An extensive literature base dating back over 50 years has demonstrated well-established empirically-supported behaviour-analytic interventions for paediatric feeding disorders (e.g., Kerwin, 1999). While intensive behaviour-analytic paediatric feeding programmes standardly target a comprehensive range of goals for children to reach typical eating, more research focuses on initial treatment for solids (Taylor & Taylor, 2023). Therefore, comparatively less research details broader goals, independence, and the process of increasing from single-bite/drink presentations to meals (Hansen & Andersen, 2020; Mann et al., 2023; Taylor & Taylor, 2024).

Recently over the past decade, children increasingly consume commercial ‘baby food’ directly via the spout on squeeze food pouches. Researchers have documented concerns of this impacting not only feeding and mealtime skill development, but nutrition, dental health, and socialisation (Brunacci et al., 2023; Koletzko et al., 2018; Rowan et al., 2022). However, no research to our knowledge has addressed transitioning from pouches to typical age-appropriate eating methods such as a spoon, or using complementary feeding devices such as spoon attachments for pouches to aid in this transition (Theurich, 2018). Past feeding research employed stimulus fading in gradually transitioning to appropriate receptacles and utensils, including from cooking measuring spoons and cups to a glass (Friedin et al., 1982), infant bottle to purees on a spoon (Johnson & Babbitt, 1993), spoon to cup (Babbitt et al., 2001; Groff et al., 2011), and syringe to cup and syringe to spoon (Groff et al., 2014).

Chopsticks are the primary utensil used in some Asian cultures, important for social participation and mealtime independence. As most feeding literature is set in the United States, to our knowledge no English-language research has targeted chopsticks. However, in writing this introduction, we searched and identified some clinical case reports in Asian languages teaching chopstick skills using nonfood items (e.g., Iwahashi & Yoneyama, 2019; Sasaki et al., 2016). Relatedly, despite the substantial cultural significance surrounding feeding, eating, and drinking, social validity data on cultural considerations and differences in feeding intervention are lacking (Becraft et al., 2023; Taylor et al., 2024).

The process in between transitioning from ‘baby food’ to age-typical meals and using utensils such as chopsticks involves a range of mealtime skills. Notable considerations are if the deficits result from issues with skill, motivation, or a combination, if these contributing factors can be determined with certainty, and hence if skills are being taught, increased, or a combination. Studies may not detail qualitative minor teaching adaptations or skill improvements observed over time. Researchers have targeted increasing self-drinking (e.g., Haney et al., 2023; Peterson et al., 2017; Peterson et al., 2015) and self-feeding while scooping (e.g., Haney et al., 2023; Hansen et al., 2023); however, information is lacking on skill teaching steps involved such as sipping from a full cup or scooping appropriate bite sizes and scraping remaining food to finish the entire bowl. Very few studies have reported teaching fork skills (e.g., Richman et al., 1980). Only two studies outside of pill swallowing have targeted independence in taking medication (Taylor, 2022; Taylor & Taylor, 2024). We are unaware of studies increasing finger-feeding or teaching steps involved in biting off a portion of food rather than pre-cut bites. However, Mann et al. (2023) depicted increasing gradually to reach full texture and regular form foods, but did not report teaching steps involved.

To our knowledge, this is the first report assessing pouch transition apparatuses, conducting pouch-to-spoon fading, increasing finger-feeding, and teaching steps in scooping, sipping, and biting off portions. Additionally, this is the first report to our awareness providing data-based treatment evaluations on comprehensively teaching 11 mealtime independence skills including teaching chopstick use. We detail a clinical case example whose only independent mealtime skill prior to intervention was specific fruit yogurt pouches directly from the spout.

Method

Participant

Moraux was a 3-year-old Asian Australian male with autism (level 3), global developmental delay, liquid/baby food/supplement dependence, medication refusal, and paediatric feeding disorder/avoidant/ restrictive food intake disorder (ARFID). His only independent mealtime skill was a few brand- and flavour- specific yogurt pouches direct from the spout. He did not finger-feed or touch utensils. He gagged and vomited in the presence of nonpreferred foods. He did not eat separate foods, age-appropriate textures, or snack foods. Moraux was reliant on a specific homemade liquid fruit ‘milkshake’ blend via a toddler straw bottle and two specific homemade lower texture mixtures (primarily starch) via spoon as a non-self-feeder with continuous tangibles. Moraux received speech, occupational, and behavioural therapy. Caregivers sought assistance for feeding concerns since 18 months of age from multiple professionals (e.g., dietitian, ear, nose, and throat physician, sensory, play, and behavioural therapies), but the problems worsened. Moraux spoke a variety of 1–2 word phrases and followed a few simple instructions. He was not toilet-trained. Moraux had sleep problems, self-injurious behaviour, separation issues, and problem behaviour with transitions. Family socioeconomic status was high. Moraux had 29 goals (full table of example goals available in Taylor & Taylor, 2023).

Setting and Materials

Sessions took place in home settings equipped with seating (highchair, children’s wooden adjustable chair, children’s table and chair sets) and number flashcards (photo in Supplementary Information 4 [SI4]). Meal-related materials included maroon spoons, pink cut-out/nosey cups, medicine cups (30mL), and medicine spoons (5mL). We conducted four treatment evaluations targeting multiple skills for independence (Table 1). In Pouch (photos in Fig. 1), apparatuses included Cherub Baby universal food pouch spoons, Nûby™ First Solids silicone Squeeze Feeder Stage 1, 4 + months, and a small maroon spoon taped to the pouch at varying distances. In Independence Generalisation, materials included non-metal forks and spoons, small (5oz capacity) round containers for hand-held scooping cups, and Edison™ children’s learning/training chopsticks Step 1, 3 + years (bottom of Fig. 1). Initial bolus sizes for foods were a level small maroon spoon or approximately 1.25 × 1 × 0.5 cm bites, for single drinks 2.5mL, for liquid vitamins 1mL on spoon and 5mL for medicine spoon and medicine cup, for liquid vitamin D3 0.5mL, for DHA squirts 1 capsule, and for chewable or gummy vitamins ¼ tab. In Independence Generalisation, sipping bolus was 10mL. Food pouches initially included two highly preferred (per caregiver report) kid’s Greek yogurt pouches (approximately 65% full). Cup drinking targeted water. Medications included Pentavite® liquid multivitamins plus iron (lemon lime, watermelon), chewable vitamins (Nature’s Way® Kids Smart Vita Gummies Vitamin C + Zinc citrus and Multivitamin + Probiotics strawberry), Nature’s Way® Kids Smart Bursts DHA orange, Ostelin® Kids Vitamin D3 liquid, and Yakult® probiotic (medicine cup). Foods targeted covered all food groups (protein, starch, vegetable, fruit plus combinations of food groups). In Independence Generalisation, we initially used foods textures, consistencies, and shapes optimal for task success (i.e., less response effort). For example, for chopsticks, we used preferred sticky seaweed rice balls, and in scooping, preferred thick yogurts and flowing (not watery) but congealing rice combinations such as congee, curries with rice, and oat mixtures. For fork, we used foods such as melons, tofu, dumplings, cooked carrot, and soft meats that would pierce easily and stick on the fork but not slide or roll (e.g., kiwi, circle shape). For biting off portions, we used strips of foods such as deli meat, cheese, French toast, hot chip, cucumber, asparagus, red capsicum, celery, then other shapes such as square sandwich, triangle pizza, and circle fish cake; however, preferably not highly preferred to decrease the likelihood of mouth stuffing. A board-certified doctoral-level behavior analyst (BCBA-D) and registered clinical psychologist conducted sessions (the first author; 14 years of experience solely in paediatric feeding including 5 years of training at an inpatient interdisciplinary behaviour-analytic feeding programme). A bachelor-level assistant/observer with 7 years of feeding data assistant experience trained by the first author was present.

Fig. 1
figure 1

Photos of the Pouch Assessment equipment (attachment spoon and squeeze bottle spoon with Greek yogurt; top photos), taped maroon spoon on pouch fading steps (middle photos), and children’s training chopsticks (from left to right: sushi, Korean side dish plates, and rice and bean sushi balls; bottom photos)

Full size image
Table 1 Treatment evaluations and targeted skills
Full size table

Response Measurement

A trained observer recorded child and feeder behaviours in the room with laptops on a realtime data programme (BDataPro) (Bullock et al., 2017). Frequency keys included: clean mouth (product measure of swallowing at anytime i.e., consumption; no food larger than size of pea in mouth at a 30-s check unless due to expulsion [food larger than size of pea passed plane of lips after deposit]) and independence (bite/drink larger than size of pea accepted without hand-over-hand assistance; additional requirements in Independence Generalisation included loading and using the utensil [scoop, fork, chopsticks], self-sipping from a an open-cup bolus, and biting off a portion of food rather than mouth-stuffing [see Table 1 and description of the condition in the Method below for verbal prompts and steps required]). For independence in chopsticks, Moraux had to open, close on the bite to grasp it, and continue grasping the bite while lifting it to his mouth for independence, but the feeder assisted in putting thumb and fingers in training rings. Observers scored incorrect procedural fidelity for feeder errors of commission and omission within 3 s (i.e., prompting sequence, tangible delivery, differential attention) and converted frequency to responses per minute (RPM). Permanent product data included grams measured on a kitchen scale and plate pictures.

Interobserver Agreement (IOA) and Procedural Fidelity

An independent observer collected data on videos across phases and conditions for 34.6% of Pouch sessions, 33.6% of Independence Generalisation, 28.1% of Medication and Drinks, and 21.5% of Variety (Finger-Feed and Spoon Self-Feed). IOA respectively averaged for independence 97.5% (range, 83.3–100%), 97% (range, 77.8–100%), 96.2% (range, 80.8–100%), 96.9% (range, 66.7–100%) and for clean mouth 100%, 97.7% (range, 71.4–100%), 97.7% (range, 80–100%), 98.6% (range, 72.7–100%). We assessed procedural fidelity for 100% of sessions. Incorrect procedural integrity respectively averaged 0 RPM, 0.01 RPM (range, 0.4-0 RPM), 0.01 RPM (range, 0.5-0 RPM), and 0 RPM (range, 0.2-0 RPM). IOA for procedural fidelity averaged respectively 100%, 100%, 99.5% (range, 92.3–100 RPM), and 100%.

Experimental Design

We used a multi-element single-case experimental design for Pouch (Fig. 2), and multiple baseline designs for Variety, Medication and Drinks, and Independence Generalisation. We made phase changes in Pouch first, followed by Variety, and lastly in Medication and Drinks.

Fig. 2
figure 2

Pouch treatment evaluation graphs of percentage independence (top graph) and swallowing/consumption (bottom graph). The first phase was a multi-element assessment of apparatuses (attachment spoon, squeeze bottle spoon, maroon spoon taped to pouch, and maroon spoon alone) under baseline conditions of escape (ES), contingent access (CA) and differential attention (DA). The second phase compared treatment with nonremoval (NR) and re-presentation (RE), CA, DA, and fading (maroon spoon taped to pouch at varying distances to the spout as depicted in Fig. 1) to maroon spoon alone (without the pouch) baseline (open circle data markers). The final phase was treatment on a maroon spoon alone and a variety pouch flavours. FR = Fixed Ratio schedule of reinforcement

Full size image

Procedure

Moraux participated in a behaviour-analytic, intensive feeding programme as described in Taylor et al. (2020). A comprehensive intake evaluation included review of records and diet record. Moraux’s physician filled out a form to medically clear and approve participation (full text form available in Taylor & Taylor, 2023). No drooling, lip/tongue control, biting, sucking, chewing, swallowing, or aspiration concerns were noted. During a direct meal observation, Moraux appropriately chewed a heaping adult spoonful of oat mixture with multiple approximately 1.25 cm cubes of raw apple. He was observed to use a pincer grip with toys. Prior to treatment, the feeder conducted paired-stimulus preference assessments (Fisher et al., 1992; Taylor & Taylor, 2024). First, we assessed tangibles. Next, we conducted separate assessments for items (pouches, foods, drinks, medicines) within each mealtime skill target, and finally, between mealtime skill targets.

Sessions occurred over an average 8.7-hour day (range, 7.1–10.6 h) daily for 2 weeks (Table 1). Treatment occurred on Day 2. Number of sessions per day varied (M = 40, range, 28 to 61). Total session time within demand (excluding within session breaks with contingent access) including baselines averaged 1.7 min (range, 0.1–11.2 min) and session time totalled 868.0 min (14.5 h). Consumption increased to 100% in the first treatment sessions (less than 10 min) for all but one of the 15 targets (except lower texture spoon after 3 sessions; 24.8 min). Sessions consisted of 4 programmed presentations (increased to 8 for drinks), with no new presentations delivered after 10 min (i.e., timecap). A ‘bite board’ consisted of various flashcards (SI4) propped up to visually display criteria. The feeder presented bites/drinks in a single-bite/drink self-feeder/drinker format approximately every 30 s by placing the preloaded plate/cup on the tray and blocked dumping. If Moraux did not accept the bite/drink within 5 s, we provided a verbal prompt. To promote independence, we did not implement stationary spoon presentation. The feeder conducted clean mouth checks every 30 s by verbally prompting “show me ah.”

Conditions

Well-established empirically-supported treatments included differential reinforcement and escape extinction (Kerwin, 1999; Volkert & Piazza, 2012). Conditions were the same in Pouch, Variety, and Medication and Drinks.

Baseline: Differential Attention (DA) and Contingent Access (CA) with Escape (ES)

The plate presentation remained until Moraux opened his mouth and allowed us to deposit the bite/drink/medicine, 20 s elapsed, or he engaged in inappropriate mealtime behaviour (IMB) or expulsion, whereby the feeder provided escape from bite/drink presentations for 20 s. If he accepted the bite/drink or had a clean mouth at anytime, we provided descriptive praise. Upon clean mouth, we provided 20-s access to tangibles.

Treatment: Nonremoval (NR) and Re-presentation (RE), DA, CA

IMB and expulsion no longer resulted in escape. If Moraux did not accept the bite/drink within 5 s of the verbal prompt, we did hand-over-hand (placed our hand over his hand with the spoon/cup/bite) and guided the spoon/cup/bite to his upper lip (e.g., Hoch et al., 1994; Kerwin et al., 1995). The feeder followed his mouth with head turns, and blocked disruptions and mouth covering. The bite/drink remained at his upper lip until acceptance or the timecap (10 min) elapsed. If he opened his mouth, we inserted the spoon/bite/cup with the exception of gags, coughs, yawns, or emesis (vomiting). We scooped up expulsions and re-presented immediately, but if the bite/drink could not be re-presented (e.g., emesis), we re-presented a new fresh bite/drink of the same food/liquid/medication.

Independence Generalisation: Baseline (DA, CA, Modelling)

Sessions were consistent with baseline differential attention and contingent access with the following exceptions. IMB and expulsion did not result in escape. Prior to each session and every 30s during session, the feeder (first author) modelled the skill paired with the accompanying verbal prompts labelling the steps (Table 1) with her own food, drink, and utensils. We blocked attempts to finger-feed without the utensil.

Independence Generalisation: Treatment: Prompting/Hand-over-Hand (HOH), NR, RE, DA, CA, Modelling)

If Moraux did not independently complete the skill within 5–10 s of the verbal prompt, we implemented hand-over-hand and guided him to complete the steps (Table 1). We used least-to-most prompting and faded prompting gradually as his independence with the skill increased. We minimised the number of verbal prompts and steps in the task analysis to those most salient and important as Moraux had already mastered some of the involved steps prior (e.g., grasping, lifting, and tilting the cup; clearing entire bolus closing lips around pre-loaded spoons during self-feeding). For scooping, Moraux had to grasp the bowl with his left hand to stabilise it (“hold cup”) while loading the spoon by scooping with his right hand (“scoop,” inserting the spoon with the spoon bowl facing into the bolus at approximately a 45-degree angle, slide the spoon forward to the edge of the bowl, and lift applying pressure to the inside of the bowl, initially at least loading the bolus size of a pea, increased to an appropriate but heaping spoon bolus). For fork, Moraux had to press the fork into the bite at approximately a 20-degree angle to pierce it (“press”) to load the fork. For biting off portions, Moraux had to insert the food on the side of his mouth between his teeth at the distance for an appropriate bite size (“side,” rather than front, approximately 1 cm depending on the food shape and texture), bite down through the food piece (“bite”), and pull the remainder of the food away from his mouth while keeping teeth closed on the food if it has not completely broken off (“pull”). For sipping, Moraux had to sip repeatedly from the bolus an appropriate sip size (approximately 2.5mL) by tilting the cup back and forth and pausing to swallow in between sips while continuing to hold the cup to his mouth (“sip,” rather than dumping/gulping the entire drink at once). For chopsticks, Moraux had to insert his thumb into the chopsticks training ring in the correct direction (“thumb in”), insert his middle and index fingers into the chopsticks training rings (“fingers in”), open the chopsticks (“open”), aim the chopsticks over the bite and close them onto the bite to grab it (“close”), then keep the chopsticks closed to continue holding the bite while lifting the bite to his mouth (“lift”). However, reaching independence criteria did not require inserting thumb and fingers into the rings (he could have assistance).

Generalisation, Caregiver Training, Social Validity, and Maintenance

Procedures were similar to Taylor and Taylor (2024) and all questionnaires are available full text in Taylor et al. (2024). Caregivers completed written social validity questionnaires on a Likert-type 7-point scale before admission, at discharge, and 3-mo follow-up. Direct observational data for social validity was collected (e.g., child choice via preference assessments, indices of happiness). We began caregiver training with both parents on mastered targets on Day 5 using behavioural skills training (BST) and gradually increased volume, schedule of reinforcement, and incorporated mealtime skills. We developed and implemented free access/choice guidelines (full text available in Taylor & Taylor, 2024) for contexts with other caregivers, and conducted two childcare visits. Caregivers conducted meals in restaurants, cafes, parks, and at relatives’ and friends’ homes. For 2 weeks postdischarge (immediate follow-up), caregivers recorded meal data on a shared electronic spreadsheet (duration, percent consumed, and overall meal rating from 1 [terrible/worse] to 10 [great/perfect]), took plate pictures, and videoed. We conducted telehealth meals and videoconferences as needed, and feedback on meals via the shared spreadsheet.

Results

For pre-treatment social validity, Moraux’s caregivers rated goal importance and preference for effectiveness and speed over minimising potential side effects maximally at 7, commenting feeding was Moraux’s most difficult issue and their biggest pain point/goal, and wanting to maximise results and see major improvements. Culturally, caregivers verbally reported children begin using chopsticks at a young age (i.e., 1-year) and at childcare. Comparatively, culturally they continued non-self-feeding of one mixed bowl food in large volumes to older ages, and used less singular foods, snack foods, and finger-feeding; however, they wanted Moraux to gain these skills. Caregivers preferred attention over tangibles, but approved of tangibles initially to obtain a faster outcome; however, requested fading and did not want him to rely on them, wanting generalisation and intrinsic motivation. Caregivers preferred escape extinction wanting the treatment to work and the faster he achieved outcomes and behaviour change the better for him and the family. Additional comments included wanting him to be pushed and not minding this to gain goals faster, but keeping in mind possible side effects. Caregivers requested longer meal blocks and hours of treatment per day.

In preference assessments, for all targets, avoidance (IMB, negative vocalisations, gagging, vomiting) was high and consumption zero. He approached the pouch with taped spoon once. Consumption (graphs in SI1) was zero in baselines except in Independence Generalisation in sipping bolus and biting off (due to a one-bite mouth stuff). For all skill targets except lower texture and finger-feed in Variety (due to expulsions), when nonremoval and re-presentation were added, consumption increased to 100% and remained high and stable.

In Pouch (Fig. 2), independence (top graph) was zero for all apparatuses, and remained consistently at zero in spoon baseline. With treatment for taped spoon, after an initial brief increase in IMB and negative vocalisations, although still requiring hand-over-hand and blocking flipping thus not meeting independence criteria, he began grasping the pouch, lifting it, and closing lips around the spout. Similarly, with treatment in spoon alone, independence increased. Consumption (bottom graph) was zero in baseline and increased to 100% immediately with non-removal and re-presentation for taped spoon and spoon alone.

In Variety (Fig. 3, top graphs), independence was zero in baseline except for one expelled regular texture bite. With treatment in lower texture, negative vocalisations and IMB decreased, and expels increased. He attempted self-feeding, but flipped the spoon and required assistance balancing. Expels and latency to acceptance decreased, and he began clearing spoon boluses with one swipe of lips. In finger-feed, independence increased in the first treatment session with no skill issues, but was variable as variety increased, and temporarily decreased with reinforcement thinning. In regular texture, independence increased in the first treatment session. In Medicine and Drinks (Fig. 3, bottom graphs), independence was zero in baseline for all targets. In cup drinking, negative vocalisations and IMB were low. Qualitatively, he required skill assistance (i.e., spillage, incorrect cup placement to lips, tongue in cup; blocking dumping, correcting lip placement and tilt and sip speed; lower lip support), but attempted (i.e., placed hands on cup and lifted, some successful lip closures). In liquid vitamins, he needed assistance balancing thin liquid. In chewable vitamins, independence increased in the initial session with no skill issues.

Fig. 3
figure 3

Graphs of percentage independence for treatment evaluations for food Variety (top 3 graphs) and Medicine and Drinks (bottom 3 graphs). Variety consisted of lower texture foods on a spoon (top tier), finger-feeding foods (middle tier), and regular texture foods on a spoon (bottom tier). Medication and Drinks consisted of open cup drinking (top tier), liquid vitamins on a maroon spoon, medicine spoon, or medicine cup (middle tier), and chewable vitamins (bottom tier). The first phase was baseline consisting of escape (ES), contingent access (CA), and differential attention (DA). The second phase was treatment consisting of CA, DA, and escape extinction in the form of nonremoval of the spoon/cup/bite (NR) and re-presentation (RE) of expulsion. FR = Fixed Ratio schedule of reinforcement

Full size image

In Independence Generalisation (Fig. 4), in baseline independence was zero in all skills except sipping bolus (bottom tier). With treatment, for all skills, Moraux accepted without hand-over-hand assistance and attempted the skill steps without IMB or negative vocalisations. With scooping (top tier), initially he dipped the back of the spoon in the cup and scooped small bites. Next, in biting off he began readjusting the distance of his grip to obtain appropriate insertion distance and re-inserting to complete the bite. Independence briefly decreased with biting off a square portion of food. Next, in fork initially, we held bites in place or propped on the plate edge. He began to improve positioning and putting pressure down, but sometimes attempted to scoop rather than pierce. His angle was too horizontal, so we attempted a light under elbow touch prompt then readjusted his grip to pincer. He began self-readjusting his grip and persisting with multiple attempts until successful with sliding bites on the plate. Finally, chopstick independence was at zero for 10 sessions, remained low (0–50%) for 24 additional sessions, then reached and remained at 100% for the final 6 sessions. He had some attempts to pierce rather than close around the bite. Qualitative gradual improvements and progression with chopsticks overtime in order included: inconsistently holding chopsticks with fingers in rings, successful partial lifts of loaded bites, opening and closing empty chopsticks, closing on the bite with aim positioned and successfully lifting, putting thumb in rings correctly while keeping fingers in, and attempting to open while aiming over the bite. Next, we lightly guided his arm to hover aim over the bite, and he began positioning, opening, closing, and lifting independently. On the final day of the programme, he no longer required arm guidance, but we assisted with the bite position on the plate if food slid. Lastly, we propped the bite against the edge of the plate and he reached 100% independence.

Fig. 4
figure 4

Graphs of percentage independence for the Independence Generalisation treatment evaluation for spoon scooping (top tier), biting off portions of food rather than pre-cut-up bites (second tier), fork (third tier), chopsticks (fourth tier), and repeated sipping from a 1oz bolus in an open cup rather than pre-measured small single-sip boluses (bottom tier). The first phase was baseline consisting of modelling, contingent access (CA), and differential attention (DA). The second phase was treatment consisting of modelling, CA, DA, nonremoval (NR), re-presentation (RE), and prompting/hand-over-hand assistance. FR = Fixed Ratio schedule of reinforcement

Full size image

Figure 5 depicts the time required for Moraux to reach independence in the skills in order achieved. Overall time across skills to reach 100% independence was 7.3 h. All skills were graduated in 10 days of treatment except chopsticks (Table 1). Finger-feeding and lower texture on the spoon were impacted by food variety (preference) rather than skill. Target time was also impacted by order of introduction.

Fig. 5
figure 5

Time to reach independence and graduate skills (in the order he learned the skills) in days for each skill (table on left; day treatment began [first column], day he reached 100% independence [second column], and total number of days the skill was targeted [last column]) and minutes for each skill (graph on the right; minutes of treatment taken to reach 100% independence in dark grey bars and total minutes of treatment time in light grey bars)

Full size image

At programme discharge, Moraux’s caregivers rated social validity high (M = 6.8/7, range 5–7; Total = 273/280, 97.5%). Open-ended comments indicated being initially nervous then ecstatic on how things developed, forever grateful to have tackled the fundamental/essential problem of eating, a close relationship with the team was vital to Moraux’s growth and an enjoyable experience, invaluable advice/methods received for behaviour/transitions in general, greatest investment decision made, reaped such amazing and effective results beyond imagination (e.g., chopsticks! ), and we would recommend to anyone. Regarding treatment components, tangible preference decreased further (prefer not to have, want Moraux to eat regardless of motivation) and escape extinction increased to maximal ratings of 7 (strongly prefer; this was and is very important in developing Moraux’s skills). Additional comments included very happy with the approach and result, so grateful team was able to quickly gauge what would be effective for Moraux, process has opened our eyes on how we want to move forward with Moraux‘s journey, and has been truly life changing.

During immediate follow-up caregivers fed 25 meal blocks over 16 days. Consumption was 100%. Average meal rating was 6.3 out of 10 (range, 2–8). Moraux’s chopsticks skills improved (observed via videos) including bites freely positioned on the plate, long noodles, boiled egg, bean, and vitamins. His aim improved and misses and drops became rare. Per caregiver report, he continued to need assistance in placing fingers in rings. He drank remaining soup juice from the bowl (a cultural goal for caregivers) and tasted his birthday cake for the first time. Moraux used all 11 independent skills in free access and in community settings.

At 3-mo follow-up, caregivers rated his overall feeding difficulties maximally at 7 and all ratings high at 6–7. They commented being so happy and still blown away. However, he needs more practice with meals outdoors at restaurants. Caregivers reported improvements in other areas of life. They commented independent skills with eating has been the biggest game changer and his development of fine motor and improvement in behaviour and other transitional activities has been most impressive. They rated social validity maximally at 7 commenting don’t know where we would be without the treatment, without this structure they’d be lost, this was the only treatment to show true results and effects were immediate, but he still required the structure and protocol and feeder. Regarding any downsides/negatives they commented No, but hope in continuing structure he will eat independently and have intrinsic motivation for less preferred foods. Additional comments included so happy with progress, understand food journey isn’t completely over, need to maintain, happy to have enrolled/undertaken the programme, without this consumption of singular variety and development of feeding skills would never have been possible.

Discussion

In 2 weeks, Moraux progressed from liquid/baby food dependence as a non-self-feeder to eating over 160 foods across food groups (SI2 & SI3) at regular texture biting off portions, self-feeding with a spoon, fork, and chopsticks, finger feeding, self-scooping, self-drinking from a cup, and self-feeding chewable and liquid vitamins (spoon, medicine spoon, medicine cup). He met 100% of goals, and skills generalised to free access contexts and maintained to 3 months. Caregivers reported high social validity particularly for escape extinction, but tangibles were less preferred. This report contributes novel cultural considerations in paediatric feeding to the literature.

We began with highly preferred pouches, Moraux’s only independent mealtime skill. We hypothesised that the spoon attachment would be an optimal initial step, the squeeze bottle spoon might have utility for increasing pouch variety and texture as it had 2 attachment options (Stage 1 4-mo, Stage 2 6-mo), and that both may be portable and practical for caregivers. However, Moraux did not accept or approach either. We chose the spoon taped to the pouch because this was most similar to both his historic repertoire (direct via pouch spout) and the terminal goal (spoon alone), and did not require commercial equipment. We proceeded rapidly with fading clinically in the interest of time and caregiver preferences to reduce diary and achieve timely substantial results. With fading, independence increased and IMB and negative vocalisations decreased. Future researchers could examine further fading steps prior to adding escape extinction for the spoon alone, and replicate with additional participants.

An additional limitation in independence generalisation was one baseline data point and lack of staggering treatment across targets. The rationale was clinical given time constraints, to minimise practicing IMB (e.g., playing with meal materials), for safety without assistance (e.g., prevent mouth stuffing in biting off), and to limit blocking of finger-feeding (targeted to increase in prior treatment). Except for sipping a 1oz bolus, lack of independence and need for skill assistance was consistently evident in baseline. In fact, in contrast to studies increasing independence based on motivation (i.e., negative reinforcement), the only skills that Moraux did not have to be taught was finger-feeding and chewing. Additionally, consistent with skill deficits, independence did not immediately increase (effect was delayed) and IMB was low. Even so, this remains a contribution to the literature in presenting graphs of baseline and treatment data with IOA and procedural fidelity, as these skills and steps are rarely reported in isolation descriptively or via data.

Moraux did not make choices to inform treatment. However, lack of staggering treatment targets was beneficial as Moraux’s skill progression did not align with expectations (i.e., scooping, fork, biting off, sipping, chopsticks), except for scooping and chopsticks. Additionally, more valuable time was allotted to treatment than baselines. Given the assistance required in learning cup drinking, his progression in sipping was unexpected. However, the bolus was small, sipping initially was variable when incorporated into meals, and he did not reach full cup sipping. Similarly, he initially needed more assistance with biting off in generalisation to meals. Also, with scooping in meals, he required assistance in learning to scrape the remainder in the bowl and adjust his grip for nonoptimal food consistencies. In contrast, once Moraux mastered fork and chopsticks, he used them highly independently and skilfully. Notably, treatment time allotted to skills varied as guided by clinical goals and caregiver preferences.

The quantitative independence data did not capture qualitative improvements observed, particularly with chopsticks. Lacking prior literature to consult for chopsticks, we created the verbal prompts and steps personally with input from the caregivers culturally. Moraux did not master chopsticks steps in chronological order, and could independently complete the end of the chain (deposit). Future researchers could add additional steps to the task analysis and depict step data. Future researchers could also examine the steps and utensils involved in transitioning from Stage 1 training chopsticks with training rings to adult chopsticks (Sasaki et al., 2016).

Given many goals, we were hesitant in targeting fork and chopsticks (i.e., response effort for Moraux). However, he had minimal IMB and displayed indices of happiness. Notably, these targets commenced following a week of intervention. Further, given teaching occurred within the meal context, he continued to cup drink and eat a wide variety of foods during this process. After mastery, Moraux preferred to use the fork and chopsticks. In chopsticks, he smiled and said “fun!” and verbalised the prompts while completing the steps (“open,” “close”). However, this may not be the case for all children.

This intervention requires competency in conducting comprehensive intakes, estimating appropriate service intensity, determining bolus sizes, textures, and consistencies, and prioritising goals and progression of treatment (Piazza et al., 2020; Taylor & Taylor, 2023; Williams & Seiverling, 2022). Additionally, expertise is required to determine optimal food targets for independence generalisation teaching (e.g., biting off portions, fork, chopsticks, scooping). Developing medication administration protocols requires multidisciplinary coordination and caregiver administration (Taylor, 2022). Finally, this process requires paediatric feeding expertise should additional treatment components be warranted for acceptance, swallowing, or teaching chewing.