Meal Presentation Summary

RESEARCH ARTICLE
An Evaluation of Sequential Meal Presentation with Picky Eaters
Colleen M. Whelan1 & Becky Penrod1
Published online: 17 September 2018
# Association for Behavior Analysis International 2018
Abstract
Results of previous research evaluating sequential presentation of nonpreferred (NP) and high-preferred (HP) foods have been
mixed, and little is known about how preferences for foods and the manner in which they are presented impact consumption. In
many households, NP and HP foods are presented together on the same plate (total meal presentation). This was true for the
participants included in this study; thus, total meal presentation served as a baseline against which to compare the effects of an
appetizer presentation method and subsequently sequential presentation (differential reinforcement). Results demonstrated that
presenting NP foods as an appetizer was not successful in increasing consumption. Consumption only increased after HP foods
were made contingent on consumption of the NP food.
Keywords Sequential presentation . Food selectivity . Differential reinforcement
Picky eating is a common childhood difficulty reported by
parents each year (Carruth & Skinner, 2000). In fact, the percentage of children identified as picky eaters has been reported
to be as high as 50% by 24 months of age (Carruth, Ziegler,
Gordon, & Barr, 2004). It is estimated that at any point in time
between 13% and 35% of parents report that at least one of
their children is a picky eater (Mascola, Bryson, & Agras,
2010; Rogers, Magill-Evans, & Rempel, 2012). Although definitions of picky eating vary widely and there is no single
definition that has been extensively adopted, it is commonly
characterized by strong food preferences and limited intake of
both familiar and unfamiliar foods (Taylor, Wernimont,
Northstone, & Emmett, 2015).
Picky eaters often engage in some form of disordered feeding behavior (Carruth et al., 2004). Namely, it is commonly
reported that picky eaters refuse to try new foods when
presented with the opportunity (Cathey & Gaylord, 2004),
as in the case of food selectivity, which has been formally
defined as the consumption of a limited variety of foods,
as well as the rejection of most novel foods when presented (Levin & Carr, 2001). This definition closely resembles descriptions of picky eating; however, picky eating
can be distinguished from food selectivity in that picky
eaters generally eat at least one food from each food
group whereas children with food selectivity may avoid
entire food groups altogether (Food selectivity, 2017).
Almost all children go through a period of picky eating,
which frequently coincides with normal developmental
growth patterns (Carruth et al., 2004). Children often resume
healthy eating behaviors; however, for some children, picky
eating can evolve into more serious feeding difficulties, such
as food selectivity (Carruth et al., 2004; Cathey & Gaylord,
2004). The effects of such feeding problems on the growth
and development of a child can be severe. A multitude of
health problems can result, such as the insufficient intake of
nutrients leading to malnutrition, inadequate weight gain, retardation in growth, fecal impaction, and severe weight loss
resulting in a diagnosis of failure to thrive (Kerwin, 1999).
Thus, it is important to address picky eating in an effort to
prevent the development of a more severe feeding disorder, as
it may be difficult to predict whether or not picky eating will
resolve on its own (Carruth et al., 2004). In a study conducted
by Ekstein, Laniado, and Glick (2010), it was concluded that
picky eating patterns place children at greater risk of being
Colleen M. Whelan, Department of Psychology, California State
University, Sacramento; Becky Penrod, Department of Psychology,
California State University, Sacramento.
The research presented in this article was completed in partial fulfillment
of thesis requirements for the master’s degree by the first author. We thank
Svea Love for her assistance in conducting this project.
* Becky Penrod
[email protected]
1 Department of Psychology at California State University,
Sacramento, 6000 J Street, Sacramento CA 95819-6007, USA
Behavior Analysis in Practice (2019) 12:301–309
https://doi.org/10.1007/s40617-018-00277-7
underweight. Further, picky eating may be accompanied by
inappropriate mealtime behaviors that could negatively impact the child’s relationship with other members of the family
and impede family functioning, as well as opportunities for
socialization.
Picky eating may be addressed by simple consequence manipulations that can easily be implemented by parents in the
natural environment. One such intervention was the focus of
this study: sequential food presentation. Sequential presentation is a consequence manipulation (differential reinforcement
procedure) that involves the contingent presentation of a highpreferred (HP) food following acceptance or consumption of a
nonpreferred (NP) food (e.g., Najdowski, Wallace, Doney, &
Ghezzi, 2003). Numerous studies have demonstrated that sequential presentation is effective when implemented in conjunction with other treatment components, such as escape extinction and demand fading (e.g., Najdowski et al., 2003;
Najdowski et al., 2010; Seiverling, Kokitus, & Williams,
2012); however, when sequential food presentation has been
examined in the absence of other treatment components,
namely escape extinction, results have been mixed. For example, Penrod, Wallace, Reagon, Betz, and Higbee (2010) conducted a component analysis and found that bite fading and
sequential presentation were effective in increasing consumption for one of three participants in the absence of escape
extinction in the form of a nonremoval-of-the-spoon procedure (NRS), whereas consumption for the other two participants did not increase until after NRS was introduced. In a
later study, Pizzo, Coyle, Seiverling, and Williams (2012)
found that sequential presentation was effective in the absence
of escape extinction; however, the study was limited to a single participant.
The independent effects of sequential food presentation
have also been evaluated in comparison to simultaneous presentation in which an HP food and an NP food are presented
together on the same spoon or fork (Piazza et al., 2002). For
example, Penrod and VanDalen (2010) compared the emerging preference for NP foods when presented simultaneously
versus sequentially. According to the authors, no differential
results were found between the two conditions; that is, neither
simultaneous presentation nor sequential presentation was effective as a single treatment component. Consumption did not
occur until NRS was introduced. However, the authors anecdotally noted that in the simultaneous condition, participants
elected to separate the NP and HP foods and eat them in a
sequential fashion, suggesting that some children may prefer
to consume the NP food separate from their HP food. It is also
possible that motivation to consume NP foods is increased
when there is a reinforcement contingency in place for
consumption.
In summary, results of previous research evaluating sequential presentation have been mixed. Moreover, little is
known about how preferences for food and the method in
which they are presented may impact the maintenance of food
consumption. Although most caregivers do not present NP
food together with an HP food on the same spoon or fork
(simultaneous presentation), in many households, HP and
NP foods are presented together on the same plate, a presentation method hereafter referred to as total meal presentation.
Another presentation method commonplace in some households is a form of sequential presentation in which parents
initially present NP foods, and after some period of time with
little or no consumption, they present the child’s HP foods.
Whereas sequential presentation, as described in the literature,
generally refers to the contingent presentation of an HP food,
we refer to this variation as an appetizer presentation, similar
to how different foods are often served in a restaurant, with
one food presented as a starter followed by another food that is
presented regardless of whether the diner has finished his or
her starter.
There may be benefits and drawbacks to each of the aforementioned presentation methods. For example, the appetizer
presentation method may be advantageous in that there is
likely a stronger establishing operation in effect at the beginning of the meal, presuming the child is hungry. On the other
hand, a potential benefit of the total meal presentation method
is that the presence of the HP food on the same plate as the
child’s NP food may serve as an abolishing operation for
inappropriate mealtime behavior. However, one pitfall of this
presentation method is that the child could consume all of the
HP food without consuming the NP food. This was true for the
participants included in this study; thus, total meal presentation served as a baseline against which to compare the effects
of sequential presentation. Given that the appetizer presentation may capitalize on a naturally occurring establishing operation (i.e., hunger), we also wanted to evaluate whether this
presentation method offered any benefit over the total meal
presentation method. Thus, prior to the introduction of sequential presentation, we evaluated an appetizer presentation
method in which a portion of the NP food was initially presented by itself for a period of time and then the HP food was
presented regardless of whether the child consumed the NP
food or not. When consumption did not increase, a subsequent
treatment phase was introduced in which the HP food was
only provided contingent on consumption of the NP food
(i.e., sequential presentation).
As previously mentioned, little is known about how preferences may impact the maintenance of food consumption
given that escape prevention procedures are often included
as a component of treatment, making it difficult to rule out
the possibility that consumption maintains through the process
of negative reinforcement. Thus, another aim of this study was
to compare emerging preferences for target NP foods with
children who were considered picky eaters and who had no
prior history of exposure to escape prevention procedures. For
the purpose of this study, we defined picky eating as
302 Behav Analysis Practice (2019) 12:301–309
consumption of a restricted number of foods (i.e., less than
three) in at least one food group and resistance to trying new
foods when presented.
Method
Participants
Two typically developing brothers participated in this study.
Lars (age 6) and Marshall (age 3) were both reported by their
parents to be picky eaters. The siblings were referred to the
Pediatric Behavior Research Laboratory at California State
University, Sacramento, to address their picky eating behavior. Both Lars and Marshall could self-feed, and they ate a
variety of foods, including many processed starches (e.g.,
Cheerios, crackers, Cheetos, etc.), some fruits, and a limited
number of proteins (i.e., hot dogs, sausage, and ham), while
refusing most other foods within the category. Both children
used to consume additional foods including hummus, avocado, carrots, ground beef, and bananas. According to parent
report, neither Lars nor Marshall would eat vegetables, following a self-generated rule that they would not eat anything
green. There was no oral motor or underlying medical factors
indicated by the parents, and neither child had been treated
previously for picky eating or food-related difficulties. Both
children were considered to be at risk for developing more
severe feeding problems if left untreated, especially given
the number of previously eaten foods that had been dropped
from their diet.
Both children were reported to engage in mealtime problem behaviors. Lars engaged in refusal behaviors, including
making negative statements about the food (e.g., “I don’t like
cucumbers,” or “Cucumbers are yucky.”); saying, “I don’t
want to eat that today,” when presented with an NP food;
and pushing the plate away. Marshall engaged in foodrefusal behaviors, including crying, vocal protesting (negative
statements in an escalated/raised tone of voice), attempting to
leave the table, attempting to throw food, and falling to the
floor. However, most of these behaviors were short in duration
and could often be redirected after several minutes of casual
mealtime conversation.
Setting and Materials
All sessions took place within the family home, at the dinner
table where meals normally occurred, with the parent as the
primary implementer. This was done in order to increase generalization to the natural environment where the children most
often consumed their meals. In addition, the brothers received
their meals at the same time, and the parents dined with them.
This arrangement most closely represented the regular mealtime routine of the family. Sessions occurred during dinner,
two to three times per week, and all meals were terminated
after 20 min had elapsed. Also present in the room was the
primary researcher, who participated in casual mealtime conversation while at the table, and an additional research assistant attended some sessions in order to collect treatment integrity data on the implementation of the procedure.
Measurement of the Dependent Variable
All sessions were video recorded. During preference assessments, data were collected on the number of trials that each
food was consumed. Consumption was scored any time the
participant picked up a bite of food and placed the food past
the plane of his lips in the absence of expulsion (i.e., no food
larger than the size of a pea was observed outside of the participant’s mouth following acceptance of the bite). The number of bites consumed was then divided by the total number of
trials each food was presented and converted to a percentage.
During experimental conditions, the total weight of NP food
consumed was measured in grams. This was done by
weighing the plate with the NP food prior to presentation of
the meal (and before the HP food was placed on the plate
during total meal presentation) and weighing the plate again
at the end of the meal. Any remaining HP food was removed
from the plate and any remaining NP food not on the plate
(e.g., food that fell to the floor) was retrieved and placed back
on the plate before weight was recorded; the difference in
weight was recorded as the grams consumed. Total grams
consumed was divided by total grams presented and converted to a portion of the serving consumed. Data were also collected on the total meal duration (data available upon request),
with meal onset defined as the moment the plate was placed in
front of the participant and offset defined as a clean mouth (no
food larger than the size of a pea remaining in the participant’s
mouth), which was determined by a single mouth-clean check
following acceptance of the final bite on the plate, or the
termination of the meal at the 20-min cutoff time.
Interobserver Agreement and Treatment Integrity
Interobserver agreement (IOA) was collected on the number
of grams consumed of the target (NP) food and total meal
duration. IOA was calculated for 100% of sessions using the
total agreement method. This was done by dividing the smaller number by the larger number and then multiplying by 100
for a percentage of agreement. Mean IOA for the number of
grams consumed was 100% and for the meal duration was
96% (range 92%–100%).
Treatment integrity was collected on the parent’s delivery
of instructions, meal presentation, and meal termination during 100% of sessions. Two observers collected IOA for treatment integrity for 56% of randomly selected sessions using
the point-by-point agreement method, by dividing the number
Behav Analysis Practice (2019) 12:301–309 303
of agreements by the number of agreements plus disagreements, and then multiplying by 100 for a percentage of agreement. Agreements were defined as both observers scoring the
same response on the same item (e.g., both observers checking
“yes” or both observers checking “no”). Disagreements were
defined as the two observers scoring different responses on the
same item (e.g., one observer checking “yes” and the second
observer checking “no”). The parent’s overall treatment integrity across procedures was 93% (range 85%–100%), and IOA
on treatment integrity was 98% (range 96%–100%) across the
sampled sessions.
Experimental Design
A concurrent multiple-probe design was used to replicate
the effects of contingent presentation (i.e., differential
reinforcement) and volume fading (for Marshal only)
across two different NP foods. Each session (meal) was
composed of a pair of foods, one HP food and one NP
food (e.g., corn [NP food] and macaroni and cheese [HP
food]). Initially, both target NP foods were presented
under baseline conditions—that is, both foods were presented together on the same plate as the child’s HP food
(total meal presentation). Prior to introducing the contingent presentation condition, an appetizer presentation
condition was introduced with one of the two target
foods; however, because the appetizer presentation did
not result in increased consumption, it was not applied
to the second food.
Preference Assessments
Paired-choice preference assessments were conducted prior to
beginning data collection, following the procedures described
by Fisher et al. (1992). The HP and NP foods that were used in
the experimental conditions were determined based on the
results of these initial preference assessments. One 12-item
assessment including 4 HP foods and 8 NP foods was conducted. All food items in the assessment were determined
based on child and caregiver report. The items selected for
treatment were foods typically served in the participants’
home. One food that was selected the highest number of opportunities (suggesting higher preference) was selected as the
HP food (defined as a food chosen between 70% and 100% of
opportunities) and was paired with two NP foods (i.e., selected on less than 20% of opportunities during the assessment) to
make up the two meal dyads of one HP food + one NP food.
The same HP food was paired with both NP foods to control
for slightly higher preferences for one food over another being
a possible controlling variable that could increase the likelihood of consumption.
Total Meal Presentation (Baseline)
During all baseline sessions, the parent presented the meal in a
manner typical of how the family normally presented meals at
home (i.e., both foods on the same plate). A beginning statement was provided as the plate was presented in front of the
child: “Here is your dinner.” The plate had one ageappropriate portion of both the NP and HP foods. For the
HP food, parents were asked to show the primary researcher
the portion they would normally serve. This portion was then
weighed, which equated to 82 g for Lars (approximately 1
cup) and 58 g for Marshall (approximately ¾ cup). The portion of NP food presented to Lars and Marshall equated to 38
g (approximately ½ cup) and 26 g (approximately 1/3 cup),
respectively. If the child consumed the entire meal within 20
min, praise was briefly provided in a natural manner for
finishing his meal (e.g., “Great, you ate everything.”). After
20 min had elapsed, if the child did not finish his food, the
plate was removed. A neutral statement, such as “OK, dinnertime is over now,” was made and the child was allowed to
leave the table. Each session was terminated after 20 min had
elapsed. If the child finished his meal before 20 min had
elapsed, casual dinner conversation would continue, and the
child was permitted to leave the table when the 20-min timer
went off. Parents were instructed to interact with their children
as they typically would but refrain from attending to any inappropriate mealtime behavior (e.g., negative statements
about the food).
Treatment 1: Appetizer Presentation
During the appetizer condition, the NP food was presented
before the HP food and the child was told, “Here is your
appetizer. The main dish will be served soon.” After 10 min
had elapsed, or after the child had consumed all of the NP food
(whichever came first), the HP food was presented and the
child was told, “Here is your main dish.” If the child had not
finished his appetizer (NP food) after 10 min had elapsed, the
main dish was still presented, and the appetizer plate remained
on the table next to his main dish so the child would have the
same amount of time to consume the NP food as in the total
meal presentation condition described previously. If the child
consumed the entire meal (both the HP and NP foods) within
20 min, brief praise was provided as noted previously, and
natural dinnertime conversation would continue until 20 min
had elapsed, at which point the child could be excused from
the table. After 20 min had elapsed, if the child did not finish
his food, both the appetizer plate and the dinner plate were
removed. A neutral statement, such as, “OK, dinnertime is
over now,” was made and the child was allowed to leave the
table. If the child did not consume all of his NP food, the
parents were then asked to avoid providing any food to the
child for at least 1 h following the termination of the meal.
304 Behav Analysis Practice (2019) 12:301–309
This request was made in an attempt to increase the child’s
motivation to eat during the session because food was not
readily available after the session had ended. It should be
noted that consumption of the entire portion of HP food was
not required, as it was not the target of treatment.
Treatment 2: Contingent Presentation
This condition was the same as the previous appetizer presentation condition with one exception. Instead of presenting the
HP food after 10 min had elapsed regardless of whether the
child consumed the NP food, the HP food was only presented
contingent on the consumption of the NP food. When the NP
food was presented, the following statement was made: “Here
is your appetizer; the main dish will be served after you’ve
eaten all of your [name of food].” This is a differential reinforcement procedure wherein the HP food is provided as reinforcement for consumption of the NP food. If the NP food
was not consumed within 20 min, then the HP food was not
presented and the meal was terminated. The experimenter removed the plate with the NP food, and stated, “OK, dinnertime is over now.” In the event that the child did not finish the
NP food, as with the previous conditions, the parents were
asked to avoid providing any food to the child for at least 1
h following termination of the meal.
Volume fading was added for Marshall only. Within this
condition, presentation of the meal and vocal statements of the
contingency remained the same as in the contingent presentation. The volume-fading procedure involved presenting a reduced volume of food. This was done to increase the likelihood of Marshall contacting the contingency of gaining access
to the rest of his dinner following consumption of the NP food.
Initially, only one bite of the treatment food (2 g) was presented. The criterion for increasing volume was one session with
100% consumption. During the following two sessions,
Marshall was presented with two bites (6 g) and four bites
(12 g), respectively, after which the full portion size was
reintroduced.
Results
During total meal presentation for Lars, the mean portion of
NP foods consumed was 9.25% (range 0%–19%) for cucumber and 14.43% (range 0%–38%) for corn. When appetizer
presentation was applied to cucumber, an increase in consumption was not observed (mean portion of serving consumed was 1.67%; range 0%–5%). Following the introduction of the contingent presentation during Session 15, Lars
contacted the contingency of not receiving the rest of his dinner because he did not consume the NP food (cucumber) when
it was presented as an appetizer. Lars did not consume an
entire portion of the NP food until Session 16 of the contingent
presentation. The entire portion of the cucumber was consumed in all subsequent sessions. Beginning with Session
23, the contingent presentation was applied to corn, and Lars
consumed 100% in all subsequent sessions (see Fig. 1).
During total meal presentation for Marshall, the mean portion of NP foods consumed was 0% for cucumber and 1.71%
for corn (range 0%–4%). When appetizer presentation was
applied to cucumber, an increase in consumption was not observed (mean portion of serving consumed was 0%).
Following the introduction of the contingent presentation during Session 15, Marshall contacted the contingency of not
receiving his HP food, after which he consumed several small
bites of cucumber in Sessions 16 and 17. Although consumption was increasing for Marshall, the volume of NP food that
was consumed was only one to two bites, which was not a
clinically significant portion. Therefore, volume fading was
added during Sessions 18, 19, and 20. During these sessions,
Marshall contacted the reinforcement contingency of receiving the rest of his dinner after finishing the NP food. During
Session 21, Marshall was again presented with an entire portion of cucumber and he consumed the entire portion in all
subsequent sessions. Beginning with Session 23, the procedure was then applied to corn, after which he also consumed
100% of opportunities (see Fig. 2).
Both Lars and Marshall demonstrated an increase in preference for the NP foods targeted (see Figs. 3 and 4). For Lars,
cucumber was selected and consumed 67% of opportunities
during the posttreatment preference assessment compared to
0% of opportunities during the pretreatment preference assessment and corn was selected and consumed 42% of opportunities during the posttreatment preference assessment compared
to 14% of opportunities during the pretreatment preference
assessment. For Marshall, cucumber was selected and consumed 72% of opportunities during the posttreatment preference assessment compared to 0% of opportunities during the
pretreatment preference assessment and corn was selected and
consumed 54% of opportunities during the posttreatment preference assessment compared to 0% of opportunities during the
pretreatment preference assessment.
Discussion
Results demonstrated that presenting NP foods as an appetizer
was not successful in increasing consumption. Consumption
only increased after the HP food was made contingent on
consumption of the NP foods. After contacting the contingency in the contingent presentation (and three sessions of volume fading for Marshall), consumption of NP food increased
to 100% for both participants. It is possible that the appetizer
presentation was not effective in part due to the participants’
history of reinforcement during family mealtimes. Based on
conversations with the participants’ parents, we suspect that in
Behav Analysis Practice (2019) 12:301–309 305
the past, when participants engaged in mealtime refusal behaviors for an extended period of time, the parents may have
then provided an alternative meal. For parents, this choice is
often motivated by the fear that their child has not consumed
an adequate number of calories. Consequently, parents may
inadvertently teach their child that food-refusal behaviors may
result in a more preferred dinner option presented at a later
time if the child waits long enough. Contingent presentation
changes this reinforcement contingency, in that the preferred
dinner options were only available following the consumption
of the NP food, and those preferred foods were not available
later if the NP food was not consumed.
Although the effects of contingent presentation (and volume fading for Marshall) were replicated across foods, it
should be noted that the sequence in which treatment conditions were introduced limits the conclusions that can be drawn
from the current study. More specifically, contingent presentation and volume fading may have been just as effective with
both the HP and NP foods presented together on the same
plate. Rather than making the HP food contingent on
20
40
60
80
100
Portion of Serving Consumed
Corn
Cucumber
Total Meal Presentation Appetizer Presentation
Consumption of Non-preferred Food During Meal
Contingent Presentation
5 10 15 20 25
20
40
60
80
100
Session
Lars
Fig. 1 Graph depicting the
portion of servings Lars
consumed during total meal
presentation, appetizer
presentation, and contingent
presentation across two different
foods: cucumber depicted in the
top panel, and corn depicted in the
bottom panel
20
40
60
80
100
Portion of Serving Consumed
Corn
Cucumber
Total Meal Presentation Appetizer Presentation
Consumption of Non-preferred Food During Meal
VF Contingent Presentation
5 10 15 20 25
20
40
60
80
100
Session
Marshall
Fig. 2 Graph depicting the
portion of servings Marshall
consumed during total meal
presentation, appetizer
presentation, and contingent
presentation plus volume fading
(VF) across two different foods:
cucumber depicted in the top
panel, and corn depicted in the
bottom panel
306 Behav Analysis Practice (2019) 12:301–309
consumption of the entire portion of NP food, parents could
require their child to alternate bites of his or her HP food with
bites of the NP food or could reinforce consumption of the
entire meal by offering a highly preferred dessert or access to a
highly preferred activity at the end of the meal. In some respects, presenting the HP and NP foods together on the same
plate may be easier for parents to manage; thus, future
research should evaluate the effects of differential reinforcement and volume fading when NP and HP foods
are presented sequentially versus simultaneously. Future
research should also assess reinforcement effects of stimuli included in evaluations of differential reinforcement. It
is noteworthy that during baseline, Lars occasionally consumed a small amount of both NP foods (this percentage
usually equated to one to three bites; see Fig. 1) and he
often made statements like, “I think I’ll try corn today”;
however, when those bites were not followed by any additional praise or reinforcement, he did not continue to
consume the NP food and finished consuming the HP
food on his plate. Given this observation, it is possible
that praise alone or other stimuli may have functioned as
a reinforcer for consumption.
Additionally, future research should evaluate the independent effects of differential reinforcement procedures.
In the current study, the possibility that other variables
influenced consumption cannot be ruled out entirely.
Given that the two participants included in the study are
brothers, they were treated simultaneously, and the same
treatment foods were selected for both. The reason this
was done was to better mimic a natural mealtime at home.
However, mimicking a natural mealtime means it is
harder to experimentally control for other influences on
consumption, such as modeling (observational learning).
Though it is unlikely that modeling alone would have
resulted in increased consumption—supported by the fact
that Marshall observed Lars consuming his NP food and
receiving his dinner during several sessions, yet consumption for Marshall still did not increase—it is impossible to
say if Marshall would have been as motivated to consume
in the volume-fading sessions if he had not been watching
his brother and family consume dinner without him.
It is important to note that in previous studies evaluating differential reinforcement procedures, results have
been mixed. This may be explained by different
Ham
Cheese Quesadilla
Mac & Cheese
Cod
Sausage
Corn
Sweet Potato
Peas
Cucumber
Broccoli
Cauliflower
Squash
Lettuce
20
40
60
80
100 Pre-Treatment
Post-Treatment
Percentage of Trials with Consumption
Lars
Fig. 3 Percentage of trials with
consumption for Lars during the
pre- and posttreatment preference
assessments, depicted by the
black and gray bars, respectively
Sausage
Cod
Mac & Cheese
Ham
Cucumber
Corn
Sweet Potato
Broccoli
Cauliflower
Lettuce
Peas
Squash
20
40
60
80
100 Pre-Treatment
Post-Treatment
Percentage of Trials Consumed
Marshall
Fig. 4 Percentage of trials with
consumption for Marshall during
the pre- and posttreatment
preference assessments, depicted
by the black and gray bars,
respectively
Behav Analysis Practice (2019) 12:301–309 307
participant characteristics across studies (e.g., diagnoses,
types of feeding problems), thus more research is needed in order to determine the profile of children this
treatment is best suited for.
For children considered to be picky eaters, differential
reinforcement may be a viable and easy procedure for
parents to implement within the natural environment;
however, for children with more severe food-refusal behaviors, such as those with food selectivity, differential
reinforcement may not be effective as a single treatment
component given these children may have a much longer
history of refusal behaviors or may engage in more serious mealtime problem behaviors in which they continue
to refuse food even when hungry.
Particularly noteworthy is the fact that preferences for the
target NP foods included in the study increased for both participants posttreatment. The differential reinforcement contingency (plus volume fading for Marshall) effectively increased
consumption of NP foods, and once participants were consuming these foods, their preference shifted. In addition to
the posttreatment preference assessment data, anecdotal observations provide further support that preferences for the
NP foods did in fact increase. For example, Lars started eating
cucumber during Session 16, and during Session 21, he requested additional cucumber and made some positive statements about the NP food (i.e., “I like cucumber now.”). It
is possible that contingencies are instrumental in bringing
the child into contact with NP foods but that continued
consumption of those foods may be attributed to changes
in preference. Long-term follow-up sessions may help
elucidate the role of preferences in the maintenance of
consumption for foods first introduced into a child’s diet
through contingency management.
Implications for Practice
& Is an easily generalizable treatment strategies designed to
address picky eating;
& Is an unobtrusive consequence-based intervention that can
be implemented by caregivers;
& Has implications for prevention of food selectivity;
& Has implications for research evaluating differential reinforcement contingencies.
Compliance with Ethical Standards
Conflict of Interest The first author declares that she has no conflict of
interest. The second author declares that she has no conflict of interest.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
References
Carruth, B. R., & Skinner, J. D. (2000). Revisiting the picky eater phenomenon: Neophobic behaviors of young children. Journal of the
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