COMPARISON OF UPRIGHT AND FLIPPED SPOON PRESENTATIONSTO 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 onexpulsion and mouth clean (product measure of swallowing) in the treatment of 3 childrendiagnosed 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 inappropriatemealtime behavior and acceptance of bites; however, re-presentation did not reduce expulsion orimprove mouth clean. Results showed a lower level of expulsion and higher percentage of mouthclean during flipped spoon presentations and re-presentations for all participants. Findings fromfollow-up analyses supported transitioning back to an upright spoon in all 3 cases, although thetime 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

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Escape extinction in the form of nonremovalof the spoon (NRS) or physical guidance is awell-supported treatment for chronic foodrefusal among children with pediatric feedingdisorders (e.g., Patel, Piazza, Martinez, Volkert,& Santana, 2002; Piazza, Patel, Gulotta, Sevin,& Layer, 2003). Both procedures increase foodacceptance by targeting inappropriate mealtimebehavior (e.g., pushing away food; headturning) maintained by negative reinforcement(i.e., escape from bite presentations). That is,the feeder persists with a bite presentation bykeeping food at the lips (NRS) or guiding themouth open using gentle jaw pressure (physical

guidance), thereby eliminating escape. Forchildren with minimal or no oral intake, escapeextinction promotes exposure to food andincreases the probability of contact with theprimary and secondary reinforcement associatedwith eating (Hoch et al., 2001). However,alternative topographies of food refusal, such aspushing bites out of the mouth (i.e., expulsion),holding food in the mouth (i.e., packing), gagging,or vomiting, may persist (Girolami, Boscoe, &Roscoe, 2007) or arise during the course oftreatment (Gulotta, Piazza, Patel, & Layer, 2005)despite improvements in acceptance. In such cases,social consequences may not maintain thesebehaviors, but they may persist as a result of anoral-motor deficit. Additional behavioral interven-tions may be necessary to establish swallowing.

Re-presentation, or recovering expelled foodand placing it back into the mouth, representsan additional form of escape extinction that has

Correspondence concerning this article should beaddressed to William G. Sharp, Pediatric Psychologyand Feeding Disorders Program, Marcus Autism Center,1920 Briarcliff Road, Atlanta, Georgia 30329 (e-mail:william.sharp@choa.org).

doi: 10.1901/jaba.2012.45-83

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2012, 45, 83–96 NUMBER 1 (SPRING 2012)

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been demonstrated to increase consumptionwhen frequent expulsion maintained by nega-tive reinforcement disrupts consumption insome cases (Ahearn, Kerwin, Eicher, Shantz,& Swearingin, 1996; Coe et al., 1997). Forexample, Ahearn et al. (1996) reported im-provement in acceptance and a decline inexpulsion associated with the use of re-presen-tation in combination with both NRS andphysical guidance for two of three children withchronic food refusal. Expulsion remained un-changed for a third participant, and the authorsdid not evaluate the relative contribution of re-presentation to address expulsion. Coe et al.(1997) examined the relative impact of differenttreatment elements on the percentage of trialswith acceptance, expulsion, and swallowing fortwo children with food refusal and gastrostomy(G-) tube dependence. During treatment, theauthors sequentially introduced a series of pro-cedures to address different refusal topographies(i.e., refusal to accept, expulsion). Treatmentinvolving NRS plus differential reinforcement(DRA) increased acceptance and improved swal-lowing for one participant, but expulsion remainedhigh in both cases. The addition of re-presentationof expelled bites to the NRS plus DRA packagereduced expulsions to near zero levels and increasedswallowing for both children.

Treatment that involves continual presentationand re-presentation of food minimizes escape andensures contact with food until swallowingoccurs; however, packing may still hinder intake(Gulotta et al., 2005; Sevin, Gulotta, Sierp,Rosica, & Miller, 2002) or expulsion may persistdespite the use of this treatment element (Ahearnet al., 1996; Girolami et al., 2007). For example,Sevin et al. (2002) and Gulotta et al. (2005)reported increased packing following the use of atreatment package that consisted of either NRS orphysical guidance plus re-presentation to addresstotal food refusal. In both studies, swallowing wasachieved only after the introduction of a redis-tribution procedure that typically involved col-lecting food held in the mouth and placing it

onto the tongue using a Nuk brush at 15-sintervals. Although the operant mechanismresponsible for this effect was not isolated ineither study, Gulotta et al. noted that, if packingrepresents refusal topography for avoiding con-sumption, then redistribution may function as aform of positive punishment for packing (i.e.,holding food in the mouth is followed repeatedlyby food placement of tongue) or negativereinforcement (i.e., improved intake occurringas a result of learning to avoid the procedure byswallowing). Avoidance of the procedure, how-ever, did not appear to be responsible forimprovements in swallowing for two of the fourparticipants in Gulotta et al. Although foodremained in the mouth for less time, the childrenrequired one to two redistributions per bite (onaverage) to produce a swallow. Improvementsalso did not remain after the procedure wasremoved, with packing increasing for all fourparticipants. Given this combination of factors,Gulotta et al. asserted that, in some cases, re-distribution may facilitate swallowing by helpingwith bolus formation and placement on thetongue, but it may not necessarily result inpermanent skill acquisition or function as a formof extinction for packing. These studies, howev-er, did not evaluate the relative contribution ofbite placement on swallowing, expulsion, orpacking.

Results from recent studies (Girolami et al.,2007; Sharp, Harker, & Jaquess, 2010; Volkert,Vaz, Piazza, Frese, & Barnett, 2011) highlightthe potential contribution of bite placement onthe tongue to improve swallowing when used incombination with other behavioral elements.Girolami et al. (2007) demonstrated that, afteracceptance stabilized through the use of NRS,presenting and re-presenting bites with a Nukbrush resulted in decreased expulsion whencompared to bites presented and re-presentedwith an upright spoon. The authors also notedthat, although expulsion improved via the alteredpresentation method, the behavior persisted evenwith the re-presentation contingency, suggesting

84 WILLIAM G. SHARP et al.

that expulsion likely was not maintained exclu-sively by negative reinforcement. By the end oftreatment, Girolami et al. reported that expul-sion remained low following the transition backto a spoon for the initial presentation; however,the researchers continued re-presentation with aNuk brush, and no follow-up assessment wasconducted after the reintroduction of the uprightspoon to clarify whether placement with a Nukbrush was necessary to promote swallowing inthe long term. In addition, the length of timenecessary to reintroduce the upright spoon wasnot evaluated systematically.

Sharp et al. (2010) compared the effective-ness of different presentation methods (uprightspoon vs. flipped spoon vs. Nuk brush) indecreasing expulsion and increasing mouthclean without the use of re-presentation duringtreatment of a child with food refusal and oral-motor deficits. Prior to the analysis, a treatmentpackage that consisted of NRS and noncontin-gent access to preferred items was associatedwith improvements in acceptance and inappro-priate mealtime behavior during meals. Thechild, however, expelled all bites, and no mouthcleans were observed. Altering bite presentationto include placement onto the middle of thetongue with the flipped spoon or Nuk brushincreased mouth clean and decreased expulsion.Expulsion and mouth clean remained relativelyunchanged with the upright spoon. However,changes in bite presentation did not lead toclinically significant improvements in these be-haviors during the analysis.

Volkert et al. (2011) evaluated the use of aflipped spoon in a treatment package thatconsisted of redistribution and swallow facilita-tion to address packing. Swallow facilitationinvolved the application of downward pressureon the back of the tongue while simultaneouslydragging the flipped spoon forward. Prior to theintroduction of swallow facilitation, NRS waseffective in increasing acceptance; however,packing emerged when the texture of the foodwas increased. For both participants, packing

decreased (and mouth clean concurrently in-creased) with the implementation of the flippedspoon treatment package. The level of improve-ment varied across participants. One participantachieved zero levels of packing, and packing waslower but remained variable for the secondparticipant. The authors hypothesized that oral-motor deficits may have contributed to thesecond participant’s more gradual response totreatment (vs. learning to avoid the flippedspoon by swallowing), noting that he appearedto require the aid of the flipped spoon toswallow.

The available research indicates that modifyingbite placement, in combination with conse-quence-based procedures, may improve swallow-ing among some children with pediatric feedingdisorders who also have oral-motor deficits.Past studies have varied in the level of improve-ment documented with a flipped spoon, andresearch has yet to evaluate whether the use ofmodified bite placement can be eliminatedfollowing clinically significant improvements inoral intake. The purpose of the current studywas to extend Sharp et al. (2010) by comparingthe effectiveness of different presentation meth-ods (upright spoon vs. flipped spoon) indecreasing expulsion and increasing mouthclean in a treatment package that also includedre-presentation for expulsion. We also soughtto reassess the impact of bite placement onmouth clean and expulsion at discharge andduring follow-up visits to evaluate the transi-tion back to an upright spoon over time.

METHOD

Participants, Setting, and Materials

The participants were three children who hadbeen admitted to an intensive interdisciplinaryday-treatment program for the assessment andtreatment of chronic food refusal and 100% G-tube dependence. Joshua and Jimmy were 2-year 1-month-old twin brothers whose medicalhistory included prematurity, bronchopulmo-nary dysplasia (BPD), gastroesophageal reflux

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disease (GERD), development delay, and visualimpairment. Greg was a 2-year 9-month-oldboy whose medical history includes prematuri-ty, GERD, BPD, patent ductus arteriosus,developmental delay, cerebral palsy, and Grade4 intraventricular hemorrhage following birth.In all three cases, inappropriate mealtime be-havior and frequent expulsions consistentlyhindered adequate consumption. Prior to ad-mission, a swallow study and occupationaltherapy examination indicated that all threechildren could swallow smooth pureed-texturefoods safely, but they also noted difficultyretaining food in the mouth due to tongueprotrusions, drooling, or limited lip closure.

Trained therapists conducted sessions inrooms (3 m by 3 m) equipped with one-waymirrors and an adjacent observation room fordata collection. Each treatment room included ahigh chair (Joshua and Jimmy) or booster seat(Greg), food, table, feeding utensils (smallmaroon spoons; plastic coated baby spoon),bib, serving tray, and a scale with an intake log.

Data Collection and Interobserver Agreement

The primary dependent variables were ex-pulsion and mouth clean. Expulsion was definedas the presence of food greater than the size of apea visible outside the mouth after the biteentered the child’s mouth, and includedinstances when a child actively pushed foodfrom the mouth as well as when it passivelydripped out. Mouth clean was defined as noresidual food larger than the size of a pearemaining inside the mouth within 30 s afterthe food initially was deposited. We did notscore a mouth clean if the child’s mouth wasclean due to an expulsion at the 30-s mark. Werecorded the frequency of expulsion and theoccurrence or nonoccurrence of mouth clean foreach bite. During all meals, a trained observercollected data on a computer using an event-recording program. A trial began when thefeeder deposited a bite in the mouth and endedwhen no food larger than pea size was visible inthe mouth. Within a trial, we coded expulsion

following initial presentation as well as subse-quent expulsion following re-presentation. Wedivided the number of expulsions by thenumber of trials conducted in each session toyield the average number of expulsions per bite.We calculated the percentage of bites withmouth cleans by dividing the number of trialsin which this behavior occurred by the totalnumber of bites that entered the mouth andconverting that number to a percentage.

An independent observer collected reliabilitydata using the same event-recording program for30%, 30%, and 27% of the sessions for Joshua,Jimmy, and Greg, respectively. Exact agreementcoefficients were calculated by dividing thenumber of agreements on the occurrence of abehavior by agreements plus disagreements andmultiplying by 100%. We defined an exactagreement as both observers recording the samefrequency of a target response in a given 10-sinterval. Mean interobserver agreement forexpulsion was 96% (range, 80% to 100%) forJoshua, 95% (range, 79% to 100%) for Jimmy,and 94% (range, 83% to 100%) for Greg. Meaninterobserver agreement for mouth clean was95% (range, 82% to 100%) for Joshua, 98%(range, 58% to 100%) for Jimmy, and 96%(range, 83% to 100%) for Greg.

Design

We compared mouth clean and expulsionacross upright and flipped spoon presentationsusing alternating treatments and reversal designs.A was treatment with an upright spoon, B was thepresentation assessment comparing the flippedspoon to the upright spoon (initial and discharge),and C was treatment with a flipped spoon. Thenumber of phases during treatment differed acrossparticipants (Joshua, ABCBCBCA; Jimmy, ABC-BA; and Greg, ABCBCBA).

Procedure

Admission lasted 8 weeks (Monday throughFriday), and we conducted one 30-min andthree 45-min meal blocks each day. Thirty

86 WILLIAM G. SHARP et al.

minutes separated the breakfast and morningsnack meal blocks, lunch occurred 45 min afterthe morning snack, and dinner took place 2.5 hrafter lunch. We divided meal blocks into five-bitesessions, with three to nine sessions conductedper meal. The number of sessions conductedduring a meal block varied based on expulsion.Although it was possible, we did not terminate asession prior to completing all five bites due toexpulsion or packing within the allotted time,ending all meals based on the time allotted forthat block.

We identified highly preferred leisure items(e.g., toys and videos) using a paired-choicepreference assessment (Fisher et al., 1992).Access to these items was dependent on thetreatment protocol (described below). We pre-sented a total of 16 foods (four fruits, fourvegetables, four starches, and four proteins) thatcaregivers had nominated, under the guidance ofa registered dietician, to match the family’seating patterns. For each meal, the feederrandomly selected one food from each groupand presented these four foods (in random order)at a pureed texture. The order of presentationremained the same within a given session.

Treatment with upright spoon. All treatmentpackages included NRS and re-presentation ofexpulsion with a bolus size of 1 cc per bitepresented on a small maroon spoon. WithNRS, the feeder placed the spoon at the child’slips, followed the lips with the spoon inresponse to head turning (i.e., moving the headmore than 45u away from the spoon), blockeddisruptions (e.g., pushing away the spoon,touching the feeder’s arms), and deposited thebite immediately once the mouth was open. Ifthe child expelled the bite, the feeder re-presented the food by quickly scooping thebolus from the face or bib with the spoon andplacing it back into the mouth. The feedercontinued to re-present the bite until it wasretained. Once the bite entered the child’smouth, the feeder checked the mouth every 30 s,unless an expulsion (and re-presentation) was

occurring, using a three-step prompting proce-dure (i.e., verbal: ‘‘show me’’; gestural: ‘‘showme like this’’ plus modeling opening the mouth;physical: ‘‘show me’’ plus gentle pressure appli-ed to the side of the teeth with a baby spoon).Movement through this sequence occurred in5-s intervals. If the child packed the bite (i.e.,held it in the mouth longer than 30 s), thefeeder continued to check for the presence offood in the mouth every 30 s until no foodlarger than pea was visible, at which time thefeeder immediately presented the next bite. If achild continued to pack a bite of food at the endof the allotted time for a meal block, theprotocol consisted of removing the bite fromthe mouth and terminating the meal; however,this did not occur during the analysis. Thefeeder provided verbal praise (i.e., ‘‘Great jobtaking your bite’’) if the child accepted theentire bite within 5 s of the initial presentationand when no food larger than the size of a peawas visible in the child’s mouth regardless oftime (clean mouth). In addition, the feederprovided Joshua and Jimmy with noncontin-gent access to preferred items throughout themeal. Greg’s treatment package involved DRAfor acceptance, with the feeder providing accessto a preferred item for 20 s after Greg acceptedthe bite regardless of time.

Initial comparison of flipped spoon and uprightspoon presentation. To assess the impact of bitepresentation method on expulsion and mouthclean, we compared the upright spoon to theflipped spoon. The analysis occurred after 12 daysin treatment for Jimmy and Joshua and 30 daysof treatment for Greg. The lag between the onsetof treatment and the initial presentation assess-ment reflected the length of time required toachieve stability in 5-s acceptance and inappro-priate mealtime behavior during treatment withan upright spoon using the protocol describedabove. The time required for Greg’s behavior toreach stabilization also was affected by illnessduring the admission.

The feeder presented all bites at midlineusing a bolus size of 1 cc. We alternated

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presentation methods between sessions, with theorder randomly selected prior to each meal. Theintervention packages described above remainedin place throughout the analysis for all threechildren. The feeder re-presented expelled bitesin the same manner as the initial presentationfor each bite. During upright spoon presenta-tions, the feeder immediately deposited the biteafter the child opened his mouth and closedthe lips around the spoon or instantaneouslyscraped the bolus on the upper lip or teeth ifnecessary due to an open mouth posture andlack of lip closure. During flipped spoon pre-sentations, the feeder placed the spoon midlinefollowing acceptance, flipped the spoon over180u, and deposited the food onto the middleof the tongue by applying gentle downwardpressure along with a concurrent wiping mo-tion, dragging the spoon toward the lips. Weused small maroon spoons during upright spoonpresentations, which was the utensil selected atthe onset of treatment for all participants. Wechanged the utensil to a coated baby spoonduring flipped spoon presentations due to prag-matic considerations regarding the ease ofturning the spoon inside the mouth (i.e., thespoon is narrower, particularly at the handle).

Treatment with flipped spoon. We used theresults of the presentation assessment to selectthe optimal presentation method based ondifferentiation in the level of mouth clean andexpulsion favoring the flipped spoon. We theninitiated bolus fading to maximize the volumeof food presented on the spoon. During thisprocess, the feeder systemically increased bitevolume (1 cc, 2 cc, 4 cc, 5.4 cc) using thefollowing decision rule: 75% or more sessionsmeeting preestablished criteria for two mealblocks. The criteria included 80% or greater 5-sacceptance and mouth cleans, as well as lowrates of expulsion (#1) and inappropriatemealtime behavior (#2) per bite. We modifiedGreg’s bolus fading criteria to involve slightlyless stringent criteria (i.e., one meal block ratherthan two; moving from a level to a heapingbolus) to maximize volume while considering

the length of time remaining in treatment.During this process, we also added a DRA formouth clean to Joshua’s protocol after heexperienced a decline in mouth clean whenthe bolus was increased to 5.4 cc, and we wereunable to regain stability by reducing the bolussize. This involved the feeder providing accessto a preferred item for 20 s after food no longerwas visible in Joshua’s mouth regardless of time.No such modifications were necessary forJimmy and Greg. For all three participants,we also addressed additional treatment goals(e.g., caregiver training, generalization) duringthis phase after the terminal bite size wasachieved.

Discharge comparison of flipped spoon andupright spoon presentation. Near the end of theadmission, we conducted a second presentationassessment to determine if treatment gainscould be maintained after the transition backto an upright spoon. The analysis occurred after34 days in treatment for Joshua, 25 days intreatment for Jimmy, and 39 days in treatmentfor Greg. Variation in the timing of the secondassessment reflected the length of time requiredto achieve stability in behavior at the terminalbite volume (including inappropriate mealtimebehavior and negative vocalizations) and toaddress additional treatment goals. We imple-mented the same overall structure as the firstpresentation assessment. The intervention pack-ages developed over the course of treatmentremained in place throughout the analysis (NRSplus DRA for clean mouth plus re-presentationfor Joshua; NRS plus noncontingent access plusre-presentation for Jimmy; NRS plus DRA foracceptance plus re-presentation for Greg). Thedischarge presentation assessment also involvedthe bite volume achieved during bolus fading(about 5.4 cc).

Follow-up analysis. Stability following treat-ment was assessed during follow-up clinic visitsconducted 2 months, 5 months, and 9 monthsafter discharge for all three participants. Anadditional follow-up visit was conducted withGreg at 3 months. Meals were conducted by

88 WILLIAM G. SHARP et al.

primary caregivers during follow-up appoint-ments.

After the participants had been dischargedfrom the day-treatment program, we askedcaregivers to complete a 45-item questionnairethat assessed three broad measures of socialvalidity (i.e., program satisfaction, treatmentgains, social acceptance) rated on a 5-pointLikert-type scale (1 5 quite dissatisfied/totallydisagree/definitely not; 5 5 extremely satisfied/totally agree/definitely).

RESULTS

Data on mouth clean and expulsion aredepicted in Figures 1 through 3 for allparticipants. The figures display the last 10sessions of treatment with the upright spoonprior to the initial presentation assessment. Allparticipants demonstrated increased acceptanceand decreased inappropriate mealtime behaviorper bite during meals in response to themulticomponent treatment package with theupright spoon (data not shown). Despiteimprovement in acceptance and inappropriatemealtime behavior, a high level of expulsionsper bite interfered with intake for all threeparticipants (M 5 12, range, 9.3 to 15.2 forJoshua; M 5 5.4, range, 3.2 to 9.5 for Jimmy;M 5 2.9, range, 2.3 to 3.7 for Greg). Joshuaand Jimmy demonstrated low levels of mouthclean (M 5 12.4%, range, 0% to 30% forJoshua; M 5 44.1%, range, 0% to 80% forJimmy) during upright spoon presentations.Greg’s percentage of bites with mouth clean wasvariable (M 5 80%, range, 40% to 100%).

During the initial presentation assessment, allthree participants experienced significant im-provements in mouth clean ( M 5 90%, range,60% to 100% for Joshua; M 5 78.3%, range,40% to 100% for Jimmy; M 5 95%, range,80% to 100% for Greg), which coincided witha decline in the mean number of expulsions perbite (M 5 1.2, range, 0.6 to 2.0 for Joshua;M 5 2.2, range, 1.4 to 3.8 for Jimmy; M 5 1.3,range, 0 to 2.0 for Greg) during presentations

and re-presentations with the flipped spoon.Mouth clean and expulsion remained un-changed with the upright spoon. We notedno difference in gram consumption betweenpresentation methods across sessions (dataavailable from the first author). The averagesession duration across all three participantswas greater with the upright spoon (M 5 410 s,range, 214 s to 581 s) than with the flippedspoon (M 5 273 s, range, 199 s to 426 s)during this phase, indicating that the partici-pants required more time to complete five biteswhile consuming approximately the samevolume of food with the upright spoon.

Based on the results of this initial assessmentwith all three participants, we selected theflipped spoon as the sole presentation methodfor use during treatment and when fading thebolus. Given the relative length of thistreatment phase (Joshua: 103 sessions; Jimmy:156 sessions; Greg: 230 sessions), the figuressummarize data for each bite volume. Tocalculate this, we divided the number ofexpulsions by the total number of trials perbite volume to yield an average number ofexpulsions for each volume. We calculated thepercentage of bites with mouth clean for eachbite volume by dividing the number of trials onwhich this behavior occurred by the totalnumber of bites that entered the mouth for aparticular volume and converting that numberto a percentage. All three participants achieved abite volume equal to about 5.4 cc by the end ofthis phase. Percentage of bite with mouth clean(M 5 98.2%, range, 90% to 100% for Joshua;M 5 100% for Jimmy; M 5 99.6%, range,90% to 100% for Greg) and mean number ofexpulsions per bite (M 5 1.9, range, 0.4 to 3.3for Joshua; M 5 0.9, range, 0.1 to 2.4 forJimmy; M 5 0.5, range, 0 to 1.6 for Greg)remained stable at this volume of intake formore than 150 bite presentations prior to thedischarge presentation assessment. Increasedoral intake resulted in significant feeding tubereductions for all three participants (51%reduction for Joshua, 62% reduction for

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Jimmy, and 47% reduction for Greg). ForJimmy and Greg, cup drinking also contributedto their intake during meals, a goal addressedfor Joshua during follow-up outpatient visits.

During the presentation assessment conduct-ed before discharge, mouth clean and the meannumber of expulsion per bite remained un-changed with the flipped spoon for all threeparticipants; however, the children differed intheir response to bites presented with an uprightspoon. All three children experienced anincrease in mean number of expulsions per biteduring bites presented with an upright spoon.Joshua and Jimmy also experienced an initialdrop in mouth clean. For Joshua, mean numberof expulsions per bite remained high and stable

(M 5 10.7, range, 8.2 to 12.4) and mouthclean remained variable (M 5 40%, range, 20%to 60%) for bites presented with an uprightspoon throughout the analysis. Levels of bothbehaviors were similar to those observed duringthe initial presentation assessment. We discon-tinued the assessment after a clear pattern ofstability to address additional treatment goals(i.e., caregiver training; generalization) prior todischarge. During Joshua’s final day of admis-sion (5 days later), we conducted a briefreassessment after parent training and general-ization were complete. Behaviors with bothmethods of presentation remained unchangedduring these six sessions. We resumed treatmentwith a flipped spoon following both analyses.

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.

90 WILLIAM G. SHARP et al.

During the second presentation assessment,Jimmy’s mean number of expulsions per biteinitially occurred at levels similar to the firstpresentation assessment, and mouth cleanimproved slightly from the near-zero levelspreviously observed. As the analysis proceeded,expulsions per bite dropped to less than 2 (M 5

3.1; range, 0.6 to 12.2) and mouth cleanincreased to 100% (M 5 90.5%; range, 40% to100%). Based on the assessment results, wereintroduced the upright spoon as the solepresentation method for use during treatment.Given the relative length of this treatment phase(240 sessions), the figure displays the average

for 40 sessions per point (involving a total of200 bite presentations). The mean number ofexpulsion per bite continued to decrease,approaching levels achieved with the flippedspoon prior to discharge, and mouth cleanstabilized near 100%.

For Greg, the second presentation began with amean number of expulsions per bite at a levelsimilar to those observed during the first presen-tation assessment, but dropped to around 1;mouth clean (M 5 97.5%; range, 80% to 100%)was high and stable. Both trends represented animprovement over the pattern observed during thefirst presentation assessment. Nonetheless, the

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.

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assessment was discontinued based on caregiverpreference for the flipped spoon. Clinical observa-tion also suggested lack of improvement in oral-motor patterns that would promote sustainedlevels of intake not captured during data col-lection, most notably tongue protrusions, associ-ated with upright spoon presentations. Theseobservations are discussed in more detail below.

Before the first follow-up appointment,Joshua transitioned back to an upright spoonfollowing a series of periodic probes conductedby his parents within 3 weeks of discharge. Percaregiver report, probes consisted of presenting afew bites with an upright spoon at the beginningof each meal and gradually increasing thenumber of bites based on low levels of expulsion.

Caregivers did not record data systematically orfollow a clinic-derived protocol during this timeperiod. Mouth clean remained high, and noexpulsion was observed at the 2-month appoint-ment with the upright spoon. Jimmy’s behavioralso remained stable with the upright spoon,with levels of mouth clean nearing 100% andlevels of expulsion close to zero during the 2-month follow-up. The family maintained thesegains at the 5- and 9-month appointments withboth children. Both children also achieved self-feeding skills and further reductions in tubefeedings. We reassessed Greg’s readiness totransition back to an upright spoon at eachfollow-up appointment. Expulsion and mouthclean remained relatively unchanged from

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.

92 WILLIAM G. SHARP et al.

predischarge levels during flipped spoon presen-tations. However, expulsion per bite continuedto disrupt meals during bites with the uprightspoon at the 2-month appointment (expulsions. 1 per bite). Expulsion persisted (although atlower levels) at the 3-month appointment, atwhich time we encouraged the family to increasethe number of bites with the upright spoon (i.e.,initially beginning each meal with the first fivebites with the upright spoon and doubling thenumber of bites after low levels of expulsion forthree consecutive meals) gradually. By the 5- and9-month appointments, all bites were presentedon an upright spoon, mouth clean remainedhigh, and expulsion approached zero.

Results of the satisfaction questionnaire in-dicated that all families were extremely satisfiedwith treatment (M 5 5). All families reported apositive change in their child’s mealtimebehaviors (M 5 4.3; range, 4.3 to 4.4), andthey all indicated that treatment was acceptablefor addressing their child’s feeding difficulties(M 5 4.7; range, 4.4 to 4.9). Items, however,did not specifically assess caregiver preferencefor spoon presentation methods.

DISCUSSION

Results of the current investigation showedclinically significant improvements in mouthclean and a concomitant decline in expulsionfollowing the addition of the flipped spoonpresentation to treatment packages that consistedof NRS, re-presentation, and reinforcement.Prior to the analysis, presentation on an uprightspoon yielded frequent expulsion of food suchthat two children demonstrated near-zero levelsof mouth clean, and a third showed variable levelsbelow clinical targets. The introduction of theflipped spoon resulted in a significant reductionin expulsions per bite for all three children. Theseimprovements coincided with rapid improve-ment in mouth clean, which remained at highlevels during treatment. These findings providefurther support for the effectiveness of alteringbite presentation, a relatively simple antecedent

modification that can optimize food placementon the tongue and may help to facilitateswallowing in some children with feedingdisorders. The positive effect of the interventionpackage was reflected by the increased volume offood consumed per session, and all three childrenreceived more than 50% of their nutritionalneeds by mouth by the end of treatment. Inaddition, caregiver training was completed suc-cessfully so that treatment gains transferred to thehome setting, suggesting that the flipped spoonprocedure can be generalized to feeders andsettings beyond trained therapists in highly struc-tured settings. Finally, follow-up data indicatedthat families were able to maintain improve-ments in feeding behavior following discharge(with two children transitioning back to theupright spoon), and posttreatment satisfactionquestionnaires reflected a high degree of socialvalidity associated with treatment. This repre-sents the first study to document the transitionback to an upright spoon following clinicallysignificant improvement in oral intake using theflipped spoon procedure.

The level of improvement documented in thecurrent study greatly exceeds that reported bySharp et al. (2010), which resulted in smallincreases in mouth clean and modest declines inexpulsion associated with the use of a flippedspoon. A key difference between the currentinvestigation and Sharp et al., however, is that thecurrent study incorporated flipped spoon pre-sentations into a treatment package that includedre-presentation. Girolami et al. (2007) achievedclinically significant improvement in expulsionwith modified placement, and re-presentationwas included throughout that analysis. Therefore,it appears that, to maximize the effectiveness ofthe flipped spoon procedure, treatment packagesmay need to include additional elements (e.g., re-presentation) to help to ensure continued contactwith food and repeated opportunities for con-sumption. This may be a particularly importantconsideration for children with significant oral-motor deficits. Participants in this line of researchwere described as showing poor oral-motor skills,

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characterized by frequent tongue protrusions,drooling, intermittent lip closure, and frequentexpulsion of food (Sharp et al.; Girolami et al.).For children who display this pattern of oral-motor skills, the flipped spoon procedure mayhelp to facilitate swallowing by assisting withbolus formation, but it does not necessarilyensure retention of food in the mouth. It shouldbe noted, however, that we did not examine theeffects of food placement with and without re-presentation. More research is needed to identifywhich subset of children with feeding disordersmay be the most appropriate candidates formodified bite presentation, including whatsubject characteristics (e.g., lack of lip closure,frequent tongue protrusions) may warrant the useof this type of procedure at the onset oftreatment.

It is noteworthy that, prior to the initialpresentation assessment, expulsion persisted athigh levels despite the use of re-presentation in allthree cases. Previous investigators (e.g., Ahearn etal., 1996; Coe et al., 1997; Gulotta et al., 2005)conceptualized expulsion as a behavior maintainedby negative reinforcement (i.e., a behavior thatprovides escape from swallowing food), with re-presentation functioning as a form of escapeextinction. Not all research findings, however,have supported such a conceptualization. Sharpet al. (2010) reported declines in expulsion aftermodifications in bite placement without the use ofextinction. Findings from Girolami et al. (2007),along with those of the current study, also provideevidence that expulsion may not be maintainedexclusively by negative reinforcement. In bothstudies, the behavior persisted despite the use of re-presentation. If re-presentation functioned asextinction, one would have expected an extinctioncurve in expulsion data, as was observed by Sevinet al. (2002). Expulsions declined in the presentstudy only with the flipped spoon, raisingquestions regarding the operant mechanisms thatare responsible for this change. One possibility,highlighted by Girolami et al., is that placement ofthe bolus onto the middle of the tongue may makeit more difficult for the child to expel the bite

while simultaneously decreasing the response ef-fort required for swallowing. An alternate expla-nation is that modifying the placement of foodonto the tongue may compensate for behaviorsthat are missing from the chain necessary forswallowing by assisting with bolus formation andposterior movement.

Future studies should evaluate the possiblefunction of expulsion and the exact mechanismthat is responsible for the observed treatmenteffect, perhaps by assessing different levels of re-presentation (e.g., NRS, NRS plus limited re-presentation; NRS plus continued re-presenta-tion) and the methods of presentation (e.g.,upright, flipped, side placement). In addition, itwill be important to determine how the locationof placement on the tongue (i.e., central vs.posterior) influences feeding behaviors acrossdifferent utensils (Nuk brush, flipped spoon). Forexample, Volkert et al. (2011) suggested that thehigh level of mouth clean achieved with theflipped spoon plus swallow facilitation, whencompared to the findings reported by Sharp et al.(2010), may be related to the location of place-ment on the back of the tongue (i.e., swallowfacilitation). However, the current study achievedhigh levels of mouth clean with placement in thecenter of the tongue. The study also is limited bythe use of different spoons during flipped andupright spoon presentations, which highlights theneed to investigate the impact of utensil type (aswell as other utensils) in treatment outcomes. Forexample, the narrower surface and shallowerbowl of the baby spoon may allow more precisebolus formation and, as a result, require less effortin facilitating a swallow.

It also will be important for researchers toidentify the mechanisms that are responsible forpromoting changes in oral-motor patterns thatpermit the transition from a flipped spoon to anupright spoon. Clinical observations during thesecond presentation assessment and follow-upindicate that changes in oral-motor skills mayhave occurred over time (e.g., increased effi-ciency with bolus formation, increased tonguemobility, increased labial seal with suction);

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however, it is unclear why the children achievedthis milestone at different times (Jimmy, 26 days;Joshua, 61 days; Greg, more than 180 days), andthe present data-recording procedures were notset up to capture what behaviors beyond ex-pulsion and mouth clean emerged during thisprocess. Possible explanations include naturallyoccurring reinforcement of key behaviors inthe swallowing chain, increased coordinationof nuero-motor responses, or even the passageof time alone. Expansion of data-collection pro-cedures to include variables such as mouth clo-sure, tongue coordination or movement, tongueprotrusion, food retraction (with lips ortongue), and food retention (e.g., latency toexpel) may help to elucidate possible mecha-nisms that are responsible for improvedmealtime performance. It also would bebeneficial to include oral-motor examinationsat each treatment change to assess continuedareas of strength and deficits.

Taken together, the current results furthersupport the use of a flipped spoon in thetreatment of pediatric feeding disorders andadd to a growing body of research that indicatesthat the method of food presentation mayinfluence consumption during meals, includingbite size (Kerwin, Ahearn, Eicher, & Burd,1995), simultaneous presentation (i.e., blending;Ahearn, 2003), and texture (Patel, Piazza, San-tana, & Volkert, 2002). These antecedent-basedstrategies can be used in combination withconsequence-based elements (e.g., NRS, re-presentation) to develop highly specific treat-ment packages that target the operant function offood refusal while possibly compensating fororal-motor deficits and reducing the motivatingoperations for food refusal. Going forward, itwill be important to evaluate specifically thesocial validity of alternative bite placement astreatment for pediatric feeding disorders andexpand the behaviors measured during the courseof a feeding intervention. This process willrequire new techniques, behavioral measures,and tools for the assessment and treatment ofpediatric feeding disorders, and will necessitate

continued interdisciplinary collaboration tooptimize measurement techniques and expandthe technology available to address pediatricfeeding disorders.

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Received January 20, 2011Final acceptance August 29, 2011Action Editor, Valerie Volkert

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