S H A R O N M . G R E I S , M A C C C / S L P , B R S - S

S T E P H A N I E M . H U N T , M S , O T R / L

Texture Progression: The Effects of Oral Sensory Defensiveness on Oral

Motor Function in ASD

Or

The effects of Autism on a child’s ability to tolerate the sensory properties of food

The effects of neurological, cognitive, sensory, and biobehavioral differences on a child’s ability to advance feeding and oral motor development

The manifestation of ASD symptoms on eating behavior and advancing texture

( Twachtman-Reilly, Amaral, & Zebrowski, Apri, 2008)

At the end of this session the participant will be able to:

Define the nature of feeding disorders in children on the spectrum

Discuss the specific presentation of feeding difficulties that are typically experienced by children on the autism spectrum

Discuss the factors which influence the normal progression of texture

Identify the oral sensory motor patterns and feeding problems of children on the spectrum

Explain intervention strategies to progress food texture acceptance and functional manipulation

International Classification of Functioning, Disability, & Health (ICF)

World Health Organization developed a framework for coding functional status

Benefits for SLP’s and OT’s working with children with feeding and swallowing problems

ICD and ICF codes are complimentary

ICD codes classify health conditions

ICF codes classify descriptions of the impact of health conditions on function

And ICF classifies severity of deviation from normal

(Lefton-Greif & Arvedson, 2007)

Nature of Feeding Disorders in ASD

Neurobiological differences of children on the autism

spectrum

Restricted range of foods

Food refusal behavior

Utensil requirements

Stringent mealtime requirements

Unusual eating behaviors (food cravings & pica)

Typical Atypical

Reflexive suck

Vocal play

Oral exploration

Sensory modulation

Progression of liquid, smooth food, soft solid food and table food

Intact constitutional capabilities

Impaired sensory modulation (sensory seeking, sensory avoidance)

Aversion to oral care and absence of oral exploratory phase

Sensitivity to taste, texture, smell, sight of food

GI disorders (GER)

Factors which Influence Feeding Development

Eating abnormalities may include:

Mechanical eating

Gulping, shoveling, stuffing food

Not chewing

Throwing food

Spitting or vomiting

Avoidance of utensils or food to lips

Excessive fads or refusals

Holding food in the mouth for long periods

(Stroh, Robinson, & Stroh, 1986; Arvedson & Brodsky,2nd edition 2002)

Atypical Oral Sensory Experiences

49% of children with ASD were orally defensive.

67 % of children with ASD were described as picky eaters.

69% had difficulty with texture progression

30% of the parent’s of children with ASD described the impact of sensory processing and mealtimes as negative

17 of 30 children with ASD selectivity for food type or texture

DeMattei, Cuvo and Maurizio (2007), Williams, Dalrymple, and

Neal (2006), Dickie, et al. (2009), Ahern, et al. (2001)

Sensory Food Aversion

A. Refusal to eat certain foods with specific taste, temperature, smell for at least one month.

B. Onset occurs with introduction of a new or different type of food

C. Aversive response and refuses all similar foods

D. Refuses all newE. Dietary deficiencies, oral motor or

speech delay or avoids participationF. No traumatic event to oropharanxG. Not related to GI or food allergies

(Chatoor, 2009)

Hyper-sensitivity Hypo-sensitivity

Oral Tactile

Negative response to specific textures

Aversions to use of feeding tools

Dislikes messiness around mouth

Olfactory and Gustatory

Prefers bland foods

Smells elicit vomiting

Extreme selectivity

Gagging

Food refusal

Oral Tactile and Proprioceptive Pocketing in cheeks or buccal

cavity Swallowing whole pieces Lengthy chewing Choking or vomiting Atypical chewing patterns Poor bolus formation

Olfactory and Gustatory Food holding Prefers crunchy and highly

flavored Disinterested in eating without

enhancement of smell

Oral

Sensorimotor Behaviors

Is it motor or sensory difficulties?

Gagging

Drooling

Tooth grinding

Immature spoon feeding skills

Immature cup drinking skills

Immature biting & chewing skills

Sensory Motor

Sight of food

Smell of food

Taste of food

Delay in chewing development

Premature swallowing

Atypical pattern of bolus transit

Gagging

Sensory Motor

Decreased oral awareness

Open mouth posture/ Low muscle tone

Inattention to the task of eating

Absence of chewing: need for sensory input to tempo-mandibular joint

Drooling and Tooth Grinding

Sensory Motor

Aversion to touch

Avoidance of molar surfaces

Food texture preferences (soft smooth)

Intact ability to initiate the task

Motor planning difficulty

Intact ability/potential to manipulate food/liquid

Immature Feeding Skills

Holistic Approach to Specific Needs of ASD

Eating Sensory

ProcessingOrganic

Learning and Behaviors

Developmental

Skills

Oral

Sensorimotor

Communication

General Guidelines for Holistic Treatment

Gradual and slow changes

Match child’s developmental level

Acknowledge sensory responses and treat respectively

Begin supportive mealtime practices as early as possible

Offer new foods at snack time or during therapy

Create a positive learning and communication environment

(Morris & Klein, 2nd edition, 2000)

Dynamic Assessment Drives the Treatment

Swallowing whole pieces

of food

Modify food texture to chopped

present in smaller pieces

Pocketing food/delayed oral transit

Increase sensory

properties of food

Pacing of bites

Visual and Verbal cues

Refusal to accept

modifications

Reduce the demand

gradual, subtle

changes

Oral Sensory Treatment Strategies

Gustatory

Cooking (gradual introduction to smells)

Learn to label smells as possible flavors

Proprioceptive

Chewing on non-food items

Facial expressions (muscle movement)

Tactile

Firm touch with wiping face

Oral care

Increased positive touch (songs, etc.)

Oral Motor Tools

Oral Sensory Exploration

Utensil choice

Cups

“ E F F E C T I V E I N T E R V E N T I O N F O R S T U D E N T S W I T H A S D I S D E P E N D E N T O N A N

U N D E R S T A N D I N G T H A T T H E B E H A V I O R O F T H E S E I N D I V I D U A L S I S T H E R E S U L T O F A

C O N S T E L L A T I O N O F N E U R O B I O L O G I C A L I M P A I R M E N T S R A T H E R T H A N W I L L F U L A C T S O F N O N C O M P L I A N C E ” . D I R E C T T R A I N I N G I N

T H E U S E O F T H E I N T E R V E N T I O N T E C H N I Q U E S D I S C U S S E D I N T H I S

P R E S E N T A T I O N W I L L H E L P T O F A C I L I T A T E T H E P A R T I C I P A T I O N O F T H E S E C H I L D R E N I N

B O T H T H E A S S E S S M E N T A N D T H E R A P E U T I C P R O C E S S .

T W A C H T M E A N - R E I L L Y E T A L , 2 0 0 9

In Conclusion

References

Ahearn, W.H., Castine, T., Nault, K., and Green, G. (2001). An assessment of food acceptance in children with autism and pervasive development disorder-not otherwise specified. Journal of Autism and Developmental Disorders, 31 (5), 505 -511.

Dickie, V. A., Baranek, G. T. Schultz, B. Watson, L.R., and McComish, C.S. (2009). Parent reports of sensory experiences of preschool children with and without autism: A qualitative study. American Journal of Occupational Therapy, 63, 172-181.

DeMattei, R., Cuvo, A. and Maurizio, S. (2007). Oral assessment of children with an autism spectrum disorder. Journal of Dental Hygiene, 81(3), 1-11.

Ernsberger, L. & Stegen-Hanson, T. (2004). Just Take A Bite. Arlington, Texas: Future Horizons, 83-100.

Fischer, E. & Silverman, A. (2007). Behavioral Conceptualization, Assessment, and Treatment of Pediatric Feeding Disorders. Seminars in Speech and Language, Volume 28, Number 3. 223-231.

Lefton-Greif, M. and Arvedson, J. (2007). Pediatric Feeding and Swallowing Disorders: State of Health, Population Trends, and Application of the International Classification of Functioning, Disability, and Health. Seminars in Speech and Language. Volume 28, Number 3. 161-165.

Linscheid, T. (2006). Behavioral Treatment for Pediatric Feeding Disorders. Behavior Modification, Vol. 3, No. 1. 6-23.

Scheerer, C.R. (1991). Perspectives on an oral motor activity: The use of rubber tubing as a “chewy”. American Journal of Occupational Therapy, 46 (4), 344-352.

Twachtman-Reilly, J., Amaral, S., and Zebrowski, P. (2008). Addressing Feeding Disorders in Children on the Autism Spectrum in School-Based Settings: Physiological and Behavioral Issues. Language, Speech and Hearing Services in Schools. Vol. 39. 261-272

Williams, P. G. and Neal, J. (2000). Eating habits of children with autism. Pediatric Nursing, 26 (3), 259-264.

Thank you!

Questions?

Sharon M. Greis

greis@email.chop.edu

Stephanie M. Hunt

hunts@email.chop.edu