1. Connie Ng & Sarah Leadley
CHEW ON THIS: TEACHING PRE-REQUISITE SKILLS TO INCREASE FOOD ACCEPTANCE
Connie Ng & Sarah Leadley

2. About Us
Connie Ng Sarah Leadley Acknowledgements : Dr. Laura Grow

3. Feeding Disorders
Includes the following topographies (Field et al, 2003)
Food refusal - Refusal to eat all/most foods & failure to meet caloric needs
Selectivity by type
Selectivity by texture
Oral motor problems (chewing etc.)
Dysphagia (swallowing)

4. Oral motor skills: Chewing: 5 18 mo. Tongue lateralisation: 7 12 mo.
Lip closure: mo.
Chewing skills should start to develop at 5 mo. With the presentation of pureed foods, and further develop as more texture is experienced. Tongue lateralisation refers to the tongue being able to move to locations in the mouth to move food back for swallowing, or move to teeth for chewing. Lip closure is the child being able to seal off their mouth and help with swallowing
O’Brien et al., (1991), Overland, M. & Rosenfield-Johnson (1993)

5. Oral motor delay
Medical disorder, neuromotor deficit, lack of early experience
Eating >> pain, nausea, fatigue
Refusal behaviour >> interferes with feeding
Piazza, 2008

6. Teaching oral motor skills: Limited Research
Gisel (1996), OT
Taught tongue lateralisation with foods placed in mouth, lip closure around a licorice stick/straw, and chewing with small pieces of gelatin/cookies.
No behavioural procedures
No measure of food consumption, but reported increase in solids during session
No generalisation
Instead measured weight gain, duration of meal, and clearing

7. Teaching oral motor skills: Limited Research
Eckman et al. (2008) ABA
Taught chewing, tongue lateralisation, and lip closure using an open cup
Reinforcement, shaping, escape ext.
Texture fading to progress to table foods
Parent training and generalisation to meals
Substantial increase in foods eaten
In both studies, potential for child to swallow without chewing
Increased foods from 3-50, and in each child

8. Case Study - Client background
9 years old
Down Syndrome and ASD
Significant medical concerns in early life & hospitalisation
Lack of early feeding experience
New home program
Buy-in gained with toilet training

9. Feeding concerns
Daily intake = baby food/yoghurt (11g/meal) and 5-6 cans of pediasure.
History of verbal refusal, gagging/spitting when more solid foods presented and risk of choking
No medical concerns prohibiting eating
Often fed by an adult
Interested in some solid/soft foods in novel contexts
i.e. would attept french fries or cake at an event

10. Initial programs Self-feeding to independence
GMI of chewing & Video modeling
Safety concerns
Referral made to Feeding Skills Team for further consultation
Attempts to replicate Eckman et al., (2008)
Further consultation about next steps and safety concerns

11. Feeding team recommendations
Spit out bowl
Combine foods with preferred dips
Play and exploration
Place foods into mouth for chewing practice with model
Add increased texture to family meals
Goal – to eat a solid meal by end of summer (<2 mo.)
No further strategies with regards to chewing and ensuring safety, besides food recommendations.

12. Seeking further consultation
Concerns with risk in using solid food
Video of sessions
Dr. UBC
Stop use of solid food in intervention sessions and concentrate on building jaw muscles for chewing
And, rule out food selectivity

13. Constructive Collaboration
Follow-up with recommendations from the feeding team
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14. Food Survey
What did the family eat daily?

15. Ruling out food selectivity
Acceptance
92% success rate during baseline phase
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16. Constructive collaboration
Effort made to use feeding team strategies… BUT:
- Use of dips/exploration unsuccessful and counter productive
- Food refusal ruled out
- Info shared with FT, including new plan to teach chewing
- Agreement gained

17. Intervention 1: Teaching ‘hard chews’
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18. Response definitions Hard chew Soft chew
Child opens mouth at least 1 cm or greater and bites down sufficient so that the tube is depressed flat
Soft chew
Child open mouths less than 1 cm and bites down so that tube is depressed flat or with a gap still visible
Expel, gag, negative vocalization (no) /

19. Intervention 1: Teaching ‘hard chews’
Child informed of bite criterion
Video model or BI models chew
Place tube into student’s mouth (Alt L/R sides)
Expels tube  re-place tube into mouth
Refuses tube in mouth  hold by mouth and present tube
Accepts the tube

20. Intervention 1: Teaching ‘hard chews’
Instruct child to chew
Count hard chews
Engages in soft chew
Feedback + Continue session until chew criterion met
Provide reinforcer

21. Intervention 1: Teaching ‘hard chews’
MASTERY CRITERIA
Hard chews at 90% accuracy across 2 consecutive sessions or 100% in one session
Level 1: 10
Level 2: 15
Level 3: 20
Food probes conducted from L2 onwards

22. Intervention 1: Teaching ‘hard chews’
BL INT – INT – INT – 20 Follow-up

23. Intervention 2: Tongue Lateralisations
Materials
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24. Intervention 2: Response definitions
Tongue lateralisation  child moves tongue in mouth sufficient to access food placed in location in conjunction with visible rising of cheek
Attempt  child moves tongue in mouth but insufficient to access food
Expel, negative vocalization, gag

25. Intervention 2: Tongue lateralisations
Child is informed of criterion
Place food into child’s mouth (6 locations)
Instruct the child to “find the food”
No response after 2 sec = Least to most prompting
Continue session until the criterion is met
Refusal  continue to present

26. Intervention 2: Tongue lateralisations

27. Summary Mastery of chewing with tube and tongue lateralisation HOWEVER
In food probes, periods of rapid soft chews noted
Was this a concern (and/or related to breathing?)
Further consultation required with regards to concerns and readiness to progress
Through different food groups

28. Constructive Collaboration #2
Session videos sent to Feeding Team
Joint appointment arranged
FT Recommended all meals to be presented solid
Sarahs slide

29. Systematic Generalisation
Chewing foods (session)
 2 x sessions, 90% HC, 100% independent TL, no gag/spit
b. Structured mealtime (with BI)
 2 x mealtimes, as above
c. Family mealtime (home and restaurants)
 2 x mealtime as above

30. Chewing Foods Food in 1x1 cm pieces
Attempt to introduce across food categories in increasing degree of hardness
Combined chewing & tongue lateralisation

31. Response definitions
Hard chew  child opens mouth at least 1 cm or greater and bites down on food (sufficient enough to hear a crunch with some foods)
Soft chew  child opens mouth less than 1 cm before biting down on food or display a series of soft chews
Lateralisation  child moves food from midline to L or R
Off molar  child moving food off his teeth and attempt to break it own with his tongue
Expel, negative vocalization, gag

32. Intervention 3: Chewing foods
Child informed of criterion
Instruct child to pick a food to chew
If expelled, guide to replace food in mouth
Continue session until food masticated
If refused, hold by mouth until accepted
Prompt movement of food where required

33. Results To date, 23 foods introduced in session
93% success rate during baseline
More practice required for solid/puree mix
All foods currently in family mealtime phase
Bite size = 1 x 2 cm

34. INDEPENDENT AND SAFELY AFTER INTERVENTION (With supervision)
ACCEPTED
AFTER INTERVENTION (With supervision)
(Total = 50+)
Pediasure
French fries
Crunchy snacks (veggie sticks, veggies puffs, cheesies, cookies)
Baby food
Chocolate cake
Bread type snacks (muffin, grilled cheese, oatmeal bear paws, grain bread with spread, burger bun, cakes)
Pasta (stuffed, macaroni, penne, lasagna)
Meats (chicken strips, breaded turkey cutlets, roasted chicken, chicken nuggets, burger patty)
Cheese (cheddar, mozzarella)
Fruits (grapes, apples, mandarins)
Veggies (cooked broccoli, cooked carrots)
Starches (yam fries, roasted potatoes, potato salad)
Other (jellybeans, gummies, vegetable re-bars, samosas)

35. Overall Summary
Behavioural approach was successful in teaching oral motor skills
Risks minimized by using non-food object
Chewing sessions a preferred task??
Generalization of skills to chewing of foods
Quick refusal of pureed food
Currently at family mealtime phase & introducing new foods into session

36. Limitations & Difficulties
Limited research to draw upon, thus some decisions ‘creative’
Intervention mostly conducted during ABA sessions, no formal parent training despite recommendations at mealtime phase
Minimal baseline data
Limited data collected beyond chewing foods in session by family
Limited adherence to systematic generalisation

37. Limitations and Difficulties
Delays in progress owing to consultation/resources
Limited feeding team involvement in treatment (once/2-3mo.)
Different interpretations of ‘progress’ and next steps
‘Holding back’ without discouraging family

38. Future directions
Further research into feeding disorders to assess the prevalence of oral-motor difficulties
ABA research in teaching oral-motor skills
Increasing intensity of feeding team involvement to allow for more comprehensive assessment and intervention
Feeding teams to involve a BCBA where required

39. References
Butterfield, W.H., & Parson, R. (1973). Modeling and shaping by parents to develop chewing behaviour in their retarded child. Journal of Behavior Therapy and Experimental Psychiatry, 4,
Eckman, N., Williams, K.E., Riegel, K., & Paul, C. (2008). Teaching chewing: A structured approach. American Journal of Occupational Therapy, 62,
Field, D., Garland, M., Williams, K. (2003). Correlates of specific childhood feeding problems. Journal of Pediatric Child Health, 39,
Gisel, E.G.. (1996). Effect of oral sensorimotor treatment on measures of growth and efficiency of eating in the moderately eating-impaired child with cerebral palsy. Dysphagia, 11,
O’Brien, S., Repp, A.C., Williams, G.E. & Christopherson, E. R. (1991). Pediatric feeding disorders. Behavioral Modification, 15,
Overland, M. & Rosenfield-Johnson (1993). Normal sequence of oral motor development and eating.
Piazza, C. (2008). Feeding disorders and behavior: What have we learned?. Developmental Disabilities, 14,