Feeding Tips for Young Children

Editor’s note: This text is an edited transcript of the webinar, Feeding Tips for Young Children, presented by Tara Warwick, MS, OTR/L.

Learning Outcomes

At the conclusion of this course, participants will be able to:

• Identify three reasons children do not eat.
• Identify three important factors for family meals.
• Describe the steps for trying new foods.

Introduction and Overview

Today, I'm going to share some feeding tips for young children. This can be a struggle, not only for families, but also for teachers and therapists. As such, it's usually a pretty hot topic. I've heard the saying that you can only control two things: what goes into your body and what comes out of your body. Feeding can be a big struggle, because that's one thing that children have some control over.

First, we're going review some statistics about feeding. Next, I'm going to discuss the developmental progression of feeding. After that, we're going to talk about some tips for feeding that can be used at home, or in the classroom. Hopefully after today's session, you will be able to share and implement some good strategies for helping increase the diversity of children's diets.

Feeding Statistics

In the United States, 25-35% of children have feeding problems. That amounts to nearly one out of every four children. Additionally, 40-70% of children with chronic medical problems have feeding disorders. If you work with children who have chronic medical issues, such as respiratory problems, chances are good that they may also have a feeding disorder. As if that weren't enough, feeding disorders can lead to malnutrition, congestion, frequent illness, and have an impact on sleep and behavior. Most of the children that I work with have autism, or some kind of challenging behaviors, and I would say a large percentage of them have sleep and behavior issues.

Interestingly, only 10% of feeding issues are from parenting, and 90% are due to some other issue. Feeding is very stressful for families. We may assume that when children won't eat, it's the fault of their parents. Many of us wrongly believe that the parents simply aren't making the child eat, instead of looking at the other factors that go along with that. It is important to remember that feeding problems may be a result of sensory or biological factors. 

Finally, studies suggest that 20% of all children have some type of feeding and/or growth issue during their first five years of life, and another 5-10% have problems significant enough to warrant the need for more targeted feeding therapy. For those of us working in early childhood, we need to be mindful of the fact that one out of every four or five children we will be working with may have some type of feeding issue that affects many areas of that child's development in the first five years of life. 

Feeding Problems

Feeding problems can cause increased stress to families. When families come home from the hospital with their first child, and if that baby is not eating properly, that is worrisome to new parents. Feeding is the first relationship that develops between a child and caregiver(s). As a new mother bringing home a newborn baby, feeding is the first way that mother and child begin to bond. If it does not go well, it can create stress and anxiety.

Another thing to think about is that feeding is the most complex sensory activity in which children participate. There are many components that go along with feeding: textures, smells, tastes, the ability to use hands and eyes together. There is a lot more to feeding than people realize. If you've never had feeding issues, if you are fine with food, you don't realize how complex the process truly is.

Developmental Progression of Feeding

The developmental progression of feeding involves many different areas, including:

• Motor and cognitive development
• Oral motor development
• Self-feeding
• Acceptance and rejection
• Texture progression
• Eating preferences, smells and tastes
• Regulation of appetite
• Signaling satiety and dislike
• Signaling hunger 

We will take a look at each of these areas to understand where children fall on the developmental continuum, and what that next step might be for progression of feeding.

Motor and Cognitive Development 

At birth, babies can bring their hands to their mouth, and open their mouth in preparation to suck. At about two months, they start holding objects; at three months, they begin to put those objects into their mouth. At four months, babies start to hold their mouth and show visual exploration of objects. Then, between four to 11 months, babies start sitting with some support, gradually transitioning to sitting on their own. At nine months, they start using a pincer grasp with their index finger and their thumb, at which time they can start picking up little pieces of food, such as Cheerios. At 9-18 months, babies begin to utter their first words, and they might attempt to say words for known foods that they like. At around 12 months, they're recognizing food by sight, smell and taste. At 12 months and beyond, they visually group foods into different categories, perhaps starting to look at preferred and non-preferred foods. 

Oral Motor Development

Before birth, sucking and swallowing is observed in the womb. At birth, babies open their mouth to suck their fist. In newborns, we can also observe a gag response to food and objects, and babies can also move their tongue in and out, up and down. From two weeks of age to about nine months, they can show an open mouth for the spoon at an early age. This response is present before the onset of complimentary feeding, at four to six months. Beginning at around six months, the gag response declines, and babies become more accustomed to the feeling of food in their mouths, although we all still have some degree of gag reflex. At six months, they can start moving the food from side to side in their mouth.

At around 6-12 months, babies begin teething. At this point, they can start chewing softer lumps and keep most foods in the mouth. Soon, they start closing their lips to clear the spoon. After those teeth have come through, they can start biting harder foods, and then they can begin coping with most textures, but chewing is not fully mature. What I see in some of the children I work with, especially children who have difficulty with feeding, they use an up-and-down bite, instead of a rotary, more mature kind of bite. At two years, toddlers can manipulate, chew and tolerage most foods offered as part of a family meal. If you work with children who are having trouble feeding, it is important to think about these stages of oral development, in order to identify areas where they are struggling.

Self-Feeding

Anywhere from four to 11 months, babies start to hold onto food and bring it to their mouth. At eight months, they might begin to try to feed from a spoon without spilling. This is a good time to make sure you're encouraging families to let children explore food. It's okay to let them get messy, give them spoons, and provide them with different utensils so they are practicing at a early stage. At eight months to two years, they're starting to drink from a sippy cup, transitioning to an open cup at around 11 months to two years. Many children that I work with who have feeding issues also have trouble using an open cup. They exhibit difficulty manipulating and holding the cup, as well as managing the cup around their mouth. Some children do better with straws; some children have trouble with straws. By 15 months, most infants can feed themselves with a spoon. 

Acceptance and Rejection

Before birth, some children will inherit a strong dislike of bitter tastes and certain food textures. At birth, babies develop a preference for strong tastes, possibly from learned exposure to amniotic food in the womb. They may like tastes, such as garlic and spices, as well as energy dense sweet and fat foods. From birth to six months, babies learn strong taste preferences from the taste of their mother's milk. At around 4-6 months, with the introduction of complementary foods, taste preferences are rapidly learned, and babies easily accept new foods. This is an opportune time to introduce a wider range of tastes, and make sure that we're not limiting foods during this time.

At 14 months of age, toddlers start rejecting food. During this time, we need to be working diligently with parents. At 20 months to eight years of age, children may exhibit a neophobic response to new foods. In other words, they reject foods simply because they are unfamiliar. At two years of age, preferences now predict food preferences throughout life. If you're working with young children, it's critical to help them as early as possible, because when they get to age two, the stage is set for preferences later in life. While it is not impossible to increase or change preferences as we age, helping parents understand that offering diverse tastes at a young age is beneficial for their child later in life.

Texture Progression

At 4-6 months, babies can cope with pureed and mashed foods. At six months, caregivers can introduce lumpy solids, and mashed food with some soft lumps. At this age, babies can bite and dissolve, with a soft chew. At eight months, they can start coping with harder, lumpy solids. Most can chew without gagging at 12 months. Some of the children that I work have a hard time going from mashed food to mixed foods. Keep in mind that for some children, the ability to manipulate different textures in their mouth can be challenging for them.

Eating Preferences: Smells and Tastes

At birth, infants show preferences for known tastes and smells. At four months, they can learn to like and accept complimentary food quite quickly and with variety. Once again, this is an opportune time when we can introduce more variety. At nine months, they can begin to understand that similar looking foods might taste the same. At 9-14 months, they start pointing to and request foods that they know they like, possibly using words or sign language, if they've learned some baby signs. This is where we see children with autism having trouble, because most children with autism don't know how to point at this age. As such, we might have more difficulty figuring out what they like, because children with autism are not able to tell us at this time.

At 14-16 months, babies begin to imitate adults' eating preferences. Therefore, at this stage, we need to make parents aware that their children are starting to pay attention to their eating preferences. At three years of age, children begin to imitate their peers' eating behavior. In early childhood settings, many times you will hear that foods a child eats at school they would never eat at home. At this age, that social imitation becomes very important. They may eat things, just because their friends are eating it. At four years, the child's range of eating preferences predicts late child and adult range. Once again, early preferences can predict what kind of range they're going to have as adults.

Regulation of Appetite

At birth, infants can reject a milk feed, resulting in a partial regulation of their calorie intake. At two months, infants have a good regulation of intake according to their internal cues. Once they reach four to six months, infants show regulation of intake of breast milk and complimentary foods. Also at four to six months, infants show preference for and rejection of foods. Additionally, they are able to respond to stressful meal time by refusing food. Stress is an appetite suppressant. In infants, all the way through older children, when children are stressed, they don't eat.

At 14 months of age, children are imitating adult eating. Once they reach about 24 months, they start imitating other children, and eat more in response to portion size. At 36 months, some toddlers respond to prompts to overeat. Also at this age, children reduce the amount eaten when pressured. Furthermore, they change their food preferences to be like their peers, and they also show preferences for restricted or withheld foods. In other words, when treats, such as cookies, are withheld, the child wants it more.

In my experience working with children who have feeding issues, you may hear doctors say, "Well, they won't starve themselves to death. Just wait until they're hungry." What I've seen, and what a lot of the research indicates, is that if you don't regularly offer food to children, they start losing their appetite, and they begin not to be hungry. We have to teach them how to be hungry again by offering meals every couple of hours, and providing snacks to start creating more of an appetite for them. If they're refusing food, and they are having some problems feeding, their appetite might not be like ours, where we get hungry every couple of hours and then we eat. Children with problems feeding are not going to start doing it on their own; we are going to have to teach and guide them.

Signaling Satiety and Dislike 

At birth, infants can show us when they're tired of something and they don't want it. They cry and they turn their head away from the nipple, they slow their suck, they push the nipple from the mouth, and you start to see different facial expressions to show us that they don't like something if they're tired of it. At four months, they might turn away from the spoon, or show that gag of disgust. At 12 months, they might throw their food or they say no to something that they don't want. At this one year of age, they can be distracted by toys and other contextual cues during meal times. Then at 14 months, after they have transitioned from a high chair to a toddler seat, they might physically move away from the meal or table.

Signaling Hunger

At birth, infants are able to root around and turn their head in search of the nipple. At four months, they show us that they're hungry by opening their mouth for food. They might move their head towards a spoon, they might watch for the food, or reach for their food. These are all ways that they can show us that they're hungry. At nine months, they might show a clear interest in feeding themselves, and point to the food they want. At 12 months, children might begin to say the words for foods they want. If you're working with a child who has difficulty with communication, they might find other ways to communicate what they like. For instance, it might be reaching for food, or the child may simply look at something that they want. I have had children who will throw everything off their tray except for what they want. For those who have communication issues, we might have to find other ways to see what those preferences are.

Picky Eaters vs. Problem Feeders

Dr. Kay Toomey, from the STAR Institute for Sensory Processing Disorders, has outlined the differences between picky eaters and problem feeders (Toomey, 2000). You can view her work here.  We all have likely had children who are picky eaters. Toomey's guidelines can help us determine when to get additional help for children who need it, in the form of targeted feeding therapy. These guidelines include:

• A picky eater has 30 or more foods in their repertoire. A problem feeder has less than 20 foods in their repertoire.
• Picky eaters and problem feeders will both often experience food jags (when a person will only eat one food item, or a very small group of food items, meal after meal). When someone eats a particular food every day, one day they may decide that they can't eat that food anymore. I have seen this happen a lot in children with autism. Parents will tell me that their child used to eat chicken nuggets every single day, but then one day they didn't want them anymore. With picky eaters, if they take a two-week break from that food, they may gain it back after having that time away from eating it. However, a problem feeder will likely never want to eat that food again.  
• Picky eaters will eat at least one food from most all nutrition or texture groups (e.g., purees, proteins, fruits). Problem feeders refuse entire categories of foods. For example, they might not eat any protein, they might not eat any meats, they might not eat any fruits or vegetables. If they completely refuse food from one category, that's a problem feeder.
• A picky eater can tolerate new foods on their plates. You're able to fix your family meal, and add a new vegetable on their plate. They may not eat it, but they can at least tolerate it being on the plate. In contrast, a problem feeder might cry, scream and have a tantrum when any new foods are presented. 
• A picky eater might have a different set of food at the meal, but they can sit at the dinner table at the same time with the rest of the family. Problem feeders can't do that. They eat a different set of foods, at a different time, and in a different location.
• Picky eaters may sometimes be reported as picky eaters at their well-child visits, whereas problem feeders are persistently reported as picky eaters.
• A picky eater can learn to eat new foods in 20-25 steps. Problem feeders require more than 25 steps to learn to eat new foods. They need a lot more work and more time to add new foods to their repertoire.

Why Children Will Not Eat

There are biological factors, as well as behavioral factors, that contribute to why children will not eat. Many times, the biological factors will lead to behavioral factors which cause the child not to eat (www.centerforautism.com).

Biological factors. A child might have some kind of physical complication that makes eating challenging, such as a cleft palate or some type of oral motor difficulties. When I'm looking at children and at their eating abilities, I'll see how they are manipulating food in their mouth, and whether they are moving the food from side to side, or if they are pushing it forward. If children have a hard time manipulating food in their mouth, they're likely not going to eat vegetables or meats, because chewing those foods entails a lot more movement in the mouth. 

In additional to physical issues, a child might have some kind of medical complication. Perhaps they've had reflux or allergies. It is possible that they have experienced bowel-related issues, such as constipation or diarrhea. As stated earlier, children who have respiratory issues are highly likely to be problem feeders. If you think about it, if a person can't breathe or hold their body upright, eating is going to be a lot more difficult, because that person is using all their energy to breathe and to hold their body upright.

Behavioral factors. Sometimes, children don't eat due to consequences from feeding. It may be the ability to get their desired food item. Perhaps the child is trying to avoid a non-preferred food item. You may have seen it happen where a child is presented with a non-desired food item (e.g., spinach), then the child cries, screams, and gets away from the table. Where some of those feeding issues may possibly have started as biological factors, they now have turned into behavioral factors, where the child has used different behaviors to get out of their feeding.

Interesting Thoughts

I attended a feeding training with Dr. Kay Toomey and Dr. Erin Sundseth Ross. I learned some interesting and eye-opening things from that training. First, I found out that adrenaline is an appetite suppressant. Stress decreases your appetite. When I talk with teachers, therapists, and parents, I inform them that if children aren't happy, if they're not calm, they're not going to eat. When we're stressed as parents, therapists and teachers, and we're trying to get children to eat, it's not going to work. We have to be relaxed, and we have to encourage them to be relaxed. Using force to get a child to eat is not going to be effective, especially with children who have had long-term problem feeding issues.

Next, it takes two years for an average child to learn how to eat. This is not an overnight process. It took years for children with feeding issues to have this food repertoire, and it's going to take time for them to learn how to tolerate and eat new foods.

It takes children an average of ten times to eat a new food before adding it to their repertoire. That's an average child. For a child with developmental delays or autism, it's probably going to take a lot more than ten times. The main point here is that we must repeatedly expose children to foods before we expect them to eat a new food.

Eating from 1-6 months is reflexive; after six months, it's a learned behavior. As such, we have to be thinking about feeding as an opportunity for teaching positive eating behaviors.

How Should We Think About Food?

Often, we place judgment on food. We label foods as good or bad. Certain foods are only for dessert; if you eat this, then you can have that. A lot of times, we use food as a reinforcement. Sometimes we have to, but with children who are problem feeders, we need to look at not putting judgment on food. It's not good or bad -- it is what it is. Help families label foods as what they are: fruits, vegetables, proteins or starches. Everything will fit into those four categories. In our descriptions of food, instead of using the terms "good" or "bad", we're going to use descriptors, such as that food is hard, crunchy or soft. Or, pay attention to the color of food (that pepper is red, that celery is green). We can also describe what the food smells like, or whether it is cold or hot. We're seeing the food as it is, versus putting judgment on it.

Steps for Helping Children with Feeding Issues

We're going to go through the following six steps for helping children with feeding issues: 

1. Positioning (90-90-90)
2. Family meals (or, in an early childhood setting, eating snacks/meals with peers)
3. Teach "eating"
4. Be aware of other contextual factors
5. Make it fun
6. Special accommodations for individuals with developmental disabilities

Positioning

Another eye-opening fact that I learned from the training I attended was that breathing is the body's number one priority, and postural stability is number two -- it's not eating. As I stated earlier, a lot of people have the thought process that children will eat eventually; they won't starve themselves to death. The body's number one priority is breathing. In the training I attended, they conducted an exercise where they had us lean over, such that we had a poor position. Then, we tried to breathe and hold ourselves up. During this exercise, it was extremely difficult to think about eating and how to feed ourselves when we weren't able to breathe or sit up properly.

From the very beginning, when working with children who have feeding problems, we must first check to see if the child is stable with good positioning. The rule of proper positioning is 90-90-90. Are the child's ankles, knees, and hips each at 90 degrees? Their feet should rest flat on a floor, or some type of surface. Their back should be against the back of the chair, and their elbows should rest on the table.

Tips for positioning. First of all, most desks and tables in early childhood classrooms are adjustable. I often witness children using chairs that are too big and tables that are too tall, and all it takes is a simple adjustment with a screwdriver. Keep in mind that it is better to adjust to be too small than it is to be too big.

Next, when working with a child, bring the child up to your level. As therapists and early childhood providers, we also have to think about our positioning. If we're always leaning over, it's not good on our backs or bodies. At our feeding clinic, we use Keekaroo chairs. These Keekaroo chairs can help bring the children up to our level, and they're highly adjustable.

Think about some kind of footrest to put under the child's feet. If a child's feet are kicking around all the time and they can't stabilize themselves, they're going to have trouble eating. You don't have to spend a lot of money. For example, you could use phone books or large boxes to put underneath their desk. 

Finally, support behind a child's back is essential to good positioning. If they are leaning backwards, there may be too much room behind them. You could place a pillow or cushion behind their back to help them sit up at 90 degrees. I've also used wedges made out of large three-ring binders to help tilt the child's pelvis a little bit so they can sit up properly. 

Family Meals

Another measure that can be used to help children with feeding issues is to encourage family meal time (or, in the ECE setting, group snack/meal time). For one of the preschools that I consult with, we changed the way that we did our snack time and our meal time, and it helped with feeding.

When you have family meals, the child should not be the highlight: the food is the focus. Additionally, meals need to be enjoyable, remembering that adrenaline and stress are appetite suppressants. If a child does not enjoy being at that meal, they're not going to eat.

Involve the child as much as possible during meal or snack time. Have the child help prepare the meal/snack, help set the table, and allow them to help with serving the meal/snack. The more they're involved, the more exposure that they're going to have around that food. As I stated earlier, it takes ten times for a typical child to try a new food. If we can get them more exposure to the food, it can help increase the likelihood that they might add that food to their repertoire.

Another big change that we made at our preschool was to start serving snacks and meals family style. Instead of handing out single snacks to each child, we started using containers to hold all the snacks. We made sure that there was something that everyone liked. The children would practice taking a snack, putting it onto their plate, and passing the container from peer to peer. This also serves to hone the childrens' social skills. Whenever we serve family style, it increases their exposure to that food. You may not wish to serve family style at every single meal, but choose a few meals that you're going to target. When doing this, it's important to make sure to include one preferred snack that every child likes. If a child does not like any of the food offered, the child will not want to sit there. At our preschool, we had ten children, and a few of them have autism. One of the children only liked spicy hot Doritos. We made sure to offer a bowl of spicy hot Doritos, so that child was sure to get something that he liked.

At first, the goal is to have the child eat the preferred item, and start learning about non-preferred items. Our goal is not to emphasize the quantity of food: it's to introduce diversity. When children have a diverse diet, and when they eat a lot of different foods, they eat more food. In the past, I've always been worried about the total amount of food, but now I worry more about the diversity and the variety of food offered. 

We also want to reduce distractions during meal/snack time. Turn off the television, put away the iPads and the toys. The goal with these meals is learning about the food. We use a learning plate for children who are having difficulty during meal times. Some children have a hard time even tolerating food being on their plate. For those children, we'll put a learning plate in front of them, and as we're serving family style, they can either put it on their plate or on the learning plate. The learning plate is not their plate, but it's teaching them gradual exposure to that food. It's still there, they're still interacting with the food, but it's not on their plate, because that might be too stressful for them. We want to set reasonable expectations for families. Have them start with small steps. At first, family-style meals could be implemented during one or two meals per week. Make sure it fits within their routine and their schedule, so that it is not a stressful environment.

Tips for family meals. Use reinforcement with caution. I used to be bad at using reinforcement to get children to eat food, which sets food on a hierarchy, versus teaching them about food. Use the same place, schedule and routine at each meal to maintain consistency. For instance, we all wash our hands, we sing some songs, we get our plates, and then we sit at the same table each time. Thinking about the size of bites on the plate: are they a good size for the child to manipulate? For children with feeding issues, they might have trouble biting and manipulating the food in their mouth, and that might be why they're not eating it. Could you cut it into smaller bites that makes it easier for them to manipulate? A general rule is one tablespoon of food per one year of age.

Keep the time in mind, and don't make children sit there for a long time. Snack time should be no more than 15 minutes; mealtimes should last no more than 30 minutes. Also, spread out meals and snacks 2.5 to 3 hours apart. Once again, we want to re-teach that appetite, where every couple of hours, we offer either a snack or a meal, and eliminate anything in between (e.g., additional snacking, milk, juice -- anything that might curb a child's appetite). Another valuable thing I learned from the training I attended is that sweets are an appetite suppressant. You'll see these children who are grazers, where if they are hungry, they will eat a few sweets, and then it suppresses their appetite such that they can go longer without eating.

Teach "Eating"

In order to instill good eating habits in the early childhood environment, we can adhere to the following guidelines:

• We are not nutritionists -- we are teachers. As such, we need to approach teaching eating as a skill that children can learn.
• The more variety a child has, the more volume they will eat. When children have a variety in their diet, they're going to eat more. 
• Encourage positive interactions with the food. Allow children to play with the food, and encourage the use of utensils.
• Children will not eat if they are stressed.
• Think about teaching problem feeders through gradual exposure, versus flooding. Gradual exposure is when you introduce new foods to the child a little bit at a time. Put new foods on the learning plate, and have the child touch it, smell it, and interact with it gradually. This is a more effective approach than telling the child they aren't going anywhere until they finish their plate. 
• Hunger can be re-taught. Every couple of hours, offer snacks and meals, and avoid in-between snacks and drinks. 
• Expand on what the child already likes using food chaining. For example, if a child only likes red fruit snacks, try a giving them a different color fruit snack, because it has the same texture. As a next step, you might try a different brand of fruit snacks. Going even further, try offering dried fruit, and finally graduate to actual fruit.
• Eliminate food packaging and containers. Many children memorize a particular food's label and packaging, to the point where they'll only eat food from those packages. Trying to eliminate those visible factors. Remove the food from its packaging, so the food stands alone, and the child cannot associate it with the packaging.
• Food jags. As stated earlier, a food jag is when you eat the same thing every day, and then you drop it. A general rule for food jags is that if you eat an item one way one day, make it a little different the next day. Then on the third day, you can go back to it, but it needs to be different the next day. There needs to be enough of a change that the child knows there's a change, but they'll still eat the food. For example, one day, cut the child's sandwich at an angle, from corner to corner; the next day, cut the sandwich into rectangles. The change needs to be noticeable, but still tolerable.

• Concentrate on the food, not the behavior.

Steps to eating. There are a total of 32 steps involved in the eating process (Toomey & Ross, 2011). For the purposes of today's presentation, we will consolidate them into four basic steps:

1. Tolerate: The first step in the eating process is to tolerate food. The child must tolerate being around the food, seeing the food, having the food on their plate or on the learning plate, and the food being placed on the table. Some children can't even tolerate seeing it in the room. In these more extreme cases, we're going to have to start with small steps for gradually getting them to tolerate the food. 
2. Interact: Next, the child needs to start interacting with the food. For example, we can encourage them to use a spoon to stir the soup, or they can use a fork to poke the cheese.
3. Smell: Smelling the food is another step in the eating process. 
4. Touch: Finally, the child must be able to touch the food, not with a spoon or a fork, but with their hands and fingers. Once the child can touch it with their hands, we can transition to having them try to put foods into their mouth, although they might spit it out at first.

Be Careful with Other Contextual Variables 

What is going on at mealtime? Is the TV on? Where is everyone sitting? What else is happening during the meal? What are the interactions like? You'd be amazed at how many children will start pairing their mealtimes with other things. For instance, I worked with a child who would only eat when SpongeBob was on, because that was the only way his parents were able to get him to sit still. As a consequence, he started associating eating with watching SpongeBob, and he would not eat unless that program was on. We had to think about how we could gradually eliminate SpongeBob from mealtime, so that he would be able to eat without that television show.

Make it Fun

Let children have fun with the meal. Find different cook books. Buy supplies that are kid-friendly. They have a whole line of different kid-friendly kitchen items. Find times outside of the meals to interact with the foods, so it doesn't have to be at actual meal times. Sometimes, I'll work on incorporating new foods outside of mealtime, where the child is just interacting with it, and not eating it. When children are hungry and they're stressed, they might not be in the right frame of mind for trying new foods. Let them get messy. This can drive some parents crazy, but when they're messy, they're interacting with the foods. Finding creative ways to interact with the food helps a child to gain more exposure to the food.

Specialized Accommodations

If you work with children who have developmental disabilities or physical impairments, or children who have autism or attentional issues, you might need to use adaptive utensils. If they're having trouble holding a spoon, you could try using a large grip spoon. Perhaps the child would benefit from a suction plate, so the plate doesn't move around. Children who have trouble drinking could use different types of cups and other adaptive drinking aids. 

Do you need to use visual supports? Working with children who have autism, it can be helpful to outline what they're going to do for the meal, so they can see the steps involved: 

1. I touch the food.
2. I smell the food. 
3. I lick the food. 

Do you need to use tangible reinforcers? First, I would try going without tangible reinforcers. However, if you have a child who is completely disinterested in any of the foods, you might have to use other types of reinforcers to get them to sit at the table, and to interact with the food. Additionally, in some cases, a timer can be helpful to indicate how long to sit at the meal, or how long before the transition to the meal. 

Case Study: Michael

Michael is a five-year-old boy with autism who had a very limited diet. He would be considered a problem feeder. His diet consisted mainly of Vienna sausages, Goldfish crackers and Capri Sun. He was having a lot of issues with constipation. His mother wanted to add more fruits and vegetables to his diet. He had no other medical issues. 

Improve Positioning

The first thing we did was examine Michael's positioning. During mealtime, he was sitting at the kitchen table, and his feet were all over the place. The chair was way too big for him, and the table was up too high. To stabilize his feet, we put some blocks under his feet. Next, we placed a couch cushion behind him to help him sit forward, which helped him to sit upright.

Organize Family Meals

Next, we helped Michael's family to organize family meals. They started a routine of doing three family style meals per week. They had a hard time even having a meal with him. Michael was one of those children who would have his own meal at his own time.

Explore Similar Food Options

We started looking for some similar options to his current food. With the Vienna sausages, we looked to see if there were any other brands he would eat. We looked at some mini hotdogs that were the same size. Additionally, Michael would only eat the Vienna sausages directly out of the can. We tried to get him to eat them off of a plate, as well as served in different ways (e.g., cut up, sometimes heated up, sometimes cold).

For the Goldfish crackers, Michael's preference was the orange, cheddar flavored ones. There are also rainbow colored Goldfish, as well as pretzel Goldfish, so we tried to build his repertoire based on that. We would gradually do that until we started looking at more fruits, vegetables, and things like that. If we were to put a fruit or a vegetable on his plate, he would freak out, and he would not even sit there. We had to slowly and gradually expose Michael to these food changes.

Use Visual Schedule

We also used a visual schedule to create a routine so we could show Michael the order of events that go along with mealtime. Our routine was:

• Sensory activity: Because he was getting ready to sit still, Michael would first jump on a trampoline 20 times, and then he would blow bubbles five times.
• Wash hands
• Sit at the table for a family style meal.
• Scrape remaining food into the trash can.
• Put plate into the sink

Conclusion

Over time, going at a slow and steady pace, we were able to increase the variety of Michael's foods. We were successful, because we had a full commitment from the family. 

In conclusion, family meals are important. In order to help problem feeders, we need to talk about food in an objective way. We can teach children how to eat by building on their current food repertoire. Finally, make mealtimes fun and non-stressful. Further resources on this topic can be found on my website at www.todaysconsultingsolutions.com.

References

• Toomey, K.A., & Ross, E.S. (2011). SOS approach to feeding. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 20 (3), 82-87. doi:10.1044/sasd20.3.82
• Johnson, D. Differentiating sensory from behavior. Retrieved from www.summit-education.com
• Toomey, K.A. Picky eaters versus problem feeders. Retrieved from www.spdstar.org
• Fraker, C. Food chaining. Retrieved from www.parentguidenews.com
• Infant and Toddler Forum. (2014). Developmental stages in infant and toddler feeding. Retrieved from www.infantandtoddlerforum.org