Feeding

FEEDING INFORMATION FOR THE RESISTANT EATER

AND

SUGGESTIONS FOR PACKING LUNCH FOR KINDERGARTEN


JOHN I. DAWES, EARLY LEARNING CENER

FEEDING WORKSHOP

Spring 2014

Presented by Amy Fischetti, M.S. CCC/SLP

TYPES OF EATERS:

· The Normal Eater: A child who is considered a “good eater” because he or she eats a variety of foods and enjoys mealtime.

· The Picky Eater: A child who has certain limitations and some possible food aversions; however, this child will eat enough of a variety of foods to maintain a well-balanced and healthy diet.

· The Resistant Eater: A child who presents with significant food aversions which prevents him or her from eating a well-balanced and healthy diet. A resistant eater has a very limited food selection and many aversions to certain foods. This child usually experiences a great deal of anxiety trying new foods and finds meal times unpleasant (and parents do too). A resistant eater, overtime, may exclude previously preferred foods from his or her diet further limiting their preferred repertoire of food.

If your child is a resistant eater, any oral motor difficulties and/or sensory difficulties need to be ruled out.

SUGGESTIONS FOR MEAL TIME SUCCESS

· Success begins with the setting of mealtime. This is extremely important. Mealtime should be consistent and predictable. Meals should always be served at the table. If you previously permitted your child to eat in front of the tv or walk around and “graze” while eating and drinking, these behaviors need to stop. This promotes an association of tv/video with food. Your child should associate meal time with the table, family eating together and family enjoying one another. The focus should be on eating and socializing. Your child should be exposed to their parents and siblings eating a variety of foods and enjoying them. You want to change the unpleasant feeling of meals to a positive one.

· Seating is important. Your child should have an appropriate seat and support while eating at the table. Preschool children are too old and big for highchairs but booster seats are appropriate. Sitting at the table for 25-30 minutes is appropriate for a preschool age child.

· Try to keep distractions during mealtime to minimum. Households are very busy, but mealtime should be a calm environment for your child. If the parent presents in a calm manner, this will reflect positively onto your child. If you are anxious and in an emotionally high state, your child will pick up on this. It will take practice and patience, but it is important to try to keep calm even if you are not. Creating a calm, supportive and nurturing environment for your child will ease the process of mealtime for everyone involved.

· Get your child involved in preparing for mealtime. Setting up a routine prior to sitting at the table will help with transitioning into meals. For example, you can set up a sequence of steps: wash hands, set the table by selecting plates and utensils for the meal, putting the food on the table, putting the drinks on the table, calling all family members to the table for dinner. Let your child help with putting the plates, napkins and utensils on the table. Children like having jobs and responsibilities. You may want to make up a checklist or visual picture schedule for your child to follow.

· Set up consistent rules for mealtime that are followed by all adults working with your child (both parents, therapist, grandparents, babysitters, etc.) and followed at every meal. Your rules should support your child’s specific needs for learning about new foods and may not be the same for all children. Some examples are listed below:

1. Remain seated at the table.

2. Keep food on your plate.

3. Stay in your seat until the timer rings.

4. Use the appropriate utensil for eating: spoon or fork.

5. Let an adult know when you are done using language, sign, PECS as appropriate.

6. Place all unused food from plate in the garbage.

· Resistant eaters will often demonstrate challenging behaviors during mealtimes due to their persistent food aversions. As a parent, you will need to decrease these behaviors by utilizing a positive behavioral approach that is consistent. Challenging behaviors take time to extinguish and replace with appropriate behaviors. Being consistent, calm, patient and supportive are key to success.

POSITIVE BEHAVIORAL INTERVENTIONS

Mealtime for a resistant eater generally causes anxiety and fear. In order to change negative experiences into positive experiences it is extremely important for your child toTRUST you, especially when you are introducing new foods. If you tell your child, “Just one more bite and we are all done”, then you must honor that. If you don’t and try to introduce another bite, you will lose your child’s trust. Your child needs clear expectations. If you say, “Just one more bite” then it is only one more bite and then your child is done eating.

Positive verbal praise is essential for success at every step. Verbal praise will reward your child for their attempts and successes and will in turn increase the frequency of the target behaviors. Your child will not fully comply and meet your expectations on the first attempt. However, as your child tries, it is important to provide a positive environment and positive feedback to increase the target behavior. For examples, see suggestions below:

1. I love the way you are sitting.

2. That was great taking a lick of the _____.

3. That was great taking a bite of the _____.

4. I am so proud of you for _______.

5. Wow, that was a good bite.

6. I like how you are holding your spoon.

Positive verbal praise should always tell your child what you are happy about. This will eventually increase the target behavior. You may need to initially pair the positive verbal praise with an immediate tangible reinforcement that is motivating for your child. This could include a preferred food (i.e. goldfish cracker, small piece of pretzel, lick of a lollipop) for a limited time (10 seconds- 30 seconds) or playing with a preferred small toy (i.e. small car, stress ball). The reinforcer you choose should be something very motivating for your child so that when you give this to your child it increases the positive behavior (tasting the new food). If it does not increase the tasting of new foods, then it is not motivating enough and you need to find a new reinforcer.

EXAMPLES OF FOOD REINFORCERS

Ø a preferred food

Ø pretzels

Ø chips- any flavor

Ø goldfish

Ø crackers

Ø low sugar fruit snacks

Ø character cookies

EXAMPLES OF NON-EDIBLE REINFORCERS

Ø toy car

Ø bubbles

Ø stickers

Ø stress/squeeze ball

Ø pegs in peg board

Ø a toy that lights up when touched

If your child does not need a reinforcer during meal- time, then a special game, book, toy, tv show, video or game on the ipad are good rewards for after meal -time.

Some children will gag or vomit at the presentation/ tasting of new non-preferred foods. If your child does not have a medical condition/physical reason for gagging and/or vomiting, such as reflux or an oral motor disorder than this is a behavioral response. It is important to try to ignore and have no reaction to this behavior. You can speak calmly to your child and reassure him or her that they are okay. If your child does react with gagging/ vomiting when presented with a new food, simply say “You are okay” and continue to present the new food. If your child vomits, clean them up and attempt one more time so that they understand that they still need to try the new food. If you do not present the food again, you will reinforce the negative behavior of gagging/vomiting and your child will continue to use this behavior to avoid new foods. This behavior will decrease in a short time if you are consistent in your response. Remember the trust factor and follow through with what you say.

STEPS FOR INTRODUCING A NEW FOOD

Children developmentally learn to eat new foods through their senses. Toddlers will often play with their food using their hands to touch and squish new foods. They will smell new foods before attempting to put them in their mouth and taste them. Exploring new foods with their senses teaches them about the sight, smell and textures of new foods. It introduces new foods in an interesting and curious way. These developmental stages can be utilized with the child who is a resistant eater.

Children learn to eat new food through the developmental stages of:

· Acceptance

· Touch

· Smell

· Taste

· Eating

Research reports that acquiring the taste for a new food can take several months, so it may take up to 10-20 exposures of a new food before a resistant eater is able to advance to the next sensory stage.

1. ACCEPTANCE: Acceptance refers to the child’s ability to accept the presence of a new food. This can range from accepting the new food in the same room to accepting the new food on the table to allowing the new food on their plate. During this stage, do not encourage or force your child to touch, smell or taste the new food. Your goal is to increase your child’s willingness and tolerance for new foods in their presence and decrease their anxiety towards new foods.

2. TOUCH: Touching new foods for a resistant eater is a HUGE step and should always be rewarded with a lot of verbal praise. Babies and toddlers learn about textures by smearing food on their trays, rubbing it in their hair and putting it all over their face. Exploring new foods through touch decreases anxiety and increases a child’s exposure and awareness of various textures. Remember, touching and playing with food should be fun but it can also be messy. Be prepared with paper towels and wipes for clean- up. If your child is resistant to touching a new food despite your examples and modeling, let him or her use a fork, spoon, pretzel stick, carrot stick, etc. to poke/touch the new food. You can also place the food in a Ziploc baggie and let your child “feel” the new food without actually having to touch it. He or she can also squeeze and crunch the new food in the baggie.

3. SMELL: Smelling new foods is a transition phase between touching and tasting. The goal is to increase the child’s willingness to bring the new food closer to his or her mouth. The sense of smell is closely associated to successful eating. Smell is an important factor with eating new foods and can cause strong reactions in children. You may notice an increase in your child’s anxiety at this stage as the new food is getting closer to his or her mouth. The goal is to positively link smell with eating new foods. Remember to be aware of all the smells in the environment (i.e. perfumes, air fresheners, candles, etc). If your child is overly sensitive to smells, competing smells in the environment may affect his or her willingness to smell new foods. Begin with foods that have a pleasant and calming scent, such as apples, cinnamon and vanilla. Gently wave the food in front of your child. You do not have to place the food directly under your child’s nose. Remember we are building trust… your child may become fearful and anxious if the food is placed too close to his or her mouth. Placement of the food item in front of your child’s face should be sufficient for him or her to experience the scent in a positive manner. Do not overload your child with many scents in one sitting. Try to focus on 1 to 3 new scents at a time.

4. TASTE: Tasting a new food begins with licking the food, then taking a small bite and finally chewing. You should allow your child to spit out a new food in the beginning if he or she becomes fearful or anxious. Licking and biting a new food are BIG steps towards success. Remember this is a lengthy process and small steps are ok.

Place a small amount of food in your child’s mouth or let your child take a bite by him/herself. Remember to use verbal praise for your child’s attempts, “I love how you are taking a bite.”, “Great job tasting the ____”, “You are doing awesome.” Remind your child to “chew and swallow”. Liquid wash downs- taking a drink- after chewing and swallowing are helpful to wash the new food down. You can also offer your child a reward with a preferred food immediately after he or she takes a bite of the new food.

After the reward of a preferred food or toy, present the child with another bite of the new food. You can offer the reward of a preferred food or toy immediately again. After several successful attempts, decrease the frequency of the reinforcer from immediate to after two to three successful tastes. Eventually, you can extinguish the reinforcer.

Additional Helpful Suggestions:

Ø Combine familiar tastes with new food items, such as a favorite condiment or sauce. A familiar and preferred taste will help with the transition to a new food and may facilitate success.

Ø Select new foods close in flavor and texture to preferred food items. Making small changes will lead to success in tasting new foods.

Ø Select foods that are child-friendly and are comfortable for the child to chew.

Ø As your child becomes more successful with tasting new foods, start to vary the textures and flavors.

Ø Your child is not going to like every food he/she tries.

Ø Always present a new food on the side molars. Most of our taste receptors are on the front of the tongue. By placing food on the side of the mouth you may avoid a gagging reflex to the new flavor.

Ø If your child likes apples, try cutting them into different shapes such as strips and dip them in apple butter or peanut-butter. Remember small steps build trust and success.

FOOD SELECTIONS

Food selections need to be individualized for each child.

1. Consider texture, color, smell, flavor, shape when selecting a new food.

2. Include bread/rolls with a meal. Most children enjoy bread and including this with a new food may facilitate success.

3. Begin with a food your child ate in the past but now refuses to eat. You will have more success with a food that has familiarity.

4. If your child prefers smooth textures, begin with foods like applesauce, yogurt, pudding- they are easier to swallow.

5. Only introduce one new food at a time.

6. Be careful with foods that have mixed textures. If you are presenting a sandwich you want to make sure that your child tolerates each part/texture of the sandwich independently. For example, for a cheese sandwich, your child must tolerate/accept eating the cheese and bread separately before putting them together. The same is true for any combination of food.

7. Remove food from any packaging and place it on a plate. Do not let your child see the food come out of the package. Many children become fixated on the packaging and will only eat Purdue chicken nuggets or Kraft mac and cheese.

8. Change the shape of food. Cut fruit or vegetables into different shapes- melon balls, chuncks. Use cookie cutters to make sandwiches and let your child help make his or her own sandwich.

9. Be mindful of portion size. If your goal is for your child to eat a hamburger, start with a slider. The size is more appropriate for his or her age and not as overwhelming in size.

FOOD CHAINING

What is Food Chaining?

A food chain is a list of foods that have similar characteristics- flavor, smell, texture, shape- as your child’s preferred foods (the foods he or she already eats). Preparing a food chain to meet your child’s individual needs is an effective way to help your child accept new foods in a gradual and nonthreatening way. New foods are added to the food chain based upon your child’s reaction to previous new foods.

Look for patterns in the foods your child already has in his /her diet. These preferred foods will have features in common- soft, crunchy, salty, sweet, hot, cold, bland, color.

Look for patterns in the foods that your child does not eat and the foods he/she used to eat but now refuses to. This will help you understand the features of foods that your child does not like.

Seek help from a trained therapist to develop a food chaining plan/menu.

RESOURCES

The Fundamentals of Feeding Children with Autism Workshop presented by Nancy Calamusa, MA CCC/SLP, Pediatric Feeding/Swallowing Specialist and Director of the New Jersey Pediatric & Feeding Associates and Daria Mintz, MS, RD, CSP Dpeartment of Pediatrics at Rutgers University RWJMC

Just Take A Bite: Easy, Effective Answers to Food Aversions and Eating Challenges by Lori EMsperger, PhD., Tania Stegen-Hansen OTR/L

Food Chaining: A Proven 6 Step Plan to Stop Picky Eating, Solve Feeding Problems and Expand Your Child’s Diet by Cheri Fraker MA CCC/SLP, Mark Fisbein, MD., Sibyl Cox, RD, LD, CLC 7 Laura Walbert MA CCC/SLP,CLC

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