Author ORCID Identifier

Date of Award

Summer 6-29-2021

Degree Type


Degree Name

Doctor of Philosophy (PhD)


Counseling and Psychological Services

First Advisor

Andrew Roach, Ph.D.

Second Advisor

Christopher Tullis, Ph.D.

Third Advisor

Sarah Hansen, Ph.D.

Fourth Advisor

Valerie Volkert, Ph.D.


Children with avoidant/restrictive food intake disorder (ARFID) may refuse to consume an adequate variety and/or volume to maintain expected physical growth and cognitive performance (Kerwin, 1999; American Psychiatric Association, 2013). This disorder can result from complicated medical histories or diagnoses of autism or related disorders and is distinct from eating disorders which include obsessive thoughts about food and body image. These children often are medically and physically able to consume food or liquid by mouth but may engage in inappropriate mealtime behavior (IMB; e.g., turning head, hitting spoon) to escape or avoid eating. Behavioral interventions like positive reinforcement and escape prevention have been shown to increase consumption and decrease IMB in children with ARFID. However, for some children, these interventions are insufficient in treating food/liquid refusal, especially passive refusal (e.g., clenching mouth while sitting still). In these cases, physical guidance procedures may be utilized to prompt the child’s mouth open to deposit food or drink. Research indicates that these procedures are effective and are rated as acceptable by caregivers; however, additional research is warranted. Chapter one is a systematic literature review of behavioral treatments of ARFID using physical guidance procedures as an open-mouth prompt to increase food acceptance and discussed limitations and implications for practice and future research. Based on the invasive nature of physical guidance, this study provides recommendations for researchers and clinicians to increase the quality of their treatment evaluations. Chapter two replicated an existing physical guidance procedure, the finger prompt (e.g., Rubio et al., 2020), and compared its efficacy and acceptability to that of a clinically utilized procedure, a spoon prompt, that had not yet been empirically evaluated. This study used an alternating treatments design embedded within a multiple baseline design across three participants to evaluate and compare the two treatments. We also defined and measured passive refusal as a primary dependent variable. Findings of this study indicated both prompts were effective in increasing bite acceptance for two participants. Caregivers perceived the finger prompt to be more acceptable. Researchers discuss limitations and future directions based on results of the study.


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