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Current Trends in Pediatric Feeding
–
Evaluation, Treatment and Outcomes
Nichole M. Turmelle, OTR
Karen E. Sclafani, MOT, ...
Learning Outcomes/Objectives
Participants will:
1. Summarize current literature related to the diagnosis
and treatment of ...
Literature Review
Literature Review:
Multi-disciplinary Team Evaluations
 Multi-disciplinary evaluations are
supported in documentation fro...
Literature Review:
Treatment Techniques
 Discusses the use of behavioral approaches to
feeding including reinforcement, n...
Literature Review:
Diagnosis of Feeding Difficulties
 DSM-IV-TR Diagnosis – Feeding and Eating Disorders in
Childhood
 I...
Literature Review:
What Was Not Documented
 Consistent outcome measures
 Medical
 Behavioral
 OT treatment options
 L...
Evaluation
To Gag or Not to Gag
Evaluation of Feeding Difficulties
 Feeding impairments are complex, often impacting
the health, development and nutritio...
Evaluation of Feeding Difficulties:
Multi-Disciplinary Team Members
 Physician
 Speech/Language Pathologist
 Occupation...
Evaluation of Feeding Difficulties:
Team Assessment
 Assessment process should include the
following components:
 Medica...
Evaluation of Feeding Difficulties:
Team Assessment
 Multi-disciplinary versus Trans-disciplinary
 Team members must be ...
Evaluation of Feeding Difficulties:
Aspects of OT’s Domain
Areas of Occupation
 Activities of Daily Living
 Eating – The...
OT’s Role in Team Evaluation:
Parent/Client Goals and Concerns
 Identify family concerns for the evaluation
 Values/beli...
OT’s Role in Team Evaluation:
Medical and Social History
 History of hospitalizations, surgeries,
illnesses
 History of ...
OT’s Role in Team Evaluation:
Assessment Tools
 Standardized Assessment
 Sensory Profile
 Peabody Developmental Motor S...
OT’s Role in Team Evaluation:
Observation of Movement
 Ability to move in the environment
 Functional skills, transition...
OT’s Role in Team Evaluation:
Observation of Social Skills
 Interaction with parents
 Ability to interact with team memb...
OT’s Role in Team Evaluation:
Observation of Feeding Skills
 Food Choices
 Identification of patterns

Texture

Temper...
OT’s Role in Team Evaluation:
Observation of Feeding Skills
 Motor
 Postural control, positioning
 Finger feeding
 Ute...
OT’s Role in Team Evaluation:
Observation of Feeding Skills
 Sensory
 Level of arousal during feeding
 Willingness to e...
OT’s Role in Team Evaluation:
Observation of Feeding Skills
 Cognitive/Behavioral/Social
 Ability to understand/follow d...
What do you think?
Oral Motor or Sensory?
Now what do you think?
Oral Motor or Sensory?
Is This Behavior or Not?
OT’s Role in Team Evaluation:
Development of Recommendations
 Individual occupational therapy
 Group occupational therap...
Treatment
Treatment Considerations
 Treatment techniques rarely happen in
isolation
 Need to consider the occupational profile of
...
Treatment Considerations
 Activity Demands (Activity Analysis)
 Tools – utensils, cups, plates, equipment

What tools a...
Treatment Techniques
 Desensitization
 Behavioral
 Ayres Sensory Integration
 Sensory-Motor
 Medication
 Group Treat...
Desensitization
 Sensory Desensitization
 Body Functions

Tactile

Oral
 Hierarchical Desensitization to Food
 Chain...
Sensory Desensitization:
Body Functions
 Tactile System
 Wilbarger Deep Pressure Protocol
 Dry textures (rice, beans, p...
Hierarchical
Desensitization to Food
 Slowly and systematically introducing new
and non-preferred foods to the child
 Ex...
Hierarchical Desensitization to Food
Taste
Foods
Touch Foods
Tolerate Sights/Smells of Foods
No Physical Interaction with ...
Hierarchical Desensitization to
Food
 No Physical Interaction with Actual Foods
 Looking at pictures of the food (books,...
Hierarchical Desensitization to
Food
 Tolerate Sights/Smells of Foods
 Shopping for food in the grocery store
 Talking ...
Hierarchical Desensitization to
Food
 Touch Foods
 Simple meal preparation
 Touching food with utensil  one finger  t...
Hierarchical Desensitization to
Food
 Taste Foods
 Licking lips after food has been placed on them
 Touching food to te...
Food Chaining
 Part of a sensory/behavioral approach to
feeding
 Reduces risk for refusal as it is based on the
child’s ...
Food Chaining
 Discusses four levels of treatment:
 Level 1 – Optimize nutritional status, scheduled
meals/snacks, analy...
Food Chaining
 Uses a rating scale
 Evaluate the success of the modification attempt
 Monitor progress in the program
...
Food Chaining: Rating Scale
 1 Gagging and/or vomiting upon touching,
smelling or seeing the foods
 1+ Gagging upon tast...
Food Chaining: Rating Scale
 6 Chews and swallows several bites of the
food item, no major grimace or reaction
 7 Chews ...
Food Chaining
 Eats Goldfish – Target is Grilled Cheese
 Goldfish
 Cheez-its
 White Cheez-its
 White crackers
 White...
Food Chaining
 Chicken Nuggets/French Fries – Target is
Other Meat
 Cut preferred chicken nugget into strips
 New brand...
Food Pairing
 Some presenters may call it “Flavor Masking”
 Using preferred food to help decrease anxiety
and increase a...
Food Pairing
 Child accepts cheese:
 Dip cheese in cracker “crumbs”
 Offer reverse cheese/cracker sandwich
 Increase s...
Food Pairing
 Child accepts pasta without sauce:
 Dip plain pasta in preferred “juice” and encourage
to eat
 Dip plain ...
Behavioral Treatments
 Reinforcement
 Positive
 Negative
 Punishment
 Escape prevention
Behavioral Treatments:
Positive Reinforcement
 When desired behaviors are rewarded in
order to encourage them to persist
...
Behavioral Treatments:
Positive Reinforcement
 Types of Positive Reinforcement
 Verbal praise, cheering
 Clapping hands...
Examples of Positive
Reinforcement
Behavioral Treatments:
Negative Reinforcement
 The removal of an aversive stimulus
immediately following a behavior, whic...
Behavioral Treatments:
Negative Reinforcement
 Types of Negative Reinforcement
 Removing the food from the table after t...
Behavioral Treatments:
Punishment
 Punishment is removing
an object/situation that
the child likes or setting
up a situat...
Behavioral Treatments:
Punishment versus
Reinforcement
 Punishment Procedure:
 Behavior occurs  consequence follows
(so...
Behavioral Treatments:
Escape Prevention
 Also called “escape extinction”
 Based on the premise that the child’s
undesir...
What types of reinforcement
are being used?
Ayres Sensory Integration (ASI®
)
 ASI "is the process by which people register,
modulate and discriminate sensations rec...
Sensory-Motor Approach
 Uses the basic principles that form the foundation
for the sensory integration frame of reference...
Medication
 Primary medical conditions that may benefit
from treatment with medication:
 GERD
 Eosinophilic Esophagitis...
Medication
 Work with physician to
determine if medication
would be helpful in
managing feeding
difficulties
 Medication...
Group Treatment
 Group treatment is a great opportunity for social
role modeling
 Approximately 12 weeks in duration, co...
Group Treatment
 Feeding trials
 Lead therapist presents each food, one at a time,
and determines when to introduce next...
Parent Education/Participation
 Parents’ understanding of their child’s
feeding/eating difficulties, as well as his/her
s...
Parent Education/Participation:
Hands-on During Feeding Trials
 It is important for parents to
become familiar with the
p...
Parent Education/Participation:
Providing Structure
 It will be easier for the
child to learn the process
and to know wha...
Parent Education/Participation:
Social Role Modeling
 Includes all members of the family during
mealtime
 Enables the ch...
Parent Education/Participation:
Portion Size
 The child can become overwhelmed or
frustrated if there is too much food on...
Parent Education/Participation:
Managing “Food Jags”
 “Food jag” is a term used when the child will
only eat the same foo...
What to avoid….
Outcomes
Measures of Feeding Treatment
 Quantities of food consumed
 Weight in grams
 Percentage consumed (oral versus g-tube)
...
Tools Used to Measure
Outcomes of Feeding
 Child Feeding Questionnaire
 Children’s Eating Behavior Inventory
 Short Sen...
Outcome Measure Tools:
Child Feeding Questionnaire
 Birch, L. L., et al. (2001)
 31-item parent questionnaire assessing ...
Outcome Measure Tools:
Children’s Eating Behavior Inventory
 Archer, L. A., Rosenbaum, P. L., & Streiner, D. L. (1991)
 ...
Outcome Measure Tools:
Short Sensory Profile
 Dunn, W. (1999)
 38-item parent questionnaire used to quickly identify
chi...
Outcome Measure Tools:
Feeding Strategies Questionnaire
 Berlin, K. S., Davies, W. H., Silverman, A. H., &
Rudolph, C. D....
Outcome Measure Tools:
Mealtime Behavior Questionnaire
 Berlin, K. S., et al. (2010)
 33-item parent questionnaire that ...
Outcome Measure Tools:
About Your Child’s Eating
 Davies, W. H., Noll, R. B., Davies, C. M., & Bukowski,
W. M. (1993)
 V...
Reference List
1. American Occupational Therapy Association. (2008). Frequently asked
questions about Ayres sensory integr...
Reference List
7. Bekem, O., Buyukgebiz, B., Aydin, A., Ozturk, Y., Tasci, C., Arslan, N., &
Durak, H. (2005). Prokinetic ...
Reference List
13. Bryant-Waugh, R., Markham, L. Kreipe, R. E., & Walsh, B. T. (2010). Feeding
and Eating Disorders in Chi...
Reference List
20. Dunn, W. (1999). Sensory Profile: Users manual. United States of
America: The Psychological Corporation...
Reference List
27. Nicholls, D. & Bryant-Waugh, R. (2008). Eating disorders of infancy and
childhood: Definition, symptoma...
Reference List
34. Schwarz, S. M., Corredor, J., Fisher-Medina, J., Cohen, J., &
Rabinowitz, S. (2001). Diagnosis and trea...
Reference List
 Information also obtained from the following
Continuing Education courses:
 Mealtime Success for Kids on...
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NJOTA - Current Trends in Pediatric Feeding

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Review of OT's role in pediatric feeding. Presented at NJOTA on 10/23/10.

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  • Hello Nichole.
    Thank you very much for the information.
    Kind regards.
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  • Is there any recognition at all of hunger, as an internal self-directed incentive to eat, playing a role? If not, why not? Also, what of the use of hunger as an appetite stimulant as opposed to a pharmaceutical intervention? This appears to be a significant knowledge gap.
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  • Karen reads objectives
  • Reviewed MANY articles in preparation, not going to review specifics of each, detailed reference list
    Citations at the bottom of each slide to assist in referencing articles
  • We will be discussing more about multi-disc team evaluations in the evaluation portion of the presentation
    Seemed like best practice, was supported in much of literature
  • Citation 33:
    Sensory prep helpful but not measured
    Will talk about use of medication further in treatment portion of presentation
  • Organic vs non-organic
    In hospital setting , not mental health we’re using ICD9 dx
    Persistent (at least 1 month in duration)
    Failure to eat adequately associated with weight loss or significant failure to gain weight, not associated with medical condition or another mental disorder
    Onset before 6 years of age.
    State regulation – infants, ASD cannot maintain appropriate level of arousal for feeding
    Fdg d/o of reciprocity – thinking about the bond between parents/child and how that impacts feeding
    Sensory food aversions
    Post-traumatic – many invasive procedures, choking, any other significant events that can cause the child to “learn” that feeding is not pleasureable
  • Outcomes that used: weight, grams of food consumed, speed of acceptance, video flouroscopy, dependence on G-tube, gags per bite, explusions per bite, skin fold thickness, mealtime behaviors upon presentation of foods
  • We see many kids, hard to determine what is normal and what is not normal.
    First video, child accepting new taste, texture. Gaggs but recovers
    Second video, baby resists this food and as you will see in later videos, all spoon feedings. This is where feeding moves from “picky” to problem.
  • As OT, might need to elicit imitation of oral motor skills with a child.
    Use of one way mirror if team is too overwhelming – one person stays to facilitate meal
  • Why has the family come for the evaluation – consider family priorities – weight gain, acceptance of foods, self-feeding
    Temporal Context – body schedules, stages of life, rhythm of activity
    Values – principles, standards or qualities considered worthwihile or desirable by the client who holds them.
    Beliefs: Cognitive content held as true
    Spirituality the personal quest for understanding answers to ultimate questions about life, about meaning and the sacred.
  • Example – child refusing to swallow. Look deeper, mother had a history of choking in recent months, coincides with onset of feeding difficulties
  • Use these questionaires as part of the intake process. Prior to preparation for this presentation, did not really consider their full usefulness. Will talk more about these later in the presentation.
  • Global mental functions – level of arousal, emotional stability, temperament, motivation, appetite, personality
  • Texture – puree, textured puree, soft solids, crunchy solids, dissolvable foods, chewy foods, mixed textures, liquids
    Color – the “white diet”
    Flavor – sweet, savory, salty, specific flavors (strawberry, banana)
    Food groups – protein, carbohydrates, fruits, vegetables, liquids, snacks
  • Child’s ability to sit up in chair (with or without assistive devices for feeding)
    Child’s ability to maintain respiratory and/or cardiac status during feeding
    Child’s strength/endurance as it relates to self-feeding
  • Arousal – ability to maintain appropriate level throughout meal; how does it change with presentation of each food
    Exploration of food with hands and mouth – what does the child do with the food spontaneously, can they be directed for higher levels
    Manipulation of food in mouth – do they pocket food, do they do better with smooth or crunchy foods, do they try to swallow foods whole so they don’t need to experience it
  • Response to structure – do they comply with first/then statements; will they work for rewards
    Influence environment – what is the families’ response to gag, vomit, crying, throwing
  • Other disciplines – PT, rehab technology, GI, allergy, EIP,
    Strategies to implement at home – structured mealtimes, development of a hunger cycle, encouragement of increased independent feeding, presentation of new food without expectation for consumtion.
  • Throughout the course of treatment, keeping this in mind
  • Stress-management technique (systematic desensitization)
    Counter-conditioning where feelings of anxiety are replaced by feelings of pleasure
    By starting with less-threatening methods (i.e., food consumption is not expected), eating becomes less anxiety-provoking and the child will be more willing to interact with the food
  • No actual interaction with the real foods
  • Simple meal prep… even just washing apples, veggies (holding them)
    Consider amount of repetitions
  • Also want to consider repetitions (increasing number of licks)
  • Don’t suggest representing a food unless the food is scaled at a 4 or above
  • Uses safe flavor/texture……..It helps the child predict what the new food will do/feel like in their mouth.
  • Reinforce all appropriate behaviors: even if it’s just staying at the table, looking at the new foods, serving oneself, touching with one finger, etc. --- This reduces anxiety
  • Pairing: Some discuss using a “transitional food” to help mask the after taste of a new food, to help cleanse the palate and avoid negative impact of new food
  • Remember if you say 1 bite, follow through, don’t request more bites
  • Force feeding: children who are force fed may learn to eat some foods to avoid being punished, but this is not a normal way of eating (escape learning)
  • Can be considered a form of negative reinforcement
    Be prepared to wait!
  • Best utilized with children with poor arousal and modulation impacting participation in feeding/mealtime situations
    Modulation- refers to the child's ability to grade response to incoming sensory information and produce behaviors that are neither over reactive nor under reactive to the situation (from aota)
    or- from SIPT book- central nervous system function of adjusting the intensity and duration of stimuli effecting a change in threshold thereby regulating neural activity
    Discrminiation- refers to the child's ability to accurately perceieve a sensation and utilize the sensation in a refined way to produce adaptive functional behaivors.
    10 Principles of Ayres SI
    Therapist ensures physical safety
    Therapist presents sensory opportunities that are keeping with the child’s identified needs (tactile, vestibular, prop)
    Therapist facilitates the child’s self-regulation of arousal level, attention and emotion
    Therapist challenges postural, ocular and bilateral motor development
    Therapist promotes praxis and organization of behavior
    Therapist tailors activity to present just-right challenge
    Therapist and child collaborate in activity choice
    Therapist ensures that activities are successful for the child
    Therapist fosters a context of play
    Therapist fosters a therapeutic alliance with the child.
    Exceptions are made for children with Autism, because the don’t have the ideation to pick and identify what they need. More direction may be necessary when presenting opportunities for sensory input.
  • Difference between SI and sensory-motor: in our facility, rarely have the ability to use actual SI treatment due to limitations in space
    *Arousal – level of alertness and responsitivity to stimuli
  • Gastoenteral –
    identified by signs/symptoms and/or medical testing
    Extended periods of GERD may result in decreased interest in eating
    EE- an inflammatory condition in which the walls of the esophagus become filled with large numbers of eosinophils (white blood cell).
    Invasive, negative experience
    Post –traumatic Eating Disorder of Infancy and Early Childhood –
    1. Infant demonstrates food refusal after traumatic event or repeated traumatic events to the oropharynx or esophagus (choking, gagging, vomiting, reflux, NG-ET tubes, suctioning and force feeding)
    The event triggered intense distress in the infant
    3. The infant experiences distress when anticipating feedings
    The infant resists feedings and becomes increasingly distressed when force fed.
    Prokinetic Agents enhance transit of intestinal material through the GI tract
    Anxiety – SSRI’s (controversial in pre-school aged children); Risperdol (anti psychotic, for irritability in children)– often used with Autistic children, but secondary gain is increase in appetite
    Keep in mind that ADHD medications can suppress appetite, so they may need to be changed or additional medications may be used to increase appetite
  • Will be getting to parent/sibling interactions
  • Therapists, parents, children ….. Each child will be at his/her own level (individual therapy presents foods that are individual to the child’s/family’s needs/desires; group must meet every child’s needs) – therefore, some kids might actually eat the particular foods presented (can be leaders)
  • Limitations (physical, cognitive, social)
  • Toomey… parents initially behind two-way mirror (during group)
  • Eating schedule… snacks no longer than 15 minutes, meals no longer than 30 minutes
    Meal routine: give verbal warning  wash hands  help set table/prepare foods  go to table  eat  clean up routine
  • Model good feeding behaviors - watch your facial expressions! Children read faces
    Over-exaggerate the motor: show and tell them how you would chew the food
  • They will “burn out”
    Will only eat the cheerios out of the yellow box
  • Many of the articles discussed patient weight gain, however not always a concern when children consume adequate calories without eating ‘healthy”.
    At times, will consider amount of food accepted by weighing food before and after, including weighing bibs etc to achieve accuracy.
    Medical evaluation – endoscopy, PH probes, growth
    Toomey – looks at the progression on the heirarchy
    Behavioral methods may consider how frequent reinforcement is required, or how quickly a child responds to requests.
  • Self-report, completed by parents about themselves and the child
    Seven factor model:
    4 factors measuring parental beliefs related to child’s obesity proneness – parental perceptions and concerns that may prompt use of controlling child-feeding practice
    Perceived parent weight: assessing parents’ perceptions of their own weight
    Perceived child weight: Assessing parents’ perceptions of their child’s weight status history
    Parental concern about child weight: assessing parents concerns about the child’s risk of being overweight
    Parental responsibility: assessing parents perceptions of their responsibility for child feeding
    3 factors measuring parental control practices and attitudes regarding child feeding
    Use of restriction: assessing the extent to which parents oversee their child’s eating
    Pressuring children to eat more: assessing parents tendency to pressure their children to eat more food, typically at meal times
    Monitoring: assessing the extent to which parents oversee their child’s eating
  • scale 1= never, 5= always
    Not familiar with it
    LIKES: used with medical dx, family systems, is this a problem (cultural/social)
    Single parents only answer 36 items, two parent homes with only one child answer 39 items
  • Winnie dunn, daniel mcintosh, lucy jane miller, vivian shyu
    Contains 38 items, versus 125 of SP
    Sections of SSP:
    Tactile – child’s response to touch experiences in daily life
    Taste/Smell – response to taste, smell experiences in daily life
    Movement – response to mvmt experiences in daily life
    Under-resp – the child’s level of noticing sensory events in daily life
    Aud – child’s ability to use and screen out sounds in daily life
    Low energy – child’s ability to use muscles to move in daily life
    Visual/aud – child’s response to sounds, sights in daily life
    Reliable outcome measure – the long sensory profile has much more detail in each section (tactile – hypersensitivity as well as tactile seeking… one area may show changes, but the other may not, which can skew results of long SP; whereas SSP is more specific)
    Likert scale (Always, Frequently, Occasionally, Seldom, Never)
  • 1= strongly disagree, 5= strongly agree
    When completing factor analysis on the FSQ, used with children ages 2-6y11m, but we use with children of all ages
  • MBQ provides a measure of feeding problems based only on the frequency of child behaviors (separates the child’s mealtime behavior problems from the strategies caregivers use to address these problems)
    Items generated by psychologists and advanced psychology trainees, as part of multi-disc fdg team
    Actually looking at dropping the choking/gagging/vomiting because they can also be due to fdg problems of a medical nature (vs. behav’l)
    1= never, 5= always
  • Scores: 1= strongly disagree, 5= strongly agree
    Not familiar with it
    Some suggest use FSQ, MBQ and AYCE in conjunction with each other so that the specific strategies used by caregivers, the problematic child feeding behaviors, and the relational components of the caregiver-child dyad can be fully assessed
    THAT’S A LOT! BASICALLY WE NEED ONE TOOL THAT CAPTURES ALL OF THIS, PLUS THE SENSORY
  • Transcript of "NJOTA - Current Trends in Pediatric Feeding"

    1. 1. Current Trends in Pediatric Feeding – Evaluation, Treatment and Outcomes Nichole M. Turmelle, OTR Karen E. Sclafani, MOT, OTR NJOTA Conference October 23, 2010
    2. 2. Learning Outcomes/Objectives Participants will: 1. Summarize current literature related to the diagnosis and treatment of feeding difficulties 2. Identify the domain areas and methods used by occupational therapists working as part of multi- disciplinary team, to assess feeding/eating skills 3. Compare available treatment options that occupational therapists can utilize to treat feeding/eating difficulties in children 4. Identify possible methods to document outcomes related to the treatment of eating and feeding difficulties in pediatrics
    3. 3. Literature Review
    4. 4. Literature Review: Multi-disciplinary Team Evaluations  Multi-disciplinary evaluations are supported in documentation from a variety of disciplines  Key disciplines identified include occupational therapy, speech therapy, psychology, nutrition and physician  Other disciplines also identified include social work, nursing and radiology  Chart review, interview, mealtime observation, clinical observations, and referrals are indicated as key parts of the evaluation  Citations: 4, 17, 21, 36, 37
    5. 5. Literature Review: Treatment Techniques  Discusses the use of behavioral approaches to feeding including reinforcement, non-removal techniques and escape prevention  Looks at cognitive behavioral approaches/education regarding the sensory aspects of food  Discusses sensory-motor preparatory activities for the mouth and body to improve feeding  Highlights the components of parent education  Looks at the use of medication, along with more traditional therapy approaches to increase appetite, improve gastric emptying and decrease anxiety surrounding feeding  Citations: 6, 7, 8, 12, 14, 15, 16, 24, 25, 26, 29, 30, 31, 33, 35, 38
    6. 6. Literature Review: Diagnosis of Feeding Difficulties  DSM-IV-TR Diagnosis – Feeding and Eating Disorders in Childhood  ICD 9 Diagnosis – Feeding Difficulties and Mismanagement  Criteria for both include:  Persistent  Failure to eat adequately, associated with weight loss  Significant failure to gain weight  Need a better system of classification  Suggested by a number of authors to better represent feeding  Current classifications do not account for feeding difficulties associated with:  State regulation  Feeding disorder of reciprocity  Sensory food aversions  Post-traumatic feeding disorder  Citations: 3, 13, 15, 22, 27, 39
    7. 7. Literature Review: What Was Not Documented  Consistent outcome measures  Medical  Behavioral  OT treatment options  Limited documentation of OT’s role during feeding therapy  Limited discussion of sensory preparation for feeding  Identified that sensory processing issues were present, but did not measure or speak to how they were addressed  Lack of protocols for treatment by OT  Oral motor  Sensory  Citations: 6, 12, 15, 16, 18, 24, 26, 29, 30, 31, 33, 35, 38
    8. 8. Evaluation
    9. 9. To Gag or Not to Gag
    10. 10. Evaluation of Feeding Difficulties  Feeding impairments are complex, often impacting the health, development and nutritional status of pediatric clients  Prevalence rates of feeding impairments span a wide range  Impact up to 25% of infants/children at some point during development  Impact 33% or more (up to 80%) of children with developmental disabilities  Citations: 6, 21
    11. 11. Evaluation of Feeding Difficulties: Multi-Disciplinary Team Members  Physician  Speech/Language Pathologist  Occupational Therapist  Psychologist  Registered Dietitian  May also include:  Social Worker  Radiologist  Nurse  Dentist
    12. 12. Evaluation of Feeding Difficulties: Team Assessment  Assessment process should include the following components:  Medical assessment  Consideration of the child’s feeding history  Assessment of motor, sensory, cognitive and psychosocial skills impacting feeding  Direct observation of feeding, including child and caregiver interactions  Video-swallow fluoroscopy (as necessary/available)
    13. 13. Evaluation of Feeding Difficulties: Team Assessment  Multi-disciplinary versus Trans-disciplinary  Team members must be competent in their own discipline-specific topics  Must also have knowledge of other discipline domains to elicit responses if necessary
    14. 14. Evaluation of Feeding Difficulties: Aspects of OT’s Domain Areas of Occupation  Activities of Daily Living  Eating – The ability to keep and manipulate food or fluid in the mouth and swallow it  Eating and swallowing are often used interchangeably  Feeding – The process of setting up, arranging, and bringing the food (or fluid) from the plate or cup to the mouth  Feeding is sometimes referred to as self-feeding  Social Participation  Community – Engaging in activities that result in successful interaction at the community level  Family – Engaging in activities that result in successful interaction in specific required/desired familial roles  Peer/friend – Engaging in activities at different levels of intimacy  Citation: 2
    15. 15. OT’s Role in Team Evaluation: Parent/Client Goals and Concerns  Identify family concerns for the evaluation  Values/beliefs/spirituality  Context and Environment – Cultural, Temporal, Physical, and Social  Self-feeding  Acceptance of a bottle  Acceptance of different food types (baby food versus table food)  Performance Patterns  Consider Habits, Routines, Rituals and Roles
    16. 16. OT’s Role in Team Evaluation: Medical and Social History  History of hospitalizations, surgeries, illnesses  History of social and psychosocial events related to feeding  Identify medications and consider their role in appetite  Look for signs/symptoms of GI distress, food allergies  Current and previous therapy services
    17. 17. OT’s Role in Team Evaluation: Assessment Tools  Standardized Assessment  Sensory Profile  Peabody Developmental Motor Scales – 2nd Edition  Parent Questionnaires  Mealtime Behavior Questionnaire  Feeding Strategies Questionnaire  3-day Food Diary
    18. 18. OT’s Role in Team Evaluation: Observation of Movement  Ability to move in the environment  Functional skills, transitions, ambulation  Quality of movement during play  Use of hands in play  Body Functions – Neuromuscular  ROM, strength, endurance, postural alignment  Body Structure – Structures related to movement  Performance Skills – Motor and praxis skills
    19. 19. OT’s Role in Team Evaluation: Observation of Social Skills  Interaction with parents  Ability to interact with team members  Play skills, both spontaneous and when directed by others  Body Functions – Mental Functions  Global mental functions  Performance Skills – Emotional Regulation Skills, Cognitive Skills, Communication and Social Skills  Imitation  Communication
    20. 20. OT’s Role in Team Evaluation: Observation of Feeding Skills  Food Choices  Identification of patterns  Texture  Temperature  Color  Flavor  Food groups  Identification of what is lacking  Food groups  Food textures  Sensory input
    21. 21. OT’s Role in Team Evaluation: Observation of Feeding Skills  Motor  Postural control, positioning  Finger feeding  Utensil use  Body Systems – respiration  Oral Motor  Biting/Chewing – placement of the food  Lip closure – on spoon, cup, straw  Lateralizing – movement of food in the mouth  Timing – duration of chewing, timeliness of swallow
    22. 22. OT’s Role in Team Evaluation: Observation of Feeding Skills  Sensory  Level of arousal during feeding  Willingness to explore foods with hands and mouth  Response to presentation of foods  Ability or inability to manipulate food in mouth
    23. 23. OT’s Role in Team Evaluation: Observation of Feeding Skills  Cognitive/Behavioral/Social  Ability to understand/follow directions  Ability to communicate needs  Response to structure  Attempts to influence environment with behaviors  Ability to be redirected
    24. 24. What do you think? Oral Motor or Sensory?
    25. 25. Now what do you think? Oral Motor or Sensory?
    26. 26. Is This Behavior or Not?
    27. 27. OT’s Role in Team Evaluation: Development of Recommendations  Individual occupational therapy  Group occupational therapy  Referral to other disciplines/specialties  Strategies to implement at home
    28. 28. Treatment
    29. 29. Treatment Considerations  Treatment techniques rarely happen in isolation  Need to consider the occupational profile of the child  Not one solution for each child
    30. 30. Treatment Considerations  Activity Demands (Activity Analysis)  Tools – utensils, cups, plates, equipment  What tools are used by the child/family; why  Space – environment of feeding, high chair  Distractions used or not used  Social – what are the expected social interactions during mealtime, cultural influences  Sequence/Timing – self-feeding skill, oral motor skills (holding food)  Performance skills – cognitive, sensory, motor demands  Required body structures/functions
    31. 31. Treatment Techniques  Desensitization  Behavioral  Ayres Sensory Integration  Sensory-Motor  Medication  Group Treatment  Parent Education
    32. 32. Desensitization  Sensory Desensitization  Body Functions  Tactile  Oral  Hierarchical Desensitization to Food  Chaining  Pairing
    33. 33. Sensory Desensitization: Body Functions  Tactile System  Wilbarger Deep Pressure Protocol  Dry textures (rice, beans, pasta)  Wet/sticky textures (Play-doh, Funny Foam)  Vibratory input to hands  Oral System  Massage to outside of mouth (towel rubs, deep pressure)  Vibratory input to inside and outside of mouth (z-vibe)  Nuk brush  Blowing/sucking activities (bubbles, whistles; drinking thick liquids through a straw)
    34. 34. Hierarchical Desensitization to Food  Slowly and systematically introducing new and non-preferred foods to the child  Exposing the child to a graduated hierarchy of anxiety-producing stimuli to help him/her overcome his/her fear of food/eating  Begin with the least-threatening technique and work up to more challenging strategies as comfort level increases
    35. 35. Hierarchical Desensitization to Food Taste Foods Touch Foods Tolerate Sights/Smells of Foods No Physical Interaction with Actual Foods Eat Foods
    36. 36. Hierarchical Desensitization to Food  No Physical Interaction with Actual Foods  Looking at pictures of the food (books, videos)  Singing songs about food, meal preparation, eating  Playing with pretend kitchen, toy food  Setting the table
    37. 37. Hierarchical Desensitization to Food  Tolerate Sights/Smells of Foods  Shopping for food in the grocery store  Talking about food characteristics  Tolerating foods in the room (away from the child, on another person’s plate)  Tolerating foods within close proximity (on table, on plate)  Serving self/others with utensils  Watching meal preparation or watching others eat the food
    38. 38. Hierarchical Desensitization to Food  Touch Foods  Simple meal preparation  Touching food with utensil  one finger  two fingers  whole hand  Picking food up  Placing food on hands, arms, shoulders, head, ears, cheeks, nose  Touching food to lips
    39. 39. Hierarchical Desensitization to Food  Taste Foods  Licking lips after food has been placed on them  Touching food to teeth  Licking food with tip of tongue, full tongue  Gnawing on food  Biting and spitting out  Biting, chewing, and spitting out  Swallowing food (small  large amounts)
    40. 40. Food Chaining  Part of a sensory/behavioral approach to feeding  Reduces risk for refusal as it is based on the child’s preferences  Emphasizes the relationship between characteristics of foods/liquids, such as taste, shape, texture, or temperature  Parents need to be provided with specific food chains and instructions on how they introduce and modify foods
    41. 41. Food Chaining  Discusses four levels of treatment:  Level 1 – Optimize nutritional status, scheduled meals/snacks, analyze patterns and preferred foods  Try to expand number of preferred foods in current taste/texture/temperature range  Level 2 – Introduce new flavors within the child’s currently preferred texture  Level 3 – Slightly alter texture of food while remaining in taste preference  Level 4 – Modify taste and texture of foods
    42. 42. Food Chaining  Uses a rating scale  Evaluate the success of the modification attempt  Monitor progress in the program  Assess changes in taste/texture preferences  Ratings also help determine which new chains may be most successful
    43. 43. Food Chaining: Rating Scale  1 Gagging and/or vomiting upon touching, smelling or seeing the foods  1+ Gagging upon tasting the food  2 Chews the food or manipulates it briefly in the mouth  3 Chews the food, but strongly aversive to the taste, grimace, refusal to try more  4 Chews and swallows food, tolerated it, but not enjoyable at this time  5 Chews and swallows the food, it was “so- so”
    44. 44. Food Chaining: Rating Scale  6 Chews and swallows several bites of the food item, no major grimace or reaction  7 Chews and swallows the food without problems  8 Chews and swallows food, takes a small serving easily, pleasant look on the face  9 Chews and swallows the food, asks for or reaches for more, appears to like the food very much  10 Chews and swallows the food, takes a serving or more easily, a strong favorite
    45. 45. Food Chaining  Eats Goldfish – Target is Grilled Cheese  Goldfish  Cheez-its  White Cheez-its  White crackers  White crackers with cheese  Plain cheese  Cheese on bread  Cheese on toast
    46. 46. Food Chaining  Chicken Nuggets/French Fries – Target is Other Meat  Cut preferred chicken nugget into strips  New brands of chicken nuggets cut into strips  Breaded chicken strips from home  Breaded pork strips  Naked chicken/pork  White meat turkey strips  Dark meat turkey strips  Beef strips
    47. 47. Food Pairing  Some presenters may call it “Flavor Masking”  Using preferred food to help decrease anxiety and increase acceptance of new food  Use a safe flavor/texture to help introduce a new food  Gradually separate the preferred and non- preferred foods at presentation  Change the ratio of preferred to non-preferred food
    48. 48. Food Pairing  Child accepts cheese:  Dip cheese in cracker “crumbs”  Offer reverse cheese/cracker sandwich  Increase size of cracker and reduce amount of cheese offered  Place cracker in mouth first, then offer cheese to help with chewing  Offer cracker for chewing, then offer cheese to help with swallowing  Offer cracker for chewing/swallowing, then offer cheese as a reward
    49. 49. Food Pairing  Child accepts pasta without sauce:  Dip plain pasta in preferred “juice” and encourage to eat  Dip plain pasta in “sauce” and encourage to eat, or wipe off then eat  Place “dot” of sauce on pasta and allow child to eat  Increase the amount of “dots”  Have pasta “fall” into the sauce  Offer lightly-covered pasta
    50. 50. Behavioral Treatments  Reinforcement  Positive  Negative  Punishment  Escape prevention
    51. 51. Behavioral Treatments: Positive Reinforcement  When desired behaviors are rewarded in order to encourage them to persist  The addition of a consequence immediately following a behavior, which increases the likelihood that the behavior will be repeated  Example of Positive Reinforcement: Jane takes a bite of her sandwich and is rewarded with verbal praise or a sticker  It is important to positively reinforce all appropriate behaviors related to feeding and eating
    52. 52. Behavioral Treatments: Positive Reinforcement  Types of Positive Reinforcement  Verbal praise, cheering  Clapping hands, high fives, hugs  Toys  Stickers  Preferred food (pairing)  Therapist/parents should adjust the frequency that the behavior is reinforced (1:1 ratio, 5:1 ratio)  Must remember that giving attention to the child when he/she refuses to eat is positively reinforcing that behavior
    53. 53. Examples of Positive Reinforcement
    54. 54. Behavioral Treatments: Negative Reinforcement  The removal of an aversive stimulus immediately following a behavior, which increases the likelihood that the behavior will be repeated  Example of Negative Reinforcement: Sam takes a bite of his chicken and then the chicken is removed from his plate  Do not confuse this concept with punishment
    55. 55. Behavioral Treatments: Negative Reinforcement  Types of Negative Reinforcement  Removing the food from the table after the child complies with request  Allowing the child to get up from the table after consuming a bite
    56. 56. Behavioral Treatments: Punishment  Punishment is removing an object/situation that the child likes or setting up a situation that the child does not like  Results in a decreased frequency of the inappropriate behavior  Example of punishment: “If you continue to spit your peas, you cannot have ice cream”
    57. 57. Behavioral Treatments: Punishment versus Reinforcement  Punishment Procedure:  Behavior occurs  consequence follows (something is either added or taken away)  behavior decreases  Reinforcement Procedure:  Behavior occurs  consequence follows (something is either added or taken away)  behavior increases  Reinforcement results in lasting behavioral modification, whereas punishment changes behavior only temporarily and can have negative side effects
    58. 58. Behavioral Treatments: Escape Prevention  Also called “escape extinction”  Based on the premise that the child’s undesired behaviors do not result in termination of the meal or demand  Non-removal of spoon, non-removal of meal  Re-presenting the food after expulsion  Example of Escape Prevention: “You have to lick the cheese three times before you can get up from the table”
    59. 59. What types of reinforcement are being used?
    60. 60. Ayres Sensory Integration (ASI® )  ASI "is the process by which people register, modulate and discriminate sensations received through the sensory systems to produce purposeful, adaptive behaviors in response to the environment"  Must follow 10 principles of ASI in order to call it true ASI treatment  If poor feeding is resultant of poor sensory integration, then providing the child with opportunities for sensory processing and integration following the principles of ASI will improve the child’s ability to participate in feeding/mealtime  Do not necessarily need to address feeding during the session  Citations: 1, 28
    61. 61. Sensory-Motor Approach  Uses the basic principles that form the foundation for the sensory integration frame of reference  Providing the child with sensory-motor activities to prepare him/her for feeding which will be addressed later in the session  Vestibular  Proprioceptive  Tactile  Oral sensory  Once arousal level is at optimal, then introduce feeding using a treatment approach pertinent to the child’s needs
    62. 62. Medication  Primary medical conditions that may benefit from treatment with medication:  GERD  Eosinophilic Esophagitis  Poor gastric motility  Secondary conditions that result from medical diagnoses may also benefit from treatment with medication:  Post-traumatic eating disorder  Anxiety  Poor appetite
    63. 63. Medication  Work with physician to determine if medication would be helpful in managing feeding difficulties  Medication, when combined with traditional feeding therapy and counseling/behavioral management, can be an effective treatment for feeding difficulties
    64. 64. Group Treatment  Group treatment is a great opportunity for social role modeling  Approximately 12 weeks in duration, cohort of 6-8 children  Structure:  Group sensory preparation activities and parent education  Wash hands  “March” to the table  Pass out plates/cups/napkins  Feeding trials  Clean-up routine
    65. 65. Group Treatment  Feeding trials  Lead therapist presents each food, one at a time, and determines when to introduce next food  Therapists, parents and other children in group model the sequence of steps to accepting foods  Parents may work with other children to move them through the hierarchy  Children may act as “leaders,” demonstrating their abilities to the group
    66. 66. Parent Education/Participation  Parents’ understanding of their child’s feeding/eating difficulties, as well as his/her strengths and limitations, is crucial to the child’s progress  Providing a supportive, nurturing and safe environment will increase the likelihood of the child exploring new foods and learning new eating skills  Behavioral treatments are important for parents to understand (reinforcement versus punishment)
    67. 67. Parent Education/Participation: Hands-on During Feeding Trials  It is important for parents to become familiar with the process in order to carry over at home  Consider when to involve the parents in treatment  May want to wait until the negative behaviors are better managed by the therapist before introducing parents  May be easier to have parents take an active role from the beginning, with coaching from therapist
    68. 68. Parent Education/Participation: Providing Structure  It will be easier for the child to learn the process and to know what to expect at meal times if the meal can be consistent in several aspects  Develop an eating schedule (minimize grazing)  Eat in the same room, at same table, in the same chair  Have the child assist with meal preparation  Have a mealtime routine
    69. 69. Parent Education/Participation: Social Role Modeling  Includes all members of the family during mealtime  Enables the child to observe others receiving consequences (praise, rewards) for their actions  Model good feeding behaviors  Discuss foods and their characteristics  Over-exaggerate the motor components  Let the child be the leader and family imitates  Provide positive reinforcement for all attempts  Do not punish
    70. 70. Parent Education/Participation: Portion Size  The child can become overwhelmed or frustrated if there is too much food on his/her plate  Therefore, it is important to present foods in manageable bites and small portions  No more than three foods on the child’s plate  One tablespoon of food per year of age
    71. 71. Parent Education/Participation: Managing “Food Jags”  “Food jag” is a term used when the child will only eat the same food, same brand, prepared the same way over long periods of time  This is a problem because:  Eventually the child will not want to eat that food anymore  The child will not accept any similar food if it is not exactly what his/her preferred food is
    72. 72. What to avoid….
    73. 73. Outcomes
    74. 74. Measures of Feeding Treatment  Quantities of food consumed  Weight in grams  Percentage consumed (oral versus g-tube)  Weight gain during treatment  Medical evaluation  Hierarchical progression  Reinforcement required/utilized
    75. 75. Tools Used to Measure Outcomes of Feeding  Child Feeding Questionnaire  Children’s Eating Behavior Inventory  Short Sensory Profile  Feeding Strategies Questionnaire  Mealtime Behavior Questionnaire  About Your Child’s Eating
    76. 76. Outcome Measure Tools: Child Feeding Questionnaire  Birch, L. L., et al. (2001)  31-item parent questionnaire assessing perceptions, beliefs, attitudes and practices regarding:  Child feeding  Their relationships to the child’s development of food acceptance patterns  Designed for use with parents of typically-developing children ages 2-11 years of age  Focus is on obesity proneness in children  Follows a 7-factor model:  4 factors measuring parental beliefs related to their child’s obesity proneness  3 factors measuring parental control practices and attitudes regarding child feeding  Likert-type scale  Obesity is not often the primary concern of children/families that are being treated
    77. 77. Outcome Measure Tools: Children’s Eating Behavior Inventory  Archer, L. A., Rosenbaum, P. L., & Streiner, D. L. (1991)  40-item parent questionnaire that assesses eating and mealtime problems in pre-school and school-aged children  28 items pertaining to the child - food preferences, motor skills, and behavioral compliance  12 items pertaining to the parent/family systems - parental child behavior controls, cognitions and feelings about one's child and interactions between family members  5-point frequency scale  Also asks "is this a problem for you?" - yes/no response  Initially designed for use with children with a wide variety of medical and developmental disorders  Takes family systems into consideration
    78. 78. Outcome Measure Tools: Short Sensory Profile  Dunn, W. (1999)  38-item parent questionnaire used to quickly identify children with sensory processing difficulties  Children ages 3-17  Measures sensory modulation during daily life - Tactile Sensitivity - Taste/Smell Sensitivity - Movement Sensitivity - Under-responsive/Seeks Sensation - Auditory Filtering - Low Energy/Weak - Visual/Auditory Sensitivity  5-point frequency scale  More reliable outcome measure, as compared to the Sensory Profile
    79. 79. Outcome Measure Tools: Feeding Strategies Questionnaire  Berlin, K. S., Davies, W. H., Silverman, A. H., & Rudolph, C. D. (2005, 2009)  40-item parent questionnaire that assesses the strategies used to address and prevent feeding problems in children (ages 2-6 years)  Factors include: - Child Control of Intake - Schedule Structure - Setting Structure - Laissez Faire - Parent Control of Intake - Coercive Interactions  Likert-type scale  Good option for treatment outcomes, as it focuses on caregiver and child factors that are frequently the target of family-based assessment and intervention around feeding/meals
    80. 80. Outcome Measure Tools: Mealtime Behavior Questionnaire  Berlin, K. S., et al. (2010)  33-item parent questionnaire that assesses the frequency of mealtime behavior problems in young children (ages 2-6 years)  Four subscales to reflect a variety of problematic mealtime behaviors: - Food refusal/avoidance - Food manipulation - Mealtime aggression/distress - Choking/gagging/vomiting  5-point frequency scale  Provides a measure of feeding problems based only on the frequency of child behaviors versus how the caregiver feels about or manages these behaviors  Can be used during evaluation process and as a treatment outcome measure
    81. 81. Outcome Measure Tools: About Your Child’s Eating  Davies, W. H., Noll, R. B., Davies, C. M., & Bukowski, W. M. (1993)  Valid and reliable 25-item parent questionnaire that assesses parental beliefs and concerns regarding their child’s eating  Used with school-aged children  Consists of three subscales  Child’s Resistance to Eating: Frequency of child’s eating behaviors  Positive Mealtime Environment: Parents’ mealtime interactions with the child  Parent Aversion to Mealtime: Parents’ feelings about mealtimes  Likert-type scale  Assesses parental feelings/beliefs regarding mealtime, but does not capture the child’s response to feeding
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    87. 87. Reference List 34. Schwarz, S. M., Corredor, J., Fisher-Medina, J., Cohen, J., & Rabinowitz, S. (2001). Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics, 108(3), 671-676. 35. Sharp, W. G. & Jaquess, D. L. (2009). Bite size and texture assessments to prescribe treatment for severe food selectivity in autism. Behavioral Interventions, 24, 157-170. 36. Simonsmeier, V. & Rodriguez, M. D. (2007). Establishment of an interdisciplinary pediatric oral-motor-sensory feeding clinic team. Infants & Young Children, 20(4), 345-354. 37. Smith, A. M., Roux, S., Naidoo, N. T., & Venter, D. J. L. (2005). Food choices of tactile defensive children. Nutrition, 21, 14-19. 38. Tarbox, J., Schiff, A. & Najdowski, A. C. (2010). Parent-implemented procedural modification of escape extinction in the treatment of food selectivity in a young child with autism. Education and Treatment of Children, 33(3), 223-234. 39. Williams, K. E., Riegel, K., & Kerwin, M. L. (2009). Feeding disorder of infancy or early childhood: How often is it seen in feeding programs? Children’s Health Care, 38, 123-136.
    88. 88. Reference List  Information also obtained from the following Continuing Education courses:  Mealtime Success for Kids on the Spectrum. Susan Roberts, MDiv, OTR/L  More than “Picky:” Taking the Fight Out of Food with Food Chaining Treatment Programs for Feeding Aversion. Cheri Fraker, CCC/SLP, Laura Walbert, CCC/SLP, and Sibul Cox, MS, RD, LD.  Picky Eaters vs. Problem Feeders: The SOS Approach to Feeding. Kay Toomey, PhD, Erin Sundseth Ross, MA, CCC/SLP, Susan Todd Massey, OTR, LCSW.  Practical Strategies for Treating Complex Pediatric Feeding Disorders: Treating the Whole Child. Mary Cameron Tarbell, MEd, CCC/SLP
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