[Dysphagia] Conditioned dysphagia

[mcgill50 at comcast.net (Pat Burns)]

Hello Dale,

This is not an uncommon condition in the population that I treat - birth to 
5.  Most of my kids have an intact swallow  but the sensory , mechanical, 
gut,  or the poor learning experiences with eating because of these issues, 
are the problem.   The variations in food acceptance across texture are not 
at all uncommon after a choking event.

All thoughts that follow are based on the Sequential Oral Sensory feeding 
protocol developed by Kay Toomey Ph.D.  (Toomey and Associates Denver, Co) 
If you work with children or adolescents I highly recommend her trainings. 
SOS is absolutely the most "behavioral" feeding protocol I have ever 
learned- and the absolute opposite of the traditional
" behavior" programs, and it works ( better, faster and more rational!)

The program I would use with this young man would be a variation of Dr. 
Toomey's "Food Scientist " protocol.

 I will provide some general thoughts-but there is nothing like training 
with Dr. Toomey for developing a treatment protocol for a kid like this.

 Look carefully at the mechanics of the chew.  This child could be 
overstuffing because of poor motor control -  if he puts enough food in his 
mouth- eventually something will hit the teeth and get masticated! In other 
words was this kid a choking event waiting to happen?

Think about sensory awareness in the mouth.  I suspect because of the 
anxiety and ADHD you mentioned that this young man may have a problem with 
the sensory area.  The mechanics are ok, but the feedback and awareness are 
off.

 No matter what I did to treat the underlying cause of the choking event, my 
treatment program would include a lot of food exploration with the other 
senses- how does it look, feel, smell, what happens when I smash it with my 
hand?   I would  do a ton of work across all 6 food textures with a lot of 
chewing and spitting out and evaluating the size of the masticated pieces 
against swallowable pieces. Also evaluation the size of the "bites"  because 
I suspect there might be overstuffing.  Give graphic representations.  Show 
the size of a bolus that will go through easily- and the size of a "to big 
bolus"  don't worry about segmental swallowing- you are teaching control and 
reducing anxiety about choking. I am talking about drawing a "swallow sized" 
circle,  taking a bite, chewing it spitting it out and evaluating -is this 
too big, too small or just right to swallow.  And how small are those chewed 
pieces? If I chew 10 times and he chews 10 times are the size of the 
masticated pieces the same?  It is gross-- but boy does it work.

 Talk and learn about food in terms of its inherent properties.  Bring the 
cognitive into the picture. Start with accepted foods and find foods that 
are similar but not exact in properties.  Praise, praise every interaction 
with any non preferred food.

If you treat a varied and  non dysphagic non eaters- SOS is the training you 
want!

Also, Dr. Toomey's office can refer you to a therapist trained in this 
methodology in your area, and you can refer this young man to that 
practitioner.

Hope this helps

Pat Burns