The Role of a Speech Pathologist in ARFID

Speech Pathologists can assist the treating team by understanding the following:

• How to assess how safe the individual’s swallowing skills are.

• How to assess how efficiently they can drink and eat the foods in their diet.

• How to assess the oral sensory skills of the individual, helping the treating team to understand how the individual experiences the sensory properties of foods and thus directing treatment goals through appropriate strategies.

1. Swallowing Skills

Swallowing is a reflex and essential in everyday life. Swallowing involves split-second timing to achieve a safe swallow, and mistimed movement can lead to food or drink going down the ‘wrong way’ or aspiration – that is, food not going into the stomach but into the lungs.

This can cause lung infections and damage. Swallowing problems can result in not only pneumonia but choking, poor nutrition, and dehydration. Eating and drinking can be uncomfortable, stressful, and frustrating. Children who have difficulty swallowing might not take in enough nutrition to support growth or brain development.

An assessment of the individual’s swallowing function is essential. Some individuals with ARFID may present with a fear of choking or may gag and cough when eating some foods and drinks. It is important to rule out any pathology causing these symptoms to help make a diagnosis.

The speech pathologist performs a clinical swallowing assessment to assess feeding safety in several diverse ways:

• Taking a thorough case history and asking in-depth questions about eating and drinking skills (see below for details).

• Observing the individual eating and drinking their everyday foods.

• Performing an oral motor examination, which involves looking inside a child’s mouth to assess the oral anatomy or structures, and oral motor function or movement.

Speech Pathologists can assess swallow safety by asking the individual and/or caregiver the following questions:

• Has there been any choking incidents? Describe what happened.

• Has there been any coughing during drinking or eating? Describe what this has looked like and whether it is ongoing.

• Have you been concerned about gagging?

• Are there any foods you avoid because you worry about how your child manages these textures and you are concerned about them choking, coughing, or gagging?

• Have you noticed any difficulty with swallowing drinks or foods?

If the speech pathologist has concerns that the individual might be aspirating, that is, food and or liquid ‘going the wrong way’ into the lungs when swallowing, then further investigations might be required in consultation with a GP and/or paediatrician.

2. Feeding / Eating Efficiency

Mealtimes can be tiring for children as they are using a range of muscles to be in an advantageous position for feeding, but also using fine motor movements in the mouth and fingers if they are eating solids. Feeding and eating efficiently allows children to obtain adequate nutrition and hydration before they fatigue. Children who have motor or sensory difficulties, as well as attention difficulties, can take a longer time to eat. When children take along time to eat and drink it impacts the time they have to do other activities and this can be frustrating and stressful for other members of the family. The Speech Pathologist works with the treating team to ensure that children are eating/drinking enough to grow within a timely manner by considering things such as the oral motor and sensory skills, mealtime routines and environment, and enjoyable mealtimes for the whole family.

3. Oral Motor / Sensory Skills

Oral motor development is assessed by:

• A thorough case history (see below for details).

• An oral motor examination.

• Observation of the individual eating and drinking, as well as observing the individual in everyday activities, such as at rest, play, home life, and social interactions.

• Observation of the child’s overall development, including speech and language skills, and gross and fine motor skills.

Oral sensory skills are assessed by:

• Obtaining a thorough food diary, a list of foods accepted by the child, and considering the different sensory properties of these preferred foods, to build a sensory food profile.

• Observing the child’s interaction with food, utensils, and the feeding environment during mealtimes, and noting sensory sensitivities and preferences.

• A thorough case history of oral motor development in early feeding and mouthing experiences.

• Taking note of other sensory sensitivities and preferences outside mealtimes and considering an occupational therapy assessment to explore further.

Taking a Feeding Case History in ARFID

Understand the individual’s early feeding experiences

• The child’s feeding/transition to solids history i.e. breast or bottle feeding, the introduction of solids, the progression of introducing solids over time, transitioning to alternative cups/bottles.

• Medical history - medical issues or episodes can influence how a child’s feeding skills develop and their enjoyment of mealtimes and eating and drinking.

• Child’s developmental history such as motor, social, and communication skills is important as they can impact the feeding development and experiences.

• Any event that might have precipitated a change in mealtimes for the child, such as a new sibling, starting daycare, any trauma.

• What things have been tried by the family to address the feeding issues and what was the outcome?

Understand the individual’s current feeding and eating

• Child’s current feeding and drinking e.g. the textures and tastes of the foods the child prefers to determine their sensory preferences, which foods are consumed safely and efficiently.

• Individual's oral motor skills and oral sensory preferences.

• Communication around eating and mealtimes e.g. how children interact with or describe the foods they encounter, how parents and carers respond to those behaviours, and how the child’s feeding challenges might impact them and their family.

The swallowing, oral motor and feeding skill assessments help inform the treating team to make an appropriate diagnosis and guide treatment planning.