feeding disorders in young children: msha conference ... · msha conference jackson, ms 3/30/12...

Feeding Disorders in Young Children: The AEIOU Approach

MSHA Conference Jackson, MS 3/30/12

Nina Ayd Johanson, MA, MS, CCC-SLP, CEIM [email protected] 1

MSHA ANNUAL CONFERENCE JACKSON, MS

MARCH 30, 2012

Feeding Disorders in Young Children:

The AEIOU Approach

Nina Ayd Johanson, M.A., M.S., CCC-SLP; CEIM [email protected]

1

3/30/12 MSHA Conference Jackson, MS

Learner Outcomes 2

  Identify 5 factors that contribute to the maintenance of pediatric feeding disorders and how to address them in treatment.

  Discuss strategies for improving the mealtime environment.

  Describe components of effective parent training.


Role of Feeding Skill Development 3

Biologic skill

Interpersonal relationship

Learning about environment

Social/Cultural Participation





Foundations to Management 4

  Basic but it is not simple

  Rarely caused by only the environment or only behavior

  Often exacerbated by environment

  Not just oral-motor and swallowing



  Top complaint of parents of young children

  Learning is in direct relation to experience

  Learning requires active participation

  Sometimes the only indicator of a medical condition or a sign of family relationship/attachment disorder



  “Shared Control” supports development

  Children learn by comparison and observation

Begin with the end in mind! S.R. Covey; 1997





7

Quality

Quantity


Feeding Development: 8

  Complex process

  Dependent on:

  Anatomic/Structural integrity

  Neurophysiologic maturation

Stevenson & Allaire; 1991



  Learned progression of behaviors influenced by:

  Oral sensation

  Fine and gross motor development

  Experiential opportunities







  Complexity of feeding compounded by:

  Child’s temperament

  Interpersonal relationships

  Environmental influences

  Culture



Feeding Development 11

Anything that interferes or contributes to the factors listed above will limit

the acquisition of feeding skills


Primary Goal of Feeding: 12

Nutrition

Fruits/Veggies

Carbs Protein





Prevalence/Incidence

  Manikam & Perman (2000)

 52% not consistently hungry

 42% end meals too soon  35% picky eaters  33% food selectivity

  25% of all children   80% of children with D.D.

  Sullivan et. Al. (2000)   >60% never assessed

  Chatoor (2003)   #1 SFA   #2 IA   #3 PTFD

  Rommel et. al. (2003)   GERD most frequently

underlying medical condition

  Dx with feeding disorder   Majority are preemies

13


Prematurity 14

  Physiologic flexion   Low muscle tone   Reflexes   Passive behavior   Disorganized state/attachment   Risk to every organ system   Iatrogenesis


Respiratory Complications 15

  Supplemental oxygen   Endotracheal tube for ventilation   Resuscitation   High risk of asthma into adulthood   Medication effects   Increased neurodevelopmental risk   Growth and nutrition





Digestive Complications 16

  Aversive Conditioning   Surgery   Medications   Delayed oral feeding   Diet restrictions   Physical competence


Allergies/Malabsorption 17

  Respiratory Congestion   Effect on weight gain   Aversive Conditioning   Caregiver compliance   Resources


Stress!

Environmental Sensory

Biologic

18





Environmental Factors 19

Factors that predict poorer outcomes

  Poverty   Single parent status   Marital conflict   History of abuse/neglect   Parental depression/anxiety   Changing family circumstances


Environmental Factors

  Impact on Diet and Appetite   Shared Control   Interaction/Management   Child/Caregiver Support   Resources   Need for Referral   Where to Begin

3/30/12

20

MSHA Conference Jackson, MS

The A.E.I.O.U. Approach

3/30/12

21





Acceptance

3/30/12

22


Exposure

3/30/12

23


Independence

3/30/12

24





Observation

3/30/12

25


Understanding

3/30/12

26


Assessment Clues

History

Schedule

Diet Interaction

Parental Concerns

27





When To Treat 28

“negative consequences of dropping out of intervention prematurely may outweigh

consequences of postponing start of intervention” Drotar, 1995

 Caregivers receptive?  Resources available?


When To Treat 29

Support Services (in place of or prior to intervention)   Home visits   Counseling (individual, couples, family)   Service Coordination   Advocacy   Respite Care   Family Assistance   Child Protective Services


When To Treat 30

Priorities   Respiratory Status/Cardiac Function

  Nutrition/Hydration Stability

  Swallowing Function

  Postural Stability





When Feeding Is Contraindicated 31

1.  Address attachment/communication environment 2.  Stimulate NNS 3.  Maintain/Normalize sensory processing 4.  Maintain/Normalize oral-facial sensation 5.  Establish feeding/mealtime experience 6.  Normalize hunger/satiety cycles; develop

association with feeding


How To Treat 32

1. Rule Out Medical Reasons   Consult Pediatrician   Screen For Contraindications   Suspect GERD, Allergies   Refer to Specialists   Comprehensive History   Minimize medical influences


GERD

Reflux Precautions:  Schedule  Surroundings  Post-meal  Diapering  Positioning  Thicken feeds  Decrease dairy/wheat

 Burp every 1-2oz.  Decrease swallowed air  Diet  NNS  Abdominal pressure  Stress

3/30/12

33





How To Treat 34

2. Establish Environmental Support   Caregiver “Buy-In”   Attachment/Bonding/Interaction   Resources/Support   Learning Environment   Structure/Schedule/Exposure   Consider hunger/satiety cycles


Caregiver Buy-In 35

The goal of a feeding program is to CHANGE the current situation

Negotiate with Family: •  Explain; Listen •  Problem-Solve •  Compromise •  Ask for a commitment


Responsive Parenting 36

Ainsworth & Bell; (1969) Early feeding experiences provide a model of parent responsivity and accessibility in other interactional contexts which shapes the child’s confidence in his or her ability to influence events

  “demand” feeding   Less crying; more positive parent perceptions   More “secure” attachment at 1yr. of age





Responsive Parenting 37

  Children dependent on caregivers for nutrition   Effective interaction, attachment, and

communication crucial for mealtime success   Responsive parenting critical to healthy

development

Maladaptive behaviors likely to increase if not effective


Effective Parent Training 38

Effective Parent Training: (Kaminski et al 2007)

  Increase positive parent-child interaction   Increase emotional communication skills   Teaching parents to use time-out   Teaching importance of consistency   Requiring parents to practice new skills during

training sessions


Resources 39

  Bare Bone Basics of Discipline Myra McPherson—parentexpress.org

  NCAST Training (ncast.org)   ABC Intervention (abcintervention.com)   Circle of Security (circleofsecurity.net)   Theraplay.org





Mealtime Interactions 40

Child’s Ability to Communicate   Hunger/fullness   Wanting more/no more   Wanting something different   Changing the pace of eating   All done   Discomfort (positioning; sensory stimuli)


Mealtime Interactions 41

Caregiver Reciprocity

  Listens, responds, waits   Sensitivity/responsivity to cues   Describes foods, process   Non-verbal communication   Makes association for child:

  Hunger/satiety with mouth, tummy


The Teaching Loop 42

Alert

Instruct Performance

Feedback

Eye Contact

NCAST; Norris-Shortle & Cosgrove





How to Help

Ellyn Satter   Behaviors that share control support homeostasis

and the attachment that follows

3/30/12

43


How To Help

  Division of Responsibility (Ellyn Satter)   Parents do the what, when, and where of feeding   Children do the how much and whether of eating---from what

parents offer   Predictable family meals and snacks

3/30/12

44


Making Choices

“Ask your child what he wants for dinner only if he’s buying” -- Fran Lebowitz

45





icontalk.com (Barbara Bloomfield) usevisualstrategies.com (Linda Hodgdon) Photo CD; Time Timer; Books schKidules.com

46


Merry Mealtime Guide 47

  Setting/Structure   Social mealtimes, with models   Limited/No distractions (no toys, no tv)   In a chair, at a table   For meals and snacks only   Be consistent   Always allow independence-help only with permission; read

“cues”



  Schedule/Routine   Pleasant beginning/end routine   Sensory transitions, if needed   Guided by medical/nutrition status   Regular Intervals (2 ½ to 3 hours apart, 5-6x/day)   Duration (10-15 min snacks; 15-30 min meals)   Use a timer   Allow extra time for OM/FM, independence, socializing   Expect child to stay at the table   No grazing-only water between meals/snacks   Use an all-done bowl






  The Food   Age/skill appropriate   Exposure: taste/texture variety, portions   Someone to describe the food   Avoid added salt, sugar, artificial flavors/colors, low/no fat,

lite   Healthy sweeteners: agave syrup, blackstrap molasses, honey

(never for under age 1), pure maple syrup   Healthy fats: real butter, olive oil, coconut milk, fish oil, nuts,

flaxseed (ground or oil)   Serve family style



  The Food (continued)   Include at least one preferred food   Offer at least 3 different foods (max 4-6)   No short-order cooking   No “walking” cups   Keep flavors and textures separate initially   Use “bridges”, “masks”, “mash-ups”, and “mixtures”   Use appropriate size/shape bowls, plates, utensils


How To Treat 51

3. Address Postural Stability/Positioning   Collaborate with PT/OT/Assistive Tech

4. Address Sensory Processing and aversive conditioning

  Normalize response to sensory stimuli





Sensory Processing 52

Sensory Responses to Food   Won’t look at food;

covers eyes/face   Turns head away,

pushes food away   Throws food   Attached to colors of

food   Closely “inspects” food   Holds nose vs. intense

smelling

  Hand/finger splaying   Wiping hands   Makes faces; body

quivers; squints eyes; startles

  Gagging; vomiting; coughing

  Pockets food; stuffs food   Anterior loss of food


How To Treat 53

5. Address Oral-Motor and Feeding Skills   Normalize the feeding experience   Consider child’s autonomy/independence   Consider child’s skill level   Consider modifications (food, equipment)   Target skill deficits

Teach Expulsion ! 3/30/12 MSHA Conference Jackson, MS

Modifications

  Physical environment   Sensory environment   Positioning/Postural stability   Other sensory stimuli

3/30/12

54





Behavior Strategies 55

Strategies that support learning, respect independence and autonomy, and foster trust:   Consistency is key   “Shaping”: break down tasks into component parts; teach

smaller steps   Desensitization: addresses the child’s anxiety   Operant Conditioning: help children make new associations

(interactions, environment, physical, sensory)

From survival…to stability…to success…to significance… (S.R. Covey; 1997)


Selected References: 56

  Bahr, D. C. (2001). Oral Motor Assessment and Treatment: Ages and Stages. Boston, MA: Allyn & Bacon.

  Barsky, Diane (2003). Effects of Medical Interventions on the Development of Feeding. Feeding and Swallowing Disorders: Perspectives on Treatment. Conference Proceedings: Philadelphia, PA.

  Birch, L.L. (1990). The Control of Food Intake By Young Children: The Role Of Learning. In E. Capaldi & T. Powley (Eds.) Taste, Experience, and Feeding (pp. 116-138). Washington D.C.: American Psychological Association.

  Birch, L.L. & Fisher, J. (1996). The Role of Experience in the Development of Children’s Eating Behavior. In E. Capaldi (Ed.) Why We Eat What We Eat: The Psychology of Eating (pp. 113-144). Washington D.C.: American Psychological Association.

  Black, M.M., Dubowitz, H., Krishnakumar, A., & Starr, R.H. (2007). Early intervention and recovery among children with failure to thrive: follow up at age 8. Pediatrics, 120(1). 59-69.


57

  Buie, T., Campbell, D.B., Fuchs, G.J. III, Furuta, G.T., Levy, J., VandeWater, J., Whitaker, A.H., Atkins, D., Bauman, M.L., Beaudet, A.L., Carr, E.G., Gershon, M.D., Hyman, S.L., Jirapinyo, P., Jyonouchi, H., Kooros, K., Kushak, R., Levitt, P., Levy, S.E., Lewis, J.D., Murray, K.F., Natowicz, M.R., Sabra, A., Wershil, B.K., Weston, S.C., Zeltzer, L., Winter, H. (2010). Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals with ASDs: A Consensus Report. Pediatrics, 125, S1-S18. DOI: 10.1542/peds.2009-1878c.

  Burklow, K., McGrath, A., & Kaul, A. (2002). Management and prevention of feeding problems in young children with prematurity and very low birth weight. Infants & Young Children, 14(4). 19-30.

  Capaldi, E. & Powley, T. (Eds.). (1990). Taste, Experience, and Feeding. Washington, D.C.: American Psychological Association.

  Capaldi, E. (1996). Why We Eat What We Eat: The Psychology of Eating. Washington, D.C.: American Psychological Association.





58

  Carr, E., Levin, L, McConnachie, G., Carlson, J.I., Kemp, D.C., & Smith, C.E. (1994). Communication-Based Intervention for Problem Behavior: A User’s Guide for Producing Positive Change. Baltimore, MD: Paul H. Brookes Publishing Co., Inc.

  Carruth, B.R., & Skinner, J.D. (2000). Revisiting the picky eater phenomenon: neophobic behaviors of young children. Journal of the American College of Nutrition, 19(6), 771-780.

  Chatoor, I. (2009). Diagnosis and Treatment of Feeding Disorders in Infants, Toddlers, and Young Children. Washington D.C.: Zero To Three.

  Cooke, L. (2007). The importance of exposure for healthy eating in childhood: a review. Journal of Human Nutrition and Dietetics, 20(4), 294-301.

  Coulthard, H., Harris, G., & Emmett, P. (2009). Delayed Introduction of Lumpy Foods to Children During Complementary Feeding Period Affects Child’s Food Acceptance and Feeding at 7 Years of Age. Maternal and Child Nutrition, 5, 75-85.

  Davis, A.M., Bruce, A.S., Mangiaracina, C., Schulz, T., & Hyman, P. (2009). Moving From Tube to Oral Feeding in Medically Fragile Nonverbal Toddlers. Journal of Pediatric Gastroenterology and Nutrition, 49 (2), 233-236.


59

  Ernsperger, L. & T. Stegen-Hanson. (2004). Just take a bite: Easy, effective answers to food aversions and eating challenges. Arlington, TX: Future Horizons, Inc.

  Field, T. (2001). Touch. Cambridge, MA: The MIT Press.   Fraker, C. and Walbert, L. (2003). From NICU to Childhood:

Evaluation and Treatment of Pediatric Feeding Disorders. Austin, TX: Pro-Ed, Inc.

  Fullar, S.A. (2008). Babies at double jeopardy: medically fragile infants and child neglect. Zero To Three, July, 25-32.

  Hanft, B.; Rush, D.; & Sheldon, M. (2004). Coaching Families and Colleagues in Early Childhood. Baltimore, MD: Paul H. Brookes Publishing Co., Inc.

  Hawdon, J.M.; Beauregard, N.; Slattery, J.; & Kennedy, G. (2000). Identification of neonates at risk of developing feeding problems in infancy. Developmental Medicine and Child Neurology, 42(4), 235-239.

  Hebbeler, K.M. & Gerlach-Downie, S. (2002). Inside the black box of home visiting: a qualitative analysis of why intended outcomes were not achieved. Early Childhood Research Quarterly, 17, 28-51.


60

  Hodgdon, L. (1999). Solving Behavior Problems in Autism: Improving Communication With Visual Strategies. Troy, MI: Quirk Roberts Publishing.

  Hurley, K.M., Black, M.M., Papas, M.A., & Caulfield, L.E. (2008). Maternal symptoms of stress, depression, and anxiety are related to nonresponsive feeding styles in a statewide sample of WIC participants. The Journal of Nutrition, 138(4), 799-805.

  Kaminski, J.W., Valle, L.A., Filene, J.H., & Boyle, C. (2007). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology. doi:10.1007/s10802-007-9201-9.

  Mason, S.J., Harris, G., & Blissett, J. (2005). Tube feeding in infancy: implications for the development of normal eating and drinking skills. Dysphagia, 20(1), 46-61.

  Morris, S. E. & Klein, M. D. (2000). Pre-feeding skills: A comprehensive resource for feeding development. San Antonio, TX: Therapy Skill Builders.

  Norris-Shortle, C., & Cosgrove, K. (2007). Teaching Loop, Adapted from NCAST Publications, Seattle. NCAST Teaching Scale Certification Course. Baltimore: PACT: Helping Children With Special Needs.

  O’Brien, M. (1996). Child-rearing differences reported by parents of infants and toddlers. Journal of Pediatric Psychology, 21(3), 433-446.





61

  Parlakian, R. & Lerner, C. (2009). Facing the challenge: what mothers have to say about their young children’s difficult behaviors. Zero To Three, January, 60-61.

  Pentiuk, S., O’Flaherty, T.O., Santoro, K., Willging, P. & Kaul, A. (2011). Pureed by Gastrostomy Tube Diet Improves Gagging and Retching in Children With Fundoplication. Journal of Parenteral and Enteral Nutrition, 35(3), 375-379. doi: 10.1177/0148607110377797.

  Pulsifer-Anderson, B. (2007). The Reflux Book: A Parent’s Guide to Gastroesophageal Reflux. Self Published.

  Salvy, S.J., Vartanian, L.R., Coelho, D.J., & Pliner, P.P. (2008). The role of familiarity on modeling of eating and food consumption in children. Appetite, 50(2-3), 514-518.

  Satter, E. (2000). Child of mine: Feeding with love and good sense. Boulder, CO: Bull Publishing Company.

  Schauster, H., & Dwyer, J. (1996). Transition from tube feedings to feedings by mouth in children: preventing eating dysfunction. Journal of the American Dietetic Association, 96(3). 277-281.

  Scheer, M.D., Levine, A., Roth, Y. et. al. (2009). Prevention and Treatment of Tube Dependency in Infancy and Early Childhood. Infant, Child, and Adolescent Nutrition, 1(2), 73-82.


62

  Sheppard, J.J. (2005). The role of oral sensorimotor therapy in the treatment of pediatric dysphagia. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 14, 6-10. doi:10.1044/sasd14.2.6

  Stark, L. J., Jelalian, E., Powers, S. W., Mulvihill, M. M., Opipari, L. C., & Bowen, A. (2000). Parent and child mealtime behavior in families of children with cystic fibrosis. Journal of Pediatrics, 136(2), 195-200.

  Toomey, K., Ross, E.S., and Massey, S. (2007). Picky Eaters Vs. Problem Feeders: The SOS Approach to Feeding. Conference Proceedings: Houston, TX.

  Twachtman-Reilly, J., Amaral, S.C., & Zebrowski, P.P. (2008). Addressing Feeding Disorders in Children on the Autism Spectrum in School-Based Settings: Physiological and Behavioral Issues. Language, Speech, and Hearing Services in Schools, 39, 261-272.

  Wardle, J. & Cooke, L. (2008). Genetic and environmental determinants of children’s food preferences. British Journal of Nutrition, Feb;99 Suppl 1:S15-21.


Signs of Distress

3/30/12

63   sighing   yawning   sneezing   sweating   hiccups   trembling   startling   gasping   facial grimacing   falling asleep   squirming   gaze aversion   straining

  bowel movement   multiple swallows   increasing high/low tone   halt hand   saying “no”   tray pound   cry face   lateral head shake   crying/fussing   pulling away   spitting   covering eyes/face





Signs of Major Distress

3/30/12

64

  coughing   choking   spitting up   gagging   retching   color change

  respiratory pauses or breath holding

  irregular respiration   arching back   bradycardia   “posturing”


feeding disorders in young children: msha conference ... · msha conference jackson, ms 3/30/12...

Documents