Intervening with pediatric feeding disorders

Teach your child to eat based on the Satter Division of Responsibility in Feeding

Through no fault of yours or anybody else, your child may not eat. Some children are exquisitely sensitive to tastes and textures, have a strong gag reflex, and throw up easily. Some children have multiple food allergies. Some children are diagnosed as having sensory processing disorders (SPD), which means that they react negatively to certain or many tastes and textures. Some children get a late start with eating because they have medical issues and/or are fed by tube during their early lives. Some children are just slow to warm up and may even be on the autism spectrum: it takes them a long time with absolutely no pressure to take an interest in new food and to learn to eat it. Some children need therapy from an occupational or speech therapist to address problems with chewing and swallowing. 

The feeding therapists that Ellyn Satter Institute trains with the Feeding with Love and Good Sense VISION workshop  do a complete assessment from birth to sort out the medical, developmental, nutritional, psychosocial and feeding dynamics issues in planning treatment that checks all the boxes. Consistently applied, and with skillful attention to complicating medical, nutritional, and oral-motor issues (you can get help through ESI coaching), the Satter Division of Responsibility in Feeding (sDOR) can form the foundation for your child’s learning to eat. You do the what, when, and where of feeding, and let your child do the how much and whether of eating. You provide appropriate food at regular meals and snacks, matter-of-factly and again and again, eat and enjoy it yourself, and let your child join in with family meals and snacks. You plan meals and snacks that are considerate of his inexperience by providing soft food that is easy to pick up, mouth, and swallow and let him eat—or not. You are very careful not to apply pressure in any way on him to eat.  You support him nutritionally in other ways while he ever-so-slowly, over weeks and months, gets the idea of eating. Then you gradually phase out the tube feeding or formula as he eats more and more. Your special-needs, slow-to-warm-up, very picky child, even if he is on the autism spectrum, will push himself along to eat, the same as any other child. Stages in feeding look the same; they just come along more slowly. Challenges at each stage are the same; it will just take your child longer to master them. Eating quirks are the same; it is just hard to sort out the “child” in these quirks from the “special needs.”

If you choose direct intervention with your child’s eating, consider this: In the best hands, direct eating intervention by an Occupational Therapist or Speech and Language professional does in-office oral-motor work with your child, addressing chewing/swallowing issues, and supports you in an accurate and thorough-going application of sDOR at home. It does not ask you to do eating work with your child. And it does not exert pressure in any way on your child to put anything in his mouth or even touch, lick, or smell any food, in or outside of the office. This is a tall order, when you consider that playing games, rewarding, and cheer-leading all represent pressure. To do do exercises or use devices to develop awareness, strength, coordination and mobility of the oral muscles, the therapist offers the child the exercise or device and waits a few seconds for the child to look, comply, open up, or not. If the child refuses, the therapist absolutely takes no for an answer. Then another day at another session, the therapist offers again, and again accepts the child’s opening up or refusal. The therapist who follows sDOR does not get the child to eat. The child gets him or herself to eat.

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Make an informed choice: sDOR or conventional treatment?

You may be offered conventional treatment for your child’s not-eating. A conventional therapist may tell you to follow the division of responsibility in feeding along with other methods listed below, but that means they don’t really understand sDOR: The advice is simply wrong. sDOR is based, absolutely, on respecting the child’s autonomy with eating. You can not both follow sDOR and try to get your child to eat certain amounts and/or types of food because that violates their autonomy. Trying to do both will hopelessly confuse you and your child. Beyond that, the choice is yours. To help you make your choice, understand what such treatment involves. Also observe your child when such methods are used to get them to eat. Are they relaxed and comfortable? Enjoying the process? Upset? How do you feel? Like your child is in good hands or like you want to rescue them? 

From the conventional perspective, some children are naturally so eating-averse that they will go hungry rather than eat foods beyond their comfort level. sDOR-oriented therapists have found that not to be the case. However, based on this conviction, conventional therapists use interventions such as desensitization, persuasion, pressure, and reward  to get the child to eat certain amounts or types of food. Those treatment methods include any or all of the methods listed in Avoid pressure. Other, more systematic treatment methods of applying pressure to get the child to eat include the following:

• Positive reinforcement: Praise, compliments, rewards (preferred food, toys, or activities), distraction with video or other means, blending preferred with non-preferred foods (gradually increasing the proportion of non-preferred food).
• Negative reinforcement (e.g., “Response Cost”): Warning, punishing, withholding preferred food until child eats non-preferred food, selective attention (ignoring the child when s/he doesn’t eat, paying attention when s/he does), stopping a video or taking away a toy if the child doesn’t eat.
• Escape extinction or non-removal of food: Holding the food in front of the child and not taking it away (even for an hour or more, even if they cry and try to get away), until they give in and take a bite. 
• Physical guidance: Physically opening the child’s mouth and putting in the food.
• Systematic approximation: Getting the child to do eating-related activities, such as chewing on a washcloth, sitting in the chair at the table, offering food and having the child touch, poke, squish, draw or sculpt the food; smell, kiss or lick the food or blow it into the trash. Any food related activities, such as cooking, gardening, and tea parties, where the agenda is getting the child to eat.  
• Food chaining: Getting the child to eat a wider variety of food by starting with favorite and then offering closely related foods that require new learning.
• Distraction: Singing, dancing, playing with toys or playing games, doing “here comes the airplane,” having the child feed the adult or a doll, TV.

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