Vol. 13 Issue 27
Severe Oral Aversion in Children
Tips for providing a solid framework of outpatient services
Practitioners who treat children with pediatric feeding disorders often face the dual challenge of increasing the volume of food clients eat by mouth while decreasing their severe oral aversion and defensiveness. There are many underlying reasons why infants and children become orally defensive. Even when these initial conditions are stabilized and/or resolved, however, many continue to show lingering signs. As a result, oral aversion remains a significant barrier for therapists trying to teach children to eat by mouth and/or to advance their oral-motor skills.
Clinicians who treat children with oral aversion often become frustrated, particularly when treatment sessions produce an agitated child who has not consumed any food. With severe oral aversion and defensiveness, it is important for therapists and caregivers to not become discouraged by the negative responses. Instead, they should set short-term, achievable goals based on each child's abilities.
In the Pediatric Feeding Program at Children's Hospital, in Richmond, VA, we treat many children from around the country who received ongoing therapy but have not managed to decrease their oral defensiveness. Children who receive intensive treatment in our day patient program have been successful in overcoming oral aversion and have begun to eat by mouth. Unfortunately, many children with this problem are unable to receive such intensive therapy.
We know that oral aversion and defensiveness must be reduced in order to master the consumption of age-appropriate volume and textures, but what are the most effective treatment techniques? How can therapists use their skills to make quick progress with children who have severe oral aversion?
Following are some tips for treating children with this level of dysfunction one to three times per week on an outpatient basis. These strategies provide a solid framework to follow as clinicians help their young patients best utilize their skills and abilities.
First, map out your plan and task-analyze the components into small, measurable steps toward your goals. Begin with short treatment sessions of 10 minutes, and gradually increase the amount of time, with your long-term goal being a 20- to 25-minute meal. Track progress with each small step toward your goals. This helps you feel like you are accomplishing something.
Predictability helps reduce anxiety. Performing the routine the same way in each therapy session helps a child to know the expectations. If you utilize a timer, for example, the child will learn to associate its ring with being done. This will eliminate the session ending based on negative responses.
For children with severe oral aversion, you may not even be able to start near their mouth. Work your way from the outer perimeter of the face in toward the mouth, then the outside of the mouth, and gradually into the mouth. Choose oral-motor exercises that work on specific muscle groups in the face, such as the Beckman Oral Motor Exercises.
Choose an exercise program that has a structured routine you can follow each time. For carry-over, provide hand-outs to parents so they can learn to do the exercises at home. Because it is hard to demonstrate and practice techniques on a child who is orally aversive, demonstrate exercises on the parent in front of a mirror and have the parent practice on you to be sure the exercises are performed correctly.
Reinforce any positive responses. Give verbal praise and tangible reinforcement for the steps identified through your task analysis. As long as the underlying issues are stabilized, you can feel more comfortable about ignoring negative behaviors. .Anticipate the length of time you expect the child will tolerate therapy, and set the timer accordingly. Don't stop just because you are met with resistance. At least attempt an approximation toward your goal, and be quick to provide positive reinforcement, such as a toy or praise, for compliance. You don't want to get in the habit of letting escape become the reward.
Provide caregivers with information about your plan and give them homework to do in between sessions. Discuss your and their philosophy about treatment. This helps them feel included in the process. Caregivers often are overwhelmed and anxious about their child's feeding difficulties. Share the progress with them as you track it. This helps them see the small steps toward improvement that might otherwise be overlooked.
Once children have decreased their aversion, the therapist can begin the process of presenting tastes of food. The next step is teaching children to open their mouth upon request to take a bite. This is the foundation you will need to make strides with oral feeding.
Clinicians who treat children with severe oral aversion and defensiveness face myriad challenges as they attempt to work through the many steps that must be mastered in order for age-appropriate consumption by mouth to occur and/or oral-motor skills to improve. Occasionally, more intensive treatment may be necessary on a consistent, daily basis to help children overcome challenges in such a way that allows them to best develop emerging skills.
Regardless of the frequency of treatment, therapists should focus on reinforcing the positive as small and measurable goals are practiced in a controlled and structured treatment environment.
For more information:
Betsy Clawson, PhD, (804) 228-5818, e-mail: Bclawson@chva.org
Carol Elliott, (804) 228-5818, e-mail: Celliott@chva.org
Betsy Clawson, PhD, is behavioral director and Carol Elliott and Amber Bishop are staff therapists at Children's Hospital in Richmond, VA.