An Introduction to the DIR Approach to Pediatric Feeding

1. An Introduction tothe DIR Approach to Pediatric Feeding Julie Miller, MOT, OTR/L, SWC Dr. Diane Cullinane, MD Patricia Novak, MPH, RD, CLE Anne Davis, MS, SLP-CCC

2. Feeding Programs at PCDA Multi-disciplinary All therapists have specialized training in feeding Occupational Therapists Speech Language Pathologists Dietitians Psychologists Child Development Specialists Developmental Pediatrician Nurse Training Parents Professionals Workshops Agency Consultation Individual therapy Groups Feeding Weight Control 2

3. D.I. R. A Developmental Road Map “You have to look at how a child’s developmental abilities, including language, cognition, motor planning, affect and emotions, work together as an integrated unit.” -Dr. Greenspan

4. D is for Development

5. D: Functional Emotional Developmental Milestones Shared Attention and Regulation Engagement Two-way communication Sustained co-regulated interactions Creative use of ideas Logical bridging of ideas

6. Milestone I: Regulation The cry of hunger brings attention, and the satiation from food helps regulation Strengthen awareness of hunger and satiation Read and respond to cues, responses to look, taste, texture, temperature

7. Assessing Regulation: Types of Signals Signs of Readiness or Interest in Food or Eating: • Laughing, smiling, excited vocalizations • Raising eyebrows and opening eyes widely • Body orientation • Visual referencing • Reaching or moving limbs excitedly Signs of Fatigue, Satiety or Disinterest: • Crying, vocal displeasure, frowning • Change in respiratory rate or sounds • Change skin tone or color • Change in body tension • Withdrawal/passivity

8. Underlying dysregulation: Rule out Distress Signals of Distress • Change in respiration • Gagging • Coughing • Choking • Change in skin coloring • Yawning • Hiccupping • Body changes: arching, squirming, facial grimacing, change in tone, posture • Eyes: • Staring, averting gaze, eye movement, change in eye shape, change in coloring around the eyes, watering • Nostril Flaring • Mouth: • Smiles/frowns • Lip retraction • Lip pursing

9. Milestone II: Intimacy and Trust Shared pleasurable interactions Shared anticipation Children enjoy mealtimes because of the food and the social interaction Anticipate pattern of meals Have fun with food play, and mealtime Share food and meals with family and friends

10. Milestone II: Intimacy and Trust Use simple songs, chants or rhythms to create a familiar fun interaction around eating, and to support a predictable pace. Use familiar routines to create a sense of trust through anticipation. Provide playful interactions to create enjoyment around eating. Allow food play “with a purpose.” “We” “Us”

11. Milestone III Two-way communication Opening and closing “circles of communication” Becoming purposeful The child’s signals gain attention, express acceptance/preference and rejection/non-preference at mealtime Developing a sense of self, and a sense of others Verbal and Non-Verbal Communication at meals

12. Milestone III: Two-way Communication Provide opportunities for the child to take initiative (gestures to indicate more, that one, taking from you, handing to you.) During feeding, watch for child’s signals to indicate readiness for next bite, or next food. Provide time and opportunity for the child to become more deliberate and interactive during feeding/ eating together.

13. Milestone IV: Co-Regulated Interactions Sustained interactions with a continuous flow Joint (Shared) problem solving A child deals with delayed gratification, frustration, excitement, and disappointment around food and eating A child negotiates around what they want, how they want it, when they want it, etc. Find the right balance of responsibility between the adult and child

14. Milestone IV: Co-regulated interactions Create the “just right” level of challenge which will allow child to persist through a difficult feeding experience with the help of caregiver/therapist engaging through continuous back and forth signaling Stress observed as change in vocalizations (pitch, quality, rate), avoidance, initiating previously mastered activities

15. Milestone V: Creative Use of Ideas Emotional Ideas: Representational Capacity and Elaboration A child uses words and actions to express ideas, wishes, and intentions Be a player: use characters, funny voices A child pretends and creates with food Use pretend ideas to make eating fun and acceptable

16. Milestone V: Creative Use of Ideas Use language, gestures (thumbs up, down), drawings, etc. to describe feelings about food. Child can understand and follow some rules about eating Use books and charts to support growth of ideas around food Create rules to support acceptable eating behaviors

17. Milestone VI: Emotional/Logical Thinking Planning, predicting, motives, consequences What would happen if…? Why? Reality based problem solving discussions What could you do if the restaurant didn’t have the right food? Negotiation, argue, debate, and opine A child thinks about eating, digestion, nutrition Protein is needed to… "Where? When? Why?"

18. I is for Individual Differences

19. Individual Differences: • Unique physiological, neurological, psychological, communication, motor and sensory processing differences. • Auditory Processing and Language: the way in which we receive information and comprehend and express it. • Motor Planning and Sequencing: how we act on our ideas or on what we hear or see. • Visuospatial Processing: the ability to make sense of and understand what we are seeing. • Sensory Modulation: the ability to modulate or regulate sensation as it is coming in to the body.

20. Individual Biologic Differences Affecting Feeding • Medical history • Genetic predisposition • Gastrointestinal function • Cognitive - Linguistic Development • Dental health

21. Sensory Differences Impact Feeding and Eating? • Tactile: • All foods similar texture • Difficulty with early finger feeding/ reliance on utensils • Overstuffing vs. gag response • Proprioception: • Difficulty sitting, attending, staying in chair • Hitting, tapping, pushing under stress • Overstuffing mouth • Food seeking

22. Sensory Differences Impact Feeding and Eating? • Visual • All food similar color range • Food appear similar • Interpreting food texture, taste prior to exploring • Gustatory/Olfactory • Intense vs. bland • Sweet vs. savory • Improved acceptance with ‘adult’ flavors

23. Sensory Differences Impact Feeding and Eating? • Vestibular • Changes in head position, remaining upright • Balance and posture (tone against gravity) • ‘place in space’ • Auditory • Sound environment • Food preparation • Mealtime cues, pacing • Distractibility

24. Sensory Processing • Keep in mind that a child’s sensory processing tolerances/ regulation skills will be challenged when they experience: • Hunger • Fatigue • Constipation • Illness • Medications • Transitions • Stressors (positive and negative)

25. Sensory Processing • Remember: • Decreased or altered sense of appetite and satiation, awareness of body sensation (interoception) • Observe child’s seeking and avoidant patterns with food • Consideration to caregiver’s own sensory needs • Impacts motivation to eat (+ OR -)

26. Individual Differences: Motor Skills • Ability to maintain a functional eating position • Consideration for child’s safety as well as effectiveness • Position in order to access food, utensils, and interaction • Able to communicate (verbal, non-verbal, gestures) with parent, feeder, and peers • Ability to demonstrate safe and effective oral motor skills • Structure • Tone and strength • Functional skills for varying solids and liquids • Overall motor coordination • Oral praxis • Safety

27. Motor Skills • Gross motor participation • Posture • Climbing in/out of chair • Fine motor participation • Utensil use • Cup/container use • Food construction • Oral motor function • Effective chewing patterns • Sufficient lip seal • Bolus formation and coordination • For communication • Spoken or manual

28. R is for Relationships

29. Relationships • How much time do we spend assessing the parent/caregiver- child relationship and the factors influencing the parent-child relationship? • The relationship determines the success of therapy • parent-child • child-therapist • parent-therapist

30. Role of the parent in the feeding relationship • Determined by the belief systems that creates the individual culture of that family. • Individual culture directs the individual's response to the environment • Shaped by the degree of personal • Acculturation • Identification

31. Talia’s place

33. D.I. R. Critical features: Warmth and security Regulation so the child is not overwhelmed ****Relatedness and engagement**** Back and forth emotional signaling and gesturing Problem solving The use of ideas in a meaningful and functional way Thinking and reasoning

34. Outcomes and Expectations To build healthy foundations for social, emotional and intellectual capacities: To attend and stay calm and regulated, while eating Engage and relate warmly to others, during meals To be curious, explore, spontaneous, flexible, around food Initiate and respond to all types of communication, during meals Communicate around a range of feelings, about eating

35. Outcomes and Expectations • Shared problem solving, around meals • Think and play creatively, with food • Empathetic, compassionate, perspective of others, during meals • Understand motives and consequences of self and others’ behaviors, around eating • Able to generalize and engage in abstract thinking, about food, nutrition, and eating

36. Resources www.icdl.com The Child with Special Needs, Greenspan Engaging Autism, Greenspan