Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Program. In this Evidence Connection article, I describe a case report of a young child receiving early intervention services and outline the occupational therapy evaluation and intervention processes for supporting this child’s activities of daily living in the home and early childhood education setting. Findings from the systematic reviews on this topic were published in the March/April 2020 issue of the American Journal of Occupational Therapy and in AOTA’s Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years. Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical decision making.
Activities of daily living (ADLs) include feeding, dressing, toileting, and personal hygiene. Occupational therapy practitioners work with young children and their families to promote participation in meaningful occupations and ADLs and to establish daily habits and routines for sleep and rest (American Occupational Therapy Association [AOTA], 2020b). Interventions to support the behaviors and skills necessary for successful feeding and toileting routines occur in the context of early intervention (EI) coaching, early childhood education programs, inpatient hospital programs, and pediatric outpatient clinics.
Eating and toileting habits are often the priority areas for families of young children with and without diagnosed disabilities, developmental delays, or challenges with behavioral regulation (AOTA, 2019; Rodger et al., 2004). Reports have indicated that 20% to 30% of infants and toddlers have feeding-related problems (Romano et al., 2015), and that these rates are as high as 50% in children with developmental conditions, such as autism spectrum disorder (Schreck et al., 2004). Occupational therapy practitioners provide a holistic outlook to the team and can address motor, sensory, cognitive, social–emotional, and behavioral factors necessary for appropriate development and directly associated with participation in mealtime and bathroom routines.
Mealtime is a critical routine in the life of families with infants and toddlers that incorporates nourishment, motor skills, and social relationship building. Considerable positive effects have been found for repeated exposure to a target food paired with reinforcement to increase consumption of and preference for that food. Parent–caregiver education and coaching approaches that address the structure and routine of meals are an effective intervention to reduce disruptive mealtime behaviors and parental stress. Parent training in behavioral strategies such as positive reinforcement, response shaping, and extinction is effective, particularly for feeding challenges requiring more intensive intervention strategies (Gronski & Doherty, 2020). Although parent training has little effect on dietary variety and nutritional status, coaching caregivers to use behavioral approaches, such as structured and routine mealtimes, can reduce parental stress and undesired mealtime behaviors (Johnson et al., 2015; Maestro et al., 2016; Sharp et al., 2014; Sobko et al., 2017; Wen et al., 2011).
Caregiver education about repeated exposure is a key intervention that can be successful for increasing acceptance of nonpreferred or new foods. Outcomes for target food acceptance are notable and most improved when exposure is paired with modeling and rewards. Using tangible rewards with exposure is significantly more effective than social rewards (Corsini et al., 2013; de Wild et al., 2017; Holley et al., 2015; O’Connell et al., 2012; Remington et al., 2012).
Toilet training is often a challenging milestone in the daily life of families with young children. Articles have indicated that toileting can be successfully taught to typically developing children through caregiver education and coaching to use consistent behavioral approaches such as increased fluid intake, scheduled toileting visits, and positive reinforcement for in-toilet elimination (Cicero & Pfadt, 2002; Keen et al., 2007; Law et al., 2016; Rinald & Mirenda, 2012). Considerable positive effects have been found for specific caregiver education about reducing or refraining from negative or punitive language when toileting errors or defecation occurs (Taubman et al., 2003).
Case Study: Owen
Owen is a 33-mo-old boy who was born at 36 wk gestation after his mother experienced symptoms of preeclampsia. Her pregnancy was otherwise unremarkable, and Owen has been a healthy child since his frequent ear infections were resolved with the insertion of tympanostomy tubes. Owen’s mother is a fifth-grade teacher at the local elementary school, and Owen’s dad is a medical corps recruiter for the U.S. Army. Owen’s mother started teaching again this school year after taking time off when Owen was born. Her husband travels several times a month for work. Owen attends a local child care center 5 days per week during school hours. The family currently lives in an apartment complex on the third floor near a main road. They currently have the support of Owen’s maternal grandparents, who live 20 min away from the military base; however, Owen’s father expects to receive permanent change of station orders at the end of the year.
Owen is physically active and enjoys going to the playground on the apartment complex common ground. He navigates the stairs safely but is a bit of a daredevil on the playground equipment. His father is always impressed with his ball skills when they go to the park on the weekends. Owen can throw and catch with ease, and he is starting to be able to hit a ball with a toy bat. He watches public television cartoons when he wakes up in the morning and after dinner on the family television or his handheld tablet. Owen does not like to sit and attend to stories or to color. He will complete simple wooden puzzles if they include familiar television characters.
Owen was first referred to EI for an evaluation related to speech and language delays. He began receiving speech and language services at age 15 mo. After the fluid in his ears resolved, he made fast progress and is now intelligible to his family and teachers and can communicate his wants and needs. The EI team met and requested an occupational therapy evaluation to address parental concerns regarding behaviors at mealtime, the limited variety of foods that Owen accepts, and his lack of toileting-readiness skills. Owen primarily eats crunchy foods (e.g., chips, crackers, cereal) but will also eat strawberries, applesauce, and certain brands of french fries. He eats an age-appropriate amount of breakfast because he can feed himself preferred finger foods. He primarily drinks water or a nutritional supplement protein shake. At dinner, he gets up from the table frequently, refuses food by throwing it, and occasionally gags on unfamiliar foods. His parents prepare him a separate meal of his accepted foods and eat their own meal later in the evening after Owen is asleep.
Owen’s early childhood program teachers have notified his parents that he is eligible to transition to the 3-yr-old classroom soon; however, he needs to make more progress on toilet training before his parents can be charged the reduced weekly tuition rate at the day care center. Owen does not indicate when his diaper is wet or soiled. He will sit on a toilet for a few seconds but has not yet been successful at eliminating into the toilet. He has started to hide in his closet or a corner of the classroom when he has a bowel movement in his diaper. Owen will retrieve a clean diaper for the changing routine, with verbal and gestural prompts. He can undress himself and pull his pants up by himself. He needs moderate assistance to get dressed, including putting his shoes on. Owen’s parents are growing frustrated with catering their morning and mealtime routines to his needs and behavior, and they are afraid that he is getting too far behind his peers.
Occupational Therapy Evaluation and Findings
Mya is the occupational therapist on the EI team who is currently serving as the primary service provider for Owen’s family. She completed an occupational profile with Owen’s parents using AOTA’s (2020a) template. Owen’s parents identified three primary performance areas as priorities: (1) an independent toileting routine and consistent daytime continence, (2) expansion of the variety of foods accepted at mealtimes and reduction in the frequency of disruptive behaviors during meals, and (3) increasing parental competence with behavior modification and fading assistance during daily living tasks.
The Infant/Toddler Sensory Profile–Second Edition (Dunn, 2014) revealed that Owen scored much higher than most children in sensory seeking and higher than most children in low registration. He also scored much lower than most children in sensory avoiding and sensory sensitivity. His scores demonstrated notable differences in processing oral sensations, touch processing, and behavioral outcomes of sensory processing.
Owen scored in the average range for visual motor (scale score = 8) and fine motor (scale score = 10) skills and slightly above average for gross motor skills (scale score = 13) on the Miller Function and Participation Scales (Miller, 2006). Other assessments included the Behavioral Pediatrics Feeding Assessment Scale (BPFAS; Crist & Napier-Phillips, 2001) and the Parenting Stress Index–Short Form (PSI–SF; Abidin, 1995). Results on the BPFAS indicated a higher than average frequency score of 92 on both child and parent behaviors related to feeding and a higher than average problem score of 10. Results of the PSI–SF indicated Parental Distress and Difficult Child subscale scores in the 90th percentile and a Total Stress subscale score in the 85th percentile. The Parent–Child Relationship Dysfunction subscale revealed a relative strength with scores in the 60th percentile.
On the basis of the evaluation results, Mya and the early intervention team developed the following goals for the individualized family service plan:
Owen will participate in toileting by indicating to his parents and teachers that he needs to go potty. We will know he has accomplished this when he pats his diaper, walks to the bathroom, or verbalizes potty 3 times a day while still dry, followed by successful elimination in the commode for 5 consecutive days.
Owen will participate in meals by eating foods that have a combination of textures without disrupting the meal. We will know he has accomplished this when he eats 3 portions of food with a combination of textures and does not throw food or get up from the table for 1 wk.
Owen’s mother and father will successfully manage the morning routine by offering minimal assistance and allowing Owen to practice his daily living skills without getting frustrated. We will know they accomplished this when they are able to use a behavioral modification or faded cuing strategy successfully 5 times in a week.
Mya reviewed evidence published in the American Journal of Occupational Therapy (Gronski & Doherty, 2020) and read the recommendations from the Occupational Therapy Practice Guidelines for Early Childhood: Birth–5 Years (Clark & Kingsley, 2020). She found the following evidence to use as she planned her intervention:
Strong evidence for parent behavioral training programs to decrease parental stress and undesired mealtime behaviors
Strong evidence for repeated-exposure feeding approaches to increase food acceptance
Moderate evidence for parent coaching regarding nonpunitive toilet training language use to reduce toileting refusal
Moderate evidence for family-centered, routine-based interventions to improve parenting behavior, satisfaction, and well-being.
Mya also decided to use caregiver education and coaching as well as caregiver-implemented behavioral toileting strategies to increase toileting independence and continence. Although evidence related to this intervention is currently insufficient, coaching is accepted and supportive of the family-centered values inherent in practice within the EI system of care (AOTA, 2019; Wallisch & Little, 2021).
Occupational Therapy Intervention
On the basis of the current individualized family service plan developed at the most recent team conference, Mya planned to provide occupational therapy services once per week in the family’s home and once per month at Owen’s early childhood program with the classroom teaching assistant. Mya took the time to consult with the family regarding their typical mealtime and morning and bedtime routines to ensure that the sessions would be centered around the times of day when Owen experienced the most difficulty with feeding and toileting activities. They agreed on an early evening time when the family would be preparing for dinner and both parents would be home from work. Additionally, after speaking to the early childhood program director, Mya determined that it would be best to visit the classroom during the transition between lunch and naptime. At that time, she could be present for a portion of Owen’s meal and support the toileting routine before rest time. Naptime would allow the teaching assistant time to step out of the classroom to discuss ongoing strategies to use with Owen.
Mya used a coaching process to engage in joint planning and reflection with Owen’s parents and teachers (Graham et al., 2014). At the end of each session, she helped them set a target, explore their options for selecting strategies to achieve the goal, and plan out what those strategies would look like within the context of their daily and weekly routines.
Sample Intervention 1: Home
Mya met with Owen’s parents while they were preparing dinner and learned that they typically serve Owen different food from what they prepare for their own dinner. Mya explained the importance and success of repeated exposure to new and nonpreferred foods (Corsini et al., 2013; Holley et al., 2015). She also helped them examine their mealtime routine to find ways that this daily activity could be more structured and consistent to support Owen with what to expect and what is expected of him (Johnson et al., 2015). She helped the family find ways to implement the “division of responsibility” for meals (Satter, 1990), in which the parents can decide when, where, and what Owen will eat, and he can decide whether and how much he will eat.
Mya used guided questioning and reflection to help Owen’s parents discover that he typically starts snacking when he comes home from child care and dinner is served less than an hour later. Owen’s dad suggested that they could modify their afternoon routine and Owen could have his snack sooner, in the car on the way home, so that he would be sufficiently hungry when dinner is served. Mya demonstrated during the family’s meal how they can reinforce his positive mealtime behaviors and ignore or redirect his undesired behaviors at the table (Sharp et al., 2014); the parents then practiced this strategy with feedback from Mya. At the end of the session, Mya helped Owen’s parents come up with two specific strategies to try each night at dinner for the next week.
Sample Intervention 2: Home
During a week when Owen’s father was out of town, Mya arrived for an earlier session to work on the toileting routine that Owen and his mother do when they arrive home from child care in the afternoon. Owen’s mother discovered that they have some downtime before dinner is prepared, and she would like to focus on toileting during this time before he is overtired after dinner. Mya helped Owen’s mother develop ways to increase his fluid intake and find strong reinforcers to use for successful toileting attempts (Keen et al., 2007; Law et al., 2016). They also found a toilet training app that features Owen’s favorite cartoon characters. Owen gets to use the app for visual prompts and reinforcement. At the end of the session, Owen’s mother expressed concern that when her parents watch Owen, they sometimes yell at him if he has a toileting accident. Mya helped her develop some neutral phrases (Taubman et al., 2003) that she can share with her parents that might be more successful to keep their positive strategies consistent across all caregivers and settings.
Sample Intervention 3: School
Mya worked closely with the teaching assistant in Owen’s classroom to understand the bathroom and lunch routine that they follow each day. At lunchtime, each child is required to be served every part of the meal (protein, vegetable, fruit, and bread). Mya reinforced this practice with the teacher and teaching assistant and emphasized the importance of repeated exposure to new and nonpreferred foods without pressure as a successful strategy for all kids and one that is consistent with what Owen’s parents are doing at home (Remington et al., 2012). When Mya sat with Owen at the lunch table, she made sure he sat with his peers so that successful eating habits and skills could be modeled within Owen’s view (Holley et al., 2015).
While Mya observed the bathroom routine in the classroom after lunch, she noticed that Owen was very disorganized on his way to get in line to go to the bathroom. He touched all the art materials on the walls, intentionally bumped into all the chairs in his path, and sometimes bumped into peers without noticing. By the time he made it to his turn to go to the bathroom, he had usually wet his pants. Mya encouraged the teaching assistants to give Owen a more structured routine when he finished eating lunch to make his visit to the toilet at the same time every day and a few minutes ahead of all his peers (Cicero & Pfadt, 2002). Owen’s teachers have sticker charts for each student and asked whether they could begin offering Owen a sticker for each successful in-toilet elimination and when Owen self-initiates going to the bathroom. Mya finished the session with a conversation about the impact of punitive and negative language (e.g., “yucky” or “stinky diaper”) around toileting for young children; she then coached the educators on developing consistent neutral phrases to use when the children have toileting accidents. Mya encouraged the teachers to praise the children for in-toilet eliminations and to respond with neutral reminders (“we go to the bathroom in the toilet, not our pants”) when they have accidents.
Occupational therapy practitioners often work closely with families on ADL performance in the natural, routines-based context of EI practice. Parent coaching and education as a part of family-centered practice involve addressing the needs of the parents and the child to support the accomplishment of family goals (Graham et al., 2014). Occupational therapy practitioners should also incorporate reinforcement, chaining, shaping, and exposure strategies to improve toileting independence, mealtime success, and parent confidence and well-being. Service delivery models support the incorporation of occupational therapy into the natural settings of early childhood education. Occupational therapy practitioners should integrate these strategies into classroom, snack time, and nap routines (Bazyk et al., 2009).