Feeding and Swallowing Assessments

1. Feeding and Swallowing Assessments Lacie Edelstein Lisa Belluzzi

2. Introduction • Assessments used for a variety of feeding disorders • Food selectivity • Oral initiation • Advancing in texture

3. Introduction • 1st assessment- summary of a formal assessment at a feeding center • 2nd assessment- summary of two informal assessments done by parents (checklists)

4. Pediatric Feeding and Swallowing Center • Before arriving for an evaluation, food and bowel movement logs are done at home • Evaluation started by any senior staff at the center • Information collected is prenatal and birth history • The complaint, any medical Rx, allergies, and medications • Any information is taken about past issues in neurology, respiratory, cardiac, and GI • Next, any genetic issues, craniofacial abnormalities, and other medical issues • Lastly, developmental history, school/program, related services received.

5. Pediatric Feeding and Swallowing Center • Second part, done by behavior analyst • Feeding history- age when problems occurred • Where there feeding skills are • History of formula- toleration, allergies • Any feeding tube information- tube, pump, schedule • Liquids- bottle/cup • Solids- self feeding/spoon fed/fingers or utensils? • Appetite • 24 hour description of meals- foods/texture/length/place • Any preferences- taste/temp/chairs/etc. • Feeding problems/behaviors • Past method to address these problems

6. Pediatric Feeding and Swallowing Center • Next, medical director/nurse practitioner • Full physical exam • Includes • Weight, height, head circumference, lungs, chest, abdomen, extremities, scoliosis, trachea, involuntary movement, tone of trunk, any other significant findings

7. Pediatric Feeding and Swallowing Center • Physical/Occupational evaluation • Posture- sitting/standing • Movement patterns • Head/neck • Trunk/pelvis • Rib cage • Cough • Significant motor findings during meal observation • Seating recommendations

8. Pediatric Feeding and Swallowing Center • Oral motor evaluation • Voice quality- breathy/hoarse/raspy • Drooling- positions/time of day • Oral structure and movement patterns • Tongue- flat/retracted/protracted/lateral shift • Oral reflexes- rooting/gagging

9. Pediatric Feeding and Swallowing Center • Feeding observations- evaluating team • Utensil • Food • Swallow • Cough • Behaviors- refusals/disrupts

10. Recommendations • For parents to leave with • Type of feeding problems • Factors that interfere: • Description of medical/motor/oral motor/learned patterns • Recommendations • Follow up will include

11. Pros • Thorough evaluation • Includes medical, motor, oral motor, behavior problems • Recommendations given on all aspects • Medication • Seating/strength exercises • Oral motor exercise/spoon placements • Rules- DR accept/swallow, RC, NCR, NRS

12. Cons • Takes up to 2 hours • Hard for child • Different people interacting with child • Hard for parent to be watched through 2- way mirrors and follow instructions • Difficult to change behavioral habits • Following recommendations takes a lot of time and patience

13. Research • There has been no formal research done on this assessment • Put together by past experiences of staff who have been in the field for many years

14. Modification/Individualization • For the most part the evaluation is consistent when it comes to all 4 sections • Everything is modified for the child depending on what the child can handle • Motor/oral motor/ behavior *not medical • All depends on age and ability of child • Try to make it as easy on the child and parents as we can!

15. Checklist #1The Children’s Eating Behavior Inventory (CEBI) • 40 items • 2-step questions • Step 1: Identify the frequency of behavior • NEVER SELDOM SOMETIMES OFTEN ALWAYS • 1 2 3 4 5 • Step 2: Identify areas of difficulty • “Is it a problem for you?” YES NO

16. Content to be assessed • Behavior of child • Just prior to mealtime • During mealtime • Immediately after mealtime • Age-appropriateness of mealtime behavior • Communication between parent and child about being “hungry” or “full” • Pace of meals • Other stimuli present at mealtime (eg. people, toys, television) • Family/parent behaviors during mealtime

17. Sample CEBI items: • My child chews food as expected for his/her age • My child uses cutlery as expected for his/her age • My child feeds him/her self as expected for his/her age • Relatives complain about my child’s eating • My child enjoys eating • I feel confident my child eats enough • I find our meals stressful • My child eats quickly • My child makes food for him/her self when not allowed • I get upset when my child doesn’t eat • At home my child eats foods that taste different • At friend’s homes my child eats food he/she shouldn’t eat • I get upset when I think about our meals • My child eats chunky foods • My child eats when upset • My child’s behavior at meals upsets our other children

18. Some problems include… • Situations that are not directly observable • Some examples are • “as expected for his/her age” • “feels confident” • “gets upset” • “enjoys” • “complains” • Words that are not operationally defined • Some examples are: • “quickly” • “chunky” • “not allowed”

19. More CEBI items: • My child helps to set the table • My child watches TV at meals • I feed my child if he/she doesn’t eat • My child takes more than half an hour to eat his/her meals • My child asks for food which he/she shouldn’t have • My child gags at mealtimes • My child vomits at mealtime • My child takes food between meals without asking • My child comes to the table 1 or 2 minutes after I call • My child chokes at mealtimes • My child lets food sit in his/her mouth • At dinner I let my child choose the foods he/she wants from what is served • I let my child have snacks between meals if he/she doesn’t eat at meals • My child asks for food between meals • My child says he/she is hungry • My child says she’ll/he’ll get fat if he/she eats too much • My child helps to clear the table • My child hides food • My child brings toys or books to the table

20. Some CEBI items addressing family issuesAre these questions appropriate for the survey? • My child’s behavior at meals upsets my spouse • I agree with my spouse about how much our child should eat • My child interrupts conversations with my spouse at meals • I get upset with my spouse at meals

21. Pros • Not time-consuming • Provides minimal information regarding child’s mealtime behavior • Provides minimal information regarding parents expectations of their child at home • If nothing else, provides information about the family or person filling out the survey

22. Cons • Subjective • Terms seldom, sometimes, often, and always create a lot of grey area in answering survey items • Not all items are observable or operationally defined • Does not address type of foods consumed or consistency/texture of foods consumed • Does not address child’s behavior between meals • Does not provide an alternative for verbal communication between parent and child • Not comprehensive; cannot be used as only assessment prior to treatment • Poor validity and reliability

23. Checklist #2Behavioral Pediatrics Feeding Assessment • 35 items • 2-step questions • Step 1: Identify the frequency of behavior NEVER SOMETIMES ALWAYS 1 2 3 4 5 • Step 2: Identify areas of difficulty Problem for you YES NO

24. Content to be assessed: • Behavior of child • Just prior to meal • During meal • Immediately after meal • Between meals • Types of food eaten (categorized by the four food groups) • Consistency of foods eaten • Time frame of meals • Family/parent attitude toward mealtime • Family/parent behavior during meals

25. Observable behaviors: eats fruits lets food sit in his/her mouth and does not swallow it whines or cries at feeding time eats vegetables eats starches (for example, potato, noodles) spits out food refuses to eat meals but requests food immediately after the meal has required supplemental tube feeds to maintain proper nutritional status chokes or gags at mealtime eats meat and/or fish takes longer than 20 minutes to finish a meal drinks milk eats only ground, strained, or soft food gets up from table during meal Nonobservable/nonoperationally defined behaviors: enjoys eating tantrums at mealtimes has problems chewing food has a poor appetite delays eating by talking would rather drink than eat tries to negotiate what he/she will eat and what he/she will not eat comes readily to mealtime eats junky foods but will not eat at mealtime will try new foods vomits just before, at, or just after mealtime Sample items regarding the child

26. Observable behaviors: When my child has refused to eat, I have put the food in his/her mouth by force if necessary I use threats to get my child to eat I coax my child to get him/her to take a bite If my child does not like what is being served, I make something else Nonobservable/nonoperationally defined behaviors: I get frustrated and/or anxious when feeding my child I feel confident my child gets enough to eat I feel confident in my ability to manage my child’s behavior at mealtime I feel that my child’s eating pattern hurts his/her general health I get so angry with my child at mealtimes that it takes me a while to calm down after the meal I disagree with other adults (for example – my spouse, my child’s grandparents) about how to feed my child Sample items regarding the parent

27. Pros • Not time-consuming • Provides information about types of food being consumed • Provides information about consistency/texture of foods being consumed • Provides minimal information regarding child’s overall mealtime behavior • Provides information about family and parent behavior during mealtimes

28. Cons • Subjective • Terms sometimes, always, never, and the numbers in between them create confusion • Not all items are observable or operationally defined • Does not provide an alternative for verbal communication between parent and child • Not comprehensive; cannot be used as only assessment prior to treatment • Poor validity and reliability

29. References • The Child Eating Behavior Inventory (CEBI) Lynda A. Archer, Peter L. Rosenbaum, & David L. Streiner (1991) Chedoke Child and Family Centre, Hamilton, Ontario Oxford Journals: Journal of Pediatric Psychology • Behavioral Pediatrics Feeding Assessment William B. Crist, Ph.D. (2001) IWK Health Centre, Halifax, Nova Scotia Journal of Developmental and Behavioral Pediatrics Nutrition in Clinical Practice

30. Modification/Individualization • Include operational definitions • would help parents to observe their child more accurately and produce less ambiguous answers to surveys being scored • Omit “feeling words” and abstract emotional situations from survey items • would help to decrease subjectivity of the survey • Expand upon the survey items to include all aspects of mealtime behavior • would create a more comprehensive assessment tool • Include a section that allows parents to list specific behaviors that they are observing in their child, and possibly rate the severity of the behavior on a simple scale • would tailor each survey to assess individual behaviors that need to be further evaluated

31. Conclusion • Formal assessment by St. Joseph’s Center for Pediatric Feeding and Swallowing proven effective • Comprehensive and consistent • Can be modified and individualized to each child • Demonstrates validity • 2 informal assessments • Presentation of each survey does not comply with behavioral principles of using operational definitions to identify observable behavior • Used in conjunction with an effective formal assessment, can provide some useful information about feeding at home

32. Questions?