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
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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
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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
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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:
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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
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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
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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
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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
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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
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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
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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
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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
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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