Feeding and eating are basic activities of daily living (B/ADL) thus it is one of the major occupation domain of occupational therapy. The role of an occupational therapist at this domain is to evaluate occupational performance and develop feeding skills that includes sensory-motor, fine motor, oral motor and processing skills. Moreover behavior pattern, habit and routine along with contextual factors during the mealtimes that facilitate feeding mechanism.
Picky and fussy eating is also called choosy eating which is most common form of feeding difficulties  among both typically developed and delayed milestone children.
The aim of case study is to promote the effectiveness of occupational therapy in picky eater children who have attained developmental milestones within typical ranges but healthy eating habits are not developed. The occupational performance of the 5 year old picky eater child was monitored through ABLLS-Assessment of Basic Language and Learning Skill. Feeding issues of the child were affecting her physical and behavioral health eventually leading to struggle in functions for BADL- basic activities of daily living and social participation.
It is observed that continuous occupational therapy session with individualized intervention plan, inculcate healthy eating habits and improve results at ABBLS.
Feeding Behavior, Daily Living, Occupational Performance, Play Therapy, Developmental Milestone, Reinforcement Schedule, Pretend Play
Occupational Therapist CS
School and Thinkmatic
[Haroon S, Occupational Therapy For Children With Feeding Difficulties And Picky Eating Habits – A Case Study.Pka.J.rehabil.2019;8(2):50-53]
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Feeding is one of the self-help and motor skill 1 which is defined as the sequence of steps required to take food into mouth that requires fine motor skills, eye hand coordination, cognitive and visual perceptual skills. Whereas eating is defined as the process takes place to the food once it is in the mouth, mainly involve oral motor skills and process-ing2.
Feeding difficulties include; inability or refusal or reluctance to eat different foods or a variety of food textures, swallowing and chewing difficulties, fussy eating, decreased appetite, limited interest in feeding and mealtime behavior3.
Some children face eating issues such as picky eating, intolerance to different textures, tastes or smells and chewing the food. Feeding issues are often related to developmental delays, cognitive or emotional problems or other medical diagnosis. It is exhibited in the form of functionality difficulties, behavioral disorders with poor occupational perfor-mance4.
Occupational therapy provides intervention to children who have difficulty in feeding by focusing on improving their occupational performance and implementing technique to enhance caregivers about strategies of developing child’s interest and curiosity to solid food items5.
Occupational therapist also address emotional component, focusing on children to overcome their food related anxiety by applying techniques of play and cognitive behavior therapy.
A 5 years old girl was referred to outpatient clinic of the school with feeding issues underlying anxiety and discomfort feeling while eating solid food, although the child has attained developmental milestones in the typical range. This study observe the improvement that occurred during a study in period of individualized occupational therapy sessions comprise of sensory integration therapy, cognitive behavior therapy techniques and play therapy.
According to the parents, child refused solid form of any food and vomits if she tries to eat or is force to eat. Parents reported their child’s temper tantrum, behavioral issues and functionality impairment in BADL such as lack of interest and motivation to participate and perform self-help skills.
Initially, the child’s food preference was same as that of infant. Her diet was restricted to meshed food or blended texture. Parents also reported that she had not practiced chewing or biting any kind of solid food. So out of habit, she was eating all kind of foods in the grinded form for all her meals in a day that are were fed by the mother or her baby-sitter. Her poor eating habit accompanied by depen-dence in her BADL as well as poor fine motor skills which was required spoon or fork eating and taking food to the mouth. During travelling also her parents would carry a hand grinder machine with them and would provide her food in grinded form.
Consequently, the eating behavior of the child impedes social and emotional development of the child. Emotional outburst was more evident during snack time at school which further affected her play behavior. It turned serious concern for the parents when they observed that due to emotional distur-bance, the child started to avoid play with peers.
The child was initially assessed on the following tools
- ABLLS: Assessment of Basic Language and Learn-ing Skill, it is used to assess the understanding of basic language and identify deficiency in self-help and motor skills. It also rules out motivational strength, attention span and other factors that inhibit child from learning. It is criterion referenced assessment tool that gives broad analysis of 544 skills from 25 skill areas.
- Short Sensory Profile: It has around 38 items grouped in three main sections; sensory processing, modulation and emotional responses
The sessions were scheduled as four days a week. Initially 20 to 30 minutes for rapport building and promotion of familiarity from environment and therapist. Once the child adjusted the sessions were stretched to 45 minutes.
The customized intervention plan is based on senso-ry integration specifically oral motor massage, play and cognitive therapy. Oral facial sensory massage was conducted to improve oral muscles health.
Tongue movement was encouraged during differ-ent play therapy to attain the movement of food in mouth. She also had anxiety issues related to chew the solid food and aversive with trying few texture and smells.
Behavior therapy techniques were applied to increase the compliance by pairing non-preferred item with preferred item to increase the compli-ance and positive reinforcement was introduced during session such as playing with her favorite activities and toys5.
Behavior issues related to eating habits were addressed by role modeling and pretend play with plastic toys of vegetables and fruits, also drawing and painting the pictures of different fruits modified the child’s behavior and reduced her resistance of eating sold food items.
In play therapy, social stories were also introduced to set up the plot for meal time and exposure to variety of food. This strategy significantly reduced the anxiety and unwillingness to experience variety of food.
Family centered therapy model was applied to train and empower parents in managing eating behav-ior issues of their child. Through parent support program, both the parents were train to apply same plan at home. Play therapy strategies were effec-tively applied by parents at home by involving other siblings and scheduled reinforcement6.
The ABLLS skill tracking system showed marked progress in the area of social interaction, play and leisure and generalized responding with the better-ment in eating habits. Figure 1 shows the initial assessment and progress in scoring after the regular sessions for six months four days a week.
Figure.1 showing the baseline with the progress
Whereas at SSP she ranged in probable difference for taste smell sensitivity, only the oral motor process-ing segment from the sensory profile was assess that showed lower range of probable difference. At reevaluation on sensory profile for the oral motor sensitivity and processing, the child scored upper range of probable difference. With such differences in the revaluation score, child also showed improve-ment in the chewing of food, interest in different form of edible along with.
This case study describes that children with picky eating behavior or chewing difficulty can be facili-tated through occupational therapy sessions. It also emphasized that occupational therapy just not help children with developmental delays or with presenting any medical problems but it also help children who have achieved their milestones within time but face anxiety and behavioral issues.
It has been observed that in addition to oral motor exercises, play therapy was identified as a reward and a method to engage and teach children. The interventions and strategies should age and client appropriate7.
The present case demonstrates the efficacy of holistic approach to target behavior. The child’s behavior was modified by combining the play therapy intervention, behavior modification strate-gies, sensory integration therapy and family centered approach. Pairing desired behavior with positive reinforcement strengthen the desired behavior. Playing with toy vegetables and social stories significantly reduced food anxiety, and parental involvement accelerated the process8.
Occupational therapy, individualize treatment plan plays significant role in shaping behavior of picky eater and developing good eating habits. Poor integration of oral sensory motor and processing may lead to eating problems.
I would like to pay deepest gratitude to Ms Neelum Zehra, senior occupational therapis, whose guidance and advice helped me in writing my case study and proved monumental towards the success of this study.
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