Isaac’s parents were at their wits’ end. Isaac, age 4, who had autism and sensory processing challenges, had reduced his repertoire of acceptable foods to 5 things: potatoes, french fries (but only a specific brand), chips, milk and juice boxes.
One year old James was gagging on any food that wasn’t a smooth puree. The repetitive gagging was making mealtimes uncomfortable for him and sometimes, the gags would cause him to vomit. His mother had been feeding him away from the rest of the family, so as not to “gross out” her husband and kids. They rarely had family dinners together.
Elizabeth’s parents were referred by their pediatrician. Elizabeth, now in 3rd grade, refused to eat anything at school. She came home famished, irritable and insisted on going to one specific fast food restaurant, where she “ate like a horse”. While she maintained her growth curve for height and weight, her grades were dropping at school due to poor nutritional intake.
Mark, eager to make friends in high school, wanted to learn to eat more than the limited foods he ate at home: raw vegetables, tepid bacon, crackers and apples. His mother never thought it was a problem, since she knew lots of kids were “picky” and he ate vegetables after all! Mark could only tolerate crunchy foods in his mouth and the one food that always appeared at friend’s home and after-school functions was hot, soft, gooey pizza. “Pizza is everywhere in high school” he told his parents.
No 2 kids are alike in feeding therapy, but parents often have the same questions about the therapy process. As a pediatric feeding therapist treating babies to teens, here are the top 9 questions I encounter most often:
• Why feeding therapy? As illustrated by the examples above, there are a multitude of reasons that parents bring their children to feeding therapy. Feeding is a developmental process where children progress through various stages of oral motor skills to learn to chew, swallow and enjoy a wide variety of foods. Whenever children stall in that progression for more than 6 weeks or when it is impacting nutritional status and/or growth, a feeding assessment is warranted.
• What is addressed in treatment? When I evaluate a child for the first time, I must consider 3 major factors that influence our ability to enjoy food: First, physiology (which includes sensory processing); Second, gross and fine motor skill development and third, the child’s behavior and family dynamics. My role is to observe and identify behaviors that kids learn to do in order to feel safe around food. In my experience, it’s very rare for a child’s feeding difficulties to be strictly “behavioral.” Turning away from the spoon, spitting, throwing food or even increased anxiety in the presence of new foods may be observed as a response to poor physiology or difficulty processing sensory input and/or inadequate motor skills. For example, a child with consistent gastrointestinal discomfort quickly learns that eating creates pain. Although the pain may be alleviated with medication, the learned behavior (e.g. fussing or refusing to sit for meals) still needs to be addressed. My job is to help the child’s anxiety decrease as confidence increases and slowly, improve the ability to tolerate new foods over time. Last but not least, a feeding therapist must always consider parenting styles and family dynamics. A child’s relationship with food always influences the family’s relationship with food and can alter family dynamics in a very unhealthy manner.
• How long will it take? Every child in feeding therapy presents with unique challenges. Length of therapy is dependent on how early in life intervention begins and the degree of medical, sensory and behavioral needs. Once I have assessed and treated the child for 2 to 3 sessions, I have a reasonable idea of all the factors that come into play. In my experience, therapy is most effective when conducted 2X a week, but 1X per week for 50 to 60 minute sessions is typical. Many kids are in feeding therapy for at least one year.
• My kid already had feeding therapy and it didn’t work – how will this be different? Please, try again, keeping in mind that perhaps a different method of treatment is a better fit for your family. I always stress to the therapists that I teach in seminars that no two kids are alike and a cookie-cutter approach to feeding therapy only works if, well, you are making cookies. The best therapists are the ones that see the bigger picture and ask: “What approach is best for this child and just as importantly, this family?”
• Can’t you just get him to eat a vegetable? Often, this is where parents want to start and end treatment: “If you can get him to eat broccoli, that’s good enough!” My job is to break each step in this complicated journey to healthy eating into tiny, manageable tasks that build success over time and yes, lead to healthy, nutritious eating. But, if my new client won’t sit at the table for mealtimes or cannot tolerate the smell of broccoli (and gags and vomits), then I have quite a bit of preliminary work to do before a child will chew and swallow broccoli. He’ll get there, with time, but I always urge parents to remember that the later feeding therapy starts, the more “unlearning” that we have to do. First, we have to unlearn the behavior of running from the table, of gagging or vomiting due to sensory overload or because gagging is now a conditioned response to pressure to eat. And, we can’t just focus on one food, assuming that others will follow. It’s more likely that the child will quickly get bored of the new vegetable and once again, refuse to eat it, unless we help him to learn to taste a variety of new foods on a regular basis.
• He eats fine at school – but at home, he won’t eat what I cook. Is it my cooking? Feeding therapists consider all environments, examine why certain settings are successful and others are not. One advantage I have as a home and community based therapist is that feeding therapy can occur anywhere. A typical week for me includes visiting school cafeterias and restaurants, as well as family dinners in the home. It’s unlikely it’s your cooking and more likely it’s a conditioned response to the environment plus a child’s expectations of what is acceptable at home vs. school. A feeding therapist doesn’t just focus on food. Creating positive family dynamics and generalizing skills to other food environments are an important factor in treatment.
• Can’t you just tell me what to do? The best I can do is give general advice when a parent writes or calls me, asking for help, but does not want to begin treatment one-on-one. A mechanic can offer general tips on how to keep your car engine running smoothly. But, just like a mechanic needs to listen to the engine when it’s not operating effectively, I need to observe your child and family’s unique relationship with food, take a close look at medical and developmental history and then devise a plan specific to your child and family ‘s needs. Even then, it takes a professional to tweak the process on a weekly basis and work with the entire family.
• My pediatrician says my child is following a steady growth curve and will grow out of the picky eating – is that true? While it might feel reassuring that he’s getting enough calories to grow, is his brain and organs getting enough nutrition to be healthy and function properly? Yes, kids typically go through a picky stage in the toddler years, but many do not grow out of it. Seeking support early on, even if for a short time to ensure that family mealtimes do not become family battlegrounds, is time well spent. It’s much more difficult to “unlearn” years of picky eating habits later in life. And, if it’s causing stress for anyone in the family, it’s worth addressing.