JOURNALOFAPPLIEDBEHAVIORANALYSIS 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 studyisthefirsttodemonstratetheeffectiveness swallowingdisorders.SanDiego,CA:College-HillPress. of this procedure as treatment for expulsion. Mazaleski,J.L.,Iwata,B.A.,Rodgers,T.A.,Vollmer,T. The results of the current and previous studies R.,&Zarcone,J.R.(1994).Protectiveequipmentas treatment for stereotypic hand mouthing: Sensory suggest that there are a variety of potential extinction or punishment effects? Journal of Applied procedures that are clinically effective as BehaviorAnalysis,27,345–355. treatment for expulsion. A gap in the literature Munk, D. D., & Repp, A. C. (1994). Behavioral assessment of feeding problems of individuals with exists, however, in understanding the reason severedisabilities.JournalofAppliedBehaviorAnalysis, why expulsion occurs and the underlying 27,241–250. mechanism responsible for the effectiveness of Patel,M.R.,Piazza,C.C.,Santana,C.M.,&Volkert,V. the various treatments, which future research M.(2002).Anevaluationoffoodtypeandtexturein thetreatmentofafeedingproblem.JournalofApplied should address. BehaviorAnalysis,35,183–186. Piazza, C. C., Roane, H. S., & Kadey, H. J. (2009). 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