She Didn’t Eat a Thing at School Today!

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It’s that time of year again and little kids are climbing onto big yellow buses, tiny hands clutching lunch boxes that are packed full with a variety of choices, with their wishful parents praying that they will “just eat something!”  But at the end of the day, especially if the child is a picky eater, parents sigh as they open the lunch box latch and see that lunch has barely been touched.

For children in feeding therapy, treatment doesn’t stop when a child is eating well in the clinic setting.  Once a child has begun to eat even a limited variety of foods, I prefer to generalize new skills to the community environments as soon as possible, even as clinical treatment continues.  The school cafeteria in the one hot spot in the community that most kids visit five times a week.  It can be a chaotic setting, as described in one of my first blog posts for ASHA, which offered some tips on how to help kids eat in the Café-FEARia.  But what can a parent do at home to encourage kids to bring a healthy lunch, even when they only eat only five to 15 foods?  Here are six tips to encourage even the most hesitant eaters to not only eat preferred foods, but phase-in eating those new options showing up in their lunchboxes:

  1. Begin with Exposure: Kids may need to see a new food multiple times before they may even consider trying it.  That means they need to see it at school too.  If you’re thinking, “But he won’t eat it, so why pack it?” remember that the first step is helping your  hesitant eater get used to the presence of that food in his lunch box again and again.  The link to this ASHAsphere post will explain more, including why food doesn’t have to be eaten to serve a purpose in food education.
  2. Pack All the Choices under One Easy-Open Lid: For my school age clients, I use a compartment or bento-style lunchbox, such as EasyLunchboxes® or Yumbox®.  Even little fingers can open the lids quickly to reveal their entire lunch, so no time is wasted when most kids in the public school system have about 20 minutes to enter, eat and exit the cafeteria.
  3. Give them Ownership in the Lunch Packing Process. Kids like predictability and need to feel a part of the process, especially when it comes to food exploration.  For my clients in feeding therapy, once they have the oral motor and sensory skills to eat a few foods, those foods get packed along with other safe choices in their lunchbox.  A child who is receiving tube feedings may still take a lunchbox if he or she is able to eat even a few foods orally.  To make them the Lunchbox Leader, we create a poster board together that has a photo of the inside of their bento box, essentially creating a “packing map.”
    Packing Map #2
    Using colored markers, I help the child list the foods they can eat with arrows pointing to where the foods go in the box. For example, the Yumbox® has compartments with fun graphics representing dairy, grains, proteins, fruit and veggies. If the child is limited to purees, we write “applesauce” next to the fruit compartment on the poster. But we also write a few more future purees that he/she just needs to be exposed to, and those show up too. Parents and kids pack the lunchbox together the night before, and the kids choose from their short lists what goes in each compartment.  If they have exactly five preferred foods and there are five compartments, then we create a rule that they need to pick a new food for at least one of the compartments.
  4. Include a Favorite, But Just Enough:  Selective eaters always eat their favorite foods first, so be sure to include their preferred food, but not too much.  Provide just enough so that you won’t be worried that they are starving, but not so much that the other less-preferred choices don’t stand a chance.  That’s why the bento boxes work so beautifully, because the individualized compartments, along with the “map” to fill them, guide the packing process.
  5. No Comments Please!  When the lunchbox comes home, resist the urge to unpack it immediately. Give everyone a chance to breathe, especially those kids with sensory challenges who have difficulty with transitions from one environment to another. When you eventually open it, no comments about the contents please!  Nothing, not positive or negative. For many kids, it creates too much focus on whether they ate or not.  That’s addressed in feeding therapy. For now, just wash it out and set it on the counter for your child to pack again later that evening.
  6. Keep Up with Other Strategies: Parents who have kids in feeding therapy understand that it’s a steady, step by step process.  Keep  up with strategies listed in this ASHAsphere post or this one and/or those recommended by your child’s therapist.

Whether you have a child in feeding therapy or a “foodie” with a palate that rivals a Top Chef, I encourage you to have all the kids in your family create a packing map and be responsible for their own lunch packing, with the kids choosing from each category while the parent provides the healthy food options and keeps the kitchen stocked.  You might be surprised to see some of your young foodie’s choices shift to the more hesitant sibling’s packing map over time!  Remember, it starts with exposure and builds from there.

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is  offered for ASHA CEUs and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

How to Use The Language of Baking

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Do you want to spice up your therapy sessions? Try this no fail recipe for pumpkin brownies. They are moist, full of chocolate flavor and absolutely delicious. You will not miss the additional oil or eggs in this recipe. There are only two ingredients, which make it easy to make and fit into a therapy session.  Whenever I bake during a therapy session, I try to focus on very simple recipes so that more time could be spent on speech and language goals. When you try to create a recipe that is too complicated, you can get lost in the activity and lose sight of your speech and language goals.

From my perspective, language and baking naturally occur together. Children really enjoy baking because it can be a stimulating sensory activity as well as language rich activity. When baking in a group, pragmatic language goals can be easily targeted (topic maintenance, turn taking, appropriate topics, etc).

The ingredients in this recipe do not need to be refrigerated and are easily found at any supermarket. They are also very affordable and yield about a dozen brownies! With no added fat, they are much healthier than the normal brownie. Also, the brownies do not contain any additional eggs or oil.

Ingredients:

1 can of pureed pumpkin (15 oz can of pureed pumpkin, not pie filling)

1 box of brownie mix (I used chocolate fudge brownies, 19.5 box)

Sprinkles or topping of your choice

Directions:

  1. Preheat oven to 375 degrees.
  2. Wash hands.
  3. Grease 8 X 8 inch square pan.
  4. Open brownie box and pumpkin can.
  5. Combine pumpkin and brownie mix in a bowl.
  6. Stir until smooth.
  7. Pour batter into greased pan.
  8. Sprinkle batter with topping of your choice (I used 3-4 tablespoons of sprinkles).
  9. Bake at 350 degrees for about 30-35 minutes or until done (till toothpick comes out clean).

10. Cut and let cool.

11. Eat and enjoy!

pumpkin brownies

Ten  speech and language goals that can targeted during baking time:

 

  1. Sequencing. Work on “first, then” and have the child retell the steps to the recipe in the correct order.
  2. Following Directions. Work on one- to two-step directions (e.g. “open the box and pour in the brownie mix”).
  3. Asking For Help: Create situations that a child needs to ask for help such as opening the box of brownies or opening the can of pumpkin.
  4. Expanding vocabulary. You can expand the child’s vocabulary by focusing on new vocabulary such as cooking utensils, ingredients, appliances, etc.
  5. Turn taking. This recipe is excellent to do in a group. Each child can take a turn pouring the ingredients into the bowl, stirring the mixture together and pouring it into the pan. Use a turn card when baking so that each child knows when it’s their turn.
  6. Describing. Have your client describe the ingredients focusing on what they look, smell and feel like. Have the child taste the pumpkin and describe the flavors. Discuss the colors of the ingredients and toppings (if you are using). Does the pumpkin look smooth? What does the brownie mix feel like? What does it smell like?
  7. Actions: Focus on actions such as, “wash,” “open,” “pour,” “combine,” “stir,” “bake,” “cut,” “sprinkle,” “eat,” etc.
  8. Choice making: Baking time is an excellent opportunity to improve choice making such as choosing what step they would like to do, what topping they want, etc. Although the recipe seems very simple, there are a lot of opportunities for making choices.
  9. Recalling information/narratives: Ask the child questions such as “What did we do first?” etc. Ask the child to tell you a story about “making pumpkin brownies.” When you are baking, take some photos with your phone or camera (if you have written permission) and use the photos to recall information and create a narrative. There are many wonderful apps out there that are ideal for creating stories with photographs. Don’t have an electronic device? Have the child draw a story about the pumpkin brownie activity.
  10. Pragmatic language goals: When baking together, pragmatic goals can be worked on. Discuss appropriate and inappropriate language and behavior when baking. If you are baking in a small group, help facilitate conversation between peers and encourage maintaining appropriate topics of discussion.

If your client is nonverbal or minimally verbal, create a communication board so they can communicate during the activity.

Carryover Books: Try reading some of these books after making the brownies together. These books can help carryover the concept of pumpkins and baking.

How Many Seeds in a Pumpkin? By Margaret McNamara

Seed, Sprout, Pumpkin Pie by Jill Esbaum

Betty Bunny Loves Chocolate Cake by Michael Kaplan

It’s Pumpkin Day, Mouse! By Laura Numeroff and Felicia Bond

Carryover Activities: Bring in a small pumpkin and decorate it during a therapy session. Each child can take home a small pumpkin that they decorated themselves.

Becca Eisenberg, MS, CCC-SLP, is a speech-language pathologist, author, instructor, and parent of two young children, who began her website www.gravitybread.com to create a resource for parents to help make mealtime an enriched learning experience . She discusses the benefits of reading to young children during mealtime, shares recipes with language tips and carryover activities, reviews children’s books for typical children and those with special needs as well as educational apps. She has worked for many years with both children and adults with developmental disabilities in a variety of settings including schools, day habilitation programs, home care and clinics. She can be reached at becca@gravitybread.com, or you can follow her on Facebook; on Twitter; or on Pinterest.

 

Collaboration Corner: Surviving Dysphagia in Schools

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(photo credit)

According to ASHA (2006), 1 in 10 public school speech-language pathologists have a student with dysphagia. I have to be honest; this is a struggle for me. Here’s why: while I have extensive dysphagia experience in medical and private home-based settings, I have difficulty defining my role as an SLP who provides dysphagia therapy in school.

Identifying the obstacles

ASHA has a fairly clear document describing the role of the school-based SLP in schools. However, the perceived obstacles can be daunting (Miller, 2008). The top 4 obstacles consistently come across are: Scheduling and environment, training staff, keeping the lines of communication open between family, staff and outside therapists, and getting student buy-in.

Removing the obstacles

Miller (2008) urges collaboration in treating students with dysphagia. I have the good fortune to work with many talented special educators, nurses, behavior specialists. While I bring the knowledge of dysphagia to the table (bad pun), recognizing the daily demands upon the child requires team-based attention. The following strategies may help balance your student’s dysphagia issues within the context of the school day:

Examine/modify the child’s schedule. Students have very little time to eat. Snack is usually 15 minutes (if at all) and lunch is about the same with recess either before or after. This means students risk missing academic time, social time, recess. Suddenly speech is the no fun allowed zone; staff/students become worried that therapy cuts into these activities.

To help with this let the child start eating in the cafeteria before everyone else arrives, use calming strategies such as music with headphones, or a favorite book for the child to read while he/she is eating. Bring a lunch buddy if it helps. Gradually set limits around how much music she/he can listen to. If a child is too overstimulated during lunch time (elementary cafeterias are quite an experience), have the student eat early and let them read a book or chat with friends. This allows mealtimes to be associated with positive feelings.

Training staff. Many students have a paraprofessional, who also needs to eat their lunch, but guess when their student may need the most support? During lunch, of course. Keep clear instructions and provide hands-on training for staff, give a copy to the school nurse. If there is a change in staffing, make sure the change is with a familiar person who also has training. I have staff sit in on times that are not during their break or lunch. I also encourage the student’s paraprofessional to eat with the student as to “normalize” the experience and to provide role-modeling around food. We have Fun Friday where everyone eats together and we do a fun food play activity. Again, create positive associations with eating (for staff and students!). Staff need consistent access to strategies that will keep the student calm, like this cue card, created by my colleague and co-author of The Behavior Code:

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Communicate closely with families. Eating is a cultural and emotional experience. Ongoing communication with family members provides insight as to when everyone is ready to move to the next step. Clearly communicate that safety is the most important factor in the decisions related to their child’s eating. Encourage parents to come in, or take pictures and video. Use a home-communication journal so notes can go between school and home, highlighting what they ate, how much they ate, and any events that may have affected their eating.

Communicating with outside SLPs. OK, so here’s the deal. Expertise exists across settings. If I don’t do VFSS  on a daily basis, I recognize that I am not an expert in that assessment tool. But if I have a background in dysphagia, have worked in schools for 11 years, have seen this student 3 times a week in their school setting for three years, guess what? I have expertise as well. I can (and should) make a referral for a VFSS by an SLP who has the skill and equipment. Likewise, private SLPs should confer with the school-based SLPs perspectives on eating. Speech-language pathologists need to reach out to one another and value these differences. These differences are a good thing (stepping off of my soapbox now….).

Make the child a part of the process. Keep it low pressure, and rewarding. Take picture of their successes and make a book about it together.  Have them review the book before they eat, so they remember their successes and eating strategies. Here’s a rather crude (but effective) example of a page I wrote with my student:

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Last but not least, set aside your own assumptions of what tastes/feels/smells good….these kids experience food much differently than you do. Remember, eating involves developing trust; it is not a forced process. The end goal is to make eating pleasurable and safe so that mealtime becomes enjoyable for everyone.

Dr. Kerry Davis is a city-wide speech-language pathologist in the Boston area. Her areas of interest include working with children with multiple disabilities, inclusion in education and professional development. The views on this blog are my own and do not represent those of my employer. Dr. Davis can be followed on Twitter at @DrKDavisslp.