Upload
laisa-marie-gregorio
View
2.264
Download
2
Tags:
Embed Size (px)
DESCRIPTION
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.
Citation preview
Teaching Chewing: A Structured Approach
Laisa Marie Gregorio, UST OT Intern, 2013
BackgroundBackground
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
BackgroundBackground 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
BackgroundBackground
Oral-motor functioning and behavioral approaches Stimulus fading Positive/social reinforcement Peer modeling Token reinforcement
= Goal of the study
MethodMethod
Participant and Setting9 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
MethodMethod
Participant and Setting5 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
MethodMethod
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
MethodMethod
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
Dependent MeasuresDependent 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
Dependent MeasuresDependent MeasuresSecondary 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
Dependent MeasuresDependent 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%)
Dependent MeasuresDependent 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%)
Procedures - Procedures - BaselineBaseline
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
Procedures - Procedures - BaselineBaseline
Baseline texture-fading sessions Presented with regular-textured table
foods and milk from an open cup Same as chewing sessions
Procedures - Procedures - BaselineBaseline
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
Procedures – Procedures – Chewing Chewing SessionsSessions
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
Procedures – Procedures – Chewing Chewing SessionsSessions
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
Procedures – Procedures – Decision Decision RulesRules
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)
Procedures – Procedures – Texture-Texture-fading Sessionsfading 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
Procedures – Procedures – Texture-Texture-fading Sessionsfading 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
Procedures – Procedures – Decision Decision RulesRules
Used to determine when texture would be increased to the next step in the fading sequenceMouth clean ≥ 80% of bites, 3/4
mealsExpels ≤ 20% of bites, 3/4 mealsGags ≤ 20% of bites, 3/4 meals
Procedures – Procedures – Food Food texturestextures
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
Procedures – Procedures – Food Food texturestextures
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
Procedures – Procedures – MealsMeals
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
Parent TrainingParent 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
Experimental DesignExperimental 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
ResultsResults
Effective in increasing both variety and texture of food eaten by both boys
Successful in eliminating the need for Frank’s gastrostomy tube feedings
ResultsResults
Sam 13 – more
than 80 foods
Frank 3 low
textured-foods – 50 foods
ResultsResults
ResultsResults
DiscussionDiscussion 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
DiscussionDiscussion 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
RecommendationRecommendation
Study was conducted in an intensive basis under tightly controlled environment of a day-treatment program -> other settings with other samples of children
THANK YOU!