JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2013, 46, 539–543 NUMBER 2 (SUMMER 2013)

AN EVALUATION OF TEXTURE MANIPULATIONS

TO INCREASE SWALLOWING
HEATHER KADEY, CATHLEEN C. PIAZZA, KRISTI M. RIVAS, AND JASON ZELENY
UNIVERSITY OF NEBRASKA MEDICAL CENTER’S MUNROE-MEYER INSTITUTE

The purpose of the current investigation was to identify an appropriate texture for initial treatment
of 1 child’s feeding problem. Variability in mouth clean (a product measure of swallowing) during a
texture assessment suggested that individual pureed foods differentially affected feeding behavior. A
single-food assessment identified individual problematic foods. We used the results of these
assessments to inform treatment, resulting in high levels of mouth clean across foods.
Key words: feeding disorders, mouth clean, packing, pediatric feeding disorders, texture

Children with feeding problems may not be
able to manage age-appropriate textures effec-
tively during initial treatment. For example,
Patel, Piazza, Layer, Coleman, and Swartzwelder
(2005) conducted a texture assessment with three
children during treatment for feeding problems.
The highest texture at which each child exhibited
competent feeding skills was different, but all
were competent on textures that were lower than
expected based on age. These findings can be
contrasted with the fact that children without
feeding problems consume a diet exclusively of
table food by the age of 3 years.
Children with feeding problems may respond
differentially to foods as a function of texture and
type. For example, Patel, Piazza, Santana, and
Volkert (2002) treated the feeding problem of a
3-year-old girl who consumed purees but
expelled higher textures. Anecdotal observation
suggested that expulsions were more frequent
when meats were presented. Decreasing the
texture of meats resulted in fewer expulsions.
Taken together, the results of Patel et al.
(2002, 2005) suggest that identification of the
appropriate texture is an important step in
treatment of children with feeding disorders.
Some children with feeding problems may be at
Correspondence should be addressed to Heather Kadey,
Kelberman Behavior and Feeding Program, SUNY Upsta-
teMedical University 600 E. Genesee St. Suite 124,
Syracuse, New York 13202 (e-mail: kadeyh@upstate.edu).
doi: 10.1002/jaba.33
risk for aspiration if fed a texture they cannot
manage. On the other hand, decreasing texture
unnecessarily may delay progression to age-
typical feeding.
In the current investigation, we identified a 5-
year-old girl with a feeding problem and a history
of packing (holding food in the mouth without
swallowing) pea-sized pieces of table food. We
extended the work of Patel et al. (2002, 2005) by
conducting a systematic texture assessment,
which suggested that mouth clean (a product
measure of swallowing) was differentially affected
by food texture and possibly by food type; a
single-food assessment to identify whether
individual foods differentially affected mouth
clean; and a treatment assessment informed by
the texture and single-food assessments to
introduce individual foods in the appropriate
texture.
METHOD
Participant and Setting
Margaret, a 5-year-old girl, had been admitted
to a pediatric feeding disorders day-treatment
program. She received approximately 70% of her
caloric needs via gastrostomy tube. Her mother
reported that Margaret chewed chopped food for
long periods and held it in her mouth. She took
lansoprazole for gastroesophageal reflux. Her
physician and speech therapist cleared her as an
appropriate and safe oral feeder. Therapists

539
540 HEATHER KADEY et al.
conducted sessions in a room (4 m by 4 m)
equipped with a one-way observation panel,
sound monitoring, and session materials (e.g.,
booster seat). Observers sat in the observation
room and collected data on laptop computers.
General Procedure and Response Measurement
Margaret’s mother indicated that a treatment
goal was to increase Margaret’s consumption of
16 foods: applesauce, asparagus, bread, broccoli
with cheese, potatoes, carrots, chicken nuggets,
fruit cocktail, green beans, grilled chicken,
mashed potatoes, pancakes, peanut butter and
jelly sandwich, peaches, pears, and strawberry
yogurt. Trained therapists conducted five daily
meal blocks, with at least 1 hr between meal
initiation (e.g., 9:00 a.m., 10:30 a.m.). The
therapist presented five (texture assessment) or
three (single-food and treatment assessments)
bites in each session. The number of bites
presented per session was decreased from five to
three to allow subsequent analyses to occur more
efficiently. In addition, the number of sessions
was limited by medical recommendations that
Margaret’s consumption not exceed 15 g in a
given meal. This restriction resulted in some
sessions with fewer bite presentations. The
therapist conducted two to five sequential
sessions within a meal, with cumulative session
length (the total amount of time to conduct all
sessions in the meal) ranging from 4 to 9 min.
Bolus was a level spoonful on a small spoon. The
feeder randomly selected five (texture assess-
ment), one (single-food assessment), or three
(treatment assessment) foods to present in each
session. The order of foods was randomized
within sessions.
The therapist presented bites approximately
every 30 s. A presentation consisted of the
therapist (a) placing the spoon approximately
5 cm from the midline of Margaret’s lips in the
texture and single-food assessments, or (b)
placing a bite of food on a spoon in a bowl in
front of Margaret in the treatment assessment.
The bite remained in its presentation position
until she accepted the bite or until 30 s elapsed.
Acceptance during the texture and single-food
assessments was defined as Margaret opening her
mouth to allow the therapist to deposit the bite
within 5 s of presentation. In the treatment
assessment, Margaret was allowed to engage in
the more age-typical response of self-feeding
(because acceptance was 100% during the
previous assessments). Acceptance was defined
as Margaret picking up the spoon and placing the
bite into her mouth within 5 s of bite presenta-
tion. If Margaret did not accept the bite (one
occurrence), the therapist removed the bowl and
presented the next bite.
The therapist said, “show me,” 30 s after the
bite entered Margaret’s mouth. Observers scored
mouth clean if no food larger than a pea was in
her mouth, unless the absence of food was the
result of expulsion, and scored pack if food pea
size or larger was in her mouth. The therapist
then presented the next bite; that is, regardless if
she had swallowed, the next bite was presented
(i.e., we moved on). The food was removed only
if Margaret was packing after the therapist
conducted the 30-s check for the last bite of
the session. If an expulsion occurred, the therapist
provided no differential consequence and pre-
sented the next bite when the 30-s interval
elapsed. Praise was delivered for acceptance and
mouth clean.
Texture Assessment
The texture assessment was an evaluation of
increasingly smoother textures to identify the
highest texture Margaret consumed with high
levels of mouth clean. Speech-therapist-recom-
mended textures included chopped (table food
hand chopped into 2-mm by 2-mm pieces); wet
ground (table food blended in a food processor to
produce small chunks of food in a liquid
medium); and puree (table food blended in a
food processor until relatively smooth). Depend-
ing on the type of food, water (e.g., green beans)
or milk (e.g., pancakes) was added to the foods to
ensure that all foods were equally viscous. Recipes
 INCREASING SWALLOWING
that stated the exact amounts of food and liquid
were developed for each food to ensure consis-
tency across trials. All 16 foods were presented at
each texture, with the exceptions of applesauce
and strawberry yogurt (presented as is from their
original containers) and instant mashed potatoes
(prepared following the recipe on the box).
Single-Food Assessment
The purpose of the single-food assessment was
to evaluate whether variability in levels of mouth
clean in the texture assessment with pureed foods
was due to specific foods (Patel et al., 2002). Two
to three sessions (depending on the impact of the
15-g volume cap) were conducted, with each of
the 16 foods presented in a random order. The
results of the single-food assessment suggested
that mouth clean was less than 80% for peaches,
peanut butter and jelly sandwich, potatoes,
chicken nuggets, green beans, asparagus, grilled
chicken, and broccoli and cheese. We included
these eight foods and bread (due to therapist
error) in the treatment assessment.
Treatment Assessment
We evaluated treatment using a BABAB(C)
design (B ¼ Magic Bullet texture; A ¼ pureed
texture). The purpose of this assessment was to
determine whether presentation of foods at a
smoother texture than puree would result in an
increase in mouth clean. The eight pureed foods
that were associated with low levels of mouth clean
in the single-food assessment were prepared using
the same recipes and were blended using a Magic
Bullet. The Magic Bullet is a type of food processor
that has the ability to grind particles of food and
food shells more effectively than a standard food
chopper and creates a smoother texture than puree.
After the single-food assessment, the therapist
presented all 16 foods (C), nine at the Magic Bullet
texture and seven at the pureed texture.
Interobserver Agreement
A second observer simultaneously but inde-
pendently collected data for 39%, 65%, and 47%
541
of texture, single-food, and treatment assess-
ments, respectively. Interobserver agreement was
calculated for mouth clean on a trial-by-trial
basis. Mean agreement was 94% (range, 63% to
100%), 99% (range, 92% to 100%), and 97%
(range, 82% to 100%) for the texture, single-
food, and treatment assessments, respectively.
RESULTS AND DISCUSSION
Figure 1 (top) depicts mouth clean during the
texture assessment. Mouth clean was highest with
pureed textures, but was variable (range, 20% to
100%). One possible explanation for this
variability was that the probability of mouth
clean differed across foods. Although pureed food
is relatively smooth, specific foods will leave a
shell residue (e.g., peas) or will be gritty (e.g.,
chicken), which may increase the difficulty of
swallowing. This question was evaluated during
the single-food assessment.
Figure 1 (middle) depicts mouth clean during
the single-food assessment. Each bar represents
mouth clean across all sessions for the individual
food (e.g., mean of Session 1 pears plus mean of
Session 2 pears plus mean of Session 3 pears
divided by 3). Mouth clean was below 80% for
eight pureed foods. Figure 1 (bottom) depicts
mouth clean during the treatment assessment.
Mouth clean was higher in the Magic Bullet
texture phases than in the pureed texture phases.
Mouth clean was close to 100% during
presentation of the nine Magic Bullet and seven
pureed foods.
Results of the current study replicated those of
Patel et al. (2005), in that the texture at which
Margaret competently ate during the texture
assessment was lower than expected based on her
age. Results also are similar to those of Patel et al.
(2002), in that individual foods differentially
affected eating. Whereas the child in Patel et al.
(2002) was more likely to expel a specific food
group, Margaret was more likely to pack specific
individual pureed foods (e.g., chicken, broccoli).
Further, we extended Patel et al. (2002) by
542 HEATHER KADEY et al.

Wet
Chopped Ground Puree

100
90
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Mean Percentage of Mouth Clean

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Puree Puree Nine Magic Bullet +

Magic Bullet Magic Magic Bullet Seven Pureed Foods
Bullet
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Figure 1. Percentage of mouth clean for the texture assessment (top), single-food assessment (middle), and treatment
assessment (bottom).
 INCREASING SWALLOWING
conducting a single-food assessment to evaluate
systematically how food types affect eating, as
opposed to relying on anecdotal information.
Recall that in the current study, bites were
presented every 30 s, independent of whether
Margaret swallowed. We moved on so that
packing did not produce avoidance of bites. The
disadvantage of moving on is that there may be
carry over from bite to bite. For example, assume
that the child always packs chicken. If presenta-
tion order is chicken then pears, packing is likely
to be 100% for the two bites because the presence
of packed chicken might increase the difficulty of
swallowing pears; the child would have to swallow
both chicken and pears. These data suggest that
both foods were problematic. By contrast, if the
presentation order was pears then chicken, and
the child swallowed pears, then packing for the
two bites would be 50%, suggesting that chicken,
but not pears, was problematic. However, it
would not be possible or efficient to analyze how
particular presentation sequences (e.g., asparagus,
potatoes, peaches) affect mouth clean because
food presentation order was randomized both
across and within sessions and not all possible
sequences were presented.
The single-food assessment allowed us to
evaluate levels of mouth clean for each food
individually and systematically. After we identi-
fied foods that were associated with low levels of
mouth clean, we manipulated the texture of
problematic foods. Decreasing the texture of
problematic foods resulted in increased levels of
mouth clean for those foods. We then were able
to present all 16 foods in textures (i.e., either
Magic Bullet or puree) that resulted in high levels
of mouth clean across foods.
An alternative method would be to present
foods individually during initial treatment
543
(e.g., in the texture assessment in the current
study). The disadvantage of this method is that
not all children exhibit feeding behavior that is
differentially affected by individual foods, and
single-food assessments are time intensive.
Another alternative would be to require the
child to swallow before presenting subsequent
bites. It is unknown if waiting for the child to
swallow before presenting the next bite would
function as reinforcement for packing, and
this should be the subject of future investiga-
tions. Of note is that we used the move-on
procedure only when personnel (e.g., speech
therapist) were available to determine if the
child has a competent swallow, per-session bite
presentations were limited, and bolus sizes were
small.
Ultimately, the goal for any child with a
feeding disorder is to progress them to age-typical
eating. Although the procedures described in this
study did not increase Margaret’s consumption of
age-appropriate textures, it provided an avenue
for her to meet her nutritional needs as well as a
starting point for increasing texture.
REFERENCES
Patel, M. R., Piazza, C. C., Layer, S. A., Coleman, R., &
Swartzwelder, D. M. (2005). A systematic evaluation of
food textures to decrease packing and increase oral
intake in children with pediatric feeding disorders.
Journal of Applied Behavior Analysis, 38, 89–100. doi:
10.1901/jaba.2005.161-02
Patel, M. R., Piazza, C. C., Santana, C. M., & Volkert, V. M.
(2002). An evaluation of food type and texture in the
treatment of a feeding problem. Journal of Applied
Behavior Analysis, 35, 183–186. doi: 10.1901/
jaba.2002.35-183
Received June 1, 2012
Final acceptance November 13, 2012
Action Editor, Joel Ringdahl