Occupational Performance Coaching for Parents of Picky Eaters

PURPOSE: This study sought to answer four research questions: (1) Does use of the Occupational Performance Coaching (OPC) model with caregivers of young picky eaters increase the caregivers’ confidence in their role and skills at family mealtimes? (2) Does use of the OPC model with caregivers of young picky eaters increase reports of positive mealtime experiences for the family? (3) Does use of the OPC model with caregivers of young picky eaters reduce maladaptive mealtime behaviors by the children? (4) Does use of the OPC model with caregivers of young picky eaters reduce the severity of the feeding problem for the children?

BACKGROUND: Although eating is a basic occupation essential for nourishment and survival of the body, as many as 30% of typically developing children and 80% of children with developmental disabilities experience feeding problems. These feeding problems impact a child’s participation and satisfaction in eating and simultaneously create stress and anxiety for the caregiver. It is estimated that as many 50% of children experience picky eating, a common feeding problem that includes rejecting certain types of foods or food groups necessary for a balanced diet. Picky eating behaviors include consumption of a limited number of foods, unwillingness to try new foods, demonstration of a strong preference for certain foods, or a limited intake of certain foods such as vegetables or meat.

Occupational therapists (OTs) are well poised to address both the family unit and the child who demonstrates picky eating behaviors. Traditional models of practice focus on the child’s impairments and performance skills necessary for feeding. Techniques include providing safe strategies for feeding, providing instruction in skills acquisition, using sensory–motor and behavioral techniques, addressing environmental and positional concerns, and recommending adapted equipment. However, focusing on a child’s impairments may limit family interaction with feeding, a naturally dynamic and interactive occupation. A family-centered approach recognizes disruptions in the child’s feeding routine and their impact on the entire family unit.

Occupational Performance Coaching uses an enablement perspective of health and occupation- and family-centered principles, with occupation being central in each stage of the intervention process. The goal of OPC is to collaboratively identify goals and potential adjustments within the home or community context to establish a better match among the skills of the child, the skills of the parent, and the occupation. The sessions involve the OT coaching the caregiver in OPC’s three domains: emotional support, information exchange, and collaborative analysis to guide actions. Once the goals are set, collaboration focuses on exploration of occupational barriers and possible task modifications that can lead to performance change.

DESIGN: A descriptive case study methodology with a pre- and postintervention design was used to examine the effects of the OPC model on families of young children with picky eating behaviors. Convenience sampling was used to identify the participants of this study. Inclusion criteria were primary caregivers who identified their child (age 6 mo to 5 yr) as a picky eater, were English speaking, and lived in the Detroit metro area. Exclusion criteria included child’s formal medical diagnosis, moderate to severe intellectual disability, history of aspiration, and diagnosis of dysphagia or use of a medically restricted diet that restricted textures (e.g., purees, solids, thin liquids). The two participants were female, homemakers, college educated, and from middle- to upper-income brackets and identified their 4-yr-old sons as picky eaters.

METHOD: The Canadian Occupational Performance Measure (COPM) uses a semistructured approach to identify an individual’s self-reported challenges with occupational performance. The individual rates his or her performance of and satisfaction with the identified challenges on a scale of 1–10 (primarily for self-care, leisure, and productivity). The COPM was administered at baseline and at three data points during the six-session trial to measure change in the caregivers’ perception of their role performance and satisfaction during mealtimes. Goal Attainment Scaling (GAS) is a measure of treatment-induced goal achievement used to measure individual goals in a quantifiable manner. GAS uses an ordinal measurement scale that measures goal performance on a five-point scale from –2 (preintervention) to +2 (best one could hope for). GAS was administered at baseline and at three data points during the six-session trial to measure change in the child’s performance goals.

The Montreal Children’s Hospital Feeding Scale (MCHFS) is a 14-item parent-report tool developed to identify feeding problems in children ages 6 mo to 6 yr. Feeding problems are categorized as motivation, oral–motor skills, food by texture, and food by type. The MCHFS measures changes in the severity of a child’s eating difficulty, with scores ranging from mild to severe feeding difficulties. The MCHFS was administered at baseline and during the sixth treatment session to measure change in the child’s feeding disability. The Mealtime Behavior Questionnaire (MBQ) is a 33-item questionnaire that examines three mealtime problems: (1) food refusal, (2) food neophobia, and (3) choking, vomiting, and gagging. Caregivers rate the frequency of the mealtime behavior on a five-point scale including 1 (never), 3 (sometimes), and 5 (always). The researcher administered all components of the MBQ at baseline and at three data points during the six treatment sessions to measure change in the child’s maladaptive mealtime behaviors.

The OT (primary researcher) completed all treatment sessions; she has 25 yr experience working with children with feeding problems. The OT administered all four baseline measurements. During the sessions, the OT used the OPC framework to collaborate with the caregivers on mealtime challenges and to problem solve possible solutions. Each intervention session ended with a family meal, during which the caregiver and child ate together as the caregiver attempted to implement strategies collaborated on during coaching to enhance the child’s mealtime participation. The OT observed mealtimes as unobtrusively as possible and occasionally provided verbal coaching for caregivers. At Sessions 2, 4, and 6, the COPM, GAS, and MBQ were readministered. The MCHFS was readministered at the sixth session.

An Excel spreadsheet was used to analyze the baseline and three data points for the four outcome measures. Raw data for the COPM and GAS and t scores for the MCHFS and MBQ were compared to identify changes in the caregivers’ and children’s performance.

RESULTS: Significant improvement in caregiver mealtime participation was noted for Child 1 but not Child 2; the caregiver of Child 2 did not feel satisfied with her role of assisting her child to swallow new foods during the OPC sessions. However, both Child 1’s and Child 2’s caregivers reported significant improvement in their satisfaction with their role of assisting their children in eating nutritious foods. The caregivers reported that the goals they created for their child’s participation in mealtimes exceeded expected levels, as indicated by a GAS change of two points. Both caregivers reported a reduction in severity level of the feeding disability according to the MCHFS. Child 1 improved from mild to no disability, and Child 2 improved from moderate to no measurable feeding disability. Both children had a reduction in the severity of maladaptive behaviors according to MBQ scores. The three maladaptive behaviors that decreased from a rating of always to sometimes or less were pushing away food, eating only a few foods, and leaving the table.

DISCUSSION: Feeding of children requires interaction between the caregiver and child. Occupational therapy theory recognizes that it is optimal that the child is treated within the family context. Common occupational therapy feeding approaches often focus on the child’s oral–motor skills or behavior management strategies. OPC recognizes that occupation occurs within a family unit and that the needs of all members of the family must be addressed to promote optimal wellness and participation. Caregivers of children with feeding disorders report high levels of stress, which makes it difficult for them to implement newly learned intervention strategies with fidelity and consistency. During OPC, the caregivers gain insight about themselves and learn specific strategies to support their performance. Caregivers learn how their actions influence their child’s occupational performance, which may have contributed to the caregivers’ improvement in role performance satisfaction.

Child mealtime participation goals were exceeded following six sessions of OPC, similar to the original OPC study. During coaching, family priorities and motivations were discussed to ensure buy-in from the caregivers, a sense of engagement, and commitment to therapy intervention. With family-centered approaches, there is enhanced parent engagement, goal attainment, caregiver psychological well-being, and satisfaction with health care services. When the goals are meaningful to the family, there is a greater probability of implementation and achievement of the goals, which contributes to positive outcomes.

In the current health care environment, there is a focus on positive outcomes and cost containment. Reduction in the severity of the feeding disability from mild to moderate feeding disability to nonclassified feeding disability is similar to the outcome of other coaching approaches for caregivers of picky eaters. The caregiver and therapist work collaboratively to enhance the capacity of the family to achieve family desired goals. Collaboration promotes a broader examination of the child since the professional knows the health conditions, child development, and best practice interventions and the caregiver knows the child’s personality, strengths, and challenges.

With OPC, caregiver–child interactions were observed during the intervention sessions. Collaborative problem solving occurred in real time to identify mismatches between child and caregiver behaviors, communication, and expectations. Both caregivers reported the presence of residual maladaptive feeding behaviors influencing the quality of the mealtime experience; however, with the caregivers’ enhanced sense of competence, they felt they had the strategies necessary to reduce the influence of maladaptive behaviors on the mealtime experience.

Maladaptive behaviors around mealtimes are not limited to the child. Maladaptive parent behaviors may include structuring mealtime poorly, presenting developmentally inappropriate foods, feeding preferred foods in response to refusal behaviors, and modeling inappropriate feeding behaviors. OTs using an OPC approach can guide caregivers in self-discovery.

IMPACT STATEMENT: The use of the OPC model for caregivers can influence occupational therapy clinical practice. The health care environment is encouraging OTs to engage families in care and to reduce the number of direct sessions. Use of the OPC model has the potential to provide OTs with a new, viable service delivery model, particularly for community-based practitioners. It helps societal needs for fiscal conservancy by reducing the number of direct intervention sessions and coaching families in being more self-sufficient.