For most of us, mealtime is a rewarding and enjoyable time of the day. We look forward to both the food and the social interaction. Imagine walking into your home and smelling fresh cookies baking or soup simmering. You hear the clanking of pots and pans and the whirl of the food processor. You ay associate the sounds and sells with familiar food and start to salivate. Your first thought may be, “How long until dinner?” For many of the clients we work with, mealtimes are frightening and challenging rather than enjoyable. Over the years, I have received countless numbers of referrals for children who reportedly had “behavioral feeding aversions. The vast majority of these clients have feeding aversions or “behavioral feeding issues. In some cases, well meaning families or therapists have actually created these aversions. Strict behavioral intervention programs may not recognize or treat the sensory or motor etiology of feeding disorders.

Consider the cases outlined below:
Jason is a five year old boy with a diagnosis of pervasive developmental delay. He is extremely hyper-sensitive to high pitched sounds. As his mother begins the preparations or dinner, Jason puts his fingers in his ears and begins rocking back and forth. The hum of the microwave and the buzz of the blender increase the intensity of Jason’s protests. Jason screams as his parents try to put him in a chair for dinner. Jason’s pediatrician suggests that he has behavioral issues. A more accurate assessment of Jason’s feeding aversion may be that his hearing sensitivities are so significant that the kitchen has become an unpleasant place for him to be.

Sarah is a ten-month-old baby girl. Initially she had trouble with bottle feedings which required several nipple and formula changes. She has a history of gastrointestinal reflux, which was addressed with position changes, thickened formula and eventually resolve with medication. She was also a difficult to calm baby who required complicated routines for bath time, dressing/undressing and bedtime. At six months of age, rice cereal was introduced. Sarah gagged and spit up. Her parents tried a variety of baby cereals, fruits and vegetables over the next few months. Sarah’s reaction was generally the same. She turned her head, pushed the food away and gagged on anything her parents were able to get into he mouth. Her parents were advised to ‘give her time and sell get used to food.” Her doctor was not overly concerned because he weight was staying on the charts due to her formula intake. Her parents were frantic. Through a sensory diet program we discovered that Sarah’s reaction to baby applesauce was very different if we put it in the freezer for fifteen minutes prior to a meal. She actually became an active participant in the mealtime experience! While dining in an Italian restaurant, her mother discovered that “Penne ala Vodka” was her favorite food. The bland taste of baby food and lukewarm temperature did not give Sarah enough information to be able to handle food successfully. In addition, her early bout with reflux made feeding an uncomfortable time of the day. Addressing underlying medical concerns improved her ability to handle feeding. A sensor diet which respected Sarah’s need for increased information made food considerably more enjoyable.

Alexandra is a two-year-old girl with a diagnosis of Down Syndrome. She reportedly did “fine” on a bottle and with pureed foods. When solid foods were introduced at approximately nine months of age, Alexandra had repeated incidents of gagging and choking. Initially, she would try any solid foods presented, but she reportedly became a “picky eater.” By fifteen months of age, she would only eat pureed foods or crunchy, salty foods, such as Goldfish and crackers. She will sometimes put a solid food she deem acceptable into her mouth, suck on it and push it out with her tongue. As I observe Alexandra eating, I note her primary pattern continues to be a suckle with both pureed foods and solid foods. Her mother has been told that Alexandra only eats purees because he “gets away with it.” I suspect Alexandra is afraid to eat solid foods. Due to low muscle tone, reduced strength and mobility in her jaw, lips, cheeks and tongue, she does not have the motor skills to chew food effectively. She is willing o eat highly salted snacks which will break down easily in her mouth. Other high tasty foods may be explored to experience the flavor and then pushed out the oral cavity using an infantile suckle pattern. As Alexandra has learned to chew, other food textures have become safe and acceptable to her.

In all of these case presentations, sensory and motor limitations contributed significantly to the “feeding aversion.” Families and therapists frequently give children with special needs foods that they do not have motor skills to handle or foods that do not address their sensory deficits. The response is often gagging, choking and throwing up. The subsequent learned reaction is to refuse to eat these food textures or tastes when they are presented. Sell meaning therapists and families are so concerned with nutrition that they miss the underlying issues which limit a child’s ability or willingness to eat. The practice of “force feeding” clients is another factor which contributes to behavioral feeding problems. The message we give children is, “I bigger thank you and I can make you eat.” The result is a lack of trust the child has for the therapist or caretaker. Our clients cannot always communicate their needs effectively, and we may miss subtle communication attempts. The diagnosis of feeding aversion or behavioral feeding problem does not always adequately represent the issues.

A comprehensive feeding evaluation must include assessment of both motor and sensory skills. Adequate respiration and postural stability are your first considerations, as stability in the body will support mobility in the mouth. Then, oral phase skills such as lip closure, tongue retraction tongue bowling, tongue lateralization and tongue tip elevation should be assessed. A five-day baseline diet, analyzed in terms of taste, texture and temperature should serve as an initial exploration of a client’s sensory preferences. Your therapy plan should focus on facilitating the motor skills required to handle feeding. Exploration of taste, texture and temperature variables should be done slowly, with only one change made at a time. Use sensory variables, such as taste and temperature, to facilitate changes in motor skills. (For example, in Sarah’s case, the addition of cold temperature to her applesauce gave her more information and encouraged increased lip closure on the spoon and more effective tongue retraction to move the bolus back in the oral cavity.) As changes are noted in motor development, a client will be better ale to handle an increased variety of textures; the client will have been an active participant in sensory exploration in the feeding interaction. Improved feeding skills will b supported by the development of trust in the caretaker/client or therapist/client relationship. For clients with underlying sensory and motor issues, behavior management approaches should be considered as secondary to sensory/motor goals.