For Referring Physicians

Strategies for Treating Children with Severe Oral Aversion

Carol Elliott, OTR/L, Betsy Clawson, Ph.D., LCP, & Amber Bishop, M.S., OTR/L

Practitioners treating children with pediatric feeding disorders often face the dual challenge of not only increasing the volume of food their client eats by mouth but also, simultaneously, decreasing their client’s severe oral aversion and defensiveness. There are many underlying reasons why infants and children become orally defensive, but even when these initial conditions are stabilized and/or resolved many children continue to show lingering signs. Due to this, oral aversion remains a significant barrier for therapists trying to teach children to eat by mouth and/or to advance oral motor skills.

Therapists who treat children with oral aversion often become frustrated, particularly when treatment sessions produce an agitated child who has not consumed any food. With severe oral aversion and defensiveness, it is important for therapists and caregivers to not become discouraged by the negative responses but rather set short-term achievable goals that stem from the child’s abilities.

In Children’s Feeding Program at Children’s Hospital in Richmond, VA, we treat many children from around the country who have received ongoing therapy but have not managed to decrease their oral defensiveness. With intensive treatment in our day patient program, these children have been successful in overcoming oral aversion and have begun to eat by mouth. Unfortunately, many children with this problem are unable to receive such intensive therapy. Here are some tips for treating children with this level of dysfunction on an outpatient basis 1-3 times per week.

Treatment Tips:

We know that oral aversion and defensiveness must be reduced in order to master consumption of age appropriate volume and textures, but what are the most effective treatment techniques? How can therapists use their skills to make quick progress with children suffering from oral aversion?

  1. Slow and steady wins the race. Map out your plan and task analyze the components into small measurable steps toward your goals. Begin with short treatment sessions (10 minutes) and gradually increase the amount of time with your long-term goal being a 20-25 minute meal. Track progress with each small step (no matter how small) toward your goals. This helps you feel like you are accomplishing something.
  2. Structured therapy sessions. Predictability helps reduce anxiety. Performing the routine the same way in each therapy session helps a child to know the expectations. Utilize a timer, for example. The child learns to associate the timer ringing with being “all done”. This will eliminate the session ending based on negative responses.
  3. “Take it one step at a time.” For severely orally aversive children you may not even be able to start near their mouth. Work your way from the outer perimeter of the face in toward the mouth, then the outside of the mouth, and gradually work your way into the mouth. Choose oral motor exercises that work on specific muscle groups in the face (we utilize the Beckman Oral Motor Exercises). Choose an exercise program that has a structured routine that you can follow each time with handouts to give parents as you teach them to do these at home. Demonstrate exercises on the caregiver in front of a mirror and have them practice on you so you can be sure they are performing them correctly. It is hard to demonstrate and practice techniques on an orally aversive child.
  4. Reinforce the positive responses. Give verbal praise and tangible reinforcement for the steps identified through your task analysis. As long as the underlying issues are stabilized, you can feel more comfortable about ignoring negative behaviors. Anticipate the length of time you expect the child will tolerate and set the timer accordingly. Don’t stop just because you are met with resistance. At least attempt an approximation toward your goal and be quick to provide positive reinforcement (toys, video, praise) for compliance. You don’t want to get in the habit of letting escape become the reward.
  5. Include the caregiver. Provide caregivers with information about your plan and homework to do in between sessions. Discuss your and their philosophy about treatment. This helps them feel included in the process. Often caregivers are overwhelmed and anxious about their child’s feeding difficulties. Share with them as you track progress, this helps them see even small steps toward improvement that they might otherwise overlook.
  6. Stair steps. Once the child has decreased their aversion, begin the process of presenting tastes of food. The next step is teaching the child to open their mouth upon request to take a bite. This is the foundation you will need to make strides with oral feeding.

Therapists who treat children with severe oral aversion and defensiveness face a myriad challenges as they attempt to work through the many steps that must be mastered in order for age-appropriate consumption by mouth to occur and/or oral motor skills to improve. Occasionally, more intensive treatment, on a consistent, daily basis may be necessary to help children with severe oral aversion overcome challenges in such a way that allows them to best develop emerging skills.

Regardless of the frequency of treatment, therapists should focus on reinforcing the positive as small and measurable goals are practiced in a controlled and structured treatment environment. These tips are designed to provide therapists who treat children with several oral aversion and defensiveness a solid framework to follow as they help children best utilize their skills and abilities.

For more information visit Children’s Feeding Program.

- Published March 24, 2003 in Advance for Occupational Therapy Practitioners

The information on this site is provided for informational and educational purposes only; it does not contain specific medical advice. If you have specific health questions or problems, consult a health care professional for personal medical advice.