In this week’s episode, Jennifer is joined by Brianna Brown, a speech therapist and member of the Thrive Tube Weaning Team. Brianna works in the Spectrum Pediatrics clinic in Alexandria, VA, working in Early Intervention, as well as working with families in our tube weaning program. Brianna and Jennifer will dive into the topic of structure around mealtimes, and how you can use structure without added stress. This episode reviews how to help kids that need more structure or support through the tube weaning process in a way that doesn’t interfere with responsive feeding. The internal drives for eating have been discussed in previous episodes, but what should you do when a child has a hard time being able to tune in to these abstract feelings? Structure can look different for every child, but it is important to continue to use a child-directed, responsive feeding approach when building in these strategies to your child’s mealtimes. Jennifer and Brianna discuss all of the different options for building in structure, including visual schedules, first/then boards, choices, and social stories. This episode reviews all of these strategies in more detail and discuss how to implement these strategies in a way that will allow your child to feel safe and build a positive relationship with food. 

You can download this episode from Itunes, Stitcher, Spotify, Google Play, or listen to it below:

Why is structure important? 

We know that children learn to eat for internal drives such as hunger, curiosity, and togetherness. As discussed in last week’s episode, there are some therapies that focus on more traditional approaches to therapy and tend to be more externally driven. Many parents ask, what happens if a child is having a hard time tuning in to those internal drives? These feelings can be more subtle and abstract, which is difficult for some children. Adding structure to mealtimes can help reduce anxiety around food, build an understanding of what mealtimes look like, and provide more support for a child who is having a difficult time recognizing these internal drives. 

What does structure look like? 

Just because you are adding structure, does not mean that a mealtime is no longer child-directed or responsive. Structure can also look different for every child, depending on the needs of that child. In general, visuals are a really helpful way for a child to learn a variety of skills. Visuals can also be used to help a child learn skills like self-regulation or how to understand more abstract feelings of hunger. So what types of visual supports are out there? 
 

Visual Schedules: 

Schedules help to prepare a child so they understand what is coming next and help with feelings of being overwhelmed or anxiety around a situation. These schedules can be around the entire day, or a specific part of their day. When working with a child, we often recommend introducing the schedule in a general way, then applying it to wherever they are with mealtimes. 

• For example, you may start with a daily schedule for a child like “Wake up, play, eat, nap” 
• Then, when it transitions to mealtimes, if mealtimes are new, you can start with “Sit, Talk, Clean up” 
• It is important to adjust these visuals to wherever a child is developmentally, some may need a picture, and others may just need a written schedule.  

First, Then Board 

A concept in language learning that we often use in tube weaning is a “first, then” board. In speech therapy this is used to work on sequencing and building the concept of “I have to do one thing before I can do the next”. It is important that this is not confused with offering an external reward or bribing a child to eat something. The first, then structure is meant to build a comfortable mealtime by pairing it together with a preferred task.  

• For example, if the first is “lunch” and the then is “playground”, then the child is learning the schedule around mealtime, but also learning that the value of the meal is NOT attached to IF they do something. 
• The reason for eating is still internal, but there is an overall positive association built with mealtimes. 
• The child must also understand that if they eat, or if they don’t eat anything, they still get to go to the playground.  

Choices 

Often when a child has been in a refusal pattern, offering choices can be another helpful tool to give them more independence and feel more comfortable. Providing choices helps a child have control over the situation and the visual support can take away some of the challenge for a child. For some children, having to ask for a food or make a choice can cause a large amount of anxiety. There are multiple mobile applications that can provide visual choices. Choices can also be awesome in the pre-eating phase to help give exposure to food choices and what foods look like, while allowing a child to feel safe. Like the visual schedule, some children may respond better when choices are built into other areas of their day before they are introduced to mealtimes. When they are ready for a mealtime, then this idea is already familiar, and they understand the language.  

Timers 

Visual timers are also another great strategy to use for some children during mealtimes. There are very child-friendly, visual timers that are on the phone to make it easy to build into mealtimes. For some children, timers can be very helpful, but for others it may feel a lot like pressure, so it is crucial to respond depending on where your child is. The timer gives a visual to provide a meaning behind time limits such as “a few more minutes”. Time is a tough concept for children to understand and providing a timer may help children feel safer and help adults hold ourselves accountable. When the timer goes off, the adult understands that the mealtime is done. 

Social Stories: 

Social stories help to teach a social rule for a child by placing them into a story and letting them know what their role is in that certain social situation. Mealtimes are naturally a very social experience, therefore there are many ways to build in a social story to your mealtime routine. These stories are usually embedded into a story book format where there are several pages that will focus on one main lesson. These stories are often used in our tube weaning and intensive feeding programs to provide a background to what a mealtime looks like socially and focus on other parts of the mealtime other than just what the child is eating. Children really love learning about themselves and we know that children often do better with a map of knowing what is coming next to help connect the dots. Social stories help provide that map. For more information on social stories, here is a great resource which shows some examples and teaches you how to make a social story.

Because feeding tubes are so medically based, it is hard for parents sometimes to tune into their parenting instinct and step away from the experts and medical model. While listening to this week’s episode, you may hear some strategies that would work well for your child, and others that would not fit at all. For all of these visual strategies, if it feels like a good fit, go ahead and do it, if not, it’s okay to say no. 

As discussed in last week’s episode, the main guiding question to keep asking yourself when learning about all these various structure strategies is: “Is this support I’m considering going to help my child understand trust food more?” If it is, do it. If not, don’t do it. That applies to these supports too!