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[00:00:00] Dr. Sharp: Hey, welcome back to The Testing Psychologist podcast- the podcast where we talk all about the business and practice of psychological and neuropsychological assessment.

This is Dr. Jeremy Sharp, your host. I have a fantastic guest with me today. Dr. Lani Jones is here to talk with us all about feeding and eating evaluation and intervention. This is an area that is overlooked a lot in our field, but it is very important as you will come to find out.

Lani talks with us all about what this area even is, what we mean when we say feeding and eating concerns, how it manifests, and how it overlaps with existing diagnoses or more familiar diagnoses. And we talk a bit about intervention as well. I think this is a good one and it really integrates well for anyone who conducts evaluations with kids, especially little kids.

A little bit about Lani. She has [00:01:00] first of all, long history of working with little kids and working in this area. But as far as her background, she got her BA from the University of Indianapolis in psychology, in Spanish. She has a master’s from Ball State University. She has a doctorate in clinical psychology with a concentration in kids and adolescents from the University of Indianapolis as well.

Lani did her pre-doctorate internship at the Waisman Center at the University of Wisconsin in Madison. She did her postdoctorate at the Riley Child Development Center at Riley Hospital for Children at Indiana University Health. She’s also an assistant professor of clinical pediatrics at the Indiana University School of Medicine.

Lani does a lot of work in her clinical practice. She conducts assessments across the board with developmental delays and neurodevelopmental disabilities, feeding evaluations are a big part of that. She also provides short-term therapy [00:02:00] for children and their families with a variety of concerns.

The other component is that Lani is a nationally recognized speaker in a number of areas particularly, feeding and eating concerns. She maintains a website called EatPlayThrive where she has a ton of resources, an amazing ebook, and some family resources. I’d definitely advise you to go check those out in the show notes after you listen to this episode.

All right. Without further ado, here is my conversation with Dr. Lani Jones.

Hey everybody. Welcome back to another episode of The Testing Psychologist podcast. [00:03:00] I’m glad to be here today. Like you heard in the introduction, I am talking with Dr. Lani Jones all about feeding and what that entails in the assessment world. I’m very happy to have her.

Lani, welcome to the podcast.

Dr. Lani: Thank you. I am always excited for an opportunity to talk about one of my favorite topics. 

Dr. Sharp: Awesome. I think that’s going to work out well because this is a topic that I don’t know much about at all. I would guess a lot of the audience probably doesn’t know a lot about it either. So I will welcome anything you’re willing to share with us.

Dr. Lani: Wonderful. I had my first experience with feeding on an internship. I did my internship at the Waisman Center at the University of Wisconsin Madison. Before that, I knew feeding teens existed; kiddos have difficulty eating and someone needs to help them, but no idea that psychologists actually had a role in that, and a [00:04:00] really vital role in a lot of ways. That was my first introduction to this whole feeding world, treatment, evaluations, and what that all looks like.

Dr. Sharp: That’s such a good point. I do work twice a month in an integrated clinic with speech therapists and occupational therapists and they do feeding stuff. I don’t know exactly what that looks like, but I’ve run into many psychologists who do it.  So, it’s really cool to be able to hear your experience and learn how this plays into our field as well.

It sounds like you got exposure relatively early if we’re talking about the internship. From that point, why is it interesting to you? Why pursue it from there?

Dr. Sharp: I still had two years of training with an internship. Fellowship was also at a children’s [00:05:00] hospital where I had feeding exposure. But I think one of the main things that drew me to it was the practical nature of it because if little ones aren’t eating well or sleeping well, oftentimes the entire household is disruptive. And even all the parents out there are probably like, yes, mm-hmm parents are tired or little ones are irritable, and these are daily activities.

With feeding, you’re doing it multiple times a day. And so, when there’s something impeding successful eating that’s impacting nutrition or growth, there’s a lot of stress and anxiety in the family. And so, this was a very practical way for a clinician that I could help families function better just in their day-to-day life.

The second piece of that was feeding difficulties are so comorbid with neurodevelopmental disorders, and that was already my area of expertise and where all my training was going. [00:06:00] And so, I was doing evaluations for autism or global developmental delays and seeing on the side, oh yes, this child is also having difficulties with feeding. And so, it was just a natural progression with all the testing psychology I was doing and all the evaluations to then say, okay, I’m already seeing this population into different capacity. And so now here’s a really practical way to further evaluate or help them treatment-wise.

Dr. Sharp: Right. I like how you phrase it as a really concrete place to intervene. It doesn’t get much more important I think for little kids and their parents than eating. You could argue that stays pretty important through the lifespan, but especially when they’re little, I hear so many parents talk about their kids having picky diets or not eating at all, or sensory issues with [00:07:00] food and all sorts of concerns. It’s nice to just be able to get in there and help with a very important developmental area. I’m sure that is really nice.

Dr. Lani: Yes, because it’s really a complex field too. I think that’s why you naturally see so many disciplines involved, like you mentioned, SLP and OT, dieticians, and MD psychologists because there could be so many underlying ideologies or a combination of factors or behaviors that are maintaining those feeding difficulties.

Dr. Sharp: Right. Maybe we could start with a big-picture view. For my sake and probably a lot of the audience, could you do a little bit of definition around, like when we say feeding issues, what does that even mean?

Dr. Lani: Generally, we’re talking the younger- the 0 to 5 is probably one of the most targeted times for [00:08:00] feeding evaluations, but definitely not to say they can’t continue on even into adolescence. But it is much different than bulimia and anorexia. When we’re talking about feeding difficulties more in that 0 to 5 period, was it originally a medical issue; like was the child born prematurely? Were there already breathing difficulties at birth? Was there some other underlying medical complication? They had a G tube or maybe there was really significant reflux? So, there’s that whole medical piece of it.

And then feeding skills. We always want to look at it too. So, are there oral motor difficulties? It could be there’s hypotonia or low tone or there’s something that their chew pattern hasn’t developed. Maybe they did just fine on the bottle, but that transition to table foods has been really difficult. Or there are sensory differences, [00:09:00] maybe the child is or isn’t on the spectrum. And so that’s a piece of it, or restrictive behaviors or food jagging. A lot of those different areas we look at more to start evaluating and determining where we go from here with treatment.

Dr. Sharp: Sure. And do feeding issues also encompass things like Pica, for example, or what other

Dr. Lani: Rumination disorder?

Dr. Sharp: Yeah, sure. Some of those more, I don’t know if you call it pathological is the right word, but just different feeding patterns choices.

Dr. Lani: Absolutely. Yes. In terms of actual diagnoses, our field is definitely lacking in that. Typically, one of the most common is failure to thrive, which is technically a medical diagnosis that’s given. Generally speaking, it means a child is growing on a curve or [00:10:00] not even on a curve, but the 3d to 5th percentile or less, but just practically speaking in my clinical work, I’ve seen a lot of MDs using that more liberally up to the 10th percentile, but it’s very nondescript because a child could technically still be growing but not getting any other nutritional intake. And so, it doesn’t really help us understand what’s going on.

And then you have like the Pica or you have the unspecified feeding disorder or you have the avoidant restrictive food intake disorder, RFID, which is from the DSM-V, which has its limitations too. And so, we don’t have a great way of really talking about a lot of those underlying feeding skill issues or that gives us a full picture.

There actually is the term pediatric feeding [00:11:00] disorder, PFD, it was just introduced in the journal in January of 2019, that lays out new diagnostic criteria that looks at the psychosocial component, feeding skills, both oral motor, fine motor, the medical piece of it, and the nutrition. I really think it’s the most comprehensive diagnostic suggestion we’ve had this far.

They are really doing a lot of lobbying and advocacy efforts around that because ideally, hopefully someday we’ll get it in the DSM and the ICD-10 codes. And so, there’ll be a lot more consistency across the board because right now it just feels very hit or miss in terms of diagnoses. Myself, I use the ICD-10 codes when I’m billing under an early intervention for our state programs. [00:12:00] And so, I just use an unspecified feeding and eating disorder. It’s there for insurance purposes. And that’s about it.

Dr. Sharp: Right. It’s unspecified. Did that diagnosis, the newish one from last January, is that emerging from the field of psychology or medicine or OT or what? Who’s proposing that?

Dr. Lani: There’s a national program organization called Feeding Matters and they are really big on the policy, the advocacy, the research, and parent support. They’re really, I’d say, one of the national leaders in terms of the feeding world. They have spearheaded these efforts in the organization. And on that paper, I forget how many authors, there were like 12, there was a lot going on with that citation; [00:13:00] there were MDs, there were psychologists, there were SLPs, there are OTs, really all disciplines, dieticians were represented. So it was a very transdisciplinary team approach to establishing that.

Dr. Sharp: I got you. Well, that raises a question for me right off the bat that may be a little out of sequence. Do you feel like working with and assessing and diagnosing these concerns is something that has to happen within a multidisciplinary team or can we operate more independently?

Dr. Lani: I am now currently in private practice. I started my career at a children’s hospital so I was a part of a team. I had MDs down the hall I could go consult with and I do definitely miss that. I think it just really depends on how complex the issue is and what the needs are. Is this something just straight-up sensory that’s related to an autism diagnosis, or is it [00:14:00] more environmental, or is there a complex medical issue? And so, I think the answer to that question is it could really be anything.

I’m a solo practitioner, but now I have established my SLPs and OTs that I consult with that are in their own practices or within the early intervention system. I guess that was a long answer to it could be either.

Dr. Sharp: Sure. It depends, right?

Dr. Lani: Yes, totally. In an ideal world, you would have a team all together at one time like I had on internship and they’re seeing the kiddo at the exact same time, you’re behind an observation mirror, someone’s leading it. And so you’re all powwowing together. But now just in the logistical world of insurance, even at most children’s hospitals, that’s not happening. You go see an MD and then you go see the [00:15:00] dietician and then you go see the SLP. And even if they’re consulting, that team approach is much more disjointed and broken up.

Dr. Sharp: Sure. I can understand that. And there are always constraints on billing and time, right?

Dr. Lani: Absolutely. Yes.

Dr. Sharp: This is super interesting to me. I think a lot of us would probably get on board with personal experience with kids and just not eating well, whether it’s clinical or not. I have a lot of questions just about what’s “normal” and what’s not. It seems like some cases are very clear. If a kid is diagnosed with failure to thrive or is eating pounds of dirt every day or something that seems pretty clear, but then there’s this huge gray area, at least for me, that I’m not sure about.

I wonder if you [00:16:00] could talk about just from a clinical perspective, what we might need to key in on or pay attention to; what’s normal, what’s not normal? That’s a broad question. You can break it down however you’d like, but hopefully, we can find our way through that.

Dr. Lani: I think the two key questions to ask are, is this a picky eater? Is this a problem eat that needs intervention? Are they growing okay? So whatever that looks like for their height and weight, and I’m not one who’s totally tied to their growth charts because I think genetics play a big role and I’ve worked with a lot of great MDS who will just look at mom and dad and be like, yeah, you’re never going to be 6ft”. Or even if you make it to 5 6″, you’re going to be tall for your family.

And so, considering that genetic component of what does it look like of how they’re growing, but even if they are [00:17:00] growing, what’s their nutritional intake looking? Maybe it’s a kiddo who has really severe food jagging, which is eating only one food or maybe two to three foods for every single meal for weeks on in. Maybe it is fresh fries from McDonald’s and that is literally the only food they’re eating.

So missing some key nutrients there, but maybe their weight is that the 25th person tile or something. And looking at those pieces of how is their nutrition and how are they growing. But then on the same hand too, looking at how is it impacting the family functioning. Just because if there’s a cultural difference or family expectations, is this negatively impacting how they’re able to have family meals or stress levels of they can never eat out or they can never have babysitters because the child only eats for one specific parent? [00:18:00] Also looking at the global impacts of family functioning and relationships too.

Dr. Sharp: Yeah, that makes sense. It seems like in that case it might veer more toward less clinical and just inconvenient maybe is the right word if it doesn’t work within the family system or it makes it hard. I don’t know. I’m just thinking out loud that a lot of our diagnostic criteria involve disruption to social or educational or daily functioning, and maybe that’s a disruption of daily functioning, right?

Dr. Lani: Significant impairment. Yes. In social occupational. Yes. All that criteria.

Dr. Sharp: Yeah. I feel like those questions are good guidelines just to be thinking about. The growth piece can certainly come from the physician. [00:19:00] And then the nutrition piece, is that where… How do you work with that in private practice when you maybe don’t have access, you’re not a nutritionist, is that just based on a parent report or what?

Dr. Lani: Initially, if the kiddo’s not super medically involved and they’re just seeing their primary care physician or pediatrician, family doctor, and then I’m asking them, how are your well-child visits going? What’s their growth like? Has your pediatrician expressed any concerns about their nutritional intake? And so getting more a lay history from that perspective where…

I have a 19-month-old I just started working with now and we’re doing a tubing, so he’s got a G tube right now. He has a GI doctor, a pulmonologist, and a dietician. And so that’s definitely something much more in-depth. And I’m [00:20:00] coordinating weigh-ins and reports with the dietician and things like that. But oftentimes, if it’s less severe then yeah, it’s just based on parent reports of, has your pediatrician had any concerns, that type of thing.

Dr. Sharp: I got you. And is that how you might decide or determine if a kid needs a feeding evaluation is just parent concern, physician concern if it’s not referred from a physician already?

Dr. Lani: Typically, it’d be coming from parents then they’re saying there’s something that seems atypical or not normal, or this child doesn’t eat like all my other kids or I’m concerned about their growth. Maybe their chewing patterns are off. I don’t think they even can eat what they need to eat or they can’t drink from an open cup. Questions like that would prompt the parent to then be [00:21:00] reaching out and saying, Hey, do we need to be doing something more about this?

Dr. Sharp: Sure. I want to ask the question. I want to dive into the evaluation process and what you’re actually doing and looking for. Before I do that, I am just curious about it, I feel like parents talk a lot about kids just being picky eaters, but they seem to be fine otherwise. Can you talk just a little bit about what is typical for kids to eat? Is it typical for kids to eat chicken nuggets and French fries until they’re 10 years old or beyond? This is just such an interesting area and very personally relevant too.

Dr. Lani: Probably not till they’re 10. I think this is when a lot of environmental factors play a role. Oftentimes, if I have a child in my office for an evaluation, say a 3 or 4-year-old and maybe it’s for [00:22:00] behavior issues, something not even related to feeding, but I’m definitely going to ask about diet and how feeding is going. And then the parent starts saying, yeah, they eat chicken nuggets and hot dogs. And you can see their face dropping and they start avoiding eye contact with them.

I’m like, oh, you mean the preschool diet. And then they get this look of relief on their face because there is some level of normalcy. 2 and 3-year-olds are not going to be eating steak most likely. That would be abnormal. I’ve met some that do, but I often get parents to come into me even at, under the age of 5 and they’re like, well, my kid won’t eat steak or a pork chop or something like that. And if their chewing patterns are still developing, they’re still learning how to grind that down. So things like processed chicken nuggets and hot dogs or ground hamburgers are much more manageable for them.

And so, there is a level of normalcy to that, but I think [00:23:00] environmentally too, just the culture of the family. Some families naturally don’t eat a big variety of fruits and vegetables. And it could be just logistical availability. It could be two working parents and what’s the quickest thing to get on the dinner table or it could be financially what’s the cheapest option. Oftentimes for generally typically developing kids, if they are pickier, it’s due to lack of exposure or just being around different foods.

Dr. Sharp: Yeah. Do you have any thoughts, I’m veering away from the assessment process although it could be shaped under recommendations, but do you have thoughts around whether it’s okay to “force kids to eat a variety of foods” or how to approach that in general, just introducing [00:24:00] variety, vegetables, particularly, or just novel foods?

Dr. Lani: Once again, every child is different in their personality and how they respond to that it’s going to be different, but we put so many labels on foods from an early age. Like this is bad food, or this is good food, or this is healthy, or this is unhealthy, or this is a breakfast food like eggs. So we can’t have eggs for dinner. Or if we do say, oh, we’re having breakfast for dinner. And so, the little ones pick up on that right away like, this is bad food, or I can only have two M&M’s or a cookie after I ate the yucky food, things like that.

And so I think being cognizant as parents of just taking away some of those labels and so presenting it, but not putting pressure around it like you have to eat this or you only get a cookie if [00:25:00] you finish all your broccoli.

The other piece I often see with that too is talking through the parents about what is a reasonable serving size because if you’ve got a 3 or 4-year-old, then you’re talking three to four tablespoons is a general serving size of food. And oftentimes, I see little ones and they have these adult serving sizes that are put on their plate. And so, just that visually can be very overwhelming to them of, oh my gosh, I have to eat all this. And stepping back and think about what a tablespoon actually looks like because a really general guideline is one tablespoon per year of age per food.

So if you have a three-year-old and you’re wanting to get them to eat some broccoli or carrots or green beans, whatever the vegetable is, then about three tablespoons. And that’s about three green beans, two little broccoli trees. [00:26:00] I mean having reasonable expectations in terms of how much you actually want them to consume of that vegetable or whatnot.

Dr. Sharp: I got you. Okay. That’s helpful. I hadn’t heard the tablespoon guideline, so I appreciate that. And I appreciate you bearing with my finley veiled attempt to get recommendations for my kids. Thanks for indulging in that.

Dr. Lani: Of course. Just keep presenting it. I talk a lot with parents about reading it in books, seeing what activities the library has to offer to talk about foods or food activities, including the child as much as they can in preparation, and just knowing that oftentimes little ones are more drawn to fruits. Fruits have more sugar content. And so developing a taste for vegetables naturally can take longer. Some little kids though don’t like sweets. And so [00:27:00] they are more drawn to vegetables, but just in those first, 5, 10 years of life, their taste buds are going to be changing and developing too.

And also the reminder of parents of just because they aren’t eating it now doesn’t mean they won’t be eating it six months down the road. So keep providing that exposure because oftentimes I hear families say, oh, well, they wouldn’t eat it once. And then they never presented the food ever again.

Dr. Sharp: Sure. That’s a good reminder that we don’t need to close the door on everything after the first time.

Dr. Lani: Yeah. Just in a non-threatening manner so to speak of giving exposure and access to it. And as they become more familiar with it, there are some things they may never like.

Dr. Sharp: Yeah. I have thought about it a lot personally and professionally, just in terms of [00:28:00] exposure and not forcing kids to do anything, but just have it around. Make it the norm that this is what our family does and over time it will hopefully get less scary.

Well, I wonder if we could talk about the actual evaluation process. And I hope that we might approach this from two different directions. One, I would love to hear about the pre-planned feeding evaluation and what that looks like, where someone that’s what they’re coming for. And you have your process. But I’d also like to approach it from the side of what we need to be asking about or aware of for “non-feeding evaluation”, like normal evaluations that might show up as red flags for feeding issues that we can then pursue a little further. Does that make sense?

Dr. Lani: Absolutely.

Dr. Sharp: And you can tackle those in whatever [00:29:00] order you would like.

Dr. Lani: Generally, during my feeding evaluation, usually I get about three hours, which I know is unheard of for a lot of you out there, especially SLPs or OTs. They maybe get 60 to 90 minutes. And those first two treatment sessions are still like the evaluation process. I know I have a luxury in that realm, but usually, it’s a diagnostic interview with a very extensive feeding history followed by a feeding observation and then an informal skills development observation as well. So three parts to it.

In that interview, going through all the basics as you would’ve any other diagnostic interview with family history and medical history, developmental history, but then on that feeding piece, really diving in and figuring out what mealtime looks like in the family [00:30:00] household. I ask a lot of questions or make statements like describe a typical meal time in your household, or describe a time when feeding was easy or was difficult, or describe a time when feeding became problematic between you and your child, things like that. really looking for that narrative to get an understanding of their story and what’s happening during the feeding times things like that.

And then for the feeding observation, I ask families to bring 3 to 4 preferred foods and 3 to 4 non-preferred foods because I usually find then maybe we’ll get 2 each if I say 3 to 4. So I tried fatted a little bit because I want to see how are they responding to the foods they are eating and then how are they responding to presentations of foods they don’t like or have never [00:31:00] eaten.

I don’t have the luxury of a one-way mirror anymore. So I am in the room with families when that’s happening. I sit back and watch how the food’s presented because are they presenting a child-size portion or coming at the child with a large serving spoon that’s even too big for an adult I’ve definitely had that happen too. And so, looking at what is the child naturally doing? What are the behaviors the parents engage in in terms of food presentation, parent-child interaction patterns, and things like that? And then as all of that’s happening, looking at those developmental skills more like their cognitive level, fine motor skills, social communication skills just to give me an idea when we’re going into treatment in terms of what’s going to be asked of them or do I need to take any of those, like their developmental level into [00:32:00] consideration and that type of thing?

Dr. Sharp: I see what you mean. Can we go back to the interview quickly? Do you use any structured interview format for the feeding portion or is this something you’ve developed over the years on your own?

Dr. Lani: Totally. That was the very cliff notes version of my evaluation and such. I just really use what I’ve developed on my own- all those pieces that I’ve picked up from other disciplines, because I’ve had the privilege and opportunity to work with all these other disciplines on a regular basis and learn their approach and what questions they take some from.

So I’d say it’s more of a transdisciplinary approach to my interview is off, that even if I am not the SLP, I’m still going to ask all those oral motor questions, speech and language questions. And then being aware of where my scope of practice- is this something I can handle in [00:33:00] treatment or do I need to refer out for that?

Dr. Sharp: I got you. I think I was struck by how you are asking questions from a few different disciplines and just balancing all of that and knowing what’s important.

Okay. You got your interview, which sounds pretty thorough, and then observation, which you described, and then from there?

Dr. Lani: Sometimes I will use… There’s the pediatric eating assessment tool. It’s called the ChOMPS- the Child Oral Motor Proficiency Scale. And those are both free on feedingplaque.com. And I have all these resources under my resources on my website because who doesn’t love a free assessment? And so that can be a really good way, especially if you have an admin sending out paperwork before the appointment, that the information on those assessments can be a way to [00:34:00] spur conversation or see what those most problematic areas are to tailor the conversation a lot around those.

Or if there does seem to be a lot of emotional behavioral concerns or family functioning, I might throw in a BASC or something. There’s also a feeding impact scale. So that’s specifically looking at that stress anxiety piece with families. Typically, just because of time constraints, even though I do have a lot compared to most, I don’t do one as a standard protocol, but just depending on where the interview leads and such if I feel like I need more detailed information or we’re on a shorter schedule and so getting some more of that information pre-evaluation then.

Dr. Sharp: I got you. That’s a good point. Do you at any point, aside from these ones that you mentioned, [00:35:00] BASC maybe, or some of these measures that are available online, which we’ll link to, by the way, are there other standardized processes for this kind of evaluation or is it a lot of interviews and the observation and that makes up the bulk of the assessment?

Dr. Lani: I would say, just talking across disciplines too, that makes up the bulk of the assessment. Depending on how that feeding observation is going, I’m definitely going to hang back initially and see if behaviors come up or refusal or the kids throw in the food across the room and how the parent responds because that’s always very rich information then to use for treatment.

But then I might come in on the back end of that and try and do a little work myself, or just see if the food’s presented in a different way or with a new person, like how is the child going to respond because sometimes they respond [00:36:00] surprisingly well in that when you actually give them structure and behavioral interventions right away, they can quickly adapt. And that’s very telling it too, or other times if there are major sensory versions, you can’t get in within 5 feet of them.

I recently had that with a little girl last week, a two-year-old and she has had a very extensive medical history and so many painful procedures. And understandably so, anything remotely looking like a doctor’s office, even though mine’s a standard office not medical, just full-on meltdown to get in the door. I could talk to her by the end of it from like a 5-foot distance, but once I tried to do some more looking at her oral motor and her chewing, she was not having it. And so we decided not to push it, but really [00:37:00] varies based on what the child brings to the table.

Dr. Sharp: I got you. I want to get really granular with this just because I’m trying to paint the picture. While you’re doing this feeding observation, are you taking notes? Are you typing on a computer? Are you videotaping it? How close are you? Any of those components just to fill in the details of what this might look like.

Dr. Lani: I’m usually pretty old school on my note-taking- so paper and pen. Throughout the entire observation, usually in my left column, are all the behavioral observations of the child. So, cognitively, speech and communications, social interactions, any red flags for ASD, or anything else. I’m documenting all of that. And then as well as the parent observations as well too. Is there something significant about how they’re interacting with the child or [00:38:00] as soon as the child throws the food across the room, they get to leave the table?

And so there are all these avoidance behaviors.

I scoot my chair back as much as I can, but my office, I’d say it’s a pretty standard size office. And so it’s not overly large and it’s not like I can really move away too far to speak, I mean, I’m within 10 feet or so, so sitting back as much as I can while taking all of those notes with pen and paper.

Dr. Sharp: I got you. Nice. Then what happens if you notice things? Maybe this flows into the wrap-up or feedback if that’s part of the deal, but what happens if you notice things that warrant further evaluations say for autism, or I’m not sure, motor concerns or something along those lines? Where does that come into play?

Dr. Lani: That really depends on [00:39:00] the payer source because I have been given strict guidelines by the state of our early intervention program that if I’m doing a feeding evaluation, I can only comment on the feeding evaluation. Even in my report, I can’t put anything about autism or recommendations or the next steps for that. And I’ll definitely mention it to family and have an off-the-records conversation because I feel like my responsibility as a professional, if I see a significant area like, oh, this is probably a play and a role in these feeding difficulties kind of thing, someone needs to address that, but highly variable.

If it’s just me and it was a private pay self-referral, then yes, we will definitely put a halt on the feeding if we need to, or finish that evaluation or have the conversation with parents of, oh, I think maybe there’s a larger [00:40:00] overarching diagnosis or question here that we need to do some more testing and pivoting away and reprioritizing where does this evaluation need to go.

Dr. Sharp: I see. And are you doing this whole process in one day? It sounds like it’s just a three-hour block. The families come in, they hang with you for a while and they walk away with their answers, I suppose.

Dr. Lani: Hopefully, yes. Hopefully, we have a lot of answers. I have a selection of toys, I’m sure like many clinicians that are very specifically chosen to look at all those developmental areas. And so, yes, just based on timing. A lot of times I start with the interview so the child is able to play while I’m focused on mom and dad. And then when they start expressing they’re hungry or after we’ve finished up the core of the interview, then we’ll move to the [00:41:00] feeding observation time.

And then once I’m able to see that and figure out, is this a skill issue or sensory or where’s treatment going to go, coming back with them and doing brief feedback or gathering more information enough to say, okay, here’s our game plan. Here are our next steps. And definitely sending them with a lot of practical recommendations the day off but then also with the plan to follow up with treatment or whatnot.

Dr. Sharp: I got you. What might be some of those recommendations, knowing that it varies case by case? Are there any common recommendations that come out of these evaluations that you could speak to?

Dr. Lani: So if it’s an oral motor concern and they have really low tone or their chew pattern has not been established, and so, it’s really a skill issue [00:42:00] that they aren’t able to move to those more complex table foods because they don’t have the skills to do so, things like different chewy tubes, we might use like the Beckman oral chew.

I might talk through with parents like 20 minutes a day and we’re going to count and chew on each side and would walk them through the placement of that. Walking through tongue lateralization. Are they able to move that food around in their mouth and get the food pushed over to their molars? So many of these things are simple for many of us. And we’ve never actually thought through like, oh, that’s what my tongue’s doing. Or it’s moving that bowl list of food over to my molars.

And giving families really practical steps of daily things to be doing to work on all those types of skills. Or maybe if it’s more of a sensory, if it’s tactile visual touch, giving them different things that each [00:43:00] meal or even between meals that they can be working on to address those concerns, or maybe it’s the logistical environment of the feeding because really step one is can we get the child sitting in a chair so we can be doing some focus work?

Because I’d say it’s probably more often than not when I ask, okay, tell me about meal times, the child is on the couch, in front of the TV, or they’re on the floor, they’re in their bedroom or just wherever they end up. And so sometimes it’s those initial behavior things of like establishing we are going to sit at the table when we eat. We’re going to have a structured meal time.

Grazing is another big issue I always talk about families with. And sometimes kiddos just have full access to food throughout the day. They’re going to get it themselves. A big culprit of this is the juice [00:44:00] in the sippy cups. And especially for kiddos who were having some growth issues, parents often see it as well they’re eating or they’re drinking. So I don’t want to take that away. But then a lot of psychoeducation around if a little one is grazing, they might consume as much as 50% less in their overall intake, because they’re never really establishing that hunger cycle. And if they have full access to juice or milk that they’re just sipping on for 8,10 hours a day, then they’re really decreasing their overall calorie intake because of the Grazing.

And that’s really hard for a lot of those parents when there are those growth issues because they’re so afraid to take things away. But grazing is definitely an issue yet that I address right away and talk through with families.

Dr. Sharp: I got you. That is interesting. I [00:45:00] didn’t really think about it like that, but that makes sense. Just thinking about this grazing phenomenon. I can see how families probably have a hard time controlling that, especially if kids get a little bit older and there’s an open pantry or something, what do you do? Do you lock the food up? Do you put it on a higher shelf? Then it’s like you’re restricting the kids and that doesn’t seem right either. That’s a complicated issue.

Dr. Lani: Absolutely. I think one of the keys we talk about is establishing some type of structure around meal times and snack times. So at least a general three meals a day, two to three snacks. And giving them plenty of access to food, that’s really no more than two and a half, three hours [00:46:00] they’re waiting, and access to like water or a little bit of liquid between those times. But I think increasing that predictability of they know when the next snack or meal time is, then doesn’t feel as much like the, oh, I’m hindering them or I’m blocking them.

And when you have that structure to some extent in place, then you know that your child, if they come to you and ask for another snack, maybe they’re in a gross spurt. Maybe they’re hungry and little ones are actually really great at regulating their caloric intake and needs if we would just give them the space to do so.

And so, another thing I often talk about with families is, one day a child may eat adult-size portions and they’re just famished and hungry all day. And then a week later they’re eating maybe like a little church mouse and they’re eating two bites. And yes, [00:47:00] helping them to learn those hunger patterns early on in that intuitive eating of what does my body need is my body actually hungry right now because on the other end of this spectrum from grazing and full access, we don’t want to make it a controlled issue and create bad foods, good foods and you can only eat at these times, but that flexible structure, I guess you could call it off knowing, okay, if my child comes to me and asks for another snack, maybe they’re just a little extra hungry that day. We all have those differences. And so, being aware of that.

Dr. Sharp: I got you. Nice. What about those evaluations that come to us that are not for feeding specifically, but there may be some feeding stuff going on, like what are some things we need to be watching out for or asking about just to tap into that area if it is present?

Dr. Lani: I think the general thing of asking about their [00:48:00] diet, like, what does your child eat? As long as they can describe at least a handful of foods from each food group. There are at least a few fruits and vegetables. There are some protein sources. There are some calcium and some carbs. They’re probably doing okay overall if there are not any major red flags in terms of nope, they have that white-brown diet and they are eating a total of five foods. And that’s it.

So looking at the quality of the foods they’re eating and also their overall food eating patterns like the grazing we just talked about, is there something hindering they’re eating? Definitely, with kiddos on the spectrum, those restrictive interests and behaviors can enter this where they can only eat off of one plate, sit in one chair at one meal time with one caregiver present and their food cannot touch. [00:49:00] Are there very restrictive rules that are impacting either the child’s functioning or family stress, things like that?

Dr. Sharp: Sure. I got you. This is such a fascinating world. It’s really got me thinking about what typical eating and feeding looks like and ways to integrate this information into our evaluations a little bit better. Feeding is a big part of many of my family’s lives and struggles, I suppose.

So, we’ve talked about the autism spectrum quite a bit in terms of a maybe overlapping diagnosis with feeding issues. Are there other mental health concerns that you tend to see feeding issues getting wrapped up in or things that well, just a higher incidence that we should be aware of?

Dr. Lani: I’d say the [00:50:00] autism and a global developmental delay probably are the two most common ones, at least that I see clinically because if there’s a global developmental delay, is there something medical that’s underlying, or is it a skills issue or are there cognitive skill is actually lower? Or is it maybe we are looking at a little spectrum me or even some early signs of ADHD, things like that?

How is that parent-child relationship? That’s one thing we haven’t touched on yet, but feeding is one of the first areas that little ones can control. And so if there’s a lot of things out of control in their environments, or especially with foster kiddos or just a lot of changes in caregivers or instability, financial stress, you can see that control factor often come out in the feeding behaviors.

Dr. Sharp: I got you. Do you know how much truth there is to that idea that [00:51:00] kids with attachment concerns, food hoarding, and so forth, what the research looks like on that, and if that is “a real thing?”

Dr. Lani: I haven’t seen any specific statistics looking specifically at like attachment disorder to feeding, but in the realm of foster care, a lot of changes in caregivers, even if it’s moved around with different family members, I think it’s pretty well established of those hoarding behaviors, or I even see it in the littler ones, like the under five of really stuffing their mouth and overfeeding themselves at meals to the point of like being sick. And so that can be an issue we have to directly address too.

Dr. Sharp: Right. That makes sense. I’ve run into some kids that seem to have very little awareness of their level of being [00:52:00] satiated. Is that the right word?

Dr. Lani: Mm-hmm.

Dr. Sharp: And typically, when I hear that, I might ask about other difficulties with body awareness that goes along with say autism or something like that. Do you run into that kind of thing as well?

Dr. Lani: In terms of their eating too much or too little or both of them?

Dr. Sharp: Yeah. The times I’m thinking of it’s too much. They just eat and eat and eat with no sense of getting full or they say they’re not getting full, and parents are like, oh my gosh, what do I do with this? Our kids are eating. And this is like months at a time. It’s not a phase.

Dr. Lani: I don’t have any research to support this, but just clinically, when I’ve seen that most frequently, it’s often the children that are actually on the smaller size of like the growth chart and stuff too. So it’s not like an obesity overweight issue, but just that if a parent wouldn’t intervene, they would keep eating and eating.

[00:53:00] I had researched some of this lately because I had a two-year-old with this and she was just a tiny little peanut, and what she was eating and I had observed her eating was really impressive. I even talked with a pediatrician too. And I’m like, do you have an explanation for this? Or like this logically does not make sense of how she’s consuming this. He’s like, “I really don’t.” He’s like, “So far, she seems healthy. There’s no other red flag.” He is like, Parents are stopping it appropriately, but then once again, it becomes that fine line too of taking your cues from the child when it seems like something’s a little off. I don’t have any good research to support the reasoning behind that or whatnot.

Dr. Sharp: Sure. It’s so interesting this. I’m going to be thinking about [00:54:00] this information for a while after we end our interview.

Dr. Lani: Just so many pieces to that puzzle of underlying etiologies or multiple areas of concern, interacting with each other. And there’s like all the medical stuff and just the basic skill. And then you throw in this whole psychology, parent-child relationship, anxiety, mental health.

Dr. Sharp: Right. Well, that’s the one thing that stands out from our chat here is that you just have to be aware of a lot of things during these assessments. Like, you are looking at the medical component and the physiological component and the behavioral component and the parenting and food choice and habit. I mean, there’s a lot to keep track of when you’re in these assessments.

So does your process change at all if it’s not one of [00:55:00] these state agency referred cases which leads to other questions, I suppose? I mean, would insurance cover this otherwise, or is it just private pay or how does the process differ if it’s not one of those state referrals?

Dr. Lani: Generally, I’d say it looks pretty much the same. Three hours is a good timeframe for me to get a good understanding and assessment of what’s going on. In terms of insurance logistics, it’s probably you’re going to be billing that 90791 like that diagnostic interview. And then in terms of any testing, oftentimes I think we would come at it from anxiety or a family relationship or some psychology term, so to speak, to get approval to do some more testing evaluation, but probably just that diagnostic interview is the biggest piece you’ll be [00:56:00] billing under. And then any feedback session would be, I think 90847 is the family treatment code. So it would be using that one for it.

Dr. Sharp: I got you. Cool. And do you have thoughts on, let’s say someone wants to add this thing to their practice and they have the expertise to do so, who do you talk to? Who do you network with? Where might these referrals come from?

Dr. Lani: I think a lot of them for me anyway, and I think just in the state of the field is probably the speech-language pathologists, the SLPs, and the occupational therapists- OTs, because they are probably two of the biggest providers in terms of just the ongoing treatment.

I know for myself being in private practice, I’ve definitely been intentional about trying to align myself with some of them. But more so even just for myself of, if I do get a child in the office and they’ve got really [00:57:00] significant world motor and I’m like, I think I need to bring in SLP in at least a consult or to an evaluation around all feeding or if there’s been swallowing studies done. And so, looking to those other disciplines to almost create your team around you when you don’t have one in-house that you’re able to establish that to a path with just consultation and referrals.

I will say though, I’ve definitely gotten a lot of questioning looks when I say I’m a feeding therapist or feeding specialist because I think outside of children’s hospitals or your major medical centers, I don’t think psychologists in terms of feeding are that visible. I know a lot of just introducing myself to other SLPs or OTs and they’re like, wait, you’re a psychologist doing the feeding. How [00:58:00] does that work? What do you really know about feeding?

I have gotten a lot of skepticism just as a psychologist trying to create that informal team around me of, oh, what do you bring to the table? What does a psychologist do as a part of a feeding team? So at least in Indiana, anyway, that’s been my response I’ve gotten a lot.

Dr. Sharp: I got you. That’s a good disclaimer. And I can totally see that. I think like I said, in the beginning, this is a realm that I’ve traditionally experienced happening with the SLPs or OTs or PTs. That makes sense.

I know that you have been working hard and you’ve been very, I think, modest and understated throughout our interview, but you have a lot of resources for people who might want to learn more about some of these things. Can you just talk through some of those resources if people are interested in learning more or [00:59:00] perhaps would want to get in touch with you if you’re open?

Dr. Lani: Oh, absolutely open to other people reaching out consulting. I do have a Facebook group it’s called Eat, Play Thrive for Professionals. It really stemmed from, I would go and do these presentations a lot at like state conferences, and then I would have SLPs OTs, and early intervention providers coming up and saying, oh, do you have more training or do you have a group? They were looking for more landing spaces because they were all doing the feeding treatment, but didn’t have those expertise or training opportunities around them. And so this Facebook group really started as a response to that, but I love it too, because from the beginning, my focus has been interdisciplinary and transdisciplinary, and so I love learning from other disciplines.

And then on my website, dr.lanijones.com. All the resources I’ve referenced on [01:00:00] here like those free assessments, the feeding matters, the pediatric feeding disorder paper, all that’s listed under my resources as well. So one-stop shop to get some of the things we’ve talked about today.

Dr. Sharp: Nice. That sounds good. And I’m a member of your Facebook group just because I’m so curious about this topic, and I have to say, you are very active. You have cool infographics. You make useful videos that people actually want to watch. So, if anybody is interested in this area, definitely check that out. I’ll link it in the show notes so that people can find it. And I know that you have been working on an ebook lately, and that is about ready to roll. Right?

Dr. Lani: Yes, that has just gotten released on my website. It is focusing on the familial impact of stress and anxiety. [01:01:00] It’s written for professionals, but also I wanted to make sure it was parent friendly though. And so trying to make sure there wasn’t too much lingo or terminology. So if this is your first exposure to feeding or you’re like, where do I go next? It’s a great introduction of giving an overview plus focusing on that stress, and anxiety piece. Or if you are a veteran and you’ve been doing it, but then you’re like, wow, it’s maybe been a while since I’ve really thought, is this family stress, anxiety, impacting my treatment?

Dr. Sharp: Nice. And I have to say too, I got “an advanced copy” before we started recording and it looks amazing. This is one of the best-looking eBooks I’ve ever seen. And it’s substantial. There’s a lot of information. This is not just a few pages thrown together. So I have to give you a shout-out for that. Thank you. You did a really good job with it. And [01:02:00] I think it has a lot of good information for people.

Dr. Lani: Thank you. Yes, I hope it’ll be a good tool and will spur just someone’s desire to get more training or more information or whatever it is they need to fill in their practice gaps.

Dr. Sharp: Sure. Well, Lani, I am very appreciative of all the time that you spent with us today. I’ve learned many things and I think others probably did too. Thanks for coming by and spending some time with me.

Dr. Lani: Well, thank you so much for having me. And yes, if anyone would like to reach out and consult because I feel like we just touched the tip of the iceberg here because there are so many directions we could go with that, but I always love the opportunity to have this discussion, so thank you.

Dr. Sharp: Yeah. All right. Take care.

Dr. Lani: Bye.

All right y’all. Thanks for tuning into my episode with Lani. I hope you’re taking away a lot of helpful tips as usual, and if nothing else, increased awareness of how feeding and eating [01:03:00] issues might come into play with the kids that we work with.

Like I mentioned at the beginning and during the show, Lani has a lot of resources on her website, which is drlanijones.com. That’s where she maintains Eat, Play Thrive, which is her speaking and consulting business related to feeding and eating intervention. So check that out. She has a fantastic ebook that does not even look like an ebook. It looks like a real book, which is incredible. And she has a family resource guide among many other resources. So check that out. Those are all listed in the show notes as well.

All right. I hope everyone is doing well. Staying healthy during the COVID-19 shutdown and doing your best work.

All right, I will talk to you soon. Take care.

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