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
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:
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
6. 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
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
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
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
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
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
Eat Foods
Swallowing food (small large portions/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
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
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:
Undesired behavior occurs consequence
follows (something is either added or taken away)
undesired behavior decreases
Reinforcement Procedure:
Desired behavior occurs consequence follows
(something is either added or taken away)
desired 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”
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
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
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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.
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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
Editor's Notes
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
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
Citation 33: 180 children, ages 8-10 years
1/2 experimental group - provided with education during school time with 12 one and a half hour sessions of taste lessions, over 4 month period of time
Food neophobia was evaluated before and after education period of exper group and again 10 months later
Used adapted food neophobia scale and willingness to taste novel food
Evaluated by presentation of 8 unknown foods
Children were informed that they would have to eat on of the not rejected unknown foods afterwards in order to increase accuracy with willingness to taste novel food
Following education, experimental group - food neophobia decreased significantly and participants' willingness to tase novel food increased compared to control group. However, in 10 month post test, these results disappeared
Therefore, sensory education can influence childrens' food neophobia but only temporarily.
Sensory prep helpful but not measured
Will talk about use of medication further in treatment portion of presentation
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.
Now that the child has gone through a comprehensive fdg eval and when recommended for tx, …
Will be discussing tx strategies that we use, we have learned from courses, and that were supported in the literature
Along with occ’l profile, keep in mind the activity demands… what might need to be changed, etc.
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)
Example: If child is punished for hitting, then hitting behavior will decrease; however if we say Quiet hands and reinforce it, the behavior of keeping quiet hands in the lap with increase
Can be considered a form of negative reinforcement
Be prepared to wait!
Positive reinforcement – when he spits out food, mom’s reaction positively reinforces that behavior
Escape Prevention – can’t get up…
Punishment (threat of) “oh, he wants two!”
Negative reinforcement – have to finish one bite before you can be done
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)
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