1. JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2012, 45, 83–96 NUMBER 1 (SPRING 2012)
COMPARISON OF UPRIGHT AND FLIPPED SPOON PRESENTATIONS
TO GUIDE TREATMENT OF FOOD REFUSAL
WILLIAM G. SHARP
MARCUS AUTISM CENTER AND
EMORY UNIVERSITY SCHOOL OF MEDICINE
ASHLEY ODOM
MARCUS AUTISM CENTER
AND
DAVID L. JAQUESS
MARCUS AUTISM CENTER AND
EMORY UNIVERSITY SCHOOL OF MEDICINE
The current study examined the effects of bite placement with a flipped versus upright spoon on
expulsion and mouth clean (product measure of swallowing) in the treatment of 3 children
diagnosed with a pediatric feeding disorder and oral-motor deficits. For all 3 participants,
extinction in the form of nonremoval of the spoon led to improvements in inappropriate
mealtime behavior and acceptance of bites; however, re-presentation did not reduce expulsion or
improve mouth clean. Results showed a lower level of expulsion and higher percentage of mouth
clean during flipped spoon presentations and re-presentations for all participants. Findings from
follow-up analyses supported transitioning back to an upright spoon in all 3 cases, although the
time required for this to occur differed across participants.
Key words: alternating treatments, antecedent manipulation, bite presentation, expulsions,
escape extinction, flipped spoon, pediatric feeding disorders, oral-motor deficits
________________________________________
Escape extinction in the form of nonremoval guidance), thereby eliminating escape. For
of the spoon (NRS) or physical guidance is a children with minimal or no oral intake, escape
well-supported treatment for chronic food extinction promotes exposure to food and
refusal among children with pediatric feeding increases the probability of contact with the
disorders (e.g., Patel, Piazza, Martinez, Volkert, primary and secondary reinforcement associated
& Santana, 2002; Piazza, Patel, Gulotta, Sevin, with eating (Hoch et al., 2001). However,
& Layer, 2003). Both procedures increase food alternative topographies of food refusal, such as
acceptance by targeting inappropriate mealtime pushing bites out of the mouth (i.e., expulsion),
behavior (e.g., pushing away food; head holding food in the mouth (i.e., packing), gagging,
turning) maintained by negative reinforcement or vomiting, may persist (Girolami, Boscoe, &
(i.e., escape from bite presentations). That is, Roscoe, 2007) or arise during the course of
the feeder persists with a bite presentation by treatment (Gulotta, Piazza, Patel, & Layer, 2005)
keeping food at the lips (NRS) or guiding the despite improvements in acceptance. In such cases,
mouth open using gentle jaw pressure (physical social consequences may not maintain these
behaviors, but they may persist as a result of an
Correspondence concerning this article should be oral-motor deficit. Additional behavioral interven-
addressed to William G. Sharp, Pediatric Psychology tions may be necessary to establish swallowing.
and Feeding Disorders Program, Marcus Autism Center, Re-presentation, or recovering expelled food
1920 Briarcliff Road, Atlanta, Georgia 30329 (e-mail:
william.sharp@choa.org). and placing it back into the mouth, represents
doi: 10.1901/jaba.2012.45-83 an additional form of escape extinction that has
83

2. 84 WILLIAM G. SHARP et al.
been demonstrated to increase consumption onto the tongue using a Nuk brush at 15-s
when frequent expulsion maintained by nega- intervals. Although the operant mechanism
tive reinforcement disrupts consumption in responsible for this effect was not isolated in
some cases (Ahearn, Kerwin, Eicher, Shantz, either study, Gulotta et al. noted that, if packing
& Swearingin, 1996; Coe et al., 1997). For represents refusal topography for avoiding con-
example, Ahearn et al. (1996) reported im- sumption, then redistribution may function as a
provement in acceptance and a decline in form of positive punishment for packing (i.e.,
expulsion associated with the use of re-presen- holding food in the mouth is followed repeatedly
tation in combination with both NRS and by food placement of tongue) or negative
physical guidance for two of three children with reinforcement (i.e., improved intake occurring
chronic food refusal. Expulsion remained un- as a result of learning to avoid the procedure by
changed for a third participant, and the authors swallowing). Avoidance of the procedure, how-
did not evaluate the relative contribution of re- ever, did not appear to be responsible for
presentation to address expulsion. Coe et al. improvements in swallowing for two of the four
(1997) examined the relative impact of different participants in Gulotta et al. Although food
treatment elements on the percentage of trials remained in the mouth for less time, the children
with acceptance, expulsion, and swallowing for required one to two redistributions per bite (on
two children with food refusal and gastrostomy average) to produce a swallow. Improvements
(G-) tube dependence. During treatment, the also did not remain after the procedure was
authors sequentially introduced a series of pro- removed, with packing increasing for all four
cedures to address different refusal topographies participants. Given this combination of factors,
(i.e., refusal to accept, expulsion). Treatment Gulotta et al. asserted that, in some cases, re-
involving NRS plus differential reinforcement distribution may facilitate swallowing by helping
(DRA) increased acceptance and improved swal- with bolus formation and placement on the
lowing for one participant, but expulsion remained tongue, but it may not necessarily result in
high in both cases. The addition of re-presentation permanent skill acquisition or function as a form
of expelled bites to the NRS plus DRA package of extinction for packing. These studies, howev-
reduced expulsions to near zero levels and increased er, did not evaluate the relative contribution of
swallowing for both children. bite placement on swallowing, expulsion, or
Treatment that involves continual presentation packing.
and re-presentation of food minimizes escape and Results from recent studies (Girolami et al.,
ensures contact with food until swallowing 2007; Sharp, Harker, & Jaquess, 2010; Volkert,
occurs; however, packing may still hinder intake Vaz, Piazza, Frese, & Barnett, 2011) highlight
(Gulotta et al., 2005; Sevin, Gulotta, Sierp, the potential contribution of bite placement on
Rosica, & Miller, 2002) or expulsion may persist the tongue to improve swallowing when used in
despite the use of this treatment element (Ahearn combination with other behavioral elements.
et al., 1996; Girolami et al., 2007). For example, Girolami et al. (2007) demonstrated that, after
Sevin et al. (2002) and Gulotta et al. (2005) acceptance stabilized through the use of NRS,
reported increased packing following the use of a presenting and re-presenting bites with a Nuk
treatment package that consisted of either NRS or brush resulted in decreased expulsion when
physical guidance plus re-presentation to address compared to bites presented and re-presented
total food refusal. In both studies, swallowing was with an upright spoon. The authors also noted
achieved only after the introduction of a redis- that, although expulsion improved via the altered
tribution procedure that typically involved col- presentation method, the behavior persisted even
lecting food held in the mouth and placing it with the re-presentation contingency, suggesting

3. PRESENTATION ASSESSMENT 85
that expulsion likely was not maintained exclu- decreased (and mouth clean concurrently in-
sively by negative reinforcement. By the end of creased) with the implementation of the flipped
treatment, Girolami et al. reported that expul- spoon treatment package. The level of improve-
sion remained low following the transition back ment varied across participants. One participant
to a spoon for the initial presentation; however, achieved zero levels of packing, and packing was
the researchers continued re-presentation with a lower but remained variable for the second
Nuk brush, and no follow-up assessment was participant. The authors hypothesized that oral-
conducted after the reintroduction of the upright motor deficits may have contributed to the
spoon to clarify whether placement with a Nuk second participant’s more gradual response to
brush was necessary to promote swallowing in treatment (vs. learning to avoid the flipped
the long term. In addition, the length of time spoon by swallowing), noting that he appeared
necessary to reintroduce the upright spoon was to require the aid of the flipped spoon to
not evaluated systematically. swallow.
Sharp et al. (2010) compared the effective- The available research indicates that modifying
ness of different presentation methods (upright bite placement, in combination with conse-
spoon vs. flipped spoon vs. Nuk brush) in quence-based procedures, may improve swallow-
decreasing expulsion and increasing mouth ing among some children with pediatric feeding
clean without the use of re-presentation during disorders who also have oral-motor deficits.
treatment of a child with food refusal and oral- Past studies have varied in the level of improve-
motor deficits. Prior to the analysis, a treatment ment documented with a flipped spoon, and
package that consisted of NRS and noncontin- research has yet to evaluate whether the use of
gent access to preferred items was associated modified bite placement can be eliminated
with improvements in acceptance and inappro- following clinically significant improvements in
priate mealtime behavior during meals. The oral intake. The purpose of the current study
child, however, expelled all bites, and no mouth was to extend Sharp et al. (2010) by comparing
cleans were observed. Altering bite presentation the effectiveness of different presentation meth-
to include placement onto the middle of the ods (upright spoon vs. flipped spoon) in
decreasing expulsion and increasing mouth
tongue with the flipped spoon or Nuk brush
clean in a treatment package that also included
increased mouth clean and decreased expulsion.
re-presentation for expulsion. We also sought
Expulsion and mouth clean remained relatively
to reassess the impact of bite placement on
unchanged with the upright spoon. However,
mouth clean and expulsion at discharge and
changes in bite presentation did not lead to
during follow-up visits to evaluate the transi-
clinically significant improvements in these be-
tion back to an upright spoon over time.
haviors during the analysis.
Volkert et al. (2011) evaluated the use of a
flipped spoon in a treatment package that METHOD
consisted of redistribution and swallow facilita- Participants, Setting, and Materials
tion to address packing. Swallow facilitation The participants were three children who had
involved the application of downward pressure been admitted to an intensive interdisciplinary
on the back of the tongue while simultaneously day-treatment program for the assessment and
dragging the flipped spoon forward. Prior to the treatment of chronic food refusal and 100% G-
introduction of swallow facilitation, NRS was tube dependence. Joshua and Jimmy were 2-
effective in increasing acceptance; however, year 1-month-old twin brothers whose medical
packing emerged when the texture of the food history included prematurity, bronchopulmo-
was increased. For both participants, packing nary dysplasia (BPD), gastroesophageal reflux

4. 86 WILLIAM G. SHARP et al.
disease (GERD), development delay, and visual following initial presentation as well as subse-
impairment. Greg was a 2-year 9-month-old quent expulsion following re-presentation. We
boy whose medical history includes prematuri- divided the number of expulsions by the
ty, GERD, BPD, patent ductus arteriosus, number of trials conducted in each session to
developmental delay, cerebral palsy, and Grade yield the average number of expulsions per bite.
4 intraventricular hemorrhage following birth. We calculated the percentage of bites with
In all three cases, inappropriate mealtime be- mouth cleans by dividing the number of trials
havior and frequent expulsions consistently in which this behavior occurred by the total
hindered adequate consumption. Prior to ad- number of bites that entered the mouth and
mission, a swallow study and occupational converting that number to a percentage.
therapy examination indicated that all three An independent observer collected reliability
children could swallow smooth pureed-texture data using the same event-recording program for
foods safely, but they also noted difficulty 30%, 30%, and 27% of the sessions for Joshua,
retaining food in the mouth due to tongue Jimmy, and Greg, respectively. Exact agreement
protrusions, drooling, or limited lip closure. coefficients were calculated by dividing the
Trained therapists conducted sessions in number of agreements on the occurrence of a
rooms (3 m by 3 m) equipped with one-way behavior by agreements plus disagreements and
mirrors and an adjacent observation room for multiplying by 100%. We defined an exact
data collection. Each treatment room included a agreement as both observers recording the same
high chair (Joshua and Jimmy) or booster seat frequency of a target response in a given 10-s
(Greg), food, table, feeding utensils (small interval. Mean interobserver agreement for
maroon spoons; plastic coated baby spoon), expulsion was 96% (range, 80% to 100%) for
bib, serving tray, and a scale with an intake log. Joshua, 95% (range, 79% to 100%) for Jimmy,
and 94% (range, 83% to 100%) for Greg. Mean
Data Collection and Interobserver Agreement
interobserver agreement for mouth clean was
The primary dependent variables were ex- 95% (range, 82% to 100%) for Joshua, 98%
pulsion and mouth clean. Expulsion was defined (range, 58% to 100%) for Jimmy, and 96%
as the presence of food greater than the size of a
(range, 83% to 100%) for Greg.
pea visible outside the mouth after the bite
entered the child’s mouth, and included
Design
instances when a child actively pushed food
from the mouth as well as when it passively We compared mouth clean and expulsion
dripped out. Mouth clean was defined as no across upright and flipped spoon presentations
residual food larger than the size of a pea using alternating treatments and reversal designs.
remaining inside the mouth within 30 s after A was treatment with an upright spoon, B was the
the food initially was deposited. We did not presentation assessment comparing the flipped
score a mouth clean if the child’s mouth was spoon to the upright spoon (initial and discharge),
clean due to an expulsion at the 30-s mark. We and C was treatment with a flipped spoon. The
recorded the frequency of expulsion and the number of phases during treatment differed across
occurrence or nonoccurrence of mouth clean for participants (Joshua, ABCBCBCA; Jimmy, ABC-
each bite. During all meals, a trained observer BA; and Greg, ABCBCBA).
collected data on a computer using an event-
recording program. A trial began when the Procedure
feeder deposited a bite in the mouth and ended Admission lasted 8 weeks (Monday through
when no food larger than pea size was visible in Friday), and we conducted one 30-min and
the mouth. Within a trial, we coded expulsion three 45-min meal blocks each day. Thirty

5. PRESENTATION ASSESSMENT 87
minutes separated the breakfast and morning occurring, using a three-step prompting proce-
snack meal blocks, lunch occurred 45 min after dure (i.e., verbal: ‘‘show me’’; gestural: ‘‘show
the morning snack, and dinner took place 2.5 hr me like this’’ plus modeling opening the mouth;
after lunch. We divided meal blocks into five-bite physical: ‘‘show me’’ plus gentle pressure appli-
sessions, with three to nine sessions conducted ed to the side of the teeth with a baby spoon).
per meal. The number of sessions conducted Movement through this sequence occurred in
during a meal block varied based on expulsion. 5-s intervals. If the child packed the bite (i.e.,
Although it was possible, we did not terminate a held it in the mouth longer than 30 s), the
session prior to completing all five bites due to feeder continued to check for the presence of
expulsion or packing within the allotted time, food in the mouth every 30 s until no food
ending all meals based on the time allotted for larger than pea was visible, at which time the
that block. feeder immediately presented the next bite. If a
We identified highly preferred leisure items child continued to pack a bite of food at the end
(e.g., toys and videos) using a paired-choice of the allotted time for a meal block, the
preference assessment (Fisher et al., 1992). protocol consisted of removing the bite from
Access to these items was dependent on the the mouth and terminating the meal; however,
treatment protocol (described below). We pre- this did not occur during the analysis. The
sented a total of 16 foods (four fruits, four feeder provided verbal praise (i.e., ‘‘Great job
vegetables, four starches, and four proteins) that taking your bite’’) if the child accepted the
caregivers had nominated, under the guidance of entire bite within 5 s of the initial presentation
a registered dietician, to match the family’s and when no food larger than the size of a pea
was visible in the child’s mouth regardless of
eating patterns. For each meal, the feeder
time (clean mouth). In addition, the feeder
randomly selected one food from each group
provided Joshua and Jimmy with noncontin-
and presented these four foods (in random order)
gent access to preferred items throughout the
at a pureed texture. The order of presentation
meal. Greg’s treatment package involved DRA
remained the same within a given session.
for acceptance, with the feeder providing access
Treatment with upright spoon. All treatment to a preferred item for 20 s after Greg accepted
packages included NRS and re-presentation of the bite regardless of time.
expulsion with a bolus size of 1 cc per bite Initial comparison of flipped spoon and upright
presented on a small maroon spoon. With spoon presentation. To assess the impact of bite
NRS, the feeder placed the spoon at the child’s presentation method on expulsion and mouth
lips, followed the lips with the spoon in clean, we compared the upright spoon to the
response to head turning (i.e., moving the head flipped spoon. The analysis occurred after 12 days
more than 45u away from the spoon), blocked in treatment for Jimmy and Joshua and 30 days
disruptions (e.g., pushing away the spoon, of treatment for Greg. The lag between the onset
touching the feeder’s arms), and deposited the of treatment and the initial presentation assess-
bite immediately once the mouth was open. If ment reflected the length of time required to
the child expelled the bite, the feeder re- achieve stability in 5-s acceptance and inappro-
presented the food by quickly scooping the priate mealtime behavior during treatment with
bolus from the face or bib with the spoon and an upright spoon using the protocol described
placing it back into the mouth. The feeder above. The time required for Greg’s behavior to
continued to re-present the bite until it was reach stabilization also was affected by illness
retained. Once the bite entered the child’s during the admission.
mouth, the feeder checked the mouth every 30 s, The feeder presented all bites at midline
unless an expulsion (and re-presentation) was using a bolus size of 1 cc. We alternated

6. 88 WILLIAM G. SHARP et al.
presentation methods between sessions, with the the length of time remaining in treatment.
order randomly selected prior to each meal. The During this process, we also added a DRA for
intervention packages described above remained mouth clean to Joshua’s protocol after he
in place throughout the analysis for all three experienced a decline in mouth clean when
children. The feeder re-presented expelled bites the bolus was increased to 5.4 cc, and we were
in the same manner as the initial presentation unable to regain stability by reducing the bolus
for each bite. During upright spoon presenta- size. This involved the feeder providing access
tions, the feeder immediately deposited the bite to a preferred item for 20 s after food no longer
after the child opened his mouth and closed was visible in Joshua’s mouth regardless of time.
the lips around the spoon or instantaneously No such modifications were necessary for
scraped the bolus on the upper lip or teeth if Jimmy and Greg. For all three participants,
necessary due to an open mouth posture and we also addressed additional treatment goals
lack of lip closure. During flipped spoon pre- (e.g., caregiver training, generalization) during
sentations, the feeder placed the spoon midline this phase after the terminal bite size was
following acceptance, flipped the spoon over achieved.
180u, and deposited the food onto the middle Discharge comparison of flipped spoon and
of the tongue by applying gentle downward upright spoon presentation. Near the end of the
pressure along with a concurrent wiping mo- admission, we conducted a second presentation
tion, dragging the spoon toward the lips. We assessment to determine if treatment gains
used small maroon spoons during upright spoon could be maintained after the transition back
presentations, which was the utensil selected at to an upright spoon. The analysis occurred after
the onset of treatment for all participants. We 34 days in treatment for Joshua, 25 days in
changed the utensil to a coated baby spoon treatment for Jimmy, and 39 days in treatment
during flipped spoon presentations due to prag- for Greg. Variation in the timing of the second
matic considerations regarding the ease of assessment reflected the length of time required
turning the spoon inside the mouth (i.e., the to achieve stability in behavior at the terminal
spoon is narrower, particularly at the handle). bite volume (including inappropriate mealtime
Treatment with flipped spoon. We used the behavior and negative vocalizations) and to
results of the presentation assessment to select address additional treatment goals. We imple-
the optimal presentation method based on mented the same overall structure as the first
differentiation in the level of mouth clean and presentation assessment. The intervention pack-
expulsion favoring the flipped spoon. We then ages developed over the course of treatment
initiated bolus fading to maximize the volume remained in place throughout the analysis (NRS
of food presented on the spoon. During this plus DRA for clean mouth plus re-presentation
process, the feeder systemically increased bite for Joshua; NRS plus noncontingent access plus
volume (1 cc, 2 cc, 4 cc, 5.4 cc) using the re-presentation for Jimmy; NRS plus DRA for
following decision rule: 75% or more sessions acceptance plus re-presentation for Greg). The
meeting preestablished criteria for two meal discharge presentation assessment also involved
blocks. The criteria included 80% or greater 5-s the bite volume achieved during bolus fading
acceptance and mouth cleans, as well as low (about 5.4 cc).
rates of expulsion (#1) and inappropriate Follow-up analysis. Stability following treat-
mealtime behavior (#2) per bite. We modified ment was assessed during follow-up clinic visits
Greg’s bolus fading criteria to involve slightly conducted 2 months, 5 months, and 9 months
less stringent criteria (i.e., one meal block rather after discharge for all three participants. An
than two; moving from a level to a heaping additional follow-up visit was conducted with
bolus) to maximize volume while considering Greg at 3 months. Meals were conducted by

7. PRESENTATION ASSESSMENT 89
primary caregivers during follow-up appoint- and re-presentations with the flipped spoon.
ments. Mouth clean and expulsion remained un-
After the participants had been discharged changed with the upright spoon. We noted
from the day-treatment program, we asked no difference in gram consumption between
caregivers to complete a 45-item questionnaire presentation methods across sessions (data
that assessed three broad measures of social available from the first author). The average
validity (i.e., program satisfaction, treatment session duration across all three participants
gains, social acceptance) rated on a 5-point was greater with the upright spoon (M 5 410 s,
Likert-type scale (1 5 quite dissatisfied/totally range, 214 s to 581 s) than with the flipped
disagree/definitely not; 5 5 extremely satisfied/ spoon (M 5 273 s, range, 199 s to 426 s)
totally agree/definitely). during this phase, indicating that the partici-
pants required more time to complete five bites
RESULTS while consuming approximately the same
volume of food with the upright spoon.
Data on mouth clean and expulsion are Based on the results of this initial assessment
depicted in Figures 1 through 3 for all with all three participants, we selected the
participants. The figures display the last 10 flipped spoon as the sole presentation method
sessions of treatment with the upright spoon for use during treatment and when fading the
prior to the initial presentation assessment. All bolus. Given the relative length of this
participants demonstrated increased acceptance treatment phase (Joshua: 103 sessions; Jimmy:
and decreased inappropriate mealtime behavior 156 sessions; Greg: 230 sessions), the figures
per bite during meals in response to the summarize data for each bite volume. To
multicomponent treatment package with the calculate this, we divided the number of
upright spoon (data not shown). Despite expulsions by the total number of trials per
improvement in acceptance and inappropriate bite volume to yield an average number of
mealtime behavior, a high level of expulsions expulsions for each volume. We calculated the
per bite interfered with intake for all three percentage of bites with mouth clean for each
participants (M 5 12, range, 9.3 to 15.2 for bite volume by dividing the number of trials on
Joshua; M 5 5.4, range, 3.2 to 9.5 for Jimmy; which this behavior occurred by the total
M 5 2.9, range, 2.3 to 3.7 for Greg). Joshua number of bites that entered the mouth for a
and Jimmy demonstrated low levels of mouth particular volume and converting that number
clean (M 5 12.4%, range, 0% to 30% for to a percentage. All three participants achieved a
Joshua; M 5 44.1%, range, 0% to 80% for bite volume equal to about 5.4 cc by the end of
Jimmy) during upright spoon presentations. this phase. Percentage of bite with mouth clean
Greg’s percentage of bites with mouth clean was (M 5 98.2%, range, 90% to 100% for Joshua;
variable (M 5 80%, range, 40% to 100%). M 5 100% for Jimmy; M 5 99.6%, range,
During the initial presentation assessment, all 90% to 100% for Greg) and mean number of
three participants experienced significant im- expulsions per bite (M 5 1.9, range, 0.4 to 3.3
provements in mouth clean ( M 5 90%, range, for Joshua; M 5 0.9, range, 0.1 to 2.4 for
60% to 100% for Joshua; M 5 78.3%, range, Jimmy; M 5 0.5, range, 0 to 1.6 for Greg)
40% to 100% for Jimmy; M 5 95%, range, remained stable at this volume of intake for
80% to 100% for Greg), which coincided with more than 150 bite presentations prior to the
a decline in the mean number of expulsions per discharge presentation assessment. Increased
bite (M 5 1.2, range, 0.6 to 2.0 for Joshua; oral intake resulted in significant feeding tube
M 5 2.2, range, 1.4 to 3.8 for Jimmy; M 5 1.3, reductions for all three participants (51%
range, 0 to 2.0 for Greg) during presentations reduction for Joshua, 62% reduction for

8. 90 WILLIAM G. SHARP et al.
Figure 1. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Joshua.
The first flipped phase presents the averages for each bite volume, summarizing a total of 230 sessions (2 cc: 77 sessions;
4 cc: 84 sessions; 5.4 cc: 69 sessions). PA 5 presentation assessment.
Jimmy, and 47% reduction for Greg). For (M 5 10.7, range, 8.2 to 12.4) and mouth
Jimmy and Greg, cup drinking also contributed clean remained variable (M 5 40%, range, 20%
to their intake during meals, a goal addressed to 60%) for bites presented with an upright
for Joshua during follow-up outpatient visits. spoon throughout the analysis. Levels of both
During the presentation assessment conduct- behaviors were similar to those observed during
ed before discharge, mouth clean and the mean the initial presentation assessment. We discon-
number of expulsion per bite remained un- tinued the assessment after a clear pattern of
changed with the flipped spoon for all three stability to address additional treatment goals
participants; however, the children differed in (i.e., caregiver training; generalization) prior to
their response to bites presented with an upright discharge. During Joshua’s final day of admis-
spoon. All three children experienced an sion (5 days later), we conducted a brief
increase in mean number of expulsions per bite reassessment after parent training and general-
during bites presented with an upright spoon. ization were complete. Behaviors with both
Joshua and Jimmy also experienced an initial methods of presentation remained unchanged
drop in mouth clean. For Joshua, mean number during these six sessions. We resumed treatment
of expulsions per bite remained high and stable with a flipped spoon following both analyses.

9. PRESENTATION ASSESSMENT 91
Figure 2. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Jimmy.
The first flipped phase presents the averages for each bite volume, summarizing a total of 156 sessions (2 cc: 28 sessions;
4 cc: 8 sessions; 5.4 cc: 120 sessions). The second upright phase presents the average of forty sessions per point,
summarizing a total of 200 bite presentations. PA 5 presentation assessment.
During the second presentation assessment, for 40 sessions per point (involving a total of
Jimmy’s mean number of expulsions per bite 200 bite presentations). The mean number of
initially occurred at levels similar to the first expulsion per bite continued to decrease,
presentation assessment, and mouth clean approaching levels achieved with the flipped
improved slightly from the near-zero levels spoon prior to discharge, and mouth clean
previously observed. As the analysis proceeded, stabilized near 100%.
expulsions per bite dropped to less than 2 (M 5 For Greg, the second presentation began with a
3.1; range, 0.6 to 12.2) and mouth clean mean number of expulsions per bite at a level
increased to 100% (M 5 90.5%; range, 40% to similar to those observed during the first presen-
100%). Based on the assessment results, we tation assessment, but dropped to around 1;
reintroduced the upright spoon as the sole mouth clean (M 5 97.5%; range, 80% to 100%)
presentation method for use during treatment. was high and stable. Both trends represented an
Given the relative length of this treatment phase improvement over the pattern observed during the
(240 sessions), the figure displays the average first presentation assessment. Nonetheless, the

10. 92 WILLIAM G. SHARP et al.
Figure 3. Percentage of trials with mouth clean (top) and mean number of expulsions per bite (bottom) for Greg.
The first flipped phase presents the averages for each bite volume, summarizing a total of 103 sessions (2 cc: 15 sessions;
5.4 cc: 88 sessions). PA 5 presentation assessment.
assessment was discontinued based on caregiver Caregivers did not record data systematically or
preference for the flipped spoon. Clinical observa- follow a clinic-derived protocol during this time
tion also suggested lack of improvement in oral- period. Mouth clean remained high, and no
motor patterns that would promote sustained expulsion was observed at the 2-month appoint-
levels of intake not captured during data col- ment with the upright spoon. Jimmy’s behavior
lection, most notably tongue protrusions, associ- also remained stable with the upright spoon,
ated with upright spoon presentations. These with levels of mouth clean nearing 100% and
observations are discussed in more detail below. levels of expulsion close to zero during the 2-
Before the first follow-up appointment, month follow-up. The family maintained these
Joshua transitioned back to an upright spoon gains at the 5- and 9-month appointments with
following a series of periodic probes conducted both children. Both children also achieved self-
by his parents within 3 weeks of discharge. Per feeding skills and further reductions in tube
caregiver report, probes consisted of presenting a feedings. We reassessed Greg’s readiness to
few bites with an upright spoon at the beginning transition back to an upright spoon at each
of each meal and gradually increasing the follow-up appointment. Expulsion and mouth
number of bites based on low levels of expulsion. clean remained relatively unchanged from

11. PRESENTATION ASSESSMENT 93
predischarge levels during flipped spoon presen- modification that can optimize food placement
tations. However, expulsion per bite continued on the tongue and may help to facilitate
to disrupt meals during bites with the upright swallowing in some children with feeding
spoon at the 2-month appointment (expulsions disorders. The positive effect of the intervention
. 1 per bite). Expulsion persisted (although at package was reflected by the increased volume of
lower levels) at the 3-month appointment, at food consumed per session, and all three children
which time we encouraged the family to increase received more than 50% of their nutritional
the number of bites with the upright spoon (i.e., needs by mouth by the end of treatment. In
initially beginning each meal with the first five addition, caregiver training was completed suc-
bites with the upright spoon and doubling the cessfully so that treatment gains transferred to the
number of bites after low levels of expulsion for home setting, suggesting that the flipped spoon
three consecutive meals) gradually. By the 5- and procedure can be generalized to feeders and
9-month appointments, all bites were presented settings beyond trained therapists in highly struc-
on an upright spoon, mouth clean remained tured settings. Finally, follow-up data indicated
high, and expulsion approached zero. that families were able to maintain improve-
Results of the satisfaction questionnaire in- ments in feeding behavior following discharge
dicated that all families were extremely satisfied (with two children transitioning back to the
with treatment (M 5 5). All families reported a upright spoon), and posttreatment satisfaction
positive change in their child’s mealtime questionnaires reflected a high degree of social
behaviors (M 5 4.3; range, 4.3 to 4.4), and validity associated with treatment. This repre-
they all indicated that treatment was acceptable sents the first study to document the transition
for addressing their child’s feeding difficulties back to an upright spoon following clinically
(M 5 4.7; range, 4.4 to 4.9). Items, however, significant improvement in oral intake using the
did not specifically assess caregiver preference flipped spoon procedure.
for spoon presentation methods. The level of improvement documented in the
current study greatly exceeds that reported by
DISCUSSION Sharp et al. (2010), which resulted in small
increases in mouth clean and modest declines in
Results of the current investigation showed expulsion associated with the use of a flipped
clinically significant improvements in mouth spoon. A key difference between the current
clean and a concomitant decline in expulsion investigation and Sharp et al., however, is that the
following the addition of the flipped spoon current study incorporated flipped spoon pre-
presentation to treatment packages that consisted sentations into a treatment package that included
of NRS, re-presentation, and reinforcement. re-presentation. Girolami et al. (2007) achieved
Prior to the analysis, presentation on an upright clinically significant improvement in expulsion
spoon yielded frequent expulsion of food such with modified placement, and re-presentation
that two children demonstrated near-zero levels was included throughout that analysis. Therefore,
of mouth clean, and a third showed variable levels it appears that, to maximize the effectiveness of
below clinical targets. The introduction of the the flipped spoon procedure, treatment packages
flipped spoon resulted in a significant reduction may need to include additional elements (e.g., re-
in expulsions per bite for all three children. These presentation) to help to ensure continued contact
improvements coincided with rapid improve- with food and repeated opportunities for con-
ment in mouth clean, which remained at high sumption. This may be a particularly important
levels during treatment. These findings provide consideration for children with significant oral-
further support for the effectiveness of altering motor deficits. Participants in this line of research
bite presentation, a relatively simple antecedent were described as showing poor oral-motor skills,

12. 94 WILLIAM G. SHARP et al.
characterized by frequent tongue protrusions, while simultaneously decreasing the response ef-
drooling, intermittent lip closure, and frequent fort required for swallowing. An alternate expla-
expulsion of food (Sharp et al.; Girolami et al.). nation is that modifying the placement of food
For children who display this pattern of oral- onto the tongue may compensate for behaviors
motor skills, the flipped spoon procedure may that are missing from the chain necessary for
help to facilitate swallowing by assisting with swallowing by assisting with bolus formation and
bolus formation, but it does not necessarily posterior movement.
ensure retention of food in the mouth. It should Future studies should evaluate the possible
be noted, however, that we did not examine the function of expulsion and the exact mechanism
effects of food placement with and without re- that is responsible for the observed treatment
presentation. More research is needed to identify effect, perhaps by assessing different levels of re-
which subset of children with feeding disorders presentation (e.g., NRS, NRS plus limited re-
may be the most appropriate candidates for presentation; NRS plus continued re-presenta-
modified bite presentation, including what tion) and the methods of presentation (e.g.,
subject characteristics (e.g., lack of lip closure, upright, flipped, side placement). In addition, it
frequent tongue protrusions) may warrant the use will be important to determine how the location
of this type of procedure at the onset of of placement on the tongue (i.e., central vs.
treatment. posterior) influences feeding behaviors across
It is noteworthy that, prior to the initial different utensils (Nuk brush, flipped spoon). For
presentation assessment, expulsion persisted at example, Volkert et al. (2011) suggested that the
high levels despite the use of re-presentation in all high level of mouth clean achieved with the
three cases. Previous investigators (e.g., Ahearn et flipped spoon plus swallow facilitation, when
al., 1996; Coe et al., 1997; Gulotta et al., 2005) compared to the findings reported by Sharp et al.
conceptualized expulsion as a behavior maintained (2010), may be related to the location of place-
by negative reinforcement (i.e., a behavior that ment on the back of the tongue (i.e., swallow
provides escape from swallowing food), with re- facilitation). However, the current study achieved
presentation functioning as a form of escape high levels of mouth clean with placement in the
extinction. Not all research findings, however, center of the tongue. The study also is limited by
have supported such a conceptualization. Sharp the use of different spoons during flipped and
et al. (2010) reported declines in expulsion after upright spoon presentations, which highlights the
modifications in bite placement without the use of need to investigate the impact of utensil type (as
extinction. Findings from Girolami et al. (2007), well as other utensils) in treatment outcomes. For
along with those of the current study, also provide example, the narrower surface and shallower
evidence that expulsion may not be maintained bowl of the baby spoon may allow more precise
exclusively by negative reinforcement. In both bolus formation and, as a result, require less effort
studies, the behavior persisted despite the use of re- in facilitating a swallow.
presentation. If re-presentation functioned as It also will be important for researchers to
extinction, one would have expected an extinction identify the mechanisms that are responsible for
curve in expulsion data, as was observed by Sevin promoting changes in oral-motor patterns that
et al. (2002). Expulsions declined in the present permit the transition from a flipped spoon to an
study only with the flipped spoon, raising upright spoon. Clinical observations during the
questions regarding the operant mechanisms that second presentation assessment and follow-up
are responsible for this change. One possibility, indicate that changes in oral-motor skills may
highlighted by Girolami et al., is that placement of have occurred over time (e.g., increased effi-
the bolus onto the middle of the tongue may make ciency with bolus formation, increased tongue
it more difficult for the child to expel the bite mobility, increased labial seal with suction);

13. PRESENTATION ASSESSMENT 95
however, it is unclear why the children achieved continued interdisciplinary collaboration to
this milestone at different times (Jimmy, 26 days; optimize measurement techniques and expand
Joshua, 61 days; Greg, more than 180 days), and the technology available to address pediatric
the present data-recording procedures were not feeding disorders.
set up to capture what behaviors beyond ex-
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