Feeding and Swallowing Assessments Lacie Edelstein Lisa Belluzzi

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

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

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.

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

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

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

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

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

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

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

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

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

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!

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

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

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 Sample CEBI items:

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”

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 More CEBI items:

Some CEBI items addressing family issues Are 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

oNot time-consuming oProvides minimal information regarding child’s mealtime behavior oProvides minimal information regarding parents expectations of their child at home oIf nothing else, provides information about the family or person filling out the survey Pros

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

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

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

Sample items regarding the child 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 parent 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

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

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

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

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

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

Questions?