Journal Reporting - Teaching Chewing: A Structured Approach
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Journal Reporting - Teaching Chewing: A Structured Approach

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By: Nicholas Eckman, Keith E. Williams, Katherine Riegel, Candace Paul ...

By: Nicholas Eckman, Keith E. Williams, Katherine Riegel, Candace Paul

OBJECTIVE. A structured intervention was used to teach chewing to two children with special needs. Neither child had a history of chewing or eating high-textured food.
METHOD. The intervention combined oral–motor and behavior components to teach chewing. A multiple baseline design was used to evaluate treatment effectiveness.
RESULTS. Both children improved their chewing skills while increasing the texture of foods eaten and the variety of foods eaten.
CONCLUSION. This structured intervention could be used to teach chewing to a range of children who did not acquire this skill during normal development.

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Journal Reporting - Teaching Chewing: A Structured Approach Presentation Transcript

  • 1. Teaching Chewing: A Structured Approach Laisa Marie Gregorio, UST OT Intern, 2013
  • 2. Background Chewing is one of many problems commonly seen in children with congenital delays, e.g. Down syndrome, autism spectrum disorder, cri du chat and cerebral palsy. Problems in chewing = neuromotor deficits and or lack of experience
  • 3. Background Institutional deprivation = lack of exposure to or practice in chewing high textured food Lack of literature  (Butterfield & Parson, 1973) Modeling, shaping and positive reinforcement = teaching a kid with DS to bite graham crackers  (Gisel et. al., 1994) oral-motor intervention for kids with CP; includes 3 components (tongue lateralization, lip control and vigor of chewing); cookie progresses in hardness; 5-7 min before school lunch meal for 10-20 weeks
  • 4. Background Oral-motor functioning and behavioral approaches  Stimulus fading  Positive/social reinforcement  Peer modeling  Token reinforcement = Goal of the study
  • 5. MethodParticipant and Setting 9 y/o Sam with Down syndrome  Eats only limited number of pureed foods  Leaves meal before finishing  Refuses to self-feed  Goal: to establish chewing, increase variety and texture of solid foods eaten, establish open-cup drinking, eliminate inappropriate mealtime behaviors  124 meal sessions, 19 days, day-treatment program
  • 6. MethodParticipant and Setting 5 y/o Frank who has had kidney transplant, stroke, microcephaly, and neuromotor dysfunction  Gastrostomy tube dependent  Only eats smooth foods  Drinks thin liquids without difficulty
  • 7. MethodParticipant and Setting  Left side weakness, difficulty coordinating tongue movement  Goal: to establish chewing, increase texture of solid foods eaten, eliminate inappropriate mealtime behaviors, eliminate gastrostomy feedings  149 meal sessions, 20 days, day-treatment feeding program
  • 8. MethodSessions were conducted by a PhD- or master’s- level feeding therapistSome by graduate interns under supervision of a feeding therapistNeither child required adaptive seatingFinal 2 weeks: different environments by different persons to promote generalization
  • 9. Dependent MeasuresData by therapist in chargeInterobserver reliability: another therapist or a graduate internPrimary behaviors: Chew: at least 3x within 5 s Mouth clean: within 30 s of acceptanceUsed as determinants of the outcomes of the intervention
  • 10. Dependent MeasuresSecondary Behaviors: Accept: within 5 s of presentation Expel: before next bite Negative vocalizations Gag: neck extension, tongue protrusion, changes in skin color Tongue lateralization Bite
  • 11. Dependent MeasuresDietary intake by pediatric nutritionistInterobserver agreement: Sam: reliability of 30% of chewing sessions – chew and mouth clean 82% agreement (7 – 100%) reliability of 39% of texture-fading sessions and mouth clean 87% agreement (23 – 100%)
  • 12. Dependent MeasuresInterobserver agreement: Frank: reliability of 24% of chewing sessions – chew and mouth clean 88% agreement (13 – 100%) reliability of 30% of texture-fading sessions and mouth clean 92% agreement (75 – 100%)
  • 13. Procedures - Baseline Conducted to assess children’s ability to eat high-textured foods and to chew Baseline chewing sessions  10 min  Child was presented with dry, crisp foods, and asked to take bites  All inappropriate meal behaviors are ignored  Attempt to leave -> redirected
  • 14. Procedures - Baseline Baseline texture-fading sessions  Presented with regular-textured table foods and milk from an open cup  Same as chewing sessions
  • 15. Procedures - Baseline Treatment package  Instruct the child to bite and chew  Improve tongue lateralization  Improve lip closure  Increase texture of foods eaten  Implemented in 2 types of meal sessions
  • 16. Procedures – Chewing Sessions Primary focus: biting and chewing  10 min  Bite a small piece of crisp, dissolvable food on molars  Bites = reinforcement  Preferred drink after each bite  Chews = additional praise  Expels = placed back
  • 17. Procedures – Chewing Sessions Primary focus: biting and chewing  Swallows w/o biting = another piece placed on molars  Refuses = held to mouth w/o comment until accepted  Gagging ignored  Alternate placing of food to L or R  Ended when timer rang
  • 18. Procedures – Decision Rules Used to change the schedule of reinforcement Size of the food pieces presented also increased Sam: termination criterion was changed from 10 min to specific number of bites (9)
  • 19. Procedures – Texture-fading Sessions Primary focus: increase tolerance of higher-textured foods, improve lip closure, improve tongue lateralization  20 min  Bite textured food  Bites = praise, given verbal prompts  Chewing or attempting to chew = praised + tangible reinforcement for 10 s  Expels = ignored, placed back  Refuses = held to mouth w/o comment until accepted
  • 20. Procedures – Texture-fading Sessions Primary focus: increase tolerance of higher-textured foods, improve lip closure, improve tongue lateralization  Gagging ignored  Alternate placing of food to L or R  Tongue lateralization = praise + tangible reinforcement for 10 s  Consumes preferred liquid = praise + tangible reinforcement for 10 s  Ended when timer rang
  • 21. Procedures – Decision Rules Used to determine when texture would be increased to the next step in the fading sequence  Mouth clean ≥ 80% of bites, 3/4 meals  Expels ≤ 20% of bites, 3/4 meals  Gags ≤ 20% of bites, 3/4 meals
  • 22. Procedures – Food textures Food textures  Pureed – smooth food w/o lumps  Ground – processed food (lumps w/ size no larger than 0.25 in)  Mashed – with a fork (lumps’ size within 0.25 - 0.5 in)  Table – regular-texture table food
  • 23. Procedures – Food textures Table – regular-texture table food  If fading procedure required less than spoonful, table food was cut into smaller pieces (approx. 0.5 in)  At the end of treatment, both boys were biting pieces off some foods Starting texture – ground Texture-fading manipulated 2 variables: texture and spoon volume
  • 24. Procedures – Meals At the end of treatment for both children Presented with a range of table foods Praises were given for accepting and chewing bites of food Conducted at a variety of settings with children’s caregivers to promote generalization
  • 25. Parent Training Done before discharge from intensive treatment Therapists as models, then return demonstration by caregivers for feedback Simplified version of data collection system Training videos and written home treatment plan
  • 26. Experimental Design Multiple baseline design was used to evaluate effectiveness of treatment 3 baseline chewing sessions and 3 baseline texture-fading sessions for Sam 5 baseline chewing sessions and 5 baseline texture-fading sessions for Frank
  • 27. Results Effective in increasing both variety and texture of food eaten by both boys Successful in eliminating the need for Frank’s gastrostomy tube feedings
  • 28. Results Sam  13 – more than 80 foods Frank  3 low textured- foods – 50 foods
  • 29. Results
  • 30. Results
  • 31. Discussion Intervention was able to achieve its goals Both boys were able to eat family meals and to eat in a variety of settings outside home Not clear which component was responsible for the results Not all of the skills targeted might be necessary for some kids  Component analysis
  • 32. Discussion Treatment differs from others with the same goals but through the use of chewy tubes or other nonnutritive objects Thus, study agrees with Gisel: use of food stimuli in treatment would elicit natural eating reaction  Also prevents possible problems in generalization
  • 33. Recommendation Study was conducted in an intensive basis under tightly controlled environment of a day- treatment program -> other settings with other samples of children
  • 34. THANK YOU! 