Received: 20 October 2018 Revised: 7 February 2019 Accepted: 14 February 2019

DOI: 10.1002/bin.1664

L I T E R A TUR E R E V I EW

Efficacy of functional analysis for informingbehavioral treatment of inappropriate mealtimebehavior: A systematic review and meta‐analysis

Valdeep Saini1 | Joshua Jessel2 | Julia A. Iannaccone2 |

Charlene Agnew2

1Department of Applied Disability Studies,

Brock University, St. Catharines, Canada

2Department of Psychology, Queens College,

New York, NY, United States of America

Correspondence

Valdeep Saini, Department of Applied

Disability Studies, Brock University, 1812 Sir

Isaac Brock Way, St. Catharines, ON, Canada.

Email: vsaini@brocku.ca

Behavioral Interventions. 2019;34:231–247. w

Children diagnosed with a feeding disorder often exhibit

inappropriate mealtime behavior such as throwing or swiping

food, which can exacerbate feeding difficulties during treat-

ment. We conducted a meta‐analysis of 86 behavioral treat-

ments for inappropriate mealtime behavior from 23 studies

to assess the extent towhich treatments based on a pretreat-

ment functional analysis were more efficacious than those

treatments not based on a functional analysis. Procedural

escape extinction and attention extinction for inappropriate

mealtime behavior, as well as differential reinforcement for

food acceptance or consumption, represented themost com-

mon treatments independent of whether a functional analy-

sis was conducted. No difference was detected between

treatments that were and were not based on a functional

analysis, and mean effect size across measures was identical

(79%). The requirement of a pretreatment functional analysis

for inappropriate mealtime behavior is equivocal given that

standard care often includes efficacious treatment compo-

nents that are not informed by a functional analysis.

KEYWORDS

feeding disorders, food refusal, functional analysis, inappropriate

mealtime behavior, meta‐analysis

1 | INTRODUCTION

Children diagnosed with feeding disorders may present with many mealtime difficulties including food refusal, limited

or restricted diet, atypical eating patterns, and oral‐motor deficits. A large body of literature suggests that many

© 2019 John Wiley & Sons, Ltd.ileyonlinelibrary.com/journal/bin 231

232 SAINI ET AL.

feeding problems (a) are caused by a combination of biological, medical, and environmental influences (Matson,

Fodstad, & Dempsey, 2009; Rommel, De Meyer, Feenstra, & Veereman‐Wauters, 2003), (b) can affect up to 80%

of children with intellectual disabilities (Field, Garland, & Williams, 2003; Gouge & Ekvall, 1975; Milnes, Piazza, & Car-

roll, 2013), and (c) may require a multidisciplinary approach to achieve typical feeding (Sharp, Volkert, Scahill,

McCracken, & McElhanon, 2017).

Several reviews and meta‐analyses have demonstrated the robust effects of behavioral treatments for feeding

problems, including increasing oral intake (i.e., calories consumed), increasing diet variety, and decreasing inappropri-

ate mealtime behavior (IMB; Marshall, Ware, Ziviani, Hill, & Dodrill, 2014; Seubert, Fryling, Wallace, Jiminez, & Meier,

2014; Sharp, Jaquess, Morton, & Herzinger, 2010; Sharp et al., 2013; Silbaugh et al., 2016). In fact, treatments based

on applied behavior analysis are the only ones with strong empirical support for addressing mealtime difficulties

(Kerwin, 1999; Volkert & Piazza, 2012).

One of the most commonly targeted mealtime difficulties is IMB, which is a highly concerning class of food refusal

behavior that occurs at mealtime and often consists of turning away from eating utensils, batting at or pushing away

eating utensils, throwing or swiping foods, liquids, and utensils, or some combination (Piazza, Fisher, et al., 2003). In

some cases, IMB can include more severe forms of problem behavior including aggression and self‐injury (e.g., Wilder,

Normand, & Atwell, 2005). IMB can exacerbate and prolong the treatment process for a child with a feeding disorder

and could be a major cause of parental stress (Didehbani, Kelly, Austin, & Wiechmann, 2011). Therefore, in addition

to increasing food acceptance and consumption, a concomitant reduction in IMB is often a goal during behavioral

treatment (e.g., Addison et al., 2012; LaRue et al., 2011).

Many researchers have relied on functional analysis procedures to determine the environmental variables respon-

sible for IMB (Girolami & Scotti, 2001; Najdowski, Wallace, Doney, & Ghezzi, 2003; Piazza, Fisher, et al., 2003). Func-

tional analysis during mealtime involves the systematic manipulation of variables hypothesized to potentially

reinforce IMB using controlled, single‐case experimental designs (Piazza et al., 2002). Although several systematic

reviews have suggested behavioral interventions are effective for treating food refusal behavior (e.g., Seubert

et al., 2014; Sharp et al., 2010), none of those reviews have specifically examined the role of functional analysis in

informing the selection of treatment procedures.

Heyvaert, Saenen, Campbell, Maes, and Onghena (2014) evaluated the efficacy of behavioral treatments for

reducing severe behavior problems in individuals with autism spectrum disorder (ASD). In a review of 213 studies,

Heyvaert et al. showed that although behavioral treatments were effective overall in reducing severe problem behav-

ior, those that were preceded by a functional analysis produced a statistically significant greater reduction. Similar

reviews have found comparable evidence for the effectiveness of functional analysis to inform behavioral treatment

(e.g., Campbell, 2003); however, some limitations may preclude extending the interpretations to IMB specifically, and

pediatric feeding disorders broadly.

First, outcomes of functional analyses of severe problem behavior can vary drastically between individuals,

with applied researchers often identifying four general classes of reinforcement (i.e., access to attention, access

to tangibles, escape from instructions, and automatic) to any number of other idiosyncratic functions (Jessel,

Hanley, & Ghaemmaghami, 2016; Schlichenmeyer, Roscoe, Rooker, Wheeler, & Dube, 2013). For example, Hanley,

Iwata, and McCord (2003) reviewed 277 published studies with functional analyses between the years 1961 and

2000. Hanley et al. found that results of functional analyses varied with the highest percentages of applications to

have been maintained by escape (34%) and attention (25%). IMB may not share these relatively mixed functional

interpretations. In fact, Hanley et al. found that for some problem behavior, the determined function was likely to

be topographically specific (e.g., a large proportion of studies concluded stereotypy was maintained by automatic

reinforcement). It is possible that the function of IMB is similarly topography specific or could be influenced by

highly specific contextual factors (i.e., the presentation of food or drinks during mealtime). Therefore, treatments

for IMB that happens in a specific context may not require the experimental methodology of a functional analysis

to identify a seemingly discernable function (i.e., IMB resulting in escape from nonpreferred foods or mealtime

context).

SAINI ET AL. 233

Second, the behavioral treatments of severe problem behavior informed by the functional analysis are likely to

differ from those in which the function of the behavior problem was not identified. Iwata, Pace, Cowdery, and

Miltenberger (1994) evaluated the importance of matching treatment procedures to behavioral function in a study

with three children with developmental disabilities who exhibited self‐injury. The authors found that extinction as

a procedure was effective only when it matched the reinforcement for self‐injury identified by the functional analysis

(i.e., attention extinction reduced self‐injury only when attention served as reinforcer). Therefore, Iwata et al. demon-

strated the importance of functional analysis in informing extinction‐based treatments when functional differences

are expected. However, treatment procedures for IMB may not differ depending on the information gathered from

a functional analysis because escape from food or mealtime situations is commonly hypothesized as the predominant

function of IMB, and thus functional differences might not be expected.

Saini, Kadey, Paszek, and Roane (in press) recently conducted a systematic review of functional analysis outcomes

in pediatric feeding disorders. They reviewed 86 published functional analyses and found that IMB was maintained in

part or exclusively by negative reinforcement in the form of escape from the bite, drink, plate, or mealtime context in

greater than 90% of cases, thus potentially corroborating the topography‐specific and context‐specific hypotheses

described above. Moreover, the high prevalence of escape‐maintained IMB held true across multiple categories of

participant and study characteristics. This suggests the knowledge of the function(s) of IMB is based on a fairly

homogenous outcome, despite a heterogeneous clinical presentation (e.g., underlying etiology, comorbid health, or

developmental concerns).

Previous systematic reviews have examined the quality, overall efficacy, and prevalence of behavioral treatments

in pediatric feeding disorders (e.g., Marshall et al., 2014; Seubert et al., 2014; Sharp et al., 2010; Silbaugh et al., 2016)

as well as functional analysis outcomes for IMB (e.g., Saini et al., in press). Therefore, the purpose of our review was

more focused. We aimed to extend the literature on the assessment and treatment of IMB by investigating the effi-

cacy of behavioral treatments informed by functional analyses. We reviewed behavioral treatment for IMB and

applied the procedure described by Heyvaert et al. (2014) to determine the extent to which functional analyses

improved outcomes. We used nonparametric effect size measures to directly compare the mean efficacy of treat-

ments that were and were not based on a prior functional analysis.

2 | METHOD

2.1 | Study identification, inclusion criteria, and exclusion criteria

We searched the databases of PsycINFO, ERIC, PubMed, Journal of Applied Behavior Analysis, Behavioral Interventions,

Behavior Modification, Research in Developmental Disabilities, and the Journal of Positive Behavior Interventions to iden-

tify English journal peer‐reviewed studies published between 2000 and 2017. We used the keywords feeding prob-

lem, feeding disorder, food refusal, and food selectivity during our search. We also examined the references of

obtained articles to identify studies we did not identify in the initial search.

We screened all studies identified through the literature search for eligibility. We included studies that met the

following criteria: (a) the study enrolled human participants between the ages of birth and 21 years; (b) the study used

direct observation of the primary dependent variable(s); (c) the study targeted IMB for reduction as a primary or sec-

ondary dependent variable; (d) the experimenters demonstrated functional control over IMB during a treatment eval-

uation using single‐subject research designs (e.g., reversal, multiple baseline, and multielement); (e) the study

displayed the effects of a given treatment on IMB graphically; (f) the experimenters conducted at least two data

points in the baseline and treatment phases for each participant; and (g) the treatment was deemed effective by

the authors of each respective study. Only studies written in English were included to extract descriptive variables

appropriately. Furthermore, the definition of IMB encompasses a wide range of topographies (e.g., aggression and

234 SAINI ET AL.

disruption). Studies were included if the inappropriate behavior occurred during mealtime and was targeted for

reduction during treatment. In other words, the specific term “IMB” did not have to be used by the authors.

We excluded studies that (a) deemed IMB to be a manifestation of a childhood eating disorder; (b) IMB required

medical or oral‐motor‐based treatment; (c) group studies that did not report results at the single‐subject level; (d)

review studies, meta‐analyses, book chapters, dissertations; and (e) the dependent variable was solely a deficit in

appropriate mealtime behavior (e.g., absence of self‐feeding skills or deficiency in chewing and swallowing).

2.2 | Variables coded, data extraction, and reliability

We further categorized studies meeting the initial inclusion criteria as being informed or not informed by a functional

analysis. We adapted the functional analysis criteria described by Hanley et al. (2003) to designate whether a study

was or was not informed by a functional analysis. Studies were categorized as being informed by a functional analysis

if (a) the experimenters conducted a pretreatment assessment prior to the treatment being introduced; (b) the pre-

treatment assessment included direct observation and measurement of IMB; (c) the experimenters included at least

two conditions and involved systematic manipulation of some environmental variable(s); and (d) the experimenters

demonstrated a functional relation between the environmental event and IMB. Functional analyses were not

required to be displayed graphically.

We extracted descriptive variables from each study and coded them using a standardized electronic checklist and

coding system. We extracted data on participant characteristics, functional analysis characteristics, and treatment

characteristics. Participant characteristics included age (years), sex, developmental diagnoses, and medical diagnoses.

If a functional analysis was conducted, we recorded the function(s) of IMB as reported by the authors of each study.

Treatment characteristics included the specific procedures used (e.g., extinction and differential reinforcement),

whether and what type of reinforcement schedule thinning was conducted, if an effort to generalize the procedures

across settings or individuals was made, and to what extent social validity measures were collected. Treatment char-

acteristics were only recorded for IMB (i.e., if other treatment components were included to address other dependent

variables besides IMB, they were not recorded). However, treatment components were recorded for other depen-

dent variables when those variables were incompatible with and directly relevant to reducing IMB (e.g., acceptance).

The first and second authors independently examined 100% of the studies that met inclusion. Raters indepen-

dently coded extracted data extracted during the review process. We assessed interrater agreement item by item

by comparing the study characteristics each rater recorded. We calculated interrater agreement by dividing the num-

ber of rater agreements by the number of rater agreements plus rater disagreements and converting the resulting

proportion to a percentage for each study. We then calculated a mean of the mean interrater agreement coefficients

for each study, resulting in a mean interrater agreement of 95% across studies. Disagreements were discussed and

resolved prior to formal data analysis by the first and second author.

2.3 | Effect size analyses

We extracted data from each study using WebPlotDigitizer (Rohatgi, 2017), a free software program that has high

interrater reliability and validity and has been used for data extraction in other systematic reviews and meta‐analyses

(Drevon, Fursa, & Malcolm, 2017, Rutkowska, Dubiec, & Nakagawa, 2014; Wagner et al., 2014). The figures from

each study were converted into image files (JPEG) for each treatment evaluation. We uploaded the image file into

WebPlotDigitizer, set the x and y coordinates of the figures, and extracted the session values by clicking on the cen-

ter of each datum. Extracted values were input into a standardized electronic coding spreadsheet.

We estimated the effects of the treatments using five different nonparametric statistics. Like previous reviews

(Campbell, 2003; Heyvaert et al., 2014), we conducted multiple effect‐size analyses because there is disagreement

in the literature regarding how to quantify results of single‐case data for meta‐analytic purposes (Allison & Gorman,

SAINI ET AL. 235

1994; Scruggs & Mastropieri, 1998). In addition, multiple measures allowed for the comparison of reliability between

the estimated effect sizes obtained from each statistical analysis. We based the effect sizes for any treatments eval-

uated in a reversal design on the first baseline phase and the last treatment phase.

We calculated percentage of nonoverlapping data (PND; Scruggs, Mastropieri, & Casto, 1987) by dividing the

number of treatment sessions in which IMB was below the lowest datum during the baseline phase with the total

number of treatment sessions. Higher percentages obtained from the PND indicated a more effective treatment with

the scale not exceeding values below 0% or above 100%. We calculated the percentage of zero data (PZD; Scotti,

Evans, Meyer, & Walker, 1991) by dividing the number of treatment sessions in which IMB was completely elimi-

nated by the total number of treatment sessions. We calculated the percentage of exceeding median (PEM; Ma,

2006) by determining the mean during the baseline phase and dividing the number of treatment sessions with

IMB below that mean by the total number of treatment sessions. The scale and interpretation of effectiveness for

PZD and PEM were identical to PND.

We calculated mean baseline reduction (MBLR; Kahng, Iwata, & Lewin, 2002) by first determining the mean value

of IMB during both the baseline phase and treatment phase. The mean value of IMB from the treatment phase was

subtracted from and then divided by the mean baseline phase. In addition, many large‐scale single‐case design studies

compare treatment effects by calculating the mean reduction in problem behavior from the final five sessions of the

treatment (e.g., Greer, Fisher, Saini, Owen, & Jones, 2016; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998;

Rooker, Jessel, Kurtz, & Hagopian, 2013). This is done to reduce the effects of any variability in responding during

the initial exposure to the treatment that may not necessarily reflect the terminal therapeutic outcomes. Therefore,

the final statistic was similar to the MBLR calculation with the exception being that the means from the baseline and

treatment were calculated from the last five sessions of each respective phase (MBLR‐5). A treatment that eliminates

IMB would result in the maximum percentage of 100% when using the statistics MBLR and MBLR‐5. If the mean of

the treatment were to equal the mean of baseline (i.e., no effect), the quotient would be 0%. Furthermore, the MBLR

and MBLR‐5 scales are sensitive to possible treatment worsening effects. Any value below 0% indicates a treatment

had a negative impact on IMB.

3 | RESULTS

We identified 11,471 articles during the initial search of large databases and journal archives. Of these, we excluded

11,198 articles because they were duplicates from the various search engines or because the titles, abstract, or key-

words did not meet the initial inclusion criteria. The remaining 273 articles met criteria for a final detailed review. We

removed 249 articles after the detailed review because authors (a) did not display IMB graphically, (b) did not target

IMB, or (c) used an inadequate experimental design. This resulted in the identification of 23 articles total,

representing 82 cases. Of these cases, 37 where designated as treatments for IMB that were informed by a func-

tional analysis, and 45 were treatments that were not informed by a functional analysis. The treatment effect sizes

of the 23 articles were analyzed using the five aforementioned nonparametric statistics.

3.1 | Participant characteristics

Table 1 displays the participant characteristics. Most participants were below the age of 6 years old (92%) and were

male (65%). Just over half the participants did not have a developmental diagnosis or one was not reported (51%),

followed by 30% diagnosed with an intellectual or developmental disability, and 14% diagnosed with ASD. Complex

medical histories were common with 39% of participants diagnosed with gastroesophageal reflux disease and 37%

diagnosed with failure to thrive. Thirty‐three percent of participants did not have additional comorbid medical diag-

noses or they were not reported in the individual studies.

TABLE 1 Participant characteristics

Characteristic n %

Age

0–5 years old 45 92

6–10 years old 4 8

Sex

Male 32 65

Female 17 35

Developmental diagnosis

Developmental/intellectual disability 15 30

Autism spectrum disorder 7 14

Down syndrome 1 2

Dual diagnosis 1 2

None/Not reported 25 51

Medical history

Gastroesophageal reflux disease 19 39

Failure to thrive 18 37

Anatomical abnormalities 5 10

Respiratory disorder/dysfunction 4 8

Gastrointestinal problems 3 6

Cardiac disorder/dysfunction 3 6

Gastrostomy‐tube dependence 3 6

Prematurity 3 6

Enzyme deficiency/excess 2 4

Vision impairments 2 4

Nervous system disorder/dysfunction 1 2

Other 3 6

None/not reported 16 33

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3.2 | Functional analysis characteristics

Table 2 displays descriptive information on the functional analyses and treatments for each application. Because mul-

tiple treatments were sometimes developed based on the results of a single functional analysis, there were 25 func-

tional analysis applications (see Data S1 for a list of participants and the corresponding study from which the data

were extracted). Escape was identified as a functional reinforcer in all 25 functional analyses and the only function

in 20 of the 25 applications. Multiple control via attention and escape was identified as the maintaining variables

in the remaining five applications.

3.3 | Treatment characteristics

Of the 37 treatments informed by a functional analysis, 33 (89%) used escape extinction either alone or as a com-

ponent in a treatment package including supplemental reinforcement procedures (Table 3). Escape extinction took

TABLE 2 Functional analysis and treatment characteristics

Characteristic n %

Functional analysis

Yes 25 36

Escape 20 80

Attention 0 0

Escape and attention 5 20

No 45 64

Treatment procedures

Escape extinction 34 41

Escape extinction and DRA 16 20

Escape extinction and NCR 11 13

Escape extinction and DNRA 7 9

Escape extinction and AE 4 5

Escape extinction and HP 3 4

DRA 3 4

DRA and response cost 2 2

NCR and response cost 1 1

NCR 1 1

Reinforcement thinning

Yes 2 5

No 42 38

N/A 49 60

Generalization

Yes 0 0

No 82 100

Social validity

Yes 7 8

No 75 92

Note. AE refers to attention extinction. D(N)RA refers to differential (negative) reinforcement of alternative behavior. RC

refers to response cost. NCR refers to noncontingent reinforcement. HP refers to high‐probability sequence.

SAINI ET AL. 237

the form of nonremoval of the spoon (Hoch, Babbitt, Coe, Krell, & Hackbert, 1994), physical guidance (Ahearn,

Kerwin, Eicher, Shantz, & Swearingin, 1996), or representation if IMB occurred after acceptance and was associ-

ated with expulsions (Sevin, Gulotta, Sierp, Rosica, & Miller, 2002). Of the five cases where attention (in addition

to escape) was also identified as a reinforcer for IMB, four treatments included attention extinction in the form of

ignoring IMB (80%). Although it should be noted that the majority of studies described ignoring or providing no

consequence for IMB, even in cases where attention was not identified as a reinforcer during the functional

analysis.

Supplemental reinforcement procedures were typically associated with bite acceptance or consumption. There

were 21 of the 37 applications of treatments following a functional analysis that used various forms of functional

and arbitrary supplemental reinforcement. Functional differential negative reinforcement (DNRA) was used in 16%

(six of 37) of applications wherein escape was provided contingent on acceptance or consumption. Noncontingent

TABLE 3 Treatment characteristics

Treatment n %

With pretreatment functional analysis 37

Escape extinction 33 89

Differential reinforcement

Functional 6 16

Nonfunctional 8 22

Noncontingent reinforcement

Functional 0 0

Nonfunctional 7 19

Other 0 0

Without pretreatment functional analysis 45

Procedural escape extinction 42 93

Differential reinforcement

Functional N/A

Nonfunctional 15 33

Noncontingent reinforcement

Functional N/A

Nonfunctional 6 13

Other 6 13

238 SAINI ET AL.

reinforcement (NCR; seven of 37) or differential reinforcement of alternative behavior (DRA; eight of 37) including

nonfunctional reinforcers (e.g., noncontingent access to the feeder's attention throughout the meal; access to pre-

ferred toys contingent on acceptance) was used in the remaining supplemental reinforcement procedures. Addi-

tionally, for 28 of 37 (76%) treatments, the feeder delivered attention in the form of positive praise statements

contingent on acceptance or consumption, regardless of the identified function or co‐occurring treatment

components.

Of the 45 treatments in which the experimenters did not conduct a functional analysis, procedures typical of

escape extinction were arranged in 42 (93%) applications; however, given that a functional analysis was not con-

ducted, it is unclear if these procedures operated as extinction. Procedures consistent with attention extinction were

also common (e.g., ignoring or providing no consequence for IMB); however, the methods of each respective study

were not always clearly described and therefore could not be coded accurately (e.g., some studies clearly stated that

IMB was ignored, whereas others did not specify if an attention contingency was or was not present).

Because functional analyses did not inform these 45 treatments, reinforcers could not be identified as functional,

and any supplemental reinforcement procedures were all considered nonfunctional reinforcement. Supplemental

reinforcement procedures included DRA (15 of 45) and NCR (6 of 45) and were like those that were used for treat-

ments that were preceded by a functional analysis (e.g., contingent use of toys for appropriate behavior, noncontin-

gent attention). There were six applications in which the experimenters included other procedures such as response

cost (e.g., Buckley, Strunck, & Newchok, 2005) or the high‐probability response sequence (e.g., Patel et al., 2006).

Similar to those treatments based on a functional analysis, the use of praise contingent on acceptance or consump-

tion was common, occurring in 41 of 45 treatments (91%).

Table 2 displays various treatment information for each individual application related to reinforcement schedule

thinning, generalization, and social validity. When reinforcement procedures were included as a supplemental

SAINI ET AL. 239

treatment procedure (44 applications), the continuous reinforcement schedules were thinned in only two of those

applications (5%). Tests of generalization across settings were not conducted in any of the 82 applications

(although a few studies did demonstrate durability of the treatment when conducted by caregivers in the same

setting; e.g., Casey, Cooper‐Brown, Wacker, & Rankin, 2006). Experimenters evaluated social validity in only seven

applications (9%).

3.4 | Effect size analyses

Figure 1 displays the results of the treatment effect size analyses across the 23 studies. Since 2001, there were nine

studies in which a functional analysis was conducted before the treatment and 14 studies in which treatment was

initiated without a functional analysis. Large effect sizes were obtained for most studies across the different statis-

tical analyses; however, some variability was present. PEM and MBLR‐5 had the largest effect sizes with all studies

above 80% and 70%, respectively. Slight reductions in effect sizes were obtained from the MBLR analysis with two

studies (no functional analyses) reaching the 40–60% range. The greatest variability was obtained when applying the

PND and PZD statistics. When using PND, three studies (no functional analyses) were below a 50% effect size. More

studies had effect sizes below 50% when applying PZD: seven of 14 without functional analyses and five out of nine

with functional analyses.

The mean effect size for treatments based on a prior functional analysis were 80% (SD = 30), 51% (SD = 32), 88%

(SD = 15), 96% (SD = 8), and 83% (SD = 29) for PND, PZD, MBLR‐5, PEM, and MBLR, respectively. The mean effect

size for treatments not based on a prior functional analysis were 79% (SD = 34), 50% (SD = 34), 91% (SD = 11.91),

97% (SD = 7), and 81% (SD = 21) for PND, PZD, MBLR‐5, PEM, and MBLR, respectively. That is, the mean effect size

was comparable and about equal for all effect size measures regardless of whether the treatment was or was not

based on a functional analysis.

Figure 2 displays results of the five nonparametric analyses for each individual treatment application. Similar to

results obtained at the study level, the greatest variability and lowest effect sizes were obtained when applying

the PND and PZD statistics. Only a minor difference in effect sizes was observed when considering treatment appli-

cations that were and were not based on a functional analysis.

4 | DISCUSSION

We reviewed the extant literature in pediatric feeding disorders to determine the degree to which behavioral treat-

ments for IMB based on a pretreatment functional analysis were more efficacious than those not based on a func-

tional analysis. Across multiple effect size measures, we did not observe markedly greater reductions in IMB for

those treatments in which a functional analysis was conducted. Mean effect sizes for both treatment groups (i.e.,

based on and not based on a functional analysis) were about equal. In many cases, treatments appeared to be based

on the prevailing hypothesis of environmental variables that maintain IMB (i.e., escape) and were efficacious in the

absence of a functional analysis. This result held true across multiple categories of participant characteristics and pro-

cedural variations across studies.

The treatments that were developed based on, or in the absence of, a functional analysis warrant consider-

ation. Our review of treatment results indicated several common components that researchers implemented

regardless of whether a functional analysis was conducted, bringing into question the prescriptive nature of this

practice. A large proportion of studies relied on extinction‐based procedures to decrease IMB (i.e., greater than

80% of treatments based on the results of a functional analysis, and greater than 90% not based on a functional

analysis, arranged escape extinction procedurally). This result, combined with other findings (e.g., Marshall et al.,

2014; Saini et al., in press; Sharp et al., 2010; Silbaugh et al., 2016), emphasizes the role of escape as a reinforcer

for IMB and the efficacy of escape extinction as a treatment component. Studies that have evaluated the efficacy

FIGURE 1 Mean effect sizes for each study. Bars represent standard error measurement (SEM)

240 SAINI ET AL.

of escape extinction relative to other treatment components have repeatedly shown that increased acceptance

and a concomitant reduction in IMB is often due to the escape extinction component (LaRue et al., 2011; Piazza,

Patel, Gulotta, Sevin, & Layer, 2003; Reed et al., 2004). Many studies arranged supplemental reinforcement pro-

cedures with extinction; however, even when other positive reinforcers are included in the treatment package

(functional or nonfunctional), escape extinction has been shown to be the necessary component (Patel, Piazza,

FIGURE 2 Effect sizes of treatments based and not based on a functional analysis. Each circle represents anindividual application. Horizontal lines represent the mean. The asterisk represents an individual applicationbelow zero

SAINI ET AL. 241

Martinez, Volkert, & Santana, 2002), which might explain why escape extinction was procedurally arranged in most

cases reviewed, even those for which a functional analysis was not conducted.

Although extinction is often used when a social function of undesirable behavior is implicated from a functional

analysis (Horner, Carr, Strain, Todd, & Reed, 2002; Lerman & Iwata, 1996), function‐based differential reinforcement

is also commonly arranged for other types of behavior disorders such as severe problem behavior. For example, a

child might be taught an appropriate alternative behavior such as communication to obtain the putative reinforcer

maintaining undesirable behavior (e.g., functional communication training; Tiger, Hanley, & Bruzek, 2008). However,

in our review, we identified only one study that arranged escape as a reinforcer for appropriate behavior when a

functional analysis suggested IMB was escape‐maintained. LaRue et al. (2011) targeted IMB by comparing the effec-

tiveness of (a) escape as a reinforcer for mouth clean (i.e., DNRA), (b) escape extinction for IMB, and (c) escape as a

reinforcer for mouth clean plus escape extinction for IMB in five children with feeding disorders. LaRue et al. found

242 SAINI ET AL.

that escape as a reinforcer alone was not effective at reducing IMB, and only when the therapists arranged extinction

were reductions in IMB observed (independent of whether function‐based DNRA was arranged). This result may

explain why most cases reviewed relied on extinction as opposed to function‐based DNRA or function‐based DNRA

plus extinction. This method represents a stark departure from how functional analyses typically inform treatments

for other types of severe behavior disorders in which DRA or DNRA are a necessary component to obtain clinically

significant reductions in undesirable behavior (Shukla & Albin, 1996).

For a large proportion of cases reviewed, researchers differentially reinforced bite acceptance or consumption

with feeder‐arranged attention and ignored IMB similar to procedurally arranged attention extinction (independent

of whether attention was a reinforcer for IMB). These components were present even when the functional analysis

only indicated an escape function, suggesting that contingent praise for appropriate behavior (e.g., acceptance and

consumption) and ignoring IMB may be inherent parts of many feeding treatments and not necessarily informed

by a functional analysis. The use of attention in this manner may likely be to increase the social and ecological validity

of the treatment rather than to reduce IMB; however, this should be resolved in future research.

Overall, the studies tended to use the same treatment components regardless of if a functional analysis was con-

ducted. This indicates that a functional analysis did not improve treatment efficiency or reduce procedural complex-

ity. Furthermore, this homogeneity among treatment procedures likely contributed towards indifference in the mean

effect sizes across treatments. However, we did observe slightly greater variability in effect sizes for those treat-

ments not based on a functional analysis. For example, in our application of PND, MBLR, and PEM, a greater range

of effect sizes was obtained and many more individual cases where the lowest effect sizes were associated with

treatments not based on a functional analysis. This could suggest that treatments not based on a functional analysis

may be more variable in overall effectiveness. However, this conclusion requires cautious interpretation because the

increase in variability could also be due to the greater number of participants not experiencing a functional analysis.

Hanley (2012) suggested that baseline levels of certain operants, such as IMB, could be established merely by pre-

senting the precipitating event (e.g., food or drink presentation). In these cases, Hanley suggested that a functional

analysis might not be necessary given that an ecologically and socially valid baseline could be established in its

absence. However, Hanley stressed that deferring a functional analysis did not mean an understanding of the main-

taining reinforcers for these types of operants was not necessary. Instead, only that a relevant baseline for evaluating

the effects of a treatment could be established by introducing the environmental stimuli germane to the treatment

process. In fact, previous studies have shown that the greatest reductions in multiply controlled IMB are observed

only when all functions are addressed through extinction (e.g., Bachmeyer et al., 2009), and these functions might

not be identified unless a functional analysis is conducted.

The results of this review are consistent with the many single‐case design demonstrations of using behavioral

treatments to reduce or eliminate IMB. However, our review is limited by the group comparisons made across treat-

ment types (i.e., those based and not based on a functional analysis) and the relatively small sample size of treatments

informed by a functional analysis. We also only included studies from the published literature, and therefore it is pos-

sible that the studies represent a sample of efficacious treatments with greater probability, as nonsignificant out-

comes might be unlikely to be published (Sham & Smith, 2014). Future researchers might consider conducting a

large‐scale consecutive‐controlled case series, which includes data from all participants who receive a given treat-

ment independent of the outcome.

As a whole, the functional analysis and treatment literature suggests that many forms of IMB are maintained by

sources of negative reinforcement, whether alone or in combination with other operant functions (e.g., social positive

reinforcement). The literature further suggests that in many cases, efficacious treatment that demonstrate reductions

in IMB have been developed in the absence of a functional analysis. Although our results complement the existing

literature on food refusal behavior, we caution researchers against extending this interpretation to other commonly

studied behavioral concerns that occur in children with feeding disorders (e.g., expulsions and packing) because the

application of functional analysis in pediatric feeding disorders has been restricted to only a small range of topogra-

phies (i.e., IMB). Those variables that control the maintenance of IMB may be functionally unrelated to other

SAINI ET AL. 243

behavioral challenges that occur during feeding (e.g., Girolami, Boscoe, & Roscoe, 2007). Therefore, functional anal-

ysis methodology may find more applicability in the functional evaluation of other difficulties during feeding such as

skill deficits or problematic food textures (e.g., Patel, Piazza, Layer, Coleman, & Swartzwelder, 2005; Patel, Piazza,

Santana, & Volkert, 2002; Sharp & Jaquess, 2009). In addition, functional analyses may prove useful in distinguishing

certain foods that are approached and consumed from those that are avoided and evoke problem behavior for chil-

dren who exhibit severe food selectivity. In which case, the functional analysis may be necessary to appropriately

implement DRA and extinction procedures. For example, a synthesis of reinforcement (i.e., escape from nonpreferred

foods and access to preferred foods) can be provided contingent on appropriate communication and the reinforce-

ment progressively thinned by increasing the response requirement of bites of the nonpreferred food items.

The advent of the functional analysis was a watershed movement that redefined behavioral treatment of severe

problem behavior to be focused on understanding the complex environmental contributors before developing a

function‐based treatment. However, our findings suggest that extending the application of functional analyses to

some therapeutic contexts, such as the treatment of IMB, may not be necessary when functional differences are lim-

ited and treatment procedures are unlikely to vary. In other words, escape extinction for food refusal and differential

reinforcement for food acceptance or consumption are essential procedural components of almost any treatment for

IMB without the need for an empirical demonstration of IMB's sensitivity to escape or attention as reinforcers during

a functional analysis. Our review in combination with others suggests that the procedures employed in many feeding

treatments designed to decrease IMB are highly efficacious and that these practices should continue to be improved

upon in future research.

ORCID

Valdeep Saini https://orcid.org/0000-0002-4616-6677

Joshua Jessel https://orcid.org/0000-0002-1649-2834

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SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at the end of the

article.

How to cite this article: Saini V, Jessel J, Iannaccone JA, Agnew C. Efficacy of functional analysis for

informing behavioral treatment of inappropriate mealtime behavior: A systematic review and meta‐analysis.

Behavioral Interventions. 2019;34:231–247. https://doi.org/10.1002/bin.1664