JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2014, 47, 694–709 NUMBER 4 (WINTER)

UTENSIL MANIPULATION DURING INITIAL TREATMENT OF

PEDIATRIC FEEDING PROBLEMS
JONATHAN W. WILKINS, CATHLEEN C. PIAZZA, REBECCA A. GROFF, VALERIE
M. VOLKERT, JENNIFER M. KOZISEK, AND SUZANNE M. MILNES
UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

Children with feeding disorders exhibit a variety of problem behaviors during meals. One method of
treating problem mealtime behavior is to implement interventions sequentially after the problem
behavior emerges (e.g., Sevin, Gulotta, Sierp, Rosica, & Miller, 2002). Alternatively, interventions
could target problem behavior in anticipation of its emergence. In the current study, we
implemented nonremoval and re-presentation of bites either on a spoon or on a Nuk for 12 children
with feeding problems. The nonremoval and re-presentation treatment improved feeding behavior
for 8 of 12 children. Of those 8 children, 5 had lower levels of expulsions, and 4 of the 8 children had
higher levels of mouth clean with the Nuk than with the spoon. We describe the subsequent clinical
course of treatment and present follow-up data for 7 of the 8 children who responded to the
nonremoval and re-presentation treatment with the spoon or Nuk. The data are discussed in terms
of potential reasons why the utensil manipulation improved feeding behavior for some children.
Key words: escape extinction, expulsion, feeding disorder, Nuk, pediatric feeding disorders, re-
presentation

One common strategy for treating problem
feeding behavior is to implement interventions
sequentially after the problem behavior emerges.
For example, Sevin, Gulotta, Sierp, Rosica, and
Miller (2002) treated the food refusal of one child
with nonremoval of the spoon, which was
associated with increased acceptance of bites
and a concomitant increase in expulsion (spitting
out the bite). Although re-presentation (replacing
the expelled bite into the child’s mouth) resulted
in decreased expulsion, it also was associated with
increased packing (pocketing or holding food in
the mouth). The investigators used a rubber-
bristled utensil called a Nuk to collect the packed
food from the child’s mouth and to redistribute it
onto the child’s tongue to decrease packing.
Implementation of treatment components
sequentially after problem behavior emerges
allows the clinician to develop an individualized
Jonathan W. Wilkins is currently affiliated with Nation-
wide Children’s Hospital, The Ohio State University,
Columbus.
Address correspondence to Cathleen C. Piazza at
cpiazza@unmc.edu.
doi: 10.1002/jaba.169
intervention with the fewest components neces-
sary to achieve efficacy. There are several potential
disadvantages, however, of sequential treatment
implementation after problem behavior emerges.
First, emergence of behavior such as expulsion
will result in escape from eating expelled bites
until an effective intervention is implemented. In
this situation, expulsion gains response strength
each time it contacts reinforcement, potentially
increasing the length of time required to reduce
subsequent behavior (Lattal & Neef, 1996).
Second, many children with feeding problems are
inexperienced eaters who do not exhibit develop-
mentally appropriate feeding behavior (Arvedson &
Brodsky, 2002). By contrast, feeding behavior in
typically eating children usually emerges according to
a predictable developmental sequence. For example,
tongue thrust or tongue protrusion is present at birth
and allows an infant to suckle during breast or bottle
feeding. The suckling pattern, of which tongue
thrust is a component, consists of a horizontal in-
and-out movement of the tongue (Arvedson &
Brodsky, 2002). Tongue thrust disappears around 4
to 6 months of age and is replaced by tongue
lateralization around 6 to 9 months of age in typically

694
 SPOON VERSUS NUK
eating children. In children with feeding problems,
tongue thrust, which often persists well beyond 6 to
9 months of age, results in the child pushing some or
all of the bolus out of the mouth (Arvedson &
Brodsky, 2002). Thus, in the absence of treatment,
the child with persistent tongue thrust makes errors
during feeding (Terrace, 1969). In this example, the
error consists of thrusting the tongue during bite
presentation, which may promote persistence of the
problem feeding behavior and interfere with
development of more age-appropriate and functional
feeding skills. The child with persistent tongue thrust
may not learn to lateralize food, which is a necessary
skill for the successful management of solids.
Rather than adding treatments sequentially as
in Sevin et al. (2002), an alternative strategy is to
include procedures during the initial intervention
that would function as treatment for specific
problem feeding behavior. With the former
approach, the clinician implements a treatment
component only after a period of time in which
he or she has determined that a specific behavior
problem such as expulsion is going to emerge,
persist, and require treatment. By contrast, with
the latter approach, the clinician programs an
intervention into the treatment to target a specific
behavior problem even though he or she does not
know whether the behavior problem will emerge,
persist, and require treatment. Programming
treatment components a priori has the advantage
of potentially minimizing the history of rein-
forcement for the behavior. This strategy also
potentially promotes use of correct feeding skills
concomitant with the point when the child first
begins accepting food.
Expulsion and packing are problems that often
emerge as children begin to accept bites during
feeding treatment. Altering the presentation meth-
od may be one way of treating problem feeding
behavior (Girolami, Boscoe, & Roscoe, 2007;
Sharp, Harker, & Jaquess, 2010; Sharp, Odom, &
Jaquess, 2012). Girolami et al. (2007) and Sharp,
Harker, et al. (2010) reported that expulsion was
lower when the therapist presented bites using a
Nuk. Sharp, Harker, et al. also reported that mouth
695
clean, a product measure of swallowing, was higher
with the Nuk than with the upright spoon.
Investigators often conduct utensil assessments
with children who have a history of treatment with
nonremoval of the spoon (e.g., Girolami
et al., 2007; Sharp, Harker, et al., 2010; Sharp
et al., 2012). That is, investigators first implement
nonremoval of the spoon and then conduct a
utensil assessment if the child exhibits an increase in
expulsion, packing, or both. We wondered whether
it might be beneficial to manipulate the utensil
during initial treatment for refusal rather than
altering the utensil after problem behavior emerged
and persisted for a period of time in the absence of
treatment. We also were interested in following
these children to describe the clinical course of
treatment associated with spoon versus Nuk
presentation. These data might provide evidence
for the generality of the treatments by demonstrat-
ing that improvements in behavior extend beyond
the confines of the study (Sharp, Jaquess, Morton,
& Hertzinger, 2010; Sharp et al., 2012).
In the current investigation, we extended the
work of Girolami et al. (2007) and Sharp, Harker,
et al. (2010) by evaluating the effects of a utensil
manipulation during initial treatment of 12
children with significant feeding problems. During
baseline, the feeder presented food on a spoon in
one condition or a Nuk in another condition. Next,
we continued alternating between utensils in the
context of a treatment for refusal. One purpose of
the study was to evaluate levels of expulsion,
acceptance, mouth clean, and grams consumed
associated with spoon versus Nuk presentation
during initial treatment of the child’s feeding
problem. A second purpose was to describe the
clinical course of treatment and to provide follow-
up data on children whose feeding behavior
improved during treatment with the spoon or Nuk.
METHOD
Participants, Setting, and Materials
Twelve children who had been admitted
consecutively to a pediatric feeding disorders
696 JONATHAN W. WILKINS et al.
program participated. Katie attended the inten-
sive outpatient program Monday through Friday
from 8:30 a.m. to 1:00 p.m. All other children
attended the day-treatment program Monday
through Friday from 8:30 a.m. to 5:00 p.m.
We followed our typical clinical course for all
12 children, which is to conduct a functional
analysis and then implement function-based
treatment. Due to space limitations, we do not
describe the functional analysis here, but see
Bachmeyer et al. (2009) for a description. The
results of the functional analyses indicated that
escape functioned as reinforcement for the
inappropriate mealtime behavior for all 12
children. Our program data suggest that approxi-
mately 55% of patients in the intensive outpa-
tient and day-treatment programs who respond
to function-based treatment will require addi-
tional components, such as presentation of food
on a Nuk, to treat expulsion and packing.
Therefore, it was a reasonable clinical course to
alternate between spoon and Nuk presentation
during initial treatment. An interdisciplinary
team (dietitian, gastroenterologist, psychologist,
and speech therapist) evaluated each child before
admission and confirmed the appropriateness
and safety of oral feeding.
The participants were Catherine, 2 years; Katie,
13 months; Kelly, 4 years; Michael, 22 months;
Melissa, 6 years; Madeline, 2 years; Nick, 21
months; Kyle, 2 years; Randy, 3 years; Betty,
15 months; Jason, 2 years; and Chloe, 2 years. All
children except Katie and Nick received the
majority of calories via enteral (e.g., gastrostomy)
or enteral plus parenteral feeds. Katie and Nick
did not consume sufficient calories for weight gain
and growth. Kelly, Michael, Melissa, Nick, Randy,
and Jason had been diagnosed with developmen-
tal delays.
The observers, feeder, and child were in a room
(4 m by 4 m) during sessions for the spoon versus
Nuk assessment, Week 7 intensive outpatient or
day-treatment sessions, and outpatient follow-up,
unless otherwise noted. The observers, child, and
caregivers were in the home during the Week 8
intensive outpatient or day-treatment home visits.
During home visits, the child was in the room in
which the family usually ate. During all sessions,
each child used age-appropriate seating (e.g.,
toddler highchair, booster seat). Also present were
utensils, food trays, gloves, and timers.
Feeders
The feeders (therapists) during the majority
of the intensive outpatient or day-treatment
admission and the observers were individuals
with bachelor’s, master’s, or doctoral degrees in
psychology, behavior analysis, or a related field.
We trained each child’s caregivers to implement
the treatment, and the caregiver served as feeder
as described below.
Design and Procedure
Design. We used a multielement design in our
analysis of the effects of utensil type (spoon vs.
Nuk). We used an ABAB design to demonstrate
functional control for the treatment.
General procedure, dependent variables, and
data collection. Trained feeders conducted two to
five meals per day with at least 1 hr between the
start of each meal (e.g., 9:00 a.m., 10:30 a.m.).
Meals lasted 30 to 45 min. Each meal consisted of
two to 10 sessions, with 1- to 2-min breaks
between each session. Each session consisted of
five bite presentations. The bolus size for each
presentation was a level small Maroon spoon
(Catherine, Katie, Kelly, Melissa, Nick, and
Randy), a half-level small Maroon spoon (Made-
line, Kyle, Jason, and Chloe), or a level baby
spoon (Michael and Betty). To level the bolus, the
feeder scooped food into the bowl of the spoon
and then scraped the bowl of the spoon on the
side of the dish. For the half-level bolus, the
feeder filled half of the bowl of the spoon with
food and scraped the spoon on the side of the
dish. The feeder equated the bolus sizes for spoon
and Nuk sessions by filling the child’s prescribed
spoon with the appropriate amount of food and
then scraping the food off the spoon onto the
Nuk. Each caregiver selected approximately eight
 SPOON VERSUS NUK
to 16 foods that the feeder presented to the child
(contact the author for a list of foods for each
child). The feeder prepared the foods at a pureed
texture, which is table food blended in a chopper
until smooth, with liquid added as needed. The
speech therapist recommended the bolus sizes
and texture.
The feeder randomly selected three foods, one
from each of the food groups of protein, starch,
and vegetable for Kyle, Jason, and Chloe (no fruit
due to dietary restrictions), or four foods, one
from each of the food groups of fruit, protein,
starch, and vegetable for all other participants, to
present during each meal. The feeder presented all
foods from the caregiver-selected food list in each
phase and with each utensil type to control for any
possible differences in behavior as a function of
food type (Patel, Piazza, Santana, & Volkert,
2002). The feeder randomly alternated the order
of food presentation from session to session.
Each food was in a separate bowl, and the
feeder placed each bowl of food on a kitchen scale
before and after each session and recorded the
pre- and postsession weights to calculate grams
consumed. At the conclusion of the session, the
feeder wiped up any spill with paper towels. Spill
was any food that was not in the child’s mouth or
the bowls (e.g., food in the bib) at the end of the
session. The feeder used the following formula to
calculate grams consumed for a single food:
(presession weight minus postsession weight)
minus (weight of paper towels with spill minus
weight of paper towels without spill). For
example, if the weights of the presession bowl,
the postsession bowl, and spill for mashed
potatoes were 40 g, 20 g, and 5 g, respectively,
then the grams consumed for mashed potatoes
for the session would be 15 (i.e., [40 – 20] – 5).
The data presented for grams consumed for each
session is the sum of the gram weights for the
three or four foods presented in the session. For
example, if the weights of the foods for a session
were 15 g for mashed potatoes, 12 g for plums,
9 g for bread, and 12 g for peas, the total grams
consumed for the session would be 48.
697
The feeder presented the bite by placing the
utensil touching the child’s lips and saying “take a
bite” approximately once every 30 s. If the child
opened his or her mouth in the absence of
inappropriate mealtime behavior (i.e., turning
the head or batting the spoon) and crying within
5 s of presentation, the feeder deposited the bite
and provided praise, and observers scored
acceptance. If the child failed to close his or her
mouth to pull the food off the utensil when the
bite entered the mouth, the feeder gently scraped
the bite on the child’s teeth with the spoon or
deposited the bite by gently rolling the Nuk on
the middle of the child’s tongue.
If the entire bite, with the exception of food
smaller than a pea, entered the child’s mouth, (not
including the bite entering the child’s mouth
during re-presentation), the observer activated a
timer for 30 s. The feeder said “show me” at 30 s to
determine if the child had swallowed and to
provide the observers the opportunity to score
mouth clean or pack. Observers had five potential
opportunities per session to score mouth clean or
pack, which corresponded to one potential
scoring opportunity for each of the five bite
presentations. Observers scored mouth clean if no
food larger than a pea was in the child’s mouth,
unless the absence of food at the 30-s check was
due to expulsion (see below for details). The
feeder delivered praise for mouth clean and
presented the next bite. If the entire bite (with the
exception of food smaller than a pea) did not enter
the child’s mouth, the feeder did not conduct a
mouth check, and observers did not score mouth
clean or pack for that bite presentation.
Observers scored pack if the entire bite
(with the exception of food smaller than a pea)
entered the child’s mouth, and food larger than a
pea was in the child’s mouth at the 30-s check. In
this case, the feeder said, “You need to swallow
your bite,” and presented the next bite. If the
child was packing at the 30-s check for the fifth
bite, the feeder said, “You need to swallow your
bite,” the observer scored pack, and the feeder
continued to prompt the child to swallow every
698 JONATHAN W. WILKINS et al.
30 s until there was no food larger than a pea in the
mouth or 10 min (Catherine, Michael, Melissa,
Madeline, Randy, and Chloe) or 15 min (Katie,
Kelly, Nick, Kyle, Betty, and Jason) had elapsed
from the beginning of the session. Note, however,
that the observer did not score mouth clean or
pack at these subsequent mouth checks. If there
was food in the child’s mouth after the expiration
of the time cap, the feeder removed it.
Observers scored an expulsion any time the
entire bite entered the child’s mouth (except for
food smaller than a pea), and food larger than a
pea exited the mouth past the plane of the child’s
lips. If there was no food in the child’s mouth at
the 30-s check because the child had expelled the
bite, the observer did not score mouth clean or
pack. Note, however, that in sessions in which the
feeder used re-presentation (in treatment, see
below), if (a) the child swallowed the re-presented
bite so that there was no food in the mouth at the
30-s check, the observer scored mouth clean; or
(b) the child did not swallow the re-presented bite
so that there was food in the mouth at the 30-s
check, the observer scored pack. The feeder
provided no differential consequences for negative
vocalizations, vomiting, gagging, or coughing.
Spoon versus Nuk assessment. The purpose of
the assessment was to evaluate the effects of
utensil, spoon versus Nuk, in the context of
treatment for refusal. The feeder used random
selection with counterbalancing to identify a
utensil to use during each session. The feeder
followed the general procedure described above
in addition to the specific contingencies de-
scribed for each condition below.
Baseline. The feeder followed the general
procedure described above, with the following
modifications. The feeder deposited the bite only if
the child opened his or her mouth in the absence of
inappropriate mealtime behavior and crying. The
feeder did not re-present expelled bites. If the child
did not engage in inappropriate mealtime behavior
and did not open his or her mouth to allow the
feeder to deposit the bite in the absence of
inappropriate mealtime behavior and crying, the
feeder held the spoon in its original presentation
position for 30 s. At the end of the 30-s interval,
the feeder removed the utensil and presented
the next bite. We arranged the following contin-
gencies based on the results of functional analyses
of inappropriate mealtime behavior conducted
before the study (Bachmeyer et al., 2009): For
Catherine, Katie, Michael, Melissa, Kyle, Randy,
and Betty, the feeder delivered attention and
removed the utensil for 30 s if the child engaged
in inappropriate mealtime behavior. For Kelly,
Nick, Madeline, Jason, and Chloe, the feeder
removed the utensil for 30 s if the child engaged in
inappropriate mealtime behavior.
Treatment. The feeder provided no differential
consequence for inappropriate mealtime behav-
ior. If the child did not accept the bite within 5 s
of presentation, the feeder held the utensil
touching the child’s lips and deposited the bite
whenever the child’s lips and teeth were open
wide enough for the feeder to insert the spoon or
Nuk into the child’s mouth, except if the child
was coughing, gagging, or vomiting. If the child
was coughing, gagging, or vomiting, the feeder
held the utensil touching the corner of the child’s
lips until the child stopped coughing, gagging, or
vomiting, and then the feeder deposited the bite.
If the child clenched his or her teeth but did not
engage in inappropriate mealtime behavior, the
feeder attempted to place the utensil between the
child’s lips and deposited the bite when the child
opened his or her mouth. If the child expelled the
bite, the feeder collected the bite on the utensil
and placed it back into the child’s mouth. If the
child engaged in more than 25 inappropriate
mealtime behaviors during a session or if the rate
of inappropriate mealtime behavior was greater
than three per minute for three consecutive
sessions, a blocker entered the room and stood
behind the child’s chair. The blocker placed his or
her hands so that they were approximately level
with the child’s chest during spoon or Nuk
presentation and blocked the child’s hands from
touching his or her mouth. This arrangement
allowed the feeder to keep the spoon or Nuk at
 SPOON VERSUS NUK
the child’s lips while allowing the child to engage
in inappropriate mealtime behavior (e.g., the
child could turn his or her head or bat at
the blocker’s hand). We discontinued use of the
blocker when the child’s inappropriate mealtime
behavior was three per minute or less for three
consecutive sessions. Sessions continued until the
child had swallowed all five bites or 10 min
(Catherine, Michael, Melissa, Madeline, and
Randy) or 15 min (Katie, Kelly, Nick, Kyle,
Betty, Jason, and Chloe) had elapsed from the
beginning of the session. If the child had food in
his or her mouth after the expiration of the time
limit, the feeder removed it. Per caregiver
request, the feeder talked to Katie and Jason
during treatment, and Jason had access to
preferred toys.
Protocol changes during the intensive outpatient
or day-treatment admission. The length of the
intensive outpatient and day-treatment admission
is approximately 320 hr, which is equivalent to
40 8-hr days. When describing the course of
treatment for each child during the intensive
outpatient or day-treatment admission in the
Results, we will refer to each 40 hr of participation
in the program as a week (e.g., Week 1, Week 2).
For each child, we began the functional analysis in
Week 1 and completed the spoon versus Nuk
assessment as indicated below (range, Weeks 2
to 5). At the conclusion of the spoon versus Nuk
assessment, we identified an appropriate utensil
for the child based on visual inspection of the data.
If the selected utensil was the Nuk, the feeder
conducted the majority of sessions with the Nuk
and one session per day with the spoon to evaluate
the child’s performance with the spoon. We used
these data to determine when we could transition
from the Nuk to the spoon. We modified the
treatment for most children to promote progress or
respond to caregiver requests during the remainder
of the child’s intensive outpatient or day-treatment
admission. The timing of caregiver training was
individualized and is described below. Note that we
also worked on other feeding goals throughout the
admission (e.g., self-drinking).
699
For most children, Week 7 in the intensive
outpatient or day-treatment admission was their
final week in the clinic. During Week 8, the
therapist observed the caregiver feeding the child
in the home. During home visits, the caregiver
followed the child’s typical feeding schedule,
which generally consisted of three meals and two
snacks. Therapists conducted multiple observa-
tions each day in the home, with at least one
observation at each meal and snack time over the
course of the Week 8 home visits.
Outpatient follow-up. After completion of the
intensive outpatient or day-treatment program, all
children who responded to the treatment with the
spoon or Nuk (except Kyle) transitioned to the
outpatient follow-up program. The child and his
or her caregiver attended 1- to 1.5-hr outpatient
sessions approximately once per week. Most
children continue with outpatient therapy until
the child is a developmentally typical feeder. (We
will not describe the course of outpatient follow-
up for the treatment nonresponders.)
During outpatient follow-up, the caregiver
continued to conduct the child’s intensive outpa-
tient or day-treatment discharge protocol described
above unless otherwise noted. Each follow-up data
point represents the child’s behavior x months from
discharge from the intensive outpatient or day-
treatment program. For example, the 12-month
follow-up data point represents the child’s behavior
12 months after he or she had been discharged
from the intensive outpatient or day-treatment
program. The last follow-up data point represents
the child’s behavior immediately before submission
of this paper.
Data Conversion and Interobserver Agreement
We converted data for acceptance and mouth
clean to a percentage after dividing the number of
occurrences of acceptance or mouth clean by the
number of bite presentations (denominator for
acceptance) or the number of bites that entered
the child’s mouth (denominator for mouth
clean). We calculated expulsions per bite by
dividing the number of expulsions by the number
700 JONATHAN W. WILKINS et al.
of bites that entered the child’s mouth, not
including bites that entered the mouth during re-
presentation.
We calculated interobserver agreement for
acceptance and mouth clean by partitioning the
session into 10-s intervals; summing occurrence
(a 10-s interval in which both observers scored
the behavior) and nonoccurrence (a 10-s interval
in which both observers did not score the
behavior) agreements; dividing by the sum of
occurrence agreements, nonoccurrence agree-
ments, and disagreements (a 10-s interval in
which one observer scored and the other observer
did not score the behavior); and converting the
ratio to a percentage. We calculated exact
agreement coefficients for expulsions by dividing
the number of 10-s intervals in which observers
scored the same frequency of expulsions by the
total number of 10-s intervals in the session and
converting the ratio to a percentage. A second
observer independently scored a mean of 37%
(range, 11% to 64%) of sessions across partic-
ipants. Mean agreement across participants was
98% (range, 79% to 100%) for acceptance, 99%
for mouth clean (range, 83% to 100%), and 97%
(range, 61% to 100%) for expulsions.
We assessed interobserver agreement for grams
consumed for Katie, Melissa, Nick, Kyle, and Chloe
by having a second observer independently record
the pre- and postsession weights and spill on a
separate data sheet and calculate grams consumed.
We calculated interobserver agreement for grams
consumed by dividing the smaller by the larger
number of grams consumed and converting the
ratio to a percentage. We assessed interobserver
agreement on a mean of 20% (range, 2% to 35%)
of sessions. Mean interobserver agreement was 97%
(range, 0% to 100%).
RESULTS
We present data for expulsions graphically
because it was the dependent variable that was
most sensitive to the utensil manipulation. We
present data for acceptance, mouth clean, grams
consumed, and follow-up in Table 1. To describe
the course of the child’s clinical treatment during
the intensive outpatient or day-treatment pro-
gram after the completion of this analysis, we
present data for the child’s final week in clinic
(Week 7) and home visits (Week 8). Data for
Weeks 7 and 8 represent the means for all sessions
conducted with the treatment during that week
with the feeders as indicated.
Expulsions per bite are depicted for Catherine,
Katie, and Kelly in Figure 1; for Michael, Melissa,
and Madeline in Figure 2; and for Nick and Kyle
in Figure 3. Data for Randy, Betty, Jason, and
Chloe are presented only in Table 1, because the
treatment was not effective. Expulsions per bite
were higher with the spoon than with the Nuk
during treatment for Catherine, Katie, Kelly,
Michael, and Melissa. Expulsions per bite were
slightly higher with the spoon than with the Nuk
in the first phase of treatment for Madeline, but
became equivalent in the second phase of
treatment. Expulsions per bite were equivalent
throughout the assessment of spoon versus Nuk
for Nick and Kyle. Recall that the feeder did not
re-present the bite in baseline. The inclusion of
re-presentation in treatment increases the num-
ber of opportunities for the child to expel the bite
in treatment relative to baseline. That is, each
time the feeder re-presents the bite, the child has
another opportunity to expel. These increased
opportunities to expel explain the overall increase
in expulsions per bite from baseline to treatment.
For Catherine, we completed the spoon versus
Nuk assessment in Week 5 of her day-treatment
admission. We continued treatment with the Nuk
because of the relatively lower rates of expulsions,
higher levels of mouth clean, and more grams
consumed. We added noncontingent attention in
which the feeder interacted as a caregiver would in a
typical meal per caregiver request and began
caregiver training in the clinic during Weeks 5 and
6. Over the course of admission, acceptance and
mouth clean continued to increase, and expulsions
and grams consumed remained stable. During
Weeks 7 and 8, feeders continued to use the Nuk in
 SPOON VERSUS NUK 701

Table 1
Summary of Results from the Spoon versus Nuk Assessment

Baseline Treatment Parent-fed sessions

Follow-up (months)
Spoon Nuk Spoon Nuk Week 7 Week 8 3 6 12 18 24
Treatment responders
Catherine
Expel 0.7 0.3 29.0 1.5 0.2 0.1 0 0 0
Accept (%) 8 1 92 35 83 87 100 100 93
Mouth clean (%) 0 2 0 59 95 97 100 100 100
Grams 1.1 1.5 0.3 4.5 7 6 9 8
Katie
Expel —a —a 2.4 0.4 0 0 0 0 0
Accept (%) 0 0 9 5 98 91 100 100 100
Mouth clean (%) —a —a 2 38 96 94 100 100 100
Grams —a —a 4.1 4.2 6 11
Kelly
Expel —a —a 4.8 0.8 0 0 0 and 0b
Accept (%) 0 0 75 60 96 94 100 and 100b
Mouth clean (%) —a —a 60 83 85 85 60 and 80b
Grams —a —a 4.6 4.2 4 4 6 and 8b
Michael
Expel 0.6 0.1 0.7 0.2 0.2 0.1 0 0.1 0
Accept (%) 8 14 75 60 98 98 100 100 100
Mouth clean (%) 16 85 94 93 98 99 100 100 100
Grams 1.6 1.0 4.4 4.2 11 13 13 18
Melissa
Expel 0.5 0.2 2.4 1.1 0.1 0 0 0.5 0 0
Accept (%) 19 20 64 72 99 95 100 41 100 100
Mouth clean (%) 8 0 2 25 72 86 100 20 73 100
Grams 0.1 0.4 3.8 3.1 4 3
Madeline
Expel 0.2 0.2 0.8 0.8 0 0 0 0
Accept (%) 45 46 86 83 99 97 100 90
Mouth clean (%) 15 32 93 89 90 88 100 100
Grams 1.1 1.0 4.2 3.8 15 15 19
Nick
Expel 0 0 0.2 0.1 0 0 0 0 0
Accept (%) 31 29 73 57 94 96 85 100 100
Mouth clean (%) 38 40 87 96 99 100 100 100 100
Grams 4.4 2.6 7.1 5.4 9 10 7 7
Kyle
Expel 0 0 0.8 0.4
Accept (%) 23 25 83 89
Mouth clean (%) 49 45 49 52
Grams 1.3 1.0
Treatment nonresponders
Randy
Expel 0 0.2 0.1 0.3
Accept (%) 1 7 81 81
Mouth clean (%) 7 17 62 64
Grams 0.1 0.6 6.9 5.7
Jason
Expel —a —a 2.9 1.3
Accept (%) 0 0 12 0
Mouth clean (%) —a —a 0 0
Grams —a —a 3.6 3.5

(Continued)
702 JONATHAN W. WILKINS et al.

Table 1
(Continued)
Baseline Treatment Parent-fed sessions
Follow-up (months)
Spoon Nuk Spoon Nuk Week 7 Week 8 3 6 12 18 24
Betty
Expel —a 0.1 1.2 1.0
Accept (%) 0 9 49 64
Mouth clean (%) —a 0 1 11
Grams —a 0.1 0.2 0.4
Chloe
Expel —a —a 7.3 1.1
Accept (%) 0 0 12 3
Mouth clean (%) —a —a 0 3
Grams —a —a 3 3.5
a
No opportunity for the behavior to occur.
b
Data from spoon and Nuk sessions, respectively.

the clinic and child’s home, respectively. At 3- and sequential verbal, gestural, and physical prompts),
6-month follow-ups, Catherine was accepting bolus fading (gradually increasing the amount of
and swallowing bites from the Nuk with caregivers food on the spoon), and differential positive
as feeders. We used three-step prompting (i.e., (attention) and negative (a break from spoon

Figure 1. Expulsions per bite for Catherine (top), Katie (middle), and Kelly (bottom).
 SPOON VERSUS NUK 703

Figure 2. Expulsions per bite for Michael (top), Melissa (middle), and Madeline (bottom).

presentation) reinforcement to teach Catherine to and 12-month follow-ups, caregivers continued

close her lips around the spoon. At 12-month
follow-up, Catherine accepted and swallowed all
bites from the spoon when presented by caregivers
or nanny.
For Katie, we completed the spoon versus Nuk
assessment and began caregiver training during
Week 4. We continued treatment with the Nuk
because of the relatively lower rates of expulsions,
higher levels of mouth clean, and more grams
consumed. Over time, expulsions decreased and
mouth clean increased during spoon sessions so
that caregivers were conducting all sessions with
the spoon by Week 7. Over the course of
admission, acceptance and mouth clean contin-
ued to increase, expulsions decreased further, and
grams consumed remained stable. During 3-, 6-,
to present bites to Katie on a spoon.
For Kelly, we completed the spoon versus
Nuk assessment in Week 2. We continued
treatment with the Nuk because of the relatively
lower rates of expulsions and higher levels of
mouth clean. We began caregiver training in the
clinic during Week 3. During Week 8 home
visits, we transitioned Kelly to the spoon for all
sessions, and caregivers began presenting one
bite after another. During outpatient follow-up,
her caregivers returned to presentation of one
session per day with the spoon and the
remaining sessions with the Nuk. At 3-month
follow-up, we conducted sessions with care-
givers presenting bites on the Nuk and on
the spoon. At that point, her caregivers
704 JONATHAN W. WILKINS et al.
Figure 3. Expulsions per bite for Nick (top) and Kyle (bottom).
discontinued outpatient therapy when her
mother was deployed.
For Michael, we completed the spoon versus
Nuk assessment in Week 3. We continued
treatment with the Nuk because of the relatively
lower rates of expulsions. We began caregiver
training in the clinic, added noncontingent atte-
ntion as described above per caregiver request,
transitioned to the spoon only, and transitioned
to a small Maroon spoon during Weeks 3, 3, 4,
and 5, respectively. During 3-, 6-, and 12-month
follow-ups, caregivers continued to present bites
on a spoon on a fixed-time 15-s schedule.
For Melissa, we completed the spoon versus
Nuk assessment in Week 2. We continued
treatment with the Nuk because of the relatively
lower rates of expulsions and higher levels of mouth
clean. We presented one food in each session,
began caregiver training in the clinic, presented
bites every 15 s, and added noncontingent atten-
tion (described above) during Weeks 2, 2, 3, 6, and
7, respectively. We trained teachers and day care
staff during Week 8 (i.e., the therapist went to the
school and day care as well as home). We provided
outpatient follow-up to Melissa via telehealth. Data
collectors were in a private room in the clinic and
were linked to the family via a secure web-
conferencing platform. The family was at home in
the kitchen and used a webcam on their computer.
At 3-month follow-up, Melissa’s caregivers pre-
sented all bites on a Nuk. We taught Melissa to
close her mouth around the spoon using three-step
prompting (sequential verbal, model, and physical
prompts). At 6-, 12-, and 18-month follow-ups,
Melissa’s caregivers presented all bites on a spoon.
For Madeline, we completed the spoon versus
Nuk assessment in Week 2. We continued
treatment with the spoon after this assessment.
We increased the bolus to a level small Maroon
spoon, presented bites every 15 s, began caregiver
training in the clinic, and increased the bolus to a
level large Maroon spoon during Weeks 2, 2, 3,
and 6, respectively. At 3- and 12-month follow-
ups, Madeline’s caregivers continued to present
 SPOON VERSUS NUK
all bites on a spoon. Follow-up data at 6 months
were not available.
For Nick, we completed the spoon versus Nuk
assessment in Week 3 and continued treatment
with the spoon. We began caregiver training in the
clinic and presented one bite after another during
Weeks 4 and 6, respectively. At 3-, 12-, and 24-
month follow-ups, Nick’s caregivers continued to
present all bites on a spoon. Follow-up data at 6
and 18 months were not available.
Kyle and his family left the program early
because Kyle completed his medical treatment,
and the family returned to their home in
another state. We do not have any additional
data for Kyle.
For Randy, acceptance increased and expul-
sions remained low during treatment. Mouth
clean increased initially but then decreased
during the second phase of treatment. As mouth
clean decreased, sessions often reached the
maximum length without Randy swallowing
all of the bites. For Betty, acceptance increased
during treatment, but mouth clean remained
low, and expulsions remained high. For Jason,
expulsions were higher with the spoon than with
the Nuk during treatment. However, acceptance
and mouth clean did not increase to clinically
acceptable levels, and sessions often reached the
maximum length without Jason swallowing all of
the bites. Therefore, we discontinued the spoon
versus Nuk assessment for these three children
and initiated an assessment with a flipped spoon.
For these three children, their final treatment
included the flipped spoon in conjunction with
other treatment components (e.g., nonremoval
of the spoon, noncontingent reinforcement). For
Chloe, acceptance did not increase during the
assessment, and negative vocalizations were
unacceptably high. In addition, sessions often
reached the maximum length without Chloe
swallowing all of the bites. Therefore, we
discontinued the spoon versus Nuk assessment.
Chloe’s caregiver discontinued therapy before we
could develop an alternative treatment for her
refusal of solids.
705
DISCUSSION
In the current investigation, we evaluated
whether presentation of bites on a spoon or a Nuk
would have beneficial effects during initial
treatment of the refusal behavior of 12 children
with severe feeding problems. These were
children with significant refusal, selectivity, or
both, who had not been exposed to the
nonremoval and re-presentation treatment in
the past. The results suggested that eight of the 12
children responded to the nonremoval and re-
presentation treatment in terms of increased
acceptance and mouth clean and low levels of
expulsions. For the eight children who responded
to treatment, five exhibited lower levels of
expulsions, and four of the five had higher levels
of mouth clean with the Nuk than with the
spoon. These data are important because they
show that utensil manipulation may be beneficial
during initial treatment for some children. Note
that this procedure did not prevent the occur-
rence of expulsion or other problem feeding
behavior, nor was the study designed to compare
reactive and proactive treatments.
The data from Sevin et al. (2002) showed that
problem mealtime behavior (e.g., expulsion and
packing) may emerge during initial treatment of
refusal. Sevin et al. added treatments sequentially
as problem mealtime behavior emerged. The
disadvantage of this sequential treatment ap-
proach was that the child in Sevin et al. escaped
many of the presented bites as a result of
expulsion when re-presentation was absent from
the nonremoval of the spoon. Data from the
functional analyses of inappropriate mealtime
behavior, defined as head turns and batting at the
utensil, conducted before this study showed that
escape from bites was a reinforcer for inappropri-
ate mealtime behavior for all 12 children in this
study; therefore, it is reasonable to expect that
repeated exposure to reinforcement in the form of
escape from bites as a result of expulsions would
maintain expulsions as well. Even though re-
presentation of expelled bites was a component of
706 JONATHAN W. WILKINS et al.
the initial treatment for all of the children in the
current investigation, re-presentation was not
effective as treatment for expulsions when the
feeder presented food on a spoon for five of the
children. Therefore, the children with high levels
of expulsions during spoon presentations experi-
enced brief escape from the bite each time they
expelled. That is, brief escape occurred from the
time the child spit out the bite until the feeder re-
presented the bite. By contrast, less escape from
bites occurred for the five children who had lower
levels of expulsions with the Nuk.
The Nuk was helpful not only in reducing
expulsions but also in increasing mouth clean for
four children. One reason why presentation of
bites on a Nuk may be associated with lower levels
of expulsions and higher levels of mouth clean is
that the feeder can place the food directly onto
the child’s tongue with the Nuk. By contrast,
placement of food on the tongue with the upright
spoon is possible only if the child closes his or her
mouth around the bowl of the spoon and pulls
the food off of the spoon or if the feeder flips the
spoon and drags the food along the tongue
(Sharp, Harker, et al., 2010; Volkert, Vaz, Piazza,
Frese, & Barnett, 2011). Placement of the food
on the tongue is important because it is one of the
first behaviors in the chain (i.e., bolus formation)
that leads to swallowing. Some children with
feeding problems may lack the skill or motivation
to move the food to the tongue to form the bolus.
If the feeder places the food on the child’s tongue,
the child only needs to elevate the tongue and
propel the food into the pharynx. In this case, the
child may be more likely to swallow correctly,
without expulsion or packing. If the child is just
learning to eat, as is the case with many children
with significant refusal who participate in initial
treatment, it may be advantageous to provide
them with the opportunity to accept and swallow
bites in a feeding context that is more likely to
be associated with low levels of expulsion and
packing. Early experiences with correct eating
behavior may be more likely to be associated with
correct eating behavior in the future, whereas
early experiences with making errors such as
expulsion or packing during eating may be more
likely to be associated with errors during eating
in the future. These are issues that should be
explored in future research.
These data replicate those of other studies that
have shown the benefits of presentation of bites
on a Nuk (Girolami et al., 2007; Sharp, Harker,
et al., 2010) for some children. Girolami et al.
(2007) showed that re-presentation of bites with
a Nuk resulted in lower levels of expulsions
than re-presentation with a spoon for one child.
Expulsions decreased further when the feeder
presented and re-presented bites on a Nuk.
Sharp, Harker, et al. (2010) showed that mouth
clean was higher with presentation of bites on a
Nuk than on a spoon for one child. Similarly, for
four children in the current investigation, levels
of mouth clean were relatively higher with the
Nuk than with the spoon. The data for the
current investigation are also similar to Sharp,
Harker, et al. in that increases in mouth clean
for Catherine, Katie, and Melissa were modest
initially. Levels of mouth clean were clinically
acceptable (i.e., above 80%) by the last week of
treatment (Week 7) in the clinic for these three
children. Our findings raise the possibility that
mouth clean for the participant in Sharp, Harker,
et al. would have increased had they continued
the intervention for a longer period of time.
Sharp, Harker, et al. reported implementing
additional treatment components to increase
mouth clean. By contrast, we continued with
essentially the same treatment for Catherine,
Katie, and Melissa, and mouth clean was above
80% during the last 2 weeks of the day-treatment
or intensive outpatient admissions. One differ-
ence between the current investigation and that
of Sharp, Harker, et al. is that Sharp, Harker,
et al. did not implement re-presentation in
conjunction with utensil manipulation. It may
be the case that clinically acceptable increases in
mouth clean occur only after repeated trials in
conjunction with re-presentation and utensil
manipulation for some children.
 SPOON VERSUS NUK
What is not clear from the current investigation
is why some children benefitted from the Nuk
whereas others were able to eat just as proficiently
with the spoon. One variable that seems reasonable
to explore is eating experience. In the current
investigation, all of the children had significant
feeding problems that affected their experience as
oral feeders. Ten of the 12 children received the
majority of their calories via tube feedings. Only
Kelly and Nick consumed 100% of their calories
orally, although their variety and volume of foods
consumed were limited. Nevertheless, percentage of
calories consumed by mouth before treatment did
not appear to be a good predictor of whether the
child would be successful with the spoon during
initial treatment. For example, Kelly, who was a
relatively more experienced feeder, benefitted from
the Nuk, and Madeline, who was a relatively less
experienced feeder, was able to eat successfully with
the spoon. Perhaps pretreatment quantification of
oral motor skills might be a better predictor of the
necessity of utensil manipulation during initial
treatment. Although our program speech therapist
evaluated all of the children before admission, she
did not conduct a standardized assessment of oral
motor skills, and this is a limitation of the current
investigation. One challenge of pretreatment
assessment of oral motor skills is that many children
with severe feeding problems refuse to accept bites
of food before treatment; therefore, it is difficult to
evaluate their level of oral motor competence in the
presence of food before treatment. One option
might be to evaluate oral motor skills in a
nonnutritive context. It is not clear whether a
nonnutritive evaluation of oral motor skills would
predict competence as an oral feeder, and that might
be a direction for future research.
A related limitation is that we did not equate
bite placement across utensils. One of the
inherent limitations of upright spoon presenta-
tion is that it is not possible to place the bite on
the child’s tongue if the child fails to close his or
her mouth around the bowl of the spoon. By
contrast, it would have been possible to scrape the
bolus onto the child’s teeth with the Nuk with the
707
goal of attempting to identify the mechanism
behind the effectiveness of treatment. Decreased
expulsion and increased mouth clean when the
therapist placed the bolus on the tongue with
the Nuk, but not when he or she scraped the
bolus onto the child’s teeth, suggest that bolus
placement was an important component of
treatment effectiveness. A related limitation is
that we did not measure whether the child closed
his or her lips around the bowl of the spoon or
whether the feeder scraped the bite onto the
child’s teeth with the spoon. These measures may
be helpful in understanding the mechanisms that
underlie the effectiveness of the Nuk and
identifying child characteristics that are associat-
ed with the need for a utensil manipulation. The
effects of bolus placement and lip closure should
be the subjects of future investigations.
Another limitation of the current study is that
treatment was not effective for four of the
participants. For three of these four participants,
the main variable that influenced our decision to
terminate the assessment and implement a differ-
ent intervention was session duration. For Randy,
Jason, and Chloe, sessions often reached the
maximum duration before the child had accepted
(Jason and Chloe) or swallowed (Randy, Jason, and
Chloe) all of the bites. In addition, Chloe had high
levels of negative vocalizations during these sessions
and persistent open-mouth posture after the
session. Chloe’s caregiver terminated services before
development of a successful treatment. We did not
continue with Betty’s assessment because her high
levels of expulsions and low levels of mouth clean
did not decrease over the course of 87 treatment
sessions. In addition, she produced copious
amounts of saliva during the sessions that mixed
with expelled food. The data from these four
participants suggest that treatments with non-
removal of the spoon and re-presentation may not
be effective for increasing consumption for all
children with severe feeding problems, and this
should be explored in future research. With three
of the children (Randy, Betty, and Jason), we used a
flipped spoon to reduce expulsions and increase
708 JONATHAN W. WILKINS et al.
mouth clean. Sharp, Harker, et al. (2010) showed
that levels of expulsion decreased and levels of
mouth clean increased when the feeder presented
bites with the Nuk and flipped spoon relative to the
upright spoon. The comparison by Sharp et al.
(2012) of upright versus flipped spoons for
presentation and re-presentation of bites produced
similar results. Future investigations should extend
the work of Sharp et al. and the current study by
comparing the upright spoon, Nuk, and flipped
spoon during initial treatment of food refusal.
Although presentation of bites on the Nuk was
associated with lower levels of expulsions (five
children) and higher levels of mouth clean (four
children), its disadvantage is that it is not an age-
appropriate utensil. We were able to transition to
presentation of bites on a spoon during the day-
treatment admission with two children and
during outpatient follow-up with three children.
The Nuk did not seem to be associated with any
other negative effects for any participant except
Catherine. Levels of acceptance were higher with
the spoon than with the Nuk for Catherine. We
continued with the Nuk, nevertheless, because
levels of expulsions were lower and levels of
mouth clean were higher, and these two improve-
ments outweighed the difference in acceptance
between the spoon and Nuk in our clinical
opinion. Levels of acceptance increased over time
with the Nuk for Catherine.
This study is important because it describes the
course of and provides data from the ongoing
clinical treatment of the children who responded to
the treatment with the spoon or Nuk following the
conclusion of the study. We also provide long-term
follow-up data for the majority of these participants.
By contrast, most studies on treatment of pediatric
feeding disorders provide data for dependent
variables only during the course of the study. Little
is known about what happens to children with
pediatric feeding disorders who participate in
clinical studies after the study ends. In the current
investigation, all of the children who responded
to the treatment with the spoon or Nuk either
maintained the gains they had made during the
study or continued to improve (e.g., increases in
acceptance and mouth clean for Catherine) during
the course of their intensive outpatient or day-
treatment admission. In addition, we provide at
least 3 months of follow-up data for all participants
except Kyle. In fact, we present 12 months of
follow-up data for all participants except Kyle and
Katie, and we present 18- and 24-month follow-up
data for two participants. The follow-up data are
important because they show that feeding behavior
maintains or improves over time and that most
caregivers continue to implement the procedure at
least over a 12-month period. To our knowledge,
this is one of the larger sets of long-term follow-up
data on children who have participated in treatment
for feeding disorders. These data are impressive in
that 75% of the families whose children responded
to the treatment continued to participate in
outpatient follow-up for at least 12 months, and
continued participation in follow-up was associated
with maintenance and improvement in their child’s
feeding behavior. It is unlikely that feeding behavior
would have improved in the absence of treatment
because these were children with long-standing
feeding problems that had not improved in the past.
In conclusion, the data suggested that use of the
Nuk was beneficial for five of the eight participants
who completed the assessment. The benefit was
primarily observed in rate of expulsions but was
paralleled to some extent in the data for mouth
clean, and a clear distinction was evident in four
children. We were able to transition all participants
from the Nuk to spoon either during their intensive
outpatient or day-treatment admission or during
outpatient follow-up. One surprising finding was
that four of the 12 participants did not respond to
nonremoval of the spoon or Nuk and re-presenta-
tion. Although the literature suggests that escape
extinction procedures, such as nonremoval of the
spoon, are effective as treatment (Ahearn, Kerwin,
Eicher, Shantz, & Swearingin, 1996; Cooper et al.,
1995; Hoch, Babbitt, Coe, Krell, & Hackbert,
1994; Piazza, Patel, Gulotta, Sevin, & Layer, 2003;
Reed et al., 2004), it is not clear how often children
with severe feeding problems fail to respond to
 SPOON VERSUS NUK
nonremoval of the spoon and re-presentation,
probably because papers on treatment failure are
rarely published (Rosenthal, 1979; Scargle, 2000).
Nevertheless, given that over half of the children
who responded to treatment benefitted from
presentation of bites on the Nuk, it may be
reasonable to consider a utensil manipulation
during initial treatment of children with severe
feeding problems.
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Received October 4, 2012
Final acceptance May 5, 2014
Action Editor, Rachel Thompson
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