Mealtime Partners, Inc.

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Mealtime Partners, Inc. (MtP) August 2009 Newsletter

Independent Eating... is a Wonderful Thing

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Independent Eating for Children

From the moment they are born, children start developing skills. Gradually they learn how to sit, walk, talk and feed themselves. These steps are known as developmental milestones and mastery should come during a predictable time frame. However, some children are unable to reach these milestones in one or more of the main areas of development: cognition, social and emotional, speech and language, fine motor skills, and gross motor skills.

Because developmental milestones are achieved in a sequential fashion, mastery of one skill will lead to another. Therefore, if one milestone is missed, the following ones are difficult or impossible to reach. For example, babies first learn to sit with assistance, and then without assistance. A few months later they are pulling up and standing, holding on to furniture. Soon after that they walk independently and then run. Even later they learn to hop, skip and jump. Without the sequential development of these early skills, the infant would not have learned how to run.

These building blocks of learning are very obvious during the first few years of life as infants grow and develop rapidly, and so many changes take place. During this time the beginnings of independence emerges. The infant becomes mobile, begins meaningful communication, begins to self-feed, and eventually becomes potty trained, learns to brush their own teeth and bathe with little help.

In normal development, the infant learns how to pick up objects and frequently explores the object with their hands, feet and mouth. As the pincer movement of the hands develops and the fine muscles in the fingers become stronger, the child develops coordination. They become able to pick up food and put it in their mouth and “gum” it into a texture that allows them to form a bolus (a ball of food mixed with saliva in their mouth), and swallow it. Finger feeding is gradually replaced with the use of utensils, but mastery of the use of a spoon or fork can take many months for some children. During this time they frequently will revert back to finger feeding when they become frustrated.

For a child who does not develop the fine muscle control of their hands that is necessary for finger feeding, mastery of handling a utensil is far more difficult. Thus, the building blocks necessary to evolve into an independent eater are interrupted and the child misses out on experiences that will help them develop in many areas, not just independent eating. Children who are unable to put “things” (toys, food, fingers and toes) in their mouth do not develop their tongue and mouth muscles at the same rate as their peers. They also do not harden their mouth to the touch of different textures in the same way that their peers do.

It is important that children with developmental delays master as many skills as possible during a similar time frame as their peers. For many, those skills are difficult or impossible to reach in the traditional way. However, with the help of assistive technology (AT) many times those skills can be acquired. For example, independent mobility can be achieved through the use of walkers, wheelchairs, or a variety of other products. With the support of AT, the child is able to explore and gain knowledge and experience in their natural environment. Communication can be supported with sign language or communication aides.

However, eating is more difficult to facilitate. Food comes in assorted shapes and textures, some of which are eaten using fingers and others that require a spoon. Many children with developmental delays eat soft textured food for a longer time than their peers because their oral motor skills are inadequately developed for them to safely eat textured foods. This creates a situation where a child who is experiencing difficulties with gaining independence eating, needs to eat soft textured foods that are difficult, if not impossible, to eat using fingers. Therefore, for them, the simple act of getting food into their mouth independently becomes complicated by the need for a utensil.

Comparing picking up food with your fingers and placing it into your mouth with picking up food on a spoon and placing it in your mouth, illustrates the increase in complexity of the task that occurs when a spoon is needed. A simplistic description of the external body requirements is as follows (issues of oral motor muscle control will be discussed in a later Newsletter): when finger feeding, the child needs eye hand coordination to locate the food, a finger/thumb pincer movement to pick-up the food, a small amount of wrist rotation, and enough elbow flexion to raise their hand to their mouth. When using a spoon, the child first needs to be able to grasp the handle of the spoon. Once they have the spoon in their hand they use eye hand coordination to locate the food (usually contained in a bowl) and they must manipulate the spoon into a bowl and move it around in the bowl so that food is either intentionally or accidentally loaded onto the spoon. This action typically requires significant wrist rotation. Next the spoon must be raised to the child’s mouth. To retain more than just a coating of food on the spoon, the bowl of the spoon must be kept on a level plane while the spoon is being raised from the bowl to the mouth. This is a very complicated movement that requires at a minimum both wrist rotation and elbow flexion. Normally, the arm is also raised at the shoulder and some shoulder rotation is evident. Throughout this process the child must maintain a grasp on the spoon. The entire event of taking a single bite of food using a spoon is dramatically more complicated than taking a bite of food using your fingers and requires a higher level of cognitive processing, and the coordination of many more muscles and more energy.

Many parents, and the medical professionals supporting them, are so concerned about learning how to provide care and support for a child who is identified as having developmental disabilities, that their main concern about eating is providing adequate calories (or nutrition) in a timely fashion (unless a child has a significant eating disorder). They are busy with so many issues that the child becoming an independent eater is not a priority. However, the child is missing out on experiences that will help them achieve developmental milestones. A simple example of this is choice making. If a child self-feeds, they can easily show their preferences in foods. They either do not eat the food items that they don’t like, or, more commonly, they simply drop it onto the floor. They are selecting what they will, and will not, eat. They are making choices, which is healthy for them in developing their independence.

It is desirable that the transition from feeding to eating be a natural evolution for a child with developmental disabilities, as it is for a child without disabilities. Children, who are fed out of necessity beyond the normal developmental time frame, in many cases, continue to be fed rather than learning how to eat. This is an easy oversight on the part of the person feeding the child. It is simple to continue doing what you have done since the child started eating solid foods. Yet if food is put in the child’s mouth without them actively participating in removing it from the spoon, they will not be given the opportunity to practice, and therefore they will not become good (i.e., develop the skills) at closing their lips around a utensil.

Good lip control contributes to clear speech. Lip closure should be encouraged and when necessary, demonstrated and assisted. Always explain to the child what you are doing and why. Initially, to assist with lip closure, the person feeding can use the thumb and index finger of the hand that is not holding the spoon, to gently close the lips of the child over the bowl of the spoon. The spoon is then gently removed from the child’s mouth. During the removal process an upward movement of the spoon should be avoided as it wipes the spoon on the top teeth/gums of the child. Once lip closure begins to evolve the next step is to develop the child’s ability to move their mouth onto the spoon and then close their lips. At this stage the person feeding should still remove the spoon from the child’s mouth. However, as the child exhibits their ability to move onto the spoon to take food, they should then be encouraged to move back, away from the spoon, with their lips closed, so that they take the food off of the spoon and keep it in their mouth. All of this is more easily accomplished when the child is positioned appropriately for eating and is able to produce a chin tuck when taking food from the spoon (refer to the Mealtime Partners June 2009 Newsletter for more information on promoting a chin tuck, and the July 2009 Newsletter for more information on good positioning for eating).

For many parents this process is slow and frustrating. It can create tension and stress at mealtimes that is very undesirable for both parent and child. To avoid creating a negative environment, they can work on feeding for the first few bites of every meal when the child is hungry.

When a child is being fed it should be remembered that they are unable to physically choose what they eat and it is up to the person feeding them to give them the opportunity to select what they will eat. Always respect their rejection of food, as long as they have had a taste of it. Allow them to communicate that they do not want what is being offered or that they would like more. Mealtimes are a wonderful opportunity for communication and if given the chance, children will let you know what they want.

A future Newsletter will discuss strategies to facilitate independent eating for those who have limited hand/arm control and who have the potential to self-feed in the traditional manner.

When it becomes apparent that a child will not develop the fine or gross motor skills to be able to self-feed, using a Mealtime Partner Dining System to assist him/her in eating can help them to master the fundamental eating skills during a more appropriate time frame and accelerate the development of other functional skills, as described above. It can also help to avoid learned dependence, and, at an early age, teach them that they can have a fair degree of control over their lives, regardless of their disabilities. The Mealtime Partner is the only powered assistive dining device that can be used by small children. It has been proven to work with children as young as three years old.

IEP Goals for independent Eating (Part 1)

The goal of the Individuals with Disabilities Education Act (IDEA1) is to ensure that all children with disabilities have available to them a free appropriate public education that meets their unique needs and prepares them for further education, employment, and independent living. IDEA states that services should be provided to enable children to function in regular education classes, and in extracurricular and nonacademic settings, to enable children with disabilities to be educated with nondisabled children to the maximum extent appropriate. To meet these requirements, it is important to include functional IEP goals for students with disabilities. Functional refers to nonacademic activities, as in “routine activities of everyday living.” The purpose of the IEP is to prepare students with disabilities for life after school. Schools should understand that, for some children, teaching them how to "function" in the world is as important as teaching academic skills. IDEA requires that regardless of whether the ultimate goal of the IEP is to teach functional or academic skills, a functional performance statement must be included in the IEP documentation [IDEA Section 1414(d)(1)(A)(i)(I)].

Functional skills are defined as skills that will promote independence and exploration. Adaptability of the skills should be encouraged so that they can be used in multiple settings and in real-life. Additionally the child’s family should rate them as a priority for the student’s IEP goals. Functional skills should be observable and measurable to be included as an IEP goal.

Many students who are supported through special education programs, lack the functional skills to independently perform any activities of daily living (ADLs). We will address students who attend regular classes, i.e., are mainstreamed, in Part 2 of this topic that will be in the September 2009 Newsletter. ADLs include bathing, dressing, toileting, mobility, communication and eating. For these students, improving their functional status should be a priority for IEP goals. Many more lack the ability to perform one or more ADL's. All of these students must be provided with assistance with these activities, e.g., going to the bathroom, getting a drink, or eating. Many special education classrooms will have one or more teacher’s aides to provide the necessary help for students. However, the ultimate goal should be for the student to become more independent in these activities.

When addressing independent eating for students who cannot self-feed, their current level of performance in the area of eating should be thoroughly evaluated and both how the evaluation was conducted and the results should be documented in their IEP. Having established the student’s current level of performance the next step is to establish goals in this area. Goals should be prioritized in the order of greatest importance and should be stated in objective, measurable terms.

Establishing goals that address gaining independence eating should be developmentally appropriate for the student and should, when reached, enhance the student’s ability to participate in the least restrictive environment. However, they should always be realistic and achievable. For example it may not be realistic to set a goal for a student to take four bites of food independently if the student currently cannot raise their hand to their mouth. During the evaluation the student’s functional abilities should be measured. If a student does not have a pincer movement or cannot grasp a utensil or is unable to raise their hand to their mouth, then intermediate steps must be evaluated as IEP goals rather than setting direct eating goals. The question must always be asked, can these skills be developed? Have previous IEP goals in this area been established, and if so, were the goals met? If the answer is that the goals were not met, then the reason(s) should be examined. Can the student, with more time and practice, develop these skills, or is it unlikely? If the likelihood is remote, perhaps a different approach should be taken. Instead of setting goals that attempt to develop functional skills in the traditional sense, which might be impossible to achieve, the student may gain great strides towards mastery of independent eating through the use of assistive technology (AT). Equipment like the Mealtime Partner dining system can enable independent eating when traditional methods fail.

When using AT to eat, the equivalent mealtime behaviors can be performed and observed. The conditions that meet the IEP goals are the same, yet how they are accomplished changes. For example, the behavior will be observed at lunch-time or at snack time (the same time regardless of whether an aide is helping the student eat using hand-over-hand techniques or the student is using a dining device). The level at which the behavior will be performed will be established (with physical assistance, verbal prompting or independently) and how the acquired skill will be measured (John will take 4 bites of food with verbal prompting at each snack). Setting goals for independent eating using AT can be compared with setting communication goals using an augmentative communication device.

Finally, it should be noted that becoming an independent eater through the use of AT can facilitate the development of many subsidiary skills. Student’s practice and gain mastery of the use of adaptive switches. They develop the ability to meaningfully make choices by eating what they want, not just what an adult offers them. Additionally, they are empowered with the knowledge that they are able to feed themselves, which gives them an example of what they might accomplish in the future!

A MtP Tip: Never trick a child into eating food they do not like. It is unfair to them to mix food they dislike with food that they like. Also it makes them distrust the person doing this! They know what you are doing and don’t have the power to stop you

August 2009 Newsletter References:

1. Individuals with Disabilities Education Act (IDEA). Code of Federal Regulations (CFR), Volume 34, Part 300



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