would have
only scored correct antecedents for the entire
session, when the feeder also checked for a
mouth clean 30 s after each bite that passed
the plane of the child’s lips if the child had
placed bites in the mouth; however, this never
occurred. Observers scored correct conse-
quences for the entire session during conditions
without prompts when the feeder delivered
brief verbal praise every time Levi placed a bite
in his mouth; delivered brief praise when the
child’s mouth was clean following the check;
delivered a verbal prompt to “finish the bite” if
the child packed the bite; delivered scripted
attention following inappropriate mealtime
behavior in attention conditions; and withheld
attention following inappropriate mealtime
behavior in the control condition.
Procedural integrity was scored for 45%, 31%,
and 35% of functional analysis sessions for Levi,
Ava, and Kam, respectively, and 35% of treatment
evaluation sessions for each child. During the func-
tional analysis, mean correct prompts and conse-
quences were 91.6% (Levi), 100% (Ava), and
100% (Kam) and 91.2% (Levi), 100% (Ava), and
97.5% (Kam), respectively. During the treatment
evaluation, mean correct prompts and conse-
quences were 98% (Levi), 100% (Ava), and 100%
10 MELANIE H. BACHMEYER et al.

Figure 1. Inappropriate mealtime behavior per minute for Levi (top) and Ava (bottom) during the functional analy-
sis with prompts (filled) and no prompts (open).

(Kam) and 94.7% (Levi), 100% (Ava), and
97.3% (Kam), respectively.
RESULTS
The results of the functional analysis for
inappropriate mealtime behavior are depicted
in Figure 1 for Levi (top) and Ava (bottom)
and Figure 2 for Kam. Levi’s inappropriate
mealtime behavior was higher in the escape
condition (M = 24.5 rpm) compared to the
control conditions with and without prompts
(M = 3.2 and 0 rpm, respectively). Inappropri-
ate mealtime behavior remained low in the
control and attention conditions without pro-
mpts (M = 0 and 0.1 rpm, respectively), but
was higher in the attention condition with pro-
mpts (M = 4.8 rpm) compared to the control
condition with prompts (M = 3.2). Thus,
results of the functional analysis conditions
without prompts suggested Levi’s inappropriate
mealtime behavior was maintained only by neg-
ative reinforcement (escape from bites), and
results of the experimental conditions with
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
Figure 2. Inappropriate mealtime behavior per minute for Kam during the functional analysis with prompts (filled)
and no prompts (open).
prompts suggested his inappropriate mealtime
behavior was also maintained by positive rein-
forcement (in the form of attention).
Ava’s inappropriate mealtime behavior was
higher in the escape condition (M = 3.7 rpm)
compared to the control conditions with and
without prompts (M = 0.1 and 0.1 rpm, respec-
tively). Inappropriate mealtime behavior was low
in the control condition without prompts
(M = 0.1 rpm) and decreased and remained low
in the attention and diverted attention conditions
without prompts (M = 0.6 and 0.5 rpm, respec-
tively), but was higher in the attention with pro-
mpts condition (M = 3.1 rpm) compared to the
control with prompts condition (M = 0.1 rpm).
Thus, results of the functional analysis conditions
without prompts suggested Ava’s inappropriate
mealtime behavior was maintained only by escape
from bites, and results of the experimental condi-
tions with prompts suggested her inappropriate
mealtime behavior was also maintained by
attention.
Kam’s inappropriate mealtime behavior was
higher in the escape condition (M = 16 rpm)
11
compared to the control conditions with and
without prompts (M = 0.6 and 0 rpm, respec-
tively). Inappropriate mealtime behavior was
higher in the attention condition with prompts
(M = 6 rpm) compared to the control condition
with prompts (M = 0.6 rpm) and in the atten-
tion and diverted attention conditions without
prompts (M = 2.3 and 1.9 rpm, respectively)
compared to the control condition without pro-
mpts (M = 0 rpm). Thus, results of both proce-
dural variations suggested Kam’s inappropriate
mealtime behavior was maintained by escape
and attention.
Figure 3 shows the results of Levi’s treat-
ment evaluation for inappropriate mealtime
behavior (top) and acceptance (bottom). Inap-
propriate mealtime behavior was high (M = 5.1
rpm) and acceptance was low and variable
(M = 30%) during the initial escape and atten-
tion baseline. After an initial increase, inappro-
priate mealtime behavior decreased to at or
near zero in the escape extinction plus atten-
tion and the escape extinction plus attention
extinction conditions (M = 4.2 and 2.2 rpm,
12 MELANIE H. BACHMEYER et al.

Figure 3. Inappropriate mealtime behavior per minute (top) and percentage of bite presentations with acceptance
(bottom) for Levi during escape plus attention baseline, escape extinction plus attention, attention extinction plus
escape, and escape extinction plus attention extinction.

respectively), and acceptance increased in both
conditions (M = 83% and 87%, respectively).
It was unclear whether the observed behavior
was a result of the contingencies in each condi-
tion or a lack of discrimination, therefore, we
compared baseline and the two interventions
individually within a reversal design to rule out
the possibility that effects in the multiele-
ment comparison were due to a lack of dis-
crimination. Baseline resulted in increased
inappropriate mealtime behavior (M = 4.1 rpm)
and decreased acceptance (M = 43%).
Acceptance was variable (M = 72%) and
inappropriate mealtime behavior was variable
and increased (M = 3.9 rpm) during escape
extinction plus attention phases. Acceptance
became stable at high levels (M = 94%) and
inappropriate mealtime behavior decreased and
remained at zero (M = 0.7 rpm) during escape
extinction plus attention extinction phases.
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS 13

Figure 4. Inappropriate mealtime behavior per minute (top) and percentage of bite presentations with acceptance
(bottom) for Ava during escape plus attention baseline, escape extinction plus attention, attention extinction plus escape,
and escape extinction plus attention extinction.

Figure 4 shows the results of Ava’s treatment
evaluation for inappropriate mealtime behavior
(top) and acceptance (bottom). Inappropriate
mealtime behavior was high and variable
(M = 12 rpm) and acceptance was low and vari-
able (M = 30%) during the initial escape and
attention baseline. During both the escape extinc-
tion plus attention and attention extinction plus
escape conditions, inappropriate mealtime behav-
ior decreased (M = 2.9 and 5.9 rpm,
respectively), and acceptance increased
(M = 68% and 66%, respectively) but remained
variable. A return to baseline resulted in increased
inappropriate mealtime behavior (M = 9.7 rpm)
and decreased acceptance (M = 46%). When we
reintroduced attention extinction plus escape,
inappropriate mealtime behavior remained high
and variable (M = 12.7 rpm), and acceptance
remained low and variable (M = 43%). When
we reintroduced escape extinction plus attention,
14 MELANIE H. BACHMEYER et al.

Figure 5. Inappropriate mealtime behavior per minute (top) and percentage of bite presentations with acceptance
(bottom) for Kam during escape plus attention baseline, escape extinction plus attention, attention extinction plus
escape, and escape extinction plus attention extinction.

inappropriate mealtime behavior remained high
(M = 6.7 rpm), and acceptance increased but
remained variable (M = 87%). Inappropriate
mealtime behavior decreased and remained at
zero (M = 4.8 rpm) and acceptance increased to
high and stable levels (M = 91%) when we
reimplemented escape extinction and attention
extinction. A return to escape extinction plus
attention and attention extinction plus escape
resulted in variable inappropriate mealtime
behavior (M = 1.9 and 2.2 rpm, respectively)
and acceptance (M = 85% and 76%, respec-
tively) in both conditions. Inappropriate meal-
time behavior became stable at zero
(M = 0.9 rpm) and acceptance became stable at
100% (M = 96%) during a final return to escape
extinction plus attention extinction.
Figure 5 shows the results of Kam’s treatment
evaluation for inappropriate mealtime behavior
(top) and acceptance (bottom). Inappropriate
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
mealtime behavior was high (M = 17.4 rpm)
and acceptance was low (M = 8%) during the
initial escape and attention baseline. Inappropri-
ate mealtime behavior remained at baseline rates
(M = 15.6 rpm) and acceptance became more
variable (M = 23%) when we implemented
attention extinction plus escape. Escape extinc-
tion plus attention resulted in decreased inap-
propriate mealtime behavior (M = 4.7 rpm)
and increased acceptance (M = 79%), but both
remained variable. A return to baseline resulted
in increased inappropriate mealtime behavior
(M = 33.6 rpm) and zero acceptance. During
both phases in which we re-implemented atten-
tion extinction plus escape, inappropriate meal-
time behavior remained high and variable
(M = 19.3 rpm), and acceptance remained low
or decreased (M = 38%). Inappropriate meal-
time behavior decreased (M = 5.3 rpm) but
remained above clinically acceptable rates, and
acceptance increased (M = 73%) but remained
variable during both phases in which we re-
implemented escape extinction plus attention.
Inappropriate mealtime behavior decreased and
remained at zero (M = 1.8 rpm), and accep-
tance increased to high and stable levels
(M = 97%) during both phases of escape
extinction plus attention extinction.
DISCUSSION
Results of the two procedural variations of
functional analyses of inappropriate mealtime
behavior showed that both methods identified
multiple functions, escape and attention, for one
child (Kam). The treatment evaluation showed
that both escape extinction and attention extinc-
tion were necessary to achieve clinically accept-
able rates of inappropriate mealtime behavior
and high and stable levels of acceptance,
suggesting that both methods identified the rein-
forcers maintaining Kam’s inappropriate meal-
time behavior. However, for two of the three
children (Levi and Ava), providing prompts only
in the escape condition of the functional analysis
15
identified only an escape function, whereas,
using prompts in all conditions identified multi-
ple functions, escape and attention. For these
two children, the intervention matched only to
an escape function (i.e., escape extinction and
attention) resulted in inappropriate mealtime
behavior above clinically acceptable rates and
increased but variable levels of acceptance. By
contrast, the intervention matched to both func-
tions (i.e., escape extinction plus attention
extinction) resulted in inappropriate mealtime
behavior at or near zero rates and high and stable
levels of acceptance for both children. Thus,
results of the treatment evaluation showed that it
was necessary to treat both functions to achieve
clinically acceptable levels of inappropriate meal-
time behavior and acceptance, suggesting that
Levi and Ava’s inappropriate mealtime behavior
was maintained by multiple reinforcers (escape
and attention). Therefore, the results suggest
that the procedural variation in which the feeder
used prompts only in the escape condition failed
to identify a positive reinforcement function
(attention) for two of three children.
It is possible that attention became a reinforcer
maintaining inappropriate mealtime behavior as a
result of the functional analysis. Levi’s responding
in the attention condition without prompts may
be interpreted as an acquisition curve; however, it
is important to note that his inappropriate meal-
time behavior also contacted the reinforcement
contingency in the attention condition without
prompts but maintained only in the condition
with prompts. These data suggest that attention
reinforced inappropriate mealtime behavior only
in the presence of prompts to eat (the relevant dis-
criminative stimuli or motivating operations for
inappropriate mealtime behavior) regardless of
whether attention maintained inappropriate meal-
time behavior before the experimental analysis.
Ava’s inappropriate mealtime behavior was
immediately differentiated in the control and
attention conditions with prompts, and
although her inappropriate mealtime behavior
increased during the attention condition
16 MELANIE H. BACHMEYER et al.
without prompts compared to the control con-
dition without prompts, responding did not
maintain in the attention condition without
prompts. Neither pattern of responding sug-
gests an acquisition curve, and thus, do not
suggest the development of a function during
the analysis for Ava.
The feeder provided highly preferred toys in
the control conditions with and without pro-
mpts but not in the escape and attention test
conditions, replicating the procedures described
by Piazza et al. (2003). Including highly pre-
ferred stimuli may be necessary to reduce the
rate of inappropriate mealtime behavior in
order to establish a control condition with
prompted bites. This may be particularly rele-
vant when programmed abolishing operations
for escape and attention are not sufficient on
their own to obtain low rates of problem
behavior when the relevant discriminative stim-
uli (i.e., bites of food) are present. Including
toys in the escape and attention test conditions
may decrease the value of escape or attention as
reinforcers for inappropriate mealtime behavior,
and thus the occurrence of behavior; when in
fact, escape or attention maintain inappropriate
mealtime behavior during times the caregivers
do not consistently use toys, resulting in false
negative findings. Further, if the child turns his
or her head or pushes the bite away as a result
of playing with the toys in the test conditions,
delivering escape or attention contingent on
these responses may result in false positive find-
ings. However, it is possible that differential
responding between test and control conditions
may be a function of the presence or absence of
preferred stimuli and not the reinforcement
contingency alone. Thus, an alternative prepa-
ration could be to compare the two functional
analysis methods without the presence of highly
preferred stimuli in the control conditions, as
in the Najdowski et al. (2003) study, and
should be considered by future researchers.
The presence of the feeder seated next to the
child in the attention with prompts condition
and the absence of the feeder at the table in the
diverted attention without prompts condition
replicate the procedures described by Piazza
et al. (2003) and Najdowski et al. (2008),
respectively. It may be that the feeder evokes
problem behavior but only when seated next to
the child; thus, the differential outcomes
observed between the two attention conditions
may have been a result of the presence and
absence of the feeder seated next to the child
and not simply the presence or absence of pro-
mpts. However, the addition of the attention
without prompts condition, in which the feeder
was seated next to the child, but did not pro-
vide prompts, showed that Ava displayed high
rates of inappropriate mealtime behavior in the
attention with prompts condition and low rates
of inappropriate mealtime behavior in both
attention conditions without prompts, regard-
less of whether the feeder was seated next to
the child (contingent attention condition) or at
the sink washing dishes (diverted plus contin-
gent attention condition). Thus, Ava’s results
suggest that the prompts, not the presence of
the feeder at the table, evoked inappropriate
mealtime behavior.
Caregivers conducted the functional analyses
in all previous studies in which the feeders pro-
vided prompts only in the escape condition,
and experimenters conducted the functional
analyses in all previous studies in which bites
were prompted across all conditions. It is possi-
ble that investigators identified multiple func-
tions only in the studies in which the feeder
provided prompts across all conditions because
of this procedural difference. However, if atten-
tion is a reinforcing stimulus, it seems that
caregivers, compared to novel therapists, would
be more likely to function as discriminative
stimuli, given their history with their own
child. In the current investigation, we held the
feeder constant across both methods (experi-
menters conducted all sessions) and the two
procedural variations resulted in differential
outcomes for two of three children.
 A COMPARISON OF FUNCTIONAL ANALYSIS METHODS
An additional difference between the previ-
ous studies discussed and the current study is
that the studies using the method without pro-
mpts included only children who exhibited
food selectivity and consistently self-fed. Pro-
viding prompts would be more consistent with
meals in the natural setting for children who
exhibit severe food refusal and do not have a
history of consistently self-feeding due to either
a lack of motivation or skill. Thus, it was
important to examine the validity of both
methods with children exhibiting a wider range
of feeding problems. We included children
who displayed self-feeding skills, but two chil-
dren (Ava and Kam) were dependent on tube
feeds for the majority of their nutrition and
their caregivers typically fed them when pre-
senting nonpreferred foods, which may be
more representative of what caregivers typically
do in the natural setting with children with
more severe feeding problems.
Results of the functional analyses in the cur-
rent study showed that differential responding
did occur for all children when the feeder pro-
vided prompts across all conditions, with inap-
propriate mealtime behavior remaining low or
decreasing over time in the control condition
despite the presence of aversive stimuli (prompts
and bites). These results are consistent with pre-
vious studies in which the feeder provided pro-
mpts in all conditions and showed that
differential responding did occur for most par-
ticipants. Some children’s behavior was
maintained by a single function and some chil-
dren’s behavior was maintained by multiple
functions, with inappropriate mealtime behavior
remaining low or decreasing over time in the
control condition (Bachmeyer et al., 2009;
Girolami & Scotti, 2001; Piazza et al., 2003).
Thus, the functional analysis results of the cur-
rent study and these previous studies show that
when the feeder presented bites and prompts to
eat in all functional analysis conditions, these
stimuli did not evoke high and undifferentiated
levels of inappropriate mealtime behavior across
17
all conditions, which would have led to incon-
clusive results. Moreover, results of the treat-
ment evaluations in the current study are also
consistent with the Bachmeyer et al. (2009)
study. Both escape extinction and attention
extinction were necessary to produce clinically
acceptable levels of inappropriate mealtime
behavior and acceptance, with all participants
whose inappropriate mealtime behavior was
maintained by multiple functions, based on
results of the functional analysis in which the
feeder provided prompts across all conditions.
Thus, results of the treatment evaluation in the
current study and Bachmeyer et al. showed that
when the functional analysis in which the feeder
provided prompts in all conditions suggested
multiply controlled inappropriate mealtime
behavior, extinction procedures matched to
both sources of reinforcement were necessary to
achieve clinically acceptable levels of inappropri-
ate mealtime behavior and acceptance. These
findings suggest that the functional analysis
method identified all the relevant functional
relations examined and did not falsely identify a
positive-reinforcement function.
Results of this study suggest that presenting
bites and prompts to eat only in the escape
condition may, in fact, omit the relevant dis-
criminative stimuli or motivating operations for
inappropriate mealtime behavior in the other
test conditions and result in false negative find-
ings for some children. These results suggest
that sources of reinforcement for inappropriate
mealtime behavior are contextual. That is, an
event such as attention functions as reinforce-
ment in the presence of prompts to eat, but
not in other contexts, such as when a child is
left alone with a plate of food on the table or
outside of the mealtime context (Bachmeyer
et al., 2009). The current results are consistent
with the findings of previous research demon-
strating that functional analysis procedures that
do not manipulate the antecedent variables that
function as motivating operations in the test
conditions may not occasion problem behavior
18 MELANIE H. BACHMEYER et al.
and thus result in false-negative findings
(e.g., Call, Wacker, Ringdahl, & Boelter, 2005;
O’Reilly, Lacey, & Lancioni, 2000). Previous
research suggests that extinction of all sources
of reinforcement may be necessary to success-
fully treat multiply controlled inappropriate
behavior (e.g., Borrero & Vollmer, 2006;
Smith, Iwata, Vollmer, & Zarcone, 1993).
Thus, identifying all sources of reinforcement
that maintain inappropriate mealtime behavior
via a pretreatment functional analysis may be
necessary to develop treatments with greater
specificity, efficiency, and effectiveness. Find-
ings of the current study suggest that it is
important to include bite and/or drink presen-
tations and verbal instructions to “take a bite
and/or drink” across all conditions in a func-
tional analysis of inappropriate mealtime behav-
ior to ensure the identification of all potential
functional relations.
It is not uncommon for clinicians to question
the utility of a functional analysis of inappropri-
ate mealtime behavior for several reasons. First,
experimenters have shown that feeding prob-
lems are often escape-maintained and escape
extinction is often necessary. Second, escape
extinction plus attention extinction and escape
extinction alone, as typically described in the lit-
erature, are structurally identical. That is, the
feeder holds the spoon at the child’s lips until
the child accepts the bite and provides no differ-
ential consequences for inappropriate mealtime
behavior during both procedures. For example,
we would not have recommended that care-
givers in the current study provide attention
contingent on inappropriate mealtime behavior
if attention extinction had not been a necessary
treatment component. Finally, we often train
caregivers to implement escape extinction plus
attention extinction as a treatment package.
However, evaluating the role of attention in
the maintenance of inappropriate mealtime
behavior can be beneficial to clinicians. It is
appropriate and essential to train caregivers to
implement escape extinction plus attention
extinction and provide feedback if a caregiver
continues to deliver attention following inap-
propriate mealtime behavior when both atten-
tion and escape function as reinforcers. By
contrast, if only escape functions as a reinforcer,
it is appropriate and essential to train caregivers
to implement escape extinction, but it should
not be necessary to train them to implement
attention extinction. It may be just as much a
mistake to assume that attention universally
functions as a reinforcer as it is to assume that it
never functions as a reinforcer. Teaching care-
givers to withhold reprimands following inap-
propriate mealtime behavior when their child’s
behavior is rule-governed, and the child
responds to verbal directions, may eliminate one
of the mechanisms those caregivers use to effec-
tively manage their child’s behavior. In addition,
some caregivers are adamant in their refusal to
ignore their child’s problem behavior. If atten-
tion does not function as a reinforcer for prob-
lem behavior, then the clinician does not need
to fight that battle with the caregiver. Alterna-
tively, the clinician could train the caregiver to
increase the magnitude, quality, or duration of
attention they provide following appropriate
behavior. However, it may be easier for care-
givers to learn and implement one treatment
component than more complex treatment pack-
ages, if both are equally effective. Teaching care-
givers to implement a procedure that is not
necessary for treatment efficacy may unnecessar-
ily negatively impact the integrity with which
caregivers implement the necessary treatment
components (Vollmer, Sloman, & St. Peter Pip-
kin, 2008). Future research should evaluate the
effects that treatments of varying complexity
have on treatment fidelity of caregivers
implementing pediatric feeding protocols.
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Received May 12, 2015
Final acceptance February 19, 2019
Action Editor, Carrie Borrero