Picky Eater vs. Problem Feeder

Eating. What’s not to love? Whether it’s a gooey, cheesy slice of pizza or a warm cookie fresh out of the oven (yum!), let’s face it -humans love to eat.  Little humans, ehh not so much. Little ones can be incredibly stubborn when it comes to eating, especially when they’re toddlers. What three year old didn’t go through a phase of just eating her go-to; whether it was mac-and-cheese, hot dogs, or PB&J. Many parents have said the words “picky eater” in reference to their child’s eating habits, but it’s important to know the differences between your run-of-the-mill picky eater versus your problem feeder.

Problem feeding is not a normal part of child development. Feeding problems are estimated to occur in up to 25% of normally developing children and in up to 35% of children with neurodevelopmental disabilities. A common definition for feeding problems is “the refusal or inability to eat certain foods.” Feeding problems can lead to serious medical issues such as malnutrition, dehydration, and impaired intellectual, emotional and academic development. Because of these potential impacts on the child’s development, early recognition and management are critical.

The table below can help you determine if your child’s eating skills are following a normal trajectory or further evaluation is needed:

Picky Eater

Problem Feeder

Eats a decreased variety of foods, usually around 30 foods Eats a restricted variety of food, usually 20 or fewer foods
Foods lost due to “burn out” (i.e. one too many hot dogs = refusal) are typically incorporated back into the child’s diet after about 2 weeks Will eat food over and over again like a picky eater but once they burn out, they will not incorporate that food back into their diet
Can tolerate new foods on their plate, will touch or taste a new food even if they aren’t really excited about it Crying/screaming/melt-down mode if a new food is on their plate and will not tolerate touching or tasting
Eats at least one food from most food group textures (e.g. crunchy, soft, puree, etc.) Refuses entire categories of food textures
Will eat a food after being exposed to it at least 10 times Will not try a new food after 10 or more exposures
Sometimes reported as a “picky eater” at pediatric wellness visits Persistently reported as a “picky eater” at pediatric wellness visits

What to do if you suspect your child is a picky eater:

  • Always eat with your child. Eating is a social experience! If your child is expected to eat alone he may feel left out or neglected. (“Why do I have to eat if no one else is?”)
  • Stick to a routine. Give your child three meals and two snacks at the same time each day (or about the same time each day, let’s be realistic here).  Offer juice or milk with his meals, not in between, to avoid filling up his tummy and decreasing his appetite. Offer water in between meals to quench his thirst.
  • At meal times, always offer him one to two preferred foods (i.e. hot dog, chicken nugget) and one new food. When he sees his preferred food, he will feel more comfortable with his plate. Try to make the new food something you’re eating as well.
  • Always talk positively about food! Even if you don’t like something, do your very best not to talk negatively about it. For example, “Mmm, these sweet potatoes are so yummy!” NOT “Ugh, these potatoes are mushy and gross!”
  • Make it fun! Get some different dips out for his chicken nuggets – ranch, BBQ sauce, ketchup, mustard! Cut sandwiches out with a cookie cutter. Use food coloring. Serve breakfast, for dinner!
  • Have your child help! Let him pick things out at the grocery store. Have him wash the vegetables or fruit. Let him mix up the batter.

What to do if you suspect your child is a problem feeder:

Works Cited:

  1. Sisson LA, Van Hasselt VB. Feeding disorders. In: Luiselli JK, editor. Behavioral Medicine and Developmental Disabilities. New York: Springer-Verlag; 1989. pp. 45–73.
  2. Palmer S, Horn S. Feeding problems in children. In: Palmer S, Ekvall S, editors. Pediatric Nutrition in Developmental Disorders. Vol. 13. Springfield: Charles C Thomas; 1978. p. 107–129.
  3. Feeding problems in infancy and early childhood: Identification and management
  4. Debby Arts-Rodas, Diane Benoit
  5. Paediatr Child Health. 1998 Jan-Feb; 3(1): 21–27.
  6. Toomey, Kay. Copyright 2000/2010. Picky Eaters versus Problem Feeders.

How Do I Know if My Child Has a Reading Disability?

Reading Disabilities are estimated to occur at a prevalence rate of 5-10%.  A disability, which is a more chronic struggle with reading without early identification and intervention, must be differentiated from the child who demonstrates a slower process in the normal developmental curve of reading development.  A disability will not resolve with repeated practice, extra attention, or the passage of time.  Below are a few clues to help figure out if there really is a disability.

Clues that Indicate Your Child May Have a Reading Disability:

  • Your child has difficulty with basic rhyming.
  • Your child has always been slow to learn the alphabet and maybe even numbers.
  • Your child struggles with sound-letter associations.
  •  Your child’s writing is illegible.
  • Your child likes to be read to but never wants to read.
  • Sight words, despite repeated practice, are easily forgotten by your child.

At times, differentiating between a disability and other factors (e.g., attention, motivation and interest, or behavior) can make accurate identification difficult.  An evaluation can help tease apart any related factors that may be impacting your child’s success.  If you are concerned with your child’s reading development, you can request an evaluation through our Neuropsychology Diagnostic Clinic.  We have clinicians trained in the diagnosis and assessment of reading disabilities and are able to provide efficacious recommendations to best help your child.
Click here to read about signs of a reading disability across grades.


The Rewards of Adaptive Bicycles for Children

Bicycle or tricycle riding is an important component of childhood. For certain children with medical complexities, there are special equipment that enable them to explore the world just like any other child.

When I was working as a physical therapist on the pediatric floor of a rehabilitation hospital, I encountered many children and families impacted by debilitating conditions and circumstances. From cerebral palsy and brain injury, to spinal injury, or cancer, many of the children I met proved that being physically and cognitively limited did not keep them from participating in stimulating play activities.

Adaptive tricycles are designed to provide less able-bodied children a way to exercise their limbs, practice their skills and encourage their participation. 

They often come with various features and accessories such as extra wide frames, trunk reinforcement, head support, leg straps, hand straps, steering assist, etc. They make it possible for children who have low muscle tone, motor control, coordination, or cognitive function to engage in locomotion.

How Can an Adaptive Bicycle Help?

For children with diagnoses that reduce their trunk control, adaptive bikes provide a safe environment where they can work on coordinating their limbs while having their back fully supported or strapped in.  For children who fatigue easily due to their medical conditions, adaptive bikes offer the option of having an adult help steer from behind.  For children who lack the motor control to alternately pedal their legs, foot straps and connected pedals make the reciprocal motion easier by putting muscles and joints through those much needed ranges. Depending on the type of bike, adaptive handles can also accommodate all kinds of grip. So when a child with upper body weakness has a hard time grasping or holding the handlebars to steer a regular bike, an adaptive bike allows them more control of their locomotion.

Durable wheels and a parking brake make adaptive bikes safe for children with a wide range of physical abilities and conditions.  Children with medical complexities who are restricted to a wheelchair can still benefit from rides in an adaptive bike.  Aerobic training and upright posture, as well as limb movements (facilitated or self-initiated), are an essential part of the growth and rehabilitation process for children of all different capabilities. All of this is made easy by special equipment such as the adaptive bike. Being outside and being able to participate in activities with other children promote emotional health and create positive environments for mental and physical growth.

The Rewards of Using Adaptive Bicycles

I have watched many children blossom behind the wheel of an adaptive bicycle. Taking part in that transition is such a rewarding process.  Children who were unable to move certain parts of their bodies after an injury were eventually able to transfer what they learned during cycling to standing and walking tasks. Toddlers who were never able to stand on their own were able to experience, for the first time, limb movements and self-propulsion locomotion. Seeing the smiles on their faces, and hearing the laughter of their parents and siblings… Those moments definitely made my job worthwhile.

What is Co-Treating?

You may have heard your therapist say, “I think a co-treat would be a great option for your child!” But what does that really entail? Will your child still be getting a full treatment session? Will his current and most important goals be worked on? Will he benefit as much as a one-on-one session? When a co-treatment session is appropriate, the answer to all of those questions is…YES!

What is a co-treatment session?

Co-treatment sessions are when two therapists from different disciplines (Speech Therapy (SLP), Occupational Therapy (OT), Physical Therapy (PT), etc.) work together with your child to maximize therapeutic goals and progress.

When is a co-treatment session appropriate?

When the two disciplines share complimentary or similar goals.

EXAMPLE: Maintaining attention to task, executive functioning, pragmatics, etc. Playing a game where the child needs to interact with and attend to multiple people while sitting on a stability ball for balance. [all disciplines]
*When children have difficulty sustaining attention and arousal needed to participate in back-to-back therapy sessions.
EXAMPLE: Working on endurance/strength/coordination while simultaneously addressing language skills. Obstacle courses through the gym while working on verbal sequencing and following directions. [SLP + PT or OT]
*When activities within the co-treatment session can address goals of both disciplines.
EXAMPLE: Art projects can address fine motor functioning as well as language tasks like sequencing, verbal reasoning, and categorizing.
*When a child needs motivations or distractions. [OT + SLP]
EXAMPLE: Research has shown that physical activity increases expressive output. Playing catch while naming items in category or earning “tickets” for the swing by practicing speech sounds.  [PT or OT + SLP]
EXAMPLE: PT’s need distraction for some of their little clients who are working on standing or walking and working on language through play during these activities works well. [PT + SLP]

Why co-treat?

  • Allows therapists to create cohesive treatment plans that work towards both discipline’s goal in a shorter amount of time.
  • Allows for therapists to use similar strategies to encourage participation and good behavior in their one-on-one sessions with the child.
  • Allows for therapists to collaborate and discuss the child’s goals, treatment, and progress throughout the therapy process. Together, they can consistently update and generate plans and goals as the child succeeds.
  • Aids in generalization of skills to different environments, contexts, and communication partners.
  • Allows for problem-solving to take place in the moment. For example, an extra set of hands to teach or demonstrate a skill or utilizing a strategy to address a negative behavior.

Co-treatments sessions can be extremely beneficial for a child. There are endless ways therapists can work together to promote progress and success towards a child’s therapeutic goals.. However, co-treatments may not always be appropriate and are only done when the decision to do so is made collaboratively with the therapists and the parents.

Contact us for more information on the benefits of co-treating in therapy sessions.

Talking to Children about Their Learning Disorders

As we all know, children are very inquisitive and ask questions all the time.  Children with learning disabilities are often pulled out of their main stream classroom, attend after school tutoring, or receive accommodations and interventions within the mainstream setting.  Parents and schools are often quite good at identifying the needs of children; however, at times are at a loss of how to approach the topic to children.

How to talk to a child about his learning disorder:

There really is no easy answer as to how to discuss learning disorders with children.  This depends on the child’s age, maturity, and ability to comprehend and understand information.  If the child starts to ask questions about why he or she is being pulled out of class or receiving work different than his or her peers it is most definitely time to discuss this with the child.  What I would recommend is to focus on the positive.  Indicate that everyone learns differently and everyone has things that they are really good and things that need a little work.

One technique that I have used in my clinical practice to explain services to children is to compare it to other medical/health issues.  (e.g. if I told you that you had a vision problem you probably would go and get glasses; if I told you that you had a hearing problem, you might get a hearing aid; so you have a weakness with learning to read so we are going to find someone to help out with that).

If the child is older I always believe it is best to be proactive and inform the child before services begin.  Let the child know what will be happening with services and accommodations in the school.
Overall, it is always best to keep the child informed about services and accommodations.  Focus on the positive and remind the child that everyone learns differently.

Click here to learn more about learning disabilities.

What Is the Difference Between Occupational and Physical Therapy for Children?

Many of the parents I meet often ask why very few occupational therapist work with infants, or why an occupational therapist (OT) is seeing their child for toe-walking as opposed to a physical therapist (PT). They often wonder why one child who has balance or coordination issues would see a physical therapist while another with similar limitations would see an occupational therapist instead. Some parents think that occupational therapists only work on fine motor skills while physical therapists only work on gross motor skills.  Physical and occupational therapists work in a variety of settings, including hospitals, neonatal intensive care units, skilled nursing homes, outpatient clinics, schools, rehabilitation centers, and doctor’s offices.  Physical therapist and occupational therapist roles differ depending on the setting they work in and the medical diagnoses they work with.

In the outpatient clinic, some of these roles may overlap.  While there are some similarities between PTs and OTs in each setting, there are a few fundamental differences between OTs and PTs in the pediatric setting.

Pediatric Physical Therapy:

In the pediatric outpatient setting, physical therapists are often musculoskeletal and movement specialists. Parents can seek out evaluations when their babies are as young as 1 month old. Physical therapists have in-depth knowledge about human musculoskeletal, neuromuscular, integumentary, and cardiovascular systems. Based on our background in stages of development and biomechanics, we help children with mobility difficulties; whether they are behind on their gross motor milestones, recovering from injury/surgery, or not keeping up with other children.

Through all kinds of hands-on or play techniques, pediatric physical therapist work with children on the following:

  • Gross motor skills
  • Strength
  • Endurance
  • Balance and coordination
  • Motor control and motor planning
  • Body awareness
  • Pain relief
  • Flexibility
  • Gait mechanics
  • Orthotics training
  • Wound care

Our focus is for children to be as mobile and as independent as possible, while training their caregivers on all aspects of a child’s physical development. This includes anything that may affect a child’s quality of movement, posture, alignment, and safety.

Pediatric Occupational Therapy

Outpatient pediatric occupational therapists are trained to improve the quality of children’s participation in their daily functional tasks.  A child’s job is to play and take part in activities at school and at home. These include important endeavors such as paying attention in class, hand writing, dressing, feeding and grooming themselves, and being able to engage in age-appropriate games. Occupational therapists are also trained to help children organize and interpret information from the environment so that they can just be kids. This may include taste aversions that limit their food intake, or texture aversions that affect their clothing tolerance, or sound aversions that affect their mood.

OTs work with children on the following skills:

  • Sensory integration
  • Cognitive endurance
  • Fine motor skills
  • Hand function
  • Visual-spatial awareness
  • Hand-eye coordination
  • Attention
  • Social skills
  • Body awareness

Occupational therapists often educate parents and teachers on the best techniques to ensure children participate in learning, self-care, and play tasks.

Why do some children need both disciplines and some only need one?

So many factors can affect a child’s ability to participate in her daily life. A child may be experiencing frequent falls or may have trouble jumping due to a number of reasons.  No matter the diagnosis or underlying medical condition, any child who is having a hard time keeping up with his peers can benefit from a comprehensive evaluation by a pediatric specialist.

Tipper vs. Dipper: How to Produce /S/ and /Z/ Speech Sounds

“Speech” can be thought of as verbal communication. It is the set of sounds that we make (using our voice and our articulators) that comprise syllables, words, and sentences. Speech alone carries no meaning, it is merely sound. Most speech sounds are mastered by 8-9 years old, with different sounds emerging at different ages.

/s/ and /z/ speech sounds can be challenging for many children. This sound is typically mastered close to 5 years old, however some children may continue to struggle past that point. When producing /s/ and /z/, there are 3 main factors to consider: place, manner, and voicing.

Place of Production:

When producing /s/ and /z/ sounds, most people can be categorized as “tippers” or “dippers.” Tippers will bring their tongue tip up to touch their alveolar ridge (the ridge behind our top teeth), whereas dippers will bring their tongue tip down towards their bottom teeth, or anywhere in between. Both placements are correct so long as the tongue stays at midline behind the teeth. Each individual will find which placement works best, however if children struggle with placement an interdental (between the teeth) lisp may result.

Manner of Production:

The /s/ and /z/ sounds are classified as “fricatives,” or pushing air out continuously through a small opening. Many children will have difficulty with the manner of /s/ and /z/ production, and will “lateralize” their airflow, resulting in a lateralized lisp.

Voicing:

/s/ and /z/ place and manner of production are identical, however these two sounds differ when it comes to voicing. /s/ is the voiceless pair to /z/’s voiced sound. For example, when producing an /s/ sound, our vocal chords are off (not vibrating), however when producing a /z/ sound, our vocal chords are on and vibrating. Try it – put your hand on your throat and feel the vibration when producing a /z/, and feel the difference when producing an /s/! Many children will understand the difference between the two sounds but may substitute one for the other.

If your child has difficult producing our “snake” sound (/s/) or our “bee” sound (/z/) a licensed speech-language pathologist can help!

Click here for more blogs on sound production: /m/, /k/ and, /b/ and /p/.

Click here for a list of books to help with specific sound productions.

Can Technology Replace Therapy?

With the changes in science and technology, there has been major changes and adaptations with pediatric therapy.  There are many applications available that provide therapists and children with technological support.  These applications can be found on a variety of sources such as, but not limited to, the iPad, Kinect, Wii, Kindle, etc.  There has been much support for such technology as evident by a New York Times article on on physical therapists using Wii Golf to help enhance the benefits of the therapy.

Now the question that should be asked is why bother with therapy when a parent can spend a lot less money and time by buying applications and video games?

The applications must be considered only one aspect of developmental therapy. They are tools that help with the therapy; however, by no means supplement the benefits of the therapy itself.  Developmental therapists have specific training on developmental therapy and how to help children develop to their potential at the quickest and most efficient manner possible.

So although there have been major breakthroughs with technology and software; I will never foresee a time in which the technology will replace the therapist.

Signs of a Sensory Issue and Who Can Help

Everyone (children and adults both) have sensory issues and concerns.  As adults, we often learn to avoid noxious sensory inputs that we find to be bothersome.  Oftentimes, children are unable to avoid the sensory concerns that they find to be bothersome.  These sensory concerns can at times have a significant impact on a child’s social, emotional, and academic functioning.  Parents and educators are often unsure of when to actually seek help or what help to seek.

Questions to think about your child’s ability to deal with sensory input include the following:

  1. Does he have trouble with bright lights?  (has to have sun glasses at all times outside)
  2. Does he hate being touched?  (avoids hugs and contact from others)
  3. Does she seek out constant contact from others? (always wants to be hugged)
  4. Does he talk too loudly or too softly?

If you answer yes to any of these questions, it may prove beneficial to have your child evaluated.  Pediatric Occupational Therapists are often well trained in the assessment and intervention of sensory concerns.  They can  often work with the child to develop tolerance to the avoidant stimuli while also providing accommodations within his or her environment that help the child.

It is important to always keep in mind that there may be other medical or psychological concerns evident.  If you suspect that there may be something in addition to sensory concerns, have a consultation with the occupational therapist in order to determine if additional assessments or interventions are needed.

Additionally, don’t rule out ADHD and many other very associated issues.  You can learn more by visiting a pediatric neuropsychologist who can pinpoint the best treatment strategy.

Click here to download your Sensory Processing Disorder Red Flag Checklist.

Digestive Issues: How to Help with Diet

Digestive issues are extremely common among kids and adults in our country. So common, in fact, that we often don’t give these issues much thought and accept these feelings as being sort of normal. As a registered dietitian, I can tell you that digestive issues are your body’s way of telling you that some changes need to be made to feel better.

Here are common digestive problems, along with causes and dietary cures:

Acid Reflux

Causes:  Overeating, making the stomach too full and as a result, the stomach contents push up into the esophagus. Reflux can also be caused by food sensitivities or allergies, especially in infants.
Diet Cures:  Eat smaller meals at regular intervals each day (3 meals and 2 snacks). Your stomach is about the size of your two hands cupped together (with two more hands on top to make a sphere), so try eating about this much at meals. Eliminate fried foods. Eat plenty of fruits, vegetables, whole grains and lean meats. Eliminate trigger foods such as caffeine, dairy, and other high fat foods (such as sausage pizza or “loaded” nachos). In infants, rule out food sensitivity or food allergy; common culprits related to reflux in infants are cow’s milk protein (dairy), soy, eggs, and wheat.

General Indigestion

Causes:  Overeating, poor quality of diet, chronic constipation, inflamed enterocytes (cells that line the gastrointestinal tract).
Diet Cures:  Eat smaller meals at regular intervals (see above). Reduce processed foods and focus on whole foods such as legumes, fruits, vegetables, whole grains and lean meats. Drink plenty of water (2+ liters/day). Vary your grain intake (often we eat some form of wheat at all meals and snacks throughout the day). Consume probiotics through quality food sources such as organic yogurt, fermented vegetables (sauerkraut, kimchi, etc), and kefir.

Chronic Constipation

Causes:  A diet that is high in refined carbs, low in fiber, and inadequate in fluids. Constipation worsens with inadequate physical activity and long sedentary periods. Kids may be constipated if they consume too much dairy.
Diet Cures:  Eat fresh fruit at least twice per day and vegetables at least 2-3 times per day. Replace refined grains with whole grains. Other foods high in fiber include legumes, nuts and seeds. Drink 2+ liters of water per day. Limit dairy to 12-24 oz per day. Engage in physical activity throughout the day; even walking and doing house chores are helpful.

Frequent Loose Stools

Causes:  Excessive intake of sugary beverages, including juice, as well as excessive intake of “diet sugars”. Can also be caused by food sensitivity/food allergy. Another cause may be imbalanced gut flora, which can occur after taking antibiotics or with prolonged poor quality of diet.
Diet Cures:  Eliminate sugary beverages and replace with water or milk (given dairy is tolerated). Limit diet beverages to 8 oz per day or less. Trial an elimination diet of common food allergens for two weeks to see if symptoms improve (dairy, wheat, soy, eggs, nuts, fish, shellfish). Consume quality probiotic food sources (see above), as well as soluble fiber which is found in foods such as bananas, oatmeal, applesauce, dried peas as in pea soup, carrots, cucumbers.

Stomach Pain, with Gas and Bloating

Causes:  Food intolerance, sensitivity or allergy. Also these symptoms occur with general overeating of unhealthy food choices.
Diet Cures:  Trial elimination of common culprits for two weeks, including lactose (in dairy), wheat, legumes including beans and nuts, eggs, and soy. Eliminate sugary beverages as well. If symptoms do not improve, investigate fructose intolerance by working with a registered dietitian. Eat smaller meals and regular intervals throughout the day reflecting the Healthy Plate Model.

If you didn’t see your digestive issues listed above, or for more specific questions, leave a comment in the section below. For more guidance on helping your family overcome digestive issues, make an appointment with a registered dietitian at North Shore Pediatric Therapy.