copyright 2008 ernsperger how to get your kids to eat dr. lori ernsperger 702-616-8717...

copyright 2008 Ernsperger

How to Get Your Kids to Eat

Dr. Lori Ernsperger

702-616-8717

[email protected]

mailto:[email protected]

http://schoolmeals.nal.usda.gov/cgi-bin/imagemap/pmap.map


Overview • Introduction to

Resistant Eaters– Prevalence– Characteristics

• Oral-Motor Development

• Environmental Factors contributing to Resistant Eaters

• Physical Factors Contributing to Resistant Eaters

• Introduction to the Treatment Plan– Environmental

Controls– Physical and Oral

Motor Activities– Stages to Sensory

Development

Tx= Treatment Strategies


5 Common Characteristics

• Eating Continuum• Characteristics

1.Limited Food selection2.Limited Food groups3.Anxiety around new foods4.Food Jags5.Diagnosed with a DD


Introduction to Resistant Eaters

• Prevalence– 75% of children on the

Autism Spectrum– 80% of children with severe

mental retardation– 30-45% of typically

developing children


Introduction to the Treatment Plan

• Goals for a comprehensive written plan– Create a safe and nurturing environment– Expand the child’s responsibilities for

preparing, eating, and cleaning up– Improve oral-motor development– Learn about new foods– Respect the child’s needs


Guidelines for Writing a Plan

• Start with you!

• Create a support network

• Take things slow

• Individualize the plan

• If mistakes are made- try again

• Have fun


Causation: Oral-Motor Skills

• Definition: Movements of the muscles in the mouth, lips, tongue, cheeks, and jaw.

• Includes the functions:biting, crunching, chewing, sucking, &licking


Causation: Oral Motor Skills

A child with poor oral-motor skills may demonstrate delays in:

• Development of motor skills (low muscle tone, poor postural control, poor bilateral coordination, poor eye-hand coordination)

• Speech and language development (facial expressions, breath control, voice volume)

• Paying attention and organizing own behavior (cannot calm self, struggles with transitions, inflexible)


Causation: Oral Motor Skills

During feeding, poor oral-motor skills may lead to:• Gagging/frequent choking• Drooling• Difficulty keeping food down• Difficulty transitioning to different textured foods• Difficulty sucking, chewing, swallowing• Picky eating habits (avoiding textures, temp.,

tastes)


Tx: Oral Motor

• Oral awareness and oral stimulation

• Mouth Box

• Mouth Madness by Catherine Orr• “Can Do” Oral Motor Cards (www.superduperinc.com)

• Oral-Motor Activities for Young Children (www.linguisystems.com)

http://www.linguisystems.com/


Tx: Chewing Activities

• Dental Check– Sensitivity

– Gum disease

– Cavities


TX: Chewing Activities

Bolus Bag

Polyester

Organza

Different colors


Respiration and Eating

• You can’t eat if you can’t breathe

• Nasal cavity, trachea, lungs

• Breathing, swallowing, and talking

• Coordination

• Important when feeding a child- pace of the meal


Tx: Blowing Activities

• Bubble Blower• Birthday horns• Straws and cotton

balls• Practice deep

breathing


Oral Motor Skills

• Phases of Swallowing– Oral Phase- 2 parts– Pharyngeal phase- movement

of the bolus– Esophageal phase- to the

stomach

• Cracker Activity– Texture– Tongue Control– Placement


Case Study: Cody

• Age 5/ PDD• Rice Baby food with applesauce (Nov. 07)• Mom tried to “slip” some food into his baby food-

he refused to eat for 4 days• May 2008- considering a feeding tube• Summer 2008- intensive eating program in ESY-

implemented new techniques including oral-motor development and parental involvement

• August 2008- Eating pizza at the food court


Causation: Sensory Integration

• Dr. A Jean Ayres

Our brain:

Receives sensory information from

our bodies and surroundings

Interprets these messages

Organizes our purposeful responses


Tx: Sensory Activities

• Importance of correct handling techniques (light touch - irritating)

• Sensory Diet to promote regulation of sensory system

• Desensitization methods– Distal to proximal– Caution: vibration

• Stimulation to face and mouth– With an OT/SLP specializing in oral

motor therapy– With the child’s permission


Proprioceptive System & Mealtimes

• Definition• Adjusting/grading jaw

opening• Hold utensils with too

much/too little force• Knowing body position in

relation to objects on table

• Grading movement to drink


Tx: Proprioceptive system• Weighted utensils• Weighted blanket• Utilize a mirror• Weighted drinking cup• Crazy Straws• Thickened liquids• Sensory diet:

wheelbarrow walkingsilly animal walkscarrying/pushing heavy itemssquishing between pillows


Vestibular System & Mealtimes

• Predictable movement for calming– Rocking, gentle swinging

• Focus all attention on moving sensations• Quick movement – alerting• Slow movements - calming• Muscle tone• Max- running around before dinner

– Heavy predictable movements


Tx: Vestibular systemSensory diet:

bouncing

swinging

climbing

calm: linear swinging, rocking gentle bouncing

**lycra material attached to a pull-up bar in a doorway


Tactile System & Mealtimes

• Definition• Hyposensitive• Hypersensitive• Gabby


Tx: Tactile system

• Organizing oral sensorium - touch can prepare a child for a meal and help focus attention (warm wash cloth on face)

• Sensory diet:

play dough- hide an object

“Feelie road”

make-up / dress-up

bath time with food


Gustatory System & Mealtimes

• Decreased taste sensitivity (inedible objects, spicy foods, extreme temperatures)

• Increased taste sensitivity (object to textures/temperatures, gag)

• Medication and a mild deficiency in zinc distorts taste

• Sweet-tasting addiction


Tx: Gustatory system

• Oral preparation activities:

washcloth

ice cubes

Nuk brush


Olfactory System & Mealtimes

• 75% of taste perceptions depend on efficient sense of smell

• Olfactory stimulus goes to the limbic system (emotions and inner drive) – strong association with memory storage

• Odor & childhood memory?

• Changing station/fried food in cafeteria


Tx: Olfactory

• Food at room temperature

• Limiting number of smells

• Calming activities:

blowing

proprioceptive input

drinking water

sucking on ice


How the Visual and Auditory systems affect mealtimes

• Alerting stimuli:shiny objects

bright colors

moving objects or peripheral movements

Television- distraction

Auditory stimulation is always there – it cannot be ignored (cafeteria)


Tx: Visual/Auditory

• Calming visual input:– dull finish utensils– lighting- low lighting or candles– table setting- minimize – Smaller plates or divided plates

• Music with a slow tempo, and regular sustained rhythm slows down breathing and heart rhythms – leads to relaxation– Supports a slower pace to the meal– Mozart For Modulation


Causation:Gastrointestinal Factors

• The child finds eating unpleasant and unsafe

• GERD- Gastroesophageal Reflux Disorder is when the stomach’s acidic contents move backward into the esophagus

• The esophagus becomes red and irritated


Symptoms of GERD

• Immediate indicators of reflux:– Sweating– Arching or stiffening of the body– Frequent irritability or sudden crying after eating– Hiccups/Burping– Increased breathing rate– Bad breath– Startle movement– Irritability/Crying– Mucus/Phlegm


Tx: Gastrointestinal Comfort

• Medical interventions– Surgery or over the counter

medicines

• Reduce stress at mealtimes– Avoid coercion

• Assist in respiration activities – Practice deep breathing

• Review positioning• Ice and water


Medical vs. Behavioral Causes

• The parental response to medical illnesses can lead to behavioral mismanagement, even acute illnesses

• The problem may begin at a biological level but can quickly turn behavioral based on the parental response

• Behavioral mismanagement of biological factors- Lauren


Causation:Environmental Factors

• Family schedules, settings, and serving sizes

• Problem behaviors• Lack of knowledge and

awareness of serious problems


Parental Responsibility

• Myth: Good parents are responsible for getting their child to eat.– “Parents and professionals working with

children are responsible for preparing and providing a balanced meal at an appropriate schedule and setting. The CHILD is solely responsible for whether they eat and how much they eat.”

– Ellyn Satter, Secrets of Feeding a Healthy Family


Cultural Beliefs and Food

• “Clean Your Plate club”

• Don’t play with your food

• Sweets and desserts are rewards for eating your meal

• Good eaters vs bad eaters


Environmental Controls

• Schedule– Written and posted

• Understandable to the child

– Timers– Includes snacks– No grazing and

only water between meals


Tx: Mealtime Setting

Create a Consistent Setting– Eating and drinking is done at the

table– Supportive and nurturing

• Role model good eating habits• Do not discuss the child’s eating habits

during the meal

– Limit distractions


Food Jags

• Insistence on the same• Food Jags and children with DD• Tx: Guidelines

– Make small changes ie food coloring– Choice-making– Include the child– Support and encouragement


Food Selection (Evans-Morris)

• Resistance– Cracker vs. bagel

• Sensory Input (spicy, sour, bitter)– Pickle vs. cheese

• Size– Sm. Cookie vs.

hamburger bun

• Shape– Pretzel stick vs. toast

• Texture Scatter– Graham Cr. Vs. nuts

• Placement– Beef Jky. Vs. Apple

• Transfer– Lunch meat vs. raw

vegies


Portion Size and Food Selection• Tx: Food selection

– Always have one preferred food item at every meal

– Pair a new food with a preferred food– Child-friendly foods– When introducing new textures, begin

with familiar textures and work “Around the plate” (Dunn-Klein)

– Temperature• Tx: Portion size

– Age appropriate plates and utensils– Measuring spoons and cups– Less is best


Tx: Behavior and Mealtimes

• Check environmental factors– Reduce stress

• Set a routine pre and post meal– Transition activities-auditory

• Written rules– PECS

• Removal from the table or room– Time out in schools

• Stick with the schedule– Timer

• Analyze the behavior


Tx Strategy:Older Students

• Deal-A-Meal• Include older and higher

functioning students in meal selection

• Identify 4-5: proteins, F/V, and carbs

• Place in photo album and display

• www.attainmentcompany.com

http://www.attainmentcompany.com/AB1031005/showdetl.cfm?&User_ID=231642&St=5572&St2=83585954&St3=-43686518&DS_ID=2&Product_ID=19&DID=11


Tx: Physical Competence

• Postural alignment

• Postural control

• Postural stability

• Case study: Easton


Postural Control -Modifications• Move ‘n Sit cushion• Foot bench• Eating utensils• Exercises to prepare body before

eating• Activities to strengthen and improve

postural control• Case study: Logan


Postural Control

• Support for the feet• 90 degree angles• Allows the body to

focus on eating• Easton

– Chair on wheels– Too large– No foot control


Stages of Sensory Development

• Fun with Food Everyday!• Children learn to eat through their senses• “Learning about new Foods”• Playful and fun• Avoid judgments• Food Rich Environment• Use of ice in treatment• 10-15 successful trials at each stage

– Systematic desensitization


Acceptance

• Exposure

• Food Preparation

• Desensitization

• Hot potato- place food in a bowl if child does not want to touch it


Touch

• Be prepared to get messy

• Use one food to touch another food

(use a pretzel stick to touch a cucumber)

• Avoid coercion

• Mystery Items


Smell

• Select Calming foods• Respect the child• Include only 1-3 new scents• Guess the smell


Tx Strategy!

• 2 in 1 Scent• Matching scents• Constructive

Playthings catalogue• Make your own with

old butter containers


Taste

• A taste can be a lick or a small bite not swallowed

• Spit bucket- when appropriate and with rules• Select foods with similar tastes and textures• When introducing new textures, begin with the

familiar texture and slowly add the new texture• Have water or ice available for cleansing


Tasting New Foods

• Hide and Seek in the mouth

• Massaging teethers or Jiggling Z-vibe to desensitize the mouth

• Bobbin’ for foods– Use a shallow pan with 1

inch of water


Steps for Implementation in Schools

• Create a food center

• Identify a time on the schedule/post

• Request food: parents, grocery store

• Select activities- may be repetitive

• Include child in set-up

• Check for communication

• Have fun!


The Role of the Educator and Therapist

• Nutritional intake is critical to overall health and learning– Vitamin deficiency

• Effects quality of life and independence• Socialization with peers

– Socially isolated

• Parent education on health and eating


Collaborative Approach

• Develop a Feeding Team to include:– Family– Physician– OT– SLP– School Psychologist– Nutritionist– Teacher


Identifying Diagnostic and Treatment Resources

• Identify professionals– Call local clinics, hospitals and universities

• Therapists who are teaching workshops– Make an appointment to meet with

therapists

• Talk to other parents and professionals– Internet list-serves


Identifying Resources (cont.)

• Questions to ask a therapist and feeding team– Multidisciplinary evaluation– Which professionals take part in evaluation

and treatment– How much time per day for treatment– How and when will goals be evaluated and

modified– How to measure progress


Choosing a Successful Mealtime Plan

Make it a priority

Identify and reduce factors that create limits

Address the body as a whole before focusing on the mouth

Use the developmental stages of eating, but know it is not a fixed recipe

Expand the child’s responsibilities for preparing, eating, and cleaning up


Recipe For Success!

Trust and acknowledge the child’s inner knowing and follow his lead

Make changes slowly

Be fully present and fully attentive when you are with the child

Want the very best for the child and family. Know that they are doing their best at the moment.

If you make a mistake , try again

It starts with you!

copyright 2008 ernsperger how to get your kids to eat dr. lori ernsperger 702-616-8717...

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