Family Meals Focus

The Ellyn Satter Institute Newsletter

The Satter Division of Responsibility in Feeding works for special needs

By Ellyn Satter, MS, MSSW, Dietitian and Family Therapist

Follow the Satter Division of Responsibility in Feeding with your child with special needs, even if he is said to have sensory processing disorder. Think of him as a normal, extremely picky child – which he is. Give him many unpressured chances to learn to eat, be patient, and prepare to be surprised and impressed with how he brings himself along with eating. He will not do, not do, not do, and then he will do! 

A premature child who has been tube fed

A mother writes that her son has been diagnosed with sensory processing disorder (SPD). “Carl was born prematurely and was in the hospital for three months. After he came home, it was one health procedure after another, and in the process he hasn’t learned to eat. Instead, he has been fed through a gastrostomy tube. Now he is two years old, he is well, and we are trying to teach him to eat. Our occupational therapist jollies Carl along and plays games until he opens his mouth, then she slips in a little brush and rubs it around. She calls that oral desensitization. Or she slips in food. Then she ‘rewards’ Carl for ‘eating’ by letting him play with a toy. Carl doesn’t like it – he starts crying when we get near the feeding clinic. At home, we are to hold the food closely in front of his mouth until he gives in and eats a bite, then reward him. We are to put on a ‘happy face’ and give him lots of praise when he eats, and not look at or talk to him when he doesn’t. We are to rave about the food, remind him that big boys eat, and play games with the food: ‘see this little [broccoli] tree, wouldn’t it be fun to eat it?’ It takes hours, we are all miserable, and his eating is getting worse, not better.”

Carl can be trusted to get himself to eat

From the perspective of the Satter Feeding Dynamics Model (fdSatter), you don’t have to get Carl to eat. Carl will get himself to eat. Carl is naturally cautious about eating – he missed out on two years’ eating experience, and it is all new to him. Not only that, but much of what happened to his mouth early on was painful. But he wants to grow up – with eating as in all ways. Even the sickest child retains that drive, and, because of it, you can trust him to manage his own anxiety about eating and push himself along. You can trust him, that is, provided you give him plenty of time, developmentally appropriate opportunities to learn, and do not pressure him in any way to eat.

The control approach applies outside pressure to get children to eat

In contrast to fdSatter, your OT believes that children with SPD or other sensory issues need pushing from the outside in order to get past their anxiety and learn to eat. She uses various forms of pressure, such as enticement, distraction, approval, reward, and punishment. Children can see through even cheerful, enthusiastic pressure and react to it by resisting, rather than mastering eating. Little wonder that pressure-based clinicians assert that “a child with a feeding problem would starve to death rather than eat foods beyond their comfort level.” Sensory issues do not make children behave in such an abnormal fashion relative to eating; pressure with feeding does.

Children with sensory issues push themselves along to learn to eat

Many children have sensory issues with feeding, but with plenty of time and no pressure, they manage their own anxiety and push themselves along to learn to eat.

Don’t let your hands be tied by an SPD diagnosis. Children with sensory issues are slow to learn, but they do learn. Keep in mind that everybody’s got something about themselves that they have to learn to manage. Many children have sensory issues – they are temperamentally negative, shy, or slow-to-warm up, are so sensitive to tastes, textures, and even smells that they gag or throw up, and are reluctant to touch certain textures or wear certain clothing. But with plenty of time and no pressure, they manage their own anxiety and push themselves along to learn.

Think of Carl as a regular child

  • Stop thinking of Carl as a special-needs child and think of him as a toddler.
  • Make a transition in your own thinking about who is helping Carl. In the past, others have treated Carl. Now you are setting feeding so he can learn.
  • Get help if you can find it, from someone who is well grounded in fdSatter. Making this transition requires a leap of faith and steady nerves.
  • Tell your health care provider what you plan to do and ask some questions.
    • Does Carl chew and swallow normally?
    • Does Carl have any neuromuscular, digestive, metabolic, or medical issue(s) that complicate or prevent his learning to eat?
    • Is Carl in good enough nutritional shape to carry him through a time when he might eat less?
    • If Carl needs additional nutritional support, how can that be provided without interfering with his eating?

Feed Carl like a regular child

Feed Carl like he is a normal, extremely picky child – which he is. Give him many unpressured chances to learn to eat, be patient, and prepare to be surprised and impressed.

  • Have a dietitian work with you in gradually cutting down on the amount and timing of Carl’s tube feeding so he can be hungry, but not starving, at meal- and snack-time.
  • Establish the version of the Satter Division of Responsibility in Feeding that is appropriate for the toddler.
  • Include Carl in the family’s regular, family-friendly meals and snacks. Include foods that fit his ability to do it himself: to pick up, mouth, chew, and swallow.
  • Trust Carl to cope with his sensory issues, including gradually developing positive attitudes about eating, getting over his fear of eating, and resolving his aversion to touching and mouthing.

Be very careful to follow the division of responsibility 

  • Be consistent in providing Carl with opportunities to learn.
  • Have regular meals and snacks.
  • Be considerate without catering with food meal planning.
  •  Be excruciatingly careful  not to pressure him in any way to eat.

Observe the little ways Carl pushes himself along to gain Eating Competence

  • He will come willingly to the table, enjoy being there, and behave nicely.
  • He will look at food and watch you eat it.
  • He will allow the serving bowl by his plate but not want the food on his plate.
  • He will put food on his plate and might even touch it but not eat it.
  • He will do his own oral desensitization by putting food in his mouth and taking it out again – probably many times.
  • Eventually he will swallow the food.

Expect progress to be uneven

  • Some days Carl will feel more like pushing himself along than on other days.
  • As fdSatter faculty member and experienced feeding therapist Pam Estes observes, he is likely to not do, not do, not do, and then he will do!

Celebrate – but quietly

Then go off by yourself, shed a tear or two, and celebrate. But don’t let Carl catch you at it. As far as he is concerned, his learning and growing is all in a day’s work.

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