This blog post expands on feeding strategies discussed in the article “How to Promote Positive Eating Habits in Children Diagnosed with Autism.” Please read this post to better understand why specific strategies are used during an OT feeding session.
What is Occupational Therapy?
“Occupational therapy enables people of all ages to participate in daily living.” (American Occupational Therapy Association, 2024).
An occupation consists of anything a person wants, needs, or has to do to provide meaning to a person’s life. Occupational Therapy (OT) is a health care profession promoting daily activity independence. Occupational Therapy practice at Bierman Autism Center focuses their therapy sessions on the occupation of play to help improve life skills like fine motor, gross motor, visual-motor, self-care, sensory processing skills, and quality of life and well-being.
To learn more about occupational therapy, check out the blog post by Maeve London titled “Occupational Therapy for Autism.”
Approximately 90% of children with autism experience feeding difficulties (Yang, 2017). At Bierman Autism Center, Board Certified Behavior Analysts (BCBA’s), Speech Language Pathologists (SLP’s) and OTs all work together to develop feeding goals for clients that focus on behavioral interventions, oral motor skills, sensory processing, and caregiver education.
What Does an Initial OT Feeding Evaluation at Bierman Entail?
When a client is first evaluated for occupational therapy services at Bierman, caregivers will fill out an intake form in which they can list specific concerns related to daily tasks with fine motor skills, gross motor skills, sensory processing, visual-motor skills, self-care skills, or feeding.
If parents list feeding as a concern, the occupational therapist and will then provide another intake form with questions specifically surrounding mealtimes and food consumption.
OTs will want to know more about:
- What a normal mealtime looks like
- What specific foods your child is currently eating, and what foods do they refuse
- Concerns related to chewing/swallowing food
- Past medical history (g-tubes, acid reflux, vomiting, etc.)
- Utensil use (can your child use a fork, spoon, or knife efficiently?)
- Specific goals surrounding feeding therapy
Once this information is obtained, the occupational therapist and occupational therapy assistants will observe the client during everyday activities and mealtime and follow up with parents to discuss feeding in more detail.
A Few Examples of What OTs Observe:
- How the child holds his/her eating utensils
- How long it takes the child to eat
- What types of food are eaten during mealtime
- Positioning – how the child is sitting during mealtime or if they do not sit while eating
- OTs will then develop feeding goals and discuss the care plan with parents, SLP, and BCBA.
Case Example
Name & age have been changed for client privacy
Norma is a 4-year-old female who has been evaluated for occupational therapy services to address feeding concerns and daily activities. Her parents reported that She is very selective in what she eats and pushes away any novel food that is presented to her. Her parents do not have concerns related to using utensils during mealtime. Norma does not currently have a set mealtime schedule and grazes throughout the day. She has unlimited access to juice/water throughout her day.
Foods Norma Currently Eats:
Foods Norma Used to Eat & Now Refuses:
- Graham Crackers
- Mac n Cheese
- Pretzels
- Oatmeal
- Chips (cheddar, Cheetos, sour cream)
- Strawberry Yogurt
- Vanilla Wafers
- French Fries
- Yogurt Bites
Where to Start?
With this specific client, I started by identifying foods similar to her preferred foods but different in one way (look, texture, size). I chose to start by introducing one novel food: goldfish. This client loves crunchy, cheddar-flavored chips, so I wanted to start with something very similar to what she already eats.
One intervention technique that I use involves following the Hierarchy of Sensory Exposure. Repeated exposure to the same food is important; working through the steps listed below is a great way to start.
- Tolerate in the same room
- Tolerate on your plate (look)
- Smell
- Touch with an object/preferred food
- Touch with fingers
- Pick up
- Put on body from back of hand and up to face
- Put on lips (kiss)
- Put on teeth
- Put on the tongue (lick)
- Hold in teeth
- Bite
- Bite through and spit
- Bite through, chew, and swallow
Important Feeding Strategies:
- Always present a preferred food alongside a novel food to reduce anxiety/stress
- Never force your child to take a bite of food
- Do not hide novel food in preferred foods – show your child you are combining the food. Hiding novel foods in preferred foods can make your child less trusting in what you are feeding them & may result in them refusing to eat the preferred food.
When Norma started OT, she would not tolerate the goldfish in the same room as her preferred foods. Over time, she became more comfortable with the food on the table next to her preferred foods. She then accepted the food on her plate next to her preferred foods.
Throughout the OT sessions, she and I worked through the Hierarchy of Sensory Exposure and utilized different techniques to help her engage with the food in everyday life, such as:
- Watching ourselves kiss, lick, or bite the food while looking into a mirror or camera
- Utilizing fun utensils (character toothpicks, plates)
- Feeding the food to preferred toys (dolls, figurines, etc.)
- Crushing the food and combining it with preferred food crumbs
- Singing songs while interacting with the food
- Breaking the food into small pieces
Other strategies I used involved:
- Creating a set mealtime to limit grazing
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- Grazing does not allow children the opportunity to feel hungry. When children have the opportunity to feel hungry, they are often times more willing to explore novel foods.
- Limited juice intake to one cup of juice before lunch. The client was previously drinking up to 2 cups of juice before mealtime and was therefore feeling full during lunchtime.
When to Stop:
- If the child requests to be “all done” with a specific food (you can always try it the next day!)
- If the child gets up and leaves the table repeatedly or visibly looks anxious/upset during feeding
- If the child is visibly upset when you move onto a new step within the Hierarchy of Sensory Exposure
- Go back to a step previously mastered on the Hierarchy of Sensory Exposure.
It can take a long time for a client to try a new food. For Norma, it took her over a year to put a new food into her mouth. She has grown in her relationship with food and continues to be more comfortable around novel foods. Currently, we are working on the last step in the hierarchy of sensory exposure in OT sessions. Norma’s most recent success involves taking a bite, chewing, and swallowing a Sun Chip!
References
American Occupational Therapy Association. AOTA. Retrieved March 28, 2024, from https://www.aota.org/
Yang, H. R. (2017). How to approach feeding difficulties in young children. Korean Journal of Pediatrics, 60(12), 379-384.
