Tommy is 4-years old and he won’t eat. He can eat. He can swallow. He can chew. He just refuses. It is difficult at home during mealtimes, and it is impossible to go to restaurants.
Sound familiar? If it does, read on.
Children with feeding issues often present with a complex array of issues that impact the entire developmental scheme. It involves physical, emotional, sensory, social and cognitive skills.
In many cases, by the time the child enters therapy, the problem has been on going for many years. Therapy often requires an intensive multi-disciplinary approach in order to accomplish long-term goals and long lasting changes.
Before treatment begins with occupational and speech therapists, it is essential to rule out any associated medical problems such as reflux, slow stomach emptying, constipation, respiratory or cardiac issues, etc.
Left untreated feeding issues can have far reaching impacts on the child well into adulthood, giving rise to physical, mental and behavioral concerns.
Eating is basically a suck-swallow-breathe pattern that is repeated over and over. Most children learn this automatically, but for some it must be taught. For this a speech therapist is often engaged to treat this along with any other oral motor associated concerns.
Behavioral issues with feeding are sometimes referred to as “conditioned dysphagia”. Conditioned dysphagia is a learned disorder that holds onto a “habit” long after the physiological need for such a behavior has ceased to be needed.
All feeding programs should have as its primary and most important goal nutrition.
Justine Joan Sheppard, SLP from Columbia University suggests that mealtime be the place to present the child with foods that they are already successful with instead of unfamiliar new experiences. However Heather K. Adams, in an article from the North Dakota Newspaper suggests a compromise. Have the child’s preferred foods, but then have a “tasting spot” at the table with new foods. The child can then try small tastes, does not have to have them on his/her plate but has had the opportunity to sample something new. The child should not be pressured, and should be allowed to reject a food after a small taste has been made.
The Kennedy Kreiger Institute has a program for children with food aversions that focus on weight gain, food by mouth intake, mealtime appropriate behaviors and self-feeding abilities. Their multi-disciplinary program is part of a continual assessment and re-assessment of measurable goals that both the child and the family can work on together.
Irene Chatoor of the Children’s National Medical Center specifically notes these issues as “Sensory Food Aversions”. She states that children have aversions to particular tastes, smells, textures, and temperatures of foods. She goes on to state that these children often have other sensory issues as well.
There is a difference between “picky eaters” and children with real food aversions. In an article by Dovey, Staples, Halford and Gibson (2007), “picky eaters” are defined as children who “consume an inadequate variety of foods through rejection of substantial amounts of foods that are familiar (and/or unfamiliar) to them. “Food neophobia” on the other hand is the avoidance of new foods. While the “picky eater” and the “food neophobic” are related, but have theoretical and behavioral differences. These authors saw that “Food Neophobia” was part of picky/fussy eating but without many of the associated behaviors.
Within these (above) categories are the “selective eater” who will only eat certain foods, and the “choosy eaters” who generally show a disinterest in eating. Sensory food aversions generally appear about age three when children are being transitioned to self-feeding. At this age children are expected to become more autonomous and less dependent. This transition for some children maybe more traumatic and therefore food issues sometimes arise.
In order to successfully address these concerns it is imperative to distinguish between children with minor food aversions and those with more serious concerns where their reluctance to eat can evolve into serious eating problems.
Treatment generally follows a basic three-step system:
- Acquisition—the child learns a new behavior relating to food i.e., chewing, orienting to food, etc.
- Fluency –the child practices the behavior to become faster at it and for it to be automatic
- Generalization—the child utilizes the learned behavior with different items in different settings.
Imbedded into these steps is the reinforcement of appropriate mealtime behaviors and the extinguishing of non-appropriate ones. This can include a reward system where an activity is offered that the child would not have access to otherwise, etc.
§ So if your child only eats burgers and pizza, try some of these suggestions:**
Introduce a grilled cheese sandwich
Introduce a grilled cheese sandwich
§ Let them use their fingers—try introducing edamame!! (full of protein!)
§ If texture is a problem puree foods to start and slowly increase the consistency
§ Use toast as it has texture and cannot easily be lost as a bolus in their mouths
§ Use dips—toast into tomato soup for example
§ Disguise protein as a dip—put it in familiar sauces and mix it in your food processor
§ Tempt them with foods they love and let them know that you want a meal the whole family can love
§ Serve veggies with ketchup—green beans can become “green fries” with ketchup
§ Teach fine motor skills with “chop sticks” using pealed carrot sticks instead of the wooden ones—if they bite down they get some nourishment instead of splinters!!
§ Gross-em-OUT—works great for some little boys—one mother reports that her son wouldn’t eat beans until she told him they made him fart!!
§ Create a “Tasting Spot” with the rule that the picky eater has to at least try a little; if they like it they can finish it, if not they can leave it.
**from various Internet sources
And remember
§ DO NOT get into power plays this is NOT about the caregiver it is about Nutrition
§ Children use food in many cases as a stress “reactor” so adding stress is counter-productive
§ Food aversions are often associated with co-existing diagnoses such as Autism, Depression, reactions to life situations, etc.
§ The goal of diet therapy is to gradually increase in-take
§ Progress is slow
§ There are often set backs
§ Eating is a major social event –it is “family time” and not being able to participate may impact the child’s self-esteem
Occupational therapy with its extensive training and research into the area of sensory integration, and speech therapy with its focus on oral motor development are ideal interventions to help the child address these sensory concerns as well as helping the family construct a positive home program.
And lastly, avoid labeling. If asked, simply respond “Tommy is not eating now, but he is trying and we are working on it with him.” Things are so much easier when done with an understanding friend. And a child’s best friend is often found in the family.
Susan N. Schriber Orloff, OTR/L, is the author of the book Learning RE-Enabled, a guide for parents, teachers, and therapists (and a National Education Association featured book), and the Handwriting on the Wall Program. Children's Special Services, LLC is the exclusive provider of P.O.P.tm Personal Options and Preferences, tm social skills programs. She was the 2006 Georgia OT of the Year and the CEO/executive director of Children’s Special Services, LLC, which provides occupational therapy services for children with developmental and learning delays in Atlanta. She can be reached through her Web site at www.childrens-services.com or at susanorloff@childrens-services.com.
