sphsc 543 march 5, 2010 questions?. treatment assessment will have identified if there is a...
TRANSCRIPT
SPHSC 543MARCH 5, 2010
Questions?
TREATMENT
Assessment will have identified if there is a problem and what the problem is.
Any treatment plan must meet three criteria:
should be safe
should strive to maintain optimal nutrition
should be farsighted
TREATMENT
What the child needs to bring to the treatment process:
… Functioning GI system
… Stable pulmonary system
… Developmentally appropriate oral sensorimotor and feeding skills
Look at relationships between oral and respiratory systems, and child’s learning and communication strategies.
TREATMENT
What influences tone/movement patterns?
Look at limiting movement patterns and look for automatic reflexes that can be elicited to promote normal patterns of movement.
Family dynamics
… Important in evaluation and treatment planning
BASIC PRINCIPLES
Facilitate normal patterns of movement and normalize ability to accept/integrate input – visual, auditory, vestibular, taste and temperature
Include treatment into typical ADLs of childhood
… Mealtime
… Toothbrushing
… Bathing
… Dressing
… Play
Remember: The ultimate goal may not be achieving full oral feeding
… Success may include whole or part nutrition by non-oral means
TREATMENT
Can be direct
… Oral “exercises”
… Non-nutritive oral stimulation (NNOS)
… Therapeutic tastes
Can be indirect
… Alterations in
Environment
Positioning
Seating
Communication signals
Food consistency
TERMINIOLOGY
Feeding Therapy
Implies primary goal is oral feeding
Oral Sensorimotor Treatment
… Primary goal is coordinated movements of the mouth, respiratory and phonatory systems for communication and oral feeding
… Focus is on the ‘total’ child
TREATMENT VS MANAGEMENT
Treatment
… Goal is to improve a problem or condition underlying feeding dysfunction
Management
… Underlying cause of problem cannot be modified by treatment techniques at this time
… Address symptomatology to maintain health and nutrition
… “Buy time” until the underlying problem changes through maturation or medical improvement
OPTIONS FOR TREATMENT/MANAGEMENT
Medical techniques
… Medications, O2, NGT
Surgical techniques
… Repair of anatomical anomalies
… G Tube placement
Modification of feeding situation
… State
… Posture and position
… Swallowing
… Oral-motor control
… Coordination of SSB
… Tactile responses
GETTING READY
Prepare the infant
… State, tone and movement, tactile responses
Prepare the environment
… Visual stimuli
… Noise
… Temperature
Prepare the feeder
STATE
Feeding possible in drowsy/semi-dozing, quiet alert and active alert states
Hypersensitive, easily disorganized –drowsy versus active/alert state
Sleepy –very alert
Look at patterns of states, transitions between states, and stability of state
May need to modify environment during feeding
STATE
Tactile
… Alerting effect
… Often combined with movement
Temperatures
… Cooler
… Change clothes/diaper
… Unbundle
… Cool washcloth
AROUSAL
From sleepy/semi-drowsy to calm, alert
… Variable, not predictable, not rhythmic
Movement
… Can have a strong alerting effect
… Picking up baby, being in an upright position
… Rocking from side-to-side
Auditory
… pitch, tone, rhythm, quiet to louder, lively music
CALMING
Irritable, crying, hyperstimulated, disorganized, easily startled
Containment and rhythmicity are key
Tactile
… Firm, deep pressure and containment
Swaddling
… Physical containment
… Tonic, disorganized
… Frequent, firm proprioceptive and deep pressure contact
CALMING
Swaddling continued
… Arms together in midline, hips flexed, head covered
… Use well-flexed, vertical position
… Use body – posture and firmness of holding
… Infant massage
Movement
… Rhythmic, constant, predictable
… Try different rhythms
… Bouncing, rocking when swaddled
CALMING
Auditory
… Decreasing auditory input
… White noise, rhythmic, repetitive music
… Minimal speech
Tone, posture, position
… Balance between flexor and extensor
… Movements should be smooth and well modulated
… Alignment of head, neck and trunk are crucial
OPTIMAL FEEDING POSITION
Overall flexion
Orientation of head and extremities about the midline
Shoulders symmetric and forward
Arms flexed and toward body midline
Hips flexed from 45-90 degrees
SEATING/POSITIONING
Look at shoulder girdle, trunk, hips/pelvis, sitting base, stability of feet, eye contact/control, head control and spinal mobility
… Soft chair (bean bag) or foam/towel between shoulders – retraction
… Vest attached to chair, foam/towels on table – protraction
… Hold shoulders down
… May need trunk supports/pads
… Rolled towels under knees – posterior pelvic tilt
… Lumbar spine – anterior pelvic tilt
… Seat depth, width, angle
SEATING/POSITIONING
… Sitting base – wider (pommel) more stable; hip adductor to bring knees together
… Foot rest, towels, blankets, books
… Eye control/contact – supine – no demands for head control.
… Feeder should be at eye level
… Head/spine – must look at hips, pelvis, trunks and shoulder girdle first. Slight recline, head rest, chin tuck
… Abdomen – build muscle tone and control. Improve breathing and postural adjustments during mealtimes
SEATING/POSITIONING
Freedom of movement – spinal movement and changes movement around body axis
FEEDING POSITIONS
En face
… Maximal head control is possible, harder to provide trunk support
Supine in lap
… Hard to control side-to-side head movement
… Hands free tube feeders, pacifier for NNS
… Can be inclined
Sidelying on lap
… Trunk straight and well supported
… Helps retracted tongue come forward
FEEDING POSITIONS
Head in greater flexion
… Facilitate sucking and lip seal
… Compensate for poor laryngeal elevation
Head in slight extension
… Assists breathing
SWALLOWING
Depends on where the problem is:
… Poor organization of bolus in oral phase
… Delayed swallow reflex initiation
… Abnormal pharyngeal phase
… Incoordination of pharyngeal/esophageal peristalsis
IMPROVE BOLUS FORMATION
Problem with tongue control
… Provide single bolus then pause to allow organization
… Small boluses (0.1-0.5 cc, 1 Tbsp to 2 oz)
… Allows establishment of suck
… Thicken liquid
Moves slower, easier for tongue to maintain bolus
DELAYED SWALLOW REFLEX INITIATION
Thermal stimulation
… Triggers faster swallow reflex in adults
… Refrigerator-chilled liquids or semisolids
… May diminish over subsequent swallows
If non-orally fed – may suck on frozen pacifier
Thicken liquid/pureed foods
Improving laryngeal closure
… Forward head flexion/chin tuck
… Angled bottle, cut out cup, straw
ASPIRATION AFTER THE SWALLOW
Usually secondary to residue
… Decreased pharyngeal peristalsis
… Dysfunction of the CP muscle
… Inadequate pressure gradients
Noisy, wet-sounding breathing that is worse following feeding
Modify food texture
Encourage “dry” swallows
Palatal trainer
DECISION-MAKING AND ASPIRATION
Degree of swallowing dysfunction
Amount of aspiration
Response to treatment
Underlying pulmonary status
Tracheostomy
Therapeutic feeds
Full PO with modifications
GER
Non-oral restriction decreases GER but may still have….
… Ascending aspiration
… Need to increase/maintain oral skills
… Provide therapeutic feeds
ORAL-MOTOR CONTROL
Hypotonia – poor stability and abnormal control
Need to ‘wake up’ or ‘alert’ CNS
… Tapping
… Vibration
… Quick stretch
Masseter and buccinator muscles
Lips/tongue
ORAL-MOTOR CONTROL
Hypertonia – abnormal movement and may lead to abnormal alignment
Neurological insult or abnormality, stress
… Preparatory movements
Handling
Body alignment
… Firm pressure
… Shaking/vibrating
… Tongue retraction
… Environmental management
TONGUE
Neck extension – functionally pulls tongue into retracted position
May be hypertonic or passively retracted
May be actively seeking point of stability (micrognathia)
Postural support – improve head/neck alignment
Handling – normalize tone, neck/shoulders
Modify tone in tongue
… Finger in midline
… Shaking, jiggling, tapping, stroking, vibrating
Longer nipple
TONGUE
Bunched, humped, retracted, hypotonic
Lacks central groove
Get tongue forward
Downward pressure to midline
Stroking forward with downward pressure
Firm straight nipple with cross-cut
TONGUE
Tongue-tip elevation – pressed against hard palate, distal to alveolar ridge
Common in preemies – may be a means of stabilization
Postural support
Preparatory handling
Quick swiping or vibration
Downward pressure
Assist with mouth opening
… Stimulation to lips
… Downward pressure on jaw
TONGUE
Protrusion – sits on lower lip below nipple and interferes with lip seal
Hypotonia/weakness/increased tone
Neck extension
Postural support – neutral or slightly flexed
Preparatory handling to reduce tone
Sensory input – firm tapping
Firm, downward pressure to midline
Firm straight nipple
Facilitate lip activity
POOR MOUTH OPENING
Poor arousal
Neurologic insult
Prepare state
Elicit rooting reflex
Assist mouth opening – gentle downward pressure
Inhibit jaw clenching – vibration, very small-range, low amplitude side-to-side movement
Touch/pressure to gums
WEAK SUCK
Ineffective feeding
Overall weakness, medical/nutritional compromise, immaturity, myopathies, respiratory/endurance
Provide oral stability – optimal positioning, firm cheek/jaw support, traction on nipple
Increasing flow rate (with caution)
JAW MOVEMENT
Excessive – no stable base for tongue, lip seal may be compromised
Develop stable base for jaw, slightly tucked chin position, develop neck flexor musculature
Preemies – often have jaw instability. Poor developed tone/bulk in oral-facial mm, minimal active neck flexion, neck hyperextension common
Neurologically-based hypertonicity – poorly balanced control between opening and closing mm. May lead to strong downward thrust of jaw
Neck hyperextension – could be immature development of neck flexion, abmormal mm tone or stress
ABNORMAL TONGUE MOVEMENT
Attempts to use marked jaw depression to create negative pressure suction
Postural support – neck/head alignment key. Don’t allow neck hyperextension. Head in neutral or slight flexion will provide additional positional stability to jaw.
External support – firm pressure under jaw. Keep pressure distal and under mandible, proximally will be under base of tongue could interfere with sucking.
ABNORMAL TONGUE
Increased neck flexion – if doesn’t respond well to external support, bring head into strong neck flexion. Help grade jaw movement. Continually monitor respiratory status.
Handling techniques to reduce overall mm tone
May need to target tongue
LIP SEAL
Negative pressure reduced or broken intermittently
Smacking/kissing, excessive fluid loss
Low tone, weakness – preemies or conditions
Excessive jaw movements
ABNORMAL TONGUE MOVEMENTS
Strong protrusion – treat tongue
Treat underlying problems first– facial weakness/hypotonia, excessive jaw movement
External support – cheeks/lips and jaw support, too.
CHEEKS
Hypotonia/weakness, diminished fat pads
Poor stability leads to poor lip seal. Excessive jaw excursion may result
Increase facial tone
Cheek/jaw support
POOR INITIATION OF SUCKING
Crying, fussing, ‘tuning out’ – baby hungry and will become increasingly frustrated
May root excessively and unable to inhibit – turns head wildly from side-to-side
Extreme mouth opening and unable to close
Tongue protrusion/lapping pattern may be attempt as sucking
Hypersensitive response or poorly developed sucking patttern
Poor state/organizational abilities – overly hungry
POOR INITIATION
Treat underlying problems – if poor state/organization treat those underlying conditions
Preparatory handling
Stabilize front of head with jaw control as needed
Place nipple firmly at midline, cheek support as needed –for central reference point
Assist with mouth closure – firm jaw control to assist with closure, grading of mouth open, vibration to relax tension and assist with closure
Facilitate appropriate tongue movement
COORDINATION OF SSB
Prolonged sucking – feeding induced apnea
Having difficulty ‘pacing’ SS and B
Strong, rapid sucking with difficulty initiating breathing even when nipple removed
More common in preemies
External pacing
Be sure baby can initiate breathing
May have better regulation later in feeding
Decrease rate of flow – thicker liquid, slower flow – to allow time to organize
COORDINATION OF SSB
Short sucking bursts
1-3 sucks in a burst before pausing for multiple breaths
Pauses too frequent/long compared to sucking bursts
May be adaptive response
VFSS
Look at respiratory status
Endurance
COORDINATION OF SSB
Uneven pattern with duration of bursts/pauses varying considerably
May be uneven pattern of breathing and swallowing within the sucking burst.
Frequent choking/coughing noted
General neurological disorganization, respiratory problem, nipple flow problem
Assist with external organization
Understand respiratory status
Pace, reduce flow rate, bolus size
ENDURANCE AND RESPIRATORY COMPROMISE
Need to increase ventilation and cardiac output to match ‘work’ of feeding
Reduced intake, poor weight gain
Generally has normal OM control and SSB
Initially feeds well but stops early in feeding
Regulate liquid flow – faster at beginning to get more in, softer nipple, slightly larger hole. Monitor carefully!!
Manipulate feeding schedule – limit feeding time, time between feedings, demand schedule
Nutritional supplements, caloric density
ENDURANCE AND RESPIRATORY COMPROMISE
Realistic expectations to cope with frustration
Structural abnormalities or respiratory disease = increase WOB
Much of available energy is used in cardiorespiratory system with little reserve for additional activity (i.e., feeding)
Increase WOB may lead to GER
Treatment for endurance should be considered
Reduce expectations for feeding
Small volume feedings
ENDURANCE AND RESPIRATORY COMPROMISE
Structural abnormalities or respiratory disease = increase WOB
Much of available energy is used in cardiorespiratory system with little reserve for additional activity (i.e., feeding)
Increase WOB may lead to GER
Treatment for endurance should be considered
Reduce expectations for feeding
Small volume feedings; pacing
Stopping or postponing oral feeding
Supplemental O2, nebulizers
VENTILATION VERSUS PERFUSION
Ventilation – amount of air in and out of lungs and alveoli
Perfusion – ability of alveoli to exchange gas
Supplemental O2 is not helpful in all respiratory problems – if perfusion is poor, increasing O2 amount will not improve saturation in blood
May still be helpful with feeding since ventilation-perfusion ratio may change with increased work
Need oximetry
INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES
Skill in balancing medical and nutritional needs with parents’ skills and expectations
Frequently an issue with respiratory/endurance problems
OM skills generally intact so leads to optimism and enthusiastic pursuit of oral feeding
Perception of failure on the part of the infant or parent if goals not readily achieved
May need to change the way in which progress is measured
… Primary goal
INCREASED NUTRITIONAL REQUIREMENTS: ADDITIONAL CALORIES
May need to change the way in which progress is measured
… Primary goal should be infant’s overall growth
… Oral feeding often comes at a high price
… Supplemental nutrition should be viewed as support rather than last resort or failure
… Provides a built-in nutritional system during setbacks
… Focus on quality of oral control and parent-child interaction rather than calories
… Small volume/partial oral to build motoric and sensory foundations, hunger/satiation
ORAL-TACTILE HYPERSENSITIVITY
Responses are exaggerated out of proportion to stimulus (e.g., placing bottle or toy in mouth)
At the extreme end of hypersensitive responses
Easily elicited, stronger, more negative and often include a behavioral response
May cry, grimace, wiggle, arch away, keep mouth closed. If feeder persists may begin to gag and may vomit.
MULTIFACTORIAL CAUSE
Immaturity and illness – immature CNS, at the mercy of physiologic status, poor regulatory filtering mechanisms, becomes a pattern
Delayed introduction of oral feeding – critical period for acquisition of oral feeding skills may be missed (Illingworth & Lister)
Unpleasant oral-tactile experiences – negative or traumatic oral-facial experiences during the course of medical treatment
TREATMENT
Adaptive, well-modulated responses is the goal.
Reduce aversive stimuli – look at care routines
Grade oral/tactile stimuli – start in a range where the child is comfortable and slowly build up to a point where it is not tolerated and then step back slightly. “Dance” on the edge of the infant’s tolerance.
… May need to start distal and move proximal
… May need to move from smooth to soft to unusual to prickly, firm to light pressure, etc.
VIBRATION
Vibratory afferents are carried along different neural pathways than light touch and touch/pressure.
More integrating and less likely to stimulate an aversive response.
Can be effective even with preemies
Hold vibrator against finger, nipple, pacifier. Use an electric toothbrush.
ORAL EXPLORATION
Mouthing toys and hands is a crucial component in helping them tolerate increasing complexity and variety of oral sensations.
Variety – don’t let child get ‘stuck’ on only one thing.
Feeding specialist needs to reintroduce this stage of normal development in a way the baby can tolerate.
NON-ORAL FEEDING
Full non-oral feeding –
… Motor deficit
… Extreme tactile hypersensitivity/aversion
… State or arousal problems
… Medical conditions that preclude oral feeding
… Any combination of these
Existing OM skills should be maintained for future oral feeding and speech
Prevent oral aversion and hypersensitivity due to lack of oral input
Facilitate oral hygiene
NON-ORAL WITH TX ORAL FEEDS
Primarily non-oral
Feeding-related functions show adequate competence to allow small amount of safe oral feeding
To improve OM skills and move toward larger volumes as able.
Safe for oral but cannot take full oral
Allowed to feed as much as possible within certain parameters (length, frequency) with balance non-oral
NON-ORAL PLUS ORAL
Limited nippling at each feeding using good techniques and within physiologic parameters.
Amount not finished is given though tube
Use only with indwelling NGT or GT
Often used with preemies
Alternate nipple and tube feedings
Should be close to taking full volume
Good for those with limited endurance
NON-ORAL PLUS ORAL
Daytime oral and nighttime tube
TRANSITION FROM TUBE TO ORAL
Begin the process of transitioning to oral feeding at the point when non-oral feeding begins
Comprehensive and aggressive oral therapy program
… Normal OM skills
… Expected short-term use (6-12 months)
Primary objectives
… Minimize negative or aversive oral stimulation
… Promote pleasurable experiences and oral exploration
… Maintain/build OM skills and interest
… Associate oral activity with satisfaction of hunger
… Maintain whatever degree of oral intake that is safe
… When possible, expand rather than introduce
TRANSITION
Consistency, whatever program is established, is essential
Assess child and parents’ readiness
Often lengthy and difficult; it’s a process
… “He will eat when he’s hungry” does not apply
… Set goals that reflect steps rather than final outcome
Establishing level and quality of OM skills
Determine swallowing ability
What’s the original medical condition?
What’s the current status?
LETTING GO
Degree of OM impairment
Lack of change/improvement in medical status
Move away from oral goal in a way that supports the child and family
Quality of life
… ‘Recreational’ oral feeding
… Tolerates oral stimulation for ongoing hygiene to face, mouth, teeth, gums
DESENSITIZATION HIERARCHY
From 18 months and older
No obvious OM deficits
May have oral sensory problems due to sensory deprivation
Tolerating –
… Be in same room
… Looking at food
Interacting –
… Uses utensils in play, preparation
DESENSITIZATION HIERARCHY
Smelling
… Tolerates odor of food
Touching
… Tolerates on fingers, hand, upper body, chin/cheek, nose, lips, teeth and tongue
Tasting
… Licks lips or tongue
… Bites and spits out
… Bites and holds in mouth before spitting out
… Chews and partially swallows
… Chews/swallows with drink
… Chews/swallows independently
DESENSITIZATION HIERARCHY
Eating
Gradual changes that lead the child to functional eating without any specific intervention by others except expected monitoring for age
Individual variation as needed
… Collaboration with MD, RD, daycare, school or other therapists, with caregivers and child as primary team members!
… Consistent approach and encouragement/feedback
MEALTIME ENVIRONMENTS
Home, daycare, school, restaurant
… Modify environment as best you can
… Placemats, utensils, cups, bowls
… Proud plates, brag books
Adaptive seating
… Lightweight, washable, easy to use
… Fits under table to allow child to be included in mealtime
ORAL CONTROL – FROM SIDE OR BEHIND
First do positioning for best posture
Middle finger
… Behind chin on belly of tongue
… Inhibits jaw opening, helps closing, indirectly inhibits tongue protrusion
Index finger
… Between lower lip and chin
… Facilitates graded jaw opening, helps control head
Thumb
… Under chin, provides jaw stability only
ORAL CONTROL – FROM FRONT
Helps maintain eye contact
Requires more control from the child
Index or middle finger
… Under chin
… Provides jaw stabilization
Thumb
… On chin
… Facilitates graded jaw opening
TOLERATING FACE WASHING
Preparation for mealtime/snack activity and at end of meal/snack
Provide postural support and stability
Provide oral control as needed
Use firm, deep pats moving distal to proximal
… Cheek bones to lips, one side then the other, upper lip stretching downward, chin moving upward
Use different textured cloths
Use rhythm/singsong
SPOON FEEDING
Wash your hands and help child wash theirs
Provide postural support and stability
Begin with jaw closed
Spoon approaches from low to midline
Graded jaw opening – support as needed
Put spoon straight in – about half way
Press down and flat on tongue, hold to allow tongue to quiet and lips to close.
Take spoon straight out
Let upper lip learn to be active so don’t scrape against the lip
SPOON FEEDING
Clamping – provide extra flexion and wait for child to relax
Sensitivity – face washing and tooth brushing
Lip retraction – positioning toward midline
Tongue thrust before swallow – better head/neck control and oral control
No swallow – chin tuck/neck elongation, reload spoon and come towards them
CHEWING
Wash your hands and help child wash theirs
Provide postural support and stability
Provide oral control
Begin with jaw closed
Food approaches from midline and low or level with mouth. Use food that is easy to handle
Graded jaw opening while maintaining flexion
Place food on chewing surface of teeth at side
Facilitate graded jaw closure
Maintain oral control; watch head and trunk
Don’t facilitate chewing motion – wait with continuous oral control
CHEWING
Tone in cheeks – use finger to stretch and release cheeks before starting
Poor lip closure – face wipe to stretch upper lip down, lower lip up. Push jaw up.
Exaggerated jaw movement – use oral control to grade jaw
CUP DRINKING
In typically developing children, spoon feeding builds to cup drinking
Wash your hands and help child wash theirs
Provide postural support and stability
Provide oral control
Thicker liquids are easier to control in the beginning
Begin with jaw/lip closure
Approach at midline or slightly below level of the mouth
Place cup between lips – not between teeth
CUP DRINKING
Rest rim on but do not push down on lower lip
Tilt cup until it touches upper lip and wait
Goal is active downward motion of upper lip to draw in liquid
Don’t remove cup unless child pulls away – watch child’s signals
Maintain oral control
CUP DRINKING
Bite reflex – move out so it doesn’t happen
Gulping – prevent with slight chin tuck/neck elongation so the kid is looking down in the cup
Use thicker liquids, cut out cup, clear cup, let child help “hold” the cup
STRAW
Prerequisites: nasal breathing, lip seal with active lip function, light jaw closure, cheek and tongue movement to build up negative pressure
Wash, provide posture support and stability, provide oral control
Dip straw into liquid and place finger over hole on top
Place straw between lips, let a drop of liquid out and wait for active suck
Gradually require more suction by keeping finger over hole
Short, wide and small diameter straws
Use juice box
BOTTLE FEEDING
Need NNS to serve as a link that will facilitate transition to NS
Wash hands, provide posture support and stability
Provide oral control from the front – tongue control with middle finger, thumb and index finger on cheek to provide movement forward to facilitate sucking
Bottle approach from midline or below
Facilitate graded jaw opening
Pressure on tongue with nipple to stimulate suck
Rock or shake nipple may help if has intermittent suck
SELF-FEEDING
Wash, provide posture support and stability
Provide oral control if it has not been discontinued prior to this stage
Begin with finger foods to eliminate use of utensils
Hand-over-hand or child holding on to your fingers as you hold the food or spoon
Food or spoon at midline on table. Gather food on spoon.
Jaw is closed.
Food or spoon at midline.
SELF FEEDING
Spoon straight in, maybe pressing down on tongue for stability/organization
Spoon straight out, maybe pausing to let lips and jaw close
May need slight chin tuck/neck elongation to prevent biting on spoon
Spoon back to plate/bowl
Finger foods follow the same pattern but are presented laterally to facilitate chewing
QUALITIES OF UTENSILS
Spoons –
… size of bowl
… depth of bowl
… Size and weight of handle
Cups –
… size
… height/width
… cut out cup – see liquid, to prevent hyperextension
… Cup lip
… Flexibility
… Handles or no handles
QUALITIES OF UTENSILS
Finger foods
… Shape
… Texture
… Way to make it graspable
TREATMENT IDEAS
You set the stage – playful, fun, positive and calm
Activities with no food
… Touch/pressure to hands/feet (weight bearing, holding, deep pressure)
… Massage and vibration – Begin distal and move proximal
… Play with cups, utensils, dolls, tooth brushes, etc.
… Rhythm, bouncing, patting, stroking
… Sensory – lentils, corn meal, rice, play doh, damp sand, damp sponge, finger paints
TREATMENT IDEAS
Food activities – play – explore, measure, pour, art, put food on toy, put toy in mouth, drive food in cars, peanut butter play doh, etc.
Help prepare food – buy it, stir, grind, pass it, feed you, join the family at meal times, wash dishes
Many short work periods better than one long one
Once a week with family follow through
Carryover to home
TOOTHBRUSHING