Behavior Analysis in Practice (2022) 15:796–803

https://doi.org/10.1007/s40617-021-00650-z

RESEARCH ARTICLE

Treatment of Food Selectivity in an Adult With Autism Spectrum

Disorder
Whitney Pubylski-Yanofchick 1,2 & Christeen Zaki-Scarpa 1,2 & Robert H. LaRue 1,2 &
Christopher Manente 1,2 & SungWoo Kahng 1,2

Accepted: 24 August 2021 / Published online: 30 September 2021

# Association for Behavior Analysis International 2021

Abstract
Food selectivity is common among individuals with autism spectrum disorder (ASD). Left untreated, food selectivity may
continue into adulthood, leading to social and nutritional deficits. Although effective treatments have been identified for young
children and the school-aged population, these treatments may not be feasible with adults. As such, effective treatments for adults
with ASD need to be identified. In this study, the participant was a 26-year-old male with ASD and a history of food selectivity.
We compared two treatments that used differential reinforcement of alternative behaviors—one using positive reinforcement and
the other negative reinforcement—to increase acceptance of novel fruits and vegetables. Both treatments resulted in increases in
the acceptance of grapes and red bell peppers. When given the choice, the participant preferred the positive reinforcement
contingency. Additionally, his food acceptance occurred in the presence of novel foods (e.g., carrots and lettuce) and settings.
This study represents one of the only studies examining the treatment of food selectivity in adults with ASD.

Keywords Adult . Autism spectrum disorder . Food selectivity . Feeding disorders

Feeding disorders are common comorbid conditions associat- of children sampled (Leader et al., 2020; Thullen & Bonsall,
ed with autism spectrum disorder (ASD; Hyman et al., 2020). 2017). Although food selectivity is not exclusive to ASD or
Ledford and Gast (2006) estimated that up to 89% of individ- related disabilities, individuals with ASD tend to have a great-
uals with ASD experience symptoms of at least one type of er likelihood of being food selective (Bandini et al., 2010;
feeding challenge. One of the most common feeding disorders Beighley et al., 2013; Nadon et al., 2011; Sharp et al., 2013).
is food selectivity, which involves a limited food repertoire Most of the research on treating food selectivity exhibited
and a high-frequency single-food intake (Bandini et al., 2010; by individuals with ASD has focused on early childhood and
Mari-Bauset et al., 2014). Food selectivity can lead to greater school-aged children (Kuschner et al., 2015), yet adults with
risks of nutritional deficiencies in vitamin D, fiber, vitamin E, ASD often continue to exhibit food selectivity. Kuschner et al.
calcium, and protein (Bandini et al., 2010; Sharp et al., 2013, (2015) surveyed adolescents and young adults with and with-
2018; Zimmer et al., 2012). Food selectivity among individ- out ASD. Participants involved in the study were 65 individuals
uals with ASD has been estimated to occur in as high as 85% diagnosed with ASD ranging from 12 to 28 years of age and 59
neurotypical adolescents ranging from 12 to 23 years of age.
Author Note The participants with ASD were more likely to self-report food
We would like to thank the Rutgers Center for Adult Autism Services and selectivity than the comparison group. These data suggest that
all those involved for their participation.
food selectivity is not a problem unique to children with ASD.
Left untreated, food selectivity may persist through adult-
* SungWoo Kahng
[email protected] hood (Fodstad & Matson, 2008). Bandini et al. (2017) exam-
ined the progression of food selectivity in 18 children with
1
Rutgers Center for Adult Autism Services, Rutgers University, New ASD. They found that 65% of those meeting the criteria for
Brunswick, USA high food selectivity during baseline (as defined as the number
2
Department of Applied Psychology, Rutgers University, of foods eaten or food repertoire) had further restricted their
Piscataway 604 Allison Rd., New Jersey 08854, USA repertoire by an average of 1.5 foods over an average of 6.4
years. Although they found that some feeding problems, such
Behav Analysis Practice (2022) 15:796–803 797

as food refusal, had improved at follow-up, individuals with university-based center and home, and he navigated the uni-
high food selectivity at baseline showed no improvement. versity on the campus buses. He had a highly developed rep-
Instead, they had further limited their food repertoires. ertoire of expressive and receptive language skills and was
Tanoue et al. (2016) conducted a longitudinal study of able to speak in full sentences. He followed oral and written
changes in food selectivity with 28 participants with ASD directions, was able to converse with his peers, engaged in
ranging from 3 to 18 years of age. They estimated the food amateur competitive sports, and read when given a book or
repertoire of their participants based on parental interviews at newspaper.
the ages of 3, 6, 12, and 18 years. The number of foods Jason was employed in an on-campus dining hall 5 days a
consumed decreased or remained stable with approximately week and was supported by a behavioral technician until he
two thirds of their participants. Bandini et al. (2017) and mastered all his job responsibilities, at which point he worked
Tanoue et al. suggested that food selectivity may likely independently. His job responsibilities included cleaning ta-
persist, if not become more pervasive in some individuals, bles and entrance doors, wiping down food stations, and serv-
into adulthood. These data suggest that food selectivity ing food. Outside of his work hours, Jason engaged in various
among individuals with ASD is unlikely to resolve without community-based leisure activities with his behavioral techni-
treatment and therefore likely to continue into adulthood. cian, such as playing table tennis, pool, and air hockey, as well
Thus, food selectivity among adults with ASD should be a as shooting basketball hoops.
greater focus of feeding disorders research. According to family and self-reports, Jason had a long his-
Recent data from the Centers for Disease Control and tory of food selectivity, specifically a limited food repertoire.
Prevention estimate the population of adults with ASD in They reported that Jason had a history of rejecting novel or
the United States to be more than 5.4 million (Dietz et al., different foods. Jason’s daily diet consisted of a select few
2020). Although robust research on the effective treatment items such as hamburgers, chicken nuggets, and peanut butter
of food selectivity exists for young children and the school- and jelly sandwiches since age 2. Staff reported that he only
aged population (Sharp et al., 2010; Volkert & Vaz, 2010), consumed peanut butter and jelly sandwiches or peanut butter
there is a dearth of research supporting effective treatments for crackers for lunch at work. Jason had no history of prior treat-
the adult population with ASD (Chawner et al., 2019). ment for food selectivity by health care providers. His parents
Research with adults is particularly important because as in- and the clinical staff supporting Jason expressed concerns
dividuals age, treatments that have been found to be effective about his food selectivity. He had taken a daily multivitamin
for young children, such as those that include extinction pro- since he was 2 years of age, and his parents reported he had no
cedures, may become untenable. Additionally, adults with history of gastrointestinal symptoms such as constipation, di-
ASD will likely have a longer reinforcement history of refus- arrhea, or upset stomach. Additionally, Jason had no history of
ing a variety of foods, thus likely increasing the resistance to difficulty chewing or swallowing foods and maintained ade-
treatment (St. Peter Pipkin & Vollmer, 2009). quate chewing and swallowing throughout the study. Jason’s
Given the number of adults with ASD in the United States BMI was 29.6.
and the likelihood that the behavior may worsen over time, it All sessions were conducted by staff at the university-
is imperative that effective treatments for food selectivity ex- based employment support center except the last two sessions,
hibited by adults with ASD be treated to ameliorate the dele- which were conducted at the campus dining hall. The room
terious effects of prolonged food selectivity. Therefore, the was equipped with a small table and chair. Additionally, staff
purpose of this study was to evaluate behavioral treatments members had clipboards with data sheets.
to increase the acceptance of novel foods with a focus on fruits
and vegetables in an adult with ASD. We compared two dif- Response Measurement and Interobserver
ferential reinforcement of alternative (DRA) procedures to Agreement
create treatment options.
Frequency data for all foods except the side salad were col-
lected on food acceptance during each session using a pen and
Method paper. Acceptance of the side salad was scored as a dichoto-
mous response (yes = 1 or no = 0). Acceptance of all foods
Participant and Setting except the side salad was defined as Jason independently de-
positing the target food in his mouth. Acceptance of the side
The participant, Jason, was a 26-year-old male diagnosed with salad was scored when the bowl was empty of all lettuce, bell
ASD. He attended a university-based employment support peppers, and carrots. If some or all of the side salad remained
center. Jason lived at home with his family and commuted in Jason’s bowl, it was not considered acceptance.
to the center Monday through Friday. He was able to indepen- Checks for a clean mouth were not used as Jason was an
dently travel by public transportation (bus) to and from the adult. However, he likely consumed all accepted foods
798 Behav Analysis Practice (2022) 15:796–803

because he never spit out food, nor did he appear to pack food, number of tasks to complete or amount of time to complete
and his speech was clear following sessions. Jason accepted each task. Each of the 10 cards was placed on the table in a line
the grapes whole and took small bites of each piece of the with approximately 5 cm between them. Jason was asked to
other target foods. All target foods were presented on a plate, read the cards and let us know which one he wanted to do the
except the side salad, which was presented to Jason in a bowl. most. Once a selection was made, he was asked to engage in
The same bowl was used across settings. the task that was written on the selected card. Once he com-
A second observer collected data during 33% of sessions. pleted the task, he was asked to make another selection until
Each session consisted of one meal. Interobserver agreement all 10 selections were chosen. The MSWO for negative rein-
was calculated by dividing the smaller amount of food accept- forcers was conducted three times.
ed by the larger amount of food accepted and multiplying the Jason demonstrated selection bias (i.e., selecting items on
result by 100. Interobserver agreement was 94% (range 86%– the left side) during the MSWO for positive reinforcers, which
100%). necessitated the use of a modified paired-choice preference
assessment (Fisher et al., 1992) in which items were presented
Experimental Design on the same plate with one item at the bottom of the plate. In
total, 10 items were presented during the preference assess-
A combined alternating-treatments and changing-criterion de- ment for potential positive reinforcers: 8 edibles and 2 activ-
sign was used to compare the efficacy of the two treatments ities. Initial preference assessments showed that croissants
and demonstrate experimental control. were his most preferred edible item (positive reinforcer) and
washing dishes was his least preferred activity (negative
Procedure reinforcer).
Following the preference assessments, we compared two
Prior to treatment, probes were conducted to determine wheth- treatments, positive reinforcement and negative reinforcement
er Jason would accept novel fruits such as apples and grapes. contingencies, to ensure Jason and his parents had treatment
Five probes were conducted, once per day, just before lunch. options. At the beginning of each week, a morning and after-
He refused to accept the food during 100% of probes. noon schedule of sessions that staff were to conduct was
Jason’s parents provided us with a list of foods that Jason posted. The first session of the day was selected based on a
did not eat but were commonly eaten by other members of the coin toss. The second session of the day was counterbalanced
family and would be readily available at home. The foods with the morning session. Morning sessions were conducted
initially targeted for intervention were grapes, baby carrots, approximately 3 hr after Jason had accepted a small breakfast.
and red bell peppers. The terminal goal was approximately Afternoon sessions were conducted approximately 4 hr after
237 mL of grapes and baby carrots, as well as one whole red lunch. Novel probes for the side salad (at the dining hall only)
bell pepper. The serving sizes of each target food were based were presented at his regular lunchtime just before he ate
on U.S. Department of Agriculture guidelines (SNAP lunch.
Education Connection, n.d.). The red bell peppers were cut
into 12 slices, approximately 0.6 cm by 10 cm each. Grapes Baseline
and baby carrots were presented whole. Although Jason’s par-
ents reported that he had never eaten baby carrots, he accepted During baseline, the experimenter asked Jason to take a seat at
up to 11 whole baby carrots during baseline. Therefore, we did the table and sat next to him. The experimenter placed slightly
not implement treatment for baby carrots. more than the terminal amount of food in front of him. The
experimenter provided Jason with the following instruction:
Preference Assessment “You can eat as many [target food] as you want; you don’t
have to eat any at all.” If Jason engaged in vocal or gestural
Prior to evaluating treatments, we conducted multiple- refusal (e.g., a statement such as “never had it, never will” or a
stimulus without-replacement (MSWO) preference assess- flat palm with fingers pointed up at chest level), the food was
ments (DeLeon & Iwata, 1996) to identify likely positive removed and the session was terminated. Alternatively, the
and negative reinforcers. All stimuli selected for the positive session was terminated after he accepted all of the food or
reinforcer preference assessment were identified through par- after 5 min passed. No beverages were present during the
ticipant interview. Activities selected to include as potential session. Jason was given the option of using a fork for the
negative reinforcers were those that were commonly available side salad only, as the other target foods were finger foods.
in the center, such as washing dishes, vacuuming, and The experimenters did not prompt Jason to eat any of the
cleaning the table. target foods at any time throughout the study, and conversa-
Potential negative reinforcers were identified by writing 10 tion during sessions was minimal, as Jason was typically
different tasks on individual index cards specifying the eating.
Behav Analysis Practice (2022) 15:796–803 799

Treatment with ‘Wash 3 dishes’ written on it] today?” Once he selected

the contingency, we started the respective treatment session.
Treatment was similar to baseline except that we compared The criterion was increased by two food pieces after three
two variations of DRA procedures: positive reinforcement and consecutive sessions in which the prespecified goal was met.
negative reinforcement. Treatment sessions alternated The terminal goal was approximately 237 mL of grapes or one
semirandomly between positive and negative reinforcement whole red bell pepper.
contingencies each day—one in the morning and one in the
afternoon. Novel Food and Setting
During the positive DRA reinforcement contingency con-
dition (DRA+), the experimenter sat next to Jason and placed Once Jason met the criteria for accepting grapes and red bell
slightly more than the terminal amount of food on a plate or in peppers, the experimenters probed a novel food: side salad.
a bowl directly in front of him. We presented more than the The side salad initially consisted of a bowl of romaine lettuce
terminal amount of food in the event that Jason accepted a (the novel food), four red bell pepper slices, and four baby
greater amount of food than the prespecified criterion. Half carrots. One session was conducted in the morning and one in
of a croissant was placed approximately 15 cm away from the the afternoon. Jason was asked to sit at the table, and the side
target food. The experimenter provided the following instruc- salad was placed in front of him. He was offered dressing, but
tion: “You can eat as many [target food] as you want, or you he declined. A fork was made available, although he did not
don’t have to eat any at all, but you need to eat [quantity] to get always use it. Side salad probes were conducted under both
the croissant.” The session ended if Jason (a) accepted the DRA+ and DRA− conditions, and he had to accept the entire
target amount of food and declared either vocally or gesturally bowl of side salad to receive reinforcement. Jason was given
that he was done, (b) engaged in vocal or physical refusal, or the instruction “You can eat as much as you want, or you don’t
(c) let 5 min pass without having accepted the specified have to eat any, but you need to eat the entire salad to [get the
amount of food. We did not immediately terminate the session ice cream sandwich / not wash six dishes].” Once two sessions
when he accepted the prespecified amount of the target food to of each reinforcement contingency were conducted at the em-
allow him the opportunity to exceed the criterion. If he accept- ployment support center, experimenters probed the side salad
ed the prespecified amount of the target food and indicated he in a new environment (dining hall, his place of employment)
was finished, the experimenter provided him immediate ac- with novel foods (spring salad mix and shredded carrots).
cess to the croissant and brief praise (e.g., “Great job!”). If Probes at the dining hall were conducted once per day, imme-
Jason did not meet the reinforcement criterion, no feedback diately before Jason’s regular lunchtime. Jason was asked to
was provided and the croissant was removed. make his own salad from the salad bar.
The negative DRA reinforcement contingency condition
(DRA−) was similar to the DRA+ condition, except that we
provided negative reinforcement contingent on consuming the Results
prespecified amount of the target food. The experimenter
placed slightly more than the terminal amount of food on a Figure 1 shows the number of grapes accepted during the
plate or in a bowl and an index card with “Wash 3 dishes” DRA+ condition (top panel) and DRA− condition (bottom
written on it in front of Jason. No other food was present. The panel). Acceptance remained low during baseline, with
experimenter told Jason, “You can eat as many [target food] Jason accepting between zero and two grapes per session.
as you want, or you don’t have to eat any at all, but you have Once treatments were implemented, Jason accepted more
to eat [quantity] or wash three dishes.” If Jason accepted the grapes during each treatment condition, eventually reaching
prespecified amount of food and declared vocally or ges- the terminal goal of 12 grapes (approximately 237 mL). There
turally that he was done, he did not have to wash the dishes. were two sessions during the DRA− condition in which Jason
If Jason engaged in verbal or physical refusal or let 5 min exceeded the predetermined goal (Sessions 8 and 16). During
pass without having accepted the prespecified amount of these sessions, the experimenter neglected to state the correct
food, he was prompted to wash dishes (“Please go into the instructions (i.e., did not state the predetermined goal).
kitchen and wash the dishes.”). He always complied with Additionally, experimenters erroneously increased the criterion
this request. (i.e., too few sessions or too many sessions) during several
We conducted a final phase in which we provided a con- phases in both the DRA+ and DRA− conditions. Despite these
current choice between DRA+ and DRA−. The croissant treatment integrity errors, his behavior increased with each cri-
(DRA+) and index card (DRA−) were placed directly in front terion shift and remained stable at each level until the criterion
of Jason on the table. Jason was asked, “Do you want to work changed in both the DRA+ (top panel) and DRA− (bottom
for this [experimenter pointed to the half croissant on a plate panel) conditions. During the concurrent-choice phase, Jason
on the table] or this [experimenter pointed to the index card consistently chose the DRA+ reinforcement contingency.
800 Behav Analysis Practice (2022) 15:796–803

Fig. 1. Acceptance of Grapes. Baseline DRA+ Choice

Note. The top panel shows the 12
positive differential reinforcement
of alternative behavior (DRA+)
condition, and the bottom panel
10 1-month
follow up
shows the negative (DRA−)
condition. The baseline, choice, 8
and follow-up data are the same
across panels. The horizontal
dashed lines are the criterion for 6

No. of Grapes Accepted

that phase. Please note that this is
a combined changing-criterion 4
and alternating-treatments single-
case design. For the sake of clari-
ty, we separated the two treat- 2
ments across panels
0
1 6 11 16 21 26 31 36 41 46
Baseline DRA- Choice
12

10 1-month
follow up

0
1 6 11 16 21 26 31 36 41 46

Sessions

Finally, the results transferred across various settings, including Changes in the reinforcers resulted in an increase in the
home and work. He continued to accept grapes at the 1-month acceptance of red bell peppers when the DRA+ and DRA−
follow-up, and his caregivers reported that he had continued conditions were reintroduced. Jason reached the terminal
eating grapes at home. goal of 12 red bell pepper slices (one whole red bell pepper)
Figure 2 shows the total number of red bell pepper slices in both conditions. Experimenters erroneously increased
accepted during the DRA+ (top panel) and DRA− (bottom the criterion (i.e., too few sessions or too many sessions)
panel) conditions. Acceptance remained variable during base- during several phases in both the DRA+ and DRA− condi-
line. Acceptance of red bell peppers decreased from baseline tions. Despite these treatment integrity errors, his accep-
during the initial implementation of the DRA+ and DRA− tance increased with each criterion shift and remained sta-
conditions. Therefore, we interviewed Jason again and ble at each level until the criterion changed in both the
reassessed his preferences for both positive and negative rein- DRA+ (top panel) and DRA− (bottom panel) conditions.
forcers using identical procedures to the initial preference as- During the DRA− condition, when we increased the crite-
sessments. We identified a small ice cream sandwich, similar rion to six red bell pepper slices, food acceptance decreased
in caloric value to the previous edible reinforcer, as the new to zero. It was not until Jason advanced to eight slices of red
positive reinforcer. While assessing for negative reinforcers, bell pepper in the DRA+ condition that he accepted them
we doubled the magnitude of each task (10 push-ups instead again during the DRA− condition. This suggests that the
of 5, etc.) and identified that washing dishes remained Jason’s DRA+ condition may have been slightly more effective
least preferred activity following an increase from three to six than the DRA− condition. During the concurrent-choice
dishes. phase, Jason consistently chose the DRA+ condition.
Behav Analysis Practice (2022) 15:796–803 801

Fig. 2. Acceptance of Red Bell BL DRA+ Choice

Peppers and Salad. Note. The top 12 1
panel shows the positive
differential reinforcement of
10 Salad
alternative behavior (DRA+)
condition, and the bottom panel Salad
+
shows the negative (DRA−) 8 Dining
condition. Red bell pepper Hall
acceptance is shown in the left y-
6

No. Red Bell Pepper Slices Accepted

axis, and salad acceptance is
shown in the right y-axis. The Modified
baseline, choice, and follow-up 4 reinforcer
data are the same across panels.
The horizontal dashed lines are

Salad Accepted
the criterion for that phase. Please
2
note that this is a combined
changing-criterion and 0 0
alternating-treatments single-case 1 6 11 16 21 26 31 36 41 46 51 56 61
design. For the sake of clarity, we
separated the two treatments BL DRA- Choice
across panels. BL = baseline 12 1

Salad
10
Salad
+
8 Dining
Hall

6
Increased
4 magnitude

0 0
1 6 11 16 21 26 31 36 41 46 51 56 61
Sessions

Results transferred across various settings, including his little difference across treatment conditions in terms of the
home and work environments. number of sessions necessary to reach the terminal goals.
Jason successfully accepted a novel food (side salad) dur- However, when presented with a choice between treatments,
ing the DRA+ and DRA− reinforcement conditions at the Jason exclusively selected DRA+.
employment support center. He also accepted a side salad with Previous research on the treatment of food selectivity has
additional novel foods (spring salad mix and shredded carrots) generally focused on children with ASD. Our results extend
at the dining hall. previous food selectivity research by demonstrating that it is
possible to treat food selectivity exhibited by an adult with
ASD who has a long history of eating a limited diet. The
Discussion effects of treatment also transferred to an untrained food (side
salad) and a novel setting (dining hall). Treatments were im-
These results showed that two variations of DRA with posi- plemented by a dozen behavioral technicians across sessions,
tive and negative reinforcement contingencies were effective which may have helped to promote the transfer of stimulus
in increasing food acceptance in an adult with ASD who had a control across foods and settings.
long history of food selectivity. Prior to the intervention, the We intervened on Jason’s food selectivity because of parental
participant had a limited food repertoire. Treatment resulted in and staff concerns. Additionally, we relied on parental inter-
the acceptance of healthier foods: grapes and red bell peppers. views to identify the target foods. When implementing a feeding
Treatment effects maintained for grape acceptance for at least program, one should ensure all precautions are taken to address
1 month. Additionally, treatment effects transferred to novel any medical issues such as food allergies. Clinicians should
foods such as carrots and lettuce across settings. There was strongly consider consulting a dietician prior to and throughout
802 Behav Analysis Practice (2022) 15:796–803

the treatment of individuals for guidance on appropriate target conditions may have been obscured because of carryover ef-
foods that may directly address possible nutritional deficits pre- fects. Therefore, future studies should consider using different
sented by an individual’s limited food repertoire, as well as foods across treatment comparisons.
appropriate serving sizes to target. Clinicians should maintain A final limitation of this study was that there was only one
a safe, controlled environment for treatment when introducing participant. Given the paucity of research on the treatment of
novel foods when evaluating food selectivity. food selectivity exhibited by adults with ASD, additional re-
Curtin et al. (2015) found that parents of individuals with search with adults will be important to identify a range of
ASD experienced higher levels of spousal stress during meal- effective treatments.
time than parents of typically developing individuals. Prior to The ability to consume a variety of foods has several ben-
the study, Jason’s caregivers expressed concern for his well- efits, such as improving and maintaining overall health and
being, social impact, and quality of life due to his limited food nutrition. Malnourishment can precipitate a multitude of med-
repertoire. Since the implementation of the current study, his ical conditions, as well as increase stress and fatigue. Another
caregivers reported that he continued to accept novel foods benefit of increasing the acceptance of novel foods to include
into his repertoire and that while attending a social function fruits and vegetables is that it may facilitate socialization at
for work, Jason accepted novel food items with his peers. novel restaurants, social gatherings, and work functions. The
Future research should include additional measures of well- ability to consume novel foods may help decrease stress in
being for participants and their caregivers. social situations where eating a wide variety of foods is typi-
We used a changing-criterion design to gradually increase cally expected and sometimes required. Food selectivity is a
food acceptance of novel foods. This meant that many ses- disruptive and potentially dangerous behavior that should not
sions were required to reach the terminal criteria. It may be the be overlooked, particularly in adults with ASD.
case that we did not need all the steps. Therefore, future re-
search should incorporate terminal-criterion probes to deter-
mine whether all the criterion changes are necessary.
Additionally, future studies may want to include maintenance Implications for Practice
data and a social validity measurement for stronger results.
Although the staff rotation may have also been beneficial & It is important to recognize that food selectivity is a prob-
for transferring the treatment effects, it may have been a lim- lem for adults with ASD.
itation to treatment integrity. Treatment integrity errors were & Differential reinforcement can be an effective treatment
made when increasing the criterion, at times drifting away for food selectivity exhibited by individuals with a long
from the proper steps of the protocol as it was written. There history of restricted food-related repertoires.
were multiple phases in which too few or too many sessions & Treatment effects may generalize to novel foods in novel
relative to the changing criterion were conducted. This fre- settings.
quent staff rotation may have made it challenging to convey & Providing participants with concurrent treatment options
the necessary criterion to all staff members. Despite these is feasible and practical.
treatment integrity failures, the treatment continued to be ef-
fective, which may suggest an increase in the preference for or
a decrease in the aversiveness of the foods. Availability of data and material Available upon request.
There were two sessions during the DRA− condition with
grapes in which the experimenter issued incorrect
instructions—the experimenter failed to state the Declarations
predetermined number of grapes to consume. During these
Conflict of interest We have no known conflicts of interest to disclose.
two sessions, Jason far exceeded the goal for that phase.
These data suggest that instructional control may have played Ethical approval This study was approved by the university institutional
a role in the increase in food acceptance. However, the rein- review board.
forcement contingency was still important because staff and
parents had repeatedly instructed Jason to consume new foods Informed consent The participant consented to participation.
in the past with no success. Future research should evaluate the
influence of instructional control on responding.
Another limitation was that we used the same foods across
the treatment comparison (DRA+ vs. DRA−). We did this to
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