Intervening with pediatric feeding disordersExtreme food selectivity, extreme picky eating, special needs
Teach your child to eat based on the division of responsibility
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, 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 matter-of-factly again and again, eat and enjoy it yourself, and let your child join in with family meals. Your special-needs, slow-to-warm-up, or very picky child 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; your child will just work harder and 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 does in-office work with the child’s eating, and supports 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, in or outside of the office. This is a tall order, when you consider that playing games, rewarding, and cheer-leading all represent pressure. In the get permission approach* to doing eating work, the therapist offers the child the food, lets the child say yes or no to it, and absolutely takes no for an answer. Using get permission, the therapist who follows sDOR does not get the child to eat. The child gets him or herself to eat.
* Klein MD. The “Get Permission” approach to mealtime and oral-motor treatment. 2003.
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 division of responsibility. 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 the division of responsibility in feeding. 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 pushes himself along to earn 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!
Child of Mine
For help feeding during the early years, read Ellyn Satter’s Child of Mine: Feeding with Love and Good Sense.
Love and Good Sense
To see what feeding looks like with “regular” children (and to find out that feeding your child is not all that much different), see Ellyn Satter’s Feeding with Love and Good Sense DVD II. For home use version, click here.
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 is just wrong. You can not both try to get your child to eat certain amounts and/or types of food and follow sDOR. 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.
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 include the following:
- Food or energy prescriptions: Setting targets for how much the child should eat.
- 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 (looking away when s/he doesn’t eat, paying attention when s/he does), stopping a video if the child doesn’t eat.
- Escape extinction: Nonremoval of the spoon (spoon held in front of the child’s mouth until s/he gives in and takes 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.
- Food chaining: Getting the child to eat a wider variety of food by starting with favorite and then offering closely related foods that are a bit more challenging.
Not sure where to start?
Start by posting your question on Facebook. (For privacy, post as a message.)