Supportive Treatment of Eating in Preschoolers (STEPS)

The Supportive Treatment of Eating in Preschoolers (STEPS) isa small group program for children ages 2 to 5 with feeding disorders and their parents in TX started by Jenny McGlothlin MS, CCC-SLP, CLC where supervised graduate students learn and facilitate intervention.  When I heard about STEPS, I was intrigued. As a feeding therapist we are always trying to serve children and their families in the most efficient way possible as well as train students. I asked Jenny to tell us more about her program.

From Jenny:

I developed STEPS in 2005 when I joined the team here at the Callier Center after working in an outpatient hospital clinic for 3 years because I saw a gap in what was offered for children with feeding disorders. After working within a model where the parents waited in the lobby during therapy, I particularly wanted to create a program focused on parent training, sensorimotor skill development, and graduate student training. The UT Dallas SLP program typically has as many as 225 graduate students at any given time with semester enrollment- we have more full-time students than any other SLP program in the U.S. We have a large university clinic with 11 SLPs (and also house an audiology clinic). https://bbs.utdallas.edu/departments/speech-language-and-hearing/graduate-programs/speech-language-pathology-ms/

STEPS provides a small-group intervention program for preschoolers ages 2 – 5 years with moderate to severe motor-based feeding disorders and accompanying sensory-motor issues. All of the children have motor-based delays, and about half them are tube-fed. Some of them are struggling with transitioning to eating age-appropriate foods and some don’t eat by mouth at all, and the individual child’s goals and therapeutic activities are tailored to their needs.

The program is designed to facilitate improved sensory and oral motor skills for feeding while providing hands-on training and education for parents. Mealtime strategies to support autonomy and engagement, stability and function during feeding, and increased family enjoyment are taught. The parents are also taught about typical development of feeding skills, why anxiety impacts eating, how to build skills for trying new food, and how to transition to different textures. The group is led by a licensed speech-language pathologist (me) and the graduate students are paired 1:1 or 2:1 with the child and their caregiver(s). I typically have 4 families and 6 graduate students every semester. Each family (child + caregiver or caregivers) sits at their own square table in a large group room with their clinician to emulate a family meal situation and I have more supportive Rifton chairs if a child needs them. The children often watch their peers in the room and engage around food; we are flexible and allow this to happen organically and then build opportunities for children to pair up if it would be beneficial. If children are around the same age and working on similar goals, we may group them together for activities. Since it

was published in 2015, every family gets a copy of my book, Helping Your Child with Extreme Picky Eating, to supplement their learning. https://www.extremepickyeating.com/about-the-book-2/

How do children get into your STEPS program? Do they need a feeding evaluation first to make sure they are ready? Is medical and nutritional management done prior to coming to the program? How old are the children?

  https://amzn.to/3Que7O1 (amazon link)

Yes! I personally evaluate all children whose parents are interested in the program and can recommend the program for children who have been referred and whom I evaluate who are a good fit. If a child has not consulted with a GI and/or dietitian (or other specialist) and that is indicated, I make a referral at the evaluation. I have a solid virtual team of GIs and dietitians with whom I work closely. I believe very strongly that there is always a reason (or many!) that children don’t eat or don’t eat well, and I do my best to figure it out with my team of providers. I get a lot of referrals from GI docs and pediatricians that I’ve worked with over the years. I also get referrals from SLPs and OTs in the community who have either been through my program (SLP grads) or just know about it due to the longevity of it and our mutual referrals over the years. For children that either aren’t ready for my program or who don’t have any oral motor delays, we offer another more sensory focused, play-based program called Food & Fun or I enroll them in individual therapy. I often have individual patients who get to the appropriate age and are still needing to work on motor skills, so I enroll them in the program. The parents benefit so much from the focused parent education time that is difficult to manage in an individual therapy session.

Is the program a certain length so it is paired with a the SLP students practicum?  How many children do you take in the program and is every child paired with a grad student? 

The program is 12 sessions (12 weeks in the fall/spring semester and 6 weeks with twice weekly sessions in the summer) plus a parent conference at the end. I accept 4, occasionally 5 families and every child is paired with at least one graduate student (sometimes 2). I do a 4 hour orientation with the grad students prior to the first session and they are assigned their patient that day and are provided with all of the pertinent information for the case.

What is the structure of the preschool- group activities? Individual activities?

The program sessions are 1.5 hours, divided into three 30-minute segments:

• Sensorimotor work
• Parent education/gross motor play for children (either playground or sensory gym with the graduate students)
• Mealtime workshop.

First 30 minutes:

During the first 6 sessions, the whole group watches videos on a Large screen tv of animals eating to engage the children and then watches videos of sensorimotor activities (Beckman and others) and then the caregivers and clinician practice them- with each other if the child isn’t ready to be touched by them and later the child can participate by doing it themselves (many of my older hypersensitive kids do well with this!) or with their caregiver or clinician. The caregivers also get handouts with visuals and descriptions that they take home, and videos are sent to them so they can practice. By having the caregivers learn how these types of movements feel in their own mouth first and modeling them, the child “rehearses” and becomes familiar with the activity. Our goal is to give the children as much bodily autonomy as possible, so we let the child determine when they are ready to participate. They are allowed to sit on their parent’s lap or in the small, supportive chairs we have; we want them to feel safe and comfortable at all times.

During the final 6 sessions, each child works on their own individual sensorimotor activities pulled from the ones everyone learned. We are very flexible in how we go about sensorimotor work- we use mirrors to facilitate engagement and allow the child to learn about their own mouth, and don’t touch them without their permission.

Second 30 minutes: The children play outside or in the gym with the graduate students, with particular attention paid to increasing trunk stability through activities recommended by a physical therapist that has consulted with my program. The parents go with me to a large conference room where either I or one of the grad students gives an interactive presentation on a topic (I have a syllabus that I follow). During most of these sessions, parents are engaged in experiential activities to assist in learning.

Third 30 minutes: We all come back together for mealtime. The caregivers bring food from home because I want to increase the child’s ability to eat family foods. We also keep a large stock of therapy foods and the grad students prep ahead of time to introduce the child to novel foods to stretch their motor skills and increase familiarity with new foods. We are narrating oral motor skills the child is using for the parents to increase understanding of their skill level, demonstrating techniques for improved feeding skills, and modeling language for parents. We often have to work to undo some negative feeding relationships between the caregiver and child.

Is it billed as feeding therapy?

Yes, it is billed as individual feeding therapy 92526, as each child is paired 1:1 and I am in the room at all times supervising.

What is the philosophy of the treatment strategies?

I use a responsive feeding approach as described here:

One of my biggest goals for the program is parent confidence and perceived competence around feeding their child and assisting the families to build more positive relationships around food, so the program is as much for the parents as it is for the children. When we can change the parents’ behaviors, we see a lot of progress in the child. They also get to share during our group parent education sessions and the parents learn from each other and don’t feel so isolated. I get positive feedback about this aspect of the program quite often.

With the grad students – do you meet ahead of time to talk about each session or do you have a plan they follow?

Yes. They plan and put together their individual activities/food for thirty minutes when they arrive and then we meet as a group for thirty minutes where each clinician discusses their therapy session from the week before and we brainstorm and I give them suggestions for moving forward. This way all the students can hear about all the children and get ideas from each other. They write up their treatment notes each session and I edit them and give feedback. They also write up an Activity Plan each week to consolidate their thoughts about the session and plan for what they can do differently. I also take videos periodically of their sessions and post them in a folder where they can view and fill out a video review form that I put together so they can learn from their own sessions.

Do you incorporate tooth brushing or cooking activities?

Yes, we work on toothbrushing as needed (and definitely talk about it with all the families to make sure there is no traumatic brushing going on!) and we often do small cooking activities with children who can participate. We have a microwave, toaster oven, toaster, fridge, and sink in the room and have access to an oven if the students wanted to use it. My grad students get very creative and come up with some wonderfully fun ideas for therapy.

Jenny mentioned that she uses the Pedi-EAT and other Feeding Flock tools in evaluations and for pre/post assessment in STEPS. www.feedingflockteam.org

Please reach to Jenny with any question: jmcglothlin@utdallas.edu

A Conversation with Jenny McGlothlin MS, CCC-SLP, CLC

Read more here:  https://calliercenter.utdallas.edu/stories-to-inspire/a-conversation-with-jenny-mcglothlin/

Bernadette’s Story – Supportive Treatment of Eating in Preschoolers (STEPS)