Key elements of your assessment include:

• Parent’s perception of the problem.
• Medical, developmental, growth and social history.
• Dietary assessment.
• Mealtime observation.

Your assessment reveals the following details:

Parent’s perception of the problem

Assessment is conducted in the home with mum and Max present:

• Mum is concerned that Max may not be getting all the nutrients he needs.
• She reports that feeding problems began at around 18 months of age after he was sick with an ear infection. “The only way I could get him to eat was to give him ‘baby food’ and feed him in front of the TV.  That way I could sneak food in without him noticing.”   
• Now, “Mealtimes are so stressful. They seem to take forever.  He won’t sit at the table with us and I have to feed him. He won’t use a spoon.”
• He is now fussy about what he will eat. “He can even taste the difference if I buy a different brand. If I put the biscuits into a container he won’t eat them. If I don’t give him what he wants he gets upset and disrupts his father’s work.”
• Max’s appetite at mealtime is described as being poor. “He never seems hungry. The only time he eats a little more is when we have been out for the afternoon and dinner is late.”

Medical, Developmental, Growth and Social History.

• Max has recently been diagnosed with Autism Spectrum Disorder.
• There are no other known medical issues currently impacting on Max’s general health or feeding difficulties.
• Despite Max’s limited diet there are no concerns regarding his growth.   
• Max lives with both his parents and older sister.  Dad works from home and finds it stressful when Max creates a fuss with eating.  Max attends child care 2 days a week where he is provided with his preferred foods but does sit at the table with other children without becoming upset.    

Dietary assessment

• Max is usually fed by mum while he watches the TV. Meals take more than 30 minutes and Max requires frequent prompting to open his mouth.
• Typical foods include: Wheat flake breakfast biscuits with plenty of milk, yoghurt no lumps, mashed potato, commercial smooth baby food which includes some fruit, vegetables and meat. He also eats dry breakfast cereal without milk, plain bread and butter and hot chips which he self feeds.
• Between meals Max goes to the pantry and requests foods such as sweet biscuits, chips or chocolate which he will self feeds. He becomes upset if he doesn’t get what he wants. 
• Drinks during the day include: 1-2 small glasses of milk, 2 cups of fruit juice and some water.

Mealtime Observation

• Max was observed eating lunch. He sat close to the television. Mum sat beside him and with frequent prompting he completed some commercial baby food followed by yoghurt. He was offered some plain bread which he refused.
• Max did not participate in the feeding or seem to be aware that he was eating. Although mum reported that if she gave him something that he didn’t like he would then refuse to open his mouth.

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Note: the same or similar goals may be shared by more than one domain of the Feeding Development Framework. The priority of potential goals should be determined in discussion with Max’s parents.    

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Suggested strategies may include:

• Provide regular meals and snacks.

Max has shown that his appetite improves when meals he has not been grazing during the day.  Establishing predictable meal and snack times will support Max to develop cycle of hunger and satiety improving appetite. 

• Aim for 2-3 hours between meals and snacks.  Ensure meals and snacks have a clear beginning and end. 
• Between meals and snacks only water is available.  Grazing on biscuits and chips etc. is avoided.
• Change mealtime environment.

For Max to increase the variety of foods in his diet and learn to engage in the social interactions of mealtimes the mealtime environment needs to change.  Max manages in a different environment at childcare.  He needs assistance to generalise this skills to home.  Change will most likely need to be achieved gradually as parents and Max gradually shift their expectations. 

• Gradually move seating back from the TV at mealtime and move towards the family meal table. 
• Change the seating slightly.  Try turning down the sound on the TV. 
• Begin by changing one meal at a time. Consider having lunch outside.

Once Max is sitting with others to eat and TV is no longer being used as a distraction consider adding a new strategy. 
Strategies may aim to encourage social interactions, increase feeding independence or introduce new foods depending on family priorities. 

• Change the types of food offered.
• Begin with a food that Max will eat and modify it to achieve a ‘just noticeable difference in taste, texture or appearance’  e.g. Max likes mashed potato consider modifying texture or adding a minute amount of another vegetable such as pumpkin or sweet potato.  As this is accepted very gradually increase the amount added.  This technique needs to be implemented very gradually in children with altered sensory perceptions.  
• Increase Max’s awareness of what others are eating and work towards Max accepting new foods.  Steps to learning to eat include accepting food on the plate, touching and exploring the food, smelling the food, licking the food, taking a bite and then finally chewing and swallowing.  Children need support to move through these steps at their own pace.
• Avoid serving food in its packaging.   Serving food from the package limits food choices as children focus on the details of the package rather than the food.
• Provide food experiences through play and other activities where there is no expectation to eat.
• Integrate dietary goals with other interventions that Max is receiving through the Early Childhood Intervention Service.
• Parents are receiving support to manage other difficult behaviours.  It may be appropriate to use similar strategies to manage mealtime behaviours.
• Possible sensory issues associated with food choices may be addressed through activities that promote acceptance of messy play.  Experiencing food textures in situations where there is no expectation to eat may be helpful.
• Speech Therapy interventions to address difficulties in communicating, following routines may be used to support mealtimes.   Identification of delays in oral motor development may also benefit from Speech pathology interventions.

Resources

• Lori Ernsperger, Tania Stegen-Hanson.  Just Take a Bite: Easy: Effective Answers to Food Aversions and Eating Challenges! Future Horizons Inc. 2004

Follow-up 

Regular follow up is recommended to:

• Support parents to implement strategies consistently.  Progress may be slow and inconsistent i.e. there may be periods of improvement alternating with periods of regression.  Parents may need assistance to reflect on changes and recognise achievements.
• Evaluate progress and effectiveness of strategies.  Consider progress in terms of changes in both Max’s eating and parental concerns.
• Build on initial strategies. Strategies may be implemented in small steps that need building to achieve goals.
• Revise goals.  Progress is likely to be slow and priorities may change over time.

Max is capable of learning new skills and changing his eating and mealtime behaviours.  Max is growing well and the need for rapid change is not urgent.  If he was found to have any vitamin or mineral deficiencies these would be treated with supplements.  A consistent approach over many months will achieve small changes to improve Max’s eating and mealtime behaviours.  It is unlikely that he will still be eating exactly the same foods as an adult.

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Possible barriers to improvement of Max’s feeding might include:

• Parents don’t believe strategies will work.  May feel they have tried it before.
• Loss of motivation by parents to achieve change.  Progress is often slow and parents may find it difficult to maintain strategies when results are not obvious. 
• Difficulty implementing strategies consistently.  Parental conflict regarding management of mealtimes.
• Personal or cultural beliefs about feeding children e.g. belief that parent needs to provide food that their child will eat.  Fear that child will starve if they don’t eat all meals.
• Other needs for Max take priority. 
• Changes in social circumstances.

Options for management of barriers might include:

• Ensure expectations for achieving changes are realistic.  Look for small positive changes.
• Modify strategies to make them more realistic or achievable.  Aim for strategies to be implemented in smaller steps.  
• Reassess possible contributors to Max’s feeding difficulties.
• Consider possibility that full details were not obtained or not all information was provided or taken into consideration at the initial assessment e.g. Max has chronic constipation contributing to reduced appetite.
• Link mealtime strategies to other interventions for Max e.g. learning to make and understand consequences of choices or understanding and following routines.
• Consider referral to another health professional for assessment or further opinion while you maintain your involvement e.g.
• Psychology referral for behaviour management strategies.
• Dietitian referral for assessment of nutritional adequacy.  Despite high consumption of ‘junk foods’ all food groups are included Max’s diet. If diet is assessed to be adequate in micro nutrients this may help reduce parental anxiety.  Alternatively if indicated advice regarding a suitable children’s multi vitamin may also reduce anxiety.
• Occupational Therapy referral for support with managing any sensory issues.

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