DIR Approach to Pediatric Feeding

Several of our therapists (Lorissa Alexander M.A. CCC-SLP, Rachel May M.S. CCC-SLP, & Sarah Norris OTR/L) recently attended a pediatric feeding course in Marietta, Georgia. The conference introduced the therapists to the DIR Approach to Pediatric Feeding (www.pasadenachilddevelopement.org). This program was presented by a wide range of professionals including a pediatrician, occupational therapist, speech-language pathologist and nutritionist.

The DIR Approach to Pediatric Feeding focuses on building relationships first and foremost to achieve better feeding skills. It is a very child directed form of therapy. In traditional feeding therapy, the therapist presents preselected foods in a hierarchy based on texture and consistency; however, in the DIR Approach, the therapist presents preselected foods in a play-based manner before introducing a hierarchy. This approach puts the child at ease with the therapist and the food, building a positive relationship with both.

The relationship is based on the child’s current milestone (emotional state). There are 6 milestones that a child develops with time and maturity. The DIR method seeks to meet the child at their current milestone and then work towards the next milestone. One skill leads to another skill and they are all tied to the child’s ability to organize his/her social emotional skills. The milestones are important because they build on each other.

The six milestones are: regulations and shared attention, engagement, two-way communication, sustained co-regulated interactions, creative use of ideas, and logical bridging of ideas.

1. Regulations and Shared Attention: Feeding therapy at milestone 1 would seek to explore food together once the child is calm and relaxed.  We should not expect a child to attempt a disliked food when they are not able to stay calm or not aware of his/her surroundings.  An example of feeding therapy at this milestone might include a game such as hiding a food item and finding it or imitating sounds and movements.
2. Engagement: At milestone 2, the therapist and the child are building trust at this stage. The child begins to trust that the therapist will not force food upon them. An example of feeding therapy at this milestone might include simple songs, chants or rhythms to create a familiar fun interaction around eating.
3. Two-Way Communication: Feeding therapy at milestone 3 would seek to create reciprocal interactions during food play. The therapist should provide time and opportunities for the child to become more deliberate and interactive (i.e. gestures to indicate more, taking from you, handing to you) during feeding/eating together. An example of feeding therapy at this milestone might include an activity to describe how a food might look, smell, or taste using descriptive words (i.e. delicious, sour, sweet, etc).
4. Sustained Co-Regulated Interactions: At milestone 4, the child negotiates around their wants and needs. It is the therapist’s responsibility to find the right balance of control between the child and adult by working trough emotional responses. An example of feeding therapy at this milestone might include games in which the child negotiates the rules (i.e. which food is first, pace, how they will eat it).
5. Creative Use of Ideas: Feeding therapy at milestone 5 involves the child’s ability to use pretend play to express emotions and introduce ideas to make eating fun and acceptable. An example of feeding therapy at this milestone might include child leading by picking up a food item (i.e. carrot stick or celery) and pretending it is a sword.
6. Logical Bridging of Ideas: At milestone 6, a child is able to use reason and logic to discuss feelings and anxieties about foods. An example of feeding therapy at this milestone might include making stories up about a food and/or making a restaurant and menus.

Feeding therapy is subjective to special considerations including: allergies, reflux, constipation, chronic illness, tube feedings (feeling hunger), obesity, and failure to thrive. The DIR feeding approach is one of many feeding therapies and should be used in conjunction with other strategies to achieve optimal feeding skills. It is important to treat each child individually and create a therapy routine specifically for each child.  

Questions? Comments? Respond below or email us at bbtherapyinc@gmail.com