Table Of ContentJOURNALOFAPPLIEDBEHAVIORANALYSIS 2011, 44, 513–522 NUMBER3 (FALL2011)
CHIN PROMPT PLUS RE-PRESENTATION AS TREATMENT FOR
EXPULSION IN CHILDREN WITH FEEDING DISORDERS
JONATHAN W. WILKINS, CATHLEEN C. PIAZZA,
REBECCA A. GROFF, AND PETULA C. M. VAZ
UNIVERSITYOFNEBRASKAMEDICALCENTER’S
MUNROE-MEYERINSTITUTE
Expulsion (spitting out food) is a problem behavior observed in many children with feeding
disorders.Inthecurrentinvestigation,weidentified4childrendiagnosedwithafeedingdisorder
whoexhibitedhighratesofexpulsion.Treatmentwithre-presentation(placingexpelledliquids
or solids back into the child’s mouth) was not effective in reducing expulsion. Therefore, we
added a chin-prompt procedure (the feeder applied gentle upward pressure to the child’s chin
and lower lip) for the initial presentation and the re-presentation. Chin prompt plus re-
presentation resulted in low rates of expulsion for all 4 children. The results are discussed in
terms of the potential underlying mechanisms behind the effectiveness of the chin-prompt
procedure.
Key words: chin prompt, escape extinction, expulsion, feeding disorder, negative
reinforcement, pediatricfeeding disorder, re-presentation
_______________________________________________________________________________
Expulsion of (spitting out) food or liquids is expulsionfunctionedasanescapebehavior(i.e.,
aproblemthatiscommonamongchildrenwith expulsion allowed the child to escape eating),
feeding disorders (Coe et al., 1997; Girolami, and re-presentation functioned as escape ex-
Boscoe,&Roscoe,2007;Patel,Piazza,Santana, tinction. The data for the child in the Sevin et
& Volkert, 2002; Sevin, Gulotta, Sierp, Rosica, al. study were consistent with an extinction
& Miller, 2002). Expulsion is problematic interpretation because rates of expulsion in-
becauseitmayresultindecreasedcaloricintake, creased in the first two sessions of treatment
longer mealtimes, and promotion of tongue with re-presentation and then decreased to near
thrust. Repeatedly engaging in tongue thrust zero.
during expulsion may inhibit the development Girolami et al. (2007) replicated and extend-
of tongue lateralization, which is necessary for ed the study by Sevin et al. (2002) by com-
advancement to higher textures (Logemann, paring rates of expulsion when the feeder re-
1983). presented expelled food with a spoon or a Nuk
Only a few studies have addressed treatment brush. The results of the comparison showed
of expulsion directly. Sevin et al. (2002) that expulsion was lower when the feeder re-
increased one child’s acceptance with non- presented expelled bites with the Nuk brush.
removalofthespoon(NRS);however,increases Giroalmi et al. hypothesized that re-presenta-
in acceptance were accompanied by increases in tion with a spoon did not function as
expulsion. These authors then used re-presen- extinction, in that it was not effective in
tation in which the feeder scooped up expelled reducing expulsion for their participant. Gir-
food and placed it back in the child’s mouth to olami et al. suggested that the lower levels of
decrease expulsions. Sevin et al. proposed that expulsion with the brush may have (a) been a
result of negative reinforcement for swallowing
AddresscorrespondencetoCathleenC.Piazza,Univer- (the child could avoid re-presentation with the
sity of Nebraska Medical Center, 985450 Nebraska brush if he swallowed the bite and did not
Medical Center, Omaha, Nebraska, 68198 (e-mail:
expel), (b) resulted from the increased effort
[email protected]).
doi:10.1901/jaba.2011.44-513 associatedwithexpulsion(thebrushallowedthe
513
514 JONATHAN W. WILKINS et al.
feeder to place the bite directly on the child’s who demonstrate poor mouth closure because
tongue, which may have made it more difficult swallowingisdifficultintheabsence ofaclosed
for the child to expel), or (c) compensated for mouth (Arvedson & Brodsky, 2002), and
oral motor skill deficits (i.e., the child did not neither procedure facilitates lip or mouth
have to lateralize his tongue to form the bolus closure.
and move it onto his tongue; all he had to do One potential method of reducing expulsion
was propel the bolus backward to swallow). in children who do not close their mouths is a
Patel et al. (2002) treated one child with a chin prompt. Speech therapists use chin
feeding problem whose expulsion did not prompts to provide support to the jaw during
decrease when the feeder re-presented expelled feeding (Arvedson & Brodsky, 2002). We
food with a Nuk brush. The authors then hypothesized that the chin prompt might be
conducted an assessment of the effects of food effective for reducing expulsion because the
type and texture (Munk & Repp, 1994) on procedure involves the feeder applying gentle
expulsion.The results of theassessment showed upward pressure on the child’s lower lip and
chin,whichshouldfacilitatemouthclosure.We
that expulsion was higher with meats relative to
found two published studies on this procedure
other food types (i.e., vegetable, fruit, starch).
withpreterminfantsinwhichfeederscombined
Decreasing the texture of meats only was
chin and cheek support to facilitate bottle
effective in reducing rates of expulsion to near
feeding(Borion,DaNobrega,Roux,Henrot,&
zero.Pateletal.postulatedthatthetexture may
Saliba, 2007; Einarsson-Backes, Deitz, Price,
have affected the child’s motivation to expel
Glass, & Hays, 1994). This procedure is dif-
(i.e., motivation to expel increased with higher
ferent from a jaw prompt (Ahearn, Kerwin,
textures, which were more difficult to swallow,
Eicher, Shantz, & Swearingin, 1996), which is
and decreased with lower textures, which were
used to open achild’s mouth byplacing inward
less difficult to swallow).
pressureonthemandibularjoint.Nopublished
In summary, although the clinical interven-
studies to date have evaluated the effects of the
tions described above have been effective, the
chin prompt as treatment for expulsion in
behavioral mechanism responsible for this
children with feeding problems.
efficacyhasnotbeenidentified.Takentogether,
In the current investigation, we treated the
the results of these studies suggest that ex-
expulsion exhibited by four children who did
pulsion occurs for different reasons (e.g., mo-
not close their mouths during presentation or
tivational deficits, skill deficits). Therefore, a
after acceptance of liquids or solids. Re-
variety of procedures may be needed to address
presentationalonewasnoteffectiveforreducing
these different underlying reasons. Our clinical
expulsion. Therefore, we evaluated the effec-
observation is that some children expel because
tiveness of a chin prompt in conjunction with
they do not close their mouths around the cup
re-presentation. We used the chin prompt to
or spoon during presentation or after accep-
facilitate closure of the child’s mouth.
tance of liquids or solids (which is different
from the mechanisms hypothesized to be
METHOD
responsible for expulsion in previous studies).
Absence of mouth closure may result in the Participants and Setting
bolus pooling out of the mouth passively or Four children who had been admitted to an
may allow the child to thrust the bolus out of intensive pediatric feeding disorders day-treat-
his or her mouth more easily (Yokochi, 1996). ment program participated. Prior to admission,
Procedures such as re-presentation or texture allchildrenunderwentacomprehensiveinterdis-
manipulation may not be effective for children ciplinaryevaluationtoruleoutmedicaletiologies
CHIN PROMPT 515
oftheircurrentfeedingdifficultiesandtoconfirm The timing and volume of tube feedings
the safety of oral feeding (i.e., no evidence of described above remained constant throughout
aspiration or the inability to swallow). the study. Each participant used age-appropri-
Ashley was a 4-year-old girl whose medical ate seating (e.g., toddler high chair, regular
history included short gut syndrome secondary chair) and drinking or eating utensils and wore
to necrotizing enterocolitis, cerebral palsy, and a bib with a crumb catcher (i.e., the bottom of
liver transplant. She was taking sodium bicar- the bib folded up to form a receptacle that
bonate. She was admitted for food selectivity, would hold expelled liquids or solids). Thera-
low oral intake, and gastrostomy (G-) tube pists conducted sessions in a treatment room
dependence. She received the majority (90% to (4 m by 4 m) equipped with one-way obser-
99%) of her calories via G-tube feedings of vation and sound monitoring.
Neocate Infant formula via pump at 135 ml/hr
from 8:00 p.m. to 7:00 a.m. Dependent Variables and Data Collection
Billy was an 11-year-old boy who had been Observers sat approximately 1.5 m from the
diagnosed with developmental delays whose child and collected data using laptop comput-
medical history included bronchopulmonary ers. The primary dependent variable was
dysplasia, extreme prematurity, and tracheosto- expulsion, which observers measured as a
my.HewastakingZantac,Extendryl,Polyvisol, frequency. Expulsion for liquids was defined
Celexa, and Miralax. He was admitted for low as each time any liquid pea size or larger, that
oral intake and G-tube dependence. He re- had not yet been swallowed, was visible outside
ceived all of his calories via G-tube feedings of the lips after any amount of liquid had passed
PediaSure with fiber mixed with pureed fruits the plane of the lips. Expulsion for solids was
and vegetables (300 ml at 7:00 a.m., 347 ml at defined aseachtimeanyfood peasizeor larger,
5:30p.m.,280mlat7:00p.m.,347mlat 9:00 that had not yet been swallowed, was visible
p.m.). outside the lips after the entire bolus of food
Christine was a 2-year-old girl whose medical had passed the plane of the lips. The definition
history included prematurity, bronchopulmo- for liquids and solids was different because it
nary dysplasia, fundoplication, and tracheosto- wasdifficultforobserverstodeterminewhenall
my.ShewastakingPulmicortandSingulair.She of the bolus of liquid had passed the plane of
was admitted for G-tube dependence and food the lips because the cup was not opaque. The
refusal. She received 99% of her calories via G- frequency of expulsion was converted to
tube feedings of Pediasure with fiber (120 ml at expulsions per bite by dividing the number of
11:00 a.m., 120 ml at 2:00 p.m., 770 ml expulsions by the total number of bites
overnightfromapproximately8:00p.m.to6:00 presented (when the feeder presented the cup
a.m.). or spoon within 4 cm of the child’s lips, not
Donald was a 22-month-old boy who had including placement of the cup or spoon at the
been diagnosed with Cornelia de Lange syn- child’s lips following re-presentation) in each
drome whose medical history included gastro- session.
esophageal reflux disease and failure to thrive. A secondary dependent variable was grams
He was taking Prevacid. Donald was admitted consumed. To calculate grams consumed, the
for G-tube dependence and low oral intake. He feeder placed the cup of liquid or each bowl of
received 90% of his calories through G-tube food (each food was in a separate bowl) on a
feedings of PediaSure (140 ml from 12:45 p.m. Tanita KD160 kitchen scale before each session
to 1:45 p.m., 140 ml from 6:00 p.m. to 7:00 and recorded the presession weight. The feeder
p.m., 580 ml from 9:00 p.m. to 4:00 a.m.). then placed the cup of liquid or each bowl of
516 JONATHAN W. WILKINS et al.
food on the scale after the session and recorded at least 1 hr elapsed between each meal. The
the postsession weight. The feeder used hospi- feeder conducted meals for the current analysis
tal-grade paper towels (which weighed 2 g each at 9:00 a.m., 11:15 a.m., and 2:45 p.m. with
without spill) to wipe up any spill. The feeder approximately3to10sessionswithineachmeal
calculated presession weight minus postsession for Ashley; 10:45 a.m. and 2:30 p.m. with
weight minus (weight of paper towels with spill approximately four to five sessions within each
minus [2 g times the number of paper towels]) meal for Billy; 9:00 a.m., 10:15 a.m., and 3:00
todeterminethegramsconsumedfortheliquid p.m. with approximately four to eight sessions
and for each food for the session. The data within each meal for Christine; and 9:00 a.m.,
presented for solid grams consumed for each 10:30 a.m., and 3:00 p.m. with approximately
session represent the total gram weight for all twotosixsessionswithineachmealforDonald.
four foods presented in the session. The first (breakfast), third (lunch), and fifth
Exact agreement coefficients for expulsion (dinner) meals of the day were 45 min in
were calculated by dividing the number of 10-s length. The second (morning snack) and fourth
intervals in which observers scored the same (eveningsnack)mealsofthedaywere30minin
frequency of expulsion by the total number of length. We used this schedule to approximate a
10-s intervals in the session and converting this youngchild’stypicalmealschedule(threemeals
ratio to a percentage. Exact agreement is a and two snacks) within the confines of an 8:30
particularly conservative measure of agreement a.m. to 5:00 p.m. day-treatment program. The
for high-rate behavior because both observers number of sessions per meal depended on the
have to score the same frequency of behavior in meal length (30 or 45 min) and the length of
theintervaltoproduceanagreement,andsmall any one session within the meal (i.e., the length
temporal deviations in scoring cause disruption of the session varied depending on the child’s
to the coefficient. A second observer indepen- behavior).
dently scored 67% of sessions for Ashley, 46% Prior to the treatment of expulsion with the
for Billy, 42% for Christine, and 19% for chin prompt, we developed treatments to
Donald. Mean agreement for expulsion was increase acceptance. During treatment, Ashley,
94% (range, 63% to 100%) for Ashley, 94% Christine, and Donald displayed high levels of
(range, 72% to 100%) for Billy, 88% (range, expulsion with liquids, and Billy displayed high
42% to 100%) for Christine, and 92% (range levels of expulsion with pureed solids. There-
67% to 100%) for Donald. We did not assess fore, thefocus of this studywas with liquids for
interobserver agreement for grams consumed. Ashley, Christine, and Donald and pureed
solids for Billy.
Design and Procedure The initial treatment for all children consist-
Design. We used an ABAB design. Baseline ed of NRS with re-presentation and planned
(A) was re-presentation, and B was re-presen- ignoring for inappropriate behavior. In addi-
tation plus chin prompt. tion, the feeder delivered noncontingent rein-
General procedure. Children participated in forcement(NCR)intheformofadultattention
blocks of feeding sessions, which we will refer continuously throughout the session to Ashley
to as meals, five times a day (e.g., 9:00 a.m., and Christine per caregiver request. Each
10:30 a.m., 12:30 p.m., 2:30 p.m., 4:15 p.m.). session consisted of five presentations. The
However, we conducted sessions for the anal- feeder presented 4 cc of Oral Restitution
ysespresentedinthecurrentstudyinonlysome Solution in a pink cutout (nosey) cup one after
of these meals; other meals targeted different the other to Ashley, approximately 1 cc of
feeding behaviors. We timed the meals so that pureed solids on a coated baby spoon approx-
CHIN PROMPT 517
imately once every 30 s to Billy, 4 cc of (Donald and Billy) after the feeder deposited
PediaSure with fiber in a pink cutout cup the liquid or solid into the mouth. If no liquid
approximatelyonceevery15stoChristine,and or solid pea size or larger was in the mouth, the
2 cc of Nutramigen Lipil in a pink cutout cup feeder delivered brief praise. If liquid or solid
approximately once every 30 s to Donald. larger than the size of a pea was in the mouth,
Billy’s mother selected the foods targeted for the feeder prompted the child to ‘‘swallow your
treatment, which included yogurt, chicken, drink [bite].’’ The feeder then presented the
peanut butter and jelly sandwiches, hot dogs, next drink or bite. If the child had liquid or
bread,pancakes,potatoes,waffles,fruitcocktail, solidpeasizeorlargerinhisorhermouthatthe
applesauce, peaches, pears, carrots, green beans, check following the presentation of the fifth
broccoli and cheese, and peas. The feeder (last) drink or bite, the feeder prompted the
randomly selected four foods to present to Billy child to ‘‘swallow your drink [bite]’’ every 30 s
in each session and presented the foods in a untileithernoliquidorsolid(peasizeorlarger)
random order during the session. wasinthechild’smouthor15min(Ashleyand
Re-presentation. During NRS with re-presen- Billy) or 10 min (Christine and Donald),
tation and planned ignoring, the feeder pre- whichever came first. We reduced the time
sentedthecuporspoontothechild’slips.Ifthe cap for Christine and Donald because the data
child accepted the liquid or solid within 5 s of forAshleyandBillyshowedthatifthechildhad
presentation, the feeder provided brief praise. If notswallowedwithin10min,theprobabilityof
the child engaged in inappropriate behavior swallowing did not increase with the additional
(head turning, batting at the cup or spoon) or 5 min (i.e., it was just an additional 5 min of
failed to accept the liquid or solid, the feeder unproductive session time). The feeder provid-
kept the cup or spoon at the child’s lips until ed no other differential consequences for
the child allowed the feeder to deposit the inappropriate behavior, vomiting, gagging, and
liquidorsolid.Thefeederre-presentedexpelled coughing.
drinks or bites by scooping up the expelled Chin-prompt assessment. Figure 1 is a photo-
liquidintothecuportheexpelledsolidwiththe graph of a demonstration of the chin prompt.
spoon and placing the bolus back into the The feeder placed his or her forefinger under
child’s mouth using NRS. Feeders began re- the child’s chin during presentation, and the
presentationassoonastheliquidorsolidpassed feeder’s forefinger remained under the child’s
theplaneof thechild’slips. Therefore,atypical chinasdescribedbelow.Aftertheliquidorsolid
re-presentation involved the feeder scooping up entered the child’s mouth, the feeder placed his
theexpelledliquid orsolid from thechild’sface or her thumb under the child’s lower lip and
or bib. If the feeder was not able to recapture applied gentle upward pressure on the child’s
the actual expelled liquid or solid, he or she chin (with the forefinger) and lower lip (with
estimated the amount of expelled liquid or the thumb) for 5 s while counting audibly
solid, used a syringe (liquids) or spoon (solids) (‘‘one, two, three, four, five’’). The feeder then
to replace the estimated amount in the cup or removed hisor her fingers from the child’schin
on the spoon, and re-presented it to the child. and lower lip. The reason the feeder counted
The levels of grams consumed were consistent aloud was to give the child a prompt that
throughout the study, which suggests that there signaled the termination of the chin prompt.
was little or no variability in re-presented bolus We used this strategy to avoid adventitious
sizes. The feeder said, ‘‘show me,’’ to check if increasesininappropriatebehaviorasaresultof
the child had swallowed the liquid or solid the possible pairing of inappropriate behavior
immediately (Ashley), 15 s (Christine), or 30 s and the termination of the chin prompt. The
518 JONATHAN W. WILKINS et al.
Figure1. Demonstration ofthe chin-prompt procedure.
feeder also used the chin prompt during re- relative to both phases of re-presentation (M 5
presentation. All other procedures were identi- 1.28) for Billy. For Christine, adding the chin
cal to baseline. prompt to re-presentation produced decreases
For Donald, the speech therapist decided to in expulsions per bite (M 5 0.79) relative to
repeathisswallowstudywiththinliquidsinthe both phases of re-presentation (M 5 3.3).
middle of the second implementation of the Finally, chin prompt plus re-presentation
chin prompt. He instructed us to present produced decreases in expulsions per bite (M
thickened liquids until the swallow study was 5 1.98) relative to both phases of re-presenta-
completed. Therefore, we gave him thickened tion (M 5 10.68) for Donald. Presentation of
liquids (with the chin prompt) after Session 84 thickened liquids with the chin prompt plus re-
for 5 days while awaiting the completion of the presentation resulted in higher levels of expul-
swallow study. The results of the swallow study sions per bite (M 5 3.1, data not shown)
confirmed that Donald was not at risk for relative to chin prompt plus re-presentation
aspiration with thin liquids, and we resumed with thin liquids, which suggests that Donald’s
treatment as described above with thin liquids. expulsion did not improve as a result of
thickening the liquids. Levels of negative
vocalizations remained low throughout both
RESULTS
conditions for all participants except Christine.
Figure 2 displays the results of the chin- For Christine, negative vocalizations did not
prompt assessment. Although slightly variable, occur during the first phase of re-presentation,
implementation of re-presentation plus chin increased to 23% during the first phase of the
prompt produced a decrease in expulsions per chin prompt plus re-presentation, decreased to
bite (M 5 0.2) relative to both phases of re- lowlevelsinthereturntore-presentation(M5
presentation(M50.74)forAshley.Addingthe 9.7%), and declined further during the second
chin prompt to re-presentation produced de- implementation of the chin prompt plus re-
creases in expulsions per bite (M 5 0.52) presentation (M 5 1.8%).
CHIN PROMPT 519
Figure2. ExpulsionsperbiteforAshley(top),Billy(second),Christine(third),andDonald(bottom).Thedouble
breaklinesonthe x axis representthe pointat which wepresented thickened liquidstoDonald.
Mean grams consumed were 19.4 for re- tation of chin prompt plus re-presentation) for
presentation and the first implementation of Ashley, 3.5 for re-presentation and 4 for chin
chin prompt plus re-presentation (grams con- prompt plus re-presentation for Billy, 10.1 for
sumed data were lost for the second implemen- re-presentation and 10.7 for chin prompt plus
520 JONATHAN W. WILKINS et al.
re-presentation for Christine, and 8.9 for re- caused him to have difficulty managing the
presentation and 9.5 for chin prompt plus re- bolus. Placement of the re-presented bite with
presentation for Donald. The negligible change theNukbrushallowedthefeedertodepositthe
in grams consumed would be expected, because bolus directly on the child’s tongue. Tongue
the number of presented bites remained the placementmayhavereducedtheresponseeffort
same in re-presentation and chin prompt plus associated with swallowing because it was easier
re-presentation conditions. The primary change for the child to propel the bolus backward to
in behavior was the reduction of expulsion, swallow when the bolus was on his tongue
which resulted in the children consuming (Girolami et al., 2007).
liquids and solids in a more timely and age- Similarly, we hypothesized that the children
appropriate manner with the chin prompt plus in our study had oral motor deficits that
re-presentation procedure. affected the likelihood that they would close
their mouths during feeding. Because normal
DISCUSSION swallowing involves elevation of the tongue,
posterior movement of the tongue, and sequen-
In the current investigation, we identified
tialcontactofthetonguewiththehardandsoft
four children whose expulsion did not decrease
palate to move the bolus into the pharynx
to clinically acceptable levels using re-presenta-
(Arvedson & Brodsky, 2002), it is much easier
tion. Adding a chin prompt to re-presentation
toswallowliquidsorsolidswithaclosedrelative
produced marked and consistent decreases in
to an open mouth. The chin prompt may have
expulsion, indicating that this procedure was
facilitated mouth closure, which may have
effective when re-presentation alone failed to
reduced the effort associated with swallowing
decrease expulsion.
(similar to the effort reductions for swallowing
One question that arises from the current
hypothesized by Girolami et al., 2007, that
investigation is why expulsion occurs. Sevin et
resulted from placement of the bolus on the
al. (2002) hypothesized that expulsion is a
tongue). Response effort for swallowing could
member of a response class hierarchy of escape-
be manipulated by facilitating (e.g., with a chin
motivated behavior. In the Sevin et al. study,
prompt) and preventing mouth closure in
treatment of refusal resulted in increases in
alternating conditions. Reductions in expulsion
acceptance and increases in expulsion. Sevin et
al.hypothesized that re-presentation functioned during the mouth closed condition would
as escape extinction or possibly punishment for suggest that the effort associated with swallow-
expulsion. That is, the child could no longer ing might be responsible for the differences.
escape eating by expelling bites of food because Simultaneous measurement of swallowing
the feeder re-presented the bites until the child would provide data regarding whether the child
swallowed (Girolami et al., 2007). was swallowing in conjunction with the chin
InSevinetal.(2002),thefeederusedaspoon prompt, which would provide further support
to re-present expelled bites. By contrast, that the chin prompt served to facilitate
Girolami et al. (2007) identified a participant swallowing via mouth closure.
whose expulsion did not decrease when the Conversely, the chin prompt in conjunction
feeder re-presented expelled bites with a spoon. with re-presentation may have increased the
Girolami et al. compared re-presentation of response effort associated with expulsion. That
expelled bites with a spoon or a Nuk brush and is, it may have been more difficult to expel
showed that expulsion was lower with the Nuk liquids or solids while the feeder was applying
brush. Girolami et al. hypothesized that the upward pressure to the child’s chin and lower
child in their study had oral motor deficits that lip.Itshouldbenotedthatthechinpromptdid
CHIN PROMPT 521
not result in the feeder closing the child’s manipulating and swallowing liquids and solids
mouth consistently. The child was able to hold (Logemann, 1983). The chin prompt may have
her or his jaw firmly so that the mouth would functioned as a prompting strategy that taught
not close; therefore, it was still possible for the the child what to do (i.e., to close his or her
child to expel during the chin prompt. The mouth) during presentation and swallowing the
effects of response effort on expulsion could be liquids or solids. One method of testing
assessed by manipulating the pressure (e.g., whether the chin prompt compensated for an
Chung, 1965) applied to the chin (e.g., a light oralmotorskilldeficitwouldbetoteachmouth
touch or firm upward pressure). However, closure outside the feeding sessions. Training
clinicians should exercise caution when imple- the skill of mouth closure should result in
menting the chin prompt, because excessive eventual reductions in expulsion in the absence
pressure may cause bruising. of intervention during the feeding session.
Alternatively, the chin prompt may have Oneunansweredquestioniswhetherthechin
functioned as punishment for expulsion. Chil- prompt would have been effective in isolation.
drenwithfeedingproblemsoftenhaveaversions We implemented the chin prompt in conjunc-
to being touched on the face (Piazza, Roane, & tion with re-presentation; therefore, it is not
Kadey, 2009). If the chin prompt was aversive, clearwhetherthechinpromptaloneorthechin
it may have reduced the probability that the prompt plus re-presentation was responsible for
child would expel so that he or she could avoid reduced expulsion. Clearly, re-presentation
future presentations of the chin prompt. Recall, alone was not effective, but it was possible that
however,thatthechildcouldnotavoidthechin we could have used the chin prompt in the
prompt altogether, because the feeder imple- absence of re-presentation. Future studies
mented it during presentation. One method of should evaluate the effects of the chin prompt
assessing the extent to which the chin prompt alone.Asecondlimitationofourstudywasthat
functioned as punishment would be to apply it we implemented the chin prompt during
after an alternative behavior (e.g., button presentation and re-presentation. Thus, it is
pressing) to determine if that alternative possible that the chin prompt would have been
behavior decreased following contingent appli- effective if we had used it only for presentation
cation of the chin prompt (Mazaleski, Iwata, or only for re-presentation. Future studies
Rodgers, Vollmer, & Zarcone, 1994). should evaluate the effects of the chin prompt
Finally, the chin prompt may have compen- for acceptance alone and for re-presentation
sated for the oral motor skill deficits of the alone.Athirdlimitationisthatthechinprompt
children in our study. We noted anecdotally is a somewhat invasive strategy and should be
that all of the children in our study exhibited fadedeventuallytoallowthechildtobecomean
open-mouth behavior in nonfeeding situations age-appropriateeater.Fadingtheprocedurewas
(i.e., their mouths ‘‘hung open’’ during every- not attempted with any of the children in our
day activities). By contrast, children without study.
oralmotordeficitstypicallyexhibitclose-mouth A final limitation is that we did not evaluate
behaviorduring everydayactivities. In addition, two of the procedures (re-presentation with a
the children had very little experience eating by Nuk brush and texture manipulation) that have
mouth prior to admission and demonstrated been published on expulsion. These procedures
little or no mouth closure during presentation would have been appropriate only for Billy,
or following acceptance of liquids or solids. because the two treatments are applicable only
Children who have little experience as oral with solid foods, and Billy was the only child
feedersmaylacktheprerequisiteskillsfororally with whom the treatment was used with solid
522 JONATHAN W. WILKINS et al.
food.WedidnotattempttousetheNukbrush Chung, S. (1965). Effects of effort on response rate.
Journal of the Experimental Analysis of Behavior, 8,
with Billy, because we thought that expulsion
1–7.
would have continued due to his open-mouth
Coe, D. A., Babbitt, R. L., Williams, K. E., Hajimihalis,
behavior during acceptance. In addition, Billy’s C., Snyder, A. M., Ballard, C., et al. (1997). Use of
food was a pureed texture, and we were extinction and reinforcement to increase food con-
sumption and reduce expulsion. Journal of Applied
reluctant to reduce it further (the lower texture
BehaviorAnalysis,30,581–583.
inthiscasewouldhavebeenbabyfood).Future Einarsson-Backes,L.M.,Deitz,J.,Price,R.,Glass,R.,&
studies should compare alternative treatments Hays, R. (1994). The effect of oral support on
sucking efficiency in preterm infants. The American
to the chin prompt for expulsion.
JournalofOccupational Therapy,48(6), 490–498.
In conclusion, the addition of a chin prompt
Girolami, P. A., Boscoe, J. H., & Roscoe, N. (2007).
to a treatment package including re-presenta- Decreasing expulsions by a child with a feeding
tion of expelled liquids or solids effectively disorder:UsingaNukbrushtopresentandre-present
food.JournalofAppliedBehaviorAnalysis,40,749–753.
decreased the expulsion of four children. This
Logemann, J. A. (1983). Evaluation and treatment of
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