healthy living

Sensory Issues in Feeding Small Children

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

Introduction:

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.  

 

 

Helpful Suggestions: For Parents of Elementary Students

This article was written by Cortney Modelewski, MA, LPC professional counselor at Cognitive Behavior Solutions and an active member of SMEDA.

For Parents of Elementary Students:  Working to Create a Positive Relationship with Food

My daughter decided she didn't like jelly after coming home from a sleepover. Her friend declared hatred of all fruit-flavored spreads, and my daughter soon followed suit and has not eaten jelly, jam, preserves, or marmalade within the last three years.
    
She is eight, and she continues to struggle with the conflicts between her wariness of food, her environment, and her hunger. These challenges are typical of elementary age children, especially younger ones.  Dovey et al (2008) provided a review of the research on children's eating behaviors. They outline the difference between what people call “picky eating,” which is having inadequate variation in diet, and “neophobia,” which is refusal or reluctance to try new foods. Environmental (i.e. home, school, and culture) and genetic factors play roles in how and why children develop these eating behaviors.

While you can't change your child's genetics, you can make changes to their environment. Here are a few tips from my household, which consists of a couple of vegetarians and a meat-and-potatoes guy, who collectively have food neophobia, sensory processing issues, food intolerance, and a food allergy.

1.    Caretakers are role models. I am not a big fan of breakfast. My child has started to say she doesn't like breakfast. I decided to suck it up and eat some toast in the morning because I want my child to eat breakfast before going to school.
2.    Enlist authorities. Our pediatrician gave my child the same speech I had given, but my child responded to the pediatrician because she's a doctor. She also started eating red peppers after a dietitian came to her school and talked about how vegetables are awesome.
3.    Make food fun! Kids like to make their own creations, and also like it when they have surprises at mealtime.
4.    Negotiate packed lunch menus. Say, “Would you like baby carrots or cucumbers in your lunch?” If my daughter has a better idea, such as broccoli, I am all for it.
5.    Try to have everyone in the family eat the same things. My husband may throw some meat on his plate of spaghetti, but we're all still eating spaghetti. This ties into the first tip. Also, your family does not pay you to be a short order cook, so don't do it. It's more frustrating and reinforces problematic beliefs and behaviors your child may have.
6.    It's okay to be frustrated when your child doesn't eat, but try not to fight. I have had many dinner wars in my time as a parent, especially after a cooked meal has followed a twelve-hour workday. Not worth it. Ask your child to taste the food – which doesn't need to include chewing and swallowing – and then drop it for the night.
7.    Unless you have a specific diet due to religious beliefs, there is no reason to call food good or bad, and if a person in your family has a medical problem that restricts certain foods, giving the restricted menu to your entire family every so often may help the child and others in the family understand the need for meals.

If you are concerned about your child's eating habits, do not be afraid to make an appointment with their primary-care provider to discuss these concerns.  UWHealth (2014) notes some red flags including weight loss, choking on food, frequent complaints about stomach pain, vomiting or diarrhea after eating, and moodiness. Your child may have a treatable eating disorder, anxiety disorder, or medical condition.

References and Resources

Terence M. Dovey, Paul A. Staples, E. Leigh Gibson, Jason C.G. Halford, Food neophobia and ‘picky/fussy’ eating in children: A review, Appetite, Volume 50, Issue 2, 2008, Pages 181-193, ISSN 0195-6663, http://dx.doi.org/10.1016/j.appet.2007.09.009.

University of Wisconsin Hospitals and Clinics Authority [UWHealth] (2014). Health facts for you.  https://www.uwhealth.org/healthfacts/parenting/518.pdf

We Can! Ways to Enhance Children's Activity and Nutrition. https://www.nhlbi.nih.gov/health/educational/wecan/index.htm

Back to Basics: Positive Body Image (Watch for Warning Signs of Eating Disorders)

     This month’s article was written and provided by Lindsay South, MA, LPC, RPT and the president of SMEDA and an active member of our group since the foundation of the organization.  She has been in practice since 1988 and treats children ages 5 to 12, adolescents, adults and families, working with issues like attention deficit and hyperactivity, learning disorders, weight and body image, eating disorders, divorce adjustment and trauma.

   

Watch for Warning Signs of Eating Disorders

     As summer is in full swing and bathing suits and shorts abound, many young teens become self conscious about their bodies. Both boys and girls are feeling more and more pressure to maintain a certain body type.

     The Winter 2006 issue of the National Eating Disorders Association (NEDA) newsletter points out that, although obesity among teens has doubled in the last 30 years, so has the emphasis on eating, exercise and weight. Messages about diet and exercise can become triggers for some teens to develop an eating disorder.

     In my practice, parents often bring a reluctant child in for counseling about eating. Adults report a confusing picture of their child’s weight changes, different eating patterns and food choices.

     Why is one teen affected and not another? Why are some girls, and a growing number of boys, more likely to take an attempt to lose a few pounds and change eating patterns into a clinical eating disorder?

      Research suggests that eating disorders do have a genetic component. Numerous studies reveal that children with a family history of either bulimia or anorexia are at greater risk for developing one of these disorders themselves. Strong themes of perfectionism, competitiveness and drive, which may be harnessed successfully by siblings or parents, if turned toward dieting, can produce obsessive dieting and exercise behavior.

      Trauma or intense family conflict can certainly make children vulnerable to the development of an eating disorder. Environmental factors, including media and advertising, are a tremendous influence. Uncharacteristically thin views of women and extremely buff, bulked up men fill magazines of young readers. This constant barrage of unrealistic body images creates a lot of body dissatisfaction.

      How can you help your puberty-aged child? NEDA developed these guidelines to provide a healthy “to do” list:

  • Model fitness and balanced nutrition by striving to feel good, not achieve a certain appearance.
  • Help your children feel good about themselves no matter what they achieve.
  • Remember that dieting is not innocent behavior; it alters neurochemistry.
  • Intervene rapidly through expert consultation when dieting appears extreme and increasingly compulsive.
  • Take off blinders and be objective about any changes in behavior and eating habits.
  • Encourage self expression, verbalization of emotions, and independent thought and action whenever possible.
  • Have an open door policy of talking to your child about everything — magazine articles, family conflicts, school difficulties, relationship problems, etc.
  • Encourage eating all foods in moderation, rather than labeling particular foods “good” or “bad” or going on a restrictive diet.
  • Discourage extreme perfectionism and exactness in everyday activities.
  • Encourage a balanced lifestyle with attention to play, relaxation, work, relationships and spirituality.
  • Address family conflicts and sources of strain openly and honestly.

      If you have tried these principles at home and continue to have concerns about your child, one of the best places to go for an initial consultation is your pediatrician. Locally, the Southwest Michigan Eating Disorders Association maintains a website, http://www.southwestmichiganeatingdisorders.org/, which additional resources and a listing of nearby physicians, registered dieticians, and counselors skilled in the treatment of all types of eating concerns. Getting a jump start on eating related problems is far easier than treating a more entrenched disorder.