J Dev Phys Disabil (2013) 25:343–354

DOI 10.1007/s10882-012-9313-1
O R I G I N A L A RT I C L E

An Evaluation of Chewing and Swallowing for a Child

Diagnosed with Autism

Heather J. Kadey & Henry S. Roane & Janet C. Diaz &

Jill M. Merrow

Published online: 28 October 2012

# Springer Science+Business Media New York 2012

Abstract Pediatric feeding disorders comprise a range of developmental and behavioral

disorders. To date, chewing and swallowing has not received as much clinical or research
focus as other aspects of pediatric feeding disorders (e.g., acceptance, inappropriate
mealtime behavior). The current analysis was conducted to increase the consumption of
non-preferred target foods in a child diagnosed with autism. An initial chewing assess-
ment was conducted to increase his compliance with chewing the target foods and a
subsequent assessment was conducted to increase swallowing. Results are discussed in
terms of the use of behavioral interventions to address chewing and swallowing.

Keywords Autism . Chewing . Non-compliance . Pediatric feeding disorders

Children with developmental delays and/or complicated medical histories often

display feeding problems, which may manifest as a variety of maladaptive behaviors
(Shore and Piazza 1997; Volkert and Vaz 2010). For example, some children may
actively refuse to accept food or liquids by engaging in disruptive mealtime behavior
(e.g., batting at the spoon, turning head away from the bite); others may passively
refuse to eat by accepting bites but refusing to chew and swallow; whereas others
may chronically vomit or gag during meals. All of these behaviors can be associated
with the removal of food or termination of the meal suggesting that negative
reinforcement likely plays a critical role in the maintenance of feeding disorders in
the majority of cases (Piazza et al. 2003).

H. J. Kadey (*) : H. S. Roane : J. C. Diaz

The Kelberman Center and Upstate Medical University, 600 E Genesee Street, Syracuse, NY 13202,
USA
e-mail: [email protected]

J. M. Merrow
Upstate Medical University, 725 Irving Ave., Suite 406, Syracuse, NY 13210, USA
344 J Dev Phys Disabil (2013) 25:343–354

Generally speaking, a child’s difficulty with eating may be related to physical

issues, behavioral issues, or both. That is, a child who lacks necessary oral-motor
skills may be less motivated to eat because eating is difficult. By contrast, a child may
possess the necessary oral-motor skills to consume age-appropriate textures but may
develop disruptive behavior patterns that minimize his/her exposure to specific
categories of foods. Lastly, a child may simultaneously possess physical limitations
related to eating as well as display difficult behaviors during meals.
Due to the complexities involved in pediatric feeding disorders, it is important that a
wide range of procedures are developed to address the various problems that may arise.
To date, the majority of research on the treatment of feeding disorders has focused on the
acceptance of refused foods and liquids (Piazza et al. 2008). While increasing accep-
tance is a critical component of the feeding process, it is but one behavior in a chain
of responses that lead to adequate food consumption. Other behaviors, such as
chewing and swallowing, are equally critical components of effective eating.
Chewing and swallowing deficiencies in children are derived from one or even all
of the following areas: motoric skill, behavior, cognition, sensory awareness, and
perception. These deficiencies may be the result of general developmental delays,
cognitive and physical disabilities, complicated medical histories, and/or caregiver
mismanagement (Arvedson 2000). Thus, the type of feeding treatment initiated
should be dependent upon the source(s) of the chewing and/or swallowing deficiency.
To date, relatively few studies have focused on developing effective treatments for
increasing chewing and swallowing in children with feeding problems. Gibbons et al.
(2007) addressed transitioning from enteral to oral feedings in a child with Down
Syndrome through the use of physical assistance to create a new lingual placement
within the oral cavity and shaping of targeted feeding skills. A second study by
Sisson and Dixon (1986) identified an effective treatment that used physical guid-
ance, in combination with instructions, modeling, behavioral rehearsal, and perfor-
mance feedback to improve mealtime behavior (e.g., appropriate utensil use, chewing
with mouth closed) in children with developmental delays and behavior disorders.
Butterfield and Parson (1973) designed a procedure that involved multiple behavioral
components (i.e., response cost, modeling, reinforcement, and shaping) to teach an 8-
year old child with developmental delays to chew solid foods. Similarly, Eckman et
al. (2008) utilized a combined oral-motor and behavioral approach to teach chewing.
Specifically, Eckman et al. used shaping to modify biting behaviors into repetitive
chewing behaviors that, in turn, increased proficiency in the oral-motor behavior of
masticating food.
Although the previously described studies addressed chewing behavior, their focus
was to increase a skill that was not yet in the child’s oral-motor repertoire (Eckman et
al. 2008; Gibbons et al. 2007) or to improve mealtime behavior (Butterfield and
Parson 1973; Sisson and Dixon 1986). To date, no studies have treated chewing and
swallowing in a child who displayed no physical deficits related to those behaviors.
That is, it was determined that the current participant possessed the necessary oral-
motor skills to safely masticate and swallow foods, suggesting that his refusal to
consume particular foods was more likely an issue of non-compliance. Thus, the
current study evaluated a procedure designed to increase his compliance with chew-
ing table-texture foods as well as subsequently increasing his swallowing of the same
foods.
J Dev Phys Disabil (2013) 25:343–354 345

Method

Participant and Setting

Max, a 6-year-old boy who had been previously diagnosed with autism by a devel-
opmental pediatrician, participated in the current study. Max was ambulatory, could
communicate through multiple-word sentences, and he was being educated in a
mainstreamed classroom at the first-grade level. He was admitted to a pediatric
feeding disorders intensive outpatient program for the treatment of his food selectiv-
ity. Per caregiver report, Max did not consume any vegetables and the only fruit he
consumed was in the form of stage-2 baby food (i.e., apple-banana and pears) or
juice. In addition, his variety of foods was limited such that he consumed approxi-
mately ten foods on a regular basis. Some of these foods included waffles, crackers,
toast, tater tots, Burger King® French fries, ice cream, yogurt, and chicken nuggets.
His caregiver also reported some abnormal eating patterns, which included eating
only the outside or edges of some foods and chewing food until it was masticated and
then removing it from his mouth without swallowing. Prior to his admission to the
outpatient clinic, Max was evaluated by a speech/language pathologist who deemed
him to be a safe oral feeder possessing age-appropriate oral-motor skills. Also, Max
was not reported to have any underlying medical conditions related to his selective
eating.
Max attended the clinic for three, 45-min appointments weekly. Three to 11
sessions were conducted per day, and Max was allowed a 5-min break in a playroom
midway through his appointment. All sessions were conducted in a self-contained
room measuring approximately 7×7 m. The room contained a table, chairs, various
materials for the feeding sessions (e.g., utensils, bowls), and a food-preparation area.

Response Measurement and Interobserver Agreement

Trained observers sat in the treatment room across the table from Max but did not
interact with him during the sessions. The observers used laptop computers to collect
data on compliance, independent chews, and swallows. Compliance was recorded
when Max successfully completed the current chew criterion (e.g., chew one time,
chew two times, etc.). Compliance was reported as a percentage by dividing the
number of bite presentations by the number of times the current criterion was
successfully completed and multiplying the ratio by 100 %. An independent chew
was scored each time Max’s jaw (teeth had to come apart at least 1 cm) made one
complete up-and-down motion while the food was clearly visible between the molars.
Independent chews were reported per bite, which was calculated by dividing the total
number of non-physically guided chews by the number of bites presented in that
session. A swallow was recorded if Max swallowed all the food (with the exception
of anything the size of a grain of rice or smaller) by the end of the 30-s bite
presentation (described below). There was only one opportunity to score a swallow
per bite presentation. Swallows were reported as a percentage by dividing the number
of bites presented by the number of bites swallowed and multiplying by 100 %.
A second observer simultaneously, but independently collected interobserver
agreement (IOA) data for 36 % of sessions for independent chews and swallows
346 J Dev Phys Disabil (2013) 25:343–354

and for 40 % of sessions for compliance. For all IOA measures, sessions were divided
into successive 10-s intervals. IOA was calculated by dividing the number of 10-s
intervals in each session with agreements by the total number of agreements plus
disagreements and multiplying by 100 %. An agreement was defined as both observers
scoring the variable in the same 10-s interval or if both recorded nothing in the interval.
Mean IOA for independent chews was 95 % (range, 77–100 %), for swallows was
100 %, and for compliance was 96 % (range, 89–100 %).

General Procedures

The study consisted of an initial chewing assessment followed by a swallowing

assessment. Prior to the study, Max’s mother selected pears, apples, carrots, cheese,
hotdog, and corn as the initial target foods. During each session, one (6×6 mm) piece
of each target food was presented (i.e., six bites were presented per session). A
presentation consisted of placing one piece of target food on a plastic spoon and
placing the spoon on a plate in front of Max. Each presentation lasted 30 s. Prior to
each session the therapist described to Max, in simple terms, what contingencies were
in place for the condition in effect (described below). Across all conditions, brief
praise (e.g., saying, “Great job taking your bite!”) was delivered for acceptance of
bites, for chewing, and for swallowing.

Chewing Assessment

The purpose of this assessment was to increase Max’s chewing of the target foods. A
prior assessment focused on developing a procedure for increasing his acceptance of
the target foods (data available upon request). The results of the prior analysis
suggested that a choice among reinforcers (using the same stimuli that were used in
the current analysis—described below) contingent on putting a bite in his mouth was
effective at increasing his acceptance of the target foods; however, Max did not chew
the foods he accepted under the same contingency.

Choice Condition (Chew 1 Time Plus Small Sr+ or Chew and Swallow Plus Large Sr+)

Across all phases in the chewing assessment Max was given a choice to (a) comply
with the current chewing criterion (e.g., chew one time, chew two times, etc.), or (b)
chew a minimum of eight times and swallow (Note: Eight chews was determined to
be the minimum number of chews necessary to sufficiently masticate the 6×6 mm
bolus for all foods prior to swallowing). If Max complied with the chewing criterion,
he received access to a small magnitude reinforcer: either a preferred toy for 30 s or
one-quarter of a mini-Oreo®. If Max chose to chew his bite a minimum of eight times
and swallow, he received a higher magnitude of the same reinforcers (i.e., either 5-
min access to a toy or one whole mini-Oreo®). These items were selected based on
the results of a toy and food preference assessment (Fisher et al. 1992). During the
choice condition, there were no programmed consequences for expulsion of the food
from his mouth.
Two pieces of 21.6×27.9 cm paper (one yellow and one green) were placed on the
table in front of Max, signaling the two choice options. The green paper represented
J Dev Phys Disabil (2013) 25:343–354 347

the chew criterion with the small-magnitude reinforcer. That is, a small, clear
container with the designated-sized mini-Oreos® was placed on one side of the green
paper and on the other side “30 seconds” was typed in 48-pt Times New Roman font.
At the bottom of the paper the criterion was typed (e.g., “chew one time”, “chew two
times”, etc.) in the same size and style of font. The yellow paper represented the chew
eight times and swallow option with the large-magnitude reinforcer. Similarly, on the
yellow paper there was a container of whole-sized mini-Oreos® and the words
“5 minutes” typed in 48-pt Times New Roman font, and “chew and swallow” typed
on the bottom of the paper in the same size and style of font. Prior to each session, the
therapist presented rules to Max via vocal instructions (e.g., saying, “Max, you can
choose to chew and swallow to get 5 min to play with your toy or eat one whole
Oreo®, or you can chew each bite once and get 30 s to play with your toy or a small
piece of Oreo®.”). Once Max was given the rules, the therapist modeled the current
chew criterion by placing a bite of food between her molars and chewing the
respective number of times according to the operational definition (i.e., chewing with
her mouth open and allowing her teeth to part at least 1 cm). If Max was chewing but
was not opening his teeth wide enough, if his mouth was not open to allow the
therapist to see, or if the food was not between his molars, he was given reminders
accordingly (e.g., the therapist said, “you need to open your mouth wide”, “you need
to move the food in between your teeth”).
During the first phase of the chewing assessment Max was asked to chew one time
or chew eight times and swallow, and only the above-described contingencies were in
place. Inherent in this choice was a third option: do nothing. If Max chose to do
nothing, then the bite was removed from the plate in front of him at the conclusion of
the 30-s bite presentation interval, and the next bite was presented until all six bites
had been presented in the session.

Choice Plus Physical Guidance Condition (Chew x Time/s Plus Small Sr+ Plus
Physical Guidance or Chew and Swallow Plus Large Sr+)

Because Max did not engage in any chewing or swallowing in the first phase of the
chewing assessment, an additional procedure was added to all subsequent phases.
That is, following the first phase of the chewing analysis, the contingencies described
above were in place for chewing the requisite number of times or for chewing a
minimum of eight times and swallowing, and a physical-guidance component was
added. Specifically, if Max did not comply with the current chewing criterion or if he
did not choose to chew eight times and swallow, a Nuk® brush was used to deposit
the bite (Sharp et al. 2010), and Max was physically guided to meet the current chew
criterion. The hand placement for physically guiding a chew was similar to the chin-
prompt procedure described by Dempsey et al. (2011). That is, the therapist gently
placed one, open-palmed hand on Max’s head. The index finger of the other hand was
placed under Max’s chin and the thumb of that hand was placed under Max’s lower
lip while applying gentle downward and upward pressure until the requisite number
of chews was completed. The therapist simultaneously counted each chew aloud.
A changing criterion design (Hartmann and Hall 1976) was used to evaluate the
treatment for chewing. The criteria for moving to the next chewing step were three
consecutive sessions with: (a) 80 % compliance or higher and (b) independent chews
348 J Dev Phys Disabil (2013) 25:343–354

per bite that were at or above at the current chew criterion. The criterion for chewing
advanced arithmetically from one chew per bite to five chews per bite (while having
the option to choose chew eight times and swallow across all criterion changes). To
demonstrate functional control, the criterion was lowered once from five chews per
bite to three chews per bite (with the 80 % compliance criterion in effect). Following
the reversal to the 3-chew criterion, the criterion increased to six chews per bite
before advancing again to the terminal criterion of eight chews per bite (i.e., there was
no intermediate step between the 6- and 8-bite criterion).

Swallowing Assessment

Throughout the chewing assessment, Max always had the option to chew and
swallow his bites for the larger magnitude reinforcer (i.e., one whole mini-Oreo®
or 5-min access to toys). At no point during the chewing assessment did Max choose
this option and contact the contingency. Although the chewing assessment success-
fully increased his chewing on the target foods, the terminal goal was to increase his
consumption of these foods. Therefore, we initiated a follow-up swallowing assess-
ment that incorporated an additional swallow prompt within the contingencies uti-
lized during the chewing assessment.
The choice plus physical guidance condition (chew 8 times plus small Sr+ plus
physical guidance or chew 8 and swallow plus large Sr+) in the initial phase of the
swallowing assessment was identical to the condition in the final phase of the
chewing assessment. That is, compliance with chewing eight times on a bite and
not swallowing (i.e., expelling the bite following meeting the requisite number of
chews) resulted in access to a small-magnitude reinforcer and chewing a minimum of
eight times on the bite and then swallowing resulted in the large-magnitude reinforc-
er. Non-compliance (i..e, not meeting one of these contingencies) resulted in physical
guidance (as described in the previous assessment). In the swallow prompt condition
(chew 8 times and swallow plus small Sr+ plus physical guidance plus swallow
prompt), compliance (i.e., chewing a minimum of eight times and swallowing)
resulted in an option to only choose a small magnitude reinforcer and non-compliance
resulted in physical guidance of eight chews (as described in the previous assessment)
and a swallow prompt. The swallow-prompt procedure consisted of quickly moving the
Nuk® brush across the middle section of Max’s tongue and then removing it from his
mouth. This is similar to the swallow-induction procedure described in Hoch et al.
(1995) except that no pressure was applied to the tongue. The choice plus physical
guidance condition and the swallow-prompt condition were compared in a multiel-
ement design.
During the swallowing assessment, Max was given the option to choose the first
two foods that would be exposed to the swallow-prompt contingency. He chose pear
and apple, which were the only two foods presented in the first swallow-prompt
session (i.e., three bites per food; six bites total per session). Prior to each subsequent
swallow-prompt session, Max could choose which food would be the next one
exposed to the swallow-prompt contingency. As foods were added to one condition,
they were removed from the choice plus physical guidance condition. Therefore, the
foods presented were as follows: Swallow-prompt session (SP) 1 included pear and
apple and Choice plus Physical Guidance session (PG) 1 included cheese, hotdog,
J Dev Phys Disabil (2013) 25:343–354 349

corn, and carrot; SP 2 included pear, apple, and carrot, PG 2 included cheese, hotdog,
and corn; SP 3 included pear, apple, carrot, and corn, PG 3 included cheese and
hotdog; SP 4 included pear, apple, carrot, corn, and hotdog and PG 4 included cheese.
The ratio of foods was counterbalanced across sessions such that six bites of various
foods was presented per session, with some foods being presented more often than
others in a single session.
In the second phase of the swallowing assessment, all six foods were exposed to
the swallow-prompt contingency. In the third phase of this assessment, the effects of
removing physical guidance and the swallow prompt were evaluated. In the final
phase of the swallowing assessment, all treatment contingencies were removed (i.e.,
reinforcement was no longer in place for chewing and swallowing).

Results

The top panel of Fig. 1 depicts the data for compliance, independent chews, and
swallows in the chewing assessment. In the initial baseline phase, Max did not
comply with either contingency (i.e., chew one time or chew a minimum of eight
times and swallow). When physical guidance was added for non-compliance with the
initial chew criterion, compliance increased to 33 % and independent chews per bite
increased to 0.33. Consequently, Max contacted the physical-guidance contingency
on four of the six bite presentations for the first session in which physical guidance
was used. In all subsequent sessions of this phase, compliance was 100 % and
independent chews per bite met the minimum chew criterion. This pattern continued
as the chew criterion increased. That is, Max’s chewing generally increased in
accordance with the increases in the chew criterion. In four sessions (Session 14,
Session 25, Sessions 27–28), Max’s chewing exceeded the minimum criterion for
independent chews per bite, and overall changes in the chewing criterion were associ-
ated with immediate changes in his behavior to a level that conformed to the new
criterion. This effect was observed even when the criterion was reduced from five chews
to three chews. At no point during the chewing assessment did Max swallow a bite.
The results of the swallowing assessment are depicted in the middle and bottom
panels of Fig. 1, with independent chewing data presented in the middle panel and
swallowing data presented in the bottom panel. Max’s swallowing was 100 % for the
first two foods (pears and apples) that were exposed to the swallow-prompt contin-
gency, even though he never contacted physical guidance or the swallow prompt (i.e.,
100 % swallowing indicates that the swallow prompt was not implemented). In the
second session, when his choice was to chew eight times on the bite (thereby
avoiding physical guidance as well as swallowing the bite) to access a small-
magnitude reinforcer or to chew eight times and swallow the bite to access the
high-magnitude reinforcer, he chose to chew eight times and expel the bite. Thus,
he opted to avoid physical guidance and swallowing. As foods were gradually
exposed to the swallow-prompt condition, Max swallowed accordingly. In addition,
Max continued to choose to avoid swallowing in the choice plus physical guidance
condition by always choosing the chew criterion option as opposed to the chew a
minimum of eight times and swallow option. Again, his swallowing maintained at
100 % despite never contacting physical guidance or the swallow prompt.
350 J Dev Phys Disabil (2013) 25:343–354

chew 1x + small
chew 1x + SM + chew 2x + chew 3x + chew 4x + chew 5x + chew 3x + chew 6x + chew 8x +
Sr+ (SM)
physical guidance (PG) SM + PG SM + PG SM + PG SM + PG SM + PG SM + PG SM + PG
or
or or or or or or or or
chew & swallow
chew & swallow + LG chew & swallow chew & swallow chew & swallow chew & swallow chew & swallow chew & swallow chew & swallow
+ large Sr+
+ LG + LG + LG + LG + LG + LG + LG
(LG)
9 100

Percentage of Trials with Compliance/Swallowing

8 compliance 90
Independent Chews per Bite

7 80
chews
6 70
60
5
50
4
40
3
30
2
20
swallows
1 10
0 0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Chew 8 times and Chew 8 times Chew 8 times Chew 8 times

swallow + SM + PG + and swallow + SM + PG + and swallow + SM and swallow
swallow prompt (SP) SP with all foods with all foods with all foods
48
pear
Independent Chews per Bite

42 pear apple
carrot
apple
carrot corn pear
36 pear
apple apple
carrot
30 corn
chew 8x + hotdog
SM + PG
24 or
cheese
chew & swallow
hotdog
18 + LG
corn
cheese
cheese
hotdog
12
6 cheese, hotdog,
corn, carrot
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Chew 8 times Chew 8 times Chew 8 times

and swallow + SM + PG and swallow + SM and swallow
SP with all foods with all foods with all foods
100
pear pear pear pear
90
Percentage of Trials with

apple apple apple apple

carrot carrot carrot
80 corn corn
70 hotdog
Swallowing

60
50
40
cheese
30 hotdog cheese
corn hotdog cheese
20 carrot corn hotdog cheese
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Sessions
Fig. 1 Independent chews per bite (left-hand y-axis; top panel) and percentage of trials with compliance
and swallowing (right-hand y-axis; top panel) during the chewing assessment (top panel). Independent
chews per bite during the swallowing assessment (middle panel). Percentage of trials with swallowing
during the swallowing assessment (bottom panel)

In addition to increases in swallowing, considerable increases in chewing were

also observed throughout the swallowing assessment. In the initial swallowing
treatment phase, the mean independent chews per bite increased to from 8.7 to
39.5. In the next phase, swallowing maintained at 100 % and the mean independent
chews per bite were 43.8. When the physical guidance and swallow prompt were
J Dev Phys Disabil (2013) 25:343–354 351

removed in the third phase, swallowing maintained at 100 % and the mean indepen-
dent chews per bite decreased slightly to 23.7. In the final phase when physical
guidance, the swallow prompt, and reinforcement were removed, swallowing main-
tained at 100 % and independent chews per bite maintained at 26.9.

Discussion

In the current study, the participant possessed the necessary oral-motor skills to safely
masticate and swallow foods, suggesting that his refusal to consume particular foods
was more likely an issue of non-compliance. Using physical guidance as a conse-
quence for non-compliance has been shown to be an effective procedure for increas-
ing compliance in a variety of demand contexts (e.g., Wilder et al. 2006). It has also
been evaluated as an important component in teaching feeding-related skills (e.g.,
Gibbons et al. 2007; Sisson and Dixon 1986). Thus, although the general procedures
used in the current study were not novel, they were successfully applied in a novel
context. As the chewing criterion increased (or decreased) in the chewing assessment,
Max’s behavior adjusted accordingly such that he was able to successfully masticate
and swallow the target foods.
The physical guidance procedure was only implemented for chewing during the
chewing assessment. It is unknown if implementing this procedure for the chew a
minimum of eight times and swallow option during the chewing assessment would
have affected levels of compliance for this behavior. Applying physical guidance to
that response might have promoted more rapid acquisition of swallowing and is a
reasonable direction of future research.
It was not until the swallow-prompt contingency was added to the treatment as a
consequence for not swallowing that we observed increases in consumption. As the
procedure was systematically introduced for each target food, subsequent increases in
swallowing were observed for those foods. The current swallow-prompt procedure
was used instead of a swallow-induction procedure because it had been determined
that Max did not display swallowing deficiencies. A swallow-induction procedure
involves applying pressure to the posterior portion of a child’s tongue using a
fingertip or oral stimulator as it is removed from the child’s mouth, thus eliciting a
swallow (Lamm and Greer 1988). The additional step of applying pressure to the
tongue was not necessary for Max (i.e., he had no swallow dysfunction) such that the
Nuk® was simply brushed across his tongue. For those children who display an
inability or difficulty swallowing, the elicitation of the swallowing response appears
more critically important than those who do not display the same limitations. This
calls into question the necessity of a swallow-induction procedure for children who
do not display the limitations related to swallowing. Perhaps for some children, the
mere presence of a finger or oral stimulator presented in the child’s mouth or on the
tongue provides adequate stimulation to motivate the child engage in the target
response.
An interesting effect of the swallow-prompt procedure was a significant increase in
independent chews per bite. In the initial phase of the swallowing assessment the
mean chews per bite were 8.7 relative to 39.5 independent chews per bite in the
swallow-prompt condition. On average Max chewed approximately four times as
352 J Dev Phys Disabil (2013) 25:343–354

much in the swallow-prompt condition even though he only needed to chew a

minimum of eight times to avoid physical guidance. One possibility is that the
increase in chewing was an avoidance behavior for swallowing. Another possibility
is that the increase in chews beyond the approximate eight chews necessary to
masticate the bite reduced the effort associated with swallowing a previously non-
preferred food. Additional research is needed to both validate and further understand
the relation between procedures designed to increase swallowing and indirect effects
on chewing.
The underlying operant mechanism of the physical guidance and swallow-prompt
procedures remain unknown. Other research utilizing a Nuk® brush (e.g., Girolami et
al. 2007; Hoch et al. 1995) suggested that the Nuk® brush may have functioned as an
aversive stimulus, which directly implicates negative reinforcement in the form of
avoidance as the underlying mechanism for the effectiveness of the procedures. To
the extent that the Nuk® was an aversive stimulus in the current study, Max’s
responding in the swallowing assessment was likely a function of negative reinforce-
ment (i.e., swallowing avoided application of the swallow-prompt with the Nuk®
brush). That is, the effects obtained after Max’s initial exposure to the Nuk® brush in
the physical-guidance procedure are indicative of a conditioned aversive stimulus
(i.e., the Nuk® was physically present during subsequent sessions of the chewing and
swallowing assessments and appeared to exert some control over Max’s responding
in the absence of direct implementation). However, the role of avoidance behavior in
the current study remains speculative, since Max did not contact the swallow prompt.
In addition to the above questions regarding the presence of the Nuk® brush,
increases in swallowing were observed following the change in the rules given prior
to sessions. This suggests that the pre-session rules may have established discrimi-
native control over Max’s responding either in conjunction with or independent of the
visual presence of the Nuk® brush. Thus, the independent effects of the physical-
guidance and swallow-prompt procedures remain unknown and are a direction of
future research.
A potential limitation of the current study is that the participant chewed with an
open mouth. While not a natural form of chewing, this response was deemed
acceptable for the participant given his existing oral-motor skills and the need for
monitoring his swallowing. Although it was not the case with the current participant,
some children may require additional intervention to progress from open-mouth to
closed-mouth chewing (e.g., Sisson and Dixon 1986). Also, in the current investiga-
tion, we segmented Max’s chewing and swallowing into discrete responses. This
delineation was deemed acceptable for Max given his oral-motor skills and the need
for monitoring his behaviors by recording the number of independent chews per bite.
Furthermore, the segmentation of chewing and swallowing permitted an evaluation of
his gradual progression of competency with the targeted skills.
The current results suggest one strategy for promoting the acquisition of chewing
and swallowing. Logemann (2000) noted several treatment strategies for promoting
swallowing, including posture changes (e.g., positioning the chin up to promote
swallowing); alterations of the bolus via taste (e.g., adding a flavor), volume,
temperature, or viscosity; manipulation of the feeding environment (e.g., increasing
the time between bite presentations); and oral-motor exercises. As noted above, other
strategies recommended to promote chewing and swallowing include using various
J Dev Phys Disabil (2013) 25:343–354 353

implements or foods that promote lateralization of the tongue (Manno et al. 2005).
For example, Kapitex.com promotes the “Jaw Rehabilitation Program” to “develop
biting and chewing skills” which involves using a Super Chew® (described as an
“oral-motor device designed to provide resilient, non-food, chewable surface for
practicing biting and chewing skills”). A biting or chewing tube may have its place
as a non-threatening item for a child to accept into his/her mouth during an interven-
tion; however, the efficacy of this approach at developing chewing skills has not been
the subject of empirical evaluation. Chewing on a tube involves only a fraction of the
sequential process that comprises mastication of food, and this response produces no
functional outcome measure (e.g., one cannot determine how successful a therapy
client has chewed on a tube). In contrast, the current study focused on practicing the
target skill within the relevant context (i.e., chewing presented foods), which was
directly linked to the desired terminal skill (i.e., swallowing those foods). Future
research could evaluate the relative advantages of such procedures against those
evaluated in the current study.

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