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

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. 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. Literature Review

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. 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. 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. 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. Evaluation

9. To Gag or Not to Gag

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. What do you think?
Oral Motor or Sensory?

25. Now what do you think?
Oral Motor or Sensory?

26. Is This Behavior or Not?

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. Treatment

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. 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. Treatment Techniques
 Desensitization
 Behavioral
 Ayres Sensory Integration
 Sensory-Motor
 Medication
 Group Treatment
 Parent Education

32. Desensitization
 Sensory Desensitization
 Body Functions

Tactile

Oral
 Hierarchical Desensitization to Food
 Chaining
 Pairing

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. 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. Hierarchical Desensitization to Food
Taste
Foods
Touch Foods
Tolerate Sights/Smells of Foods
No Physical Interaction with Actual Foods
Eat Foods

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Behavioral Treatments
 Reinforcement
 Positive
 Negative
 Punishment
 Escape prevention

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. 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. Examples of Positive
Reinforcement

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. 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. 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. 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. 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. What types of reinforcement
are being used?

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. What to avoid….

73. Outcomes

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. 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. 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. 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. 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. 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. 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. 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

82. Reference List
1. American Occupational Therapy Association. (2008). Frequently asked
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px
2. American Occupational Therapy Association. (2008). Occupational
therapy practice framework: Domain and process (2nd
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3. American Psychiatric Association. (2000). Diagnostic and statistical
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ed., text rev.) Washington, DC: Author.
4. Amirault, L. M. (2008, October). A four-part approach to assessing
feeding disorders in children. Therapy Insider, 7-9.
5. Archer, L. A., Rosenbaum, P. L., & Streiner, D. L. (1991). The Children's
Eating Behavior Inventory: reliability and validity results. Journal of
Pediatric Psychology, 16(5), 629-642.
6. Babbitt, R. L., Hoch, T. A., Coe, D. A., Cataldo, M. F., Kelly, K. J.,
Stackhouse, C. & Perman, J. A. (1994). Behavioral assessment and
treatment of pediatric feeding disorders. Developmental and Behavioral
Pediatrics, 15(4), 278-291.

83. Reference List
7. Bekem, O., Buyukgebiz, B., Aydin, A., Ozturk, Y., Tasci, C., Arslan, N., &
Durak, H. (2005). Prokinetic agents in children with poor appetite. Acta
Gastro Enterologica Belgica, 68, 416-418.
8. Berger-Gross, P., Coletti, D. J., Hirschkorn, K., Terranova, E., & Simpser, E.
F. (2004). The effectiveness of risperidone in the treatment of three children
with feeding disorders. Journal of Child and Adolescent
Psychopharmacology, 14(4), 621-627.
9. Berlin, K. S., Davies, W. H., Silverman, A. H., & Rudolph, C. D. (2009).
Assessing family-based feeding strategies, strengths, and mealtime
structure with the Feeding Strategies Questionnaire. Journal of Pediatric
Psychology, 1-10.
10. Berlin, K. S., Davies, W. H., Silverman, A. H., Woods, D. W., Fischer, E. A.,
Rudolph, C. D. (2010). Assessing children’s mealtime problems with the
Mealtime Behavior Questionnaire. Children’s Health Care, 39(2), 142-156.
11. Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Sawyer, R., &
Johnson, S. L. (2001). Confirmatory factor analysis of the Child Feeding
Questionnaire: a measure of parental attitudes, beliefs, and practices about
child feeding and obesity proneness. Appetite, 36, 201-210.
12. Blissett, J. & Harris, G. (2002). A behavioural intervention in a child with
feeding problems. Journal of Human Nutrition and Dietetics, 15, 255-260.

84. Reference List
13. Bryant-Waugh, R., Markham, L. Kreipe, R. E., & Walsh, B. T. (2010). Feeding
and Eating Disorders in Childhood. International Journal of Eating Disorders,
43(2), 98-111.
14. Celik, G., Diler, R. S., Tahiroglu, A. Y., & Avci, A. (2007). Fluoxetine in
posttraumatic eating disorder in 2-year-old twins. Journal of Child and
Adolescent Psychopharmacology, 17(2), 233-236.
15. Chatoor, I. (2002). Feeding disorders in infants and toddlers: Diagnosis and
treatment. Child and Adolescent Psychiatric Clinics of North America, 11,
163-183.
16. Chatoor, I. (2009). Sensory food aversions in infants and toddlers. Zero to
Three, 29(3), 44-49.
17. Clawson, B., Selden, M., Lacks, M., Deaton, A. V., Hall, B., & Bach, R.
(2008). Complex pediatric feeding disorders: Using teleconferencing
technology to improve access to a treatment program. Pediatric Nursing,
34(3), 213-216.
18. Coulthard, H. & Blissett, J. (2009). Fruit and vegetable consumption in
children and their mothers: Moderating effects of child sensory sensitivity.
Appetite, 52, 410-415.
19. Davies, W. H., Ackerman, L. K., Davies, C. M., Vannatta, K., & Noll, R. B.
(2007). About Your Child's Eating: factor structure and psychometric
properties of a feeding relationship measure. Eating Behaviors, 8, 457-463.

85. Reference List
20. Dunn, W. (1999). Sensory Profile: Users manual. United States of
America: The Psychological Corporation.
21. Fayed, N., Berall, G., Dix, L., & Judd, P. (2007). A dynamic and
comprehensive practice model of paediatric feeding practice.
International Journal of Therapy and Rehabilitation, 14(1), 7-15.
22. Field, D., Garland, M., & Williams, K. (2003). Correlates of specific
childhood feeding problems. Journal of Paediatrics and Child Health, 39,
299-304.
23. Franklin, L. & Rodger, S. (2003). Parents’ perspectives on feeding
medically compromised children: Implications for occupational therapy.
Australian Occupational Therapy Journal, 50, 137-147.
24. Girolami, P. A., Boscoe, J. H., & Roscoe, N. (2007). Decreasing
expulsions by a child with a feeding disorder: Using a brush to present
and re-present food. Journal of Applied Behavior Analysis, 40, 749-753.
25. Gowers, S., Claxton, M., Rowlands, L., Inbasagaran, A., Wood, D., & Yi,
I. (2009). Drug prescribing in child and adolescent eating disorder
services. Child and Adolescent Mental Health, 15(1), 18-22.
26. Maune, N. C. (2007, March). Pediatric feeding issues: Reexamining
assessment and intervention using the sensory integrative frame of
reference. Sensory Integration Special Interest Section Quarterly, 30(1),
1-4.

86. Reference List
27. Nicholls, D. & Bryant-Waugh, R. (2008). Eating disorders of infancy and
childhood: Definition, symptomatology, epidemiology, and comorbidity.
Child and Adolescent Psychiatric Clinics of North America, 18, 17-30.
28. Parham, L. D., Cohn, E. S., Spitzer, S., Koomar, J. A., Miller, L. J., Burke, J.
P., et al. (2007). Fidelity in sensory integration intervention research.
American Journal of Occupational Therapy, 62, 216-227.
29. Patel, M. R., Piazza, C. C., Martinez, C. J., Volkert, V. M., & Santana, C. M.
(2002). An evaluation of two differential reinforcement procedures with
escape extinction to treat food refusal. Journal of Applied Behavior Analysis,
35, 363-374.
30. Paul, C., Williams, K. E., Riegel, K., & Gibbons, B. (2007). Combining
repeated taste exposure and escape prevention: An intervention for the
treatment of extreme food selectivity. Appetite, 49, 708-711.
31. Pizzo, B., Williams, K. E., Paul, C., & Riegel, K. (2009). Jump start exit
criterion: Exploring a new model of service delivery for the treatment of
childhood feeding problems. Behavioral Interventions, 24, 195-203.
32. Pliner, P. & Hobden, K. (1992). Development of a scale to measure the trait
of food neophobia in human. Appetite, 19, 105-120.
33. Reverdy, C., Chesnel, F., Schlich, P., Koster, E. P., Lange, C. (2008). Effect
of sensory education on willingness to taste novel food in children. Appetite,
51, 156-165.

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. 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