Posts made in March 2011

Feeding Issues and Sensory-Motor and Emotional Development

Tommy is 4-years old and he won’t eat.  He can eat.  He can swallow.  He can chew. He just refuses. It is difficult at home during mealtimes, and it is impossible to go to restaurants.

Sound familiar?  If it does, read on.

Children with feeding issues often present with a complex array of issues that impact the entire developmental scheme. It involves physical, emotional, sensory, social and cognitive skills.

In many cases, by the time the child enters therapy, the problem has been on going for many years.  Therapy often requires an intensive multi-disciplinary approach in order to accomplish long-term goals and long lasting changes.

Before treatment begins with occupational and speech therapists, it is essential to rule out any associated medical problems such as reflux, slow stomach emptying, constipation, respiratory or cardiac issues, etc.

Left untreated feeding issues can have far reaching impacts on the child well into adulthood, giving rise to physical, mental and behavioral concerns.

Eating is basically a suck-swallow-breathe pattern that is repeated over and over.  Most children learn this automatically, but for some it must be taught.  For this a speech therapist is often engaged to treat this along with any other oral motor associated concerns.

Behavioral issues with feeding are sometimes referred to as “conditioned dysphagia”.  Conditioned dysphagia is a learned disorder that holds onto a “habit” long after the physiological need for such a behavior has ceased to be needed.

All feeding programs should have as its primary and most important goal nutrition.

Justine Joan Sheppard, SLP from Columbia University suggests that mealtime be the place to present the child with foods that they are already successful with instead of unfamiliar new experiences.  However Heather K. Adams, in an article from the North Dakota Newspaper suggests a compromise.  Have the child’s preferred foods, but then have a “tasting spot” at the table with new foods. The child can then try small tastes, does not have to have them on his/her plate but has had the opportunity to sample something new.  The child should not be pressured, and should be allowed to reject a food after a small taste has been made.

The Kennedy Kreiger Institute has a program for children with food aversions that focus on weight gain, food by mouth intake, mealtime appropriate behaviors and self-feeding abilities.  Their multi-disciplinary program is part of a continual assessment and re-assessment of measurable goals that both the child and the family can work on together.

Irene Chatoor of the Children’s National Medical Center specifically notes these issues as “Sensory Food Aversions”.  She states that children have aversions to particular tastes, smells, textures, and temperatures of foods.  She goes on to state that these children often have other sensory issues as well.

There is a difference between “picky eaters” and children with real food aversions.  In an article by Dovey, Staples, Halford and Gibson (2007), “picky eaters” are defined as children who “consume an inadequate variety of foods through rejection of substantial amounts of foods that are familiar (and/or unfamiliar) to them.  “Food neophobia” on the other hand is the avoidance of new foods.  While the “picky eater” and the “food neophobic” are related, but have theoretical and behavioral differences.  These authors saw that “Food Neophobia” was part of picky/fussy eating but without many of the associated behaviors.

Within these (above) categories are the “selective eater” who will only eat certain foods, and the “choosy eaters” who generally show a disinterest in eating.  Sensory food aversions generally appear about age three when children are being transitioned to self-feeding.  At this age children are expected to become more autonomous and less dependent. This transition for some children maybe more traumatic and therefore food issues sometimes arise.

In order to successfully address these concerns it is imperative to distinguish between children with minor food aversions and those with more serious concerns where their reluctance to eat can evolve into serious eating problems.

Treatment generally follows a basic three-step system:

  1. Acquisition—the child learns a new behavior relating to food i.e., chewing, orienting to food, etc.
  2. Fluency –the child practices the behavior to become faster at it and for it to be automatic
  3. Generalization—the child utilizes the learned behavior with different items in different settings.

Imbedded into these steps is the reinforcement of appropriate mealtime behaviors and the extinguishing of non-appropriate ones.  This can include a reward system where an activity is offered that the child would not have access to otherwise, etc.

  • So if your child only eats burgers and pizza, try some of these suggestions:**
    Introduce a grilled cheese sandwich
  • Let them use their fingers—try introducing edamame!! (full of protein!)
  • If texture is a problem puree foods to start and slowly increase the consistency
  • Use toast as it has texture and cannot easily be lost as a bolus in their mouths
  • Use dips—toast into tomato soup for example
  • Disguise protein as a dip—put it in familiar sauces and mix it in your food processor
  • Tempt them with foods they love and let them know that you want a meal the whole family can love
  • Serve veggies with ketchup—green beans can become “green fries” with ketchup
  • Teach fine motor skills with “chop sticks” using pealed carrot sticks instead of the wooden ones—if they bite down they get some nourishment instead of splinters!!
  • Gross-em-OUT—works great for some little boys—one mother reports that her son wouldn’t eat beans until she told him they made him fart!!
  • Create a “Tasting Spot” with the rule that the picky eater has to at least try a little; if they like it they can finish it, if not they can leave it.

**from various Internet sources

And remember

  • DO NOT get into power plays this is NOT about the caregiver it is about Nutrition
  • Children use food in many cases as a stress “reactor” so adding stress is counter-productive
  • Food aversions are often associated with co-existing diagnoses such as Autism, Depression, reactions to life situations, etc.
  • The goal of diet therapy is to gradually increase in-take
  • Progress is slow
  • There are often set backs
  • Eating is a major social event –it is “family time” and not being able to participate may impact the child’s self-esteem

Occupational therapy with its extensive training and research into the area of sensory integration, and speech therapy with its focus on oral motor development are ideal interventions to help the child address these sensory concerns as well as helping the family construct a positive home program.

And lastly, avoid labeling.  If asked, simply respond “Tommy is not eating now, but he is trying and we are working on it with him.”  Things are so much easier when done with an understanding friend.  And a child’s best friend is often found in the family.

Susan N. Schriber Orloff, OTR/L, is the author of the book Learning RE-Enabled, a guide for parents, teachers, and therapists (and a National Education Association featured book), and the Handwriting on the Wall Program. Children’s Special Services, LLC is the exclusive provider of P.O.P.tm Personal Options and Preferences, tm social skills programs. She was the 2006 Georgia OT of the Year and the CEO/executive director of Children’s Special Services, LLC, which provides occupational therapy services for children with developmental and learning delays in Atlanta. She can be reached through her Web site at www.childrens-services.com or at susanorloff@childrens-services.com.

Quirky Kids: Sensory Driven–what makes the TICK what makes them TICKED

The story of two children:

Johnny:

Five-year old Johnny is a mess. His teachers float between anger and frustration about him.  He has few friends and those he makes he cannot keep.  His parents walk on eggshells around him never knowing how he will react in a given situation.  And even worse, he talks about not liking himself and how he hates “everyone”.

In school he can be great, but then the fire alarm can go off and he is a “lost cause” for the rest of the day. Unable to “reset” himself, he stays “on guard” and anxious.  He does not like to stand in line to go to lunch because he says that the other kids “hit him”.  On the playground he is a “wild-man” running with abandon bumping into people and things and barely noticing. His gait is awkward and he cannot reasonably participate in team sports. He habituates wearing the same clothes so Mom has several of the same outfits ready for him each day.  He does not eat in school because the smells in the lunchroom “make him sick”.

Brent:

Brent is 6 years old.  He is smart, both his parents and his teachers agree on that.  At home he is interactive and plays well with his older brother Max aged 8.  Mostly he plays with Max’s friends and they generally include him.

At school the children are friendly to him, but he rarely gets invited for play dates, and during recess he seems to be a loner or randomly hangs with the same 1-2 classmates.

While he is not the athletic “star” he is not the worst either, but he is at the lower end of physical performances.  Academically bright, he nonetheless is very forgetful and turning in homework is a problem.

He insists on wearing long sleeves even in the summer and will not go into the water at the beach without a full body suit or at minimum a long sleeve t-shirt.

Although congenial and generally obedient, he does seem to be always in a “fog” needing guidance and redirection.

What is going on with these children? Are they lazy? Defiant? Uncaring?  The answer is most probably an unequivocal NO.

Both Brent and Johnny are having processing issues.  Obviously Johnny is much more overtly involved than Brent, but both are displaying developmental “red flags”.

Taking a sensory processing view of these behaviors, several issues come clear. Breaking observed behaviors into auditory, visual, tactile, movement, body awareness (muscle/bone/joint), olfactory/taste, and emotional categories it is easy to see the patterns of a skewed sensory processing impacting all of the above areas.

Johnny needs sensory “calming” while Brent needs sensory stimulation.  Both are having sensory processing issues but at opposite extremes.  Johnny needs to learn how to slow it down, and Brent needs to learn how to be more fluid. 

Brent needs to learn to be more assertive and to learn to try new things.  Johnny needs to learn how to be more discriminating and make better activity and behavioral choices.  Brent is probably harder to identify than the “squeaky wheel” Johnny. But clearly they both need help developing skill sets that are more in line with their life demands.

So how do we know when to seek outside help, and when to not? Although there are many developmental checklists online, I caution readers to use them sparingly and in conjunction with input from an occupational therapist or other related professional. One concern does not make an “issue”.  However, there are some questions you can ask yourself as a guide to whether or not you should look deeper.

You may want to ask:

Does your child_____________

  • Seem to need more “protection” than other children
  • Excessively fidgets or appears “on the go” most of the time
  • Seem to be unusually forgetful
  • School is a struggle
  • Refuse certain foods
  • Reject certain textures in clothing and/or habituates wearing the same clothes over and over
  • Motor skills are intimidating
  • Resist combing his hair/getting it cut
  • Seem to have “weak” muscles; tires easily
  • Has a difficult time calming down when upset
  • Has difficulty accepting criticisms
  • Social issues dominate school concerns
  • Doesn’t want to go to school
  • Depression* (*anger, “show off,” hypochondria, bossy behaviors, to name a few)

If your “quirky” kid has a reasonable number of friends, gets good grades, is generally an easy member of the family, has age-appropriate interests, is able to transition and go with flow, etc., then just love his quirks.

If however, any of the above-mentioned items are a concern to you, then I suggest you

consider consulting a developmental pediatrician.  They usually provide a lot of much needed answers. It is important to note that there is a huge difference between a developmental pediatrician and a general pediatrician.  The one most families go to is trained to look at developmental milestones, wellness and the absence of illness. The developmental pediatrician looks at neurological, emotional, physical and motor/cognitive development.  They look at the “nitty-gritty” of development and can discern if there are ambiguities that need to be addressed. They are one-stop shopping in the discovery process of how and why your child is performing the way he/she is.

To quote Mel Levine, MD author of “One Mind at a Time”; “Children do not outgrow anything but their clothes.”  So do not wait for your child to “grow out of it” or to “mature”.  Specific issues evolve but they do not go away, and research clearly supports the benefits of early intervention.

Sensory Interventions with the Autistic Child

Many of the characteristics of a child with autism also mirror those of a child with sensory processing disorder.  Autism as a sensory issue is very tricky, so many things over lap and intertwine. The classic indicators seem to almost be the same. However, it is important to differentiate between the two. The following lists help to illustrate the similarities and the differences between the two conditions.

Sensory Integrative issues may be characterized by:*

  1. Either be in constant motion or fatigue easily or go back and forth between the two.
  2. Withdraws when being touched.
  3. Refuse to eat certain foods because of how the foods feel when chewed.
  4. Be oversensitive to odors.
  5. Be hypersensitive to certain fabrics and only wear clothes that are soft or those they find pleasing.
  6. Dislikes getting his or her hands dirty.
  7. Is uncomfortable with some movements, such as swinging, sliding, or going down ramps or other inclines. Your young child may have trouble learning to climb, go down stairs, or ride an escalator.
  8. Have difficulty calming him or her after exercise or after becoming upset.
  9. Jumps, swings, spins excessively.
  10. Appears clumsy, trips easily, poor balance; odd posture
  11. Social skill issues/authority issues.
  12. Tantrums
  13. Overly sensitive to criticism
  14. Either always on the go or very sedentary
  15. Memory difficulties and/or problems following directions
  16. Has difficulty with buttons or snaps.
  17. Is overly sensitive to sound. Vacuum cleaners, lawn mowers, leaf blowers, or sirens, etc.
  18. Lacks creativity/variety in play; plays with the same toys in the same manner over and over etc.

While Autism and or PDD issues may be characterized by:

  1. Insistence on sameness; resistance to change
  2. Difficulty in expressing needs; uses gestures or pointing instead of words
  3. Repeating words or phrases in place of normal, responsive language
  4. Laughing, crying, showing distress for reasons not apparent to others
  5. Prefers to be alone; aloof manner
  6. Tantrums
  7. Difficulty interacting with others
  8. May not want to cuddle or be cuddled
  9. Little or no eye contact
  10. Unresponsive to normal teaching methods
  11. Sustained odd play
  12. Spins objects
  13. Inappropriate attachments to objects
  14. Apparent over-sensitivity or under-sensitivity to pain
  15. No fear of danger
  16. Noticeable physical over-activity or extreme under-activity
  17. Uneven gross/fine motor skills
  18. Not responsive to verbal cues; acts as if deaf although hearing tests in normal range.

(*complied from various sources)

Not every child on the spectrum will exhibit all of these issues.  However there will be areas of relatedness and it is in these similarities an understanding of unique interventions can be found.

For example let’s look at “Patrick”:

              Five-year old Patrick is always on the ‘go’. His teachers do not know what to do about him.  He has few friends and those he makes he cannot keep.  He cannot sit in circle time. Lining up to go out to recess is unpredictable.  And even worse, he talks about not liking himself and how he hates everyone and “everyone” hates him.

           He has his favorite toys and his favorite clothes and that is what he plays with and wears,  with little to no deviation.

          School is a challenge. He seems to either escalate or get so lethargic that he cannot move. He seems unable to “reset” himself, he stays “on guard” and anxious.  He does not like to go to PE or to lunch because he says that the other kids  “pick on him and hit him”.  On the playground he plays mainly with girls, and the boys seem to ignore him.  When he runs he does so with abandon bumping into people and things and barely noticing. His gait is awkward and when he runs his arms are up and sometimes he runs on his tip toes. He does not seem to respond to facial expressions or to be able to register empathy for others. He complains that things “hurt” him even when there is no evidence of that.

         Making eye contact and following a slow moving object is impossible for him without accompanied very cues. Hyper sensitive to smells, he complains about odors in art class, the lunchroom and on the school bus.

         Recall of academic information is difficult and varied repetition seems to be the best learning path at this time.

       Easily upset and emotionally labile, he seems uncomfortable in his own “skin”.

 Children on the spectrum often have pronounced sensory issues. To understand Johnny’s primary areas of concern, how therapy helps, and what can parents do at home, please refer to the following chart.

Presenting Issue Behavioral Manifestation Sensory Processing Concern Treatment Approach* Anticipated Outcomes
Auditory Concerns:

Easily startled by unexpected noises

Easily Distracted

Screams and yells and has temper tantrums Not hearing sounds with auditory figure ground discrimination or with sound/activity relationships

Attention floats and does not stay on topic

The Listening Program ™

Games that incorporate unexpected noises with the “warnings” of noises decreasing as tolerance increases

Increased noise tolerance

Increase attention to task with diminishing supports

Visual Concerns:

Does not seem to see objects in his immediate visual field

Bumps into people and things and falls a lot Visual figure ground and visual constancy issues

Does not use visual motor ideation to plan movements

Obstacle courses

Use of weight appropriate free weights during gross motor games to increase sense of body in space

Increased motor planning in familiar situations—translating this into less familiar tasks as tolerated
Movement:

Always on the go

Takes risks during play

Seeks movement

Does not know how to slow self down and he just builds momentum until outside forces slow him (teacher, etc.) Perseverative quality to his movements

Skewed motor planning

Depressed vestibular processing

Quick change activities where increasingly the sequence or order of things changes and he has to make movement, planning and/or postural adjustments Slow it down!  Have the child make a “plan” keep it to a maximum of 4 things—1stdo____

2nd , 3rd and 4th ___

stick to the plan and make choices for the next time

Tactile:

Habituates wearing the same clothes

Expresses discomfort when touched

Demonstrates exaggerated responses to touch

Tantrums if “right” clothes not available

Will not try to put on anything new even if pre-washed

Gets into fights when he is trying to make friends

Tactile defensive behaviors

This causes adverse emotional reactions both in school and home

Timed trials for adjusting to new fabrics: i.e. “you only have to wear this for 3 minutes” or only while you are brushing your teeth and increase time tolerances

Provide “expected” unexpected touch and rate with child the reactions

Increased ability to tolerate new fabrics and to try new pieces of clothing

Modulated reactions to touch

Olfactory/taste:

Smell in lunchroom, art class, etc. are noxious to him

Nutrition issues and he becomes lethargic in the afternoons due to lack of food and this impacts his school work Textures in mouth may be a negative trigger and over-sensitivity to smell is operating here Make a dinner “Tapas” bar where he gets to eat whatever he usually chooses but must also take a taste and intentionally smell a new food Increase repertoire of tolerated foods

Will eat in the lunchroom with support—first place him near the door and then slowly move him into the room

Emotional:

Easily upset

Difficult for him to self-regulate

Labile mood swings

Few friends

Hard for him to enter into group play

Uncomfortable with who he is

Unpredictable behaviors make it hard to anticipate his needs

Peers see him as “weird” so he is often not asked to play and when he asks he is often rejected

Isolated from others in classroom group time due to behaviors

Almost absent self-regulation skills

Chaotic responses not always fitting the circumstance

Social isolation

Organizational deficits

Make a game together where he is in charge of making the rules (but you are in charge of making it reasonable) and “rig” it so (gently) he is not always “winning”.  Warn him of this in advance and talk about reactions and choices make a “reaction box”©*** Use gross motor games to create simulated social and motor planning actions and activities and get him into a new comfort zone!

*Treatment Approaches are suggested ones there are many ways to address these issues

**The Listening Program ™–available commercially

***The “reaction box”—exclusive to Children’s Special Services, LLC  Get a heavy cardboard man’s shoe box; decorate it with paint, contact paper, etc. put in it on separate slips of paper good behavior choices ONLY. When he is upset let him pound on the box for a while and then he picks a choice out of the box and you help him achieve that “choice”.

So what do you treat first?  Everything! That is Occupational Therapy, changing the context in which one lives so that life can be lived with greater ease.