Question & Answer - Feeding, Eating, & Drinking

Why are pediatric feeding disturbances difficult to treat in children with sensory processing disorders?

Pediatric feeding disturbances are not only common in children with sensory processing disorders (SPD) but are often more difficult to treat due to the many factors that contribute to feeding aversions. Children who experience sensory processing difficulties frequently have increased anxiety and aversion to accepting even small variations of a favorite food, whether it be a sandwich cut in a different way, a colored goldfish cracker instead of a regular goldfish cracker they have come to know and expect, or their drink in a different cup. Take the child’s usual and accepted meal to a new setting, possibly a babysitter’s home or a restaurant, and discover that even when presented in the way the child always eats the food at home or in school, he simply cannot bring himself to take a bite of the food. The frustration and difficulties surrounding mealtime and eating may also be an indication of difficulties in other areas of function.

If these patterns sound familiar to you as a caregiver, then you are likely to also relate to the following anxieties and frustrations that countless parents have expressed to me over the last 12 years while working with pediatric feeding. Here are some concerns I have heard from parents:

-All of the other kids at the birthday party get so excited about the cupcake and ice cream, and my daughter cries and wants to go home.

-I just wish he would eat chicken nuggets!

-He will only eat the chicken nuggets from chick fil A and only in the box. If they are taken out of the box, he throws a tantrum.

Now, if you are anyone other than a family member experiencing this on a daily basis,  you may assume that these feeding behaviors have developed solely as a result of parents falling into some typical power struggles to which we can mostly all relate if having raised children or grandchildren at any point. So parents are often told by well-meaning friends and relatives:

-You have to make him eat.  

-If she is hungry enough she will eventually eat that.

-Or maybe, He does that because you let him. He’s holding out, and he knows you will give him what he really wants in the end. 

Although some of these statements may indeed be a part of the problem behavior, they are likely just that – a part. 

In order to address eating concerns, you must break down the entire pattern, identify contributing factors, as well as incorporate what clinical experience and research have shown us. In order to change these patterns and get from point A to point E (eating!), we must pay attention to B through D in the process. A feeding assessment helps to bring the pieces of the process together by identifying typical vs. atypical oral sensory-motor development, feeding history, patterns used with types of foods eaten, as well as the child’s relationship with eating and those who are the mealtime partners or doing the feeding with a baby or those needing assistance.  Even when strong sensory aversions are identified, these may be indications of respiratory, gastrointestinal discomfort, family eating patterns, as well as food allergy or intolerance that are actually exacerbating existing hypersensitivities. Therefore, forcing or bribing will likely lead to deepened feeding aversions and increased anxiety.  

Children with the feeding complications of accepting only certain foods in certain ways along with a number of other factors for each accepted food may have learned to expect that the same foods will be offered at each meal in the same way. Additionally, the reason they may be eating something at home and not in daycare or vice versa is likely because the routine in the new environment had not been adapted to their predictable routine wherever that may be. The stress surrounding mealtime may have become too much for parents to handle when they have repeatedly tried introducing new foods unsuccessfully. Without an understanding of the overall condition and factors contributing to refusal, parents and caregivers can become stuck in a cycle without support and, at the end of the day, we all do what we need to do to get by, especially under stress.

These children typically progress with feeding goals and expanding foods by establishing a predictable, consistent routine in therapy as well. This allows for the new changes to be introduced within that framework. Bridging the progress into other environments may come much later but can be accomplished also by establishing a predictable routine in which these new skills and foods can then be incorporated (See Establishing Predictable routine at http://pickytots.blogspot.com/2010/01/email-responses-to-families.html?m=1).

I often hear the question, “What causes this?” in regard to a child’s feeding complications. Rarely, there is only one factor. In children with SPD, it is common to find inadequate oral sensory-motor feeding patterns leading to disorganized and undeveloped chewing skills, difficulty with food bolus preparation within the oral cavity, and, in turn, difficulty and discomfort initiating the swallow. Which came first, the chicken or the egg? This saying comes to mind when stepping back to look at the big picture. 

Did sensory concerns contribute to oral motor feeding delays, or did the oral motor feeding delays contribute to the sensory issues with feeding? There is not a right or wrong answer because both can be true. Visualize yourself feeling nauseous and you don’t want to look at a certain food, much less put it in your mouth. If you do put it in your mouth and something feels off because you are already feeling queasy, you might gag and even vomit. 

Sometimes chewing skills have never developed because a child has never actively chewed food. Therefore, the organization and patterns needed to chew were never developed. Food scattered across the tongue can feel especially undesirable, just downright gross, to the person already hypersensitive to certain food textures. Developing the needed oral sensory-motor feeding skills and systematically decreasing hypersensitivities can help eating become enjoyable and manageable for a child. When sick, or if there is underlying reflux, food sensitivity, or allergy then it is difficult to progress with feeding. This is why addressing each component of a child’s feeding is necessary.

A checklist from http://www.sensory-processing-disorder.com/ provides helpful information regarding signs that may indicate that a child has a sensory processing disorder or specific needs that should be further assessed. “The purpose of the "SPD Symptom Checklist for Infants and Toddlers" is to help parents and professionals who interact with children become educated about particular signs of sensory processing disorder in the youngest children and babies. It is not to be used as the absolute diagnostic criteria for labeling children with sensory processing disorders, but rather, as an educational tool and checklist. Professionals (usually occupational therapists) who diagnose this disorder have their own tools in addition to checklists to observe and test for SPD (formerly called SID or Sensory Integration Dysfunction).”

ABOUT THE AUTHOR

Kristina Starnes, M.S. CCC-SLP is a speech -language pathologist who specializes in pediatric feeding and swallowing disturbances. Kristina lives in Fayetteville, Arkansas where she and her daughters spend time together enjoying their college town and the Ozark Mountains. She is the owner of Therapy Tree, LLC and also enjoys writing and sharing information related to pediatric dysphagia on her blog Fun with Food and Facebook support pages. Kristina has a passion for promoting awareness, treatment, and prevention of feeding and swallowing disorders; connecting with others who share the same vision; and striving to help others overcome negative associations surrounding food.