1. SNACKids© Sally Asquith, MS, CCC-SLP Amanda Morse, MS, CCC-SLP
Carolina Speech & Language Center, Inc.
Summerville, SC

2. Disclosures
We have no financial or non-financial disclosures.

3. Gratitude
M and mom pic

4. Agenda PFD dx Our clientele Frustration SNACKids© Outcomes
Ideas and opportunities

5. PFD: Pediatric Feeding Disorder

6. Pediatric Feeding Disorder dx
PFD and Feeding Matters
Setting standards, making policy
Four domains
Medical
Psychosocial
Nutrition
Skills (that’s us)
Dx criteria and lingua franca coming

7. Feeding Matters plug Put feedingmatters.org on your favorites bar!

8. Our clientele

9. Infants to young adults
#1 = ARFID: Avoidant/Restrictive Food Intake d/o
#2 = Oral dysphagia ICD-10 R13.11
2* to…
hx of prematurity
ASD
Reflux/GERD
Down Syndrome
choking episode
hypertrophic (giganto) adenoids

11. ARFID Avoidant/Restrictive Food Intake Disorder ICD-10: F98.29
“Psychological” in nature
ARFID is not:
anorexia nervosa
bulimia
due to poverty

12. Super limited, rigid intake

13. The DSM-V provides the following diagnostic criteria for ARFID:
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
1.  Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 2.  Significant nutritional deficiency. 3.  Dependence on enteral feeding or oral nutritional supplements. 4.  Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

14. ARFID/neophobia/oral dysphagia?
“The cup”

15. ARFID/neophobia/oral dysphagia?
Restaurant specific
“The French fries have to come from McDonald’s and he only eats them in the car”
Brand specific
“When WalMart changed the container for Great Value yogurt, it took months for him to try it again and believe that it was the same.”
Label specific
“He must see that it’s a Spaghettios with meatballs can, remove all trace of the meatballs before serving or he won’t eat them. He won’t eat the plain Spaghettios.”

16. Other common diagnoses
Oral dysphagia
Failure to advance textures due to…
POOR ORAL-MOTOR SKILLS
Oral-pharyngeal dysphagia
G-tube dependency (to wean or not to wean)

17. Frustration. “He won’t eat anything we eat
Frustration!! “He won’t eat anything we eat.” “My doctor said she’ll grow out of it but it’s been two years.” “He screams just looking at a bite of new food.”

18. Frustration = positive challenge
Get those kids to eat!!

19. LB, day 1 video

20. An idea… Sprouted ten years ago ~~~
Group tx works for speech-language d/o…
Eating is a natural, social activity…
Maybe the kids would be less vigilant and more open to eating food among peers…

21. Could we possibly get our tough, challenging kids to ENJOY eating
Could we possibly get our tough, challenging kids to ENJOY eating? ****************************************************************** Could we create an environment that was casual and anxiety-reducing? ******************************************************************* Could we foster spontaneous, natural socializing with peers?

22. The snack room was born!
Group pix

23. It is fundamentally a social activity.
Initial trials were rewarding, then thoroughly revolutionized our therapy, underscoring the concept of why we eat, beyond basic nutrition:
It is fundamentally a social activity.

24. Advancing Competence in Kids
SNACKids©
Social Nourishment,
Advancing Competence in Kids

25. Hypothesis
Is PFD tx more effective in an incidental, peer-rich environment than in an individual, adult:child setting/power structure?
There is a paucity of research in this area. Most research focuses on behavioral interventions (e.g. Ledford & Gast).
To date, a literature search has rendered no results in this particular area.

26. Methodology Retrospective chart review of
All current patients (n 170)
Pts receiving dysphagia tx (n 59, or 35%)
We also codified the methodology of incidental, naturalistic, peer-rich therapy in a designated space

27. Protocol
Designated space ideally with walls, open shelves, closed cabinets.
*Clearly separated by a door that closes.*
Equipped with refrigerator, m/w, toaster oven, toddler seat, high chair; a low, sturdy table and chairs for six children; and a drop-leaf table for two adults or teens.
Food photos form a border near the ceiling.

28. Snack rm pic

29. More protocol Systematic desensitization approach uses:
“support-not-force” (Dunn Klein)
SOS principles (Toomey)
“food chaining” (Fraker and Walbert)
Natural, unlegislated flow of adults and peers in and out of the snack room 
A casual and easygoing environment

30. Where do we start??

31. Social Nourishment It’s got to be real.
Normal(ish) context
True affection, faith, and trust
Healthy amount of fun and humor
Incidental, spontaneous interactions with peers and adults, with food as the lingua franca
This completely natural aspect is CRITICAL in creating a relaxed, no-pressure environment
The focus automatically shifts from a perception of demand + power to a perception of social sharing
Fear, apprehension, and vigilance decrease

32. Advancing Competence
At the child’s tolerance/perceived safety level for:
Diet expansion
Tongue-lip-jaw dissociation
Bolus management/direction, and/or safety
Chewing
Lateralization
Drinking
Volume
NPO = currently NPO, transitioning

33. TOOLS: adult language style
Bona fide questions only
Neutral, factual comments
(“This apple is crunchy”)
Clear, unambiguous instructions
(“Sit, please”)
Modeling and teaching descriptive vocabulary based on “Food is Good” chart

34. TOOLS: visual supports
X-large “Food is Good” board for:
To-scale drawings of bolus sizes, from a dot (“crumb”) to 1 ¼” (huge bite”)
Vocabulary of texture, temperature, and flavor
Individual dry erase boards

36. Tools Beckman Oral Motor as indicated
Maroon spoons, Reflo cups, nosy cups, divided plates
Most materials are disposable

37. Snack room videos

38. Outcomes

39. Results Current total caseload = 170
Current dysphagia caseload = 59 (35% of total pop)
Pts (n 59) referred specifically for feeding tx = 33% (n 20)
Pts recruited because we asked: (n 39) = 67%
Progress across all pts = 100%
All pts demonstrated significant progress, regardless of dx, hx, age, gender, or goal type
The ARFID 5 pt is now 30+ and swallows small boli

40. More results
Classifying by # of ARFID helped define our PFD population
56% (n 33) had ARFID at SOC
ARFID 5 = 1
ARFID 10 = 9
ARFID 15 = 0
ARFID 20 = 18
ARFID 30 = 5

41. What we OBSERVED but did not classify or measure:
Happiness with friends
Relaxation around food
Reduced stress levels in pts and parents
More neutral affect
More SMILES 

42. PP/YF pic

43. LB and PP video

44. Conclusions A peer-rich/casual setting supports PFD tx.
Asking families “How is his/her diet?” recruits X% more pts and reveals occult dysphagia.
Specifying the ARFID improves setting metrics and describing varying levels of ARFID.

45. Limitations: The future: We did not code pts by therapeutic goals.
We are creating a streamlined goal bank to track progress by specific goal type.
The future:
Standardized assessments from UNC-CH
Pre/mid/post parent surveys
Assessing stress; such as cortisol levels, heart rate, respiration?

46. Ideas and opportunities

47. Scope of practice ASHA Principle of Ethics II Rules of Ethics
Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.
Rules of Ethics
Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

48. Free stuff Krisi Brackett’s Pediatric Feeding News
Sheri Fraker/Laura Walbert’s blog
Key web sites:
Diane Bahr’s Ages and Stages
Feeding Matters
Catherine Shaker
Feeding Flock, UNC-CH
Read daily posts on SIG 13
Find a mentor
Visit clinics

49. Pretty cheap stuff Join SIG 13 – only $35 per year
Read “Food Chaining” by Sheri Fraker and Laura Walbert
Read “Feeding and Nutrition for the Child with Special Needs” by Marsha Dunn Klein and Tracy Delaney

50. References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.
American Speech-Language-Hearing Association Code of Ethics. Accessed 1/30/17.
Beckman D. Beckman Oral Motor Assessment and Intervention. 1986, revised Published by Beckman & Associates, Inc., 1211 Palmetto Ave., Winter Park, FL
Dunn-Klein M. Anxious Eaters Anxious Mealtimes. Mealtime Notions. Accessed 9/16/2016.
Fisher, M., Rosen, D., Ornstein, R., Mammel, K., Katzman, D., Rome, E., Callahan, S., Malizio, J., Kearney, S., & Walsh, G. (2013). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55 (1), Extracted 1/15/17 from Pub Med
Fraker C, Fishbein M, Cox S, & Walbert L. Food Chaining Boston, MA: Da Capo Press.
Ledford J & Gast J. (2006). Feeding Problems in Children with Autism Spectrum Disorders: A Review. Focus on Autism and Other Developmental Disabilities, 21,
Norris, M., Robinson, A., Obeid, N., ,Harrison, M., Spettigue, W., & Henderson, K. (2014). Exploring avoidant/restrictive food intake disorder in eating disorder patients: A descriptive study. International Journal of Eating Disorders, 47,  Extracted 1/15/17 from Pub Med
 Toomey K, Ross, E. SOS Approach to Feeding. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), October 2011, Vol. 20, doi: /sasd

51. Thank you! Sally Asquith – s.asquith@mycsal.com
Amanda Morse –