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SOS Approach to Feeding with Dr. Kay Toomey
963 Plays1 year ago
Join host Wilmari Myburgh and Dr. Kay Toomey, a feeding therapist and the founder of the SOS Approach to Feeding, as they discuss the complexity of eating and the causes of feeding problems.
In this episode, Dr. Toomey explains how cognitive shifts can contribute to problem feeding and when picky eating becomes a problem. She gives an overview of the Sensory-Oral-Sequential approach to feeding and explains the myths of eating. Dr. Toomey discusses the best first approach to feeding therapy and how to attend an SOS Training Conference. She also provides resources for listeners to connect with her and learn more about the SOS Approach to Feeding.
At the end of the episode, Wilmari and Dr. Toomey have some fun with a rapid fire question segment. Tune in to learn more about the complexity of eating and the SOS Approach to Feeding!
Jump through this episode using our timestamped chapters:
[00:00:02] Start
[00:00:29] An Introduction to Dr. Toomey and How She Got Involved in Feeding Therapy
[00:08:21] The Complexity of Eating: Understanding the Causes of Feeding Problems
[00:16:30] Cognitive Shifts and Picky Eating: When Does Picky Eating Become Problem Feeding?
[00:34:33] Exploring the Sensory-Oral-Sequential Approach to Feeding
[00:42:17] Tenets of the SOS Approach: Understanding the Myths of Eating
[00:49:47] Systematic Desensitization: The Best First Approach
[00:54:51] Attending an SOS Training Conference: The Foundation for Feeding Therapy
[00:59:18] Connecting with Dr. Toomey: Finding Resources on the SOS Approach to Feeding Website
[01:01:18] Fun Rapid Fire Questions
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Transcript
Introduction to the Podcast
00:00:01
Speaker
Welcome to Growing OT, the podcast that's developed and produced by the Society of Alberta Occupational Theramists. SAOT wants to get listeners excited about the wonderful world of OT. I'm your host, Vilmarie Myberg, and we'd love it if you could please take a moment to subscribe or leave us a review on Apple Podcasts, Zencaster, or wherever you're listening to us right now.
Focus on Feeding and Guest Introduction
00:00:26
Speaker
Today's episode will focus on the clinical practice area of feeding, and joining us to share her expertise, we are fortunate to speak with Dr. Kay Thuniek, who is a pediatric psychologist. She's worked with children who don't eat for almost 35 years. If her name sounds familiar, it's because she's developed the SOS approach to feeding as a family-centered program for assessing and treating children with feeding problems.
00:00:53
Speaker
Dr. Tumi speaks nationally and internationally about her approach. Dr. Tumi helped to form the Children's Hospital, Denver's Pediatric Oral Feeding Clinic, as well as the Rose Medical Centre's Pediatric Feeding Centre. Dr. Tumi co-chaired the Pediatric Therapy Services Department at Rose Medical Centre prior to entering private practice.
00:01:16
Speaker
Dr. Tumi acted as the clinical director for Tumi Associates Inc feeding clinic and then the SOS feeding solutions at STAR before shifting into clinical consultation in order to focus on her teaching. Dr. Tumi is currently the president of Tumi and Associates Inc.
00:01:35
Speaker
Well, welcome doctor to me. We are so happy to have you with us today on our second episode.
Origins and Evolution of Feeding Practices
00:01:42
Speaker
And I was hoping that to kick us off, you'd be willing to speak a bit about how you got into this area.
00:01:48
Speaker
Absolutely. Welcome, everyone. Thank you so much for listening to this podcast. Obviously, thank you to Robin and her whole team, including our folks on the podcast and SAOT for asking me to do this. I've had the privilege of speaking in the past for SAOT. Obviously, it's a phenomenal organization and we'd like you to go ahead and
00:02:16
Speaker
Become a member, especially if you're an OT in Canada. I'm sure there will welcome any part of Canada that you belong to because they are such a great organization. As you just heard, I have been in the field a very long time.
00:02:35
Speaker
Being a pediatric psychologist is a little different kind of discipline to be involved in the field of feeding, especially early on. I got involved in the field because of a particular clinical case.
00:02:50
Speaker
And in the mid 1980s, unfortunately, the prevailing belief about when children didn't eat is that it was always the parents fault. It could potentially be something major from a medical standpoint, but most people believed when children didn't eat and grow, that was because of something their parents were doing inappropriately.
00:03:11
Speaker
And I got involved in a case because a little two and a half, three year old child came into the hospital where I was working as a consultation liaison psychologist. And she had been recommended to get a gastrostomy tube placed. And in the mid 1980s, having a G2 placed was actually quite a major surgery.
00:03:32
Speaker
Today, what we call G-tubes are not really G-tubes, they're G-buttons. We call them G-tubes still based on the history because what we used to do is take an adult urine fully catheter. We would stitch it through the abdominal wall into the stomach itself and then adhere everything down.
00:03:53
Speaker
And then the two, of course, would be hanging from the child's abdomen and we would put a hemostat clamp on the end of it to make sure nothing leaked out. And that was my first experience with working with a child who didn't eat well. And I got called in as a pediatric psychologist because the feeling by the medical team was this child was going to have this very major medical procedure because her parents obviously were at fault for not feeding her appropriately.
00:04:22
Speaker
And you're the psychologist, you go fix this family situation was sort of what I was told. So I had no idea what I was doing. I had never worked with someone who had a feeding problem in the past, knew very little about it.
Understanding Feeding Challenges
00:04:36
Speaker
And so went in with my all my assessment tools and my assessment battery and
00:04:41
Speaker
did this whole evaluation of the parents and the child and discovered as I was doing that, that I had a set of warm, lovely, delightful, caring parents who were very well adjusted, a child who was also very well adjusted, very well attached to her parents very appropriately. And that the family was doing absolutely everything that anybody told them to do.
00:05:07
Speaker
But they had a child who wasn't physically competent to do the task and that nobody ever considered that maybe this child didn't have the skills to eat the foods that everybody thought she should be eating in the way that they thought she should be eating. And that's what got me interested in the field is I wanted to understand as a psychologist
00:05:27
Speaker
Why do we blame parents when kids don't eat? What is that all about? And so a lot of it has to do with the history of our field, but what I can let your listeners know is that the research is really quite clear that parents are the cause of children's feeding difficulties in only about three to 7% of the cases. And so one of the first pieces of advice I give people when they come to my conferences
00:05:53
Speaker
is I talk about the fact that if we as professionals are assuming these parents are causing these children's feeding difficulties, we are going to be wrong 93 to 97% of the time so that we really need to not go there because we are wrong if we assume that it's the parents.
00:06:14
Speaker
And that in actuality, feeding is the most challenging thing we do as a human organism. It is the only thing we do as a human being that requires that we have all seven areas of human functioning work correctly. Not only do each of those different areas have to be working well, we have to be able to integrate across and within each of those seven areas to make eating work well.
00:06:39
Speaker
And it's why so many kids look pretty good at play. They look pretty good at school. They look pretty good at this self-help or other physical activity. And when it comes to eating and feeding, it all falls apart because it's actually the most complicated thing we do. And from a sensory standpoint, it's the only thing children do where they have to simultaneously integrate eight new pieces of sensory information every time they move, which of course is what you do when you chew.
00:07:06
Speaker
And there are only two human behaviors across our lifespan where we will need to do that level of complexity of sensory integration. And it's why so many children who have sensory difficulties struggle to make those different transitions from bottle and brass to purees or from purees to textured table foods because the sensory requirements of the task are just too much for them to be able to handle.
00:07:34
Speaker
So that was kind of a long-winded explanation, but that's really how I got interested in the field. And of course, over the years, working with occupational therapists has been such a critical part of what I do because the whole sensory aspects of eating are unique to eating and unique to the feeding work that kids have to do.
00:08:00
Speaker
Yeah, it sounds like there's really a need to shift that thinking as therapists to really look at what else is going on as opposed to approaching the situation from a place of blaming the parents. Exactly. That's really interesting to note. Can you tell us a little bit about some of the main causes of feeding problems?
00:08:26
Speaker
Yes, yes. You know, one of the things that we know is that when children don't eat well, it is because something about their body isn't working correctly. There are many people out there who think that treating and eating issues are all in kids' heads or all in the parents' heads. It's not either. It's neither in the children's head. It's neither in the parents' heads. It's really all in the child's body.
00:08:54
Speaker
that when the body is put together correctly, when children are intact from a central nervous system standpoint, when they are intact from an organ system standpoint, muscles, et cetera, they are going to be able to progress through the normal developmental stages that happen in the process of learning to eat. And there are times in normal development
00:09:20
Speaker
where all children, regardless of their neurodiversity, are going to struggle a little bit with eating because of different developmental shifts that happen in our lifetime. As long as everything about you, physically, neurologically, is put together well, you will navigate those transitions without much difficulty.
00:09:40
Speaker
But if you have any kind of physical issue, any type of neurodiversity, if you have any kind of difference in your developmental process, you are potentially not going to be able to get through those normal developmental shifts in a way that supports you continuing to eat, or even learning to eat in the first place.
Developmental Stages and Feeding Difficulties
00:10:03
Speaker
Because people think eating is automatic, it's instinctive, it's natural, it happens no matter what.
00:10:09
Speaker
That is true for the majority of children. However, there is a certain percentage of children who that isn't how it works. We know between five to 10% of the world's children are going to struggle significantly with feeding problems. That is a group of kids we refer to as problem feeders. We also know from the research that 25 to 35% of the world's
00:10:39
Speaker
children are going to struggle with some kind of picky eating at some point in the first decade of their life. So there's this other myth out there that people hear where they say, oh, all kids are picky. Don't worry about it if your kids are picky. All kids are picky and they'll all outgrow it.
00:10:56
Speaker
Well, the research really doesn't support that either. So we know that 25% to 35% of the world's children will struggle with some kind of picky eating at some point in the first decade. That certainly is not all children.
00:11:11
Speaker
25 to 35 percent is still a pretty big percentage. That's why families need people like occupational therapists in their lives to help their children navigate these times of development where their children can get tripped up if things are possibly just a little bit off from that developmental standpoint.
00:11:34
Speaker
So what we see from the research is that only about a third to a half of those children who struggle with picky eating will actually independently outgrow that picky eating problem without some kind of professional assistance.
00:11:53
Speaker
So for us as feeding therapists, that's a pretty big percentage of children around the world who really need our help, who need us to understand what it means to be an effective feeding therapist so we can help these children and families navigate these struggles that they may be having. What the research also shows is out of those 5% to 10% of the children who are the problem feeders,
00:12:21
Speaker
only about 8% of those children.
00:12:25
Speaker
will outgrow that problem with their feeding and eating without some kind of professional assistance. So this idea that for all children, eating's just automatic, natural instinctive happens no matter what. The research simply does not support it. And in fact, what we know from some of the most important longitudinal studies that we have out there, the main one being a data set out of the UK called the ALSPAC study.
00:12:54
Speaker
the Avon longitudinal study of children and parents is that at four weeks of age, 40% of children are still trying to figure out how to eat in the first place.
00:13:09
Speaker
at four weeks of age, 40 percent of children are still trying to figure it out. I know your moms out there who have been breastfeeding moms, they know this already. It is not as easy automatic instinctive as what everybody paints it to be. It's a little more difficult than what people tried to go into the process telling you it's going to be. What we know from the research is that eating is driven by your appetite instinct predominantly,
00:13:36
Speaker
where it's so strong that Mother Nature is going to kind of make you eat, even if your body isn't working well at all, for only the first four to six weeks of life. After four to six weeks of life, that appetite instinct actually shifts and changes and it lessens and your primitive motor reflexes, which hopefully you're born with, are going to take over as the primary driver of your eating.
00:14:03
Speaker
But of course, our children who are born premature, our children who are born with genetic disorders, our children who have cerebral palsy, they don't have those primitive motor reflexes intact. And so what we see is those kids can potentially struggle right off the get-go, even though theoretically those drives are supposed to be so strong.
00:14:26
Speaker
After the primitive motor reflexes take over around four to six weeks of age as the primary driver of eating, what you're going to see is that stays in place only until about four to six months. So you have this very short window.
00:14:42
Speaker
in which you have appetite instinct and you have primitive motor reflexes to really help you continue to eat and grow and thrive while your job as that developing baby is to begin to get yourself neurophysiologically regulated enough.
00:15:02
Speaker
that you can participate and engage in the world and begin to bring some of those reflexive patterns under voluntary motor control. Because between four and six months of age, those primitive motor reflexes essentially go away.
00:15:18
Speaker
They should all be coming out from underneath the central pattern generators and out into volitionally controlled motor movements so that after six months of age when those primitive motor reflexes for eating, there's only one left for the rest of our lives into adulthood left for eating.
00:15:38
Speaker
All even that one comes under volitional control. So after six months of age, eating is actually a learned behavior. And you only have three choices. You either learn to eat, you learn to not eat, you learn to kind of sort of eat. That's it. Those are your three choices. So we have to, as the adults in the child's world, be able to be persistent enough and consistent and smart enough to figure out, OK, where did this child get off the track of learning to eat appropriately?
00:16:08
Speaker
How did this child learn to not eat? How did this child learn to only kind of sort of eat? And of course that becomes a big piece of what our job is as feeding therapists and to figure out where in the normal developmental process did this child get off track and why, right?
00:16:28
Speaker
Yeah, definitely. And you did kind of touch on this, but I'm hoping you can give us a little bit more on when does a picky eater become a problem feeder?
Transition from Picky Eating to Feeding Problems
00:16:41
Speaker
I think let's start by talking about when do typical eaters become picky eaters.
00:16:47
Speaker
When is it that kids begin to get off track? What are those normal developmental stages that kids need to be able to navigate in order to be able to learn to eat correctly? The first one actually we've already been talking about, which is that shift around four to six weeks of age where the appetite drive
00:17:09
Speaker
is no longer so strong and those primitive motor reflexes come on board. So that's the first big shift in development that we can see where kids can begin to falter in their eating and even their growth already. The next is going to be around that four to six month age range because in that four to six month age range we have to be
00:17:32
Speaker
awake, alert, engaged enough with the world that we can begin to bring those reflexive motor patterns under volitional control. And around the world, the most common age to get a gastrostomy tube placed if you don't get it out of the NICU because you ended up in the NICU.
00:17:53
Speaker
is actually at seven months of age because those children who are not awake, engaged, alert enough in those first six months or have something else very major going on physically that's interfering with their ability to be neurophysiologically regulated, those kids when those reflexes go away developmentally, their eating goes away as well.
00:18:19
Speaker
And you see them begin to crash about four months of age. It gets progressively worse until it's six months of age. They really crash and they end up with a G-tube at seven months of age. And so the next big developmental time point that children need to navigate is between 12 and 14 months of age. And the second most common age to get a gastrostomy to placed around the world is around 14 to 16 months of age.
00:18:46
Speaker
because kids who don't navigate the next stage are going to again fall apart and what happens between 12 to 14 months of age is developmentally children should become self-aware. So very little children don't understand that they're their own organism on the planet.
00:19:04
Speaker
They are the planet. They are the world. You are them. They are you. Everything in the world is them. Everything in the world happens because they are the world. We call it in psychology, the stage of narcissism. We talk about you have a symbiotic relationship with your primary caregivers. It's not until you begin to crawl away from them.
00:19:25
Speaker
cruise away from them, walk away from them, that you actually figure out your own separate organism on the planet in the world. And that's when children become self-aware that they are separate.
00:19:40
Speaker
When children become self-aware and figure out they're separate, they have their own opinions about things. They figure out they want to do things themselves. Your passive little baby that you used to be able to do anything you wanted to is gone. They crawl back to the light socket you try to take them away from. They no longer passively let you just get them dressed. They don't lie still for having their diaper changed.
00:20:10
Speaker
Yeah, if they don't like something that you're doing, and they want to start doing things themselves, including they want to start to feed themselves more and more. So if you think about as an adult, if somebody tries to give you a spoonful of food,
00:20:29
Speaker
Do you automatically jump on that fork or jump on that spoon? Most of us don't. Most of us take a deep breath, give me a second, okay, I'm ready to take that bite. Because being spoon fed or fork fed or even finger fed by other people is actually uncomfortable because they get the volume wrong. They put it too far in your mouth. They don't put it far enough in. They
00:20:51
Speaker
miss and hate your lips or your cheeks and when you're self-aware being fed by others can actually be kind of frustrating and so you start to see in 12 to 14 months of age children want to do more and more of their own feeding
00:21:07
Speaker
take over more and more of the task. They also are going through a flavor shift in this 12 to 14 month age range. They don't want those boring single flavored cubes of apples you give them or carrots that you give them, the things that have no flavor. They want more sophisticated interesting flavors. When children are
00:21:35
Speaker
typically developing, what you're going to see is their physical skills will come along to meet this desire that happens when they become self-aware of doing the things themselves. And so in the 12 to 14 month age range, we shift from where the parents are doing more of the feeding of the child to where the child's doing more and more of the feeding themselves.
00:22:00
Speaker
But what happens if the child's physical systems aren't intact? What if the child is not neurologically intact? What if they have sensory processing issues? What if they have oral motor issues? And the parent continues to advance their diet, but the child doesn't have the physical skills to eat those foods, but they have the desire to do it themselves.
00:22:27
Speaker
Now we have all sorts of power struggling and headbutting going on between the child and the parent. Because the child wants to do it themselves, the parent recognizes the child can't do it, the parent over pushes, the child pushes back, and we end up in a really uncomfortable space between the parent and the child.
00:22:49
Speaker
and the kids will get into more and more food refusal as a result of all of that. In addition, once I become self-aware, the best way for me to assert myself as being different from you, mom or dad, is by doing something different than you want me to.
00:23:08
Speaker
And what you see happen across the board developmentally is around 12 to 14 months of age, children simply choose to not eat sometimes at meal times because they're asserting themselves as their own independent person. And when you look at growth curves for children around the world, children's growth goes up very steeply, very exponentially for the first 12 months of life. And then every child's growth curve takes a little right hand dip
00:23:39
Speaker
and makes this right hand curve because all of a sudden the kids are like, yeah, I have better things to do than to eat. I have places to go. The world to explore. I don't want to do this eating thing. Don't take me out of my play. I was in the middle of something. I don't want to do this eating thing. Yeah, it's the only thing they have control over, really. Exactly.
00:24:02
Speaker
Exactly. And so it's fascinating to me to look at the confluence of the seven areas of human function and how when something happens developmentally in one area, it then has a domino effect and it impacts the other areas. As long as each area is working correctly and the child is very developmentally, physically, neurologically intact,
00:24:25
Speaker
There will be little blips in development, tiny bits of power struggling, and the child and the parent will figure it out. When the body doesn't work, the child and parent can't figure it out without some kind of help. Our next big stage is going to be our terrific twos.
00:24:46
Speaker
It's called the terrible twos for a reason. There are really good developmental reasons. There are several major developmental shifts that are happening between two and three. A year, I figure out I'm my own separate organism on the planet. I become self-aware.
00:25:02
Speaker
At two, I have to finish the stages of separation and individuation where I figure out who am I as my own person separate from my primary attachment figure. So I have that all going on. And of course, the best way to assert myself as different than my primary attachment caregiver is not just to do something different, but to actually do the exact opposite.
00:25:28
Speaker
of what you want me to. And that's why two-year-olds do things opposite of what you want them to do. They're trying to figure out who are they that's separate from you, their primary attachment figures. In addition, they're making a massive shift in cognition.
00:25:46
Speaker
They are shifting out of what we call sensory motor stage of cognition, where they don't have theory of mind. They don't talk to themselves. They don't think. They don't have a mental life the way you and I do. We all think in words and pictures. We talk to ourselves all the time.
00:26:04
Speaker
You know, we have this mental life below the age of two children don't the only way they understand the world is based on how they physically engage with the world and Around two to three. They actually develop a mental life. So their whole way of understanding the world is
00:26:21
Speaker
radically changes from only being able to understand the world on a physical basis to having a mental life. This is what Barry Brazelton called a touchpoint in development. These are key times in development where children need to navigate a massive shift in the way they interact with the world. One of the things we see with children who have developmental delays
00:26:47
Speaker
is that when they hit these touch points, it's almost like they can only focus on one area of development at a time. And for children who are developmentally delayed, when they're going through these touch points in one area of development, another area of development oftentimes regresses. And what we see during these big cognitive shifts is the part of development that seems to take the hit is children's sensory functioning.
00:27:15
Speaker
So they're super aware of all sorts of things as being different in the world because they can now actually literally think about the world. And many things don't feel good because their sensory systems have crashed and regressed. And they're also a little oppositional.
00:27:33
Speaker
because they're trying to figure out who they are, separate from their own attachment caregiver. And this is why what you see when you look at the research is about 25 to 50% of parents of children who are in the terrible twos are going to say their children all of a sudden become picky eaters. Because when your sensory systems don't work well,
00:28:02
Speaker
You don't want to have to deal with lots of new things that your sensory systems have to process. So if I can fuss at my parent and convince my parent to give me chicken nuggets every day for lunch, I don't have to turn on my sensory brain. If I can fuss at my parent and get them to give me sugary kids cereal every day for breakfast,
00:28:26
Speaker
That melts away in my mouth and I don't have to turn on my sensory brain or use any oral motor skills. And that's what we see two-year-olds do. Two-year-olds also don't like new things that grownups want them to do. And so people talk about that kids seem to develop this resistance to things that are new. Well, it's because of this, what I call the perfect storm of development at two.
00:28:53
Speaker
Your whole way of understanding the world changes. Your sensory systems all go into a regressive state. So now you're super aware of everything that doesn't feel good and you're a little oppositional on top of it.
00:29:05
Speaker
And it is literally the perfect storm. And that's why we see a huge increase in picky eating between two and three.
Developmental Shifts and Feeding
00:29:15
Speaker
And unfortunately, what many professionals tell parents, well-meaning professionals tell parents is pick your power struggles, pick your battles. If your child wants to eat hot dogs every day for dinner, let them do that. Don't power struggle. That's probably the worst piece of advice a professional could ever give a family.
00:29:35
Speaker
because what happened is that you're encouraging the child to engage in a food jag where they eat the same food prepared the same way over and over again. The problem with that is our brains are use it or lose it organ system.
00:29:52
Speaker
And if you give me my perfectly prepared hot dog every day for dinner, I don't have to turn on my sensory brain to eat that food. And I'm going to lose the sensory pathways for eating that food that's a different brand, a different shape, a different color, a slightly different flavor, a different temperature. Because the more perfect you make my food, the fewer brain pathways I have to eat it when it's not perfect.
00:30:19
Speaker
And so we end up with kids who are losing brain pathways because they're being allowed to food jag. And for children who have feeding disorders, when children who have feeding disorders food jag, they eventually burn out on that food, and then that food is eliminated from their food repertoire.
00:30:41
Speaker
Now what we know from the research is that 80% of children who are picky eaters will have some times where they will food jack, but also a third of typical eaters will also engage in food jagging because it is part of the normal developmental process.
00:31:02
Speaker
For children who are typically developing, if they food jag, they eat the same food over and over and over again, they get sick and tired of it, and they do what we call burnout. If you give a child who's food jagged and burned out on a food, who's typically developing about a two week break, they will come back and eat that food again.
00:31:25
Speaker
That's not what happens with children who have feeding problems, especially those who have feeding disorders. Children who have feeding difficulties, if you allow them to food jag and they burn out on a food, if you give them a two week break from that food and you try to re-present it, they will act like either they've never seen it before in their whole entire lifetime, or it's the worst thing on the planet you could possibly feed them. And so what we see happens is that
00:31:54
Speaker
Allowing a child to food jag is how you take an okay eater and end up creating this picky eater between two and three, who then stays picky after they shift into the next developmental stage. Children who are typically developing may go through a short time of picky eating,
00:32:15
Speaker
but they will move out of it when they get to be three and four and five. That's not what kids who have feeding difficulties do. If they shift from being a typical eater to a picky eater, they stay in the picky eating.
00:32:30
Speaker
And then we have two more major developmental shifts that happen where kids get tripped up from a feeding standpoint. The next one is going to be between five to seven, and the next one will be between nine and 11. And so those kids who come out of the twos and threes as a picky eater, if you give in and allow them to food jag again between five to seven, you're going to turn your picky eater into a problem feeder.
00:32:59
Speaker
If you have a child who is picky before they hit two to three and you let them food jag, your picky eater is going to turn into a problem feeder between two and three. We have kids who were seeming to eat okay. They hit the developmental shifts at five to seven, nine to 11, and you can see picky eating start in those age ranges as well.
00:33:22
Speaker
Because again, what happens between five to seven and nine to 11 is we have two more major shifts in the way we think about the world, our cognitive development. So between five and seven, we're shifting out of what we call pre-logical thinking. So from ages two to three to five to seven, we are in pre-logical thinking or magical thinking.
00:33:48
Speaker
Between five and seven, we shift out of pre-logical thinking into logical thinking. Again, our whole way of understanding the world changes. It's a touch point. Our sensory systems regress. So we're super aware of anything that's new and uncomfortable. Then we get through that stage. We stabilize out. We hit nine to 11 and we go from logical thinking
00:34:13
Speaker
to abstract thought. We have another big shift in the way we understand the world. It's a touch point, the sensory systems regress, and we have another whole time period where they are at risk for picky eating, or if they were already a picky eater,
00:34:29
Speaker
becoming a problem feeder.
The SOS Approach to Feeding Disorders
00:34:31
Speaker
I'm wondering if you can tell us about the sensory oral sequential approach to feeding and how that fits into the types of issues that you've already been discussing with us. So we know that developmentally the shifts that children need to navigate not only are sensory but they're also oral motor as well.
00:34:54
Speaker
And there are differences in oral motor stages along development also. It actually takes children two to three years to learn how to eat from an oral motor standpoint.
00:35:10
Speaker
And so we have to go from this reflexive sucking motion that we're born with to having volitional control over suckling to learning how to move our tongue on purpose back and forth to move food from the front of the mouth to the back of the mouth. Then we have to learn how to move textured foods from the front of our mouth to our back molars so we can chew them.
00:35:39
Speaker
And we then learn how to chew soft things. And then we have to learn how to chew harder things. And around 15 to 18 months, we have to learn another oral motor skill that's a bolus collection skill to be able to grab when a food shatters in our mouth.
00:36:03
Speaker
So if you ate something like a pretzel rod, took a big bite and crunched down, you'd end up with a gazillion pieces in your mouth. And your tongue has to be able to sweep around inside your mouth, collect up all those pieces into a ball or bolus of food.
00:36:19
Speaker
get it onto the back molar to get it finished chewing up. We actually swallow texture table food from the back molar area of the mouth, not across the middle of the tongue. Then we're going to spend from ages two to three refining the strength and the coordination of our chewing with bigger and bigger pieces of harder and harder to chew foods.
00:36:42
Speaker
So this idea that kids just automatically know how to eat, it doesn't really happen that way. It's about a two to three year process to actually learn how to eat from an oral standpoint. So we talk about the way we want to think about children.
00:36:59
Speaker
and helping children is by following the normal oral and sensory sequential patterns that should be occurring across development. And we developed the SOS approach to feeding
00:37:15
Speaker
because philosophically what we believe in our approach is that normal development has happened literally for thousands of years because that's what works best for the human body. And so we need to try to follow the normal developmental processes as closely as we can. And so the SOS approach to feeding was developed really to look at following those normal
00:37:44
Speaker
sensory oral motor sequences that kids should be accomplishing. Now, SOS also stands for save our ship. And when you're the parent of a child who doesn't eat well, you feel like you're drowning multiple times a day because what else do we do with our children multiple times a day where you have the privilege of feeling like a failure as a parent because your child isn't eating, your child isn't eating.
00:38:13
Speaker
And so we're hoping with SOS to also be a lifeline to the families. So it's a lifeline to the families, but obviously also a way to help children who have feeding difficulties. And really the SOS approach to feeding came out of the early work that I did at Children's Hospital. When I first went to Children's Hospital in the late 1980s, there were
00:38:38
Speaker
about seven to nine different departments and disciplines, all of whom said they worked with children who didn't eat and none of them ever talked to each other. None of them ever talked to each other. So we developed a feeding consortium where we met as a group, at least one representative from every discipline and department. And we met once a month for over a year. And what we discovered is that no one discipline or department had all the answers.
00:39:06
Speaker
that eating was actually so complicated, we needed to have a multidisciplinary approach to working with children who had feeding difficulties. And it was really out of that work that we identified the seven different areas of human function that need to be looked at when kids don't eat well. We have to look at all their organ systems because if you're not medically intact, physically intact, that's going to impact your eating.
00:39:33
Speaker
We have to look at all their muscle systems because your whole GI tract is a muscle system. We have to have good postural stability. We have to have fine motor skills, gross motor skills, oral motor skills in order to be able to eat well. We have to look at all eight of the kids' sensory systems in order for them to be able to eat well.
00:39:56
Speaker
We have to look at normal stages of development and how kids are on track or not on track. We have to look at their learning capacity, their learning history, their learning style is part of the process. We also have to look at their nutrition because if they don't have the right nutrients, they're not going to be able to grow, develop, participate in the world. And then of course, we do need to look at the environment and the role the environment plays.
00:40:23
Speaker
And we discovered that five major disciplines do a really good job to be able to assess those seven areas of human function that I just listed. And so we felt like we needed to develop a transdisciplinary approach
00:40:43
Speaker
for working with kids who didn't eat well so that individual providers could be able to assess and address the majority of feeding difficulties that would happen within those seven areas of human function. And that's how the SOS approach to feeding program was created is to create this multidisciplinary, transdisciplinary,
00:41:08
Speaker
approach or program for looking at assessing kids who have feeding difficulties and then of course creating and using a transdisciplinary approach to treat those children. At some point as an individual provider even using SOS you're going to have to call in a colleague.
00:41:24
Speaker
Right. It sounds like a all hands on deck situation. Very much. Very much so. There's a lot you can do as an individual provider, but we all have to rely on our colleagues and we all need to network with our colleagues and
00:41:42
Speaker
have colleagues we can call on when one of those seven areas is too complicated or beyond our training within our discipline and work collaboratively together. We talk about an SOS, you should have a minimum of three people on your feeding team at all times. It should be you, the therapist, the child's primary care physician, and the child's parent.
00:42:10
Speaker
Because if we don't have the parent as a team member, we're not going to be successful. Right. I've read that the steps to eating are a large part of the SOS approach. And I'm wondering if you can talk a little bit about what the steps to eating are.
00:42:26
Speaker
Absolutely, absolutely. So if it's okay, I want to talk just a little bit about some of the tenants about the SOS approach, and I'll kind of wind back to that a little bit. One of the major tenants of the SOS approach is that there are myths about eating that are out there, that if we as adults, as professionals, believe these myths about eating,
00:42:50
Speaker
we are not going to be able to effectively assess and treat children who have feeding difficulties. And one, we talk about there's 10, there's what we call the top 10 myths of eating. One of the top 10 myths about eating is this idea that eating is instinctive, automatic, it happens no matter what, when we know that eating is actually extremely complicated, and it requires all seven of those areas of human function.
00:43:20
Speaker
And another myth that's out there about eating is this idea that when it's time to eat, we simply sit down and eat. That eating is a two-step process. You sit down, you eat. Some people say it's a three-step process. You sit down, you touch your food, and you eat. That's actually not how it happens.
00:43:43
Speaker
For typically developing children, learning to eat new foods is about a 20 to 25 step process. For children who have feeding difficulties, on average, it's a 32 step process to learn how to eat a new food. For children on the autism spectrum, generally we're looking at somewhere between 40 and 60 steps to learn how to eat a new food.
00:44:10
Speaker
because eating actually begins with your sensory systems. All eating begins with your eyes. Eating does not begin at the mouth. It begins with being able to visually tolerate the food in front of you, to be able to visually look at and begin to learn about and understand the food in front of you.
00:44:37
Speaker
We talk about there's six major steps in the process of learning to eat and within the six major steps there are several other smaller steps depending on this child's sensory functioning and depending on their oral motor abilities.
00:44:56
Speaker
And so visually tolerating the food is the first of the major steps. And one of the things that we see is people who are visual learners tend to be picky eaters because they look at a food, decide they don't like the way it looks, and then they refuse to ever try it.
00:45:15
Speaker
The next series of steps have to do with what we call Interacts With. Interacts With steps are about you doing something to the food that changes it, but that you are not directly touching the food. So you may be stirring it, pouring it, cutting it. You may pick it up with a napkin. It may be in a package.
00:45:42
Speaker
By manipulating something like American cheese and its little plastic wrapper, I can figure out what temperature it's going to be. If I squish it, how much pressure is it going to take to break it apart? How's it going to move once it starts breaking it apart?
00:45:59
Speaker
So what I'm doing is I'm bringing on board my proprioceptive systems. I'm bringing on board my vestibular systems. As I change the food, I'm going to be moving around a little bit with the food. I'm bringing on some of my interoceptive systems as well.
00:46:19
Speaker
We talk about the next major series of steps are the smell steps. Now there is overlap across the steps certainly with smell, but for some children who have feeding difficulties we actually have to work
00:46:35
Speaker
in feeding therapy with them initially with foods that have no smell to them until they master the visual and interact with steps before we can start introducing foods that have smell to them. And so smell steps are kind of the next ones that come on board. Then the touch steps come on board and
00:46:59
Speaker
The feel of food and playing in the food, actually touching it, manipulating it with your hands, is teaching your body the physics of the food. Again, what temperature it is, how heavy it is, how light it is, how much pressure it's going to take to break apart. What kind of shatter pattern might it have?
00:47:20
Speaker
How is it going to move in your mouth? So by manipulating things with your hands, you're literally teaching your body the mechanics of that food in your mouth. Because we have hundreds of thousands of sensory receptors on the surface of our skin. And that's why babies wear their food.
00:47:41
Speaker
Wearing your food is actually part of the process of learning to eat it because you're teaching your body the physics of that food. So once it gets in your mouth,
00:47:51
Speaker
Your body already knows how to begin to manage that food. So touch starts with fingertips. It goes up the body, top of the head, outside of the face, inside of the face, lips, teeth, tongue, and then inside the mouth. So there's a lot of touch steps. Then of course we're bringing in taste steps.
00:48:14
Speaker
once it gets into the mouth, but you actually have taste at the smell steps as well, because smell and taste are chemical sensory systems. And that's why when you go to the movie theater and you think, wow, I can almost taste that popcorn. Actually, you are tasting that popcorn because you have scent receptors in the back of your throat. And so when you get big smells,
00:48:36
Speaker
you're actually getting some taste as well. Like I said, there's some overlap across the steps a little bit, but taste inside the mouth is going to change as you get it further in the mouth because different parts of the tongue have different taste perception and textured table food tastes different as you break it apart.
00:48:59
Speaker
So if you think about eating a saltine cracker, when you first put the cracker in your mouth, all you get is salt, right? But as you chew it, it gets more and more starchy and bready tasting. And that's what happens to lots of foods is they'll change flavor as they change consistency as you chew. And then of course, the last step is the eating, which is really the oral motor swallowing.
00:49:25
Speaker
steps is what we're talking about there. So it's a pretty complicated process in order to be able to eat. And it starts with sensory and moves into oral. So sequential oral sensory is the process that we have to follow.
00:49:44
Speaker
It sounds like in that process too, as clinicians, there's a lot of opportunity to grade that experience based on what the child is able to handle or tolerate.
00:49:56
Speaker
That's actually an excellent, excellent point. And one of our second major tenants in SOS is the idea that systematic desensitization is the best first approach to helping children learn how to eat. Because in systematic desensitization used correctly, the child is always in charge.
00:50:20
Speaker
And a systematic desensitization approach is a responsive feeding approach because your job as the adult is to role model how to work with the food. The child's then it's up to them whether they're going to follow your lead or not.
00:50:40
Speaker
And if the child doesn't follow your lead, you as the adult need to back up and follow the child's lead to figure out where they need to go. So it's very much watching the child following the child's lead.
00:50:57
Speaker
There are a number of people out there who don't understand the correct use of systematic desensitization, and they just push through and try to grade the tasks, but then make the children follow the grading that the adults have set up.
00:51:13
Speaker
That's not how systematic desensitization works. Done correctly when the child is signaling they can't move forward, your job as the adult is to stop what you're doing to back down where the child's at and follow the child's lead. It's all about being responsive to where the child is at.
00:51:35
Speaker
Now, of course, systematic desensitization isn't the only approach to feeding, but we believe it's the best first approach. If it doesn't seem to be working well, there are other approaches that you then can look at potentially.
00:51:52
Speaker
trying and following, but the SOS is very much a systematic desensitization and responsive feeding approach to working with kids who have feeding difficulties. The third major tenet in SOS is, of course, that we follow normal development as best as this child is neurologically capable of doing that.
00:52:13
Speaker
And then in SOS, our fourth major tenet is we use real food as our tools. We teach kids to eat food by using food as our tools. And so we use food in our therapy sessions. And the way that we choose our foods, the foods we exactly choose, how we link the foods together, how we present the foods, how we role model working with the foods, that's how we teach children to advance up the steps to eating.
00:52:43
Speaker
and achieve their oral, motor, and sensory skills. And then the fifth major tenet in SOS is we do that all through play because we know that children's job is to play, that that's what their occupation is. As occupational therapists, you guys know that better than anybody.
00:53:02
Speaker
Children's job is to play and we know that children learn best through play. So we want to use what we call play with a purpose and the purpose is learning. Play with the purpose of learning to help these children be able to overcome whatever feeding difficulties they have.
Training and Resources for SOS Approach
00:53:20
Speaker
It's so fascinating to me because we make up songs to teach kids their letters. We make fun little games to teach them how to count. We put toys in front of them to encourage them to crawl to the toy or to learn to walk to the toy. But somehow when it comes to eating, there is no play, no play, no play involved. It's all about compliance. It's like, what is that all about?
00:53:44
Speaker
What you know what is that all about we know that's not how to learn so we need to be playful we need to be engaging and it's one of the reasons why personally i love working with occupational therapist. Because i don't know that i've ever met an occupational therapist who isn't playful and engaging.
00:54:04
Speaker
It's something that you all do so well. And of course, the whole sensory component of feeding is why an occupational therapist is absolutely a critical member of any feeding team that you're going to participate with. Even if you're not an occupational therapist, you want to find your occupational therapy colleagues because they are such a help and a boon to the treatment that you're going to do
00:54:33
Speaker
And so it's why it's always such a delight to work with SAOT because OT is, they're a major, major important critical part of any feeding team.
00:54:49
Speaker
Can you talk to us a bit about the different types of SOS training that you offer if someone's wanting to get more education in this area? And thank you for that opportunity. So we have four major levels of SOS training.
00:55:05
Speaker
All SOS training starts with attending one of our main training conferences and that can be done other virtually or in person. I am going to put in a plug for in person. It is very fun.
00:55:21
Speaker
to do in person because you get to play with your colleagues and you get to do all sorts of different activities engaging activities with your colleagues and then of course you get a chance to network but but we know that for some people that's very difficult for them to travel so we do have both in-person and virtual conferences that's the main
00:55:46
Speaker
training level and after that conference you would be an SOS trained feeding therapist. For the majority of therapists that's really a comfortable level for them, but there are a number of therapists who have special populations of kids they work with, kids on the severe end of the autism spectrum, kids who have reflux, kids who have tubes, and we have a series of
00:56:12
Speaker
online pre-recorded advanced workshops that people can take after they take the main training conference. And they just take them at their own convenience in their own homes and they range from an hour and a half to four and a half hours depending on what the topic is. And people can get further SOS training by attending one of the advanced workshops. And that's our next level of training.
00:56:36
Speaker
The third level of training is what we call mentorship. It is also online, but it's live online, and it's a course with 12 students, two SOS professors, and you are working with your colleagues and the SOS professors about how do I make the SOS program work really well in my clinical setting, whether that's school, home,
00:57:00
Speaker
inpatient, outpatient, private practice, hospital based, and how do I make sure that I'm using the program correctly? You videotape yourself treating kids and that videotape is shared with your colleagues and you give each other ongoing feedback. So the mentorship is really for those people who want to become
00:57:23
Speaker
more of an expert in providing feeding therapy. Maybe somebody who is doing primarily feeding therapy as part of their practice. Mentorship is a really good step for them. The fourth level of training
00:57:39
Speaker
is SOS certification. And so to become an SOS certified feeding therapist, it is also a 12-week online course that's live, only six students, two professors, and the course is much different. It's really about
00:57:57
Speaker
refining your clinical skills. You also videotape yourself seeing a client twice so we can see clinical progress across the course of the certification. And then there's a test that you have to take for certification.
00:58:15
Speaker
And so the SOS certification is really for people who want to be experts in providing SOS feeding therapy. So people who want to do research on SOS, we ask them to move to the certification level.
00:58:30
Speaker
There are lots of different feeding programs out there. And many therapists actually in treatment use a blend of different approaches. And so an SOS-certified therapist would be someone who uses pure SOS. And that is their approach and their philosophy and the only
00:58:48
Speaker
techniques and strategies that they would use. So it's just that first main training conference that's the really big one. It is four and a half days. The first half day approximately is actually a pre-recorded online piece that you take and then you either do four days in person or four days virtually.
00:59:16
Speaker
Well, Dr. Toomey, thank you so much for sharing your energy and your expertise with us today. I know our listeners will take away a lot of value from the information that you shared, especially the details about just having a shift in thinking about the way that we're approaching these feeding difficulties with clients, and also just all of the information that you shared about the different steps to eating.
00:59:40
Speaker
So we really appreciate it. If our listeners have a question or are interested in connecting with you online, what's the best way for them to reach out? So the best way to reach us is to reach out to us on our website and that's just www.sosapproachtofeeding.com
01:00:00
Speaker
and they can go online. And if they're professionals, they can go to the professional tab and they can search for the various professional resources that we have available. There is also an education tab if they're interested in attending a conference.
01:00:17
Speaker
Families can also come to our website. We have a huge number of resources for families on our website so there is a family tab as well.
Personal Insights and Career Reflections
01:00:27
Speaker
We have a free two and a quarter hour feeding and caregiver workshop that families can take that really can help them get started in
01:00:38
Speaker
understanding why their child maybe isn't eating very well and what are some straightforward practical things that they can do to help their child eat better. We also have a whole series of parent caregiver resource libraries
01:00:55
Speaker
that are e-books that parents can choose to purchase and read through to help, especially if their child's more in that picky eater and problem feeder range. And so coming to the website is really the best place to access a whole variety of resources.
01:01:16
Speaker
We do have a few fun rapid fire question to end things off with you. It seems only appropriate to ask you about this since we've talked so much about feeding today. What is your favorite food? Oh, I am definitely a grease and salt person.
01:01:36
Speaker
My most favorite food on the planet is potatoes. And unfortunately, in SOS, we don't count them as vegetables. We count them as starches. Although I guess you could potentially make them with enough other things to make them into a vegetable, but that's definitely where I'm at. Give me a potato, I'm happy. And what is your least favorite food?
01:02:04
Speaker
You know, I actually struggle with things that are really bitter. One of my colleagues thinks I have the supertaster gene because I'm always complaining about how things are bitter and she doesn't agree. And so one of my least favorite foods on the planet is arugula.
01:02:23
Speaker
because they don't like how bitter it is. But there's a lot of other really good leafy green vegetables. That's right. At least you're not limited to arugula. If you could have any other job, what would it be?
01:02:38
Speaker
Wow, that one I don't have an easy answer for because I love what I do. I really love the teaching that I do. I think at one point early on in my life, I thought I was going to be a marine biologist because I also love to swim. I would probably say that that would be the other job that I would have gone down
01:03:02
Speaker
If I hadn't gone down the psychology route is to something that let me play all day on the beach and in the water, that would be a perfect job. Well, your love for this area really does come through speaking with you about it. So we really appreciate you sharing your passion with us today. Thank you so much for your time. Oh, thank you so much for this opportunity.