If you have determined that your child is a Problem Feeder, looking for a feeding specialist in your area is a great next step. While there are a lot of strategies and things you can do at home, it is likely that your child has some skill deficits that are interfering with the typical eating development and will require a consult with a professional to address. Because eating is such a complex task, there are lots of areas for things to go wrong, and a professional can help to make sure these areas are addressed and strengthened to support your child and family.
Red Flags that your child would benefit from feeding therapy include:
Being fed by a NG or G-Tube
Relying on a baby or toddler formula (Pediasure, Carnation Instant Breakfast) for a majority of your child’s nutrition after the age of 2 years.
Ongoing poor weight gain (dropping percentiles on the growth curve) or weight loss
Ongoing choking, gagging, or coughing during meals
Ongoing problems with vomiting
History of a traumatic choking incident
History of eating and breathing coordination problems, with ongoing respiratory issues
Reporting that your child is “picky” at 2 or more well child checkups
Inability to transition to baby food purees by 10 months of age; inability to accept any table food solids by 12 months of age, and/or inability to transition from the breast/bottle to fluid in a cup by 16 months of age
Has not weaned off baby foods by 16 months of age
A food range of less than 20 foods, especially if foods are being dropped over time without new foods being added to replace them
An infant who cries and/or arches at most meals
If your family is fighting about food and feeding (Meals are battles)
If the child is difficult for EVERYONE to feed
Therapy Approaches – You have choices
Next, it is important to understand the different types of therapy approaches, as different approaches feel more comfortable to different families. The two main approaches used for feeding therapy are Systematic Desensitization and Flooding. Here is a quick summary of the differences between the two approaches:
Experience the feared stimuli (food) in small hierarchically organized increments
Allowed to “move away” from exposure
Goal = to stay calm while being exposed to a variety of new foods (maintain a competing response in the face of increasing incremental exposures)
Experience the feared stimuli (food) at full exposure
Held in the exposure with escape being prevented
Goal = to be exposed to a variety of foods without exhibiting any undesirable ‘behaviors’ (to have peak fear response with no undesirable consequence during repeated full exposures)
Types of Reinforcement
Therapy approaches also use either Positive Reinforcement, Negative Reinforcement, or a combination of both. Reinforcements are different strategies that are used to encourage or reward the child to do something new or different with foods Here is a quick summary of these styles:
Positive Reinforcement: Goal = Skill
Systematic Desensitization tends to use more natural reinforcers. Natural reinforcers are things that happen as a result of the behavior. Examples of natural reinforcers around mealtimes include: I feel full after I eat and my stomach ache goes away, or feeding my non-preferred food to the dog means that I don’t have to eat it anymore.
Object reinforcers are used by both flooding and systematic desensitization approaches. Object reinforcers are things that we do as a reward a child for doing a behavior that we like. An example of an object reinforcer around mealtimes might be: the child gets to watch a show on the iPad as long as they keep taking bites of food or if the child eats their dinner, they can have dessert.
Programs can create lasting behavior changes because the child builds the skill required for eating
These programs follow typical development, which is how children normally learn to eat
Programs build intrinsic motivation
Therapy is fun for everyone
The child is an active participant in mealtimes, and learns to eat independently
These programs take time to learn new skills fully – remember, it takes a typically developing child around 2 and a half years to learn to eat a full table foods diet.
Negative Reinforcement: Goal = Volume
Flooding programs typically use negative reinforcement combined with object reinforcement
Some Flooding programs also combine negative reinforcement with limited access to parent
Programs can teach the child to swallow liquids/purees quickly (sometimes in just a few weeks)
High recidivism (relapse) rate after you leave the program, especially if you do not continue to use the negative reinforcements used during the program
You cannot force someone to swallow textured table foods, and a liquid and puree diet are only age appropriate for children under 1 year old.
Creates external motivation to eat (most of us eat because of internal motivation)
Programs are aversive and lead to high adrenaline, which disrupts appetite recognition (limits internal motivation to eat because they don’t feel hungry)
Programs rely on passive participation (the child is fed, versus feeding themselves)
If mealtimes are a constant battle in your home, finding a skilled feeding therapist in your community can make a huge difference. We hope this information is helpful as you consider your choices.