Professional Documents
Culture Documents
Feeding Therapy
Feeding Therapy
NJOTA Conference
October 23, 2010
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
Literature Review
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
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
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
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
Evaluation
To Gag or Not to Gag
Evaluation of Feeding Difficulties
Citations: 6, 21
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
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)
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
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
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
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
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
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
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
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
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
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
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
What do you think?
Oral Motor or Sensory?
Now what do you think?
Oral Motor or Sensory?
Is This Behavior or Not?
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
Treatment
Treatment Considerations
Desensitization
Behavioral
Ayres Sensory Integration®
Sensory-Motor
Medication
Group Treatment
Parent Education
Desensitization
Sensory Desensitization
Body Functions
Tactile
Oral
Hierarchical Desensitization to Food
Chaining
Pairing
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)
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
Hierarchical Desensitization to Food
Eat Foods
Taste
Foods
Touch Foods
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
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)
Food Chaining
Reinforcement
Positive
Negative
Punishment
Escape prevention
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
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
Examples of Positive Reinforcement
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
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
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”
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
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”
What Types of Reinforcement Are
Being Used?
Ayres Sensory Integration (ASI®)
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
Parent Education/Participation
7. Bekem, O., Buyukgebiz, B., Aydin, A., Ozturk, Y., Tasci, C., Arslan, N., &
Durak, H. (2005). Prokinetic agents in children with poor appetite. Acta
Gastro Enterologica Belgica, 68, 416-418.
8. Berger-Gross, P., Coletti, D. J., Hirschkorn, K., Terranova, E., & Simpser, E.
F. (2004). The effectiveness of risperidone in the treatment of three children
with feeding disorders. Journal of Child and Adolescent
Psychopharmacology, 14(4), 621-627.
9. Berlin, K. S., Davies, W. H., Silverman, A. H., & Rudolph, C. D. (2009).
Assessing family-based feeding strategies, strengths, and mealtime structure
with the Feeding Strategies Questionnaire. Journal of Pediatric Psychology,
1-10.
10. Berlin, K. S., Davies, W. H., Silverman, A. H., Woods, D. W., Fischer, E. A.,
Rudolph, C. D. (2010). Assessing children’s mealtime problems with the
Mealtime Behavior Questionnaire. Children’s Health Care, 39(2), 142-156.
11. Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Sawyer, R., &
Johnson, S. L. (2001). Confirmatory factor analysis of the Child Feeding
Questionnaire: a measure of parental attitudes, beliefs, and practices about
child feeding and obesity proneness. Appetite, 36, 201-210.
12. Blissett, J. & Harris, G. (2002). A behavioural intervention in a child with
feeding problems. Journal of Human Nutrition and Dietetics, 15, 255-260.
Reference List
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Reference List
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