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Practical strategies for parents and teachers when supporting a child who is struggling to eat

Once we understand the many reasons a child in our care may struggle to eat, and we understand that selective eating may be a red flag for an underlying neurodevelopmental or sensory integration difference. Then as caregivers, we ask what can I do next? Which practical strategies can I use at home or in school to support a child who is struggling with eating?

The first and most important step is to have a child evaluated by a trained and registered medical professional, it is important to rule out medical conditions. A specialist speech and language therapist will be able to check that a child can swallow safely.

An occupational therapist can assist with feeding and eating difficulties because both feeding and eating are occupations, and so this is their area of expertise. The therapist might look at how eating can be broken down into smaller easier steps that a child can manage, or suggest that you change something in the environment such as finding more suitable seating, reducing noise, smells or distractions. An occupational therapist with post-graduate training in Ayers’ Sensory Integration will be able to both assess and treat any underlying sensory integration and processing difficulty which can be interfering with eating. In this post-Kath Smith (OT) talks about how a child’s gross motor movements, seating and posture can interfere with eating, and how these can be addressed by an occupational therapist.

But what next? what can we do at home and in school to support therapy? How can we transfer the things we have learned from the therapist to our own environments and to the (at least) 6 opportunities a day we get to interact with our kids to support them to become confident, adventurous eaters.

Here are some of the strategies we have tried, every child is an individual and so some ideas will work and some won’t. I also say, its best to take baby steps in the right direction, big changes that happen quickly are not helpful for anxious children. Just make one small change, as they say, Rome was not built in a day!

  1. Keep an open mind, Listen to what the occupational therapist is saying, you are the expert in your child, but she is the expert in supporting our kids to overcome the difficulties they face. It is very likely that your therapist has seen and treated other children with similar issues before. This works best when we collaborate.
  2. Ditch the rewards, punishments and star charts.
  3. Think about seating
  4. Reduce sensory overload from the environment
  5. Reduce stress and pressure
  6. Pick your battles
  7. Use a visual support
  8. Try to understand how your child views food
  9. Make it fun
  10. Serve a buffet
  11. Model Model Model…

For more ideas have a look at these blogs and websites

From the Empowered Educator – 15 Strategies to encourage SPD toddlers to eat!

From Ellyn Satter Institute – The Division of Responsibility in Feeding 

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The importance of a comprehensive assessment

Thank you to the families who gave consent and our secret blogger OT for this contribution.

“A little while ago, two mums approached me and both asked about assessments for their children. Both were young adults, academically highly able and struggling with their self-organisation and motor skills.

Both young people consented to an assessment and completed, through self-report, the Adult/ Adolescent Sensory History (AASH) questionnaire. They were also assessed with the Sensory Integration and Praxis Test (SIPT). The SIPT is a standardised assessment with normative data for ages 4 through 8 years, 11 months. On this particular assessment tool, sensory integration and processing skills scores plateau at around this age, though the test is still informative for people beyond this age, who should have achieved.

The young lady assessed has a diagnosis of social anxiety and has low confidence, while the young man is quite a confident character. She has a history of bumps, trips and spills, and will tell anecdotes of these with great humour; while he prefers to focus on what he does well in conversation.

I love the AASH, the reports it gives highlight each sensory system, differentiate between discrimination and modulation difficulties and addresses motor planning, sequencing and social/ emotional aspects of sensory integration and processing needs.

It uses clear, non-patronising language and activities appropriate to adults and adolescents. It shows up really clearly a person’s (or their caregiver’s as necessary) perception of their sensory integration and processing needs and how these affect their day to day life. In this instance, the young lady highlighted many sensory processing needs.

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The young man reported almost no difficulties, his only score in the primary sensory systems section was mild proprioceptive difficulties. When questioned as to the accuracy of his answers, he tended to reply “well, nobody likes that, do they?”

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Having scored the AASH checklists, I completed a SIPT with each person. The SIPT is a battery of 17 tests which assess a person’s sensory integration and processing including perceptual-motor skills through tasks with standardised administration and normative data against which to compare an individuals test results. Guess which person showed more significant difficulties in the direct assessment? 

On the SIPT assessment scores between -1 and +1 standard deviation are considered typical, above +1 are strengths and scores below -1 are of clinical significance and require support and will benefit from direct intervention.

The exception to this being Post Rotatory Nystagmus in which a low (below -1) or high score (above +1) indicates significant difficulty inhibiting response to vestibular information and often relates to a low Standing and Walking Balance score.

Here are the young lady’s SIPT results:

 

 

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Definite movement, balance and body awareness difficulties but also some areas of significant strength, particularly around her visual skills and imitation, which she uses to compensate for her body awareness difficulties.

Here’s the young man’s chart:

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Strong visual skills, compensating for significant challenges in the other areas.

This experience taught me so much. From the AASH scores, I was expecting the young lady to have much more problems in the SIPT than the young man, their conversation about their lifestyles confirmed this expectation. Still, then the assessment showed so clearly how much of that was related to confidence.

An evaluation based solely on checklists is not enough. It tells you what a person perceives to be their difficulties, guides the direction of evaluation and adds experiential evidence to the overall assessment.

A good questionnaire is evidence-based and norm-referenced, but it always needs to be triangulated with direct observation and where possible structured and standardised assessment. These tools can tell you so much about the respondent’s confidence and resilience and what they find easy or difficult in day to day life. But I have learned it is a mistake to rely upon one alone when assessing somebody’s sensory integration and processing skills and needs”.

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Research into Practice: A study of safety and tolerability of rotatory vestibular input for preschool children

The answer to a question on SI4OT, a FB group for OT’s curated by our social media team, includes this interesting article.

This study was focussing on the vestibular system, and the researchers tried to work out the exact amount of vestibular input needed in therapy. The results strongly suggest that it is very individualised and requires direct therapist observation to know. This is exactly in line with Ayres’ teachings. There is no exact amount that can be prescribed

A study of safety and tolerability of rotatory vestibular input for preschool children

The use of sensory input to support function, health and wellbeing is an art and a science.

The science is knowing for instance that habituation of tactile input to Ruffini nerve ending is usually fairly rapid – eg light touch as we put arms in shirt sleeves while habituation to pain receptors will vary a lot and maybe ongoing after tissue damage we can’t always see.

The art is that our response to sensory input to sensory systems will vary greatly and is very individualised. This response is not just linked to immediate registration and perception of the input – meaning and memory need to be considered too.  Think about happy smells and songs that stay in your head all day. Think too about the response to trauma when a person smells their abuser’s perfume.

There is no recipe for how much to give and when. This is the art and science of ASI. So many factors impact on what a person needs and when to have an adaptive response.

This is why sensory input is not just something you can prescribe someone by saying;

“Give Jane 20 mins on a swing 3x a day” 

gray swing

Essential to practice is the person’s response to sensory input – Do they have an adaptive response?

“Ayres (1972b) described the adaptive response as central to praxis intervention. Adaptive responses are purposeful actions directed toward a goal that is successfully achieved, and the production of adaptive responses is thought to be inherently organizing for the brain. Ayres (1972b, 1985) further emphasized that SI intervention was a transaction among client, task, and environment.”

Bundy, A. and Lane, S. [2019], Sensory Integration Theory and Practice, 3rd Edition, [Philadelphia]. Available from: FADavis.

Watching and seeing this response to input, alongside feedback from the parents/family/person is what we do to understand each person’s unique responses and pattern. However, knowing and remembering that many things can impact on this, day to day and even minute by minute is essential. 

 

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CPD: Understanding and Applying Trauma-Informed Approaches Across Occupational Therapy Settings

AOTA has really helpful and supportive articles right now – promoting the best clinical practice, with an emphasis on participation in occupation.

This article is particularly pertinent to OT’s using ASI theory and practice to create therapeutic environments supporting and scaffolding participation in daily life for those with trauma.

Read the full article here.

 

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What is Ayres’ Sensory Integration Therapy?

At ASI Wise, to avoid confusion, we use the term sensory integration and processing difficulties. Different terms are used in different places to describe sensory integration difficulties. Some therapists may use sensory processing difficulties instead. Some may even use sensory processing disorder.

We currently have a robust test,  the SIPT, that allows us to describe sensory integration difficulties and reference research evidence to interpret the unique scores and pattern of scores that the child gets across 17 test items. We can use this data to inform our clinical reasoning, create a hypothesis about what sensory difficulties are contributing to participation challenges in everyday life. We set goals, plan and deliver the intervention, Ayres’ Sensory Integration Therapy measuring therapy outcomes. This is best practice.

“Active, individually tailored, sensory motor activities contextualised in play at the just right challenge, that targets adaptive responses for participation in activities and tasks.”

ESIC Schaaf 2019

Core to the practice of Ayres’ Sensory Integration is a central belief in the ‘adaptive response’.

“Ayres (1972b) described the adaptive response as central to praxis intervention. Adaptive responses are purposeful actions directed toward a goal that is successfully achieved, and the production of adaptive responses is thought to be inherently organizing for the brain. Ayres (1972b, 1985) further emphasized that SI intervention was a transaction among client, task, and environment.”

Bundy, A. and Lane, S. [2019], Sensory Integration Theory and Practice, 3rd Edition, [Philadelphia]. Available from: FADavis.

Ayres’ Sensory Integration assessment and therapy is typically post-graduate education for Occupational Therapists, Physiotherapists and Speech and Language Therapists. Please check that your therapist has ASI Education that meets level 2 education standards as recommended by ICEASI.

For more information about programmes offering Certification in Ayres’ Sensory Integration across the globe, please visit www.cl-asi.org.

 

Thank you Saša Radić – Kabinet aRTisINCLudum aRTis INCLudum for sharing these.

Read “Occupational Therapy Interventions for Children and Youth With Challenges in Sensory Integration and Sensory Processing: A School-Based Practice Case Example”  – one young person’s story from AJOT May 2019 here. [Frolek Clark et al 2019].