416 GLORIA R. LEON

SUMMARY A case report is presented illustrating a method of mother-child interaction

that can be used to observe in a clinical setting the kinds of child problem behaviors parents complain about in the home situation. The Observed Interaction is de- scribed, and a comparison is made between parental complaints, the results of the interaction, and responses to projective materiaI. The advantages of using the interaction technique in terms of economy in time, as well as objectivity and reliability of scoring are discussed.

REFERENCES 1. BEE, H. L. Parent-child interaction and distractibility in 9-year-old children. Sferrill-Paln~er Quart., 1967, 15, 175-190.

2. BIJOU, S. W. Experimental studies in child behavior: normal and deviant. In Krasner, L. and Ullman, L. P. (Eds.) Research in Behavior Modification. New York: Holt, Rinehart, & Winston, 1965.

WAHLER, R. C., WINGEL, G. H., PETXHSON, It. F. and W MORRIS ON, D. C. Mothers as behavior therapists for their own children. Behau. Res. Ther., 1965,3, 113-134.

ZEILBERGER, J., SAMPEN, S. E. and SLOANE, H. N. Modification of a child’s problem behaviors in the home with the mother as therapist. J . appl . Behau. -4naZ., 1968, 1, 47-53.

3.

4.

CONDITIONING OF CONSUAIMATORY RESPOSSES YOUNG CHILDREN

LOGAN WRIGHT

University of Oklahoma Medical Center

PROBLEM

IK

A child’s refusal to emit appropriate consummatory responses (of fluids, solid foods or oral medication) can constitute an important medical-psychological prob- lem. Such problems are extremely prevalent, and almost no family has been without the experience of having a child who refuses to accept oral medication, drink his milk, or eat his spinach. However, these problems can also be crucial or even lethal under certain circumstances. For instance, when prolonged and continuing medi- cation is necessary, the oral route is always preferable and sometimes essential. Although nasogastric tubes can be inserted to permit forced delivery of medica- tions into the stomach of a patient who refuses t o injest it, rebellious patients are often times capable of regurgitating such medication after it has been gavaged. There are reported instances c2) where patients have either refused or regurgitated medication which was necessary for them to sustain life. Other examples of situ- ations in which the consummatory response is crucial involve growth failure, mal- nutrition and possible mental deficiency in children who refuse solid foods; and the imminent danger to life of the occasional patient who refuses fluids,

I n spite of the fact that problems involving consummatory responses are both prevalent and crucial, very little information regarding the conditioning of such responses has appeared in behavioral or medical literature. The two exceptions to this general rule are a report“) on the treatment of adolescent anorexia nervosa by means of desensitization, and the conditioning of young children t o accept oral medication by Wright, Woodcock and Scott c 2 ) . The purpose of this investigation was to study the applicability of conditioning techniques to consummatory responses which differed from those treated in the tiyo studies cited above. Halston’s(’) study involved (a) the use of desensitization as a technique, (b) with an adolescent patient, (c) who was suffering from a very unusual type of psychological disturb-

CONDITIONING OF CONSUMMATORY RESPONSES IN YOUNG CHILDkEN 417

ance: anorexia nervosa. This study differs from Halston’s in that it (a) relies more on traditional operant techniques, (b) utilizes preschool aged children, (c) whose psychopathology seems more narrowly circumscribed. The earlier study by Wright, Woodcock and Scott ( 2 ) also employed operant techniques with preschool aged Ss whose psychological difficulties appeared rather circumscribed (refusal to accept pills). However, this investigation differs from that study in that the consummatory responses treated here involve a total refusal to accept either fluids or solid foods (rather than pills). Also, the Wright, Woodcock and Scott study, while in many ways similar to the present investigation, has never been reported in the psycho- logical literature.

~IETHODOLOGY AND RESULTS The Ss for this study were three white females between two and six years of

age. Sl was a three year, nine-month-old mongoloid child who suffered from diabetes, but who refused to accept fluids orally. This patient had a two year history of totally rejecting fluids in spite of the fact that a variety of liquids had been offered from every conceivable form of container. A nasogastric tube which provided for forced delivery of fluids directly into the stomach had remained continually in- serted for approximately nine months. Cardboard sleeves which prevented S1 from bending her elbows and thus being able to remove the nasogastric tube were also employed. Just prior to conditioning, SI had gained increased ability to re- move the nasogastric tube when her sleeves were off for changes of clothing, etc. Also, there was a growing concern over the possibility that the nasogastric tube and cardboard sleeve arrangement were having an adverse effect on Slls develop- ment, while her diabetic problem made proper fluid intake a progressively more crucial matter.

The total conditioning experience lasted 14 days. An attempt was made for the first two days to employ solid foods as reinforcement for accepting fluids. E (the author) would either sneak or force a teaspoon of fluid into Slfs mouth a t mealtime, and then provide a small bite of solid food. However, foods did not appear to constitute a potent reinforcement for this patient. Social reinforcement mas attempted next. SI was placed in a private room which afforded her no social contacts except when being fed, having diapers changed, etc. For the next two days, E attempted on 10 separate occasions to induce Sl to accept fluid from a teaspoon. E mould enter the room, and when Sl reached out for him, a teaspoon of fluid was placed betiyeen S1 and E. If SI accepted the teaspoon of fluid, she was hugged and told “that’s good.” If SI rejected the teaspoon of fluid, E would retreat from the room for 60 seconds before making another attempt. Whenever Sl accepted a teaspoon of fluid and obtained social reinforcement, E would then place S1 back in her bed and offer another teaspoon of fluid. If this was accepted, she received additional social reinforcement. If i t was rejected, E would then retreat from the room. Ten consecutive rejections of fluid was employed as a criterion for dis- continuing a session. The social reinforcement was successful only in inducing S1 to accept approximately three to five teaspoons of water on five occasions daily. Consequently, i t was necessary to administer additional fluids through a naso- gastric tube. After the ten sessions (two days) in which attempts were made to condition S1 to accept fluids by means of social reinforcement, i t was decided that toys would be added to social contact in an attempt to increase the potency of reinforcement. S,’s isolation was then intensified by having all play objects removed from her room. Conditioning now consisted of E entering Slls room and offering her a toy as well as social reinforcement on the contingency that she accept a teaspoon of fluid. During the first session carried out according to the above procedure, S1 rejected a plastic loop toy offered by E , but instead reached into the pocket of his white coat and retrieved a black felt-tipped fountain pen. She then pulled the pen apart, and joyfully threw both halves on the floor. With this, E bent down, picked up both halves, and offered them to Sl simultaneously. How-

418 LOGAN WRIGHT

ever, she seemed hesitant to accept them. E then placed the two parts of the pen together and offered it to S1, which she accepted joyfully, pulled apart and again threw on the floor. At this point, it was apparent that the most potent available reinforcer was a combination of social reinforcement and cognitive stimulation provided by E and a fountain pen which could be detached and thrown onto the floor. B began offering S1 a teaspoon of fluid in exchange for the fountain pen which she could pull apart and throw on the floor. It was also decided that a shaping program would be employed which required S1 to eventually accept fluids from a tablespoon, then a training cup, and finally to drink from a regular cup.

On the fifth day of conditioning, when the fountain pen toy and social contact were first combined as reinforcement, S1 consumed all of the fluids that were otrered her. After ten sessions (two days) in which XI accepted most of the fluids offered her by means of a teaspoon, a tablespoon was employed in an attempt to approxi- mate her toward drinking from a cup. After 15 sessions (three days) with the tablespoon, E substituted a training cup consisting of a regular tea cup with a plastic lid and small spout. On the 10th day of conditioning, S1 was required to accept two tablespoons of fluid for each reinforcement experience. During the l l t h , 12th and 13th days of conditioning, S1 accepted all the fluids offered her from a training cup. However, she displayed a great lack of facility in drinking from this cup, as she had shown some difficulty in swallowing the fluids which were provided earlier by spoon. This appeared to be the result of prolonged experience with the nasogastric tube which delivered water directly into her stomach and prevented her from acquiring well developed drinking and swallowing responses. During the 15 sessions with S1 which took place on the l l t h , 12th and 13th days of treatment, she was required to drink progressively larger amounts of the fluid from a training cup in order to receive reinforcement. The initial amount required was approximately 1/15th of the 180 cc. of fluid offered during each session. This amount was increased by 1115th per session so that by the end of the third day of experience with the training cup, SI would be required to consume the entire 180 cc. of fluid in order to receive one reinforcement experience consisting of social contact and an opportunity to play with the fountain pen toy. S1 was able to consume all of the fluids offered to her during these three days. On the 14th day of conditioning, S1 accepted all of the fluids offered her from a regular drinking cup without any deli berate social reinforcements (beyond that necessary to provide her with the water) and without the fountain pen toy as reinforcement. During the seven days of post-conditioning follow-up, S1 accepted all fluids offered her by members of the nursing staff , with no deliberate reinforcement provided.

Sz was a two year, four-month-old abandoned child with generalized develop- mental retardation who weighed only nine pounds. This patient refused all solid foods and most fluids, except water. The patient subsisted on approximately 200 calories per day obtained primarily from chocolate milk (occasionally with sugar added). Etiologically, it was impossible to determine whether the patient’s develop- mental failure was due to her poor appetite, if the poor appetite was secondary to the growth failure, or if possibly some common third factor had produced both the growth failure and poor eating habits. Conditioning with the second S was also of two weeks’ duration. When E would enter S21s room, she would respond with smiles, an increased activity rate, and babbling and cooing. For this reason, it was decided to employ social reinforcement in an attempt to induce this patient t o accept solid foods. SZ was offered small bites of strained baby food (meats, potatoes, other vegetables, fruits, or pudding) on three occasions daily. If she accepted, she was hugged, told “that was good,” and E lingered in her presence for five additional seconds. If SZ refused the food, E wouId sit down in a chair out of the sight of S2. Ten consecutive rejections of food were used as a criterion for terminating a session. The caloric intake for SZ increased from less than 200 per day to approximately 400 on the first day of conditioning. This amount in-

CONDITIONING OF CONSUMMATORY RESPONSES IN YOUNG CHILDREN 419

creased to approximately 600 calories per day during the two week conditioning period, and this level was maintained during the two week follow-up period.

S3 was a five year, six-month-old retarded child who had refused solid foods since age two. She gave up her bottle during the first two years of life, and even- tually accepted strained foods, cereals, chewable meats, potatoes and other foods. Hoivever, sometime following the second birthday, S3 began to gag when attempting to masticate and swallow meats, and this response soon generalized to most other solid foods. By age three, she was subsisting solely on a diet of eggnog (with vita- mins added) and refused all solid foods or even fluids containing solid particles such as ice, etc. In the case of S3, conditioning lasted for only five days. It was possible to rely upon fluids as a part of the reinforcement for accepting solid foods. It was decided to employ a combination of fluids and social contact as reinforce- ment for accepting solid foods. It was also felt that a shaping technique would be employed by adding apricot flavored syrup, strained apricot baby food and bits of diced apricots to the eggnog which S3 would accept, and which was used as a reinforcement for S3’s accepting solid food (chicken and noodles). A similar shaping procedure was employed with the chicken and noodles, with S3 first being offered strained chicken, and then approximated toward eating bites of chicken and noodles. In order to provide a degree of social deprivation and therefore increase the potency of social reinforcement, S3 was provided a private room and not permitted contact apart from the experimental procedure, and a few instances in which bed linens needed to be changed, etc. Since eggnog was the only substance which S3 was milling to consume, a shaping program was begun in which S3 was offered eggnog on five occasions daily. The flavor and viscosity of S3’s eggnog was altered sys- tematically by adding apricot flavored syrup, strained and diced apricots. Social reinforcement in the form of a hug and the statement “that’s good,” was also offered with each spoonful of the apricot-eggnog and chicken-noodle mixture. No other fluids were provided. During three of the five daily sessions, S3 was offered a mix- ture of chicken, noodles and soup. If she accepted one teaspoon of this substance, she was permitted one teaspoon of the apricot-eggnog mixture as reinforcement.

S3 was either shaped or desensitized to the consumption of strained, and then diced, apricots. During the latter portion of the four day conditioning period, S3 could still be induced to consume chicken noodle soup in exchange for the rein- forcement of the apricot flavored substance, even though the viscosity of the apricots had been altered drastically. Such changes apparently had little effect on the mixture’s reinforcement potential. The patient was rapidly shaped from eating strained chicken soup to the consumption of small bits of chicken and noodles. After four days, she was discharged to her parents who have since con- tinued to add to S3’s repertoire of solid foods.

SUMMARY Three female patients between two and six years of age who refused to accept

either fluids or solid foods were subjected to conditioning programs involving primarily operant techniques and shaping. Conditioning of appropriate consum- matory response was accomplished in all cases within three weeks after the initiation of therapy, and responsibility for Ss’ eating and drinking was successfully returned to nursing personnel. A description for the conditioning programs, and a com- parison of them ni th other behavior therapy studies of consummatory responses, are provided.

REFERENCES 1. HALSTCIS, E. A. Adolescent anorexia nervosa treated by desensitization. Behau. Kes. Ther.,

2 . WRIGHT, L., WOODCOCK, J. M. and SCOTT, R. Conditioning children when refusal of oral medi- 1963, 3, 87-91.

cation is life threatening. Pediatrics, 1969, 4-4, 969-972.