Episode 297: Navigating the Complexities of Feeding Therapy with Amy Williams MS, OTR/L, SWC

Hi and welcome to episode 297 of the Untethered Podcast. Today we have Amy Williams joining us. Amy is a pediatric occupational therapist, feeding specialist and founder of San Diego Feeding Therapy. In providing clinic, school based and in home experiences. Amy loves to help take the guesswork out of mealtimes by providing concrete strategies to help restrictive eaters try new foods, tolerate changes at the table and become confident nutritious eaters. In addition to providing child led and neurodiversity affirming in home feeding therapy, she also has an advanced practice certification and swallowing assessment and evaluation or intervention. Amy brings a unique sensory regulation and oral motor approach which works holistically with the child and meets a family wherever they are comfortable with respect to food. Quick disclaimer. All information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Holly Balkan. I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019, thanks for being a loyal listener. As we jump into today's episode. Remember to listen with correct oral rest posture, tongue up, lips closed, teeth apart.

Breathe through your nose.

Let's get started. Hi Amy. Welcome to the podcast.

Hi. I'm really excited to be here.

Um, before we jump in, first of all, I just want to say thank you for obviously being one of our creators of a course inside of our pediatric feeding certification. I know you have your own courses which we'll talk about later, but we were really excited to have you, you know, dive into supporting complex sensory feeders. So just a big thank you for that.

Yeah. Excited to be included in this great education course.

Yeah. So before we jump into like, you know what, what it is you're doing now, I know that you have a little bit of a backstory about how you even got into what you' today. So if you're willing to share that with us, I would love for you to tell everybody a little bit about you and kind of what brought you to Even doing this work.

Yeah. So I mainly focus on feeding therapy. And that really started because both of my sisters, both older and younger, are crazy picky eaters. Very restrictive in what they like, what they don't like, and I am not allowed to help them at all. I've tried for years. I've tried all the strategies I could think of, and they both are like, I see what you're doing.

Stop it.

So my older sister is neurodivergent, she's autistic, and a marriage and family therapist. And then my younger sister is neurotypical and a physical therapist. So they are both in the same allied health feeding world that I am. They both have worked with clients that have feeding difficulties as well. But it really kind of has given me a great perspective on what that family dynamic is and how sensory preferences and complex feeding needs can show up and present very differently even within the same, you know, family dynamic.

Wow. So, I mean, I think, I think that's such an interesting perspective to hold as a feeding therapist. Right. To have had that own, your own life experience, especially because they won't let you help, like, you won't. They won't let you help even like today. And so I'm sure that, like, you can see, I know you put here that basically, you know, supporting complex feeders is not a one size fits all. So I would love to, like, dive into that a little bit because I think that is a constant theme that has come up for me as a feeding therapist in my years of, you know, doing therapy. And that's also one of the things that kept me on my toes and kept it exciting for me because I was like, I was always having to think and like, put on, put on the thinking hat, get creative, like, try to figure out, like, okay, this worked last week or this worked for this kid, but why is it not working now? What are we going to do? So I just, I feel like it always kind of kept me on my toes. But I would love for you to speak, like, to what that means to you. Like, what does it mean to you that supporting these complex sensory feeders is not a one size fits all, like, approach.

Yeah, I think it aligns very closely to what you just said. That, like, you have to be on your toes at all times. Because whatever you did last week, the next 10 minutes doesn't help anymore. It doesn't work anymore. I think the biggest thing is, and a big focus on the course that I created for you all is that there's not a simple plan, a simple formula that you're going to follow. Right. And really what it ends up breaking down to is, is the nervous system feeling safe and feeling regulated, because that's the foundation for everything. I mean, feeding is one of the only tasks we do every day that involves every single sensory system, whether you want it to be involved or not. And so when we're working with these complex sensory feeders, we can't just say, okay, they've got a oral aversion and now I'm going to do X, Y and Z. Like that is only one component of it. We also need to think about what other sensory systems are impacted and involved and how that creates this feeling of safety or lack thereof, and how that can change our approach, like moment to moment.

Yeah, totally. I wanted to reach through the camera and hug you and you were like, nervous system. We have to look at the nervous system. I was like, yes. Oh my goodness. And I feel like I've been talking about that a lot lately. People may be getting sick of me saying that, but I'm like, it's, it's just such an important thing to even mention that. I feel like is not talked about enough in the feeding therapy world. And then the other thing you mentioned too, just like that, there were evolving. We're involving every single sensory system. Right. So you mentioned that. Like, you know, but beyond that. So can you tell us a little bit more about like what those sensory systems are? Like, what systems are you talking about?

Yeah, so we have like our basic five sensory systems, like sight, smell, touch, sound, taste. And then we have these like, more hidden sensory systems. And traditionally, especially in the OT world, that has been limited to the proprioceptive and vestibular system. So kind of knowing where you are in space, getting feedback from your joints in your proprioceptive system. And then vestibular would be kind of knowing if you're right side up, upside down, keeping your body safe. But another one that really has become a big deal and should be a big deal, especially in the feeding world is interoception. And so kind of understanding those internal body cues, letting you know, am hungry, Am I full? Am I just losing my appetite? And it's not really fullness. Am I hot and am I cold? And so when we're starting to deep dive into these complex sensory feeders, we can look at what those five outward senses are doing, which is kind of the easiest thing to identify as what's going wrong or impacting what they're doing or what they're not doing. But we actually have to Think further back and dig a little bit deeper be these sensory detectives to figure out are those three basic underlying hidden sensory systems online? Are they functioning? Are they taking in too much information? Are they not getting enough information to keep their body and their regulation online? And so we kind of have to look at the behaviors which to me is a form of communication. What are they communicating that isn't working for them? Because until we deal with that sensory foundation and supporting our sensory eaters in that way, we cannot add more to their sensory system of different foods. Changing the color, changing the plate, changing the texture, making them sit still. Like none of that is going to help their eating long term because their system is so dysregulated already.

Yeah, okay. This is, this is just so good. I mean, I know you say like, like basically a regulated nervous system, right? Basically the sensory systems and the nervous system like that. That ultimately should be our biggest goal. And I think it a long time even as a feeding therapist to realize that in my early days because you know you're, you take courses and you learn about what to do in feeding therapy. And it wasn't until I saw some kids that were completely in fight or flight that it really like, I was just like, they're not ready. They're not ready and able to accept what I'm bringing to the table today. Like both literally and figuratively, like they are not available for this and that's not their fault. Like I need to figure out how to help them. And so in those like my early days I was like, I need an ot. Like I need to bring an ot. I need someone who can help them with their sensory system. Like let's figure out how to regulate them and then we can start to reintroduce, you know, some of these food expansion goals that we have. And really like you said, like you can't work on expanding temperature, taste, color, right, Texture, all the things if they're not readily available for it. And so, you know, I think that's just, it's such a beautiful point to highlight because again we have to regulate. They're not we but like they need to be able to regulate their nervous systems. And I think that falls on us then to teach them how to do that.

Yeah, I think we is the right way to describe that because so much of self regulation is based off of co regulation. We're trying to create that space where they feel safe enough to show us the dysregulation and not feel like they're going to be reprimanded or Told they have to do something different or, you know, ignored and said that's not what you're really feeling. Like your body seems like it's fine. So even if they're showing up in this masking form of pretending like they're okay because they want some sort of reward or positive compliment or create that relationship that they think they need, that co regulation comes into play, because if they're not actually feeling safe and actually showing signs of safety, then we're still not going to be able to make changes when we're at the table.

Yeah. So there. So you're. I'm hearing you say, like, they. They also need to feel safe.

Yeah.

So there's this, like, felt safety. I know you talk about. Can you talk about that a little bit more? Because I feel like that's something that I don't want people to gloss over. What you just. I feel like it's so important that these children know. Not just children, but anybody really, but like, they know that they are safe and that they feel it.

Yeah, absolutely. So that came to my attention through Stephen Porges polyvagal theory. And so we're breaking down our sympathetic and parasympathetic system, typically into those two areas. But what Stephen Porges does is break it down into three. He kind of puts it on this hierarchical ladder where the top of the ladder is this ventral vagal system. It's when we're online, we're regulated. We're in a place of learning and alertness and safety. But if you bump down the ladder because he feels like they're all connected, then we're at this sympathetic system. So that's our typical fight or flight. We're activated. That's where we're reactive. Instead of kind of taking the time to understand what our body's feeling and then respond a different way. And then if we bump down again on the ladder, we end up at this dorsal vagal state, which is being so overstimulated or dysregulated that you're actually shut down. And so the best way for him to kind of explain and for me then to explain to other people is that this feeling of safety is being able to understand all the cues internally and externally. And we're going to take those cues and weigh them. We're going to say, okay, how many of these cues make me feel safe? I have, you know, lighting that's dimmer. I get to sit at a place that doesn't have a lot of people around me. There's not a lot of food in front of me, you know, I just got to jump on a trampoline so I feel regular. Those are all safety cues. But then we have to also think about those danger cues. Am I listening to other siblings running around, Even though they're in the next room? And that screaming is setting me off as mom or dad cooking in the kitchen? And so even though they're not at the table with me, those smells are nearby, and that's making me feel like, oh, no, are they going to come over and make me eat that food next? Are they going to make me smell that food next, Touch that food next? And so they kind of. You have to go in and figure out what is outweighing the other. Are those safety cues outweighing the danger cues or the danger cues outweighing safety? And when safety wins, that internal nervous system is saying, hey, we can stay in this ventral vagal state. I feel connected to my language. I feel connected to problem solving, to those higher cognitive functions. And I'm able to then take on a new challenge. I'm now able to be around a new food or I'm in that ventral vagal state, But I can only handle what's safe for me right now. Right now, my focus is getting my body fed, and that's what I'm going to do. But if you try and add something else to my nervous system, we're moving on. We're bumping down the ladder, and I can't handle it. Yeah. And so that's a big thing with these sensory feeders, Is that they have constant cues. They have to be aware of and to seek out. And a lot of times, our complex sensory feeders Are so conditioned to be in that fight or flight or be in that dorsal vagal shutdown system that that's what their body is trained to look for. They're constantly looking for danger cues because that's how they keep their nervous system safe. And so we have to kind of go in and say, I hear you. This is terrifying. Your body is terrified. But what can I do to make you feel safe again? To help you realize that there's a space for you to grow and to learn and to feel listened to and connected. And a lot of times that, like, isn't at the table at first. So you're creating this bond and this felt safety away from the table, and then slowly bringing it closer to the table, to food, to those challenges that brought you into therapy in the first place.

Yeah, I love that. I love that you're sitting here talking about this And I'm thinking about even just like a child with anxiety in general, you know, this is so applicable to, so you, you said something that really stood out to me that they're so conditioned to seek like almost like the negative input, right? Like the, the, the danger cues. Like what, what could possibly go wrong? It's like instead of thinking about what could go right or how could this be successful, it's like your brain is just already conditioned to be like something's going to go wrong, what's it going to be? Like what is going to go wrong? What's going to happen? What do I need to expect? Right? And so just a completely different way of living in a sense. Like your brain is just in a completely different place. And so I was like listening to this and I was like, wow, this is like, I mean it's, it's just, it's brilliant really. But like it really applies across a lot of our kids, even our not, you know, non feeding patients, the kiddos that will come into our, our therapy rooms and, or, and you know, we go into their homes or schools and they, they, I talk a lot about like we need to be, they need to be regulated. Like we need to be regulated. And I, like you brought up the co regulation too, because I often, you know, I think it's one of the hardest conversations, at least for speech pathologists to have with parents. It comes up a lot. Or it's like, how do I tell this parent that they need to chill out so their kid chills out, they're.

Feeding off of all of that energy, those danger cues, right? If the parent is terrified that the child's going to choke or have a meltdown or those are all warranted fears, but their anxiety and their nervous system dysregulation is just absorbed by our complex sensory feeders. Whether they're telling you or not, they're going to show you that they, they've absorbed it and they're reflecting it right back.

Yeah. Okay, so you also have something written here, sensory cup and flipping your lid. So I don't want to gloss over those, those phrases either for me. And this is kind of what, I don't always refer to it as a sensory cup per se, but I've told parents, it's like imagine that you have like 10 buckets of energy and you know, it's like you get, you get up in the morning and if you're a kid who has a dysregulated nervous system and all of a sudden it's like brushing your Teeth. Took entire bucket away. And putting on your clothes, took an entire bucket away. And just getting to the kitchen, took another bucket. And then eating breakfast is another bucket. I'm like, by the time you get to school, you maybe have five buckets left. We're starting on like 50% energy at the start of the day, right? And so, and I kind of explain this to parents because when I'm trying to explain just nervous system dysregulation and how we really want to focus on kind of supporting them and everything and kind of keeping them out of fight or flight and why also sleep is important, all the myo stuff, you know, I think it's, it's interesting, but I'm wondering, is like a sensory cup, is it something similar to like that concept?

Yeah, it is. So in the course, actually, I talk about how you take this nervousness information and how you can share it with parents. So like the spoon theory or the bucket, like, what you're talking about is one way, talking about like polyvagal theories another way. And then a sensory cup is one of my go to ways too. So that idea is just like everyone has a cup. They're all different sizes based off of your own nervous system and past experiences and trauma responses and all that kind of stuff. And every time sensory input is presented to you, there's a little bit of water that's poured into that cup. So like you said, when you wake up and you have to brush your teeth, now you're dealing with that texture of the toothbrush on your mouth. You have a different flavored toothpaste that maybe you like or don't like. Then you have to go downstairs and eat and there's a TV on and siblings running around. So every little sensory bit of information pours a little bit of water into this cup. And we get to a point where that cup cannot hold any more liquid, any more sensory input. And if we're able to poke little holes throughout the day into that cup with regulating activities, with that feeling of safety, whether it's, you know, being with a parent and having a deep pressure hug, it could be getting to eat breakfast in a separate room that's quiet, but things that can lower the volume in that cup, that helps the child be ready for more input throughout their day. But if they're at this point where there's so much input coming in and not enough coming out, we're going to overflow. And so that's where you start to see these quote unquote behaviors when the child is just communicating I can't. I can't do it anymore. I'm overwhelmed. And you might think all that happened was I said, let's go inside and take off our shoes to get a snack. And that's too much. That extra direction, the idea of having to go sit at a table to pick what's next for a snack. After a full day of snack school, that cup has already filled to the brim and it's overflowing. And so as the cup fills up throughout the day, that's us realizing that that nervous system is being tested and you know, pulled against like a rubber band. And at some point it's going to snap, it's going to overflow. And that leads into this, like, flipping of your lid. Because we go into Dan Siegel's like, model of the brain. So you have like the brain stem and the amygdala, which is this bottom level. And the top level is going to be our complex thinking, our ability to problem solve, our language, all of that, that's up in that cerebral cortex. And so when the child is dysregulated and when the cup has been completely full, their lid flips. Right. They are now in this primitive brain where they are feeling dysregulated, feeling unsafe, Right. They don't have time to think about, am I hungry, am I full, do I have to go to the bathroom, am I upsetting someone? They're like, I am unwell. I don't know how to communicate that with you because I don't have access to this part of my brain that problem solves and accesses language, whether it be verbal language or AAC or anything like that. And until we co regulate and we create that feeling of felt safety again and connect that top and bottom part of the brain, we're not going to get to a place where they're ready for more input, whether it's preferred input or not. Right. We can't just throw a bunch of sensory strategies at them and hope for the best. So their system is offline. And so we kind of have to understand that that sensory cup overflowing and that lid flipping are signs that we need to step in and create a space of safety and create a set of routines or ideas that are going to help their body, like, get back online and feel regulated before we expect any other kind of food demands or demands otherwise.

Yeah, I love that and I'm. Thank you for sharing that because when I, when I went through your course, I was like, I remember you talked about this, but I would never be able to explain it as beautifully as you do. So thank you for taking the.

I put a video of Dan Siegel in my course because I still can't explain this as well as the man who created it.

But you explained it so beautifully today, so it's so good. It's so good. Thank you. So, okay, so then, you know, there's also behavioral approaches versus, like, relationship approaches. So can you speak to that a little bit? Because I think that that is, you know, one of the things that I get so often is like, oh, this kid is misbehaved, or, oh, my child is not a good listener. Oh, my child is so lazy. Oh, my child. It's like people attach a lot of lab. Um, and so I'm constantly going like, well, yes, there is a behavioral component to this, but at the same time, behavior follows something else. Like, there was something to bring that behavior on. And maybe we should kind of be going to the root of why this behavior is happening in the first place. Like, children are not inherently bad. So I don't know if that kind of taps into this a little bit, but that's just what was, like, coming up in my brain. So I'd love for you to speak to, like, the whole behavioral versus relationship approach. It.

Yeah. I think something that I really wanted to convey in this course with the complex sensory feeders is that coming in with this expectance of compliance in order to get rid of behaviors or eat better at the table doesn't set ourselves up for success as therapists, and it doesn't set the kids or the families up for success either. And for a long time, this behavior approach to feeding therapy was the gold standard. Like, that is what we were taught. I came in even just six years ago as an OT and was like, okay, they have to sit at the table. They need 90, 90, 90. We need, like, all these things. And they're not wrong. There's times where having the right postural support is going to make a difference for our kids that are having a hard time swallowing.

Right.

There's a time and a place where being at the table is what matters, that they're not so overwhelmed or distracted by things around them that they can't focus on the food. But I really think that this kind of black and white approach, where you get praised for certain things and there's punishment for doing something else, or, like, an iPad gets taken away unless they take a bite with a spoon versus using their hands when that motor plan isn't considered and the dysregulation isn't Considered that was a big focus I wanted to hone in on in this complex sensory feeders course. Because coming in with this approach that we don't want compliance, we want connection. That's what's going to create long term success. A behavior approach can get results and they can get results fast because the child is learning like, I need to do X, Y and Z to get my iPad back, which is my safety item, which makes me feel comfortable and like I can navigate the rest of the world. And so I know I have to eat this food that makes me want to gag because it means I get my iPad back. And that's how I can safely go to sleep at the end of the night and not completely dysregulate. And so in the moment, the child is eating more of that specific food, but in long term, they're learning that their internal system doesn't matter. And that's not something that we want to be teaching as we're building these confident eaters. We want to be teaching that connection matters more than this compliance. We want to have a relationship approach that is coming in and saying, I see you, I see your nervous system and I want to respond like in line with it. Melanie Potok is a wonderful speech language pathologist and she talks about how feeding therapy is a dance. And to me, that is the relationship approach. Right. I am moving simultaneously with the child whether they're in full dysregulation or whether they're completely comfortable or somewhere in between. A relationship approach is going to see those moments where they're safe and there's a space for you to add in some focus areas on their goals. Right. And they're going to see the moment where they're safe and we want them to stay safe. We don't need to push them in that moment. We don't need to offer something different. And so a big part of this course is kind of talking about how we can meet the child in the moment and where they're at and ways that we can accommodate and change our expectations rather than pushing the child into this box of we need to comply, we need to eat more, we need to have only the healthiest foods, like what can we do that supports their nervous system from the beginning and gives them kind of that space to move and to grow with us.

I love that, I love that. And I think you're really speaking to some of the expectations that we can change. Right. To meet their needs. Because like you, like you're saying the whole behavioral approach versus relationship, like I, I Took a course, I won't name it, at one point in my career. And it was very, very much so behaviorally based, even though I was taught in that course, that less than 5% of like behavior or feeding disorders are truly like rooted out of behavior alone. Which again, I don't think anything is rooted out of behavior alone because I think there's always an antecedent right before. So anyways, that's neither here nor there. The point is, I think very early on I was very uncomfor with the thought that like we needed to treat the behaviors because it felt like a band aid approach. And I think what I'm hearing you say too is it very much so. It might work in the short term, but it's not sustainable, it's not gonna work in the long term or it's going to teach the child, like you said, that like their internal system doesn't matter. And I think that's not the relationship that we want to build with them between us or with them between food. Right. Like we want them to have an enjoyable relationship with us and with food. So I like that you're, you're talking to that because I, I almost couldn't put it in words, but early on in my, my, you know, therapy career, I remember just like sitting with a child and we were on the floor and the kid's spinning some wheels and I started spinning some wheels and the kid like looks over at me and it's like we're like regulated, right? We're co regulating. Like we're kind of. Nobody needs to say anything. I'm just hanging with you, doing your thing, doing what you're doing. And now I've got your attention. And now you're kind of interested in me because I'm doing what you're doing. I'm not telling you what to do. I'm not questioning what you're doing, right? It's like your body obviously wants to do that right now, so let's roll with it. And I can't tell you, like from just taking that kind of an approach how much easier therapy was because the children were like, we were connected. And people would be like, this is amazing. How do you do this? And I'm like, I can't teach this. I don't know people. I'm just like getting down and playing with them and gaining their trust. Like gain their trust. That's the number one thing I can tell you is if you can gain their trust. And what I realize now is they were co regulating with me. I was calm. They were calm. Our nervous systems were both, like, in check. You know, we were both available and that was a big thing. Like, even in speech sessions, I'd get kids who were just not available that day. And I was like, this is going to be a waste of both of our time. So instead of having this, like, battle at the table, like, let's get down on the floor, and I'm going to see how I can creatively work my goals into play and into what you're available for right now without them even knowing we were working on anything, you know. And so I think it's a little harder when there's food present because clearly everybody knows, like, the elephant is in the room. But, but, but no, I think it's. It's just, again, not something that anyone really talks about. Talks about. You know, maybe. I think it's now becoming more spoken about. It's becoming. People are becoming more aware of it. And I'm really hoping that it becomes a big topic of conversation. But, you know, making sure that child is regulated, I think that's huge.

Yeah, absolutely. I think a lot of it, at least I've attributed a lot of my knowledge shift has been because of this, like, neurodiversity affirming movement. Right? Like, there's such a push from neurodivergent voices to say, hey, you need to listen to our experience. You need to let us be the ones to tell you that this is uncomfortable. You can't tell me that I'm wrong. Like, I don't tell you, when you say I'm hungry, I don't go, no, you're not. Like, that's, that's true. Whatever I'm feeling is what's accurate. And so to be able to come in with this approach of connection and of understanding and of just wanting to learn about what they're experiencing and why and how we can support them in that moment rather than tell them that they're feeling it wrong or that you do something different or it's not enough. Like, that's what our focus as feeding therapists or therapists in general, I think really should be. And that really leads into us kind of changing our expectations. Right? Like, we need to come in and say, it's okay if they're going to have meals that are just their safe foods. We don't always need to put out an extra piece of food in their lunchbox that's brand new to them because that might taint the rest of the food. Like, that sets them off. And so how can we create this space where sometimes they're just going to eat their preferred foods because it's what their body needs to poke little holes in their sensory cup? And when can we figure out, okay, here's the foods that I want to expand on that meet their sensory profile needs for texture and temperature and smell. And let's expand with those first. Right? Let's find every single meltable solid out there that doesn't have weird little bumps when it melts in your mouth. And how many different food categories can we get with that meltable solid texture before we food chain it into something else? And so if we're able to take our expectations and change them and create a space of interest and connection and compassion, that can really help expand, like, in the long term?

Yeah, it's beautiful. I love that. I love all of this. So one thing that popped into my head, and actually it popped in twice now, but I totally forgot about it before, like, just. Just in the short time that we've been talking. Way to go with your memory, Holly.

So I go right through it usually.

It's all good. I'm a fast talker, too. It's all good. No, we haven't brought this up. And I'm curious to know your take on, like, using tools, especially with kiddos who are like, these, you know, complex sensory feeders who maybe bridge the gap between getting them to the table or getting them working on certain, you know, sensory oral motor skills before we actually introduce new foods. Like, is that something you're for, against? I'm curious to know, like, your stance on that.

It depends on the kid, so I don't fall in one category or the other, but I do have a lot of, like, oral motor training. I was trained by slps when I was starting off as a feeding therapist. And so at first, a lot of my training was related to tools, and now I bring tools out. But the child has to be the one to accept them and bring them into their mouths. So an example that I talk about in the complex sensory feeders course is this little girl who has a G tube. And when we started, I just, like, touched her face to do a Beckman exam, and she completely threw up everywhere. So her sensory system was so overwhelmed that just, like, touch to her lip was too much. And so we backed off from the mouth, completely created that space of safety. And then I started presenting different tools, like the Z vibe that buzzed. I had just, like, regular teethers, like, different things that she could interact with, and we use them to, like, play with Pretend food and to feed dolls and to brush their hair with the toothbrush on the Z vibe. And, like, just gave her ways to interact with them without needing to be near her face. And then eventually worked our way into me kind of like modeling how I would use them in my mouth. And now I walk into the sessions and she sits down and she's like, blue buzzy. And she asks for it. She's like, I want this specific thing and I'm gonna put it in my mouth and move it back and forth. And that's creating the input needed. Both. That's regulatory for her, but then also that she can use to work on that, like, lateral tongue movement. So I think they're all connected. Absolutely. And I think a lot of times with our complex sensory eaters, the idea that you have to be using food as the tool, which I think is a great approach to have, that doesn't work for them because they see that food and they're like, get that out of my space. So if we can find the opportunity to bring something else in that still gives them the input and helps them move it around. It's a great way, like you said, to kind of bridge that gap if they're ready for it and if they need support in that way.

Yeah, no, we're very much so on the same page. And I always like to ask people that because I feel like there's a camp where. And I've obviously watched your course, so I kind of knew your take, but I was like, we're just going to let you explain it here because, you know, not everybody's seen that. But, you know, I know that there are some people who are just, like, completely anti using tools. And I'm like, but why some children? And like you said, it's very individual specific. If they. It's not like, part of like. And you also said in the beginning there's no, like, map that I can give you. That's like step one, step two, step three, you're going to do this and then this and then that. Like, no, it's a stance between art and science. And it's a dance, like, Melanie talks about between kind of figuring out where the child is headed in this exact moment in this session today, right now and here, you know, here and now. But, yeah, I mean, I started to find, like, just the sight of the food or knowing that it was going to be present was enough to turn their. You know, basically they were done. They turned off their nervous system, went into complete fight or flight. And the session Was totally tanked. And so I basically started saying to parents, like, you can send foods in, put them in individual containers, like, one thing per container. Have it in glass so they can see what it is without smelling it. Right. And I started to learn about. More about the sensory system where I was like, like, we need to control the environment a little bit if we want them to one, stay regulated. Trust that I have their best intentions in mind. Right. And I found that by slowly introducing those foods, a lot of the kids were, you know, they were much more regulated. It was a little bit easier, if you will. I don't want to say it was easy, but, you know, easier. Whereas I had other kids who still, like, the second they saw the lunch bag, they were like, nope, I'm done. And so I was like, we cannot even bring that in yet. Like, we have got to work with them and get. Like, we're gonna. That's a goal. We're gonna work up to that point, and we're not ready yet. And so tools became a really great thing. But even to your point, sometimes just the touch on the face and they'll vomit. Like, I know that's not every case, and that's more severe. But you do get these cases where sometimes you put it in their mouth and they gag.

Right.

Or you. They put their own finger in their mouth and they gag every single time. Right. And it's not that they don't want to experience explore. It's like their body's not ready for it. And so I do find that tools have been super helpful in my own practice with certain cases where we're just not ready for the food yet. And we have to work up towards getting those even anywhere around the face or the mouth. Right. It's like, we gotta play with them first. There's no buzzy on. Then the buzzy comes on, and we're still playing with it, and then we're kind of moving it up the body slowly, and eventually, you know, it's in the mouth. But I love how you also highlighted that, that you modeled it and then she, you know, like, that one individual was able to then mirror what you did and start bringing it to her own mouth. Because I think I've noticed as well, like, the kids who have that. That higher level of control over the tool, they also tend to do. They're more regulated.

Absolutely. And I think a big part of the modeling is, again, something that gets covered in the course. Because I never want the child to feel like I'm asking them to jump through Hoops. So I am doing everything I'm asking them to do or everything that might help their sensory system. So a big thing is creating, like you said, kind of changing our environment, but also, like, changing the accommodations that we're offering for them. So what can we do to make mealtimes easier for them? And so, again, that might be not sitting. 90, 90, 90. So I'm going to model standing and eating at the counter, eating on the floor, sitting on my knees, because it gives me more postural control and support, and that. That's extra input through the bottom of bottom half of my body. Right. I'm going to model all those things without saying, okay, now you try. Now you do it. Now you bring it closer to your face. Like, this is me. I'm showing you that I can do it and feel safe. And I can also show you that I can do it and you don't have to. I think that's a big thing. Like you said, when the lunchbox comes out and they're in complete panic mode, they maybe have been through some sort of behavioral feeding program where they say, okay, when I see the lunchbox, I'm expected to bring something to my mouth five times, whether I want to or not, whether. Whether I'm regulated or not. Right. And so they've learned that lunchbox is a sign of danger. I'm no longer safe. I can't do it. And so what can we do to change that perspective? And not just so that they can be around that lunchbox, but so that they can be safe in that environment? Can we change the way food is presented? Can it always be in one spot in the kitchen and they can come over to it as needed? I mean, I've had so many kids that will take a bite and go jump on a trampoline. And parents are like, aren't they going to choke? And I was like, if I was worried about their oral motor skill, yes, we do something different. But I know that they can keep a bolus of food in that bottom cheek for 25 minutes on end while being swung upside down in a circle. They could jump on a trampoline because it helps their body feel regulated, and then go back and take another bite when they want to. And so we kind of have to figure out how are we challenging these. These norms of what feeding should be, what mealtime should be, to create a space for our complex sensory feeders that need more support, or not even more support, need a different approach. And that's what we kind of have to help parents through also is that this is what you thought meal times are going to look like because it's the way you were raised or because it's what friends are telling you. And that can be like a sense of grief and loss for these families. So how can I support them to show the positive interactions and the positive reasons that we're making these changes ourselves so that the child feels comfortable and confident and connected around foods. And in turn that leads to a different looking meal time. But that's more pleasant and positive for everybody involved.

Yeah, yeah. And so, I mean there's definitely supports, accommodations, things that can be put in place to, you know, help these children have successful meal times. And you know, not that it's severe, but like one of my own kids and she didn't always do that. Well, actually, as I, as I back up, let me back up that, that statement. Take that back. I was gonna say she didn't always do this. She stands with like one leg on the floor and a knee on the chair and like that's, that's the best way she will feed. And she's even more like adventurous in that position than not. And I was gonna say she didn't always do that. That's because her, her leg couldn't reach the chair always or the floor. She used to like, she would want to stand like on a chair when eating or she would always be propped up somehow. And that's how she's always fed best. And that was just again, I think her kind of regulating herself in that situation because she is very, you know, she's my sensory kiddo and you know, she's very successful in life. But at the same time it's like feeding is a challenge. It always has been. And you know, you do kind of look. I kind of look over sometimes and I'm like looking at my other one who's like sitting down and now starting to copy, but doesn't need to copy right what the other one's doing. I'm like, no, you need to sit on your bottom. Like, it's like I started making these rules where I'm like, well, we sit on our bottom when we eat because we digest it food more easily that way. And she's like, but this one's not. And I'm like, well, that one needs to do that.

You don't.

At the same time, I'm like, maybe she does, but I really think she's just kind of likes to do everything her big sister does. So, you know, there's that. But no, it's very interesting when you start to observe children eating and you see all the different ways they do it. Because obviously, yes, safety is a factor that we want to consider at times, but when we know that a child is safe, like, what are the accommodations? Like, what are. Like, you mentioned some already, but, like, are there any other thoughts that you have on that topic that. That we can be doing to allow children to feel safe, you know, be safe and also enjoy their meal time that may not follow the traditional, you know, the norm, if you want to call it that, of what it looks like to eat at a table?

Yeah. I think the biggest accommodations that I'm making, like, in my day to day practice is, like I said, not having to sit at the table. So it could be like your daughter, like, kneeling and standing. It might be being in like one of those toddler counter standards at the table, like, at the counter nearby. It might be like setting up a picnic or a blanket on the floor. I think another big accommodation is figuring out what sensory things are needed at the table. And so for a long time, the idea of having an iPad out was just like an absolute. No. Like, parents would come in and be like, they watch the iPad. It's the only way they can eat. I'm like, okay, we gotta start. We gotta back it down. I said that. I'm like, we need to slowly get rid of the iPad. And there are some kids that see the iPad and are completely offline. They are like, I'll take anything in my mouth. Moving on. But there's also some kids that need that iPad. They need music. They might need a story being read or a game being played with the parents that reminds them that they're safe. And so that accommodation is super important. It's really important to know your child, to know, okay, is this pushing them over the edge or is this the thing that's keeping us feeling safe, Keeping those safety cues outweighing the danger cues? I got a little girl who's a very complex sensory eater, who's blind. And for a long time, one of our goals was to have her stop listening to music while she eats. And I came one day, and I don't know what light bulb went off in my head that wasn't on. When I wrote the goal six months before, I was like, why are we doing this? And that's a big thing we have to ask ourselves as we're changing our expectations and creating accommodations is why did I write a goal that she has to stop listening to music? It's what calms her body. She stays at the table and tries different foods. When there's music on, she's not unaware of what's going on. I still offer her two different foods, like, in certain, you know, sections on her plate, and she feels them and decides if she wants it and pushes it away. Like, it's not like she just picks anything up and puts it right into her mouth. Like, she still has the ability to discriminate between the foods, to smell them, to interact with them, but that music is what regulates her. And if we think about going to a restaurant with other people, like, there's music going on in the background. I'll watch TV with my husband while I eat dinner. Like, there's things that we do that aren't, quote, unquote, the perfect way to eat, but it's like, what our nervous system needs. If I'm not ready to sit at a table and have a whole conversation with my husband about the day I might be on my phone, and that's just me saying, hey, I need to regulate before I want to sit down and talk about things and add more sensory input to my body. And so I think those two things, like adjusting where you're eating and then adjusting how you're eating and being able to have either screens or sensory fidgets, or being able to walk away and take a break and jump on a trampoline or get a big squish and come back. Those things are not traditional in feeding therapy, but I think that they should be. I think that we should be making these changes to accommodate what the individual's, like, sensory system really needs.

Yeah. Yeah. No, I'm sitting here listening, like, taking notes. I'm like, this is good. I, you know, it's. It's interesting because, yes, like, and I feel like we've done a lot to accommodate and even my own practice. And, like, you know, I'm not practicing at the moment, but when I was. I still have a team that does. But, you know, the iPad is a big sticking point for a lot of parents, because there's a lot of parents who will say, like, we have to use an iPad for my child to eat. And I'm almost. I don't think I ever asked them the question. Well, that's probably not true. I probably did ask them. I'm like, is it your goal to not have the iPad at the table? Or is it your goal to have it and not feel bad about it? Do you know what I mean? And, like, to understand that that's what your child needs? Because I Can think like five kids off the top of my, you know, mind right now that I worked with that. If they had that iPad in front of them, they would eat. They would eat what was put in front of them, which obviously was not obviously, but oftentimes was their preferred foods. But if they didn't have the iPad, it was a massive struggle to get them to eat enough, like, calorie dense, you know, foods in a single setting to. For the parent to feel like, okay, my child is going to be well nourished. So it really became down to, you know, is my child getting nourished? Whether it's preferred foods or, you know, these new foods we want to explore, or is my child not getting nourished? Right. It was more so a question of nourishment or not. And so that's where I think of parents who listen to this are probably going to take a massively deep sigh and kind of go like, okay, it's okay for me to let my child have the iPad or to have the TV on or to have something that helps my child regulate themselves to allow them to eat. And that doesn't mean that I'm a bad parent. That doesn't mean that I'm doing something wrong. I think we need to, like, move away from defining what typical and normal is. Like, I would say there's. There's no such thing as normal. There's no such thing as normal. So what works for one family can look completely different than what works for another. And it works for one child, obviously, you know, and I'm preaching to the choir here, but I just, I love that you focused in on that because I think, you know, yes, there's other accommodations and parents have different rules about, like, eating environments and everything. But that iPad. That iPad is a big, big sticking point. And I know in many feeding courses I have been taught, like, not to use an iPad as a reward, not to use, or maybe to take it away and like, to kind of actually use it. I've seen people use it as rewards, and I'm like, I think that's the wrong way to go about doing it. We don't want to punish the child with the iPad for not doing something. But if they do truly need something to kind of, you know, regulate themselves, like, that's such an interesting conversation.

Yeah, we want it to be accessible. I mean, that's kind of the big goal. I think a big, A big part of this complex sensory feeders course is figuring out what does that child need to feel regulated and how can we make sure it's accessible at all times versus it being taken away or added back in like they shouldn't, like you said, be punished or rewarded with something that brings them regulation and makes their nervous system feel safe and feel online. So it's really, really important aspect. Yeah.

Well, amazing. This has been awesome. I know we could talk all day, but I know you have patience to see. So is there anything that we didn't cover that you wanted to highlight or did we kind of hit all the.

Talking points notes that I had written? I think we hit all the talking points. I feel good about it. Yeah.

Yeah. Awesome. Okay, so tell us. I know. I mean, obviously I can link where they can get the course that you created for us for through the certified pediatric Feeding Therapist certification. It is available to the public as well if you're not in the certificate. But Amy, you have your own courses, you're online. So tell us like where we can find you.

Yeah, so you can find me on Instagram at San Diego Feedingtherapy and then online, my website is just san diegofeedingtherapy.com I have a couple like entry level courses out. But most related to what we've been talking about, these complex sensory feeders is in the new year I have a little bit more like interdisciplinary courses coming out. So there's a hypotonia course coming out with myself and apt Dr. Bianca at NeuroFit and then also a neurodiversity affirming approach to feeding therapy. Just like an entry level one that people can listen to within an hour or so. It's not like a long course for that with my older sister who again is neurodivergent and a marriage and family therapist. So we're coming from a couple different lenses. I know as much as I say I'm a neurodiversity affirming therapist, like I don't have the full lived experience. I'm a neurotransmitter typical individual. And so I'm trying to figure out how can I pull some different providers together and come at a, you know, a comprehensive resource. So if you want to take a look at that, that's on my website under courses also.

Amazing. Well, that's exciting. I mean, I know your sister won't let her help you, but at the same time she's won't let you help her. But it sounds like she's helping you, so at least there's something awesome coming out of this, right?

And she has a living experience. She can say, look, I'm getting the nutrients that I need with my preferred food. So how can we set everyone else up for success and understanding and all that kind of stuff? So directly to kind of what this complex sensory feeders course is all about? Yeah.

Amazing. Well Amy, thank you so much for your time and expertise. I really appreciate you joining me today.

Yeah, thank you for having me and for giving me the opportunity to create this course for all your learners.

Thanks for listening to this podcast. If you found value in this episode and want to hear more of these Myotots, air weight and feeding related episodes, be sure to leave a review on Apple Podcasts and share this episode on your social media platforms. You can access free resources and all I offer@halibalkin.com or pop over to Hollybulcken on Instagram to get all the latest updates.