JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2012, 45, 83–96 NUMBER 1 (SPRING 2012) COMPARISON OF UPRIGHT AND FLIPPED SPOON PRESENTATIONS TO GUIDE TREATMENT OF FOOD REFUSAL WILLIAM G. SHARP MARCUS AUTISM CENTER AND EMORY UNIVERSITY SCHOOL OF MEDICINE ASHLEY ODOM MARCUS AUTISM CENTER AND DAVID L. JAQUESS MARCUS AUTISM CENTER AND EMORY UNIVERSITY SCHOOL OF MEDICINE The current study examined the effects of bite placement with a flipped versus upright spoon on expulsion and mouth clean (product measure of swallowing) in the treatment of 3 children diagnosed with a pediatric feeding disorder and oral-motor deficits. For all 3 participants, extinction in the form of nonremoval of the spoon led to improvements in inappropriate mealtime behavior and acceptance of bites; however, re-presentation did not reduce expulsion or improve mouth clean. Results showed a lower level of expulsion and higher percentage of mouth clean during flipped spoon presentations and re-presentations for all participants. Findings from follow-up analyses supported transitioning back to an upright spoon in all 3 cases, although the time required for this to occur differed across participants. Key words: alternating treatments, antecedent manipulation, bite presentation, expulsions, escape extinction, flipped spoon, pediatric feeding disorders, oral-motor deficits ________________________________________ Escape extinction in the form of nonremoval guidance), thereby eliminating escape. Forof the spoon (NRS) or physical guidance is a children with minimal or no oral intake, escapewell-supported treatment for chronic food extinction promotes exposure to food andrefusal among children with pediatric feeding increases the probability of contact with thedisorders (e.g., Patel, Piazza, Martinez, Volkert, primary and secondary reinforcement associated& Santana, 2002; Piazza, Patel, Gulotta, Sevin, with eating (Hoch et al., 2001). However,& Layer, 2003). Both procedures increase food alternative topographies of food refusal, such asacceptance by targeting inappropriate mealtime pushing bites out of the mouth (i.e., expulsion),behavior (e.g., pushing away food; head holding food in the mouth (i.e., packing), gagging,turning) maintained by negative reinforcement or vomiting, may persist (Girolami, Boscoe, &(i.e., escape from bite presentations). That is, Roscoe, 2007) or arise during the course ofthe feeder persists with a bite presentation by treatment (Gulotta, Piazza, Patel, & Layer, 2005)keeping food at the lips (NRS) or guiding the despite improvements in acceptance. In such cases,mouth open using gentle jaw pressure (physical social consequences may not maintain these behaviors, but they may persist as a result of an Correspondence concerning this article should be oral-motor deficit. Additional behavioral interven-addressed to William G. Sharp, Pediatric Psychology tions may be necessary to establish swallowing.and Feeding Disorders Program, Marcus Autism Center, Re-presentation, or recovering expelled food1920 Briarcliff Road, Atlanta, Georgia 30329 (e-mail:firstname.lastname@example.org). and placing it back into the mouth, represents doi: 10.1901/jaba.2012.45-83 an additional form of escape extinction that has 83
84 WILLIAM G. SHARP et al.been demonstrated to increase consumption onto the tongue using a Nuk brush at 15-swhen frequent expulsion maintained by nega- intervals. Although the operant mechanismtive reinforcement disrupts consumption in responsible for this effect was not isolated insome cases (Ahearn, Kerwin, Eicher, Shantz, either study, Gulotta et al. noted that, if packing& Swearingin, 1996; Coe et al., 1997). For represents refusal topography for avoiding con-example, Ahearn et al. (1996) reported im- sumption, then redistribution may function as aprovement in acceptance and a decline in form of positive punishment for packing (i.e.,expulsion associated with the use of re-presen- holding food in the mouth is followed repeatedlytation in combination with both NRS and by food placement of tongue) or negativephysical guidance for two of three children with reinforcement (i.e., improved intake occurringchronic food refusal. Expulsion remained un- as a result of learning to avoid the procedure bychanged for a third participant, and the authors swallowing). Avoidance of the procedure, how-did not evaluate the relative contribution of re- ever, did not appear to be responsible forpresentation to address expulsion. Coe et al. improvements in swallowing for two of the four(1997) examined the relative impact of different participants in Gulotta et al. Although foodtreatment elements on the percentage of trials remained in the mouth for less time, the childrenwith acceptance, expulsion, and swallowing for required one to two redistributions per bite (ontwo children with food refusal and gastrostomy average) to produce a swallow. Improvements(G-) tube dependence. During treatment, the also did not remain after the procedure wasauthors sequentially introduced a series of pro- removed, with packing increasing for all fourcedures to address different refusal topographies participants. Given this combination of factors,(i.e., refusal to accept, expulsion). Treatment Gulotta et al. asserted that, in some cases, re-involving NRS plus differential reinforcement distribution may facilitate swallowing by helping(DRA) increased acceptance and improved swal- with bolus formation and placement on thelowing for one participant, but expulsion remained tongue, but it may not necessarily result inhigh in both cases. The addition of re-presentation permanent skill acquisition or function as a formof expelled bites to the NRS plus DRA package of extinction for packing. These studies, howev-reduced expulsions to near zero levels and increased er, did not evaluate the relative contribution ofswallowing for both children. bite placement on swallowing, expulsion, or Treatment that involves continual presentation packing.and re-presentation of food minimizes escape and Results from recent studies (Girolami et al.,ensures contact with food until swallowing 2007; Sharp, Harker, & Jaquess, 2010; Volkert,occurs; however, packing may still hinder intake Vaz, Piazza, Frese, & Barnett, 2011) highlight(Gulotta et al., 2005; Sevin, Gulotta, Sierp, the potential contribution of bite placement onRosica, & Miller, 2002) or expulsion may persist the tongue to improve swallowing when used indespite the use of this treatment element (Ahearn combination with other behavioral elements.et al., 1996; Girolami et al., 2007). For example, Girolami et al. (2007) demonstrated that, afterSevin et al. (2002) and Gulotta et al. (2005) acceptance stabilized through the use of NRS,reported increased packing following the use of a presenting and re-presenting bites with a Nuktreatment package that consisted of either NRS or brush resulted in decreased expulsion whenphysical guidance plus re-presentation to address compared to bites presented and re-presentedtotal food refusal. In both studies, swallowing was with an upright spoon. The authors also notedachieved only after the introduction of a redis- that, although expulsion improved via the alteredtribution procedure that typically involved col- presentation method, the behavior persisted evenlecting food held in the mouth and placing it with the re-presentation contingency, suggesting
PRESENTATION ASSESSMENT 85that expulsion likely was not maintained exclu- decreased (and mouth clean concurrently in-sively by negative reinforcement. By the end of creased) with the implementation of the flippedtreatment, Girolami et al. reported that expul- spoon treatment package. The level of improve-sion remained low following the transition back ment varied across participants. One participantto a spoon for the initial presentation; however, achieved zero levels of packing, and packing wasthe researchers continued re-presentation with a lower but remained variable for the secondNuk brush, and no follow-up assessment was participant. The authors hypothesized that oral-conducted after the reintroduction of the upright motor deficits may have contributed to thespoon to clarify whether placement with a Nuk second participant’s more gradual response tobrush was necessary to promote swallowing in treatment (vs. learning to avoid the flippedthe long term. In addition, the length of time spoon by swallowing), noting that he appearednecessary to reintroduce the upright spoon was to require the aid of the flipped spoon tonot evaluated systematically. swallow. Sharp et al. (2010) compared the effective- The available research indicates that modifyingness of different presentation methods (upright bite placement, in combination with conse-spoon vs. flipped spoon vs. Nuk brush) in quence-based procedures, may improve swallow-decreasing expulsion and increasing mouth ing among some children with pediatric feedingclean without the use of re-presentation during disorders who also have oral-motor deficits.treatment of a child with food refusal and oral- Past studies have varied in the level of improve-motor deficits. Prior to the analysis, a treatment ment documented with a flipped spoon, andpackage that consisted of NRS and noncontin- research has yet to evaluate whether the use ofgent access to preferred items was associated modified bite placement can be eliminatedwith improvements in acceptance and inappro- following clinically significant improvements inpriate mealtime behavior during meals. The oral intake. The purpose of the current studychild, however, expelled all bites, and no mouth was to extend Sharp et al. (2010) by comparingcleans were observed. Altering bite presentation the effectiveness of different presentation meth-to include placement onto the middle of the ods (upright spoon vs. flipped spoon) in decreasing expulsion and increasing mouthtongue with the flipped spoon or Nuk brush clean in a treatment package that also includedincreased mouth clean and decreased expulsion. re-presentation for expulsion. We also soughtExpulsion and mouth clean remained relatively to reassess the impact of bite placement onunchanged with the upright spoon. However, mouth clean and expulsion at discharge andchanges in bite presentation did not lead to during follow-up visits to evaluate the transi-clinically significant improvements in these be- tion back to an upright spoon over time.haviors during the analysis. Volkert et al. (2011) evaluated the use of aflipped spoon in a treatment package that METHODconsisted of redistribution and swallow facilita- Participants, Setting, and Materialstion to address packing. Swallow facilitation The participants were three children who hadinvolved the application of downward pressure been admitted to an intensive interdisciplinaryon the back of the tongue while simultaneously day-treatment program for the assessment anddragging the flipped spoon forward. Prior to the treatment of chronic food refusal and 100% G-introduction of swallow facilitation, NRS was tube dependence. Joshua and Jimmy were 2-effective in increasing acceptance; however, year 1-month-old twin brothers whose medicalpacking emerged when the texture of the food history included prematurity, bronchopulmo-was increased. For both participants, packing nary dysplasia (BPD), gastroesophageal reflux
86 WILLIAM G. SHARP et al.disease (GERD), development delay, and visual following initial presentation as well as subse-impairment. Greg was a 2-year 9-month-old quent expulsion following re-presentation. Weboy whose medical history includes prematuri- divided the number of expulsions by thety, GERD, BPD, patent ductus arteriosus, number of trials conducted in each session todevelopmental delay, cerebral palsy, and Grade yield the average number of expulsions per bite.4 intraventricular hemorrhage following birth. We calculated the percentage of bites withIn all three cases, inappropriate mealtime be- mouth cleans by dividing the number of trialshavior and frequent expulsions consistently in which this behavior occurred by the totalhindered adequate consumption. Prior to ad- number of bites that entered the mouth andmission, a swallow study and occupational converting that number to a percentage.therapy examination indicated that all three An independent observer collected reliabilitychildren could swallow smooth pureed-texture data using the same event-recording program forfoods safely, but they also noted difficulty 30%, 30%, and 27% of the sessions for Joshua,retaining food in the mouth due to tongue Jimmy, and Greg, respectively. Exact agreementprotrusions, drooling, or limited lip closure. coefficients were calculated by dividing the Trained therapists conducted sessions in number of agreements on the occurrence of arooms (3 m by 3 m) equipped with one-way behavior by agreements plus disagreements andmirrors and an adjacent observation room for multiplying by 100%. We defined an exactdata collection. Each treatment room included a agreement as both observers recording the samehigh chair (Joshua and Jimmy) or booster seat frequency of a target response in a given 10-s(Greg), food, table, feeding utensils (small interval. Mean interobserver agreement formaroon spoons; plastic coated baby spoon), expulsion was 96% (range, 80% to 100%) forbib, serving tray, and a scale with an intake log. Joshua, 95% (range, 79% to 100%) for Jimmy, and 94% (range, 83% to 100%) for Greg. MeanData Collection and Interobserver Agreement interobserver agreement for mouth clean was The primary dependent variables were ex- 95% (range, 82% to 100%) for Joshua, 98%pulsion and mouth clean. Expulsion was defined (range, 58% to 100%) for Jimmy, and 96%as the presence of food greater than the size of a (range, 83% to 100%) for Greg.pea visible outside the mouth after the biteentered the child’s mouth, and included Designinstances when a child actively pushed foodfrom the mouth as well as when it passively We compared mouth clean and expulsiondripped out. Mouth clean was defined as no across upright and flipped spoon presentationsresidual food larger than the size of a pea using alternating treatments and reversal designs.remaining inside the mouth within 30 s after A was treatment with an upright spoon, B was thethe food initially was deposited. We did not presentation assessment comparing the flippedscore a mouth clean if the child’s mouth was spoon to the upright spoon (initial and discharge),clean due to an expulsion at the 30-s mark. We and C was treatment with a flipped spoon. Therecorded the frequency of expulsion and the number of phases during treatment differed acrossoccurrence or nonoccurrence of mouth clean for participants (Joshua, ABCBCBCA; Jimmy, ABC-each bite. During all meals, a trained observer BA; and Greg, ABCBCBA).collected data on a computer using an event-recording program. A trial began when the Procedurefeeder deposited a bite in the mouth and ended Admission lasted 8 weeks (Monday throughwhen no food larger than pea size was visible in Friday), and we conducted one 30-min andthe mouth. Within a trial, we coded expulsion three 45-min meal blocks each day. Thirty
PRESENTATION ASSESSMENT 87minutes separated the breakfast and morning occurring, using a three-step prompting proce-snack meal blocks, lunch occurred 45 min after dure (i.e., verbal: ‘‘show me’’; gestural: ‘‘showthe morning snack, and dinner took place 2.5 hr me like this’’ plus modeling opening the mouth;after lunch. We divided meal blocks into five-bite physical: ‘‘show me’’ plus gentle pressure appli-sessions, with three to nine sessions conducted ed to the side of the teeth with a baby spoon).per meal. The number of sessions conducted Movement through this sequence occurred induring a meal block varied based on expulsion. 5-s intervals. If the child packed the bite (i.e.,Although it was possible, we did not terminate a held it in the mouth longer than 30 s), thesession prior to completing all five bites due to feeder continued to check for the presence ofexpulsion or packing within the allotted time, food in the mouth every 30 s until no foodending all meals based on the time allotted for larger than pea was visible, at which time thethat block. feeder immediately presented the next bite. If a We identified highly preferred leisure items child continued to pack a bite of food at the end(e.g., toys and videos) using a paired-choice of the allotted time for a meal block, thepreference assessment (Fisher et al., 1992). protocol consisted of removing the bite fromAccess to these items was dependent on the the mouth and terminating the meal; however,treatment protocol (described below). We pre- this did not occur during the analysis. Thesented a total of 16 foods (four fruits, four feeder provided verbal praise (i.e., ‘‘Great jobvegetables, four starches, and four proteins) that taking your bite’’) if the child accepted thecaregivers had nominated, under the guidance of entire bite within 5 s of the initial presentationa registered dietician, to match the family’s and when no food larger than the size of a pea was visible in the child’s mouth regardless ofeating patterns. For each meal, the feeder time (clean mouth). In addition, the feederrandomly selected one food from each group provided Joshua and Jimmy with noncontin-and presented these four foods (in random order) gent access to preferred items throughout theat a pureed texture. The order of presentation meal. Greg’s treatment package involved DRAremained the same within a given session. for acceptance, with the feeder providing access Treatment with upright spoon. All treatment to a preferred item for 20 s after Greg acceptedpackages included NRS and re-presentation of the bite regardless of time.expulsion with a bolus size of 1 cc per bite Initial comparison of flipped spoon and uprightpresented on a small maroon spoon. With spoon presentation. To assess the impact of biteNRS, the feeder placed the spoon at the child’s presentation method on expulsion and mouthlips, followed the lips with the spoon in clean, we compared the upright spoon to theresponse to head turning (i.e., moving the head flipped spoon. The analysis occurred after 12 daysmore than 45u away from the spoon), blocked in treatment for Jimmy and Joshua and 30 daysdisruptions (e.g., pushing away the spoon, of treatment for Greg. The lag between the onsettouching the feeder’s arms), and deposited the of treatment and the initial presentation assess-bite immediately once the mouth was open. If ment reflected the length of time required tothe child expelled the bite, the feeder re- achieve stability in 5-s acceptance and inappro-presented the food by quickly scooping the priate mealtime behavior during treatment withbolus from the face or bib with the spoon and an upright spoon using the protocol describedplacing it back into the mouth. The feeder above. The time required for Greg’s behavior tocontinued to re-present the bite until it was reach stabilization also was affected by illnessretained. Once the bite entered the child’s during the admission.mouth, the feeder checked the mouth every 30 s, The feeder presented all bites at midlineunless an expulsion (and re-presentation) was using a bolus size of 1 cc. We alternated
88 WILLIAM G. SHARP et al.presentation methods between sessions, with the the length of time remaining in treatment.order randomly selected prior to each meal. The During this process, we also added a DRA forintervention packages described above remained mouth clean to Joshua’s protocol after hein place throughout the analysis for all three experienced a decline in mouth clean whenchildren. The feeder re-presented expelled bites the bolus was increased to 5.4 cc, and we werein the same manner as the initial presentation unable to regain stability by reducing the bolusfor each bite. During upright spoon presenta- size. This involved the feeder providing accesstions, the feeder immediately deposited the bite to a preferred item for 20 s after food no longerafter the child opened his mouth and closed was visible in Joshua’s mouth regardless of time.the lips around the spoon or instantaneously No such modifications were necessary forscraped the bolus on the upper lip or teeth if Jimmy and Greg. For all three participants,necessary due to an open mouth posture and we also addressed additional treatment goalslack of lip closure. During flipped spoon pre- (e.g., caregiver training, generalization) duringsentations, the feeder placed the spoon midline this phase after the terminal bite size wasfollowing acceptance, flipped the spoon over achieved.180u, and deposited the food onto the middle Discharge comparison of flipped spoon andof the tongue by applying gentle downward upright spoon presentation. Near the end of thepressure along with a concurrent wiping mo- admission, we conducted a second presentationtion, dragging the spoon toward the lips. We assessment to determine if treatment gainsused small maroon spoons during upright spoon could be maintained after the transition backpresentations, which was the utensil selected at to an upright spoon. The analysis occurred afterthe onset of treatment for all participants. We 34 days in treatment for Joshua, 25 days inchanged the utensil to a coated baby spoon treatment for Jimmy, and 39 days in treatmentduring flipped spoon presentations due to prag- for Greg. Variation in the timing of the secondmatic considerations regarding the ease of assessment reflected the length of time requiredturning the spoon inside the mouth (i.e., the to achieve stability in behavior at the terminalspoon is narrower, particularly at the handle). bite volume (including inappropriate mealtime Treatment with flipped spoon. We used the behavior and negative vocalizations) and toresults of the presentation assessment to select address additional treatment goals. We imple-the optimal presentation method based on mented the same overall structure as the firstdifferentiation in the level of mouth clean and presentation assessment. The intervention pack-expulsion favoring the flipped spoon. We then ages developed over the course of treatmentinitiated bolus fading to maximize the volume remained in place throughout the analysis (NRSof food presented on the spoon. During this plus DRA for clean mouth plus re-presentationprocess, the feeder systemically increased bite for Joshua; NRS plus noncontingent access plusvolume (1 cc, 2 cc, 4 cc, 5.4 cc) using the re-presentation for Jimmy; NRS plus DRA forfollowing decision rule: 75% or more sessions acceptance plus re-presentation for Greg). Themeeting preestablished criteria for two meal discharge presentation assessment also involvedblocks. The criteria included 80% or greater 5-s the bite volume achieved during bolus fadingacceptance and mouth cleans, as well as low (about 5.4 cc).rates of expulsion (#1) and inappropriate Follow-up analysis. Stability following treat-mealtime behavior (#2) per bite. We modified ment was assessed during follow-up clinic visitsGreg’s bolus fading criteria to involve slightly conducted 2 months, 5 months, and 9 monthsless stringent criteria (i.e., one meal block rather after discharge for all three participants. Anthan two; moving from a level to a heaping additional follow-up visit was conducted withbolus) to maximize volume while considering Greg at 3 months. Meals were conducted by
PRESENTATION ASSESSMENT 89primary caregivers during follow-up appoint- and re-presentations with the flipped spoon.ments. Mouth clean and expulsion remained un- After the participants had been discharged changed with the upright spoon. We notedfrom the day-treatment program, we asked no difference in gram consumption betweencaregivers to complete a 45-item questionnaire presentation methods across sessions (datathat assessed three broad measures of social available from the first author). The averagevalidity (i.e., program satisfaction, treatment session duration across all three participantsgains, social acceptance) rated on a 5-point was greater with the upright spoon (M 5 410 s,Likert-type scale (1 5 quite dissatisfied/totally range, 214 s to 581 s) than with the flippeddisagree/definitely not; 5 5 extremely satisfied/ spoon (M 5 273 s, range, 199 s to 426 s)totally agree/definitely). during this phase, indicating that the partici- pants required more time to complete five bites RESULTS while consuming approximately the same volume of food with the upright spoon. Data on mouth clean and expulsion are Based on the results of this initial assessmentdepicted in Figures 1 through 3 for all with all three participants, we selected theparticipants. The figures display the last 10 flipped spoon as the sole presentation methodsessions of treatment with the upright spoon for use during treatment and when fading theprior to the initial presentation assessment. All bolus. Given the relative length of thisparticipants demonstrated increased acceptance treatment phase (Joshua: 103 sessions; Jimmy:and decreased inappropriate mealtime behavior 156 sessions; Greg: 230 sessions), the figuresper bite during meals in response to the summarize data for each bite volume. Tomulticomponent treatment package with the calculate this, we divided the number ofupright spoon (data not shown). Despite expulsions by the total number of trials perimprovement in acceptance and inappropriate bite volume to yield an average number ofmealtime behavior, a high level of expulsions expulsions for each volume. We calculated theper bite interfered with intake for all three percentage of bites with mouth clean for eachparticipants (M 5 12, range, 9.3 to 15.2 for bite volume by dividing the number of trials onJoshua; M 5 5.4, range, 3.2 to 9.5 for Jimmy; which this behavior occurred by the totalM 5 2.9, range, 2.3 to 3.7 for Greg). Joshua number of bites that entered the mouth for aand Jimmy demonstrated low levels of mouth particular volume and converting that numberclean (M 5 12.4%, range, 0% to 30% for to a percentage. All three participants achieved aJoshua; M 5 44.1%, range, 0% to 80% for bite volume equal to about 5.4 cc by the end ofJimmy) during upright spoon presentations. this phase. Percentage of bite with mouth cleanGreg’s percentage of bites with mouth clean was (M 5 98.2%, range, 90% to 100% for Joshua;variable (M 5 80%, range, 40% to 100%). M 5 100% for Jimmy; M 5 99.6%, range, During the initial presentation assessment, all 90% to 100% for Greg) and mean number ofthree participants experienced significant im- expulsions per bite (M 5 1.9, range, 0.4 to 3.3provements in mouth clean ( M 5 90%, range, for Joshua; M 5 0.9, range, 0.1 to 2.4 for60% to 100% for Joshua; M 5 78.3%, range, Jimmy; M 5 0.5, range, 0 to 1.6 for Greg)40% to 100% for Jimmy; M 5 95%, range, remained stable at this volume of intake for80% to 100% for Greg), which coincided with more than 150 bite presentations prior to thea decline in the mean number of expulsions per discharge presentation assessment. Increasedbite (M 5 1.2, range, 0.6 to 2.0 for Joshua; oral intake resulted in significant feeding tubeM 5 2.2, range, 1.4 to 3.8 for Jimmy; M 5 1.3, reductions for all three participants (51%range, 0 to 2.0 for Greg) during presentations reduction for Joshua, 62% reduction for
90 WILLIAM G. SHARP et al. Figure 1. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Joshua.The first flipped phase presents the averages for each bite volume, summarizing a total of 230 sessions (2 cc: 77 sessions;4 cc: 84 sessions; 5.4 cc: 69 sessions). PA 5 presentation assessment.Jimmy, and 47% reduction for Greg). For (M 5 10.7, range, 8.2 to 12.4) and mouthJimmy and Greg, cup drinking also contributed clean remained variable (M 5 40%, range, 20%to their intake during meals, a goal addressed to 60%) for bites presented with an uprightfor Joshua during follow-up outpatient visits. spoon throughout the analysis. Levels of both During the presentation assessment conduct- behaviors were similar to those observed duringed before discharge, mouth clean and the mean the initial presentation assessment. We discon-number of expulsion per bite remained un- tinued the assessment after a clear pattern ofchanged with the flipped spoon for all three stability to address additional treatment goalsparticipants; however, the children differed in (i.e., caregiver training; generalization) prior totheir response to bites presented with an upright discharge. During Joshua’s final day of admis-spoon. All three children experienced an sion (5 days later), we conducted a briefincrease in mean number of expulsions per bite reassessment after parent training and general-during bites presented with an upright spoon. ization were complete. Behaviors with bothJoshua and Jimmy also experienced an initial methods of presentation remained unchangeddrop in mouth clean. For Joshua, mean number during these six sessions. We resumed treatmentof expulsions per bite remained high and stable with a flipped spoon following both analyses.
PRESENTATION ASSESSMENT 91 Figure 2. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Jimmy.The first flipped phase presents the averages for each bite volume, summarizing a total of 156 sessions (2 cc: 28 sessions;4 cc: 8 sessions; 5.4 cc: 120 sessions). The second upright phase presents the average of forty sessions per point,summarizing a total of 200 bite presentations. PA 5 presentation assessment. During the second presentation assessment, for 40 sessions per point (involving a total ofJimmy’s mean number of expulsions per bite 200 bite presentations). The mean number ofinitially occurred at levels similar to the first expulsion per bite continued to decrease,presentation assessment, and mouth clean approaching levels achieved with the flippedimproved slightly from the near-zero levels spoon prior to discharge, and mouth cleanpreviously observed. As the analysis proceeded, stabilized near 100%.expulsions per bite dropped to less than 2 (M 5 For Greg, the second presentation began with a3.1; range, 0.6 to 12.2) and mouth clean mean number of expulsions per bite at a levelincreased to 100% (M 5 90.5%; range, 40% to similar to those observed during the first presen-100%). Based on the assessment results, we tation assessment, but dropped to around 1;reintroduced the upright spoon as the sole mouth clean (M 5 97.5%; range, 80% to 100%)presentation method for use during treatment. was high and stable. Both trends represented anGiven the relative length of this treatment phase improvement over the pattern observed during the(240 sessions), the figure displays the average first presentation assessment. Nonetheless, the
92 WILLIAM G. SHARP et al. Figure 3. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Greg.The first flipped phase presents the averages for each bite volume, summarizing a total of 103 sessions (2 cc: 15 sessions;5.4 cc: 88 sessions). PA 5 presentation assessment.assessment was discontinued based on caregiver Caregivers did not record data systematically orpreference for the flipped spoon. Clinical observa- follow a clinic-derived protocol during this timetion also suggested lack of improvement in oral- period. Mouth clean remained high, and nomotor patterns that would promote sustained expulsion was observed at the 2-month appoint-levels of intake not captured during data col- ment with the upright spoon. Jimmy’s behaviorlection, most notably tongue protrusions, associ- also remained stable with the upright spoon,ated with upright spoon presentations. These with levels of mouth clean nearing 100% andobservations are discussed in more detail below. levels of expulsion close to zero during the 2- Before the first follow-up appointment, month follow-up. The family maintained theseJoshua transitioned back to an upright spoon gains at the 5- and 9-month appointments withfollowing a series of periodic probes conducted both children. Both children also achieved self-by his parents within 3 weeks of discharge. Per feeding skills and further reductions in tubecaregiver report, probes consisted of presenting a feedings. We reassessed Greg’s readiness tofew bites with an upright spoon at the beginning transition back to an upright spoon at eachof each meal and gradually increasing the follow-up appointment. Expulsion and mouthnumber of bites based on low levels of expulsion. clean remained relatively unchanged from
PRESENTATION ASSESSMENT 93predischarge levels during flipped spoon presen- modification that can optimize food placementtations. However, expulsion per bite continued on the tongue and may help to facilitateto disrupt meals during bites with the upright swallowing in some children with feedingspoon at the 2-month appointment (expulsions disorders. The positive effect of the intervention. 1 per bite). Expulsion persisted (although at package was reflected by the increased volume oflower levels) at the 3-month appointment, at food consumed per session, and all three childrenwhich time we encouraged the family to increase received more than 50% of their nutritionalthe number of bites with the upright spoon (i.e., needs by mouth by the end of treatment. Ininitially beginning each meal with the first five addition, caregiver training was completed suc-bites with the upright spoon and doubling the cessfully so that treatment gains transferred to thenumber of bites after low levels of expulsion for home setting, suggesting that the flipped spoonthree consecutive meals) gradually. By the 5- and procedure can be generalized to feeders and9-month appointments, all bites were presented settings beyond trained therapists in highly struc-on an upright spoon, mouth clean remained tured settings. Finally, follow-up data indicatedhigh, and expulsion approached zero. that families were able to maintain improve- Results of the satisfaction questionnaire in- ments in feeding behavior following dischargedicated that all families were extremely satisfied (with two children transitioning back to thewith treatment (M 5 5). All families reported a upright spoon), and posttreatment satisfactionpositive change in their child’s mealtime questionnaires reflected a high degree of socialbehaviors (M 5 4.3; range, 4.3 to 4.4), and validity associated with treatment. This repre-they all indicated that treatment was acceptable sents the first study to document the transitionfor addressing their child’s feeding difficulties back to an upright spoon following clinically(M 5 4.7; range, 4.4 to 4.9). Items, however, significant improvement in oral intake using thedid not specifically assess caregiver preference flipped spoon procedure.for spoon presentation methods. The level of improvement documented in the current study greatly exceeds that reported by DISCUSSION Sharp et al. (2010), which resulted in small increases in mouth clean and modest declines in Results of the current investigation showed expulsion associated with the use of a flippedclinically significant improvements in mouth spoon. A key difference between the currentclean and a concomitant decline in expulsion investigation and Sharp et al., however, is that thefollowing the addition of the flipped spoon current study incorporated flipped spoon pre-presentation to treatment packages that consisted sentations into a treatment package that includedof NRS, re-presentation, and reinforcement. re-presentation. Girolami et al. (2007) achievedPrior to the analysis, presentation on an upright clinically significant improvement in expulsionspoon yielded frequent expulsion of food such with modified placement, and re-presentationthat two children demonstrated near-zero levels was included throughout that analysis. Therefore,of mouth clean, and a third showed variable levels it appears that, to maximize the effectiveness ofbelow clinical targets. The introduction of the the flipped spoon procedure, treatment packagesflipped spoon resulted in a significant reduction may need to include additional elements (e.g., re-in expulsions per bite for all three children. These presentation) to help to ensure continued contactimprovements coincided with rapid improve- with food and repeated opportunities for con-ment in mouth clean, which remained at high sumption. This may be a particularly importantlevels during treatment. These findings provide consideration for children with significant oral-further support for the effectiveness of altering motor deficits. Participants in this line of researchbite presentation, a relatively simple antecedent were described as showing poor oral-motor skills,
94 WILLIAM G. SHARP et al.characterized by frequent tongue protrusions, while simultaneously decreasing the response ef-drooling, intermittent lip closure, and frequent fort required for swallowing. An alternate expla-expulsion of food (Sharp et al.; Girolami et al.). nation is that modifying the placement of foodFor children who display this pattern of oral- onto the tongue may compensate for behaviorsmotor skills, the flipped spoon procedure may that are missing from the chain necessary forhelp to facilitate swallowing by assisting with swallowing by assisting with bolus formation andbolus formation, but it does not necessarily posterior movement.ensure retention of food in the mouth. It should Future studies should evaluate the possiblebe noted, however, that we did not examine the function of expulsion and the exact mechanismeffects of food placement with and without re- that is responsible for the observed treatmentpresentation. More research is needed to identify effect, perhaps by assessing different levels of re-which subset of children with feeding disorders presentation (e.g., NRS, NRS plus limited re-may be the most appropriate candidates for presentation; NRS plus continued re-presenta-modified bite presentation, including what tion) and the methods of presentation (e.g.,subject characteristics (e.g., lack of lip closure, upright, flipped, side placement). In addition, itfrequent tongue protrusions) may warrant the use will be important to determine how the locationof this type of procedure at the onset of of placement on the tongue (i.e., central vs.treatment. posterior) influences feeding behaviors across It is noteworthy that, prior to the initial different utensils (Nuk brush, flipped spoon). Forpresentation assessment, expulsion persisted at example, Volkert et al. (2011) suggested that thehigh levels despite the use of re-presentation in all high level of mouth clean achieved with thethree cases. Previous investigators (e.g., Ahearn et flipped spoon plus swallow facilitation, whenal., 1996; Coe et al., 1997; Gulotta et al., 2005) compared to the findings reported by Sharp et al.conceptualized expulsion as a behavior maintained (2010), may be related to the location of place-by negative reinforcement (i.e., a behavior that ment on the back of the tongue (i.e., swallowprovides escape from swallowing food), with re- facilitation). However, the current study achievedpresentation functioning as a form of escape high levels of mouth clean with placement in theextinction. Not all research findings, however, center of the tongue. The study also is limited byhave supported such a conceptualization. Sharp the use of different spoons during flipped andet al. (2010) reported declines in expulsion after upright spoon presentations, which highlights themodifications in bite placement without the use of need to investigate the impact of utensil type (asextinction. Findings from Girolami et al. (2007), well as other utensils) in treatment outcomes. Foralong with those of the current study, also provide example, the narrower surface and shallowerevidence that expulsion may not be maintained bowl of the baby spoon may allow more preciseexclusively by negative reinforcement. In both bolus formation and, as a result, require less effortstudies, the behavior persisted despite the use of re- in facilitating a swallow.presentation. If re-presentation functioned as It also will be important for researchers toextinction, one would have expected an extinction identify the mechanisms that are responsible forcurve in expulsion data, as was observed by Sevin promoting changes in oral-motor patterns thatet al. (2002). Expulsions declined in the present permit the transition from a flipped spoon to anstudy only with the flipped spoon, raising upright spoon. Clinical observations during thequestions regarding the operant mechanisms that second presentation assessment and follow-upare responsible for this change. One possibility, indicate that changes in oral-motor skills mayhighlighted by Girolami et al., is that placement of have occurred over time (e.g., increased effi-the bolus onto the middle of the tongue may make ciency with bolus formation, increased tongueit more difficult for the child to expel the bite mobility, increased labial seal with suction);
PRESENTATION ASSESSMENT 95however, it is unclear why the children achieved continued interdisciplinary collaboration tothis milestone at different times (Jimmy, 26 days; optimize measurement techniques and expandJoshua, 61 days; Greg, more than 180 days), and the technology available to address pediatricthe present data-recording procedures were not feeding disorders.set up to capture what behaviors beyond ex-pulsion and mouth clean emerged during this REFERENCESprocess. Possible explanations include naturally Ahearn, W. H. (2003). Using simultaneous presentationoccurring reinforcement of key behaviors in to increase vegetable consumption in a mildlythe swallowing chain, increased coordination selective child with autism. Journal of Appliedof nuero-motor responses, or even the passage Behavior Analysis, 36, 361–365. Ahearn, W. H., Kerwin, M. E., Eicher, P. S., Shantz, J., &of time alone. Expansion of data-collection pro- Swearingin, W. (1996). An alternating treatmentscedures to include variables such as mouth clo- comparison of two intensive interventions for foodsure, tongue coordination or movement, tongue refusal. Journal of Applied Behavior Analysis, 29, 321–332.protrusion, food retraction (with lips or Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P.,tongue), and food retention (e.g., latency to Owens, J. C., & Slevin, I. (1992). A comparison of twoexpel) may help to elucidate possible mecha- approaches for identifying reinforcers for persons withnisms that are responsible for improved severe and profound disabilities. Journal of Applied Behavior Analysis, 25, 491–498.mealtime performance. It also would be Coe, D. A., Babbitt, R. L., Williams, K. E., Hajimihalis,beneficial to include oral-motor examinations C., Snyder, A. M., Ballard, C., et al. (1997). Use ofat each treatment change to assess continued extinction and reinforcement to increase food con- sumption and reduce expulsion. Journal of Appliedareas of strength and deficits. Behavior Analysis, 30, 581–583. Taken together, the current results further Girolami, P. A., Boscoe, J. H., & Roscoe, N. (2007).support the use of a flipped spoon in the Decreasing expulsions by a child with a feeding disorder: Using a brush to present and re-presenttreatment of pediatric feeding disorders and food. Journal of Applied Behavior Analysis, 40,add to a growing body of research that indicates 749–753.that the method of food presentation may Gulotta, C. S., Piazza, C. C., Patel, M. R., & Layer, S. A.influence consumption during meals, including (2005). Using food redistribution to reduce packing in children with severe food refusal. Journal of Appliedbite size (Kerwin, Ahearn, Eicher, & Burd, Behavior Analysis, 38, 39–50.1995), simultaneous presentation (i.e., blending; Hoch, T. A., Babbitt, R. L., Farrar-Schneider, D.,Ahearn, 2003), and texture (Patel, Piazza, San- Berkowitz, M. J., Owens, J. C., Knight, T. L., et al. (2001). Empirical examination of a multicomponenttana, & Volkert, 2002). These antecedent-based treatment for pediatric food refusal. Education andstrategies can be used in combination with Treatment of Children, 24, 176–198.consequence-based elements (e.g., NRS, re- Kerwin, M. E., Ahearn, W. H., Eicher, P. S., & Burd,presentation) to develop highly specific treat- D. M. (1995). The costs of eating: A behavioral economic analysis of food refusal. Journal of Appliedment packages that target the operant function of Behavior Analysis, 28, 245–260.food refusal while possibly compensating for Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M.,oral-motor deficits and reducing the motivating & Santana, C. M. (2002). An evaluation of two differential reinforcement procedures with escapeoperations for food refusal. Going forward, it extinction to treat food refusal. Journal of Appliedwill be important to evaluate specifically the Behavior Analysis, 35, 363–374.social validity of alternative bite placement as Patel, M. R., Piazza, C. C., Santana, C. M., & Volkert, V. M. (2002). An evaluation of food type and texture in thetreatment for pediatric feeding disorders and treatment of a feeding problem. Journal of Appliedexpand the behaviors measured during the course Behavior Analysis, 35, 183–186.of a feeding intervention. This process will Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M.,require new techniques, behavioral measures, & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in theand tools for the assessment and treatment of treatment of food refusal. Journal of Applied Behaviorpediatric feeding disorders, and will necessitate Analysis, 36, 309–324.
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