Feeding the Picky Eater Strategies for All Families Presented by Jillian O’Brien, MS OTR/L Michelle Segovias, MS, OTR/L Pediatric Development Center 125 Presumpscot Street Portland, ME 04103 (207) 699-5531 www.pediatricdevelopmentcenter.com jillianrobrien@gmail.com Designed to assess and address all the factors involved in feeding difficulties treats the whole child Philosophically based on the idea that the child is always right , Behaviors are communication

Feeding Eating is the most difficult sensory task that children can do! 20% of typically developing children vs. 60-70% of kids with ASD Feeding problems is often the first sign of other developmental challenges – When kids don’t eat well it is an indicator that something is not going well developmentally It takes a typically developing child 2 years before they have gained all the skills necessary for feeding. Increased tendency to FOOD JAG REDUCED RANGE Slow feeders, difficult to feed, very choosy, DECREASED ABILITY TO SCREEN OUT IRRELEVANT INFO, INHIBIT SENSORY INPUT AND HABITUATE TO IT. Kids on the ASD, typically have overall limited praxis, decreased postural stability, increased repetitive movements, decreased ability to participate in COMPLEX TACTILE use of hands, poor body awareness, auditory hyper-sensitivity, decreased joint social attention – WE LOOK AT FOOD and PEOPLE to Learn to EAT. MICROSCOPIC LEARNING – all details PACKAGING BECOMES PART OF THE FOOD GENERALIZAITON – kids on the ASD can get caught up in the details and cannot see that all the food in a category have shared features Can not tell that the food is the same unless it is exactly the same. Food CHANGES SOOOOOO MUCH Packaged food is preferred, because changes less, package at least always stays the same. Hard Munchables – well defined shape, safest texture Color and Shape - very visual – have a theme in your hierarchy ex) Pringle, yellow sucker, yellow licorice, orange licorice, dry papaya spear, orange drink . Sweet foods – one flavor kids on spectrum can distinguish Mirrors – often kids on spectrum feel more comfortable looking at you modeling behavior in the mirror than directly face to face. Work up hierarchy as tolerated -0 We want them to be an active participant – actively processing stimuli show and tell hands and eyes working together increase visual Strategies Passing food Routine of what is done with every food Sing songs that have known movements Stay at table, make sure postural stability is well supported Lots of reassurance Use mirror Play hide and seek –in hands, in mouth, under napkin plate or cup

“One of the common myths about eating is that it is easy and instinctive. Eating is actually the most complex physical task humans engage in. It is the only physical task that utilizes all the body’s organ systems: the brain and cranial nerves; the heart and vascular system; the respiratory, endocrine, and metabolic systems; all the muscles of the body; and the entire GI tract. Swallowing alone requires the coordination of 26 muscles and six cranial nerves” –Kay Toomey SOS credit

Myths about Mealtime Eating is the body’s #1 priority Eating is instinctive Eating is EASY Eating is a two-step process It is not okay to PLAY with your food If a child is hungry they will eat Children need only 3 meals Either organic or behavioral problem Certain foods are eaten at specific times a day Mealtimes are proper social occasion Either Organic or Behavioral: Talk about – Get a full GI study, rule out any medical complications SEE Top Ten Myths of Mealtime in America Handout to discuss WHY IT’S FALSE!!! NO FOOD POLICE Ex) if dinner is a disaster switch up when which foods are served – because any food can be eaten at any time. Healthy vs. junk food is playing into kids black and white thinking. All food is ok in certain amounts. Food is a protein, starch, fruit, veggie, fats and sugars just come along for the ride. Goal is balanced diet.

Sensory - Changes with every Chew Sight Sound – consistency is different Touch – texture is different Taste – molecules are broken Smell – molecules are broken Balance – head shifts every chew Proprioception – pressure is different Interoception – sensation of movement in esophagus changes, streth on stomach and appetite.

Bag of Treats Saltine Cheerios Baby Puffs Twizzlers Cheeto Saltine, chew five times, place into center of tongue, try to swallow (Can cheat by smooshing into palatte, forward tongue thrust, tongue pokes out, squishing and swishing lips disappear and sway cheeks) Saltine – chew with front teeth, try to swallow – observe lips – lips pursed up, food too far forward Take small bite and eat normally observe what tongue, teeth, cheek doing, where swallowed. – tip of tongue moved to back molar, side of cheek and tongue on top of teeth, swallowed from back corner of mouth Cheerio – put on molars and bite down to see how it shatters, put under tongue doesn’t melt. Put flat on tongue use tongue to stand it up on back molars Puff – do same, collapses and dissolves Cheeto – collapses and dissolves Twizzler – activate transverse tongue reflex and then move tongue to opposite cheek as far as you can, helps move gag reflex back.

Meltable Solids vs. Hard Mechanicals Dissolves Shatters Towne Crackers Cheerios Graham Crackers Pretzel Sticks Thawing pancakes Saltine Crackers Snap Pea Crisps Hard Cookies Cheetos Fritos

Hard Munchables: Stick Shaped Move the child’s gag reflex back Allow practice with lateral movements Jaw strengthening Kinesthetic awareness in the mouth, make cognitive map of mouth boundaries. Change very little in the mouth, to help prepare for foods that do change Hard Munchables (8 months) – just for exploring only – jicama, carrot stick, dried papaya, frozen pancake, lolipop Meltable Hard Solid (9 months) – cheeto, towne cracker, thawing pancake Soft cubes (10 months) – avocado, soup ingredients, banana, fruit bread Soft Mechanicals single textures (11 months) soft lunch meats, pastas, cooked egges, white bread no crust Soft mechanical mixed textures (12 months) macaroni and cheese, fish sticks Hard Mechanicals – simple (16-18 months) cheerios, saltines, steak, fruit leathers HOW CHILD MANAGES FOOD CAN TELL YOU WHERE CHILD IS DEVELOPMENTALLY AND HOW LONG THERAPY MAY TAKE DON’T NEED MOLARS TO CHEW IF STRENGTH IS GOOD ENOUGH AND HAVE GOOD PLACEMENT BUT MOLARS HELP

Strategies and Suggestions for Working with a Picky Eater Sequential Oral Sensory Protocol by Kay Toomey, PhD Tolerates Interacts with Smells Touch Tastes Eats It’s hard to be neat when you’re learning to eat!

This is a 32 step list, however for ASD the steps increase to 40-50…it will be a slow process but progress will happen! However, children with ASD will often re-enter at the same step! Important to embrace the SMALL steps!

Strategies to Try at Home! 1. Create a Meal/Snack Schedule No Grazing Offer at least one preferred food item at every meal and/or snack Provide only water between scheduled meals and snacks Most children under the age of 5 follow a meal-snack-meal-snack-meal schedule. If your child is consistently hungry at a specific time each day, change the schedule to accommodate a meal or snack during that time. Write/create a schedule that the child can understand: use a picture schedule if necessary and post the schedule in a visible location Use a timer to tell when the next meal or snacktime will begin Be sure the child knows how long the mealtime will last and use a timer to set the pace and length of the meal. Meals should last between 15-30 minutes and snacks between 10-15 minutes. If your child is a ‘grazer’ and you are trying to create a schedule, their appetite will need to adjust to feeling hungry at different times of the day and on average it will take 2 weeks to regain appetite conditioning

Strategies to Try at Home! 2. Think Oral Motor Skills Practice spitting out foods! Use Straws Use Mirrors Avoid surprise foods such as salads and scatter foods (i.e. rice) This is an essential skill for a child to feel safe with trying new foods! Make this into a fun game and you will be surprised what children will put into their mouth! Over-exaggerate the correct motor movements Straws! help to provide proprioception through the oral motor muscles- use them before, during, and after mealtimes Put a mirror in front of the child during mealtimes; this can help provide an increased sense of body awareness

Strategies to Try at Home! 3. Play Mess Cookie Cutters Pretend foods, cook Color pictures Use foods to make a picture, Let children experiment with foods through stirring, squashing, smelling, or pouring. Let children make a mess with food; encourage any kind of interaction with the food. Use cookie cutters to cut food into different shapes Use pretend food to feed stuffed animals or dolls. Play restaurant or go on a pretend picnic. Color pictures of food or use food to color, such as using a pretzel rod and melted cheese to color a mouse or frosting to color snow. Use foods to make a picture, such as a person (i.e cookies for eyes; licorice for hair; M&M nose; jelly bean ears; pretzel rod legs) Encourage children to open lids of containers and packages of foods. Let them help grab foods out of the refrigerator. Talk about the properties of the food before you begin handling or tasting it. Cook meals with children Let children experiment with foods through stirring, squashing, smelling, or pouring. Allow the use of non-latex gloves, utensils, or paintbrushes

Strategies to Try at Home! 4. Family Use Positive reinforcement Don’t Copy negative reactions to food Create a food chart Kids can assist with shopping Make mealtime fun! Reinforce ANY interaction with food! Don’t short order cook: if the child does not eat the meal that is prepared, end the meal and offer a meal or snack again after two or three hours. If you are concerned about nutrition, consult a dietician and pediatrician. Use age-appropriate sized plate and utensils and appropriate portion sizes. A good general rule is to use one tablespoon of each type of food for each year of the child’s age. However for a non-preferred food, it is better to start with a smaller portion amount so that the child can see progress and feel successful. Create Food Logs- and remember small accomplishments are important! Use positive and not negative reinforcement! Negative reinforcement (i.e “eat this or you can’t get down”) will not have long lasting effects. Positive reinforcement takes longer but will have longer lasting results as intrinsic motivation towards eating is created! Don’t copy negative reactions to foods. Discuss the food properties and provide a positive reaction. Create a food chart to categorize food properties with descriptors such as: crunchy, soft, wet, flaky, smooth, slimy, tough, rough, bumpy, squishy, tart, and sweet. Designate a certain meal each day and have each family member/ child in class participate. Have children assist with grocery shopping, including finding objects and placing them into the cart. Make mealtime fun and not stressful! Stress releases adrenalin, which is an appetite suppressant! If the child is coming to the table feeling stressed they will NOT feel hungry! GIVE CONCRETE SIMPLE FEW SUGGESTIONS (because parents are nervous and stressed and therefore cognition drops down a level and are in concrete operational) write down all recommendations, draw pictures, use “body based” teaching experiences Buy a plain placemat to help create cue of eating space Seating Recommendations: Use a no skid mat under the child’s rear end Everyone needs a food rest Use lateral side supports if needed The tray/table surface should fall between the child’s belly button and breast level. Child is forward enough that their knees are over the edge of the seat of the chair. FOOD IS THE FOCUS – child is not the focus of the meal Imitate young child is highly motivating Learning plate – take time to talk, look, comes from, flavor, texture, poke at it, keep cognitive doors open. Beginning set up – warning, transition activity – wash hands push stool to sink for proprioceptive input, Middle – serve family style, eat, empty plate on child’s plate, child serves self and passes it on (starting on hierarchy with interacting) End – clean up – throw/blow (kiss it goodbye, blow off hand, spit out) one piece of each food into trash provides clear ending, concrete, increases interaction can test if they are really hungry or not, could get in more calories. , dishes to sink, wash hands (AWAY FROM TABLE, MAYBE MAKE ENJOYABLE WITH PLAYING IN WATER INSTEAD OF AT TABLE WITH WASH CLOTH WEAR CHILD DISLIKES IT AND RELATES IT TO MEAL TIME) HELP FAMILIES RECOGNIZE SKILL LEVEL AND MATCH FOODS TO THIS LEVEL

Food Jags What are they and how to avoid? Eats the same food prepared the same way every day or at every meal! Children will eventually get burned out on these foods and they are typically permanently lost out of that child’s food range.

Prevention Small Changes Offer food ONLY every OTHER Day Change the shape, color, taste, texture JUST noticeable difference Goal is 30 different foods Child has to use their sensory brain every time they sit down to eat Tolerates changes in order of shape, color, taste, texture 30 foods – to eat starch, protein, veggie/fruit at every meal 5 meals a day for 2 days Pick 1 food to start changing a little – but not food with most nutritional value. Let them change the shape of the food – cookie cutter, recognize preferred food in diff. shape, add seasoning, powdered jello, gravy mix, add texture changes.

Cues to Eating People Utensils Room Furniture Food Time Learn in different situations, environment cues become conditioning cue complex to eating Cues become part of the food – how they recognize preferred foods – this is why children may eat a particular food in one environment but then not in another- they associate eating that food with each of the specific cues within the environment Changing Conditioning Cue Complex slowly will help kids eat in all environments EX) change seating placement at table, can be good first step to change non-feeding environment People – number of people, who is present Utensils – dishes, cups, silverware, placemats, table cloth, containers Room – location in home, school, décor, view from chair, type of lighting in the room Furniture – arrangement, location of child’s seat, and other’s at table Food – texture, consistency, color, temperature, size, shape, type, odor Time – day, night, noon

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