Author: Linn Wakeford, M.S., OTR/L
About Sally
Sally is a charming 2 ? year old girl with Down Syndrome. She lives with her parents, an older brother and a baby brother, and attends an all-day childcare program. She likes singing, baby dolls, books, climbing, art activities, and playing with her brothers. Sally likes her own way of doing things, but also learns well by having adult guidance and clear expectations, and by watching her classmates and older brother. Once she realizes she is capable of doing something on her own, she is usually motivated to do so!
Background
Sally's childcare program is inclusive, meaning that children with special needs attend along with typically developing children. The intervention team for any child with special needs includes the parents, classroom staff, occupational, physical and speech therapists, and a special educator. Therapy services are provided in the classroom setting, with a combination of direct work with the child and consultation to teachers and parents.
Over the past year and a half, a number of intervention strategies have been used to help Sally develop more independence at mealtime, particularly self-feeding skills. This was identified as a priority area of need by Sally's parents, and they have worked closely with Sally's teachers and therapists on setting goals and following through with strategies. As Sally developed new skills and learned to use them consistently, new goals were set; in that sense, evaluation has been an ongoing process.
Goals and Strategies
At about one year of age, Sally was able to hold a graham cracker and bite/chew on it, but did not pick up Cheerios or other small foods to finger feed, and she preferred to be fed rather than feed herself. She was eating a variety of food textures, with no significant problems with chewing or swallowing. Her intervention team (including parents) agreed that consistent independent finger feeding was an appropriate goal. Strategies included:
? making sure she was sitting in a chair that gave her good support, had her feet resting on the floor or footrest, and table or tray at mid-chest height
? presenting finger foods of some type at every meal, particularly foods she really liked, to increase her motivation
? clear and consistent expectations from all adults (teacher, parent, therapist) that she do some part of feeding herself
? making sure she was successful by presenting foods so they were easy to pick up (larger chunks could go on a plate or tray, but smaller pieces were at first presented in the adult's hand or in a pinch-type grasp by the adult, until Sally developed the finger skills to pick little things up off a plate)
? turn-taking (adult feeds her one piece, she feeds herself the next, etc.)
? seating her at the end of the table in her classroom so she could see her classmates, and using her classmates as models of how to feed yourself
? praise, clapping?lots of support for doing it herself and calm re-direction when she refused ?.
? presenting food in bite-sized pieces, and reminding her to take one bite at a time (as she got better at self-feeding, she tended to put too much in her mouth sometimes)
Within 3 ? months, Sally had met the goal of consistent independent finger feeding.
At the same time that finger feeding was being addressed, Sally's use of a cup was evaluated, at the request of her parents. Both they and the teachers noted that Sally was having a hard time using a "sippy" cup. Sally was able to bring the cup to her mouth and place her mouth around the spout, but was dribbling a lot of liquid as she drank. Sally really needed to be drinking from something that required her to get her lips closed tightly, and sippy cups do not encourage that kind of control. Sally also needed to learn, along with her classmates, to hold the cup with control and to put it back down on the table after drinking. Strategies used to address drinking from a cup at meals included:
? use of a small, two-handled cup with a straw - it encouraged the use of two hands and wasn't too heavy, but gave her something easy to hold onto - the straw required more tightly closed lips and allowed less leakage
? light hand-over-hand assistance to first learn to pick cup up with both hands and bring straw to mouth (this was a different movement than she was used to with the sippy cup, where she needed to tip her head back)
? adult sitting near her at meals used physical prompts (not moving her, but giving her touch cues to guide her movement) to re-direct her hands to place the cup on the table, rather than drop it to the floor (of course, we didn't catch her fast enough sometimes, but enough so she got the message?)
? if she dropped the cup, she had to get up and pick it up (adult staying calm, not punitive); if she dropped it twice in a short period of time, the adult removed the cup from Sally's reach and she had to request it to get more drink
? again, consistent, clear expectations from all adults involved in her mealtime routines, and lots of praise
By the time the finger feeding was consistent, using the straw cup was also consistent and independent. Sally's intervention team decided that spoon feeding was an appropriate next goal (her classmates were spoon feeding, though not neatly, of course). Sally still liked being fed and tended to resist utensil use at meals, but was beginning to use more "tools" in her play (paint brushes, hammers, crayons, etc.), and would put spoon-type toys in her mouth, so she was really getting ready to learn spoon feeding. Strategies used to support her included:
? again trying to make sure she would be successful in her attempts - we got her a spoon that fit her hand well and had some weight to it, so she could really "feel" it in her hand, and we got her a "scoop" bowl and plate that suction to the table and are higher on one side to scoop against with the spoon
? started with foods that are easy to scoop, like yogurt, pudding, applesauce
? we continued to make sure her chairs (at home and childcare) were supportive and the right size for her and the table height
? hand over hand assistance at first to learn the scooping motion and get the feel of the spoon, then moving to the adult just holding the very end of the spoon (but not touching her hand) to stabilize it and allowing Sally to direct the movement?eventually moving to the adult providing verbal support, but no physical assistance
? starting with expectations that she would do a certain number of bites and be fed some, and then increasing those expectations as Sally became more independent, until the expectation was that she would feed herself all the food for which a spoon could be used, at each meal
? praise, consistency, and patience
In six months, Sally was spoon feeding herself independently and consistently. After about 10 months of intervention, Sally's self-feeding skills and mealtime behaviors were similar to her peers, and no new feeding goals were written. While the strategies listed above were being used, Sally was also learning other routines related to mealtime, including handwashing before meals and using sign language for "more," "milk," and other meal-related requests. Currently Sally makes mealtime requests using a combination of pointing to pictures, using words and using signs. She feeds herself from scoop bowl or plate, and drinks from a small open cup independently. She takes paper products to the trash can at the end of the meal, and washes her hands before and after meals with minimal assistance.
The team approach to this intervention was a key element, and Sally's parents and teachers were consistent and diligent in following through with the strategies we tried. Sally's parents led the way in how hard to "push" Sally to develop these new skills, but were always seeking input about new strategies and what realistic expectations might be. And, of course, Sally did a great job herself, persisting with us (with some tears and anger at times) until she saw what she could accomplish on her own, and then doing it!
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