How to Get Your Kids to Eat Dr. Lori Ernsperger 702-616-8717
How to Get Your Kids to Eat Dr. Lori Ernsperger 702-616-8717 [email protected] copyright 2004 Ernsperger / Stegen-Hanson Overview • Introduction to Resistant Eaters – Prevalence – Characteristics • Oral-Motor Development • Environmental Factors contributing to Resistant Eaters • Physical Factors Contributing to Resistant Eaters • Introduction to the Treatment Plan – Environmental Controls – Physical and Oral Motor Activities – Stages to Sensory Development copyright 2004 Ernsperger / Stegen-Hanson The Role of the Educator and Therapist • Nutritional intake is critical to overall health and learning – Vitamin deficiency • Effects quality of life and independence • Socialization with peers – Socially isolated • Parent education on health and eating copyright 2004 Ernsperger / Stegen-Hanson Food For Thought If there is no foodThere is no thought! copyright 2004 Ernsperger / Stegen-Hanson Collaborative Approach • Develop a Feeding Team to include: – Family – Physician – OT – SLP – School Psychologist – Nutritionist – Teacher copyright 2004 Ernsperger / Stegen-Hanson Mystery Food • Learning about new foods • “Fear Factor” copyright 2004 Ernsperger / Stegen-Hanson Introduction to Resistant Eaters • Prevalence – 75% of children on the Autism Spectrum – 80% of children with severe mental retardation – 30-45% of typically developing children copyright 2004 Ernsperger / Stegen-Hanson 5 Common Characteristics • Eating Continuum • Characteristics 1. Limited Food selection 2. Limited Food groups 3. Anxiety around new foods 4. Food Jags 5. Diagnosed with a DD copyright 2004 Ernsperger / Stegen-Hanson Limited Food Selection • Eats less than 20 foods – As little as 1 or 2 foods • Selects only foods with a similar trait – Only white foods • Limited in taste and texture – Pureed foods only • Bottle fed or formula past developmental stage copyright 2004 Ernsperger / Stegen-Hanson Limited Food Groups • Breads and cereal group – Carb lovers • May eat some from the meat group – Chicken nuggets • Very few fruits or vegetables – Bananas-sweet – Apples- no skin copyright 2004 Ernsperger / Stegen-Hanson Anxiety and New Foods • • • • Tantrums when introduced to a new food Refuses to approach the table Gagging or vomiting Highly sensitive olfactory system copyright 2004 Ernsperger / Stegen-Hanson Food Jags • Insistence on same foods – Crinkle cut carrots • Common in typically developing 2 yr olds – PB & J • After several weeks/months, child refuses the food – Used to eat hot dogs copyright 2004 Ernsperger / Stegen-Hanson Developmental Delays • Medical and neuromuscular disorders – CP and GERD • Mental retardation – Down Syndrome • Premature at birth – Window for introducing soft munchables and solids • Autism and PDD copyright 2004 Ernsperger / Stegen-Hanson Neophobia • Fear of new foods • Typically developing stage for 2-3 year olds • Outgrown by age 5 • May linger into adulthood without treatment • Food Neophobia Scale (Pliner and Hobden) – How did you score? copyright 2004 Ernsperger / Stegen-Hanson Causation: Oral-Motor Skills • Definition: Movements of the muscles in the mouth, lips, tongue, cheeks, and jaw. Include the functions: biting, crunching, chewing, sucking, & licking copyright 2004 Ernsperger / Stegen-Hanson Causation: Oral Motor Skills A child with poor oral-motor skills may demonstrate delays in: • Development of motor skills (low muscle tone, poor postural control, poor bilateral coordination, poor eye-hand coordination) • Speech and language development (facial expressions, breath control, voice volume) • Paying attention and organizing own behavior (cannot calm self, struggles with transitions, inflexible) copyright 2004 Ernsperger / Stegen-Hanson Causation: Oral Motor Skills During feeding, poor oral-motor skills may lead to: • Gagging/frequent choking • Drooling • Difficulty keeping food down • Difficulty transitioning to different textured foods • Difficulty sucking, chewing, swallowing • Picky eating habits (avoiding textures, temp., tastes) copyright 2004 Ernsperger / Stegen-Hanson Digestive system • Oral Cavity teeth pulverize, salivary glands, tongue - pharynx • Esophagus peristaltic muscular contractions • Small Intestine Enzymatic and mechanical digestion • Large Intestine absorption of water, minerals, and certain vitamins • Rectum and Anal Canal non-nutritive residue copyright 2004 Ernsperger / Stegen-Hanson Causation: Respiration and Eating • • • • • You can’t eat if you can’t breathe Nasal cavity, trachea, lungs Breathing, swallowing, and talking Coordination Important when feeding a child- pace of the meal copyright 2004 Ernsperger / Stegen-Hanson Case Study • Sarina – Oral-motor assessment revealed – Drooled excessively as a baby – Did not explore toys with her mouth – Only ate biscuits and crackers which were easily dissolved copyright 2004 Ernsperger / Stegen-Hanson Causation: Environmental Factors • Family schedules, settings, and serving sizes • Problem behaviors • Lack of knowledge and awareness of serious problems copyright 2004 Ernsperger / Stegen-Hanson Parental Responsibility • Myth: Good parents are responsible for getting their child to eat. – “Parents and professionals working with children are responsible for preparing and providing a balanced meal at an appropriate schedule and setting. The CHILD is solely responsible for whether they eat and how much they eat.” – Ellyn Satter, Secrets of Feeding a Healthy Family copyright 2004 Ernsperger / Stegen-Hanson Cultural Beliefs and Food • “Clean Your Plate club” • Don’t play with your food • Sweets and desserts are rewards for eating your meal • Good eaters vs bad eaters copyright 2004 Ernsperger / Stegen-Hanson Causation: Sensory Integration • Dr. A Jean Ayres • Our brain: Receives sensory information from our bodies and surroundings Interprets these messages Organizes our purposeful responses copyright 2004 Ernsperger / Stegen-Hanson Causation: Sensory Integration Dysfunction • Sensory Modulation Dysfunction fluctuates between over-reacting and under-reacting to sensory messages • Dysfunction in Sensory Discrimination how full is his cup? how full is his mouth? how loud is his voice? • Dyspraxia difficulty conceiving of, planning, organizing and carrying out a sequence of unfamiliar actions (pouring milk into the cereal bowl) copyright 2004 Ernsperger / Stegen-Hanson How the Proprioceptive system affects mealtimes • Definition • Adjusting/grading jaw opening • Hold utensils with too much/too little force • Knowing body position in relation to objects on table • Grading movement to drink copyright 2004 Ernsperger / Stegen-Hanson How the Vestibular system affects mealtimes • Definition • Focus all attention on moving sensations • Muscle tone copyright 2004 Ernsperger / Stegen-Hanson How the Tactile system affects mealtimes • • • • • Definition Hyposensitive Hypersensitive Austin Touch can prepare a child for a meal and help focus attention (wiping face) copyright 2004 Ernsperger / Stegen-Hanson How the Gustatory system affects mealtimes • Decreased taste sensitivity (inedible objects, spicy foods, extreme temperatures) • Increased taste sensitivity (object to textures/temperatures, gag) • Medication and a mild deficiency in zinc distorts taste • Sweet-tasting addiction copyright 2004 Ernsperger / Stegen-Hanson How the olfactory system affects mealtimes • 75% of taste perceptions depend on efficient sense of smell • Olfactory stimulus goes to the limbic system (emotions and inner drive) – strong association with memory storage • Odor & childhood memory? • Changing station/fried food in cafeteria copyright 2004 Ernsperger / Stegen-Hanson How the Visual system affects mealtimes • Alerting visual stimuli: shiny objects bright colors moving objects or peripheral movements • Calming Visual stimuli – Candlelight – No TV copyright 2004 Ernsperger / Stegen-Hanson How the Auditory system affects mealtimes: • Auditory stimulation is always there – it cannot be ignored • Music with a slow tempo, and regular sustained rhythm slows down breathing and heart rhythms – lead to relaxation copyright 2004 Ernsperger / Stegen-Hanson Mystery Food • Learning about new foods • “Fear Factor” copyright 2004 Ernsperger / Stegen-Hanson Causation: Gastrointestinal Factors • The child finds eating unpleasant and unsafe • GERD- Gastroesophageal Reflux Disorder is when the stomach’s acidic contents move backward into the esophagus • The esophagus becomes red and irritated copyright 2004 Ernsperger / Stegen-Hanson Symptoms of GERD • Immediate indicators of reflux: – – – – – – – – – Sweating Arching or stiffening of the body Frequent irritability or sudden crying after eating Hiccups/Burping Increased breathing rate Bad breath Startle movement Irritability/Crying Mucus/Phlegm copyright 2004 Ernsperger / Stegen-Hanson Long Term Indicators of Reflux • • • • • • • • • • Accepts only fluids Eats only small amounts Frequent sore throat Sleep difficulties – restless, awakens often Frequent meal refusal Unexplained temperature elevations Black tarry stool Enamel on the teeth deteriorates Refuses anything around or in the mouth Inability to gain weight despite caloric intake copyright 2004 Ernsperger / Stegen-Hanson Medical vs. Behavioral Causes • The parental response to medical illnesses can lead to behavioral mismanagement, even acute illnesses • The problem may begin at a biological level but can quickly turn behavioral based on the parental response • Behavioral mismanagement of biological factors- Lauren copyright 2004 Ernsperger / Stegen-Hanson Introduction to the Treatment Plan • Goals for a comprehensive written plan – Create a safe and nurturing environment – Expand the child’s responsibilities for preparing, eating, and cleaning up – Improve oral-motor development – Learn about new foods – Respect the child’s needs copyright 2004 Ernsperger / Stegen-Hanson Guidelines for Writing a Plan • • • • • • Start with you! Create a support network Take things slow Individualize the plan If mistakes are made- try again Have fun copyright 2004 Ernsperger / Stegen-Hanson Part One: Environmental Controls • Schedule – Written and posted • Understandable to the child – Timers – Includes snacks – No grazing and only water between meals copyright 2004 Ernsperger / Stegen-Hanson Mealtime Setting Create a Consistent Setting – Eating and drinking is done at the table – Supportive and nurturing • Role model good eating habits • Do not discuss the child’s eating habits during the meal – Limit distractions copyright 2004 Ernsperger / Stegen-Hanson Food Jags • Insistence on the same • Food Jags and children with DD • Guidelines – – – – Make small changes ie food coloring Choice-making Include the child Support and encouragement copyright 2004 Ernsperger / Stegen-Hanson Portion Size and Food Selection • Food selection – Always have one preferred food item at every meal – Pair a new food with a preferred food – Child-friendly – Temperature • Portion size – Age appropriate plates and utensils – Measuring spoons and cups – Less is best copyright 2004 Ernsperger / Stegen-Hanson Behavior and Mealtimes • Check environmental factors • Set a routine pre and post meal – Transition activities-auditory • Written rules • Removal from the table or room – Time out in schools • Stick with the schedule • Analyze the behavior copyright 2004 Ernsperger / Stegen-Hanson Behavioral Intervention • If the child’s exhibits noncompliance and/or tantrums after the mealtime plan is implemented, consider the following: – Does the child receive at least one preferred item at every meal? – Is the positioning and seating appropriate? – Is the environment stress free? – Is the child empowered to end the meal in a positive manner? (PECS-finished) copyright 2004 Ernsperger / Stegen-Hanson Part Two: Physical and Sensory Competence • Postural alignment • Postural control • Postural stability • Case study: Logan copyright 2004 Ernsperger / Stegen-Hanson Postural Control -Modifications • • • • • Move ‘n Sit cushion Foot bench Eating utensils Drinking utensils Exercises to prepare body before eating • Activities to strengthen and improve postural control • Case study: Logan copyright 2004 Ernsperger / Stegen-Hanson Oral-Motor Activities • Improve awareness and dissociation of movement – Scrunch eyes, nose, cheeks and mouth to make them tight, then relax – Blowing activities – Nuk brush/toothbrush activities – Mouth Madness Games- “Crazy Bumble Bee” – Mouth exploration of eating utensils copyright 2004 Ernsperger / Stegen-Hanson Chewing Activities • Dental Check • Locate chew items in convenient locations in child’s environment • Chewy tube – Counting games • • • • Baby safe feeder or bolus bag Mouth box Strips of food Selection of Chewy Foods – Carrots, celery, beef jerky, licorice copyright 2004 Ernsperger / Stegen-Hanson Sensory Activities • Importance of correct handling techniques (light touch - irritating) • Desensitization methods – Distal to proximal – Caution: vibration • Stimulation to face and mouth – With an OT/SLP specializing in oral motor therapy – With the child’s permission copyright 2004 Ernsperger / Stegen-Hanson Gastrointestinal Comfort • Medical interventions – Surgery or over the counter medicines • Reduce stress at mealtimes – Avoid coercion • Assist in respiration activities – Practice deep breathing • Review positioning • Ice and water copyright 2004 Ernsperger / Stegen-Hanson Mystery Food • Learning about new foods • “Fear Factor” copyright 2004 Ernsperger / Stegen-Hanson Part Three: Stages of Sensory Development • • • • • • • Children learn to eat through their senses “Learning about new Foods” Playful and fun Avoid judgments Food Rich Environment Use of ice in treatment 10-15 successful trials at each stage – Systematic desensitization copyright 2004 Ernsperger / Stegen-Hanson Acceptance • • • • Exposure Food Preparation Desensitization Hot potato- place food in a bowl if child does not want to touch it copyright 2004 Ernsperger / Stegen-Hanson Touch • Be prepared to get messy • Use one food to touch another food (use a pretzel stick to touch a cucumber) • Avoid coercion • Mystery Items copyright 2004 Ernsperger / Stegen-Hanson Smell • • • • Select Calming foods Respect the child Include only 1-3 new scents Guess the smell copyright 2004 Ernsperger / Stegen-Hanson Taste • A taste can be a lick or a small bite not swallowed • Spit bucket • Select foods with similar tastes • Have water or ice available for cleansing copyright 2004 Ernsperger / Stegen-Hanson Tasting New Foods • Hide and Seek in the mouth • Bobbin’ for foods – Use a shallow pan with 1 inch of water copyright 2004 Ernsperger / Stegen-Hanson Mystery Food-Revealed • Learning about new foods • “Fear Factor” copyright 2004 Ernsperger / Stegen-Hanson A Recipe for Success • Eating new foods – Not all children will like all foods – Set realistic goals • Collaborate with school and home • Focus on the whole child • Happy Eating! copyright 2004 Ernsperger / Stegen-Hanson
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