This article was written by Teri Olbrot, OTRL, an occupational therapist with decades of experience in feeding young children and is currently in private practice.
Sensory Issues in Feeding Small Children
Picture a baby, teetering on his little bottom as he finds his balance, reaching out with tiny fingers for his first bites of food. A whole new world of sensory experiences is at his fingertips! A baby’s early feeding experiences should bring rich sensory discoveries of taste, textures and smells. Exploring new foods and learning to eat should be happy, exciting, and fun for a child. Unfortunately, that is not always the case. As an occupational therapist, I frequently work with young children and their families regarding eating and feeding concerns. Some of these children are ill and need different strategies and assistance to receive their nutrition. Other children have the ability to eat, but self-limit their diet in unhealthy ways, putting their growth and development at risk. While many children might be “picky eaters” at different times in their lives, most will outgrow their pickiness, if it isn’t reinforced. This article is about another group of children, those who don’t respond to the typical interventions and have developed intense and often phobic responses to food. Their poor relationship with food causes distress to themselves and their families, who are desperate to feed them, and presents a risk to normal growth and development. Sensory Integration Theory offers an explanation for these difficulties and possible solutions.
What is Sensory Integration Theory?
Sensory Integration Theory was first described by Jean Ayres, an occupational therapist and neuroscientist, who defined it this way: “The neurological process that organizes sensation from one’s own body and the environment and makes it possible to use the body effectively within the environment.” This theory offers one way to understand a child’s difficulty with food.
Eating is a profound sensory experience, intimately involving the senses of touch, smell, taste, sound and sight. Why we prefer one food over another is an enigma, difficult to explain. The mouth feel of smooth pudding is very pleasant for some, but noxious to another. A crunchy or chewy texture will please some and cause others to gag.
Eating and feeding skills also involve the proprioceptive senses (muscle memory and motor planning) and vestibular senses (knowing where our body is in space). We use these skills to grade how hard to squeeze a sandwich as we bring it to our mouth; to determine how to grasp the handle on our coffee cup and take a sip while reading the newspaper; and how to navigate a spoonful of soup as it travels through space on its way to our lips.
Another sensory skill is self regulation, which plays a big part in eating skills and mealtimes. Self regulation involves impulse control, delayed gratification, following directions, and cooperating with others.
Our environment and meal time experiences also affect our sensory system. Memories of eating and being fed with love, watching others eat with pleasure and joy, and experiencing new foods without pressure or force, influences our sensory system in a very positive way. When eating is painful or difficult due to illness, when food tastes bad to us or if we simply aren’t hungry but must eat, our sensory reactions are impacted in a negative way.
How negative eating patterns are reinforced:
Parents are often mystified and justifiably concerned when their child won’t eat and will try anything to get them to “just take a bite.” Extended family and friends frequently weigh in on the matter, more often than not, adding more pressure than viable solutions. Some of the more common strategies used, often learned by parents during their own childhood, include making the child stay at the table until the food is eaten, using a preferred food as a reward, or comparing the non-eater to someone else who eats “better.” Even positive reinforcers, like stickers, high fives, verbal praise, are of limited or no value in building a healthy relationship with food. There is no point in asking a child to “please eat it for me.”
Once a pattern of refusal is in place, parents may beg, plead, threaten, bribe or punish their child out of desperation and helplessness. They may follow their child around with food, or present an array of possibilities at mealtime, in the futile hope that maybe this time, their strategy will work. Often, they rely on “junk” food to get calories in, or settle for a diet of highly flavored processed food such as chicken nuggets, sweetened cereal, or flavored yogurt.
Is it a sensory problem? Is it a behavior problem?
Paradoxically, the harder parents, caregivers, and even therapists try, the more imbedded the child’s eating problems may become. Like the fable of the Wind and the Sun, we need to find a way to “warm up” the child, gaining his trust and cooperation, so that he or she feels safe enough to put his defenses down. Force may win a battle or two, but never leads to a healthy relationship with food or happy family meals.
It can be difficult to tease out where the sensory issues end and the behavior issues kick in, but as a child adapts his behavior in response to his environment, sensory issues can easily become problem behaviors. The sensitive gag reflex may resolve, but the protests to and refusals of the foods that triggered it will remain.
Tools for Therapists and Parents:
While a typical child will respond like a charm to modifying the mealtime environment, it is rarely that simple for a child with deeply imbedded sensory issues. Mealtime modifications, however, are a crucial first step in the treatment plan.
Here are some typical recommendations for structuring mealtime:
- Plan meals and snacks at regular intervals, i.e., every three hours. Serve only water between these times.
- Limit mealtimes to about 20-30 minutes.
- Facilitate self feeding whenever possible by offering age appropriate foods cut into sticks or chunks that the child can manage on their own.
- Limit verbal prompts. “Take a bite,” “just try it,” “you liked this yesterday,” are not helpful. This is very challenging for desperate parents and therapists, who feel they must do SOMETHING! Pretend you don’t care. Enjoy your own meal, while pleasantly smiling and making conversation. Fake it! T. Berry Brazelton points out in his book, Touchpoints, that if a parent or therapist permit a power struggle at mealtime, the parent/therapist will always lose. It is much more empowering for a small child to watch us squirm than follow their appetite
- Refer to Louise Satter’s Division of Responsibility: Parents provide structure, support, and opportunities for eating; children choose how much and whether to eat.
Once a functional mealtime environment is established, the treatment plan continues. An occupational therapist’s job is to analyze an activity (eating and feeding), determine where the activity has broken down, (food is thrown on the floor) then modify or change the activity in a functional way to meet a goal. For instance, the first goal for the child who throws food on the floor is that he allows the food to stay on the plate. The process can be summarized as follows:
1. Determine the “just right challenge” for the family and the child. Break things down to what is doable today.
2. Implement gentle persistence.
3. Be cognizant of what you can control and what you cannot. The family and therapist control the treatment strategies; the child controls the pace of progress.
4. Remember the goal: Good growth and development; a happy relationship with food.
5. Keep your expectations modest because you might not get what you want. Individual tastes and preferences are very personal. Accepting someone just as they are, especially a child, is a huge gift.
With time and patience, teamwork, and a carefully designed treatment plan, a well nourished child and peaceful mealtimes are entirely possible.