Once a child has been diagnosed with a Pediatric Feeding Disorder due to oral dysphagia or sensory processing disorder or, if diagnosed by a psychologist, ARFID (Avoidant/Restrictive Food Intake Disorder), they will likely be referred for treatment. Eating is a learned behavior. It is only instinctive for the first 6 months of life. Older children must either teach themselves, or be taught (Toomey). Treatment for a feeding disorder can be completed by a Speech-Language Pathologist (SLP), Occupational Therapist (OT), Board-Certified Behavior Analyst (BCBA), Dietician, or Psychologist. All of these disciplines have overlapping and unique approaches to treatment, so a Pediatric Feeding team that involves more than one specialist may be best for your child. As an SLP who is part of a feeding team that involves an OT and BCBA, some approaches to treatment that I utilize alongside the team include the Food Chaining Approach, The Sequential Oral Sensory approach (SOS), and the Escape Extinction approach.

Food Chaining has become recently popular due to a book written by Fraker and Cox called Food Chaining: The Proven 6 Step Plan To Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. To summarize this approach, clinicians and parents would “chain” from food that children currently enjoy by changing 1 aspect of the food at a time: either color, texture, flavor, or shape. For example, if a child enjoys cheetos, you might “chain” to orange veggie sticks (changing flavor), then to green veggie sticks (change in color), then to green veggie chips (change in shape), then to zucchini cut in a circle and placed on the chip (change of texture), then remove the chip. The child is now eating zucchini, and it was introduced slowly in a non-threatening manner! In this procedure, food is not forced on children- they are able to touch and explore it themselves, the clinician models eating it, and children are encouraged to take a bite, but they decide if they would like to try it or not. Using food chaining, children will slowly and positively increase their repertoire of acceptable food.

The Sequential Oral Sensory (SOS) approach was developed by Dr. Kay Toomey, a psychologist who specializes in Pediatric Feeding Disorders. This procedure includes another slow process of children having repeat exposures to foods prior to being forced to take a bite. For example, a child would tolerate a new food, let’s say apple slices, on their plate without expectation of eating it. Once that is tolerated, the apple will slowly and systematically move closer to their mouth, again without expectation of eating. They will touch it first with a fork or toy, then their hand, then put it on their arm, then their cheek, then kiss it, then lick it, then take a bite and spit it out, then chew, and finally swallow the apple slice. This could take a couple of days or even weeks. The idea is to allow children to have positive interactions with the food so that eating is enjoyable and they control what is placed in their mouth according to their comfort level. Eventually the child will be able to more quickly and independently follow the above steps with a new food to independently increase their diet. Children will gain confidence and learn that new foods aren’t as scary as they once thought.

The Escape Extinction approach is an effective, evidence based approach used to aid with feeding problems across all ages and is often utilized in ABA therapy by a BCBA or Behavior Technicians under the guidance of a BCBA. Eating novel food items and non-preferred food items is broken down into easier steps to aid your child with succeeding in their feeding journey. Keeping the presentation of bites and the bite sizes predictable decreases anxiety and allows the child to feel more in control during meal times. We never move up in bite size until we are certain your child is able to handle the bite at that size and has the skills needed to properly lateralize the food item, masticate the bite, and take consecutive bites. Furthermore, this approach reinforces appropriate feeding behavior while extinguishing inappropriate or disruptive feeding behaviors by not allowing the child to escape from taking bites by using a non-removal of the spoon. Often times, children will spit out food, swallow food without chewing, pack bites, turn head away from the bite, or engage in aggression. When these behaviors occur, we do not remove the bite from their lips until the bite has been taken, and provide prompts and reinforcement for taking bites and chewing appropriately.

Children enrolled in the feeding program Metro EHS Pediatric Therapy are evaluated and treated as unique individuals, so these approaches, along with others, are often combined to best help your child experience success with eating.

Sources

2019. Tooomey, Kay. SOS Approach To Feeding.
2020. Tarbox, J and Tarbax, C. Training Manual for Behavior Technician Working with Individuals with Autism Spectrum Disorder. Retrieved from Sciencedirect.com.
2021. Fraker, Fishbein, Cox, Walbert. Food Chaining: The Proven 6 Step Plan To Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. Da Capo Lifelong Books.

Q: What is the RBT certification?

A: RBT certification is a paraprofessional certificate that is in the behavioral analyst field, and you work under the BCBA or BCABA treating and providing services to our kids.

Q: What are the requirements?

A: What it takes to become an RBT here at MetroEHS is you must be 18 years old, a high school diploma, you need the 40 hours of training, and then take a competency test with the supervisor, and then you apply at the BACB website, and take a test, and become an RBT.

Q: What does the training consist of?

A: The RBT training consists of like an interactive and comprehensive 40-hour training that you work in a small group or one on one with other technicians or your BCBA. You’re out in the clinic, hanging out with the kids, learning and watching how they run programs. That could be at the table time or out in natural environment and once you understand the new words in the ABA field, you take your competency test and take the test at the website.

Q: What is the competency test?

A: The competency test is when the supervisor comes out the clinic with you and they watch how you run programs, they interview you, ask questions about the terminology and it’s pretty much just one on one time or you and the supervisor and your client to make sure you understand the terminology and what you’re actually doing and it’s highly encouraged to actually take your RBT test within 90 days of your 40 hour training. It is free of charge. You take the test at the BACB website.

Apply now!

Q: How do I maintain my credentials?

A: To maintain my credentials as an RBT here at MetroEHS, I track all my supervision hours, and I retake my competency test at the year mark or year anniversary of my RBT testing date.

Q: What are the benefits if earning an RBT certification?

A: MetroEHS offers two benefits for becoming an RBT. One is a raise and two, once you become an RBT, you have more opportunities to move up the ladder and become admin or fun stuff.

We are proud to sponsor Live in the D, and excited to have joined them this month to bring Autism Awareness.

Tati Amare:
As we watch children grow, we see them develop in many different ways, from infant to toddler to child. As they grow, we celebrate milestones like first steps or first words, but what if the child in your life hasn’t reached a milestone by a certain age or at all? That’s where our sponsor, MetroEHS can help families and children thrive when developmental challenges present themselves. Joining us now here from MetroEHS is our sponsor for Autism Awareness Month is Dawn Sterling, a board certified behavioral analyst with MetroEHS Pediatric Therapy. Good morning and thank you for being with us.

Dawn Sterling:
Good morning. Thank you for having me.

Tati Amare:
This is a lot to think about, but MetroEHS prides itself as a neighborhood therapy company that is accessible to everyone because you have 14 locations and 3 more on the way. Explain the work that you do with families and what makes MetroEHS unique.

Dawn Sterling:
Yes, so we are a pediatric therapy service provider and what really makes us unique is the different variety of services that we offer all in one location. So each neighborhood therapy center has a speech and language pathologist, occupational therapy, physical therapy, applied behavior analysis. We also have dieticians and mental health professionals working with us, and what really sets us apart is our feeding therapy program. So what we do, and its uniqueness, is this wrap around the whole child. So we focus on the whole child developmentally. So whatever a family may be concerned with or struggling with, we’ve got services and support for those families.

Tati Amare:
For every need. I like that. Now if I’m a parent at home and for family members of children, what are some signs that we should look for that may indicate that there may be developmental concerns with our children?

Dawn Sterling:
That’s a great question. So we look for what is called developmental milestones. So your pediatrician is a great person to get that resource from. So if you are at all concerned about your child meeting milestones, maybe they’re not meeting them in the timeframe that you expected, or maybe they had some of these milestones and they’re dropping off, you’re going to start with your pediatrician. They may recommend evaluations. Always pursue those. It’s better to rule out any concerns than to perhaps miss it.
Sometimes what’s recommended is behavior therapy. Applied behavior analysis is one type of therapy that can really help with children with developmental disabilities, and not just autism. These therapies, speech therapy, feeding therapy, occupational therapy, they are for a variety of diagnoses, global childhood developmental delay, any sort of developmental delay that your evaluators may see, there is a related service that can support these families.

Tati Amare:
All right. Now you’ve brought in some example of the items that you use to work with children. So walk us through these tools. I’m going to hold these up.

Dawn Sterling:
Thank you, Tati.

Tati Amare:
Of course.

Dawn Sterling:
MetroEHS is a collaborative pediatric center, so we collaborate with all of our service providers such as SLPs, or Speech Language Pathologists, that may help us design core boards for learners that are not communicating fully with their words yet. We also will collaborate with our occupational therapists on staff for things that may meet a young child’s sensory needs. We are movers and shakers, so sometimes we need to have things that we can play with in our hands, it might be scented to wake up some of those senses. We also have sensory oral chews. We work with a lot of very young kids and we know developmentally young children like to mouth on things.

Tati Amare:
Yeah, this is perfect.

Dawn Sterling:
So this is food grade silicone, it’s safe, it’s safer than the wooden puzzle piece that your toddler might be putting in their mouth. And then we do work on daily living skills, and this is from our OT department, as well. When children are learning to utilize a straw, this cup can be very helpful because we can squeeze it to give them a little bit of that liquid and really show them this is something you might want as we build up their ability to have independence with eating, drinking.

Tati Amare:
And all of that stuff.

Dawn Sterling:
Again, the whole child.

Tati Amare:
Yeah, definitely. Definitely. Okay, so I have to ask you before, because we’re just about running out of time, how rewarding is it for you to be in this position and have the impact with these kids?

Dawn Sterling:
It is the most incredible experience. We get to partner with families. The parents are a viable and valuable member of our treatment team, so we get to work with them and really see what their children and their families are achieving as a result of our therapies. So that is the biggest impact, is seeing progress with our kids.

Tati Amare:
That’s awesome. Dawn, thank you so much for being with us.

Dawn Sterling:
Thank you. Thank you for having me.

Tati Amare:
This is going to be helpful for a lot of families out there. Remember, MetroEHS has 14 locations and 3 more on the way across Metro Detroit. To find a location near you and to see how they can help your family, go to metroehs.com.