“Tell me and I forget. Teach me and I remember. Involve me and I learn.”
As I finish my 16th year as a feeding therapist, I have come to realize that I have learned a few things about learning. Learning is at the crux of what I do every day. Helping parents understand how learning to eat happens and teaching them how to transition success into the home is crucial to the child learning to be a competent eater. I do my best, through involving the child with a feeding disorder in therapy which meets them where they are, to find their Zone of Proximal Development for feeding progress. The zone of proximal development (ZPD) has been defined as:
“the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance, or in collaboration with more capable peers” (Vygotsky, 1978, p. 86).
While we usually talk about ZPD in terms of other types of learning, it is an apt description of what is happening when children eat with their trusted adult caregivers as well as their siblings and peers at school. Parents and more competent peers provide a trustworthy model as well as guidance for how to eat novel foods. Without this scaffolding, children may not have access to a notion of ‘normal eating’, and that is what we are trying to achieve. Wood et al. (1976, p. 90) defines scaffolding as targeting:
‘Those elements of the task that are initially beyond the learner’s capacity, thus permitting him to concentrate upon and complete only those elements that are within his range of competence’.
Consider: the child who struggles to eat a variety of textures due to poor oral motor skills…the child who has high anxiety about eating due to years of vomiting…the child who has been forced or coerced into eating foods they aren’t yet comfortable eating…This is the child who benefits from scaffolding so that they can remain in their ZPD during mealtimes. When we don’t pay attention to their current skill and comfort levels, we can miss opportunities to achieve the ZPD. Wood et al. (1976) named certain processes that aid effective scaffolding. In feeding therapy, and in generalization of therapeutic strategies to the home, I emphasize these ideas to parents. Here is how these processes are born out in therapy:
- Gaining and maintaining the learner’s interest in the task.
If a child is not interested in eating (due to zero hunger because of continuous or scheduled tube feeds providing most, if not all of their caloric needs or because of grazing throughout the day), gaining and maintaining their attention at the table is a struggle, at the very least. Once a child’s oral skills will support adequate eating, a reduction in tube feedings is very effective in creating an internal drive to eat. For oral eaters, facilitating enhanced appetite through provision of finite eating opportunities without grazing in between gives children a chance to eat to fullness rather than just eating enough to curb hunger signals.
- Making the task simple.
When aversion and anxiety around feeding are high, allowing a child to focus on eating only the foods they are competent and comfortable eating for a period of time simplifies the task of eating. Seeing safe foods on the table creates a sense of calm, as they are reassured that there is something they can eat easily. They can begin to eat enough quantity of those foods that match their sensorimotor skill level and don’t require oral motor skills or sensory processing that they perhaps can’t handle. With further skill development, greater variety is possible. Once the child’s anxiety is reduced, the child is free to develop curiosity and to learn about other foods.
- Emphasizing certain aspects that will help with the solution.
By visually and verbally emphasizing specific skills that are required to eat new foods, as well as the sensory characteristics of that food, a child can begin to wrap their mind around what it would be like to actually EAT that food. For instance, I can demonstrate eating a pickle, and then emphasize how, when I bite a pickle, I have to use my big back teeth because it is crunchy (and loud!) and also comment that it is salty (like the child’s favorite chips). This creates a cognitive bridge for the child to cross, familiarizing the food for them without asking them to actually eat it. It is also important for adults in this dynamic to realize that our solution (which likely results in eating) may not match the child’s desired solution (which may only result in engaging with a food in some way).
- Control the child’s level of frustration.
Frustration, anxiety, discomfort- all of these things negatively impact eating. If a child can’t bite into their sandwich and gives up before they even get started, we can facilitate eating by cutting it into manageable strips or squares. If the idea that someone is going to make them eat something is giving them anxiety, we can remove pressure from the feeding situation (which actually makes children eat less, according to research) and allow them to just be a participant in the mealtime rather than the focus. If they don’t enjoy touching food with their hands, we can show them how toothpicks or tongs are a fun and easy way to pick up their food. One of the first things I tell parents is to serve family style. This reduces a child’s frustration (and anxiety) about having foods on their plate that they didn’t really want, and usually leads to increased eating.
- Demonstrate the task.
One of the most important things that I stress to parents is for them to eat with their child. Children need to eat with trusted adults, and the research makes this a clear choice in the development of feeding skills. Adults are their model for competent eating of a wide variety of foods. Feeding children away from adults and providing separate food offerings restricts the learning that could be happening. Just watching their parent eat a new food is often enough to at least spark interest in a child who has been allowed to go at their own pace.
By having parents and caregivers participate in my therapy sessions, I am hoping that they will see themselves as my partner in the feeding process and that, through capitalizing on their expertise on their own unique child, I can guide them to a more successful and responsive feeding interaction.
In a series called The Science of Learning, Alan Lesgold says “Experts, because of their expertise, are able to automate basic tasks, or processing, in order to free up cognitive space to tackle more complex aspects of a problem. They’re also able to see patterns, and organize knowledge, differently than novices.”
Experienced feeding therapists are experts at seeing patterns in a child’s eating habits and preferences and making sense of them, pulling that information together and responding in a way that allows the child to take a step forward. They can see where the child is missing skills and help them bridge the gap between where they are now and where they need to be.
Parents have expertise in their child’s unique personality and temperament. They have a good idea of what their child will enjoy or dislike. The child’s interactions with them over time have cemented these ideas about the child, and even though the child may be gradually changing, the parent may still see them through the previously established lens.
To understand how parents may not be able to fully grasp what we are trying to convey to them during our therapy sessions, we must come to terms with, and replace, their misconceptions (ideas that are complete, but wrong) with new information about their child. In a post about the perils of misconceptions in the learning/teaching process, Julie Booth states “Misconceptions can influence how new knowledge is interpreted, and can result in missed opportunities for learning.”
A child may be changing right before their eyes, gaining new skills in therapy sessions with the therapist, learning how to use their mouth in more efficient and comfortable ways—and the parent may not be able to see it. Their misconception—while completely understandable—that the child is still unable to eat well and can’t be trusted to eat enough is the stumbling block that may stall progress. In contrast to that misconception, children are described as having preconceptions (underdeveloped knowledge or incomplete ideas, which are less ingrained and easier to fix), which we can shape and mold into a self-concept that includes competency with eating.
This may look like this:
Adult: My child doesn’t like to eat.
Child: I don’t know how to eat comfortably, but I’d like to.
Lesgold goes on to say that the child “needs to learn how to stretch their knowledge and the true expert teacher matches the level of scaffolding to the level of expertise of the child in order to help him or her stretch beyond what that child has fully mastered.” There’s that idea of scaffolding again!
My Trust Triangle depicts this balance of scaffolding and partnership. There are three points in the therapy triangle: therapist, child, and caregiver, and all three partners are learning during the therapy session. The therapist is learning the child’s preferences, quirks, and attitudes about food (as well as how the dynamic between child and parent works), the caregiver is learning how to implement strategies and techniques that the therapist is modeling, and the child is learning what is safe, how to use their mouth, and what kinds of things they might try at a later date.
When incorporating the STEPS+ approach into therapy, you can’t separate the child’s reactions to food from the larger feeding context, just as you can’t separate the sensory and motor systems when viewing feeding skills.
The dynamic triangle helps us understand the relational aspect of therapy.
- Child relationship with parent/therapist: child learns what and who to trust when it comes to food, with the child’s challenges filtered through that dynamic
- Parent relationship with therapist: parent learns new way to view their child’s behaviors and how to promote improved skills
A final word about progress: Trusting the child means also trusting them to make slow but steady gains toward the life skill of learning to eat. We wouldn’t expect a child to walk or toilet train faster than they are capable of, and need to remember that for a child with significant negative history around eating, it may take longer than we (or parents) would like. One of our jobs as feeding therapists is to show parents the progress that they may not be able to see. Those small steps add up to big changes!