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Question of the Week: Structuring Your Treatment for Success

Posted Oct 13 2009 10:06pm
Q. What should you do as a therapist if you have a patient who is approaching school age who can drink liquids successfully, has tried a bite of two of Jell-O (a solid that becomes liquid in your mouth) and enjoys licking flavor off of high flavor solids but cannot bite, chew and swallow? Treatment so far has worked on desensitization, exploration from a sensory perspective and the child has made gains, but not expanded the diet.
A. We would use a combination of Marsha Dunn Klein's Get Permission Approach and Food Chaining. We would focus on teaching the child about eating, theme based activities such as Luau's, bake sales, cooking "shows" and teaching the child about health, food and nutrition in fun ways.

For this particular case, things are not progressing with food repertoire because there is too much of a gulf between what liquids are and what the solids are like. The child does not know how to chew. The patient likes to lick but has no motor plan to know how to chew. Food is not liquid. Liquid for the most part is always liquid and does not change except it gets a bit thicker at time. You chew all foods differently. Some foods are always different (one banana is smooth and more green, the other is mushy and ripe) and it is those changes in ripeness, texture and so on that throw many of our kids off. This is why so many of our kids like processed foods that are always the same (chips, crackers, etc). A child cannot be expected to know how to chew who has not ever successfully chewed up a bite of food and swallowed it. You have to break it down to a level where he can succeed. Not just at the level of the food and combining foods for food chains, it is much, much more than that.

First of all I would focus on helping the child be successful again with Jell-O. I would not push it, because once you are successful with a food you want it to happen again and the child feels it. If you push, he will never, ever again try that food. So in sessions, play around with Jell-O. Different flavors,different colors, different shapes (make those fun Jell-O molds, make a Jell-O rainbow, use the Jell-O cups and make them your volcanoes for your Luau theme). Poke them with toothpicks and see which one you like the taste of the best. Cut and slice Jell-O. Watch it melt and turn to liquid again. Put a straw in it and suck the Jell-O out of the base of your straw for your oral motor activities that are fun. There is a lot you can do. Add carbonation so they have a bit of fizzy taste and see if the child likes that or not. Cookie on. But don't do Jell-O every day, every session, just keep adding fun ways to explore it in treatment while introducing some new things too.

Like, for example Cool Whip or Reddi-Whip in the fun cans. You can work on it on the top of your Jell-O or on your divided plate and work toward tasting this very easy to eat fluffed texture food. Not with a spoon, dip tasting spoons, DuoSpoons, curly straws, toothpicks and other fun utensils in it. It does not coat like heavy puddings or other dense thick consistencies that may be too much to handle. If that is handled, explore whipped fluff style desserts and yogurts. I also have a lot of kids who like lemon, lemonade, lemon juice from a real lemon, later whipped lemon fluff dessert, lemon sherbet (much different that ice cream), lemon pie filling (not creamy, the gel type filling) and later to Key Lime Pie filling. I have had many, many kids do this successfully.

But how do you get kids to taste? First of all, get some other kids in there. Make your own cooking show. Have Chef hats, aprons and cook and play. Use a video camera and film them cooking, stirring and tasting to see if their food is too "hot" or too cold...have fun. Use puppets that eat in your sessions. Children learn so much from other kids. Children learn by play, they model each other and play...well that is their way to explore, learn and grow. Get someone who can model tasting, don't push it, don't say "take a bite" to the child you are working with...but what can you do? Get some little tiny paint brushes and brush a bit of flavor on the pads of your fingers or your fingernails if you want to have fun with "nail polish." Say "I am going to take my polish off now" and lick the "paint" off two fingers and tell the child about how it tasted...don't put too much on, just a tiny amount. Or have the child paint it on for you. Or dip a chopstick and a Nuk brush as your tasting utensils or dip a straw in the flavors you are going to try. Have the child hand it to a parent, sibling or friend. Say "I am going to put a dot of this on the top or on the side of my tongue" and put it on. Say mmmmm! Take a photo with the digital camera of yourself with taste on your tongue, or take a picture of the other child, not the child in treatment, getting a taste. Make silly faces and have fun but at no time direct the child in treatment to eat or take a bite.

Talk about bites by size, the wonderful Marsha Dunn Klein does this with mouse bites, bunny bites to elephant bites as size increases. Once the pressure is off, some children will go ahead and taste it just being allowed to choose and having this model. I have had dress up activities where I have fun hats, feather boas,clunky jewelry and I have pureed fruit as our lipstick. We look in the mirror and use a tiny sponge to put on red lipstick. We take our pictures. The kids get a taste of pureed fruit on the lip without being pushed to take a bite. You may only be swallowing flavored saliva at this point but it is a start. You are moving in the right direction.

Make a solid crunchy food something the child has a chance to be able to "chew" by crumbing programs. Crush the solid food with rolling pins in Ziploc bags or with toy cars, etc (tell the kids our teeth do this) and get tiny specks of it on the finger and taste it. Follow the same low pressure approach with lots of modeling. Put the crumbs on a variety of utensils, fingers, in ladels and see if you can get your tongue inside and lick it out. See if you can work your way up to larger crumbs. This progresses to meltable solids like graham cracker or vanilla wafer. You try to run your teeth over it and get a crumb off with your teeth. See if the child will try to do the same thing.

Keep offering new foods to learn about, look at and explore. Use your divided plates and consider tastes of other liquids such as broth soups (tortilla, onion, chicken noodle, Egg drop, tomato) and you put one drop from an eye dropper of Mommy's soup (cream based or cheese soup) into the spoon or mix a bit of thickened cream chicken soup into the chicken broth in a separate small bowl. See if you like it (how it looks, how it smells, have the child give mommy a bite or a sister or brother a bite).

These are just some ideas of how to get started. I would like to see a child like this work toward other foods such as watermelon (puree to a slushie), strawberry ice cream topping/ice/ real strawberries in the Magic Bullet as a drink, other fruit slush drinks, Fruit Chillers, Dole 100% fruit bars, Icees, shaved ice, Ice Pops and work toward thicker texture of frozen Go-gurts, to fudge bars, orange dream pops, ice milk and later to things like cantaloupe, watermelon, mango, salsa, spaghetti sauce, chocolate sauce, pureed fruits and gradually keep working to expand the diet.

These types of patients are very challenging and it is very important to work on the swallow and teach the child what you have to do to taste and swallow these food items. Take the mystery out of chewing. Teach the child where to put the food in the mouth, how to bite down (sensory wise this feels freaky!), what teeth you use, what your tongue does next, what happens when you swallow...use puppets that eat and model, model, model...cut tiny slivers off of a food and make it something that is not so intimidating and overwhelming. Work up in bite size and texture as tolerated.

Is this easy? No
Does it take a lot of work and a lot of patience? Yes
Can it be done? Yes!!
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