This week, Jake Greenspan returns to discuss the new FOODTIME program. Jake is the co-founder and co-director of The Floortime Center in Bethesda, MD, the son of late, great Dr. Stanley Greenspan who created the Developmental, Individual differences, Relationship-based (DIR) Model and the Greenspan Floortime Approach. FOODTIME is a new evidence-based intensive feeding program for picky and rigid eaters that looks at the sensory, oral motor, and emotional components of eating. It is an individualized treatment plan targeting the specific needs of a child that focuses on helping the child choose to increase their repertoire of food to make mealtime a more positive experience.
FOODTIME: A developmental approach to picky and rigid eating with Jake Greenspan
About three years ago they began creating an approach that they identified a need for, for a variety of children–not just those with autism–at the Floortime Centre who have behavioural, learning, and social difficulties and picky and rigid eating habits or more medically-complex feeding issues. Jake found that there was a gap in what was being provided. Many programs were behavioural, and one of the better ones was non-behavioural: a sensory-based feeding program. His head Speech and Language Pathologist (SLP) and head Occupational Therapist (OT) wanted to learn more about the reasoning behind and ways to support picky and rigid eating profiles.
While it was great in training them in oral sensitivities and underreactivities, and chew and swallow patterns, it skipped over one of the most important experiences of meal time: the emotional experience, including who you’re eating with. The behavioural approaches will often use rewards or tokens for eating which disassociates from the enjoyment of meal time with a family member. The Floortime Center wanted to focus on the emotional component.
Jake’s father, Dr. Greenspan, always believed in sensory integration and that the sensory system is mediated by the emotional system. So they took the oral/motor elements of eating and the sensory components that might be creating aversions and eating difficulties and asked themselves how they could really integrate what they know about the emotional development of a child and the experiences and relationships they have with their caregivers and with the environment.
How FOODTIME works
Next Jake says, they asked how they could use that to re-organize a child’s perception of the eating experience–not just from a physical or sensory perspective, but emotionally. They started seeing really nice results with children at the Center, Jake says. Kids started really enjoying their experience at mealtime with their caregivers. Jake’s team has seen much more drastic changes when the training is consolidated into a shorter time period, as suggested by neuroplasticity research.
They typically offer 24 one-hour sessions over a period of 12 weeks. They can also stretch it out a bit if desired. On average, children are increasing their eating each session by choosing new foods and eating more. We know from brain research that every experience we have wires itself into our brain, Jake says: in our sensory cortex, such as sitting at the table or putting food in our mouth and enjoying the taste or texture of our food, or the ease with which we can chew and swallow our food. Each physical element of eating leads to enjoyment or displeasure. An unenjoyable experience can lead to aversion and anxiety.
“If we can’t create a positive experience around eating for our kids–and part of that is the experience with our caregivers–then we’re not understanding the full experience of our child. We might only improve a chew pattern, and this won’t lead to long-term change.“
Looking at the FULL experience of the child
First we have to work on enjoying the experience of sitting at the table and looking and touching at the food with their hands. Only then can you can begin to scaffold into trying new foods and working on chewing. Jake says it’s about working on their ENJOYMENT of the food before working on their repertoire. This is Floortime where we get shared joy by joining the child, following their lead, and THEN expanding. We let THEM choose the new foods they want to try (from a list) so they’re in control of the experience.
A child is going to feel more out of control the more things are being done to them such as feeding them (i.e., force feeding them or putting them in a more easy environment and using tokens). As soon as they are out of that environment or away from those conditions, they will resort back to what’s emotionally pleasurable and comfortable. This isn’t always pushing themselves to doing new things, unless they associate trying new foods as a positive experience and that’s how we generalize these things, Jake says.
When caregivers create power struggles or control issues, it has a much more negative effect on the child, so it’s so important that these experiences be involved with caregivers rather than just therapists. Parents need to be involved since they are whom the children typically eat with. It’s about fun and the positivity of the experience. It’s about the full experience of the child. First work on the enjoyment of food, then expand the repertoire.
Working with the child
You always have to eat, so this is the area you can really work on Floortime. I suggested to Jake that this might be a good entry point to learn about the DIR model, through this FOODTIME program. Since you really can’t force eating, it forces parents to learn this experience. Jake says that Dr. Greenspan really believed in the three functions that you cannot force: eating, sleeping, and going to the bathroom. If you make these into a rigid experience, there will be long-lasting repercussions that will effect the child’s long-term development.
Jake stresses that we always have to repair the relationship before sitting at the table. Now it becomes a fun place to be. It’s just like with potty training where you have to make the bathroom a fun place. Doing Floortime in bathrooms makes the bathroom a fun place rather than a scary place. It has to be a positive place within a positive, social relationship and a nurturing environment. Directing the child (i.e., commanding the child to do this or that) is not nurturing.
FOODTIME can almost be more of an intervention for the parents than the child. It’s for both. Jake says they are not saying it’s the parents’ fault or that they created any of these issues, but they have to resolve some of the issues from some of the physiological differences that then spawned some of the current eating issues to make parents part of the solution. These are the individual differences: the physiological processes of the child that we need to respect and we might not understand because we haven’t experienced that ourselves. Jake gave us a few examples of this in the podcast.
It’s so important for caregivers to realize that the level of olfactory or visual sensitivity at the sight or smell of food is a reflex, not self-induced and not under the child’s control. It’s a physiological and physical manifestation of their experience. Jake talked about one kid who would gag at the sight of soft food like sauces. What they did was find soft things that he could look at and feel that wouldn’t cause the reaction and slowly work towards expanding from there. A lot of people with a fear of heights have vestibular issues and you can’t just force them to stand up high.
The Nuts and Bolts of FOODTIME
At The Floortime Center, therapists trained in The Greenspan Floortime Approach and The Sequential-Oral-Sensory (S.O.S.) Approach to Feeding gear sessions towards keeping the child engaged and interested while targeting specific feeding goals.
The needs of the mouth are different than other parts of the body. They look at oral tactical sensitivities or chewing patterns and medically complex cases such as kids with feeding tubes and other complicated feeding issues.
Jake says that it’s really about the emotional experience. The goal is to change behaviour but the techniques to address the behaviour are comprehensive and wholistic versus just addressing the symptoms. FOODTIME meets the child where they are developmentally and looks at all aspects of the child, including the people around them and their environment.
Why? Because all of the research on neuroplasticity suggests that a developmental approach creates long-term neurological change versus a behavioural approach that creates only short term change and can actually lead to maladaptive outcomes. To create long-term changes, you have to address the core issues that lead to the symptoms.
Jake says they are hearing anecdotal evidence that there are kids now able to go to restaurants or family gatherings when they couldn’t before. Just like anything in life, we have to give before we can expect, Jake says his father would say. So if we want our child to be more flexible, adaptable, and tolerant, then we have to ourselves be more flexible adaptable and tolerant!
Some families might not be as supportive of play or respecting the child’s full experience, but Jake says every culture wants their child to be happy and well-nurtured, communicative and social. The only difference is how adaptable you are as a caregiver. Good problem-solvers are adaptable and creative. This might mean moving away from the norms of our culture sometime. When you focus on being adaptable and problem-solving, most resistant caregivers come around. Those who don’t do not see the same success with their child because it decreases their child’s adaptability too. Every organism needs adaptability to survive.
Jake says they take all of this into consideration. Some families need to take things more gradually. But if they have a focus on community, family and culture with large extended family dinners, they’ll practice outside of dinner time–maybe at breakfast or lunch–and work on it gradually. FOODTIME is adaptable too, individualizing each program to each individual family.
What about regression when families settle and then go back to old ways where the child doesn’t find eating fun anymore? You can see this during times of increased stress and challenge during transitions, or at particular times of the years. Sometimes as the child is trying to regain control, you’ll see rigid behaviours in eating or in the bathroom. We always need to remember to respect the child’s full experiences when we have regressions. Address emotional development and control issues the child might be experiencing in the rest of their life. When some of these kids get older they become aware of the stress in their life and they can communicate and self-advocate with their caregivers.
Taking Developmental Stage Into Consideration
At the earlier stages there’s a lot more play, sensorimotor activities, bonding/connecting around physical sensations and emotional experiences, and helping the child manipulate the food in a non-verbal or non-logical format. They might not yet be picking their own food but Jake said they might put a few things out in front of them and they get to use their gestural communication to do that.
Jake says it’s important to be building up the developmental levels inside and outside of FOODTIME sessions. Then, as the child becomes more verbal, communicative, and logical, you talk more about the food, the symbolizing elements of the food, playing with the food in the pretend world, and communicating logically about it. FOODTIME works at any developmental stage. At the earliest stages, it really does look like Greenspan Floortime: doing a lot of play and regulatory experiences. You’re trying to desensitize the child, become more connected, and get them co-regulated with their caregivers.
Providing the Safety Net
When a child is feeling safe and secure with their caregiver, feeding is not a stressful experience. If the child is already on high alert because the child is anxious or a reactive child and they’re not getting the co-regulated reactions and nurturing experiences from their caregiver, no program is going to work for them. Dr. Rick Solomon brought up the Vygotsky zone of comfort in our last podcast. In order to a child to their zone of proximal development, you really want to make things fun.
I gave Jake an example of how my own son is a great eater and will try different foods at restaurants, but has become accustomed to eating the same thing everyday at home. Jake suggests planning meals in advance with him could expand his food choices by helping him to make constructive decisions for himself and plan ahead. Make it fun, Jake says! We also need to set expectations and rules such as “We can’t have the same food each night. You can only choose 1 of the 2 favourites one night.” Jake says that when the child gets to choose, like it or not, it’s their choice.
Jake suggested that instead of our son guessing what he may or may not get to eat, set expectations so he can anticipate when these things are available or not. Jake says that Dr. Greenspan was supportive of these types of behavioural techniques: organizing things in a certain way so kids could anticipate when they would get things they enjoy, like chocolate, as long as it’s not done repetitively as just a reward, but as part of something regular.
The more we make sweets into a reward, the more kids crave them and we create addictions and perseverative behaviour by giving it value and creating a reward schedule. If we make it readily available on Tuesday, Thursday, and Saturday, for instance, the child knows the days he can have it and that’s the way it is. You can do this with computer time as well. This way the child can anticipate when it’s going to come versus seeking it all the time.
How to access FOODTIME
FOODTIME is currently only available in the two Floortime Center locations, but there is an online 1.5-hour lecture at stanleygreenspan.com. For professionals interested in learning how to include FOODTIME in their practice, there will be a small group training for professionals this fall. If you are interested you can contact The Floortime Center for details. There are requirements for training. They will start with O.T.s and SLPs to start with because the knowledge base to understand the chewing and swallow patterns and sensory information is required basic knowledge. So although training is limited at first, it will open up in time.
A huge thank you to Jake for taking time out of his busy schedule to tell us about this fantastic new approach to eating challenges, FOODTIME. If you enjoyed this podcast and found it helpful and informative, please consider sharing it on Facebook and/or Twitter. If you have any questions, comments or related experiences to share, please feel free to comment in the Comments section below!
Until next time… here’s to affecting autism through playful interactions!