Evaluation of Bolus Size and a Chin Prompt to Treat Expulsion

Conrad B. Hillman, Alessandro DiBari, Daniele Rizzi, Erica Scandurra,
Jennifer M. Kozisek, Suzanne M. Milnes, Cathleen C. Piazza
University of Nebraska Medical Center’s Munroe-Meyer Institute


  • Previous research has demonstrated that manipulating the response effort associated with eating may affect feeding behaviors (e.g., acceptance, swallowing).

  • Kerwin, Ahearn, Eicher, and Burd (1995) showed that spoon volume was inversely correlated with levels of acceptance and mouth clean.

  • Wilkins, Piazza, Groff, and Vaz (2011) showed that expulsion decreased when the feeder implemented a chin prompt, which may have increased the response effort for expulsion.

  • In the current investigation, we extended the findings of Kerwin et al. and Wilkins et al. by using a bolus manipulation and a chin prompt to treat liquid expulsion.


  • Participant

    • Katia: 14-month-old girl diagnosed with total food and liquid refusal Setting
  • Setting

    •  4-m by 4-m room equipped with one-way observation and sound
  • Dependent Variables

    • Expulsion: Liquid larger than a pea exiting the mouth, which we converted to expulsion per drink (number of expulsions/number of drinks that entered the mouth)
  • General Method

    • Sessions typically consisted of 5 drink presentations
    • Feeder presented cup to the child’s lips approximately every 45 s
    • Feeder held the cup at the child’s lips until he or she could deposit the drink (i.e., nonremoval of the cup)
    • Feeder scooped up expelled drinks and deposited them back into the child’s mouth (i.e., re-presentation)
  • Bolus Manipulations

    •  Feeder presented either a 2-cc or 4-cc bolus in each session
  • Chin Prompt

    • During presentation and re-presentation, feeder placed his or her index finger under
      the child’s chin and his or her thumb under the child’s lower lip while applying gentle,
      upward pressure to close the mouth
    • Feeder counted audibly to 5 and discontinued the chin prompt

Bolus Manipulation

Grafico ABAI ABA Autism 2016

2-cc Reversal

Result and Discussion

  • The 2-cc bolus was associated with lower levels of expulsion compared to the 4-cc bolus.

  • Expulsion decreased further when the feeder implemented the chin prompt in both the 2-cc and 4-cc bolus conditions.

  • These results replicate those of Kerwin et al. (1995) and Wilkins et al. (2011).

  • The reason for the difference in the efficacy of the chin prompt with the smaller bolus is unclear.

  • One reason may be that the smaller bolus size was associated with less effortful swallowing and the chin prompt was associated with more effortful expulsion.

  • Alternatively, the child may have lacked the oral motor skills to effectively manage the larger bolus.

  • In patients with poor oral-motor skills, a smaller bolus may be easier to manage and control, which may facilitate swallowing and eliminate or minimize the risk of aspiration (Logemann, 1998).

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