Picky Eating Habits or Sensory

Processing Issues? Exploring Feeding

Difficulties in Infants and Toddlers YEC
Marcee is the 2-year-old daughter of Tom care center. Marcee would throw food items brother’s wide-mouth cup but spilled at least
and Tina. She enjoys playing with blocks and and push cups and utensils to the floor. The half of the liquid each time she used it. This
looking at books. Her favorite activities are other children began to imitate her continues to occur, with at least two to three
playing outside and spending time with her behaviors, and mealtimes were becoming spills every day.
mom while she cleans the house. Marcee difficult for the children and the staff. Jenna According to Tina, the only way she can
attends a child care center, Kreative Kids, for recommended that Tom and Tina take get Marcee to eat is to leave preferred foods
approximately 5 hr a day while Tina is at her Marcee for a feeding evaluation at the on a child-sized table and let Marcee eat
part-time job. Marcee is always excited to see community hospital. throughout the day. Both Tom and Tina
her friends and her teacher, Jenna. Tina and Tom report that Marcee is a follow Marcee around the house trying to get
Jenna and the other child care staff picky eater and eats only brown foods, such her to eat. She will not sit in her booster seat
members are concerned about the as oatmeal, wheat crackers, chicken strips, at the table. Marcee’s mother and father take
disruptions that Marcee has been causing at bread, Tater Tots, French fries, and turns sitting at the dinner table with
snack times and mealtimes. She approached sometimes, Cheerios. If those foods are not Marcee’s siblings during mealtime. Marcee’s
Tina with concerns about Marcee’s eating available, Marcee refuses to eat. Marcee does older brothers do not exhibit any feeding
habits right after her 2nd birthday. Jenna drink milk but will not drink any type of problems. Tina is concerned about Marcee’s
reported that Marcee would not remain at juice. Tina first introduced a cup with a spout nutrition and the toll her eating habits have
the table with the other children at snack when Marcee was 10 months old, but she taken on the family. Tina feels that Marcee’s
time and refused to eat anything at the child refused to use it. She preferred her older eating has taken over her time and focus.

Stacy D. Thompson, PhD

Deborah A. Bruns, PhD
Southern Illinois University Carbondale
DOI: 10.1177/1096250609351805
Kari W. Rains, MS, CCPS [Link]
Child and Parenting Specialist © 2010 Division for Early Childhood
Stillwater, OK

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 Exploring Feeding Difficulties / Thompson

F
or infants and toddlers habits. One toddler prefers spicy
demonstrating feeding foods whereas another child finds
problems, it is critical to find spicy foods to be overwhelming.
These differences, if extreme, may
the basis for the problems to create
be caused by sensory processing
more pleasurable mealtimes for the
issues. If a child has a sensory
child, his or her family members,

“
processing problem, one or more
and caregivers. Feeding difficulties developmental feeding difficulties
can affect general health (e.g., may persist and produce challenges
If a child has a sensory weight gain), developmental gains, for the child and his or her
and emotional well-being (Benoit, caregivers at each mealtime. For
processing problem, one 2000; Rudolph & Link, 2002). example, one infant may need more
Understanding the cause of feeding flavorful foods to elicit a willingness
or more developmental problems and developing to eat, or a highly sensitive toddler
may eat only certain textures of
appropriate interventions can
foods or may refuse table foods,
feeding difficulties may promote feeding-related
developmental skills (e.g., pouring,
such as meat or fruits. Signs of
feeding difficulties or “red flags”
utensil use), facilitate overall
persist and produce development (Chatoor, 2009;
may be first seen in an infant or
toddler who is not meeting
Gomez, Baird & Jung, 2004), and
challenges for the child enhance family relationships.
developmental feeding milestones,
including successful weaning from
There is a growing knowledge breast to bottle feeding and from
and his or her caregivers base regarding sensory processing bottle to solids and/or cup (see
problems and their possible effects Table 1 for examples of red flags).
at each mealtime. on daily routines and activities
(Kranowitz, 2005; Lynch & Simpson,
Providing parents and other
caregivers with information about

” 2004). A sensory processing problem

refers to an individual’s inability to
process incoming stimuli from his or
her environment in a productive way
sensory processing issues related to
feeding can assist both the caregiver
and young child.
Dunn (1997) proposed a
(Dunn, 1997, 2001). For example, a conceptual model describing how
child may refuse to eat foods that feel sensory processing issues may affect
too lumpy, such as oatmeal or yogurt development in young children. The
with fruit added. Efforts can then be central nervous system is responsible
made to provide the child with for how we interpret information
smoother-textured foods. Sensory from the environment. A child’s
processing issues can also be neurological threshold guides
manifested as feeding problems, such behavior and sensory integration
as Marcee’s eating difficulties. This during daily routines and activities
article will describe assessment (Dunn, 1997, 2001). In this model,
methods, strategies, and outcomes a neurological threshold is the
related to feeding problems with amount of stimulation needed for a
underlying sensory processing issues child’s nervous system to respond to
in infants and toddlers. his or her environment. For
example, one child may need a great
deal of texture or very intense
Feeding and Sensory flavors in his or her foods, whereas
another child would be
Processing Problems overstimulated by those same foods.
A behavioral response is the
Every young child has specific “manner in which the young child
likes and dislikes in his or her eating responds in relation to the

72 YOUNG EXCEPTIONAL CHILDREN Vol. 13, No. 2, March 2010

 Exploring Feeding Difficulties / Thompson

Table 1
Red Flags of Feeding-Related Sensory Processing Problems
Does not mouth or explore with mouth when developmentally appropriate
Excessive gagging, coughing, retching, or vomiting that interferes with eating or nutrition
Weight loss or lack of weight gain for at least 2 to 3 months
Severely restricted variety of foods and/or liquids
Difficulty progressing or inability to progress to solid foods
Restricted volume intake
Stressful mealtimes (e.g., power struggle between toddler and parent)
Severe behavior problems at mealtimes (e.g., throwing food items)
Persistent food refusal
Feeding periods longer than 30 to 45 minutes
Prolonged dependence on puréed foods
Holding and/or storing food in cheeks or under tongue interfering with food intake

SOURCE: Data were derived from [Link]/milestones_feeding.html and

[Link]

thresholds” (Dunn, 1997, p. 24). In Infants and toddlers with poor

reference to the previous example, if registration have high thresholds
the first child gets the exciting, and tend to not be interested in their
intense foods, then he or she will environment, including mealtimes.
eat, but if the second child gets Foods may not be attractive or tasty
those same foods, he or she most to them. A toddler may do
likely will refuse to eat. Each child everything but eat his or her food at
has unique responses to his or her mealtimes. For example, he or she
environment, or sensory may place his or her fingers in it,
modulation. These responses examine the texture of the fabric on
become a problem only when they his or her high chair, throw food on
interfere with the ability to engage the floor, or rub food into the high
in typical daily activities, such as chair tray. In contrast, young

“
The ability to regulate
eating. The ability to regulate
information to generate an
appropriate response to food choices
(sensory modulation) is an
children who demonstrate sensitivity
to stimuli have low thresholds and
tend to be “distractible or
hyperactive” (Dunn, 1997, p. 31).
information to generate an important ability for appropriate These children may not be able to
interactions in any environment. settle down to eat, have trouble
appropriate response to Infants and toddlers with poor
sensory modulation are likely to
remaining at the table, or fuss to get
out of their high chairs. They can
have maladaptive behaviors, or also be very cautious or negative
food choices (sensory behaviors that negatively affect about trying new foods, such as
feeding behaviors, which may those with novel colors, flavors, or
modulation) is an include feeding problems. In relation textures.
to children’s sensory processing, The third component is sensory
important ability for Dunn (1997) proposed four
components of sensory modulation
seeking. These children have high
neurological thresholds and engage in
related to problems with sensory behaviors to increase their sensory
appropriate interactions in processing: (a) poor registration, (b) experiences. These children fidget,
sensitivity to stimuli, (c) sensory play with their food, touch everything,
any environment. seeking, and (d) sensory avoiding. and chew on nonfood objects, such
Following is a description of how as clothing, to increase sensations,

” each can affect feeding. but these children may be so busy

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 Exploring Feeding Difficulties / Thompson

with these behaviors that they do diary, perform a functional

not eat. Finally, sensory-avoiding behavioral assessment (FBA), or
children have low neurological complete standardized assessment
thresholds. For example, specific instruments. These methods will be
smells may make a toddler described in more detail in the
physically uncomfortable or even following sections.
nauseated. The child may try to “get
out of” dinner and other activities
related to feeding by withdrawing or Interviews
throwing a temper tantrum because To determine whether a child
there is too much stimulation from has a sensory processing issue, an
the overhead lights, smells, textures, initial step is to conduct an interview
and so on. Additionally, they often with parents and caregivers.
create rituals for typical daily Questions should include typical
activities to help meet their sensory feeding habits, such as mealtimes
needs. and snacks, food preferences, and
The above information provides
areas of concern, as well as a
a basis to begin assessing the cause
detailed feeding history (e.g., age
of the feeding issues and to
when the child first ate solids, age
formulate a solution. To assess
when the child was able to use a
feeding problems in infants and
spoon with minimal spillage). A list
toddlers with sensory processing
of preferred and nonpreferred foods
issues as the primary cause, a
should also be compiled. For this
number of steps should be followed.
assessment method, it is critical to
The first step is conducting a feeding
ask questions that are open-ended to
assessment that includes all
collect information about the depth
caregivers and professionals
and breadth of feeding problems (see
working with the young child. The
Table 2 for sample interview
assessment data are used to generate questions).
a hypothesis about the possible
cause. The hypothesized cause is
then used to develop and implement Food Diary
a plan with individualized strategies
A food diary is kept to
to meet the child’s needs. Finally, the
document intake, successes,
effect of these feeding strategies
problems, and challenges. Parents
must be monitored to make
and caregivers write down the types
necessary adjustments and optimize
of food offered, what was eaten,
sensory-related feeding outcomes.
and the approximate amounts (e.g.,
This monitoring must be ongoing
3 oz of formula from an 8-oz bottle,
and incorporate all adults involved
2 oz of Stage 2 baby foods).
with the child’s care.
Observational notes from mealtimes
provide in-depth information about
Feeding Assessment behavior, positioning, utensil use,
and other feeding-related skills in
There are a number of the home, child care, and
approaches to collect assessment community settings (Branscomb &
data to determine whether a young Goble, 2008; Olive, 2004). Detailed
child has a feeding or sensory notes should be kept by all
processing problem. Parents, caregivers (e.g., mother, child care
caregivers, and other professionals provider, grandparents) involved in
can conduct interviews, keep a food feeding the infant or toddler to

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 Exploring Feeding Difficulties / Thompson

Table 2
Sample Interview Questions

Interview Protocol

1. Describe when your child first began to

a. Accept liquids from a cup
b. Use a cup independently
c. Accept solids, including baby food (fruits, vegetables, meat), blended foods, finger
foods, and table foods
d. Use a spoon with minimal spillage
2. Tell me about your child’s overall intake of liquids and solid foods on a typical day, includ-
ing information such as what he or she has for breakfast and what he or she has for a
snack before bedtime.
3. Tell me about the pattern of your child’s weight gain since he or she was an infant. For
example, was it steady or did it drop off for two or more months at a time?
4. Tell me about your child’s favorite foods.
a. What are they and how often does he or she request them?
b. How long does it take for a food to become a preferred item?
5. Describe how your child reacts when you introduce a new food.
6. How does your child indicate when he or she is finished with a meal or snack?
7. What are your thoughts about how your child eats and drinks compared to other children
his or her age?

provide a holistic view of feeding Specifically, an ABC analysis

strengths and challenges. For identifies the antecedents or
example, if a toddler avoids sensory “triggers” of the problem behavior,
input and his or her grandmother offers a detailed description of the
feeds him or her in a brightly lit problem behavior, and identifies the
room with music, there will be consequences of the problem
minimal intake in this setting or behavior. Possible antecedents or
similar settings, such as a child care triggers can range from the young
center or restaurant. child being overtired or feeling
unwell to an overstimulating
Functional Behavioral environment (e.g., loud music or
noises, temperature too warm for
Assessment personal comfort; Girolami &
Conducting an FBA is a means Scotti, 2001). Data for an ABC
to piece together a possible cause or analysis are collected through
causes as well as explain the reasons structured observations. O’Neill and
behind various types of problem colleagues (1997) recommend
behavior (O’Neill et al., 1997; collecting data for a minimum of
Sugai, Lewis-Palmer, & Hagan- three to five sessions. These sessions
Burke, 2000; Sugai, Sprague, & can occur in home, child care, and
Horner, 1999). An FBA generally is community settings.
composed of a number of steps and The outcome of conducting an
often includes performing an ABC analysis is an understanding of
antecedent-behavior-consequence a problem behavior’s form and
(ABC) analysis to arrive at a function. The form refers to the
hypothesis for the cause of a feeding observable behavior, such as
problem (Girolami & Scotti, 2001). pushing food away, clenching teeth,

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 Exploring Feeding Difficulties / Thompson

and gagging. Function defines “distinguishes between edible and

“why” a problem behavior occurs inedible objects,” and “may have
and is categorized into one of four definite food preferences” (Parks,
types: to (a) escape (e.g., removal 1992). Skills that are identified as
from nonpreferred activity or emerging or not observed offer
individual), (b) gain access to an targets for instruction. There are
item or activity, (c) gain or maintain several other criterion-referenced
attention from an individual, or (d) assessments that can provide helpful
obtain stimulation (O’Neill et al., information. For example, the
1997; Sugai et al., 1999, 2000). Developmental Profile 3 (Alpern,
Specifically, an ABC analysis offers 2007) includes items about self-
documentation of antecedents and feeding and food refusal, and the
consequences that can be used to Early Intervention Developmental

“
An ABC analysis offers
develop strategies to address a wide
range of problem behaviors.
Profile (Rogers & D’Eugenio, 1981)
offers both assessment items and
activity ideas relating to feeding.
In addition, the Infant/Toddler
Standardized Assessment
documentation of Sensory Profile (Dunn, 2002)
This type of assessment is examines six areas of sensory
processing, including feeding-related
antecedents and available in a number of different
formats, including parent interviews, concerns, such as mouthing objects
direct observation, and criterion- and food refusal. Caregivers rate the
consequences that referenced systems. The following infant or toddler on a scale from
examples include items related to almost always to almost never. The
can be used to develop feeding and follow established resulting scores indicate whether the
procedures for administration, child exhibits low registration,
sensation seeking, sensory sensitivity,
strategies to address a scoring, and interpretation. Results
assist in developing intervention or avoidance of sensation. An
plans that can be implemented by example of a comprehensive
wide range of problem parents, caregivers, and standardized assessment instrument
professionals. Two examples of that includes sensory processing
behaviors. frequently used standardized and/or feeding-related items is the
assessments are provided. Battelle Developmental Inventory

” The Hawaii Early Learning

Profile (HELP; Furuno et al., 1988) is
a criterion-referenced (measures how
a child performs relative to an
(Newborg, 2004).

Feeding Strategies
instructional or behavioral target
rather than a normative sample) and The following sections provide an
curriculum-based (facilitates overview of general feeding strategies
gathering information about a child’s and specific sensory modulation
skills in relation to a curriculum and strategies that can be used to assist
using information as a basis for infants and toddlers with sensory-
making instructional decisions) based feeding difficulties. Feeding
assessment system focusing on all strategies will be described
developmental areas. The 685 HELP (naturalistic to more structured) in
skills are grouped into 58 “strands” addition to strategies addressing the
for assessment and progress four components of sensory
monitoring. HELP strands include modulation. Specifically, the first set
items related to sensory processing of strategies is appropriate for the
and oral motor development, such as majority of young children, and the
“hypersensitive responses,” sensory modulation strategies focus

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 Exploring Feeding Difficulties / Thompson

Tom and Tina took Marcee to see her and refusals of food came when
pediatrician, Dr. Steeples, with their Marcee was asked to transition from
concerns about Marcee’s eating an activity she enjoyed. For example,
behavior. He recommended an at child care, snack time was right
evaluation with a developmental after outside play, which is one of
pediatrician, Dr. Ramirez, because Marcee’s favorite activities. Dinner at
feeding issues were not his area of home follows play with a
expertise. After an in-depth interview neighborhood friend or outdoors. In
with both Tom and Tina and reviewing light of her diagnosis, feeding
Tina’s and Jenna’s feeding diaries, FBA strategies to address the two sensory
data (ABC analysis), and observations modulation issues were recommended:
of Marcee eating a snack in her office, Schedule feeding opportunities before
Dr. Ramirez diagnosed Marcee with a outdoor playtime as much as possible
sensory processing disorder in the and reinforce Marcee’s intake of
areas of poor registration and avoided foods. Dr. Ramirez encouraged
sensation avoidance. Assessment data consistency at all mealtimes and with
indicated that the disruptive behaviors all caregivers.

on those infants and toddlers who or she may be too uncomfortable to

may need additional interventions to eat. In addition, distractions should
address their unique sensory needs. be reduced, such as music and
lighting. Moreover, it is important
to examine feeding utensils to
General Feeding Strategies determine whether a young child
needs adaptations, such as a spoon
After identification of a sensory
with longer handle or a cup with
modulation–based feeding problem,
two handles. The environment
it is necessary to plan, implement,
includes the caregivers and their
and evaluate feeding strategies to
feeding interactions with the young
address the problem. Similar to the
child. Efforts should be made to
described feeding assessment
observe the infant or toddler with
methods, it is critical to involve all
different caregivers to ascertain an
caregivers so that strategies are
optimal match between a young
applied consistently (Sugai et al.,
child’s sensory processing needs and
1999, 2000). For example, use of

“
The environment plays
specialized positioning in a toddler’s
child care center should be mirrored
in his or her home. Strategies
should also be monitored for
adult responsiveness to these needs.
For example, if an infant feeds best
in a quiet room on a caregiver’s lap,
he or she should not be fed by an
adult who prefers to place him or
a key role in the effectiveness and phased out when
her in an infant carrier.
no longer needed (e.g., use of an
adapted cup).
use of feeding Activity-based intervention (ABI).
Environmental modifications. The ABI offers the most naturalistic
strategies to address environment plays a key role in the option for general intervention
use of feeding strategies to address (Pretti-Frontczak & Bricker, 2004).
sensory processing sensory processing difficulties. The Parents and caregivers work
high chair a toddler uses during together to identify opportunities to
difficulties. mealtimes can affect his or her
acceptance of food items. For
work on feeding skills throughout
the infant’s or toddler’s daily
instance, if the child’s high chair is routines and activities so that

” inclined too far forward or back, he parents and caregivers can readily

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 Exploring Feeding Difficulties / Thompson

implement and monitor these “real-

life” opportunities. This approach Tina and Jenna made some
also broadens the possible routines environmental changes to activities
and activities to integrate feeding before and after Marcee’s mealtime
skills with other developmental and incorporated peer models. At
tasks, such as working on fine home, breakfast, lunch, and dinner
motor skills during dressing and were scheduled after a quiet activity,
sensory play to encourage such as reading a book or watching a
appropriate feeding skills. Daily video. Ms. Jamison, Marcee’s speech
schedules should also be reviewed and language pathologist (SLP), also
for adjustments to better match the recommended rubbing Marcee’s
child’s feeding-related sensory cheeks and jaw area before meals. At
processing issues. An additional ABI child care, outdoor play was moved to
strategy is to keep a food diary to the beginning of the day, and snack
document preferences and intake. time came after circle time or group
time. Jenna also moved Marcee to a
Peer and adult models. Modeling is table with several peers who were
another means to teach feeding willing to try new foods and who were
behaviors (Hendy, 2002). Young also advanced in their self-feeding
children naturally imitate, and this skills. The final change was providing
can be used for teaching feeding Marcee with an air cushion under her
skills. Adults as well as more-skilled bottom to provide additional support
same-age peers and older children, when she sits in her chair.
including siblings, can provide “how-
to” examples and feedback (Hendy,
Direct instruction. A more
2002; Howe, Brittain, & McCathren,
structured method of teaching
2004; Lynch & Simpson, 2004;
feeding skills involves directly
Moore, Tapper, & Murphy, 2007).
working with the infant or toddler
Modeling also ensures multiple
to initially touch, taste, and
opportunities for practice and
finally, eat or drink the avoided
reinforcement from peers in home,
foods and liquids. The approach
child care, and community settings.
includes the provision of daily,
multiple opportunities for skill
development and reinforcement
(Marchand-Martella, Slocum, &
Martella, 2004). The young child
is reinforced for attempts with
specific food items along with
increasing requirements to obtain
reinforcement. For example, a
toddler is offered a favorite song
to listen to after tasting a non-
preferred food. As his or her
intake increases, the song is
offered only after he or she
consumes at least half of the
portion. It is important to take
steps to reduce or eliminate more-
structured strategies so that the
young child learns to perform
these skills independently.

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 Exploring Feeding Difficulties / Thompson

Table 3
Resources for Feeding-Related Materials

Company Description Contact Information Web Site

Abilitations Sensory and therapy equipment Abilitations [Link]

P.O. Box 922668
Norcross, GA 30010-2668
(800) 850-8602
Beyond Play Early intervention products Beyond Play, LLC [Link]
1442A Walnut Street #52
Berkeley, CA, 94709
(877) 428-1244
Enabling Devices Learning and assistive devices Enabling Devices [Link]
Toys for Special Children
385 Warburton Avenue
Hastings on Hudson, NY 10706
(800) 832-8697
Fun and Function Resources for therapeutic Fun and Function [Link]
play and education P.O. Box 11
Merion Station, PA 19066
(800) 231-6329
Sammons Preston Rehabilitation equipment Patterson Medical/Sammons Preston [Link]
and supplies 1000 Remington Boulevard, Suite 210
Bolingbrook, IL 60440
(800) 323-5547
The Wright Stuff Home health care products and The Wright Stuff [Link]
adaptive equipment 111 Harris Street
Crystal Springs, MS 39059
(877) 750-0376

Professional support. An SLP or may be part of the team that works

nutritionist can recommend adapted with an infant or toddler to address
utensils, including spoons, cups, and sensory processing difficulties that
bowls and products such as Thick It affect feeding. For example, an OT
to assist with liquids and high- can assist with oral motor activities
calorie supplements for weight gain to increase a young child’s
(e.g., PediaSure, Ensure pudding). awareness of and tolerance of tastes
SLPs may also suggest the use of or textures, and a therapist can also
supplements, which can be found in provide consultation about feeding
local drugstores and more implements (spoon, fork, and plate)
specialized items by searching and positioning.
products made by companies such
as Sammons Preston. (Refer to Table Sensory Modulation Strategies
3 for companies that produce
feeding-related materials and Table Strategies addressing the four
4 for book and Web site resources.) components of sensory modulation
A growing number of occupational associated with feeding problems are
therapists (OTs) receive training in provided in the following section.
sensory processing etiologies and The general strategies discussed
interventions (Dunn, 2007). An OT earlier can be implemented with a

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 Exploring Feeding Difficulties / Thompson

Ms. Jamison provided Jenna with ate at least three bites of provided
several new cups to try with Marcee. snacks and mealtime items. If the
She also offered packets of Thick It to weather did not allow outdoor play,
add to her juice to give it a thicker Tina or Jenna would read Marcee a
consistency. Jenna agreed to try both favorite book. During the 1st week, a
and spoke with Tina about the new slight increase in Marcee’s food intake
strategies. It was also decided that was noted, because Tom and Tina
Marcee would be given 5 additional were very consistent about following
minutes of outdoor playtime when she through with the new strategies.

variety of infants and toddlers with describes a sensory diet as specific

feeding difficulties. They require few sensory activities to match a child’s
additional materials or specialized unique sensory needs. For more
training. The strategies that follow, specific assistance to work with a
in contrast, are more specialized and young child with sensory processing
specifically address the previously issues, a parent or caregiver can also
described sensory modulation consult an SLP or an OT with
components. expertise in feeding problems. Table
The following strategies are 5 summarizes components,
considered a “sensory menu” with descriptions, indicators, and
choices matching an infant’s or strategies for addressing the four
toddler’s sensory needs. types of feeding-related sensory
Additionally, Kranowitz (2005) processing issues.

Table 4
Additional Resources

Books
Ayres, A. J. (2005). Sensory integration and the child: 25th anniversary edition. Los Angeles:
Western Psychological Services.
Biel, L., & Peske, N. (2005). Raising a sensory smart child: The definitive handbook for helping
your child with sensory integration issues. New York: Penguin.
Bundy, A. C., Lane, S. J., Fisher, A. G., & Murray, E. A. (2002). Sensory integration: Theory and
practice. Fort Collins, CO: F. A. Davis.
Koomar, J., Kranowitz, C., Szklut, S., Balzer-Martin, L., Haber, E., & Sava, D. I. (2007). Answers to
questions teachers ask about sensory integration: Forms, checklists, and practical tools for
teachers and parents. Arlington, TX: Future Horizons.
Kranowitz, C. S. (2005). The out-of-sync child: Recognizing and coping with sensory processing
disorder. New York: Perigee.
Miller, L. J., & Fuller, D. (2006). Sensational kids: Hope and help for children with sensory
processing disorder. New York: Penguin.
Web Sites
[Link] Provides information about
feeding milestones from birth to 3 years of age.
[Link] Provides
articles, tips for parents, and warning signs of feeding disorders.
[Link] Provides a sensory processing
disorder checklist and links to products such as adapted cups and seating devices.

80 YOUNG EXCEPTIONAL CHILDREN Vol. 13, No. 2, March 2010

 Exploring Feeding Difficulties / Thompson

Table 5
Feeding-Related Sensory Processing Issues

Component Description Indicators Sensory Modulation Strategies

Poor registration: high Requires a great deal of Withdrawn Offer foods with texture (e.g., crunchy foods)
neurological threshold; stimulation to eat or Difficult to engage Provide foods with strong flavors and/or
responds minimally drink (intense smells
to surroundings flavors, textures) Add temperature to foods (e.g., very
Sensitivity to stimuli: Less input to get a Hyperactive cold water to drink, warm apple sauce)
low neurological response Distractible Eat at a quiet table or in a quiet room
threshold; responds Difficulty focusing Decrease distractions during mealtime
to most elements on task at hand (e.g., turn off lights, turn off music)
in surroundings
Sensory seeking: devotes Needs more input, such Fidgets Provide physical activity before mealtime
a great deal of energy as movement, touch, sound, Plays with food Add texture to food (e.g., raisins to oatmeal)
seeking out stimulation and visual stimulation to Handles everything Offer adapted positioning, such as therapeutic
to meet neurological respond to meal Chews on nonfood items ball or sit pad in chair
threshold needs and snack items Suggest child brings preferred object to
mealtimes (e.g., favorite book, fidget toy)
Sensory avoiding: expends Withdrawn Engages in behaviors to avoid Use a picture schedule to indicate what is
a great deal of energy to Develops rituals for situations that might be coming next or what to expect during the day
avoid stimulation because daily activities overwhelming (e.g., noisy Sit child at the end or alone at a table
of low neurological dinner table, textured Provide transition object during mealtime
threshold sensitivity snack items)

Poor registration. Working with an stimuli can involve a variety of

infant or toddler with poor strategies. If an infant cannot settle
registration (less awareness of in a caregiver’s arms for a bottle, for
sensory input) requires a direct example, he or she should be
approach. If presenting a specific swaddled. If an older toddler arches
food or drink item does not when his or her mother positions
encourage a child to eat, the parent him or her in a high chair or booster
or caregiver must make the food seat, an alternative seating system
item more attractive in presentation should be devised that is safe and
as well as taste. For example, a also less restricting. The use of a
smiley face pancake is more visually child-sized table and chair is an easy-
appealing than a basic pancake (add to-implement alternative. The
raisins, whipped cream, and/or introduction of new textures and
syrup). A spice or condiment with a feeding utensils should be used in a
strong smell can be used, such as systematic and consistent manner to
cinnamon or vanilla or almond address the child’s sensitivity.
extracts added to pancake batter. Persistence is necessary in working
ABI can also be used to provide through distractibility during food
opportunities to engage the young presentation and refusal of food
child in preparing the food item to items. A new food often needs to be
heighten interest (e.g., exploring the offered 15 to 20 times before it is
item with hands and/or mouth accepted (Birch, 1999; Carruth et al.,
during preparation). 1998; Forestell & Mennella, 2007).

Sensitivity to stimuli. Helping an Sensory seeking. Young children

infant or toddler who is sensitive to exhibiting this component of

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 Exploring Feeding Difficulties / Thompson

“
sensory modulation seek stimulation For both feeding strategies and
while they eat. Offering a variety of specific sensory modulation strategies,
Consistency of techniques finger foods provides stimulation
and also helps focus the young
it is critical to monitor the child’s
progress. As children’s feeding needs
child’s senses for new food are supported effectively, there are
between and among experiences. For example, eating positive outcomes adults look for.
saltines provides tactile and The following sections address these
caregivers is critical. gustatory (relating to sense of taste) areas.
feedback to prepare the child for the

”
introduction of a new texture or Progress Monitoring
consistency of a familiar food item,
such as oatmeal containing dried Feeding strategies must be
fruit pieces. A finger food, such as monitored to ensure progress in
chicken nuggets, can also be used to targeted skills and behaviors.
help a toddler explore new tastes, Additional ABC analyses can be
such as dipping sauces (e.g., ranch, conducted to examine the young
barbecue, honey mustard). An SLP child’s behaviors after modifications
or OT can offer weighted utensils or changes to antecedents and/or
and cups with straws to meet the consequences. Criterion-referenced
child’s unique sensory seeking needs. assessment also offers opportunities
to monitor progress through
Sensory avoiding. The final type of frequent data collection. This
sensory modulation difficulty approach also offers linkages with
necessitates the use of individualized curriculum-based assessment systems
strategies for the infant or toddler to to ensure that strategies are
become comfortable with new foods implemented during daily feeding-
instead of avoiding them. It is best related activities and routines (Pretti-
to begin with preferred foods while Frontczak & Bricker, 2004).
supporting the infant or toddler to Standardized instruments, such as
progress to the next feeding-related
developmental milestone. Consis-
tency of techniques between and
among caregivers is critical,
especially if the child is prone to
avoidance behaviors, such as having
a tantrum, throwing food, and
gagging. In addition, results of an
FBA assist in determining specific
antecedents and consequences as
well as the function of the problem
behaviors (escape, gain access to an
item or activity, gain or maintain
attention from an individual, or
obtain stimulation). For example, if
a toddler avoids textured foods, it is
important to offer the child these
food items using strategies
specifically addressing sensation
avoidance behaviors (e.g., peer
models, reinforcement) so that over
time, the foods become preferred.

82 YOUNG EXCEPTIONAL CHILDREN Vol. 13, No. 2, March 2010

 Exploring Feeding Difficulties / Thompson

the Infant/Toddler Sensory Profile Chatoor, 2009; Rudolph & Link,

(Dunn, 2002) or HELP (Furuno 2002). Improving feeding skills
et al., 1988) can also be used to assists the child in both his or her
ascertain developmental progress in immediate setting and future
sensory processing and feeding skills. learning environments and other
areas of development. This can also
contribute to improving eating
Feeding Outcomes experiences with friends and in the

“
Eating solid foods and
There are a number of positive
outcomes to addressing feeding
problems in infants and toddlers.
Most important is the child’s
community (e.g., McDonald’s,
birthday parties). Furthermore,
addressing feeding problems
provides opportunities to acquire
taking in adequate improved feeding. Eating solid foods and refine developmental skills (e.g.,
and taking in adequate amounts of pincer grasp to pick up raisins, eye-
fluids provides nourishment, which hand coordination for spoon
amounts of fluids provides is particularly important for brain feeding; Olive, 2004). These
development, general health, and developmental gains can be
nourishment, which is improving relationships between the considered positive “by-products” of
young child and his or her parents sensory modulation-focused feeding
particularly important for and caregivers (Benoit, 2000; strategies.

brain development,
general health, and
The changes in mealtime routines plate with Tater Tots and French fries.
improving relationships were helpful to Marcee and her Because Tina was concerned about the
family. She no longer throws food and lack of fruit and vegetables in Marcee’s
between the young child now sits at the table with her siblings
for up to 10 min. She needs the air
diet, she began to add small chunks of
apples and peaches to Marcee’s
cushion only when a snack or meal oatmeal. Marcee would eat around
and his or her parents and requires use of a spoon. She does not them or spit them out when she found
use it for finger foods or cup drinking. them. Ms. Jamison suggested pureeing
caregivers Adding new foods to her these items. Tina pureed the fruit
repertoire is taking time but is before adding it to Marcee’s oatmeal,

” occurring. For example, Tina started

adding apple jelly to Marcee’s toast a
little bit at a time. Tina gradually
increased the jelly until it was visible
and she ate at least a few bites every
morning. Tina gradually increased the
coarseness of the fruit across 3 weeks,
and eventually, Marcee ate the chunks
and added to the texture of the toast. of fruit in the oatmeal. Jenna has tried
After Marcee adjusted to the jelly and several of these ideas with success as
toast, Tina started putting ketchup on well. Tina and Jenna will continue to
Marcee’s plate with her chicken strips. introduce new foods in a variety of
Marcee refused to eat it at first, but creative ways. They have learned that
Tina kept putting ketchup on the plate the key to creating successful
and encouraging Marcee to try it. After mealtimes is to offer foods in a way
Marcee started eating the ketchup, that meets Marcee’s sensory processing
Tina started adding ketchup to the needs.

Vol. 13, No. 2, March 2010 YOUNG EXCEPTIONAL CHILDREN 83

 Exploring Feeding Difficulties / Thompson

Note
You may reach Stacy Thompson by e-mail at stacyt@[Link].

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