Intervening with pediatric feeding disordersExtreme food selectivity, extreme picky eating, special needs
Teach your child to eat based on the Satter Division of Responsibility in Feeding
Through no fault of yours or anybody else, your child may not eat. Some children are exquisitely sensitive to tastes and textures, have a strong gag reflex, and throw up easily. Some children are diagnosed as having sensory processing disorders (SPD), which means that they react negatively to certain or many tastes and textures. Some children get a late start with eating because they have medical issues and/or are fed by tube during their early lives. Some children are just slow to warm up and may even be on the autism spectrum: it takes them a long time with absolutely no pressure to take an interest in new food and to learn to eat it. Some children need therapy from an occupational or speech therapist to address problems with chewing and swallowing.
But there will come a time when your child’s medical issues have stabilized and he can learn to eat the food you eat. Consistently applied, and with skillful attention to complicating medical, nutritional, and oral-motor issues (you can get help through ESI coaching), the Satter Division of Responsibility in Feeding (sDOR) can form the foundation for your child’s learning to eat. You do the what, when, and where of feeding, and let your child do the how much and whether of eating. You provide appropriate food at regular meals and snacks, matter-of-factly and again and again, eat and enjoy it yourself, and let your child join in with family meals and snacks. You plan meals and snacks that are considerate of his inexperience by providing soft food that is easy to pick up, mouth, and swallow and let him eat—or not. You are very careful not to apply pressure in any way on him to eat. You support him nutritionally in other ways while he ever-so-slowly, over weeks and months, gets the idea of eating. Then you gradually phase out the tube feeding or formula as he eats more and more. Your special-needs, slow-to-warm-up, very picky child, even if he is on the autism spectrum, will push himself along to eat, the same as any other child. Stages in feeding look the same; they just come along more slowly. Challenges at each stage are the same; it will just take your child longer to master them. Eating quirks are the same; it is just hard to sort out the “child” in these quirks from the “special needs.”
If you choose direct intervention with your child’s eating, consider this: In the best hands, direct eating intervention by an Occupational Therapist or Speech and Language professional does in-office oral-motor work with your child, addressing chewing/swallowing issues, and supports you in an accurate and thorough-going application of sDOR at home. It does not ask you to do eating work with your child. And it does not exert pressure in any way on your child to put anything in his mouth, in or outside of the office. This is a tall order, when you consider that playing games, rewarding, and cheer-leading all represent pressure. To do eating work, the therapist offers the child the food or other stimulus and waits a few seconds for the child to look, react, open up, or not. If the child refuses, the therapist absolutely takes no for an answer. Then another day at another session, the therapist offers again, and again and accepts the child’s opening up or refusal. The therapist who follows sDOR does not get the child to eat. The child gets him or herself to eat.
Raising Special Needs Children
to be Competent Eaters
by Ines Anchondo, Pam Estes, and Ellyn Satter
- Adoptive and foster child feeding problems
- ARFID: What is it? What does it have to do with feeding dynamics and eating competence?
- Division of responsibility in feeding works for special needs
- Does following the division of responsibility mean you have to starve children to make them eat?
- Picky eating: Born or made?
- Eating management as a part of medical nutrition therapy for children with diabetes and impaired glucose tolerance
- Eating management as a part of medical nutrition therapy for children with cystic fibrosis
- Feeding pressure on all sides
Need personal help?
Consider ESI coaching
Coaching with an ESI expert can help you understand and address your child’s eating and support you, step-by-step, as you learn to feed with joy and confidence.
On the right are resources to help you learn how to feed based on the Satter Division of Responsibility in Feeding (sDOR). Read one of Ellyn Satter’s books and watch the feeding videos to get a clear understanding of good feeding and how children naturally behave with eating when you follow sDOR. Be considerate without catering in your meal-planning so each meal has one or two foods your child generally eats. Then adjust your expectations of your child. When you apply sDOR, your goal is not to get your child to eat a certain amount or type of food, but for your child to feel good about eating and behave well at mealtime.
Observe how your child gradually learns to eat
- 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 want 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 lose his anxiety about the food by looking, touching, smelling, and putting it in his mouth and taking it out again – again and again.
- He will not do, not do, not do and then one day he will eat!
You may be offered conventional treatment for your child’s not-eating. A conventional therapist may tell you to follow the division of responsibility in feeding along with other methods listed below, but that means they don’t really understand sDOR: The advice is simply wrong. sDOR is based, absolutely, on respecting the child’s autonomy with eating. You can not both follow sDOR and try to get your child to eat certain amounts and/or types of food because that violates their autonomy. Trying to do both will hopelessly confuse you and your child. Beyond that, the choice is yours. To help you make your choice, understand what such treatment involves. Also observe your child when such methods are used them to get them to eat. Are they relaxed and comfortable? Enjoying the process? Upset? How do you feel? Like your child is in good hands or like you want to rescue them?
From the conventional perspective, some children are naturally so eating-averse that they will go hungry rather than eat foods beyond their comfort level. sDOR oriented therapists have found that not to be the case. However, based on this conviction, conventional therapists use interventions such as desensitization, persuasion, pressure, and reward to get the child to eat certain amounts or types of food. Those treatment methods include any or all of the methods listed in Avoid pressure. Other, more systematic treatment methods of applying pressure to get the child to eat include the following:
- Positive reinforcement: Praise, compliments, rewards (preferred food, toys, or activities), distraction with video or other means, blending preferred with non-preferred foods (gradually increasing the proportion of non-preferred food).
- Negative reinforcement (e.g., “Response Cost”): Warning, punishing, withholding preferred food until child eats non-preferred food, selective attention (ignoring the child when s/he doesn’t eat, paying attention when s/he does), stopping a video or taking away a toy if the child doesn’t eat.
- Escape extinction or non-removal of food: Holding the food in front of the child and not taking it away (even for an hour or more, even if they cry and try to get away), until they give in and take a bite.
- Physical guidance: Physically opening the child’s mouth and putting in the food.
- Systematic approximation: Getting the child to do eating-related activities, such as chewing on a washcloth, sitting in the chair at the table, offering food and having the child touch, poke, squish, draw or sculpt the food; smell, kiss or lick the food or blow it into the trash. Any food related activities, such as cooking, gardening, and tea parties, where the agenda is getting the child to eat.
- Food chaining: Getting the child to eat a wider variety of food by starting with favorite and then offering closely related foods that require new learning.
- Distraction: Singing, dancing, playing with toys or playing games, doing “here comes the airplane,” having the child feed the adult or a doll, TV.
Not sure where to start?
Start by posting your question on Facebook. (For privacy, post as a message.)