Strategies to promote early eating skills

by Sandy Joint, State Education Adviser for Deafblindness,
Education Queensland

 

Introduction

Every child is unique and  masters eating skills at different rates and ages. Deafblind children are no different  and will go through similar development stages as they learn to eat. This article provides advice on practical ways to develop effective eating skill in deaf blind chlidren who are functioning at a developmental levels below twelve months.

 

Prior to this, when a mother feeds her child she is primarily concerned with ensuring her child recieves adequate nutrition, and that the child learns to enjoy and cooperate with the feeding activity. It is not until the child starts to demonstrate signs of readiness to feed and drink independently that they begin to show the child how to eat independently and assist them learn this process.

 

In the non deafblind child readiness for eating independently is demonstrated  by behavioural indications such as, trying to hold their bottle,  reaching for their cup, taking your hand to get you to put food in their mouth,  or trying to pick the spoon up from the plate --  are all behavioural indication that tell us the child is ready to start some basic feeding and drinking skills.  It is not until after the developmental level of twelve months that these skills start to develop, and many years later before they are refinded.

 

 

 

Basic strategies and environmental considerations

·         Make sure ‘eat time’  is always an enjoyable and fun activity. Feeding a deafblind child will take time, try to allocate enough time so you do not have to rush feeding your child. The less you rush the more relaxed it will be for both of you and your child.  You are also more likely to use tactile signs on your child as they eat if you are relaxed and not in a hurried.

·         Make sure the room is a pleasant temperature, quiet and has good lighting to assist residual vision. Noisy areas with lots of people coming and going will stop your child using residual hearing to attend to your actions and communication.

·         Develop a consistent routine established around specific times and certain places to help your child learn to anticipate and remember actions. Anticipation will reduce the fear of what might happen to them. Through anticipation they will learn to try and imitate, and consequently learn the skill.

·         If your child does not have neck control feed them in a semi reclining position. If you use a chair ensure it is a safe and secure chair and with a high back and head supports if he/she still does not have head control. Sit close to the child so you can sign to them

·         When the child shows readiness to develop independent eating skills (e.g., reaching for their cup, putting their hand on yours while they feed you. ) position objects and food for eating in the same place to make it easier for the student to find, and in a position that your child is most likely to see, some children have only perifial vision or vision in only one eye.

·         If your child has any residual vision use non-slip bowls and plates that contrast with the colour of the table or mat they are place on. Use cutlery that has brightly coloured handles so they are easier to find and identify. Do not use cutlery that has shape edges.

·         Provide hands on assistance until the child can undertake the task independently. Whenever possible try and encourage the child to do things for themselves . Withdraw help gradually.

·         Do not be concerned about mess, all child are messy to begin with, and will spill food. Be prepared by having a towel and damp wash cloth ready to protect both your clothing and the child's, baby wash cloths are also a useful aide.

 

 

Language input

Every activity the student participates in including  care activities, is an important language learning time. Always use as much language as possible to explain what you are doing. When telling the student what to do, use the same sentences and structures.  Repetition will assist the student connect the concept of what they are doing to words and actions.  Do not however make things so repetitious that the student will turn off.  Do use different words and structures occasionally.  Ideas of sentences you could use are included at the back of this booklet.

 

Always tell a student when an activity is about to begin or finish.  This will give warning to the student and provide security and comfort  e.g., never just push the spoon in the students mouth always warn them it is coming by saying “eat time” [show them the spoon]  “you eat”  [name of food],  let them feel the food.  Similarly when they have finished an activity tell sign “[name of food] finished”  followed by “eat finish”

 

Tell the student the name of the food they are eating. Repeat the name of the food at least three times while they are eating that food. By learning that different tastes have names it will assist them understand that different objects and actions have names.

 

To increase concepts and language do take the student to new eating environments occasionally e.g., outside for a picnic.  Do introduce the student to new foods frequently so their vocabulary can be increased. This will also help them to eat a variety of foods.  If you only give them the same foods they will be come less tolerant of change and possibly reject tasting new foods.

 

Please learn and use the signs presented in this booklet/series.  Always remember  if you are not prepared to learn and use these signs never expect the student to learn and use them. The more signs you learn and use the more signs the student will learn and begin to use.

Eating is one of the best times to foster language. This is because a deafblind child's sense of taste is not effected.  During feeding time there is often many opportunities to ‘feed in language’. This is because it usually takes time to feed a deafblind child.

 

Language related to eating presented to non deafblind chidren in the early stages tends to focus on actions words to developing  skills, cooperation, and tastes to help food choice.   These words and sentences  tend to be presented as  short command direction like sentences to get the child to attend to the feeding process and undertake the actions required.  The following are typical statements that consist of two to three words, they are invariably used just before or while a non deafblind child is doing the eating activitiy:

            good boy

            open up/wide

            swallow chew

            eat the banana for mummy

            eat  up

            more

            you want more

These words and sentences should also be used with your child who is deafblind. Most of these same sentences can be presented to your child if you use the Body Signing approach which places tactile signs directly on to your  child’s body. This approach reduces manipulation of the childs hands and allows language to be put in while the child is actively engaged in eating. Remember when doing any form of tactile sign to use both your voice along with the tactile signs when you are communicating with your child. The tone and pitch of your voice will help your child attend and focus on what you may be trying to say and sign to them. The tactile signs will provide better clues to assist understanding of residual hearing.

 

Always warn the child that you are about to feed them by giving the appropriate tactile signs e.g., “eat time”. Use the same sentences and structures when telling the student what to do. If the student has no, or limited language skills, use mainly body signs so there is less manipulation.  This is especially important with infants as you will not be able to sign on to the hands of infants who still have reflex grasps, or tightly clenched hands.

 

Always make  tactile signs for the specific food the child is eating or drinking, Do not just sign the word ‘food’ name the foods they will be eating try and tell the child the names of foods and drinks they are eating or drinking  e.g.,  “banana” “milk” “water”  “apple”.

 

Tactile sign and say  the name of the food at least three times while the child still has the food inside their mouth e.g. “banana banana banana” . Repetition will assist the student connect the concept of what they are doing to the words and actions you are doing with them.  Do not however make it so repetitious that the student will turn off.  Do use different words and structures occasionally.

 

Use as many tactile signs as you can while feeding the child, signing and saying  additional comments as you feed the child e.g.,you eat banana; you like banana, banana good,

more banana.  These comments will help to emphasise the name for the taste that is still inside their mouth; in turn this will help develop concepts and understanding that different tastes have different labels and help with the process of real choice making. Taste  brings a great deal of information to the child. To help develop language try various flavours in their bottle or cup e.g., orange juice, blackberry, egg flip, chocolate, strawberry milk, water etc.

 

Words said verbally can be shorteden to two sylable repetitions to assist residual hearing understanding  e.g., ‘nana’ [banana], ‘co co’ [chocolate].

 

Finally always let the child know when feeding time finishes. This will be their signal that they can now attend to an other activity.

 

 

Praise

Regardless of which activity you are doing it is important you use lots of praise and use affirmations of encouragement. This is especially important when the child is learning to tolerate new tastes textures or when you are trying to teach them a skill that will develop feeding independence.

 

Students who are dual sensory impaired need a lot more praise and reassurance to continue an activity than other children; this is because they do not get reassurance from smiles, voice sounds and other gestures the sighted/hearing student picks up incidentally. Always praise the student as they undertake the tasks. This can easily be done by  using tactile signs such as ‘good’ and ‘yes’ ,or by letting the student feel your head nod up and down, feeling your thumb extended out, a little neck massage. If the student gets something wrong do not chastise them, redo the activity with them, praise them for redoing the activity.

 

 

Choice

Do not force a student to eat something they do not like.  This is the first opportunity a student who is deafblind has to demonstrate choice.   If you force the student to eat a food they dislike, the student will develop eating difficulties and you will have many problems trying to feed the student.  If the student is extremely difficult to feed consult with parents, teacher etc. to find out why this is occurring.

 

To pose questions and to assist independent choice making, pause then sign “yes no” after a statement. From the body movement, and expressions given by the student sign the response you feel the student would like to make if they could e.g., if they become excited, reach out sign ‘yes’;  if they with draw or push away sign ‘no’.

 

Tactile signs to emphasise

All tactile signs presented during this early stage of eating should consist mainly of body signs as children at this developmental level will have immature hands with reflex and primitive grasps. Students at this stage of development object to their hands being manipulated. The use of full coactive signs requires a great deal of manipulation and there is a strong chance your child will react negatively and start to develop tactle defensive behaviours such as pulling their hands away. Words that you can sign easily on to the child for each skill will be presented as emphasis signs after each strategy

 

 

Strategies to develop specific eating skills

 

Bottle feeding

Nurse your baby and hold your baby when you feed them. Encourage your child to pat the bottle with one then both hands this can be done by playing imitation type games. Gradually encourage them to place their hands on the bottle (each time a little longer) then to bring the bottle up to their mouths. To foster this skill uses the smallest, lightest bottle you can find, only partly fill the bottle.

 

Introducing solids

Introduce solids as near to normal weaning time as possible, unless there is a medical or physical problem there is no reason why this can not occur normally.  Conditions such as  CHARGE will need additional assistance from qualified specialists.  Solid food is necessary to maintain adequate health and nutrician. Teeth also need the stimulation of solid foods. Children who do not eat solids are are more prone to develop dental problems. Solid food is also needed to assist regular and natural bowel movement. Start to introduce a  training cup that has a  special sucker in which thickened liquids can be put in. Gradually increase the thickness and quantity of the liquids  by putting small amounts of fine cereal and pureed fruit and vegetables into the childs milk. Tactile signs such as ‘you swallow’ will be needed to encourage the child to open their mouth and suck from the different sucker.

 

Introducing new foods

Introduce your child to new tastes as soon as he/she is ready   Start by introducing one new taste or food consistancy at a time.  New foods or food consistancies are best introduced at  the beginning of a feeding session. This is when the student is hungriest and more likely to tolerate different tastes.  Only offer a little at first and follow it with something the child enjoys eating.  Make sure you communicate this change by naming the food, this will help reduce food refusal.

Try and encourage the student to taste as many foods as possible.  By tasting foods early and not being forced to eat ones he does not like he will acquire a larger range of tastes.  This will give you more opportunities to extend communication.  You will also be more able to establish likes and dislikes.

 

Tactile signs to emphasise  

            ‘good boy/girl’, ‘you like’, ‘apple good’,

 

 

Learning to take food from a spoon

Spoon feeding can be introduced using a teaspoon place it on the child's lips encourage your child to take some food from a  teaspoon only offer a very small portion at a time.

Start with just a few sessions at first. Place the spoon touching his/her lips . Never just push the spoon in the students mouth always warn the child. The tactle sign ‘swallow’ will be needed to encourage your child to open their mouth as they will not see the visual prompt of a spoon approaching. This prompt is needed to reduce the possility of feeding difficulties that deafblind children can easily develop.  

 

 

Chewing

Chewing will need to be taught in conjunction with teaching the student to eat solids. Chewing is needed to help jaw and tongue control, and lip mobility. This is an important developmental process that will also help develop of movements necessary to assist speech development. The development of chewing skills will help to reduce drooling. Children who are deafblind do not develop chewing incidentaly. This is because they have no opportunities to observe others eating, nor verbal encouragement to try and bite foods and move their mouth. This means this skill will need to be deliberately taught.

 

Activities to assist chewing

·         When the  student has no difficulties swallowing pureed food, very gradually (to the point the student does not notice) make the purees more lumpy to encourage the student to begin the chewing process.

·         Offer food such as rusks, or hard biscuits to encourage chewing.  Encourage the child to chew these pieces by giving your child opportunities to incidentally feel the movements of your jaw, and your neck when you are eating. This can be achieved by sitting your child on your lap faceing you when you are munching on biscuits, carrot sticks etc. This will help your child develop a concept of what chewing is and when it is used.  It will also help the child to learn how to imitate the  chewing action. Sign and say ‘chew’ to encourage the action.

·         Be careful while developing this skill that your child is not just swallowing bigger pieces, or leaving them in a part of their mouth until they have broken down.

·         To help the chewing process give the student hard toys and objects that can be mouthed and chewed such as teething rings.

 

Tactile signs to emphasise.

‘you chew’, ‘you swallow’, ‘biscuit’,

 

 

Coactive approach

By this stage your child should be showing signs of readiness to learn how to feed them selves. Now is the time to gradually introduce the coactive approach. To use this approach effectively  sit beside them but slightly behind. In this position you will not only be able to work co-actively with the student but also in a position so you can watch responses, expressions and attempts to undertake the task.  Signal that you are about to work co-actively with the student by placing your hands on their arms first, then bring your hands down to theirs. When developing any new skill using the co-active approach start by showing the skill only a few times each session (this will reduce student frustration and refuse possible refusal of  co-active contact).

 

Drinking from a cup

Your child will need to learn how to hold and pick up a cup before they can learn to put it down.

To start with use cups that are light are easier to pick up, have two handles and a lip that is easy to drink from. Only put small portion of liquid into the cup to begin with so it is easy to lift or tip to drink from. If your child as any residual vision use brightly coloured cups that are easy to see and find  unbreakable cups.  If they have no vision use a cup with an embossed pattern that is interesting to feel.   Use the new flavours in the cup, and the least enjoyed in the bottle, this will help facilitate the change.

 

Use a coactive instruction approach. Sit or stand beside the student. Place your hands over the student and do the activity with them. Show the student how to hold the cup with both hands and how to bring it up from the table to his mouth. Show the student how to tip the cup up so they can drink the fluid inside.Gradually withdraw your help as the student is able to do each step remember at first your child will not be able to put the cup down yet and will need assist other wise it will be dropped or thrown.

 

Introduce sucker cups first, then a training cup that has handles on either side, cover the hole first so the child uses the method of sucking that he has been used to with a bottle. Gradually increase the hole size to foster drinking from the cup. Start by using a cup with cover (and handles at side)  encouraging the child to use two hands around the cup when drinking and replacing it on the table.  It is important to encourage the cup to be put down and not thrown.

Introduce the feel of the cup on his lips first, put only a few drops in the bottom to begin with so the child does not choke trying to drink and maybe some nice taste on the rim to encourage drinking.  Give the drink just a little at a time

 

When the student is able to do this skill use a training mug that does not have handles and show the student how to cup their hands around it. Go through the different levels of traing cups until you are only using one with a spash cover at the back before moving onto a regular unbreakable cup.

 

Tactile signs to emphasise

‘you hold’, ‘you try’, ‘milk good’, ‘you like’,

 

 

Finger feeding

Finger feeding is a vital developmental stage to assist  self feeding skills. Before you can get a student who is deafblind to eat with a utensil you will need to make them aware of where they can find food and how it can be taken from the plate to their mouths.

 

Use a coactive approach of guiding the students hands to the food and showing them how to pick up the food with their fingers and bring it to there mouth to eat.  Place only  a few pieces on a plate. add to their plate when they are finished.  By putting only a few pieces of food  on the plate at a time it will be easier for the child to grasp and pick up. It will also give you an opportunity to tell your child the name of the food he/she is eating. Gradually withdraw you assistance as the student demonstrate their ability to find and bring the food to their mouth.

 

Start with a favourite food  soft easy to pick up.Pieces should be no bigger then your fingernails to start with. Make sure the pieces can be swallowed safely if they have not developed effective chewing skills.  Ensure that the child swallowed each piece before you give them more, never let the student store things in their mouth. This means they do not have sufficient skills to cope with what you are giving them (go back to previous stages). 

 

Tactile signs to emphasise

‘you eat’, ‘eat banana/(name of food)’, ‘Apple/(name of food) good’, ‘you like’,

 

 

Holding and using a spoon  to eat from

Ensure your child can finger feed without prompts before attempting to teach them to eat with a spoon.

 

Before beginning spoon feeding encourage the child to pickup and play with a variety of  spoons especially while you are feeding him in this way he will learn to associate the spoon with feeding.

Begin with foods that will cling to a spoon easily. Show your child how to push food onto his/her spoon with their fingers then how to bring the spoon to thier mouth. Later when they have achieved this skill how to put the spoon in a bowl to obtain food. Use a hand over hand or co-active approach to show the student how to feed themselves for example place your hand around the child's while holding a spoon then show them how to bring food from the plate to their mouths.

Use the co-active approach to show the student how to feed themselves for example to help develop spoon feeding,  put the spoon in the students hand then place your hand around the students while holding a spoon, then show them how to  scoop and bring food from the plate to their mouths. Start by co-actively feeding just a  few spoonfuls to begin with. Increase the number of spoonfuls as your child learns to tolerate manipulation of their hand. As the student learns to hold the spoon reduce the amount of assistance i.e., once inside the mouth release your grip over the child's hand and let the child take the weight of the spoon  continue reducing assistance until you need only a prompt to remind to continue feeding. Gradually increase the number of spoonfuls the student  is expected to help with. Once the child is independent with feeding try not to feed him any more and it will only create reliance again.

 

When you feel attempts by your child to hold and bring the spoon to his/her mouth, reduce the amount of hand over hand hold to the point you are just supporting your childs hand. As your child learns to hold the spoon reduce the amount of assistance i.e. from the hand then just supporting the wrist, then elbow then a contact with arm as a reminder to keep feeding. At first you will find your child will be able to hold and move the spoon between their bowl and mouth in a very messy way with limited food finding their way to their mouth. This skill will however will develop with practice and the development of other fine motor skills.

 

Tactile signs to emphasise [words and sentences]

‘you hold’, ‘you hold spoon’, ‘you try’ ‘good boy/girl’, ‘you good’, ‘put banana/(name of food) on spoon’, ‘banana/(name of food) on’

 

An extended version of this article along with Body Signs to assist eating is available in booklet form and can be obtained through request by faxing + 61 7 3393 0994.