Diagnosis and Management of Sensory vs' BehaviorallyBased Feeding Disorders

1
Diagnosis and Management of Sensory vs.
Behaviorally-Based Feeding Disorders

• Arden Hill, MS, CCC-SLP
• Sarah Halloran, MS, CCC-SLP
• Childrens Speech Feeding Therapy, Inc.

2
Prevalence

• Feeding disorders occur in (Rudolph Link,
  2002)
• 25-35 of developmentally normal children
• 40-70 of children with developmental
  disabilities and/or chronic medical conditions

3
Sensory Issues

• Where do they come from?
• Prematurity
• Chronic illness
• Multiple medical interventions/medications
• Underlying neuro issues
• Diagnosis with SI as a component

4
Sensory Issues

• Where do they come from?
• Unpleasant oral-tactile experiences
• Delayed introduction of oral feeds
• GI issues

5
Behavioral Issues

• Where do they come from?
• Bad habits/desperation
• Poor limit setting
• Lack of mealtime structure and routine
• Passive eating with distractions
• Inconsistent expectations re eating

6
Sensory Issues with Behavioral Override

• Behaviors often stem from somewhere else
• Normal cognition yields behavioral issues
• Children with underlying sensory issues rarely
  just eventually eat
• Underlying issues must be addressed
• Similar rules imposed with eating as with other
  behavioral management

7
Sensory Issues - Presentation

• Often avoids whole foods or texture groups
• Difficulty tolerating sensory input
  sight/smell/touch/taste
• Eats the same regardless of people/place
• Overstuffs oral cavity/takes tiny bites
• Stores food for later
• Gags as a sensory response
• Excessive drooling

8
Behavioral Issues - Presentation

• Rarely selective avoidance
• Eats better for certain people/places
• Gags to get attention
• Rarely underlying neuro or medical issue

9
Abnormal Sensory Responses

• Hyposensitivity
• Hypersensitivity
• Assess the childs comfort level with food within
  the sensory domain and begin your treatment at
  that level

10
Hyposensitivity

• Reduced awareness of non-nutritive and nutritive
  stimuli in the mouth, heightened sensory
  threshold to oral input
• Poor suck
• Liquid pooling
• Liquid loss
• Gag (protection vs. rejection)
• Overstuffing/pocketing

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Hypersensitivity

• Heightened awareness of non-nutritive and
  nutritive stimuli in the mouth, decreased sensory
  threshold to oral input
• Heightened gag
• Refusal of foods
• Refusal to progress in textures

12
Hunger/Satiety Patterns

• Children with GI issues,
• Prematurity
• Alternative means of nutrition
• Grazers
• Medication may aid in stimulating hunger

13
Behavioral Issues

• Behaviors stem from somewhere
• Children with clearly defined feeding issues
  rarely just eventually eat
• Underlying issues must be addressed
• Similar rules imposed with eating as with other
  behavioral management

14
Critical Information to Consider Prior to
Initiating Treatment

• Medical History
• Underlying diagnosis
• GI issues
• Surgeries
• Medications

• Feeding History
• Early feeding history
• Primary means of nutrition
• Previous treatment

15
Critical Information to Consider Prior to
Initiating Treatment

• Developmental History
• Cognitive abilities
• Communication skills
• Motor skills (i.e., physical and occupational
  therapy)

• Nutrition
• Anthropometrics
• Dietary restrictions and food allergies
• Supplements

16
Critical Information to Consider Prior to
Initiating Treatment

• Psychological and Behavioral Issues
• Emotions of child and family
• Anxiety/depression
• Behaviors at mealtimes and in other settings
• Structure and limits in the childs environment

• Family Dynamics
• Cultural
• Socioeconomic
• Environment
• Parents/Siblings
• School/Daycare

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What is sensory integration?

• Sensory pertains to our senses
• Hearing, sight, smell, touch, taste, and
  perception of motion/movement and gravity
• Integration refers to the process of unifying and
  allowing the brain to use the information that
  the senses gather and take into the body

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Sensory-Based Feeding ProblemsNon-nutritive
Stimulation Protocol

• Oral stimulation of the lips, teeth/gums, cheeks,
  tongue, and palate with Nuk brush
• Develop tooth brushing protocol for therapy and
  home
• Introduce mild tastes on finger, cloths, and
  brushes as tolerated

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Sensory-Based Feeding ProblemsSensitivity to
Food Experiences

• Visual
• Olfactory
• Tactile
• Gustatory

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Sensitivity to Food ExperiencesVisual

• Non-mealtime visual experience
• Object-based, picture-based system
• Establish comfort level with food proximity
• Work on tolerating food on the table, on the
  childs plate, etc.

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Sensitivity to Food ExperiencesOlfactory

• Introduce mild smells
• Establish comfort with proximity to smells
• Handling directly
• Presenting on another object
• Increase intensity of smells
• Scented therapy tools

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Sensitivity to Food ExperiencesTactile

• Water play
• Sensory bean bags
• Painting with food GET MESSY!!
• Food activities (i.e., flower pots, boats,
  gingerbread houses)
• Cooking activities
• Pizza, muffins, waffles, fruit salad, soup

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Sensitivity to Food ExperiencesGustatory

• Hierarchical Approach (Toomey, 2000)
• Kissing
• Licking
• Bite and remove
• Bite, chew and spit
• Bite, chew, swallow
• Consider taste, temperature, texture
• Structure movement through hierarchy with an all
  done bowl

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Treatment of Poor Hunger/Satiety

• Guidelines for following normal mealtime schedule
  including 3 meals and 2-3 snacks daily
• Pair tube feedings in high-chair/booster seat
  with or immediately after the oral feeding
• Medication may aid in stimulating hunger

25
Management of Behaviorally-Based Feeding Problems

• Rule-out medical, motor, or sensory involvement
• Parent education
• Promote ownership in older child
• Referral to behavior specialist and/or
  psychologist/psychiatrist

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Use of Reinforcement as a Part of Feeding Therapy

• Use reinforcers to develop new skills
• Age appropriate reinforcers including puppets,
  books, peg boards, card games
• Natural reinforcers should be used at home
• Homework sticker charts