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

1. Teaching Chewing:
A Structured
Approach
Laisa Marie Gregorio, UST OT Intern, 2013

2. Background
 Chewing is one of many problems commonly
seen in children with congenital delays, e.g.
Down syndrome, autism spectrum disorder, cri
du chat and cerebral palsy.
 Problems in chewing = neuromotor deficits and
or lack of experience

3. Background
 Institutional deprivation = lack of exposure to or practice
in chewing high textured food
 Lack of literature
 (Butterfield & Parson, 1973) Modeling, shaping and positive
reinforcement = teaching a kid with DS to bite graham crackers
 (Gisel et. al., 1994) oral-motor intervention for kids with CP;
includes 3 components (tongue lateralization, lip control and
vigor of chewing); cookie progresses in hardness; 5-7 min before
school lunch meal for 10-20 weeks

4. Background
 Oral-motor functioning and behavioral
approaches
 Stimulus fading
 Positive/social reinforcement
 Peer modeling
 Token reinforcement
= Goal of the study

5. Method
Participant and Setting
9 y/o Sam with Down syndrome
 Eats only limited number of pureed foods
 Leaves meal before finishing
 Refuses to self-feed
 Goal: to establish chewing, increase variety and
texture of solid foods eaten, establish open-cup
drinking, eliminate inappropriate mealtime behaviors
 124 meal sessions, 19 days, day-treatment program

6. Method
Participant and Setting
5 y/o Frank who has had kidney transplant, stroke,
microcephaly, and neuromotor dysfunction
 Gastrostomy tube dependent
 Only eats smooth foods
 Drinks thin liquids without difficulty

7. Method
Participant and Setting
 Left side weakness, difficulty coordinating tongue
movement
 Goal: to establish chewing, increase texture of solid
foods eaten, eliminate inappropriate mealtime
behaviors, eliminate gastrostomy feedings
 149 meal sessions, 20 days, day-treatment feeding
program

8. Method
Sessions were conducted by a PhD- or master’s-
level feeding therapist
Some by graduate interns under supervision of a
feeding therapist
Neither child required adaptive seating
Final 2 weeks: different environments by different
persons to promote generalization

9. Dependent Measures
Data by therapist in charge
Interobserver reliability: another therapist or a graduate
intern
Primary behaviors:
 Chew: at least 3x within 5 s
 Mouth clean: within 30 s of acceptance
Used as determinants of the outcomes of the intervention

10. Dependent Measures
Secondary Behaviors:
 Accept: within 5 s of presentation
 Expel: before next bite
 Negative vocalizations
 Gag: neck extension, tongue protrusion, changes in skin
color
 Tongue lateralization
 Bite

11. Dependent Measures
Dietary intake by pediatric nutritionist
Interobserver agreement:
 Sam: reliability of 30% of chewing sessions – chew
and mouth clean
82% agreement (7 – 100%)
reliability of 39% of texture-fading sessions and
mouth clean
87% agreement (23 – 100%)

12. Dependent Measures
Interobserver agreement:
 Frank: reliability of 24% of chewing sessions – chew
and mouth clean
88% agreement (13 – 100%)
reliability of 30% of texture-fading sessions and
mouth clean
92% agreement (75 – 100%)

13. Procedures - Baseline
 Conducted to assess children’s ability to eat
high-textured foods and to chew
 Baseline chewing sessions
 10 min
 Child was presented with dry, crisp foods, and asked
to take bites
 All inappropriate meal behaviors are ignored
 Attempt to leave -> redirected

14. Procedures - Baseline
 Baseline texture-fading sessions
 Presented with regular-textured table foods
and milk from an open cup
 Same as chewing sessions

15. Procedures - Baseline
 Treatment package
 Instruct the child to bite and chew
 Improve tongue lateralization
 Improve lip closure
 Increase texture of foods eaten
 Implemented in 2 types of meal sessions

16. Procedures – Chewing Sessions
 Primary focus: biting and chewing
 10 min
 Bite a small piece of crisp, dissolvable food on molars
 Bites = reinforcement
 Preferred drink after each bite
 Chews = additional praise
 Expels = placed back

17. Procedures – Chewing Sessions
 Primary focus: biting and chewing
 Swallows w/o biting = another piece placed on molars
 Refuses = held to mouth w/o comment until accepted
 Gagging ignored
 Alternate placing of food to L or R
 Ended when timer rang

18. Procedures – Decision Rules
 Used to change the schedule of reinforcement
 Size of the food pieces presented also increased
 Sam: termination criterion was changed from
10 min to specific number of bites (9)

19. Procedures – Texture-fading
Sessions
 Primary focus: increase tolerance of higher-textured
foods, improve lip closure, improve tongue
lateralization
 20 min
 Bite textured food
 Bites = praise, given verbal prompts
 Chewing or attempting to chew = praised + tangible
reinforcement for 10 s
 Expels = ignored, placed back
 Refuses = held to mouth w/o comment until accepted

20. Procedures – Texture-fading
Sessions
 Primary focus: increase tolerance of higher-textured
foods, improve lip closure, improve tongue
lateralization
 Gagging ignored
 Alternate placing of food to L or R
 Tongue lateralization = praise + tangible reinforcement for
10 s
 Consumes preferred liquid = praise + tangible
reinforcement for 10 s
 Ended when timer rang

21. Procedures – Decision Rules
 Used to determine when texture would
be increased to the next step in the
fading sequence
 Mouth clean ≥ 80% of bites, 3/4 meals
 Expels ≤ 20% of bites, 3/4 meals
 Gags ≤ 20% of bites, 3/4 meals

22. Procedures – Food textures
 Food textures
 Pureed – smooth food w/o lumps
 Ground – processed food (lumps w/ size no
larger than 0.25 in)
 Mashed – with a fork (lumps’ size within
0.25 - 0.5 in)
 Table – regular-texture table food

23. Procedures – Food textures
 Table – regular-texture table food
 If fading procedure required less than spoonful, table
food was cut into smaller pieces (approx. 0.5 in)
 At the end of treatment, both boys were biting
pieces off some foods
 Starting texture – ground
 Texture-fading manipulated 2 variables: texture and
spoon volume

25. Procedures – Meals
 At the end of treatment for both children
 Presented with a range of table foods
 Praises were given for accepting and
chewing bites of food
 Conducted at a variety of settings with
children’s caregivers to promote
generalization

26. Parent Training
 Done before discharge from intensive
treatment
 Therapists as models, then return
demonstration by caregivers for feedback
 Simplified version of data collection system
 Training videos and written home treatment
plan

27. Experimental Design
 Multiple baseline design was used to evaluate
effectiveness of treatment
 3 baseline chewing sessions and 3 baseline
texture-fading sessions for Sam
 5 baseline chewing sessions and 5 baseline
texture-fading sessions for Frank

28. Results
 Effective in increasing both variety and texture
of food eaten by both boys
 Successful in eliminating the need for Frank’s
gastrostomy tube feedings

29. Results
 Sam
 13 – more
than 80 foods
 Frank
 3 low
textured-
foods – 50
foods

30. Results

31. Results

32. Discussion
 Intervention was able to achieve its goals
 Both boys were able to eat family meals and to eat in a variety of
settings outside home
 Not clear which component was responsible for the results
 Not all of the skills targeted might be necessary for some kids
 Component analysis

33. Discussion
 Treatment differs from others with the same
goals but through the use of chewy tubes or
other nonnutritive objects
 Thus, study agrees with Gisel: use of food
stimuli in treatment would elicit natural eating
reaction
 Also prevents possible problems in generalization

34. Recommendation
 Study was conducted in an intensive basis under
tightly controlled environment of a day-
treatment program -> other settings with other
samples of children

35. THANK YOU!
