No more tears at tea time: An occupational therapy approach to feeding difficulties

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1 Child Early Intervention Medical Centre Occupational Therapy Department Presents No more tears at tea time: An occupational therapy approach to feeding difficulties Presented by: Jennifer Logan Occupational Therapist

2 What is Occupational Therapy? Occupational Therapy is a goal based approach to assisting people complete the tasks required in their everyday lives. Occupational Therapists use fun activities to help our clients achieve their goals in their daily lives.

3 What areas does Occupational Therapy cover at CEIMC & CLEMC? Fine motor skills Gross motor skills Visual motor skills Sensory processing skills School readiness skills Self care skills

4 Feeding Skills Eating and drinking is a very complex process. Structural anatomy of the mouth Oral Motor Skills Suck swallow breathe mechanism Sensory processing Behaviour

5 Feeding Problems Insufficient food intake Food refusal Fussiness for type or texture of food Inadequate caloric intake Skill Deficits Chewing, sucking and swallowing coordination Self - feeding

6 Feeding Problems Continued Disruptive Behaviours Crying Spitting out food Pushing away food Knocking food off plate or table Leaving seat Aggressive behaviours towards others Self injurious behaviours (Ahearn, 2001)

7 Incidence of Feeding Problems Children with diagnoses of developmental disabilities frequently have feeding difficulties. Studies have estimated up to 30% of children with autism spectrum have difficulties with feeding. (Ahearn, Castine, Nault & Green, 2001; Archer, Resenbaum & Steiner, 1991)

8 Physiological and Biological Causes Present and past medical conditions History of surgical procedures particularly any involving nasal - gastric feeding or PEG feeding Allergies and food sensitivities Gastro intestinal reflux Metabolic disorders Constipation Upper respiratory infections Structural or muscular abnormalities Motor planning disorders Sensory processing disorders Dental health issues Prematurity

9 Environmental Causes Lack access to variety of textures, foods or food temperatures Inappropriate size or shape of feeding utensils Chair and table inappropriate size Emotionally or anxiety charged environments Excessive distractions

10 Behaviour Typical development: Child need many exposures to a new food before accepting it into their diet Young children often prefer to have a narrow diet Frequently see food refusal behaviours: - turning head - pushing away food - throwing food - spitting out food

11 How picky is too picky? Typically when a child is failing to thrive medical intervention becomes involved When to seek intervention for the child? If the child is having insufficient food intake to maintain growth and health If the child is unable to participate in typical meal time situations in the family home or school environments If the child is unable to participate in social meal time functions such as a Birthday Party

12 Multidisciplinary Team-Based Approach Paediatrician Speech Therapist Occupational Therapist ABA Therapist Case Management Teachers Parents and Carers

13 Motor Planning This is a complex planning task, it is the ability to plan, think and problem solve around motor tasks. Children who have difficulties with motor planning require additional support to learn new tasks as almost all tasks have a motor control aspect, including gross motor, fine motor, oral motor and visual motor skills. Meal time Impact: Opening containers Completing hand to mouth movement with utensils Lip closure Coordination of jaw to chew foods Control of tongue Saliva management Coordination of suck swallow and breathe patterns

14 Representation in primary sensory Cortex (Lundy-Eckman, 1998)

15 Suck Swallow Breathe Synchrony This is a complex automatic movement pattern typically present at birth to ensure survival. A normal swallow requires the coordination of cranial nerves and up to 26 muscles. Inability to control this area can contribute to Gagging or chocking during snacks and meals Poor saliva management Oral health issues Upper respiratory infections Difficulty regulating autonomic nervous system responses Difficulty with postural development.

16 Sensory Processing There are 7 common senses that we rely on to interact with our environment effectively. Sight / Vision Hearing / Auditory Taste/ Gustatory Smell / Olfactory Touch / Tactile Proprioception Vestibular

17 Sensory Processing Sensory processing in the mouth can have a significant impact on meal times. Hyper and hypo sensitivity can impact food choice and food tolerance. Textures Temperatures Tastes Size of bite Squirreling food in mouth

18 Taste / Gustatory Our sense of taste is a survival mechanism to ensure we avoid dangerous foods and helps us identify suitable foods to provide our daily caloric needs. Meal time impact: Child may show excessive seeking of a particular taste Child may incorrectly sense that a food is noxious resulting in food refusal

19 Tactile We are all constantly receiving tactile inputs to the touch receptors located in our skin, our hair, our nails by our clothes and accessories that constantly touch us. This allows us to interact with our world, helping us to identify the objects and surfaces we are in contact with. A child can be overly sensitive to touch or can seek out touch excessively. Meal time impact: Over selectivity in foods. Refusal to eat different brands of the same food Gagging response to undesired textures Swallowing food prior to effectively chewing Mouthing non-food objects Difficulties brushing teeth

20 Proprioception The proprioceptive system is part of the central nervous system which receives and processes information from muscles, joints and ligaments. Meal time impact: Child may have difficulty with: Location and movement of food in mouth Force and intensity required to chew foods Ability to stabilise jaw (at the tempro-mandibular joint) Saliva management Obtaining and controlling food during self feeding

21 Vestibular The vestibular system is located in the inner ear and is activated by movement or by changing head position. This system is responsible for balance skills and impacts on our overall level of alertness Impacts on meal times: Child may be always on the go Child may be excessively lethargic Move n sit cushion is helpful for use in the classroom for children who need to move to keep their attention levels up.

22 When to recommend intervention? If the child: Coughs during meal times Gags during meal times Shows extremely strong taste preferences Shows extremely strong textural preferences If the child is unable to eat the typical family diet If the child is unable to meet their nutritional needs on their existing diet Oral defensiveness must be treated to ensure the success of any other interventions

23 What can be done in the classroom? 15 minutes prior to snacks and meal times provide access to oral motor input and proprioceptive input. Sensory Diet Sensory Tool Kit Provide adequate seated support for children with poor postural support

24 Sensory Diet A sensory diet is recommended for all children to ensure they are meeting their sensory needs on a daily basis. This will help ensure children are not missing out on learning experiences due to avoidance of specific sensory modalities. The sensory diet also helps ensure that the child is able to receive the sensory inputs they are seeking in a safe, effective manner. A sensory diet should be implemented throughout the day at home, in the clinic, at school and in the community. This will help to ensure the child s sensory needs are met enabling the child to participate more effectively in a variety of learning experiences.

25 Sensory Diet Example Proprioception 1/09/10 2/09/10 3/09/10 4/09/10 5/09/10 Carry heavy items (e.g. books) Holding up the wall Jumping with a rope Hanging from a trapeze bar Climbing equipment Roll into a ball and rock Blow into home made silly putty Observations

26 Fiddle toys Oral motor toys Sensory Tool Box

27 Recommended resources Recommended Reading: The Out of Sync Child by Carol Stock Kranowitz The Out of Sync Child has fun by Carol Stock Kranowitz Picky Eating Solutions by Betsy Hicks Deceptively Delicious by Jessica Seinfeld Making a Difference: Behavioral Intervention for Autism. Maurice, Fozz & Green. Recommended Resource Suppliers:

28 Questions Do you have any questions?

29 How to contact the Occupational Therapy Department Jennifer Logan Occupational Therapist CEIMC: CLEMC: