Clinical Information Related to SOS

Some families tell us they don’t like their children to get ‘messy’ during meals. Can we still do SOS?

Yes – it simply means that you need to help the family understand WHY their child needs to get messy. Consider the following points:

• We can learn a lot about food by looking at it, touching, smelling, and interacting with it, which helps us anticipate what it will be like once it is in our mouth. SOS uses Play with a Purpose to help the child learn about new foods.
• As with any developmental activity (walking, talking, learning to ride a bike, etc.), children learn to eat best through play.
• Learning to eat comes before manners. Often things that we interpret as poor manners (fidgeting in their seat, leaning on elbows on the table, touching food, etc.) are a sign that the child is having difficulty with the act of eating.
• It is okay to have different goals for different meals. In some meals when we are offering familiar foods, the goal might be to work on manners and eat an age-appropriate volume of that food. In other meals, the goal may be to expose the child to new food and help them learn how to eat it.

What is the difference between Systematic Desensitization and Flooding?

In psychology, desensitization involves the use of competing relaxation responses (e.g. deep breathing, play) during exposure to a graduated hierarchy of a stimulus known to cause anxiety. The aim is for the person to stay calm as they progress through the small steps towards the end goal. If the person starts to get distressed, the therapist should move back a step in the hierarchy and re-establish calmness before trying to move forward again.

Flooding involves exposing a patient to vast amounts of the feared stimulus. It is expected that the patient would initially be very anxious, but it is hoped that the anxiety will decrease over repeated exposures. Flooding begins at the ‘end’ and assumes the child will eventually ‘get the skills’ to be successful.

Flooding uses the assumption that a person cannot maintain a high level of anxiety for extended periods of time. However, if the child does not have the skill to complete the task, then ‘anxiety’ is not the only problem and flooding is not the answer.

Systematic desensitization allows the therapist to continue evaluating the child with every exposure and assumes the therapist and child will work together to build the skills within the child to become successful.

Consider this analogy: If you wanted to teach a child to swim, flooding would encourage you to throw the child into the water and assume they will figure out how to get to land. Systematic desensitization would encourage you to bring the child to the water, encourage them to put their toes in the water, then their feet, legs, bottoms, body, arms, shoulders, and finally their face, before moving them off the edge and into the open water.

Related to feeding and mealtimes, it is important to remember that distress evokes an adrenalin response, and this adrenalin response will generally suppress hunger to some degree. Therefore, it is best to avoid distress during mealtimes.

What is the difference between Positive and Negative Reinforcement?

Reinforcement is any response to a behavior that causes an increase in the probability of that behavior occuring in the future.

• Positive Reinforcement means that you respond to a behavior by adding a desired stimulus that causes an increase in the probability of that behavior occurring in the future. For example, if the child eats, then gets praise/attention, they will be likely to eat more. If the child isn’t eating, gets praise and attention, they will be likely to keep ‘not eating’.
• Negative Reinforcement means that you respond to a behavior by removing an undesirable stimulus that causes an increase in the probability of that behavior occurring again in the future. Response prevention programs (or negative reinforcement programs) provide an undesired stimulus, and when the child does the desired behavior, the undesired stimulus goes away.

Punishment is any consequence following a behavior that causes a decrease in the probability of that behavior occurring in the future.

• Positve means ‘to apply’, so Positive Punishment means applying an undesirable consequence following a behavior to promote less of that behavior. For example, if a child is yelled at while eating (“Why aren’t you eating more?!”) that is a positive application of an undesirable response, so it decreases the likelihood of the behavior (eating) occurring (punishment = decrease the behavior)
• Negative means to remove, so Negative Punishment means removing a desired response to promote less of that behavior. For example, if a child does not eat anything for dinner and the option of dessert (desired response) is removed (negative), that will lead to less refusing of dinner.

Why doesn’t SOS use oral motor tools to teach children to eat?

Many oral motor programs offer a systematic skill development necessary for oral motor strength and coordination. They may use a pre-set series of whistles, straws, or some other type of tool to help build oral motor strength. In your therapy, you can substitute foods for these “tools”. SOS Approach to Feeding focuses on typical development. We do therapy the same way we see typically developing children learn to eat. Typically developing children do not learn to eat with a pre-set order of tools. They learn to eat with food. If children learn to do oral motor activities with the tools, they do not always automatically transfer these to foods. Therefore, tools can often be an extra step in your therapy. Using foods instead of tools may shorten up the total therapy time.

In addition, oral motor programs are frequently done by the therapist to the child. It is a passive action for the child (i.e., therapist putting their finger in the child’s mouth to “desensitize the gag reflex”). This is NOT systematic desensitization (one of the Tenets of the SOS Approach to Feeding). This is flooding. We want the child to be in charge, and we want the child to be putting things in their own mouth.

How do the new IDDSI guidelines apply to the Developmental Food Continuum?

The purpose of the IDDSI is to standardize practice for labeling texture-modified foods and thickened liquids. In SOS we are not typically using texture-modified foods or thickened liquids. In the Developmental Food Continuum we are not discussing or using texture-modified foods. We are describing the use of typical foods.  Using the IDDSI system/language, the majority of the food discussed and used in SOS would all be lumped together under “Regular”.

In SOS, we will not be changing our descriptions of foods to match the IDDSI, because it is not relevant for the majority of children that we work with.  IF we are working with a child who has a modified diet (like thickened liquids) then YES, we would use the IDDSI to describe the level of thickening for liquids or the modified diet we need to use for that particular child.

As a Dietitian, how would I use the SOS Approach to Feeding? Is it helpful for me to take the course?

We frequently have dietitians attend our training conference and they find the information very helpful in their work.  Typically, the dietitians we train use our General Treatment Strategies in their daily dietitian work with children (along with the information about the complexity of feeding and feeding milestones).  The part of the training conference that is very specific to how to do Feeding Therapy is also helpful for them because it teaches all the professionals how to think about food from a sensory and oral-motor standpoint (these things being what makes the children unable to eat the nutritious foods that dietitians recommend to families).  Understanding how the foods they are recommending may or may not match this child’s feeding skills sets is what determines what foods should be suggested so that the child will have a chance at actually being able to eat those foods.

However, most of the dietitians we train do not carry out the feeding therapy portion of the program independently.  While the training conference does train everyone how to do an SOS Approach to Feeding Therapy session, most dietitians do not have enough experience and/or graduate-level training in providing rehabilitative therapy to feel comfortable doing the actual therapy sessions themselves without working in close contact with either Speech Pathologists or Occupational Therapists.  The dietitians in my Clinic and others we know who are actually doing therapy sessions have usually started by working with a multidisciplinary team conducting live assessments and then participating as a therapist in an SOS Approach to Feeding Therapy Group, where an OT or SLP are acting as the Group Leader.  This gives the dietitian that direct clinical experience they need to feel comfortable than seeing children individually for feeding therapy.  Most of the dietitians we know who actively do feeding therapy are also getting supervision for their work with an OT or an SLP to assure their use of the program.