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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.

Published in: Health & Medicine
  • Hello Nichole.
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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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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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  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