ERIC EJ931967: Sequential Treatment of a Feeding Problem Using a Pacifier and Flipped Spoon

2011·0.14 MB·English

by  ERIC

JOURNALOFAPPLIEDBEHAVIORANALYSIS 2011, 44, 387–391 NUMBER2 (SUMMER2011)
SEQUENTIAL TREATMENT OF A FEEDING PROBLEM
USING A PACIFIER AND FLIPPED SPOON
KRISTI D. RIVAS, CATHLEEN C. PIAZZA, HEATHER J. KADEY,
VALERIE M. VOLKERT, AND VICTORIA STEWART
UNIVERSITYOFNEBRASKAMEDICALCENTER’S
MUNROE-MEYERINSTITUTE
Parents may be reluctant to treat the feeding disorder of a chronically ill child who exhibits
distressed behavior during feeding. In this study, we identified a child with chronic medical
problems and a feeding disorder who cried during feedings. We introduced treatment
componentssequentiallytoaddressparentalconcernsaboutcrying.First,weusedapacifierto
reduce crying, and then we used a flipped spoon to increase mouth clean. The results showed
thatasequentialapproachtotreatmentcanbeeffectiveforchildrenwithcomplexmedicaland
behavioralproblems.
Keywords: feedingdisorders,flippedspoon,gastroschisis,pacifier,pediatricfeedingdisorders
_______________________________________________________________________________
Children who are chronically hospitalized METHOD
often show distress (e.g., crying) during routine
Participant, Setting, and Materials
caregiving activities (Derrickson, Neef, &
Jason was a 6-month-old boy with short gut
Cataldo, 1983). These distress behaviors may
secondary to gastroschisis who had been
generalize to a variety of routine caregiving
admitted to an intensive outpatient program
activities,particularlyfeeding.Infact,anumber
for 2 to 8 hr per week for 7.5 weeks. He had
of studies have shown that feeding difficulties
been referred for food and liquid refusal and
(e.g., refusal, crying) are more common in
gastrostomy (G-) tube and total parenteral
children with chronic medical problems (e.g.,
nutrition (TPN) dependence. He received G-
Field, Garland, & Williams, 2003). Caregivers
tube and TPN feedings throughout his admis-
may be reluctant to feed a child who is
sion.
distressed.
Sessions were conducted in a room with a
One way to approach the dilemma of one-way observation window and sound mon-
parental reluctance to feed a child who is itoring. Materials included a rubber-coated
distressed is to treat behaviors sequentially (i.e., Gerber baby spoon, high chair, pacifier, bowls,
reduce levels of crying first and then evaluate food trays, gloves, timers, and a scale.
theeffectsoftreatmentonotherbehaviors).We
used this sequential treatment approach with a Response Measurement, Interobserver
child who had a history of chronic medical Agreement, and Design
problems,exhibitedhigh levelsof cryingduring Trained observers collected data on laptop
feedings (at which time his mother was computers, scoring acceptance of the pacifier and
reluctant to feed him), and packed accepted acceptance of bites separately. Observers scored
bites of food. acceptance for each presentation of the pacifier
or bite when Jason actively leaned toward the
pacifier or spoon, respectively, with an open
Address correspondence to Cathleen C. Piazza, Pediat- mouth in the absence of inappropriate behavior
ric Feeding Disorders Program, Munroe-Meyer Institute, (e.g., head turns, bats) and crying, resulting in
985450 Nebraska Medical Center, Omaha, Nebraska
the feeder inserting the pacifier or spoon into
68198(e-mail: [email protected]).
doi:10.1901/jaba.2011.44-387 Jason’s mouth within 5 s of the presentation.
387
388 KRISTI D. RIVAS et al.
Observers scored a presentation when the Two observers recorded data simultaneously
therapistplacedthepacifierorspoon4cmfrom but independently during 58% of sessions.
Jason’s lips (not including placement of the Total interval agreement was calculated for
pacifier or spoon following re-presentation). acceptance, mouth clean, and incorrect atten-
Observers scored mouth clean when no food tion by summing occurrence (both observers
larger than a grain of rice remained in Jason’s scored the occurrence of the behavior) and
mouth 30 s after the entire bite entered his nonoccurrence (both observers did not score an
mouth(notincludingtheabsenceoffooddueto occurrence of the behavior) agreements; divid-
expulsion).Thenumberofacceptancesormouth ing by the sum of occurrence agreements,
clean was divided by the total number of nonoccurrence agreements, and disagreements
presentations (denominator for acceptance) or (one observer scored the occurrence and the
other observer did not score the occurrence of
bites entering the mouth (denominator for
the behavior); and converting this ratio to a
mouth clean), and these ratios were converted
percentage. Mean interobserver agreements
to percentages.Observersscoredthe durationof
were92%(range,61%to100%)foracceptance
crying (at least 3 s of audible vocalizations that
of bites,96% (range, 78%to 100%)for mouth
were accompanied by tears, frowns, protruded
clean, and 96% for incorrect attention (range,
lowerlip,orshakingofthebody).Theduration
72% to 100%). Mean agreements were 89%
ofcryingwasdividedbysessionduration,andthis
(range, 39% to 100%) for crying and 98%
ratiowasconvertedtoapercentage.Thetherapist
(range, 79% to 100%) for incorrect escape,
weighed each bowl of food before and after the
which was calculated by dividing the smaller
sessionandused2-gpapertowelstocleanspills.
durationbythelargerdurationin each10-sbin
The therapist calculated grams consumed as
and converting this ratio to a percentage.
presession bowl weight minus postsession bowl
We used an ABABCDCDEDE design in
weight minus (paper towel weight with spill
which A was baseline, B was baseline plus
minus[2gtimesthenumberofpapertowels]).
pacifier, C was NRS, D was NRS plus pacifier,
Observers scored feeder behavior to measure
andEwasNRSpluspacifierplusflippedspoon.
procedural integrity. They scored the duration
of incorrect escape during phases including General Procedure
nonremoval of the spoon (NRS). Incorrect
A trained therapist conducted 20-min meals
escape was defined as the feeder holding the
one to three times per day with at least 1.5 hr
spoon more than 4 cm from Jason’s lips at any
between meals and approximately three to four
time (a) after the 30-s timer signaled the onset
five-bite sessions within meals. We introduced
of a bite presentation until the feeder deposited
the participant’s mother as the feeder at Session
the bite into his mouth or (b) when any food 84 because Jason was about to return home. In
larger than a grain of rice was outside the lips each session, the feeder presented a quarter of a
(after the bite had entered his mouth) until the level spoonful of baby food (carrots, turkey,
feeder re-presented the bite. Observers scored chicken, green beans) in a random order across
the frequency of incorrect attention when the sessions, but in the same order within sessions.
feeder provided any vocal statement to or The feeder presented bites at Jason’s midline
physical contact with Jason within 3 s of accompanied by a verbal prompt to ‘‘take a
inappropriate behavior; this was converted to a bite’’ approximately every 30 s. The feeder
percentage after dividing the frequency of delivered brief verbal praise following accep-
incorrect attention by the number of inappro- tance. The feeder implemented a mouth check
priate behaviors. Mean incorrect escape was 30 s after the bite entered Jason’s mouth to
1%; mean incorrect attention was 0%. determine if he had swallowed. The feeder
SEQUENTIAL TREATMENT 389
delivered praise and the next bite if no food NRS. If Jason did not accept the bite within
larger than a grain of rice was in Jason’s mouth 5 s, the spoon remained at his lips until the
following the first 30-s check (except if the feeder deposited the bite into his mouth. The
absence of food was due to expulsion). The feeder re-presented expelled bites. The session
feeder delivered a verbal prompt (e.g., ‘‘swallow wouldhaveendedafter10minifthefeederwas
your bite’’) and the next bite if any food larger not able to deposit all of the bites (this never
than a grain of rice remained in the mouth at happened).
the 30-s check. If there was food larger than a NRS plus pacifier. The procedures were
grainofriceinthemouthafterthepresentation identical to NRS with the addition that the
of the fifth bite, the feeder repeated the prompt feeder presented the pacifier as soon as she
to ‘‘swallow your bite’’ every 30 s until no food deposited the bite into Jason’s mouth.
larger than a grain of rice was in his mouth or NRS plus pacifier plus flipped spoon. The
10 min had elapsed from the beginning of procedures were identical to NRS plus pacifier
session. If Jason had food in his mouth at the with the following addition. We focused on
end of 10 min, the therapist scooped the food increasing mouth clean by presenting and re-
presenting bites on a flipped spoon, which
out of his mouth with a spoon.
consisted of the feeder inserting the upright
Baseline.The feeder followed the procedures
spoon into Jason’s mouth, turning the spoon
described above and deposited the bite if
180u, dragging the bowl of the spoon along
Jason opened his mouth in the absence of
Jason’stongue,anddepositingthebolusoffood
inappropriate behavior and crying. The feeder
in the middle of Jason’s tongue (Volkert, Vaz,
held the spoon at midline for 30 s if Jason did
Piazza, Frese, & Barnett, in press). We used the
not accept the bite, provided no differential
flipped spoon because Volkert et al. (in press)
consequences for crying or inappropriate
showed that this procedure reduced packing
mealtime behavior, did not re-present expelled
(the converse of mouth clean).
bites, and interacted with Jason (e.g., sang)
throughout the session.
Baseline plus pacifier. The procedures were RESULTS AND DISCUSSION
identical to the baseline with the following
As shown in Figure 1 (top), the pacifier was
additions. If Jason accepted the bite, the feeder
effectiveindecreasingcryinginthetwobaseline
presented a pacifier to Jason’s lips immediately.
plus pacifier phases (Ms 5 35% and 12%).
The feeder presented the pacifier 5 s after the
Although levels of crying were low in baseline
bite presentation if Jason did not accept the
plus pacifier, Jason did not accept any bites
bite,andthespoonremainedatmidlinefor30s
(Figure 1, middle), and his gram intake was
whilethepacifierwasinhismouth.IfJasondid minimal (M 5 0.36). Therefore, we imple-
not accept the pacifier (which was atypical), it mented NRS to increase acceptance of bites.
remained at his lips for 30 s from when the Levels of acceptance increased during NRS (M
feeder presented the bite. The feeder re- 5 95%), but high levels of crying reemerged
presented the pacifier (at Jason’s lips or into (M558%).Reintroductionofthepacifierplus
hismouth)ifJasonspititoutandremoveditat NRSresultedindecreasedlevelsofcrying(M5
the end of the 30-s interval. We used a pacifier 36%) and high levels of acceptance (M 5
because he accepted it readily and stopped 100%), which were replicated in the reversal to
crying when his mother gave it to him outside NRS (Ms 5 86% and 76% for crying and
thefeedingsessions,andbecauseourinitialgoal acceptance, respectively) and NRS plus pacifier
was to eliminate crying but not necessarily (Ms 5 30% and 90% for crying and
increase acceptance. acceptance, respectively). Grams consumed also
390 KRISTI D. RIVAS et al.
Figure1. Percentageofcrying(top),acceptanceofbites(middle),andmouthclean(bottom).NRS5nonremoval
ofthe spoon, BL5 baseline.
increased during NRS plus pacifier (M 5 1.3). spoontodecreasethepackingoftwopreschool-
These data show that the pacifier was effective ers. Our data suggest that the flipped spoon
in reducing crying. We continued to use the may be just as effective for much younger
pacifier for the remainder of the analysis children.
because of its demonstrated effects on crying. In the current investigation, we evaluated the
Although acceptance was high during NRS, separate effects of treatment on multiple
levels of mouth clean (Figure 1, bottom) were dependent variables (Cooper et al., 1995).
low. The addition of the flipped spoon to NRS Feedingdisordersprovideanexcellentsubgroup
plus pacifier resulted in high levels of mouth for this type of analysis because of the
clean (M 5 82%). The effects of the flipped complexity of behaviors that comprise the
spoon on mouth clean were replicated in a disorder. In this case, Jason was chronically ill
reversal (Ms 5 47% and 92% for NRS plus and had high levels of crying during feeding.
pacifier and NRS plus pacifier plus flipped Therefore, his mother was reluctant to feed
spoon, respectively). Grams consumed re- him.
mained stable (M 5 1.4). The data from the This study is unique in that we used a
current study replicate and extend those of pacifier toreducecrying,whichisnottypicalin
Volkert et al. (in press), who used a flipped the behavior-analytic literature. However, pac-
SEQUENTIAL TREATMENT 391
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