Feeding and Swallowing Clinic

Behavioral and Sensory Feeding Problems

Sensory Feeding Problems- What Are They?

These are problems where something about the way food looks, tastes, smells, or feels is overwhelming or uncomfortable to a child.

Children with sensory problems commonly have difficulty transitioning from one food texture to another.  They may remain "stuck" on liquids or "stuck" on pureed or baby foods and refuse foods with more texture. Sometimes children with sensory problems have uncontrollable gagging or vomiting reactions to foods.

Behavioral Feeding Problems- What Are They?

These include all other problem behaviors that occur around meals. Examples include but are not limited to: refusal to sit at the table for meals, refusal to self feed (when able to do so), and disruptive mealtime behaviors such as throwing food, stealing food from others, crying screaming, vomiting to get out of the meal, and others.

Distinguishing Sensory and Behavioral Feeding Problems from Other Kinds of Feeding Problems

While some behaviors are clearly behavioral in nature (sneaking food, for example) others may not be as clear. Food refusal, for example, can be a behavioral problem, but it can also be caused by oral-motor, digestive or sensory problems.  Therefore, before treating behavioral feeding problems, oral-motor and digestive problems must be ruled out or addressed first.  Next, sensory problems and behavioral problems may need to be distinguished from one another, as sensory problems will probably require some form of sensory stimulation or de-sensitization, while behavioral problems may require other kinds of strategies.

Food Selectivity- A Sensory or A Behavioral Feeding Problem?

Food selectivity means being very selective about the foods one eats. Food selectivity differs from "pickiness" in degree.  Picky eaters usually eat at least one food from all of the food groups. Children with food selectivity, however, often avoid one or more food group entirely. They may eat no fruits or vegetables and/or no meats. They may eat no red foods, or no green foods, or no smooth or wet foods.  They may eat only one brand of a particular food and refuse to eat any other brand. They may drink only water and refuse all other beverages. They may eat no more than 3-5 different foods altogether.

Food selectivity is seen in children with a variety of different diagnoses, but it is most commonly seen in children on the autism spectrum.  Not every child on the autism spectrum has food selectivity, but a significant sub population of children with autism do have food selectivity.

Is food selectivity a sensory feeding problem or a behavioral feeding problem? Unfortunately, there is no one answer.  Each child is different, including children on the autism sprectrum.  Some children clearly have sensory reactions to food and need de-sensitization strategies.  Other children have more behaviorally based problems and require other kinds of strategies.

For All Feeding Problems... First Establish a Regular Mealtime Routine.

Establishing a regular mealtime routine is a key component of most feeding plans.  It teaches children a regular routine and also provides opportunities for teaching positive mealtime behaviors.  Mealtime routines include serving meals at roughly the same times each day and involving the children in developmentally appropriate tasks, such as: setting the table, bringing food to the table, helping to clear the table, etc. Young children may be prepared for meals by being put into their highchairs and given food or a favorite toy to play with while they wait for mealtime.

Strategies for Sensory Feeding Problems

These are two commonly used sensory approaches for feeding problems.  Please note that they may not be appropriate for all children with sensory feeding problems.

A sensory diet is a daily routine of sensory experiences. Like a "real" diet, a sensory diet can be offered as a series of sensory "meals" containing specific activities individualized for each child. For feeding, a sensory diet might consist of daily opportunities to play with food. These activities allow children to become familiar with the sight, smell, touch, taste, and texture of foods. Over time, these play experiences may help some children overcome their reluctance to try new foods or food textures.

Sensory de-sensitization is the process of reducing a child's reaction to sensory stimuli.  For example, if new foods upset a child, we start the de-sensitization process by offering only a tiny amount of a new food at first (1/16 of a teaspoon) and offering it no more than a few times during a meal.  These tiny bites of food can be offered in between bites of food that the child likes. Once the child gets used to the routine of having tiny bites of new food a few times during meals, the bites can be gradually made larger and the child can be given more bites in a row.

When done slowly and gradually, de-sensitization can be a very effective way to expand the diet.

Strategies For Behavioral Feeding Problems

Strategies for behavioral problems can vary quite a bit.  Here are several approaches that are more commonly used. Please note that these may not be appropriate for all children with behavioral feeding problems.

Break Each Goal Into Very Small Steps. Reward Each Step.

Breaking a task into very small, tolerable steps increases the likelihood that a child will be able to succeed at each step. A common strategy is to start with a step the child can already do, or does do regularly.  The next time he performs this step, he is praised and rewarded.  For example, introducing a tiny bite of new food, as described above in the "Sensory De-sensitization" section, is also a behavioral strategy, because it breaks a goal into very small steps and advances the steps over time.

Rewarding children for doing something that we want them to do reinforces the behavior, and makes it more likely that they will do it again the next time we want them to do it.  For some children, praise is enough of a reward. For other children, praise alone may not be enough. In these cases, a reward could be a bite of favorite food, a brief opportunity to play with a favorite toy at the table, or watch part of a favorite video, movie, or TV show, listen to favorite music, etc.

Every time a child performs a particular step, he is praised and rewarded.  The same step may be repeated a number of times over a series of meals, or days, or weeks, until the child can complete the step without difficulty. Then he is guided to the next step in the plan, and so on, until he achieves the final step of the goal.

Start At Zero.

This is a technique more applicable to older children.  Children start each day with no toys, games, television, or favorite activities. They must earn each of these items or activities by completing specific steps or modeling certain behaviors.

Token Economy.

This is a technique that works well with some children and adolescents. In this sytem, each time the child completes a step, he earns a star or a check. When he has earned a certain number of stars or checks, he gets a reward (such as renting a favorite movie, a sleepover, etc).

Resistant and Destructive Children

Some children are very resistant to change, no matter how small, and will increase undesirable behaviors when a new routine is begun. Some children may initially cooperate with a new plan and then backtrack or become resistant.  A few children have such destructive behaviors that behavioral plans must be very carefully designed to keep children and families safe while still providing appropriate rewards for good behaviors and appropriate discouragements for bad behaviors. Professional guidance is required in all of these cases.

Which Techniques To Use When?

Professional help is usually required to determine what kind of feeding problem a child has and what strategies are likely to be most effective. Any child with a persistent feeding problem should be evaluated by a clinician with expertise in feeding problems or by an interdisciplinary feeding team.

Getting Started With A Feeding Plan.

Professional help is usually required before most parents can successfully start feeding plans with their children. We recommend that any child with a feeding problem be seen by an interdisciplinary feeding team.