Are you a pediatric speech or occupational therapist looking for some feeding therapy ideas? Or, maybe you are a play therapist, counselor, dietician, or another professional working with a picky eater and you want to learn more about picky eating and how to help them. You have come to the right place!
My name is Chelsea and I have been a pediatric speech-language pathologist since 2015. I have worked with a lot of children and their families with a variety of feeding disorders. I see how many struggles families go through when they have children who are picky eaters. I am here to share my knowledge and skills that have been developed from years of practice and numerous trainings. However, I definitely do not claim to have all the answers, so I welcome discussion in the comments section below!
Picky Eating Overview
I am going to assume that you have found this post because you are somewhat familiar with picky eating, so I will keep the background information short. You can read the full details about why children are picky in Big Kids, Small Menus: Learn Why Your Child May Be a Picky Eater as well as learn some basics that I share with families in Big Kids, Small Menus: How to Help Your Picky Eater at Home.
According to Kay Toomey, a pediatric psychologist and feeding expert, there are 8 characteristics of picky eating:
- Strong preferences
- Limited variety
- A restricted number of foods they will eat
- Avoiding new foods
- Refusing the “right” foods or the “right” amounts
- Getting more upset than peers
- Requiring a special meal by their parents
- May eat differently in different contexts
Why Are Kids Picky
There are a number of reasons why children become picky eaters. Many are not preventable, however, there are a number of things you can do from the very beginning to support a child’s eating. But, below are a few possible reasons your client may be picky. This is not an exhaustive list, but it will give you an idea.
- Developmental: Changes in cognitive development, growth spurts, and caloric needs
- Sensory Challenges
- Oral Motor Difficulties
- Medical Needs: Feeding tubes, prolonged NICU or other hospital stays, gastrointestinal issues, and many more
Prevention
If you are working with families and young children, it is important to educate about picky eating prevention as much as possible. While many children may have underlying challenges that lead to picky eating, there are numerous ways we can support eating skills from the very beginning.
They may still end up picky. But why not provide the family with the tools to reduce the negative outcomes as much as possible? Plus, many of the things I recommend as prevention tools are also the things that I start with when I begin feeding therapy with a family.
What does this look like?
- Support successful infant feeding (e.g. breast or bottle feeding). If there is an issue with either of these aspects of feeding, encourage families to seek guidance from a lactation specialist or other infant feeding specialist. So often babies who struggle with some aspect of feeding early on are back on my caseload because of difficulty with solids and/or become picky eaters.
- Transition to solid foods. It is important that we are helping parents and caregivers understand the importance of how a child starts solid foods, because this is their first exposure to “real food”. Their early experiences will shape their later relationships with food. Do you work with a lot of infants? Check out my ebook for all the details. This would be a great resource for therapists (and other professionals) as well as parents.
- Educate on the importance of eating together as a family (at the table with children in a proper high chair), allowing children to feed themselves, and targeting as much real food as possible.
- Educate other professionals. It is our job to share this knowledge. When I worked in a hospital setting I quickly learned that most of the pediatricians, therapists, and dieticians were still providing outdated information to families. I also felt really overwhelmed with how I was going to tackle educating everyone. But, I took it one step at a time and worked on solid educational materials (with good evidence) to provide them. I took time to meet with each individual or group and shared this information. I also learned that I needed to educate them often because hearing it from me once wasn’t enough. After some persistence, I got our pediatricians on board! They were handing out a parent flyer I made at each 4 month well check that provided an overview of how to start solid foods. When I look back on this flyer it was definitely not perfect, but it was quick and easy to read and provided the basics. And, the information was getting out to the people who needed to hear it, so that was a win for me. Our department also put together quarterly trainings for our therapy team, so I volunteered for one of these to educate on feeding as well. Do what you can with what you have. And if you don’t have time, share this website and our blog posts with your colleagues to lessen your load 😉
Where to Start
Obviously, like you have been told a million times over … you must start with an evaluation to determine the needs of the child and family you will be working with. From there, you can sort out all of the aspects of their picky eating, make recommendations for your therapy and other professionals, and create your treatment plan.
Feeding Evaluation
Here are some of the things I might include in an evaluation. I determine what is included based on how the child is responding to me and what further information I need to gather after a case history interview (and intake forms).
Oftentimes, this is not all completed at the initial evaluation and may be part of dynamic assessment as we enter the first few therapy sessions.
Additionally, when I say “forms” I may have families complete an actual form or I may write down my own notes on the form or my own piece of paper. I am generally a blank paper evaluator (but I know that is not everyone’s style).
Food Repertoire Form(s)
This is where parents or caregivers provide a list of foods that their child does and does not eat. I also like to include a section for “what does the family eat” to understand the type of diet that is in the home, what foods the family would like to see their child eat, and understand any cultural food habits.
Eating Schedule Form(s)
This will be a list of meals, snacks, and liquids with the timeframe of each that the child usually has on most days of the week. I also usually include a section about who else is eating with the child during these meals and snacks.
Feeding Observation (also known as a “Bedside Swallow Evaluation” or a “Clinical Evaluation of Swallowing”)
All portions of the feeding assessment are important, but I would say this is *almost always* the most important. I usually ask parents to bring a few preferred and non-preferred foods, because I want to see the child eat exactly how they would with exactly what they would if I were not there. When I worked in a clinic setting, the child was outside of their normal environment, so I wanted to recreate their meal as much as possible. With my current practice, I am in their home, so it works beautifully for naturalness, but I am still an unfamiliar person, so that can still affect them.
Oral Motor Evaluation
I love oral motor and myofunctional skill assessments. But, many kids are averse to an unfamiliar person touching their mouths. So, I often resort to a basic “silly faces” in the mirror strategy during the first session, while observing their rest posture and movements during eating tasks. Then, I begin to work my way into their mouths with graded stimulation with progressive sessions.
What does graded stimulation look like? Depends on how sensitive the child is, but overall, I try to show them the oral tool I am going to use and let them explore it (if needed). I also allow them to engage with my gloves (if needed). I use a mirror and sit behind them so they can see me. I start with singing a familiar song and touch their hands, arms, shoulders, cheeks, lips, inside their mouths, and complete the exercise(s). I only touch them while singing and then make a big deal about me stopping once the singing stops. After a few times of this, they start to associate my singing with the touching and when I stop singing I stop touching. That way, I have built trust and predictability. I never continue touching past my singing, but I have been known to add a verse or change tempo just a bit to increase the time and their tolerance.
You will find more in-depth info on this, and much more in my upcoming oral motor series, so be sure to subscribe to our newsletter so you don’t miss out 🙂
Instrumental Assessment
This may be necessary to further assess the parts of eating that we cannot directly observe. FEES: A flexible endoscopic evaluation of swallowing and Videofluoroscopic Swallow Study (VFSS) or Modified Barium Swallow Study (MBSS) are often used. These are often done in hospitals or other medical clinics, however, I have also heard of mobile FEES studies!
If you are not the one doing these studies, make sure you find some local places that you can refer people to and collaborate with the professional(s) doing them. I always ask for a copy of the reports as well as an email or phone call with the professional who completed them.
When I worked in the hospital, and I was the one doing them, I worked closely with families to prepare for the studies, and for some kids we even visited the radiology room before the study. I reviewed the results, in detail, with families, and often let them view it along with me to get the best understanding of what was happening.
If I was completing it for an outpatient, I tried to collaborate before and after with the referring SLP and I always reviewed the results with the referring physician’s office. This is a lot of work. But it is necessary to take these steps to ensure the whole team understands what is going on with the child.
Response to Therapeutic Interventions
At any point during the evaluation, I may try some different strategies and see how the child responds.
A few examples, not an exhaustive list, are provided below:
- Stabilize a child’s feet in their chair.
- Offer a dip for a non-preferred food.
- Provide a “no thank you” plate for the child to remove their food.
- Use food games, such as peek-a-book or sneezing food from my head.
- And many more.
For parents who may feel hesitant or unsure about evaluations, you can direct them to our evaluation posts to help them answer basic questions.
What to Expect at a Speech Therapy Evaluation
Feeding and Swallowing Evaluation
WHs of Speech Therapy: Who, What, When, Where, and Why
Parent Roles in Speech Therapy
Putting It All Together
Once the evaluation is completed, it is time to interpret the results and make recommendations and a treatment plan. This is probably my favorite part of the whole process … it is like a puzzle.
The first step, which is often completed during the initial evaluation, is to determine what the family wants. This includes understanding their goals and pain points.
Yes, we are the professionals who have a lot of education, experiences, and skills that we feel the child and family should work on. But, it is most important to make the families preferences and our recommendations mesh together into a cohesive plan.
The next step is to review all of the gathered information and make a diagnosis(es), additional recommendations, therapy frequency, and set some goals.
Diagnoses
It is important to provide a specific diagnosis and/or diagnoses. Some common ones that I refer back to include:
- Pediatric Feeding Disorder (acute or chronic)
- Dysphagia, oral phase
- Oropharyngeal Dysphagia
- General Selective Eating
Recommendations
If I am the first person a child with picky eating is seeing, it is fairly uncommon for me to remain the only person they will see. I am usually recommending one or more of the additional services listed below. However, similarly to my point above, I also try to meet people where they are and if adding more services to their plate at a particular time does not work well for them, we can always revisit these recommendations.
- Occupational Therapy: to address sensory challenges, feeding skills, and/or motor deficits
- Physical Therapy: to address motor challenges, positioning, and/or stability
- Dietician/Nutritionist: to address their nutritional needs
- Counseling and/or Play Therapists: to work through anxiety, behavior challenges, or other associated difficulties
- Psychologists, Psychiatrists, Developmental Pediatricians: to rule in/out further diagnoses, such as avoidance restrictive food intake disorder (ARFID), Autism Spectrum Disorder (ASD), and more
Therapy Frequency
This is such a debatable topic in the therapy world. Many argue that frequent therapy is best, while others believe that bursts of therapy work well, and yet others space therapy out to monthly or even less frequent sessions.
I would say I see value in all of these depending on the needs of the child and family, the scheduling availability of both the family and the therapist, insurance and payment, and many more factors.
Some examples of frequencies I recommend:
For younger children, I tend to lean toward more frequent sessions, such as weekly or even 2x/week.
For older children, I tend to try and space sessions out to 1-2x/month to promote more of a coaching model and encourage carryover into the home.
For children who are “phasing out” of therapy, we may taper to 1x/month and then to 1x/quarter and then maybe a follow-up phone call or consultation.
Goals and Treatment Plan
Ahh goals… the bane of every therapist’s existence.
When I am setting goals for picky eating, I generally try to set at least a few goals that were specifically provided by the family. Then, I set a few more goals based on the therapy approach(es) I will be using with them in sessions.
So, let’s discuss some of the common therapy strategies and I will include some sample goals I would use for each. Please note, I do not consider goal writing my greatest strength. AND I now work in a private practice setting, where I do not bill insurance, so my goal writing skills have become quite lax as compared to my hospital days.
Therapy Strategies
Obviously there are a number of different ways we can go about addressing picky eating. I typically combine a few different approaches for each child. This is a list of the common approaches I might use, but it is not an exhaustive list, nor do I use each strategy for each child.
Expose Explore Expand (EEE)
Melanie Potock has so many wonderful resources on her website! This idea is one of my favorite methods.
- Expose the child to a new food.
- Explore the new food together.
- Expand the new food into their repertoire and/or expand their exploration to more foods.
What this might look like in a therapy session…
Introduce the new food- this may be a “target food” for the week or a variation of an already preferred food. Talk about the food using neutral food language – describe its shape, color, food group, etc. Or, you can describe how it is similar or different from a preferred food.
If the child is very averse to this food, you can even start with non-food tasks, such as interacting with a play food item, reading about the food in a book, or playing themed games with the food.
After this initial exposure to the food, we start to explore the food. Maybe we cut it open and explore the inside of it, play a food game with it (rolling and smashing, peek a boo, or sneezing it off our nose), or pair it with a preferred food to try a bite.
Once we have targeted the food for one (or more) session(s), I assign the food as “homework” and provide ways to expand this food. This may include working with the child (and family) to determine different ways they could present the target food to encourage more exposure, in hopes of increased chances of them trying it, and finding a way that they “like” it.
Additionally, we work together to determine ways that we can use this food to expand to other foods. For instance, if the target food was a sausage link, we may later use the sausage link to expand to more “stick foods” or other meats.
I will likely use this, in some form, with every child I work with. Some goals I may use:
- Child will explore at least 5 new foods during therapy sessions in 1 report period.
- Child will expand their food repertoire by adding 3 new foods in 1 report period.
- Child will interact with at least 3 different foods within 1 therapy session, across multiple therapy sessions, in 1 report period.
Food Chaining
Food chaining is when we move between multiple foods, some preferred and some new, but each subsequent food has at least one similarity to the previously targeted food.
I often use this and Expose Explore Expand together because they complement each other well.
We can start with a preferred food and use it to expose the child to new foods, while allowing them to play and explore the new foods, and expand to additional foods.
It is important to note that progress is anything forward, so even if they do not eat the target foods right away, that is ok! If they are willingly interacting with the foods, that is progress. When this is the case, I often repeat the same food chains multiple times to see how a child will improve across multiple trials.
Example food chains:
These are a few of the food chains taken directly from our Feeding Therapy Packs available on our Teachers Pay Teachers Store! We have a pack for a variety of single target foods, such as blueberries or strawberries. They are mostly print & go with some additional ideas to use in your therapy sessions. These are designed for busy therapists who don’t have time to prep all the things, but want to provide high-quality therapy activities when targeting specific foods.
Start with preferred food Chocolate pudding + red sprinkles then move to the next food with a similar color and texture crushed freeze dried strawberries then to the next food with a similar color but different texture tiny pieces of strawberries sprinkled on top
Start with preferred food Potato chip then move to the next food with a similar texture Freeze dried blueberry “chip” then to the next food with a similar color but different texture blueberry
Start with preferred food Cheese puff ball then move to the next food with a similar shape Meatball then move to the next food with a similar shape Blueberry
Some goals I may write that align with this strategy:
- Child will increase interaction with at least 3 different foods, evidenced by less averse response, increased time of interaction, and/or progression toward the mouth, across multiple therapy sessions.
- Child will add at least 1 variation of at least 1 new food into their diet over a 6 month period.
Neutral Food Language
I talk a lot about this in Big Kids, Small Menus: How to Help Your Picky Eater at Home. It is important that we use and we teach the families we work with to use neutral food language.
Food is food. It all serves a purpose – nourishment, social, cultural, taste, and more!
Yes, we want to aim for a nutritious diet because we know that is how we keep our bodies healthy. But, we also keep our bodies healthy by enjoying various tastes and textures. We enjoy eating socially with friends and family. We participate in cultural traditions at birthdays or other celebrations. And it all has its place.
This is one of the earliest things I teach in therapy – “don’t yuck my yum”.
Instead of using polarizing words or negative food language, I teach children and families to view food as food instead of “healthy” or “junk”.
I teach children to describe food rather than say they like/dislike it or instead of saying it is gross. Is it squishy, sour, or sweet? Is it crunchy, salty, or juicy?
I allow children to rate the food (sometimes) but this one depends on the kid.
I use social stories or Youtube videos to help children learn about the foods or see others eating new foods. Melanie Potock has a great social story template.
Some goals that may align with this strategy:
- Child will engage in social stories to learn about new foods, with 75% participation.
- Child will describe food characteristics at least 50% of the time, with cues as needed.
- Child will refrain from negative food language for a 30 minute session, across multiple therapy sessions, with cues as needed.
Affirmations
Similarly to neutral food language, with some kids (especially older kids), I use positive affirmations about food.
I usually have a few written out and if a kid negatively describes a food, I point to an appropriate affirmation to help them learn how to shape their negative language into neutral language.
I often use a balloon analogy with them … each time you say/think something negative about a food, you put more air into the balloon. The bigger it gets, the more likely it is to pop. Do we want a balloon to pop in our face? NO. So, each time they say something negative they put air in, but when they replace it with an affirmation, they let a little air out (plus a silly noise to make it fun). You can even use a real balloon if that helps!
A few examples of affirmations:
- “I am learning about ___”
- “I can try ___”
- “I am giving my brain a chance to think about ___”
Some goals that align with this strategy:
- Child will use positive affirmations about food, with 75% attempts, with cues as needed.
Visuals
I don’t know many therapists who don’t love a good visual support!
Depending on the kid I am working with and their needs, I may use a variety of visuals to support our sessions. Some examples:
- Visual timer for transitioning to or from the table
- First/Then for transitioning between foods
- Pictures of foods
- Food groups
- Food rating form
- Mats or pictures to decorate with foods
- Food interaction progression (see, touch, smell, lick, taste)
- Food games
- Social stories or affirmations
Some goals that align with this strategy:
- Child will stay at the table for at least 10 minutes during food presentation, with visual supports.
Food Games/Crafts
Another very common strategy I use in therapy is food play. Children learn through *play* and it is important to make food fun.
This pairs well with EEE and Food Chaining and I often use all 3 together in therapy sessions.
Games I often play:
Peek-A-Boo: Hide the food under different things and find it. Once they are fairly comfortable with the new food, hide it in your mouth and show/spit it out. Then use your teeth… oops I bit it!
Rolling Games: I play “roll roll roll the blueberry back and forth it goes, roll roll roll the blueberry back and forth it goes” to the tune of Row Row Row Your Boat while rolling it back and forth.
I roll the foods to different spots on the table (to the napkin, to the plate, to my tongue)
When it is time to clean up, roll the food off the table into the trash can.
Sneeze Game: Take turns sneezing the food from your head, nose, lips.
Smashing Game: I play a food Whack-A-Mole game where we smash different foods. Then, I use different things to smash the food, including my teeth.
Crafts:
I love to make silly faces, paint in pudding (or yogurt or applesauce), build bugs or sea creatures, and/or use foods and dips as paintbrushes.
The food craft ideas are endless and are readily available online.
Final Thoughts
While these are not all the strategies I would use in therapy, they are the main ones. My goal here was to paint a picture of what feeding therapy might look like for picky eaters. I hope this was helpful, and I would love to continue the conversation to learn what others are doing in feeding therapy! Feel free to leave a comment below!
References:
Expose Explore Expand. Melanie Potock. Obtained from: https://mymunchbug.com/2017/07/track-food-exposures/
Food Chaining: The Proven 6 step solution to stop picky eating, solve feeding problems, and expand your child’s diet (2007). Cheri Fraker, Dr. Mark Fishbein, Sibyl Cox and Laura Walbert, CCC/SLP, CLC
Romeo, C. (2023). Just a Phase or Cause for Greater Concern. Citing Kay Toomey’s Presentation with Feeding Matters. Obtained from: https://www.feedingmatters.org/picky-eating-just-a-phase-or-cause-for-greater-concern/
Cover image and Pinterest images are not originals to Three Roads Therapy LLC. Obtained from Canva: Emma Rahmani form corelens; Yan Krukau from Pexels; Karola G from Pexels; Jonathan Borba from Pexels; danielgonzalezphotographer; Tetiana Nekrasova from capturenow
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