Introduction
I've been a therapist for over 11 years and recently got into doing some teaching. Picky eating is kind of a buzz word lately. We talk about our own child who doesn't eat or we have children on our case load. I happen to have my own picky eater/borderline problem eater. In this course, I am going to discuss treatment strategies for those picky and problem eaters. We will also discuss some case studies at the end of the course.
Create a Plan of Care
Creating a plan of care (POC) is where this all starts. I know when I first got out of school I thought, "Why do we have to have all this paperwork? Why do we have to write all these lengthy plans of care?" But if we don't have a good map for where we're going, we are going to have a hard time getting there. That is what the POC is – it is a map of your treatment. It all starts there.
Our goals need to be SMART goals, which you may have heard before. This is not just in therapy it is in every kind of goal you write whether it's therapeutic or not. You want it to be:
- Specific
- Measurable
- Attainable
- Results focused
- Timed
What does that mean? So, what specifically do we want the child to do? We want to them to chew. Okay, what kind of chew - vertical chew, rotary chewing, munching? We need to be really specific in what we're wanting. Then how are we going to measure it? How do we know when it's met? We could, for example, use number of times or the percentage of time. Is it attainable? We want something reasonable for the child’s developmental stage. Just because they're five years old doesn't mean they can't have a goal that would be similar to a two year old development. If they are at a two year old developmental stage then a goal to reach a two year old developmental stage is appropriate. Again, we want to make sure it's attainable for that specific patient, not just based on what age they are. Next, the goal should be results focused. What are we trying to improve upon? Is it to decrease length of meals? Is it to tolerate a tougher solid food? Know specifically what result we are trying to obtain.
Timed means how long it will take to obtain that goal - six weeks, 12 weeks? Is it a long term goal? We want to have both short-term and long-term goals however, be sure to differentiate them. We might write a similar goal, one for a shorter duration of time than one for a longer duration of time. I usually do about six to 12 weeks for my short term goals. If I do much longer than that parents think that they are not meeting the goals. We want to show them that there is progress in that four to six week period, even if it is mild progress. They don't see the big functional change yet. But then we show them, "Here's our short-term goal and here's the long-term goal. In the next six months this is what you might expect to see.”
Additionally, I always have a patient education goal. Whether that's the patient's independence or the family's independence strategies. But there is always a parent, family component to my goals. I used to sometimes write, “Family or caregiver will demonstrate independence with home exercise program to generalize to new skills in the home in six months.” That is a pretty good goal. One goal I try to do now is, “Family or caregiver will demonstrate independence with X skill.” Rather than stating “the home program” in the goal I will be more specific. For example, I want them to get better at meal time strategies in the home or I want them to focus on oral motor activities in the home and demonstrate independence with X, Y, or Z. Be more specific if possible. That way we can see when the families continue to make progress because we know that this is not just something that is between the therapist and the patient, the family needs to be involved.
Example 1 - Chewing
Let’s look at a few examples.
Less desirable goal: “Patient will chew solid food.”
That makes sense since that is what they are here for. But what does the “map” look like for getting to the point where they are better at chewing?
Better short-term goal: “Patient will demonstrate a vertical chew…” (This goal states specifically the kind of chew that I'm focusing on) “…to a mechanical soft creating an adhesive bolus…” (Because it doesn't matter if they're chewing up and down if they're not getting a cohesive bolus. I’m adding that into the goal to be very specific on what I'm wanting.) “…on four out of five opportunities to further enhance patient's diet…” (They're going to then be able to eat different foods based on a better chew) “…to further enhance their diet in six weeks.”
This “better goal” has all of those SMART components. It’s indicating what I am working towards and what I need to be working on in therapy to get where I'm going. So, it's a good map. Again, that is the short-term goal. In about six weeks, depending on where my patient started, that goal should be attainable.
Better Long-term Goal: “Patient will demonstrate a vertical chew to at least three different mechanical soft foods, creating an adhesive bolus in 90% of opportunities during meals as reported by parents for their enhanced patient's diet in six months.”
We are not talking just a few times in therapy, we are talking over time with family that they are recording 90% of opportunities during meals. The goal is very specific about the family giving feedback on the vertical chew for mechanical soft foods. We could change it and say, "This patient's good with mechanical soft, I really want to get to a chewy food.” Then we can be specific with that. Again, we want to make it specific to the patient.
Example 2 – Spoon Feeding
Next, let's look at some spoon feeding examples.
Less desirable goal: “Patient will PO a puree via spoon without difficulty.”
“Without difficulty” could be signs or symptoms of aspiration. It could mean without anterior spillage. With this goal, it is hard to be sure what that means. We want to make sure we're specific by looking at why we are writing the goal. Is that goal for bolus management? Is that goal because they refuse that food; they can't stand that texture? When we know the “why” it can change how we write the goal. .
Better short-term goal (related to bolus management): “Patient will PO stage two puree via maroon spoon… (I'm being specific on even the type of spoon)... with appropriate lingual cupping in 90% of bites when PO'ing two ounces of food, showing appropriate management of bolus, without signs or symptoms of distress in six weeks.”
This is still a short-term goal. We are being very specific that the appropriate management of the bolus is our goal. We are looking at that lingual cupping for management.
Better short-term goal (related to food refusal): Another option if their oral motor is really a challenge for them could be the following, “Patient will PO stage two puree via the maroon spoon with appropriate lingual cupping in 90% of bites when PO'ing two ounces of food without refusal.”
This short-term goal is talking about refusing the food. They don't like that food so we are working on the oral motor whereas the previous goal is working on the management of the food. We want to be sure that the goal is telling us what to work on. Remember, goals should be written in such a way that another clinician can take the goal and do your treatment session. Goal A is working on oral motor management and goal B is showing that the child doesn’t like that flavor or texture.
Example 3 – New Foods
Less Desirable Goal: “Patient will add two new foods in six months to his or her preferred list.”
I'll admit that this is a goal I used to use a lot. What I realized is that if I can use this goal for that many patients, then it is probably not specific enough.
Better Short-term Goal: “Patient will tolerate licking at least 25% of foods presented in therapy of any consistency for a duration of two seconds or less over three consecutive sessions in the next six weeks.”
This sounds like a mouthful. But, we have to ask ourselves what is the level the patient is at? If they are just tolerating playing with foods and we want them to get it near their mouth and lick it, we aren’t going to stick to just one food. We are going to have a lot of foods. They're probably not going to do a lot of foods 100% of the time. But they might do a few foods 100% of the time. But if I lower that percentage I get more foods. So, the goal is a broad range of foods. They're tolerating licking at least 25% of the foods they're given in various therapy sessions, 25% of the time. That's for any consistency, not just puree, a meltable solid or mechanical soft. It's any consistency.
Notice, we also want to include how long they are going to lick the food. We don’t want them to do just play with it on their tongue or do a little snake lick. We want to see two seconds or less over three consecutive sessions in the next six weeks. This is very, very specific and ideally would be attainable for the patient. Also, this goal is definitely measurable. We can use a + or - tally system to indicate “did it” or “didn’t do it”. So that's very good.
Better Long-term Goal: “Patient will tolerate a bite and spit out of at least 50% of food presented in therapy of any consistency of a duration of two seconds or less over three consecutive sessions in the next six months.”
This goal goes up a level because in six months we hope they improve to the next level. They are still tolerating it more in their mouths and we are expecting a few more foods than before.
Review with Family
So let's look at reviewing this with the family. Now that we have built this really great road map, we know where we are going, we know the plan and we are in control. But we're missing a huge piece if we don’t have the family’s buy in. We have to review these goals with the families. We need to ensure that the family understands the role that they play along the way. They need to understand that they don't just sit in the waiting room, wait for us to come get them, tell them what we did and then they go home. If possible, they should be in the session and observe what we are doing. We want to explain, “This is what we are doing this week. And until I see you next week, here is what your focus is. If they don't know what the goals are they are going to be a little empty on working on it at home.
So review the goals with them, bring them in and make them a part of the team. A lot of times they're the leader of the team and they need to know what our goals are, so that they can be working on them too.
The main thing to discuss with the family is the meal/snack schedule. I get a handful of children who have a decent meal/snack schedule but most of the time my problem eaters have gone to grazing. We have to be able to kick that habit, for lack of a better term. An important goal that I write, and a large part of the problem that they need to work on, is creating a meal/snack schedule. We'll address the meal/snack schedule a bit more when we talk about roles and responsibilities. But ensure they have a meal/snack schedule.
Get them in a high chair or booster chair if that's needed and appropriate for them. I don’t necessarily mean a high chair that is used for infants, but a chair at the table that has them at the proper positioning of 90 degrees at the hips, 90 degrees at the knees and 90 degrees at the ankle for the best mobility support for their body. Seat them at the table so that they're eating with everybody and socially engaging. You can give social reinforcement at the meal/snack schedule.
Also, be sure to work with the dietician to make sure they're getting a good calorie count and encourage the family to write down what they're eating and how much they are eating if possible. They don’t have to list things down to the ounce, just get an idea of what they're eating when.
Medical Management
The medical team is very important to treatment. I want to highlight what makes up the medical team. The primary care doctor is often our first point of contact. They may be the person who actually gave the referral and they are the triage person for the family. They are going to triage out any difficulties that come up along the way. Oftentimes a gastroenterologist is involved in the team. The dietician needs to be involved, especially if there are any weight issues. Occupational therapy and physical therapy will assist in determining what is going on with gross motor and fine motor skills. If we don’t know where the child is with motor skills then we won’t have a very good plan for where to go next with oral motor skills. Remember, oral motor all comes from where the child is for gross motor and fine motor skills. There may be an ABA therapist on the team as well.
Another factor to consider is if we recommend to the PCP that a certain specialist be included on the team and they aren’t added, then figure out why and start from there. We also want to think about whether or not the family implemented our recommendations. (We will address that in more detail later in the course.)
It is ok to go ahead and start treatment even if the family hasn’t seen any of the specialists because there is a lot that we can do for food tolerance. Visually and tactilely we can get started in treatment. But we want to continue to encourage families to follow the recommendations that have made along the way as we're building rapport with them. Sometimes the only reason the family isn’t listening to our recommendations is because we just haven’t gotten their buy-in yet. We don't have their support just yet, so it’s important to take that time, earn that support, get that buy in and then we might see them starting to go along with some of the medical management team's recommendations.
