JOURNAL OF APPLIED BEHAVIOR ANALYSIS

2014, 47, 694–709

NUMBER

4 (WINTER)

UTENSIL MANIPULATION DURING INITIAL TREATMENT OF PEDIATRIC FEEDING PROBLEMS JONATHAN W. WILKINS, CATHLEEN C. PIAZZA, REBECCA A. GROFF, VALERIE M. VOLKERT, JENNIFER M. KOZISEK, AND SUZANNE M. MILNES UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

Children with feeding disorders exhibit a variety of problem behaviors during meals. One method of treating problem mealtime behavior is to implement interventions sequentially after the problem behavior emerges (e.g., Sevin, Gulotta, Sierp, Rosica, & Miller, 2002). Alternatively, interventions could target problem behavior in anticipation of its emergence. In the current study, we implemented nonremoval and re-presentation of bites either on a spoon or on a Nuk for 12 children with feeding problems. The nonremoval and re-presentation treatment improved feeding behavior for 8 of 12 children. Of those 8 children, 5 had lower levels of expulsions, and 4 of the 8 children had higher levels of mouth clean with the Nuk than with the spoon. We describe the subsequent clinical course of treatment and present follow-up data for 7 of the 8 children who responded to the nonremoval and re-presentation treatment with the spoon or Nuk. The data are discussed in terms of potential reasons why the utensil manipulation improved feeding behavior for some children. Key words: escape extinction, expulsion, feeding disorder, Nuk, pediatric feeding disorders, representation

One common strategy for treating problem feeding behavior is to implement interventions sequentially after the problem behavior emerges. For example, Sevin, Gulotta, Sierp, Rosica, and Miller (2002) treated the food refusal of one child with nonremoval of the spoon, which was associated with increased acceptance of bites and a concomitant increase in expulsion (spitting out the bite). Although re-presentation (replacing the expelled bite into the child’s mouth) resulted in decreased expulsion, it also was associated with increased packing (pocketing or holding food in the mouth). The investigators used a rubberbristled utensil called a Nuk to collect the packed food from the child’s mouth and to redistribute it onto the child’s tongue to decrease packing. Implementation of treatment components sequentially after problem behavior emerges allows the clinician to develop an individualized Jonathan W. Wilkins is currently affiliated with Nationwide Children’s Hospital, The Ohio State University, Columbus. Address correspondence to Cathleen C. Piazza at [email protected]. doi: 10.1002/jaba.169

intervention with the fewest components necessary to achieve efficacy. There are several potential disadvantages, however, of sequential treatment implementation after problem behavior emerges. First, emergence of behavior such as expulsion will result in escape from eating expelled bites until an effective intervention is implemented. In this situation, expulsion gains response strength each time it contacts reinforcement, potentially increasing the length of time required to reduce subsequent behavior (Lattal & Neef, 1996). Second, many children with feeding problems are inexperienced eaters who do not exhibit developmentally appropriate feeding behavior (Arvedson & Brodsky, 2002). By contrast, feeding behavior in typically eating children usually emerges according to a predictable developmental sequence. For example, tongue thrust or tongue protrusion is present at birth and allows an infant to suckle during breast or bottle feeding. The suckling pattern, of which tongue thrust is a component, consists of a horizontal inand-out movement of the tongue (Arvedson & Brodsky, 2002). Tongue thrust disappears around 4 to 6 months of age and is replaced by tongue lateralization around 6 to 9 months of age in typically

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SPOON VERSUS NUK eating children. In children with feeding problems, tongue thrust, which often persists well beyond 6 to 9 months of age, results in the child pushing some or all of the bolus out of the mouth (Arvedson & Brodsky, 2002). Thus, in the absence of treatment, the child with persistent tongue thrust makes errors during feeding (Terrace, 1969). In this example, the error consists of thrusting the tongue during bite presentation, which may promote persistence of the problem feeding behavior and interfere with development of more age-appropriate and functional feeding skills. The child with persistent tongue thrust may not learn to lateralize food, which is a necessary skill for the successful management of solids. Rather than adding treatments sequentially as in Sevin et al. (2002), an alternative strategy is to include procedures during the initial intervention that would function as treatment for specific problem feeding behavior. With the former approach, the clinician implements a treatment component only after a period of time in which he or she has determined that a specific behavior problem such as expulsion is going to emerge, persist, and require treatment. By contrast, with the latter approach, the clinician programs an intervention into the treatment to target a specific behavior problem even though he or she does not know whether the behavior problem will emerge, persist, and require treatment. Programming treatment components a priori has the advantage of potentially minimizing the history of reinforcement for the behavior. This strategy also potentially promotes use of correct feeding skills concomitant with the point when the child first begins accepting food. Expulsion and packing are problems that often emerge as children begin to accept bites during feeding treatment. Altering the presentation method may be one way of treating problem feeding behavior (Girolami, Boscoe, & Roscoe, 2007; Sharp, Harker, & Jaquess, 2010; Sharp, Odom, & Jaquess, 2012). Girolami et al. (2007) and Sharp, Harker, et al. (2010) reported that expulsion was lower when the therapist presented bites using a Nuk. Sharp, Harker, et al. also reported that mouth

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clean, a product measure of swallowing, was higher with the Nuk than with the upright spoon. Investigators often conduct utensil assessments with children who have a history of treatment with nonremoval of the spoon (e.g., Girolami et al., 2007; Sharp, Harker, et al., 2010; Sharp et al., 2012). That is, investigators first implement nonremoval of the spoon and then conduct a utensil assessment if the child exhibits an increase in expulsion, packing, or both. We wondered whether it might be beneficial to manipulate the utensil during initial treatment for refusal rather than altering the utensil after problem behavior emerged and persisted for a period of time in the absence of treatment. We also were interested in following these children to describe the clinical course of treatment associated with spoon versus Nuk presentation. These data might provide evidence for the generality of the treatments by demonstrating that improvements in behavior extend beyond the confines of the study (Sharp, Jaquess, Morton, & Hertzinger, 2010; Sharp et al., 2012). In the current investigation, we extended the work of Girolami et al. (2007) and Sharp, Harker, et al. (2010) by evaluating the effects of a utensil manipulation during initial treatment of 12 children with significant feeding problems. During baseline, the feeder presented food on a spoon in one condition or a Nuk in another condition. Next, we continued alternating between utensils in the context of a treatment for refusal. One purpose of the study was to evaluate levels of expulsion, acceptance, mouth clean, and grams consumed associated with spoon versus Nuk presentation during initial treatment of the child’s feeding problem. A second purpose was to describe the clinical course of treatment and to provide followup data on children whose feeding behavior improved during treatment with the spoon or Nuk. METHOD Participants, Setting, and Materials Twelve children who had been admitted consecutively to a pediatric feeding disorders

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program participated. Katie attended the intensive outpatient program Monday through Friday from 8:30 a.m. to 1:00 p.m. All other children attended the day-treatment program Monday through Friday from 8:30 a.m. to 5:00 p.m. We followed our typical clinical course for all 12 children, which is to conduct a functional analysis and then implement function-based treatment. Due to space limitations, we do not describe the functional analysis here, but see Bachmeyer et al. (2009) for a description. The results of the functional analyses indicated that escape functioned as reinforcement for the inappropriate mealtime behavior for all 12 children. Our program data suggest that approximately 55% of patients in the intensive outpatient and day-treatment programs who respond to function-based treatment will require additional components, such as presentation of food on a Nuk, to treat expulsion and packing. Therefore, it was a reasonable clinical course to alternate between spoon and Nuk presentation during initial treatment. An interdisciplinary team (dietitian, gastroenterologist, psychologist, and speech therapist) evaluated each child before admission and confirmed the appropriateness and safety of oral feeding. The participants were Catherine, 2 years; Katie, 13 months; Kelly, 4 years; Michael, 22 months; Melissa, 6 years; Madeline, 2 years; Nick, 21 months; Kyle, 2 years; Randy, 3 years; Betty, 15 months; Jason, 2 years; and Chloe, 2 years. All children except Katie and Nick received the majority of calories via enteral (e.g., gastrostomy) or enteral plus parenteral feeds. Katie and Nick did not consume sufficient calories for weight gain and growth. Kelly, Michael, Melissa, Nick, Randy, and Jason had been diagnosed with developmental delays. The observers, feeder, and child were in a room (4 m by 4 m) during sessions for the spoon versus Nuk assessment, Week 7 intensive outpatient or day-treatment sessions, and outpatient follow-up, unless otherwise noted. The observers, child, and caregivers were in the home during the Week 8

intensive outpatient or day-treatment home visits. During home visits, the child was in the room in which the family usually ate. During all sessions, each child used age-appropriate seating (e.g., toddler highchair, booster seat). Also present were utensils, food trays, gloves, and timers. Feeders The feeders (therapists) during the majority of the intensive outpatient or day-treatment admission and the observers were individuals with bachelor’s, master’s, or doctoral degrees in psychology, behavior analysis, or a related field. We trained each child’s caregivers to implement the treatment, and the caregiver served as feeder as described below. Design and Procedure Design. We used a multielement design in our analysis of the effects of utensil type (spoon vs. Nuk). We used an ABAB design to demonstrate functional control for the treatment. General procedure, dependent variables, and data collection. Trained feeders conducted two to five meals per day with at least 1 hr between the start of each meal (e.g., 9:00 a.m., 10:30 a.m.). Meals lasted 30 to 45 min. Each meal consisted of two to 10 sessions, with 1- to 2-min breaks between each session. Each session consisted of five bite presentations. The bolus size for each presentation was a level small Maroon spoon (Catherine, Katie, Kelly, Melissa, Nick, and Randy), a half-level small Maroon spoon (Madeline, Kyle, Jason, and Chloe), or a level baby spoon (Michael and Betty). To level the bolus, the feeder scooped food into the bowl of the spoon and then scraped the bowl of the spoon on the side of the dish. For the half-level bolus, the feeder filled half of the bowl of the spoon with food and scraped the spoon on the side of the dish. The feeder equated the bolus sizes for spoon and Nuk sessions by filling the child’s prescribed spoon with the appropriate amount of food and then scraping the food off the spoon onto the Nuk. Each caregiver selected approximately eight

SPOON VERSUS NUK to 16 foods that the feeder presented to the child (contact the author for a list of foods for each child). The feeder prepared the foods at a pureed texture, which is table food blended in a chopper until smooth, with liquid added as needed. The speech therapist recommended the bolus sizes and texture. The feeder randomly selected three foods, one from each of the food groups of protein, starch, and vegetable for Kyle, Jason, and Chloe (no fruit due to dietary restrictions), or four foods, one from each of the food groups of fruit, protein, starch, and vegetable for all other participants, to present during each meal. The feeder presented all foods from the caregiver-selected food list in each phase and with each utensil type to control for any possible differences in behavior as a function of food type (Patel, Piazza, Santana, & Volkert, 2002). The feeder randomly alternated the order of food presentation from session to session. Each food was in a separate bowl, and the feeder placed each bowl of food on a kitchen scale before and after each session and recorded the pre- and postsession weights to calculate grams consumed. At the conclusion of the session, the feeder wiped up any spill with paper towels. Spill was any food that was not in the child’s mouth or the bowls (e.g., food in the bib) at the end of the session. The feeder used the following formula to calculate grams consumed for a single food: (presession weight minus postsession weight) minus (weight of paper towels with spill minus weight of paper towels without spill). For example, if the weights of the presession bowl, the postsession bowl, and spill for mashed potatoes were 40 g, 20 g, and 5 g, respectively, then the grams consumed for mashed potatoes for the session would be 15 (i.e., [40 – 20] – 5). The data presented for grams consumed for each session is the sum of the gram weights for the three or four foods presented in the session. For example, if the weights of the foods for a session were 15 g for mashed potatoes, 12 g for plums, 9 g for bread, and 12 g for peas, the total grams consumed for the session would be 48.

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The feeder presented the bite by placing the utensil touching the child’s lips and saying “take a bite” approximately once every 30 s. If the child opened his or her mouth in the absence of inappropriate mealtime behavior (i.e., turning the head or batting the spoon) and crying within 5 s of presentation, the feeder deposited the bite and provided praise, and observers scored acceptance. If the child failed to close his or her mouth to pull the food off the utensil when the bite entered the mouth, the feeder gently scraped the bite on the child’s teeth with the spoon or deposited the bite by gently rolling the Nuk on the middle of the child’s tongue. If the entire bite, with the exception of food smaller than a pea, entered the child’s mouth, (not including the bite entering the child’s mouth during re-presentation), the observer activated a timer for 30 s. The feeder said “show me” at 30 s to determine if the child had swallowed and to provide the observers the opportunity to score mouth clean or pack. Observers had five potential opportunities per session to score mouth clean or pack, which corresponded to one potential scoring opportunity for each of the five bite presentations. Observers scored mouth clean if no food larger than a pea was in the child’s mouth, unless the absence of food at the 30-s check was due to expulsion (see below for details). The feeder delivered praise for mouth clean and presented the next bite. If the entire bite (with the exception of food smaller than a pea) did not enter the child’s mouth, the feeder did not conduct a mouth check, and observers did not score mouth clean or pack for that bite presentation. Observers scored pack if the entire bite (with the exception of food smaller than a pea) entered the child’s mouth, and food larger than a pea was in the child’s mouth at the 30-s check. In this case, the feeder said, “You need to swallow your bite,” and presented the next bite. If the child was packing at the 30-s check for the fifth bite, the feeder said, “You need to swallow your bite,” the observer scored pack, and the feeder continued to prompt the child to swallow every

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30 s until there was no food larger than a pea in the mouth or 10 min (Catherine, Michael, Melissa, Madeline, Randy, and Chloe) or 15 min (Katie, Kelly, Nick, Kyle, Betty, and Jason) had elapsed from the beginning of the session. Note, however, that the observer did not score mouth clean or pack at these subsequent mouth checks. If there was food in the child’s mouth after the expiration of the time cap, the feeder removed it. Observers scored an expulsion any time the entire bite entered the child’s mouth (except for food smaller than a pea), and food larger than a pea exited the mouth past the plane of the child’s lips. If there was no food in the child’s mouth at the 30-s check because the child had expelled the bite, the observer did not score mouth clean or pack. Note, however, that in sessions in which the feeder used re-presentation (in treatment, see below), if (a) the child swallowed the re-presented bite so that there was no food in the mouth at the 30-s check, the observer scored mouth clean; or (b) the child did not swallow the re-presented bite so that there was food in the mouth at the 30-s check, the observer scored pack. The feeder provided no differential consequences for negative vocalizations, vomiting, gagging, or coughing. Spoon versus Nuk assessment. The purpose of the assessment was to evaluate the effects of utensil, spoon versus Nuk, in the context of treatment for refusal. The feeder used random selection with counterbalancing to identify a utensil to use during each session. The feeder followed the general procedure described above in addition to the specific contingencies described for each condition below. Baseline. The feeder followed the general procedure described above, with the following modifications. The feeder deposited the bite only if the child opened his or her mouth in the absence of inappropriate mealtime behavior and crying. The feeder did not re-present expelled bites. If the child did not engage in inappropriate mealtime behavior and did not open his or her mouth to allow the feeder to deposit the bite in the absence of inappropriate mealtime behavior and crying, the

feeder held the spoon in its original presentation position for 30 s. At the end of the 30-s interval, the feeder removed the utensil and presented the next bite. We arranged the following contingencies based on the results of functional analyses of inappropriate mealtime behavior conducted before the study (Bachmeyer et al., 2009): For Catherine, Katie, Michael, Melissa, Kyle, Randy, and Betty, the feeder delivered attention and removed the utensil for 30 s if the child engaged in inappropriate mealtime behavior. For Kelly, Nick, Madeline, Jason, and Chloe, the feeder removed the utensil for 30 s if the child engaged in inappropriate mealtime behavior. Treatment. The feeder provided no differential consequence for inappropriate mealtime behavior. If the child did not accept the bite within 5 s of presentation, the feeder held the utensil touching the child’s lips and deposited the bite whenever the child’s lips and teeth were open wide enough for the feeder to insert the spoon or Nuk into the child’s mouth, except if the child was coughing, gagging, or vomiting. If the child was coughing, gagging, or vomiting, the feeder held the utensil touching the corner of the child’s lips until the child stopped coughing, gagging, or vomiting, and then the feeder deposited the bite. If the child clenched his or her teeth but did not engage in inappropriate mealtime behavior, the feeder attempted to place the utensil between the child’s lips and deposited the bite when the child opened his or her mouth. If the child expelled the bite, the feeder collected the bite on the utensil and placed it back into the child’s mouth. If the child engaged in more than 25 inappropriate mealtime behaviors during a session or if the rate of inappropriate mealtime behavior was greater than three per minute for three consecutive sessions, a blocker entered the room and stood behind the child’s chair. The blocker placed his or her hands so that they were approximately level with the child’s chest during spoon or Nuk presentation and blocked the child’s hands from touching his or her mouth. This arrangement allowed the feeder to keep the spoon or Nuk at

SPOON VERSUS NUK the child’s lips while allowing the child to engage in inappropriate mealtime behavior (e.g., the child could turn his or her head or bat at the blocker’s hand). We discontinued use of the blocker when the child’s inappropriate mealtime behavior was three per minute or less for three consecutive sessions. Sessions continued until the child had swallowed all five bites or 10 min (Catherine, Michael, Melissa, Madeline, and Randy) or 15 min (Katie, Kelly, Nick, Kyle, Betty, Jason, and Chloe) had elapsed from the beginning of the session. If the child had food in his or her mouth after the expiration of the time limit, the feeder removed it. Per caregiver request, the feeder talked to Katie and Jason during treatment, and Jason had access to preferred toys. Protocol changes during the intensive outpatient or day-treatment admission. The length of the intensive outpatient and day-treatment admission is approximately 320 hr, which is equivalent to 40 8-hr days. When describing the course of treatment for each child during the intensive outpatient or day-treatment admission in the Results, we will refer to each 40 hr of participation in the program as a week (e.g., Week 1, Week 2). For each child, we began the functional analysis in Week 1 and completed the spoon versus Nuk assessment as indicated below (range, Weeks 2 to 5). At the conclusion of the spoon versus Nuk assessment, we identified an appropriate utensil for the child based on visual inspection of the data. If the selected utensil was the Nuk, the feeder conducted the majority of sessions with the Nuk and one session per day with the spoon to evaluate the child’s performance with the spoon. We used these data to determine when we could transition from the Nuk to the spoon. We modified the treatment for most children to promote progress or respond to caregiver requests during the remainder of the child’s intensive outpatient or day-treatment admission. The timing of caregiver training was individualized and is described below. Note that we also worked on other feeding goals throughout the admission (e.g., self-drinking).

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For most children, Week 7 in the intensive outpatient or day-treatment admission was their final week in the clinic. During Week 8, the therapist observed the caregiver feeding the child in the home. During home visits, the caregiver followed the child’s typical feeding schedule, which generally consisted of three meals and two snacks. Therapists conducted multiple observations each day in the home, with at least one observation at each meal and snack time over the course of the Week 8 home visits. Outpatient follow-up. After completion of the intensive outpatient or day-treatment program, all children who responded to the treatment with the spoon or Nuk (except Kyle) transitioned to the outpatient follow-up program. The child and his or her caregiver attended 1- to 1.5-hr outpatient sessions approximately once per week. Most children continue with outpatient therapy until the child is a developmentally typical feeder. (We will not describe the course of outpatient followup for the treatment nonresponders.) During outpatient follow-up, the caregiver continued to conduct the child’s intensive outpatient or day-treatment discharge protocol described above unless otherwise noted. Each follow-up data point represents the child’s behavior x months from discharge from the intensive outpatient or daytreatment program. For example, the 12-month follow-up data point represents the child’s behavior 12 months after he or she had been discharged from the intensive outpatient or day-treatment program. The last follow-up data point represents the child’s behavior immediately before submission of this paper. Data Conversion and Interobserver Agreement We converted data for acceptance and mouth clean to a percentage after dividing the number of occurrences of acceptance or mouth clean by the number of bite presentations (denominator for acceptance) or the number of bites that entered the child’s mouth (denominator for mouth clean). We calculated expulsions per bite by dividing the number of expulsions by the number

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of bites that entered the child’s mouth, not including bites that entered the mouth during representation. We calculated interobserver agreement for acceptance and mouth clean by partitioning the session into 10-s intervals; summing occurrence (a 10-s interval in which both observers scored the behavior) and nonoccurrence (a 10-s interval in which both observers did not score the behavior) agreements; dividing by the sum of occurrence agreements, nonoccurrence agreements, and disagreements (a 10-s interval in which one observer scored and the other observer did not score the behavior); and converting the ratio to a percentage. We calculated exact agreement coefficients for expulsions by dividing the number of 10-s intervals in which observers scored the same frequency of expulsions by the total number of 10-s intervals in the session and converting the ratio to a percentage. A second observer independently scored a mean of 37% (range, 11% to 64%) of sessions across participants. Mean agreement across participants was 98% (range, 79% to 100%) for acceptance, 99% for mouth clean (range, 83% to 100%), and 97% (range, 61% to 100%) for expulsions. We assessed interobserver agreement for grams consumed for Katie, Melissa, Nick, Kyle, and Chloe by having a second observer independently record the pre- and postsession weights and spill on a separate data sheet and calculate grams consumed. We calculated interobserver agreement for grams consumed by dividing the smaller by the larger number of grams consumed and converting the ratio to a percentage. We assessed interobserver agreement on a mean of 20% (range, 2% to 35%) of sessions. Mean interobserver agreement was 97% (range, 0% to 100%). RESULTS We present data for expulsions graphically because it was the dependent variable that was most sensitive to the utensil manipulation. We present data for acceptance, mouth clean, grams

consumed, and follow-up in Table 1. To describe the course of the child’s clinical treatment during the intensive outpatient or day-treatment program after the completion of this analysis, we present data for the child’s final week in clinic (Week 7) and home visits (Week 8). Data for Weeks 7 and 8 represent the means for all sessions conducted with the treatment during that week with the feeders as indicated. Expulsions per bite are depicted for Catherine, Katie, and Kelly in Figure 1; for Michael, Melissa, and Madeline in Figure 2; and for Nick and Kyle in Figure 3. Data for Randy, Betty, Jason, and Chloe are presented only in Table 1, because the treatment was not effective. Expulsions per bite were higher with the spoon than with the Nuk during treatment for Catherine, Katie, Kelly, Michael, and Melissa. Expulsions per bite were slightly higher with the spoon than with the Nuk in the first phase of treatment for Madeline, but became equivalent in the second phase of treatment. Expulsions per bite were equivalent throughout the assessment of spoon versus Nuk for Nick and Kyle. Recall that the feeder did not re-present the bite in baseline. The inclusion of re-presentation in treatment increases the number of opportunities for the child to expel the bite in treatment relative to baseline. That is, each time the feeder re-presents the bite, the child has another opportunity to expel. These increased opportunities to expel explain the overall increase in expulsions per bite from baseline to treatment. For Catherine, we completed the spoon versus Nuk assessment in Week 5 of her day-treatment admission. We continued treatment with the Nuk because of the relatively lower rates of expulsions, higher levels of mouth clean, and more grams consumed. We added noncontingent attention in which the feeder interacted as a caregiver would in a typical meal per caregiver request and began caregiver training in the clinic during Weeks 5 and 6. Over the course of admission, acceptance and mouth clean continued to increase, and expulsions and grams consumed remained stable. During Weeks 7 and 8, feeders continued to use the Nuk in

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Table 1 Summary of Results from the Spoon versus Nuk Assessment Baseline

Treatment

Parent-fed sessions Follow-up (months)

Spoon Treatment responders Catherine Expel 0.7 Accept (%) 8 Mouth clean (%) 0 Grams 1.1 Katie Expel —a Accept (%) 0 Mouth clean (%) —a Grams —a Kelly Expel —a Accept (%) 0 Mouth clean (%) —a Grams —a Michael Expel 0.6 Accept (%) 8 Mouth clean (%) 16 Grams 1.6 Melissa Expel 0.5 Accept (%) 19 Mouth clean (%) 8 Grams 0.1 Madeline Expel 0.2 Accept (%) 45 Mouth clean (%) 15 Grams 1.1 Nick Expel 0 Accept (%) 31 Mouth clean (%) 38 Grams 4.4 Kyle Expel 0 Accept (%) 23 Mouth clean (%) 49 Grams 1.3 Treatment nonresponders Randy Expel 0 Accept (%) 1 Mouth clean (%) 7 Grams 0.1 Jason Expel —a Accept (%) 0 Mouth clean (%) —a Grams —a

Nuk

Spoon

Nuk

Week 7

Week 8

3

6

12

0.3 1 2 1.5

29.0 92 0 0.3

1.5 35 59 4.5

0.2 83 95 7

0.1 87 97

0 100 100 6

0 100 100 9

0 93 100 8

—a 0 —a —a

2.4 9 2 4.1

0.4 5 38 4.2

0 98 96 6

0 91 94

0 100 100

0 100 100 11

0 100 100

—a 0 —a —a

4.8 75 60 4.6

0.8 60 83 4.2

0 96 85 4

0 94 85 4

0.1 14 85 1.0

0.7 75 94 4.4

0.2 60 93 4.2

0.2 98 98 11

0.1 98 99

0 100 100 13

0.1 100 100 13

0 100 100 18

0.2 20 0 0.4

2.4 64 2 3.8

1.1 72 25 3.1

0.1 99 72 4

0 95 86 3

0 100 100

0.5 41 20

0 100 73

0.2 46 32 1.0

0.8 86 93 4.2

0.8 83 89 3.8

0 99 90 15

0 97 88 15

0 100 100 19

0 90 100

0 29 40 2.6

0.2 73 87 7.1

0.1 57 96 5.4

0 94 99 9

0 96 100 10

0 85 100 7

0 100 100 7

0 25 45 1.0

0.8 83 49

0.4 89 52

0.2 7 17 0.6

0.1 81 62 6.9

0.3 81 64 5.7

—a 0 —a —a

2.9 12 0 3.6

1.3 0 0 3.5

0 100 60 6

and and and and

18

24

0b 100b 80b 8b

0 100 100

0 100 100

(Continued)

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Table 1 (Continued) Baseline

Treatment

Parent-fed sessions Follow-up (months)

Betty Expel Accept (%) Mouth clean (%) Grams Chloe Expel Accept (%) Mouth clean (%) Grams

Spoon

Nuk

Spoon

Nuk

—a 0 —a —a

0.1 9 0 0.1

1.2 49 1 0.2

1.0 64 11 0.4

—a 0 —a —a

—a 0 —a —a

7.3 12 0 3

1.1 3 3 3.5

Week 7

Week 8

3

6

12

18

24

a

No opportunity for the behavior to occur. Data from spoon and Nuk sessions, respectively.

b

the clinic and child’s home, respectively. At 3- and 6-month follow-ups, Catherine was accepting and swallowing bites from the Nuk with caregivers as feeders. We used three-step prompting (i.e.,

sequential verbal, gestural, and physical prompts), bolus fading (gradually increasing the amount of food on the spoon), and differential positive (attention) and negative (a break from spoon

Figure 1. Expulsions per bite for Catherine (top), Katie (middle), and Kelly (bottom).

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Figure 2.

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Expulsions per bite for Michael (top), Melissa (middle), and Madeline (bottom).

presentation) reinforcement to teach Catherine to close her lips around the spoon. At 12-month follow-up, Catherine accepted and swallowed all bites from the spoon when presented by caregivers or nanny. For Katie, we completed the spoon versus Nuk assessment and began caregiver training during Week 4. We continued treatment with the Nuk because of the relatively lower rates of expulsions, higher levels of mouth clean, and more grams consumed. Over time, expulsions decreased and mouth clean increased during spoon sessions so that caregivers were conducting all sessions with the spoon by Week 7. Over the course of admission, acceptance and mouth clean continued to increase, expulsions decreased further, and grams consumed remained stable. During 3-, 6-,

and 12-month follow-ups, caregivers continued to present bites to Katie on a spoon. For Kelly, we completed the spoon versus Nuk assessment in Week 2. We continued treatment with the Nuk because of the relatively lower rates of expulsions and higher levels of mouth clean. We began caregiver training in the clinic during Week 3. During Week 8 home visits, we transitioned Kelly to the spoon for all sessions, and caregivers began presenting one bite after another. During outpatient follow-up, her caregivers returned to presentation of one session per day with the spoon and the remaining sessions with the Nuk. At 3-month follow-up, we conducted sessions with caregivers presenting bites on the Nuk and on the spoon. At that point, her caregivers

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Figure 3. Expulsions per bite for Nick (top) and Kyle (bottom).

discontinued outpatient therapy when her mother was deployed. For Michael, we completed the spoon versus Nuk assessment in Week 3. We continued treatment with the Nuk because of the relatively lower rates of expulsions. We began caregiver training in the clinic, added noncontingent attention as described above per caregiver request, transitioned to the spoon only, and transitioned to a small Maroon spoon during Weeks 3, 3, 4, and 5, respectively. During 3-, 6-, and 12-month follow-ups, caregivers continued to present bites on a spoon on a fixed-time 15-s schedule. For Melissa, we completed the spoon versus Nuk assessment in Week 2. We continued treatment with the Nuk because of the relatively lower rates of expulsions and higher levels of mouth clean. We presented one food in each session, began caregiver training in the clinic, presented bites every 15 s, and added noncontingent attention (described above) during Weeks 2, 2, 3, 6, and 7, respectively. We trained teachers and day care

staff during Week 8 (i.e., the therapist went to the school and day care as well as home). We provided outpatient follow-up to Melissa via telehealth. Data collectors were in a private room in the clinic and were linked to the family via a secure webconferencing platform. The family was at home in the kitchen and used a webcam on their computer. At 3-month follow-up, Melissa’s caregivers presented all bites on a Nuk. We taught Melissa to close her mouth around the spoon using three-step prompting (sequential verbal, model, and physical prompts). At 6-, 12-, and 18-month follow-ups, Melissa’s caregivers presented all bites on a spoon. For Madeline, we completed the spoon versus Nuk assessment in Week 2. We continued treatment with the spoon after this assessment. We increased the bolus to a level small Maroon spoon, presented bites every 15 s, began caregiver training in the clinic, and increased the bolus to a level large Maroon spoon during Weeks 2, 2, 3, and 6, respectively. At 3- and 12-month followups, Madeline’s caregivers continued to present

SPOON VERSUS NUK all bites on a spoon. Follow-up data at 6 months were not available. For Nick, we completed the spoon versus Nuk assessment in Week 3 and continued treatment with the spoon. We began caregiver training in the clinic and presented one bite after another during Weeks 4 and 6, respectively. At 3-, 12-, and 24month follow-ups, Nick’s caregivers continued to present all bites on a spoon. Follow-up data at 6 and 18 months were not available. Kyle and his family left the program early because Kyle completed his medical treatment, and the family returned to their home in another state. We do not have any additional data for Kyle. For Randy, acceptance increased and expulsions remained low during treatment. Mouth clean increased initially but then decreased during the second phase of treatment. As mouth clean decreased, sessions often reached the maximum length without Randy swallowing all of the bites. For Betty, acceptance increased during treatment, but mouth clean remained low, and expulsions remained high. For Jason, expulsions were higher with the spoon than with the Nuk during treatment. However, acceptance and mouth clean did not increase to clinically acceptable levels, and sessions often reached the maximum length without Jason swallowing all of the bites. Therefore, we discontinued the spoon versus Nuk assessment for these three children and initiated an assessment with a flipped spoon. For these three children, their final treatment included the flipped spoon in conjunction with other treatment components (e.g., nonremoval of the spoon, noncontingent reinforcement). For Chloe, acceptance did not increase during the assessment, and negative vocalizations were unacceptably high. In addition, sessions often reached the maximum length without Chloe swallowing all of the bites. Therefore, we discontinued the spoon versus Nuk assessment. Chloe’s caregiver discontinued therapy before we could develop an alternative treatment for her refusal of solids.

705 DISCUSSION

In the current investigation, we evaluated whether presentation of bites on a spoon or a Nuk would have beneficial effects during initial treatment of the refusal behavior of 12 children with severe feeding problems. These were children with significant refusal, selectivity, or both, who had not been exposed to the nonremoval and re-presentation treatment in the past. The results suggested that eight of the 12 children responded to the nonremoval and representation treatment in terms of increased acceptance and mouth clean and low levels of expulsions. For the eight children who responded to treatment, five exhibited lower levels of expulsions, and four of the five had higher levels of mouth clean with the Nuk than with the spoon. These data are important because they show that utensil manipulation may be beneficial during initial treatment for some children. Note that this procedure did not prevent the occurrence of expulsion or other problem feeding behavior, nor was the study designed to compare reactive and proactive treatments. The data from Sevin et al. (2002) showed that problem mealtime behavior (e.g., expulsion and packing) may emerge during initial treatment of refusal. Sevin et al. added treatments sequentially as problem mealtime behavior emerged. The disadvantage of this sequential treatment approach was that the child in Sevin et al. escaped many of the presented bites as a result of expulsion when re-presentation was absent from the nonremoval of the spoon. Data from the functional analyses of inappropriate mealtime behavior, defined as head turns and batting at the utensil, conducted before this study showed that escape from bites was a reinforcer for inappropriate mealtime behavior for all 12 children in this study; therefore, it is reasonable to expect that repeated exposure to reinforcement in the form of escape from bites as a result of expulsions would maintain expulsions as well. Even though representation of expelled bites was a component of

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the initial treatment for all of the children in the current investigation, re-presentation was not effective as treatment for expulsions when the feeder presented food on a spoon for five of the children. Therefore, the children with high levels of expulsions during spoon presentations experienced brief escape from the bite each time they expelled. That is, brief escape occurred from the time the child spit out the bite until the feeder represented the bite. By contrast, less escape from bites occurred for the five children who had lower levels of expulsions with the Nuk. The Nuk was helpful not only in reducing expulsions but also in increasing mouth clean for four children. One reason why presentation of bites on a Nuk may be associated with lower levels of expulsions and higher levels of mouth clean is that the feeder can place the food directly onto the child’s tongue with the Nuk. By contrast, placement of food on the tongue with the upright spoon is possible only if the child closes his or her mouth around the bowl of the spoon and pulls the food off of the spoon or if the feeder flips the spoon and drags the food along the tongue (Sharp, Harker, et al., 2010; Volkert, Vaz, Piazza, Frese, & Barnett, 2011). Placement of the food on the tongue is important because it is one of the first behaviors in the chain (i.e., bolus formation) that leads to swallowing. Some children with feeding problems may lack the skill or motivation to move the food to the tongue to form the bolus. If the feeder places the food on the child’s tongue, the child only needs to elevate the tongue and propel the food into the pharynx. In this case, the child may be more likely to swallow correctly, without expulsion or packing. If the child is just learning to eat, as is the case with many children with significant refusal who participate in initial treatment, it may be advantageous to provide them with the opportunity to accept and swallow bites in a feeding context that is more likely to be associated with low levels of expulsion and packing. Early experiences with correct eating behavior may be more likely to be associated with correct eating behavior in the future, whereas

early experiences with making errors such as expulsion or packing during eating may be more likely to be associated with errors during eating in the future. These are issues that should be explored in future research. These data replicate those of other studies that have shown the benefits of presentation of bites on a Nuk (Girolami et al., 2007; Sharp, Harker, et al., 2010) for some children. Girolami et al. (2007) showed that re-presentation of bites with a Nuk resulted in lower levels of expulsions than re-presentation with a spoon for one child. Expulsions decreased further when the feeder presented and re-presented bites on a Nuk. Sharp, Harker, et al. (2010) showed that mouth clean was higher with presentation of bites on a Nuk than on a spoon for one child. Similarly, for four children in the current investigation, levels of mouth clean were relatively higher with the Nuk than with the spoon. The data for the current investigation are also similar to Sharp, Harker, et al. in that increases in mouth clean for Catherine, Katie, and Melissa were modest initially. Levels of mouth clean were clinically acceptable (i.e., above 80%) by the last week of treatment (Week 7) in the clinic for these three children. Our findings raise the possibility that mouth clean for the participant in Sharp, Harker, et al. would have increased had they continued the intervention for a longer period of time. Sharp, Harker, et al. reported implementing additional treatment components to increase mouth clean. By contrast, we continued with essentially the same treatment for Catherine, Katie, and Melissa, and mouth clean was above 80% during the last 2 weeks of the day-treatment or intensive outpatient admissions. One difference between the current investigation and that of Sharp, Harker, et al. is that Sharp, Harker, et al. did not implement re-presentation in conjunction with utensil manipulation. It may be the case that clinically acceptable increases in mouth clean occur only after repeated trials in conjunction with re-presentation and utensil manipulation for some children.

SPOON VERSUS NUK What is not clear from the current investigation is why some children benefitted from the Nuk whereas others were able to eat just as proficiently with the spoon. One variable that seems reasonable to explore is eating experience. In the current investigation, all of the children had significant feeding problems that affected their experience as oral feeders. Ten of the 12 children received the majority of their calories via tube feedings. Only Kelly and Nick consumed 100% of their calories orally, although their variety and volume of foods consumed were limited. Nevertheless, percentage of calories consumed by mouth before treatment did not appear to be a good predictor of whether the child would be successful with the spoon during initial treatment. For example, Kelly, who was a relatively more experienced feeder, benefitted from the Nuk, and Madeline, who was a relatively less experienced feeder, was able to eat successfully with the spoon. Perhaps pretreatment quantification of oral motor skills might be a better predictor of the necessity of utensil manipulation during initial treatment. Although our program speech therapist evaluated all of the children before admission, she did not conduct a standardized assessment of oral motor skills, and this is a limitation of the current investigation. One challenge of pretreatment assessment of oral motor skills is that many children with severe feeding problems refuse to accept bites of food before treatment; therefore, it is difficult to evaluate their level of oral motor competence in the presence of food before treatment. One option might be to evaluate oral motor skills in a nonnutritive context. It is not clear whether a nonnutritive evaluation of oral motor skills would predict competence as an oral feeder, and that might be a direction for future research. A related limitation is that we did not equate bite placement across utensils. One of the inherent limitations of upright spoon presentation is that it is not possible to place the bite on the child’s tongue if the child fails to close his or her mouth around the bowl of the spoon. By contrast, it would have been possible to scrape the bolus onto the child’s teeth with the Nuk with the

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goal of attempting to identify the mechanism behind the effectiveness of treatment. Decreased expulsion and increased mouth clean when the therapist placed the bolus on the tongue with the Nuk, but not when he or she scraped the bolus onto the child’s teeth, suggest that bolus placement was an important component of treatment effectiveness. A related limitation is that we did not measure whether the child closed his or her lips around the bowl of the spoon or whether the feeder scraped the bite onto the child’s teeth with the spoon. These measures may be helpful in understanding the mechanisms that underlie the effectiveness of the Nuk and identifying child characteristics that are associated with the need for a utensil manipulation. The effects of bolus placement and lip closure should be the subjects of future investigations. Another limitation of the current study is that treatment was not effective for four of the participants. For three of these four participants, the main variable that influenced our decision to terminate the assessment and implement a different intervention was session duration. For Randy, Jason, and Chloe, sessions often reached the maximum duration before the child had accepted (Jason and Chloe) or swallowed (Randy, Jason, and Chloe) all of the bites. In addition, Chloe had high levels of negative vocalizations during these sessions and persistent open-mouth posture after the session. Chloe’s caregiver terminated services before development of a successful treatment. We did not continue with Betty’s assessment because her high levels of expulsions and low levels of mouth clean did not decrease over the course of 87 treatment sessions. In addition, she produced copious amounts of saliva during the sessions that mixed with expelled food. The data from these four participants suggest that treatments with nonremoval of the spoon and re-presentation may not be effective for increasing consumption for all children with severe feeding problems, and this should be explored in future research. With three of the children (Randy, Betty, and Jason), we used a flipped spoon to reduce expulsions and increase

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mouth clean. Sharp, Harker, et al. (2010) showed that levels of expulsion decreased and levels of mouth clean increased when the feeder presented bites with the Nuk and flipped spoon relative to the upright spoon. The comparison by Sharp et al. (2012) of upright versus flipped spoons for presentation and re-presentation of bites produced similar results. Future investigations should extend the work of Sharp et al. and the current study by comparing the upright spoon, Nuk, and flipped spoon during initial treatment of food refusal. Although presentation of bites on the Nuk was associated with lower levels of expulsions (five children) and higher levels of mouth clean (four children), its disadvantage is that it is not an ageappropriate utensil. We were able to transition to presentation of bites on a spoon during the daytreatment admission with two children and during outpatient follow-up with three children. The Nuk did not seem to be associated with any other negative effects for any participant except Catherine. Levels of acceptance were higher with the spoon than with the Nuk for Catherine. We continued with the Nuk, nevertheless, because levels of expulsions were lower and levels of mouth clean were higher, and these two improvements outweighed the difference in acceptance between the spoon and Nuk in our clinical opinion. Levels of acceptance increased over time with the Nuk for Catherine. This study is important because it describes the course of and provides data from the ongoing clinical treatment of the children who responded to the treatment with the spoon or Nuk following the conclusion of the study. We also provide long-term follow-up data for the majority of these participants. By contrast, most studies on treatment of pediatric feeding disorders provide data for dependent variables only during the course of the study. Little is known about what happens to children with pediatric feeding disorders who participate in clinical studies after the study ends. In the current investigation, all of the children who responded to the treatment with the spoon or Nuk either maintained the gains they had made during the

study or continued to improve (e.g., increases in acceptance and mouth clean for Catherine) during the course of their intensive outpatient or daytreatment admission. In addition, we provide at least 3 months of follow-up data for all participants except Kyle. In fact, we present 12 months of follow-up data for all participants except Kyle and Katie, and we present 18- and 24-month follow-up data for two participants. The follow-up data are important because they show that feeding behavior maintains or improves over time and that most caregivers continue to implement the procedure at least over a 12-month period. To our knowledge, this is one of the larger sets of long-term follow-up data on children who have participated in treatment for feeding disorders. These data are impressive in that 75% of the families whose children responded to the treatment continued to participate in outpatient follow-up for at least 12 months, and continued participation in follow-up was associated with maintenance and improvement in their child’s feeding behavior. It is unlikely that feeding behavior would have improved in the absence of treatment because these were children with long-standing feeding problems that had not improved in the past. In conclusion, the data suggested that use of the Nuk was beneficial for five of the eight participants who completed the assessment. The benefit was primarily observed in rate of expulsions but was paralleled to some extent in the data for mouth clean, and a clear distinction was evident in four children. We were able to transition all participants from the Nuk to spoon either during their intensive outpatient or day-treatment admission or during outpatient follow-up. One surprising finding was that four of the 12 participants did not respond to nonremoval of the spoon or Nuk and re-presentation. Although the literature suggests that escape extinction procedures, such as nonremoval of the spoon, are effective as treatment (Ahearn, Kerwin, Eicher, Shantz, & Swearingin, 1996; Cooper et al., 1995; Hoch, Babbitt, Coe, Krell, & Hackbert, 1994; Piazza, Patel, Gulotta, Sevin, & Layer, 2003; Reed et al., 2004), it is not clear how often children with severe feeding problems fail to respond to

SPOON VERSUS NUK nonremoval of the spoon and re-presentation, probably because papers on treatment failure are rarely published (Rosenthal, 1979; Scargle, 2000). Nevertheless, given that over half of the children who responded to treatment benefitted from presentation of bites on the Nuk, it may be reasonable to consider a utensil manipulation during initial treatment of children with severe feeding problems.

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treatment of a feeding problem. Journal of Applied Behavior Analysis, 35, 183–186. doi: 10.1901/jaba.2002.35-183 Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 36, 309–324. doi: 10.1901/jaba.2003.36-309 Reed, G. K., Piazza, C. C., Patel, M. R., Layer, S. A., Bachmeyer, M. H., Bethke, S. D., & Gutshall, K. A. (2004). On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. Journal of Applied Behavior Analysis, 37, 27–42. doi: 10.1901/jaba.2004.37-27 Rosenthal, R. (1979). The file drawer problem and tolerance for null results. Psychological Bulletin, 86, 638–641. doi: 10.1037/0033-2909.86.3.638 Scargle, J. D. (2000). Publication bias: The “file-drawer” problem in scientific inference. Journal of Scientific Exploration, 14, 91–106. Sevin, B. M., Gulotta, C. S., Sierp, B. J., Rosica, L. A., & Miller, L. J. (2002). Analysis of response covariation among multiple topographies of food refusal. Journal of Applied Behavior Analysis, 35, 65–68. doi: 10.1901/ jaba.2002.35-65 Sharp, W. G., Harker, S., & Jaquess, D. L. (2010). Comparison of bite-presentation methods in the treatment of food refusal. Journal of Applied Behavior Analysis, 43, 739–743. doi: 10.1901/jaba.2010.43-739 Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13, 348–365. doi: 10.1007/ s10567-010-0079-7 Sharp, W. G., Odom, A., & Jaquess, D. L. (2012). Comparison of upright and flipped spoon presentations to guide treatment of food refusal. Journal of Applied Behavior Analysis, 45, 83–96. doi: 10.1901/jaba.2012.45-83 Terrace, H. S. (1969). Extinction of a discriminative operant following discrimination learning with and without errors. Journal of the Experimental Analysis of Behavior, 12, 571–582. doi: 10.1901/jeab.1969.12-571 Volkert, V. M., Vaz, P. C. M., Piazza, C. C., Frese, J., & Barnett, L. (2011). Using a flipped spoon to decrease packing in children with feeding disorders. Journal of Applied Behavior Analysis, 44, 617–621. doi: 10.1901/ jaba.2011.44-617 Received October 4, 2012 Final acceptance May 5, 2014 Action Editor, Rachel Thompson

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