WEBVTT 2 00:00:10.559 --> 00:00:21.780 Ann-Marie Orlando: hello, and welcome to the CARDcast a podcast of the University of Florida's Center for autism and related disabilities. My name is Ann-Marie Orlando, associate director at CARD and research assistant. 3 00:00:23.070 --> 00:00:33.090 Ann-Marie Orlando: professor in the Departmeng of Psychiatry. The mission that the CARDcast is to share with our listeners relevant information about who we are, what we do and what we can do to help you. 4 00:00:33.780 --> 00:00:43.140 Ann-Marie Orlando: Over the course of our CARDcast series, we will be talking with members of our staff, as well as constituents and their families, service providers and researchers 5 00:00:43.800 --> 00:00:57.210 Ann-Marie Orlando: Who are the groundbreaking work in the field of autism. We also hope to give you a fuller picture and better understanding of autism spectrum disorder and related disabilities such as dual sensory impairment and developmental disabilities with sensory impairment. 6 00:01:02.220 --> 00:01:13.380 Ann-Marie Orlando: Thank you for joining us today our guest for this podcast is Dr Vivian ibanez who is coordinator for the feeding program at the Florida Autism Center. Welcome Vivian. 21 00:02:42.420 --> 00:02:46.050 Vivian Ibanez: hi, thank you for having me today i'm really excited to have this discussion. 22 00:02:46.860 --> 00:02:50.820 Ann-Marie Orlando: So am I Vivian tell us a little bit about your background. 23 00:02:51.900 --> 00:03:02.550 Vivian Ibanez: Sure, so I grew up in Baltimore Maryland and by being in that area had learned about some of the services that a children's hospital called Kennedy krieger Institute was offering. 24 00:03:03.030 --> 00:03:10.200 Vivian Ibanez: And they ended up doing a rotation as an intern on their neuro behavioral unit, which was my first exposure to behavior analysis. 25 00:03:10.440 --> 00:03:18.030 Vivian Ibanez: And it left quite an impression on me so much that I decided to pursue my masters in behavior analysis, while working at Kennedy Krieger. 26 00:03:18.510 --> 00:03:26.190 Vivian Ibanez: As soon as I had started as a student, there was an opening in the pediatric feeding program, which is another service that Kennedy Krieger offers. 27 00:03:26.490 --> 00:03:36.840 Vivian Ibanez: And that was my first exposure to pediatric feeding disorders and I became very interested just in terms of the Biological and social significances of eating. 28 00:03:37.290 --> 00:03:42.900 Vivian Ibanez: And I continue to pursue my masters, while doing work on that unit and clinical research. 29 00:03:43.290 --> 00:03:51.150 Vivian Ibanez: And because I continued and fell in love with feeding I ended up going to the Nebraska Medical Center to continue to gain experience in this area of specialty. 30 00:03:51.630 --> 00:04:04.770 Vivian Ibanez: followed by a postdoctoral fellowship here at the University of Florida, and now I am here coordinating the development of a new pediatric feeding disorders program through the Florida Autism Center in partnership with UF CAN. 31 00:04:05.910 --> 00:04:27.330 Ann-Marie Orlando: that's so great, we recognize here at card what a huge need it is to have services around helping people who have feeding aversion to have feeding over selectivity things like that. What are some common concerns that you see related to nutrition for individuals with autism. 32 00:04:28.020 --> 00:04:33.630 Vivian Ibanez: Sure, so the topic of nutrition is a very important one, I think, when we think about it. 33 00:04:34.260 --> 00:04:43.530 Vivian Ibanez: We often think about macro and micronutrients and, of course, by no means, am I a registered dietitian but i've been fortunate enough to work a lot on interdisciplinary teams, where. 34 00:04:43.770 --> 00:04:51.090 Vivian Ibanez: i've had a lot of conversations with registered dietitians to kind of understand just the profound impact that nutrition has on. 35 00:04:51.780 --> 00:05:06.030 Vivian Ibanez: Learning, behavior and many areas of our life. Specifically with kids with autism, we often see that they'll present with what some might know as food selectivity and I will kind of give a heads up that really feeding concerns in general are. 36 00:05:06.690 --> 00:05:11.760 Vivian Ibanez: may present very differently so you might have some kids who have difficulty with eating enough. 37 00:05:12.090 --> 00:05:18.270 Vivian Ibanez: to the point where maybe they're not gaining weight and growing you'll have other kids who aren't eating the right kinds of foods. 38 00:05:18.480 --> 00:05:28.470 Vivian Ibanez: to the point where maybe they're at risk for diabetes or hypertension or other health consequences and then of course there's a combination now specifically in 39 00:05:29.160 --> 00:05:37.770 Vivian Ibanez: children or individuals with autism what we're noticing is that right, in line with one of the core symptoms, also known as resistance to change or. 40 00:05:37.770 --> 00:05:39.060 Vivian Ibanez: Insistence on sameness. 41 00:05:39.360 --> 00:05:51.270 Vivian Ibanez: We see that manifestation with foods, where they might only be eating three or four foods. They may be, eliminating entire food groups or very insistent on only eating in certain ways. 42 00:05:51.600 --> 00:06:00.360 Vivian Ibanez: So, even with preferred foods they may be very specific about the order in which they have to consume the foods or the color the texture the temperature. 43 00:06:01.050 --> 00:06:13.260 Vivian Ibanez: Even sometimes there are kids who maybe have very specific preferences for certain brands so again, a lot of different manifestations, in terms of what we see with feeding concerns, but I would say that predominantly in. 44 00:06:13.560 --> 00:06:16.470 Vivian Ibanez: Children or individuals with autism, we tend to see. 45 00:06:16.710 --> 00:06:19.380 Vivian Ibanez: More so foods selectivity than anything else. 46 00:06:21.630 --> 00:06:27.810 Ann-Marie Orlando: Yes, we see that a lot will have parents come to us and talk about how their child will only eat chicken nuggets. 47 00:06:28.260 --> 00:06:34.980 Ann-Marie Orlando: But it has to be this particular brand of chicken nuggets and they have to be cooked in a certain way and served in this certain dish. 48 00:06:35.400 --> 00:06:48.960 Ann-Marie Orlando: or something like that, and that can be really challenging for the family, because it really limits the variety of foods that are available for the family and also the family's ability to go out to dinner or have a picnic or. 49 00:06:50.100 --> 00:06:52.890 Ann-Marie Orlando: You know, have meals with families and things like that. 50 00:06:56.190 --> 00:06:56.430 Ann-Marie Orlando: Go ahead. 51 00:06:56.730 --> 00:06:59.070 Vivian Ibanez: I think, just like you hit the nail on the head, I think that. 52 00:06:59.310 --> 00:07:12.510 Vivian Ibanez: Two of the reasons that I fell in love with this area that i've been specializing in for for the last few years is the biological significance, so of course if this topic we're talking about in terms of nutrition and the. 53 00:07:12.960 --> 00:07:22.590 Vivian Ibanez: implications of that has but also like you just mentioned, it can be really stressful for caregivers if their sole responsibility is to ensure that their child. 54 00:07:23.400 --> 00:07:28.590 Vivian Ibanez: eats well eats the right kinds of foods grows meets their feeding developmental milestones. 55 00:07:28.920 --> 00:07:39.780 Vivian Ibanez: And if they either can't do that or have to engage in very specific routines to get their kids to eat even preferred foods it's really stressful I. 56 00:07:40.230 --> 00:07:48.420 Vivian Ibanez: Had a client one time, where the family had decided to go on a cruise and they had packed a specific cup the child consumed the liquid in. 57 00:07:49.140 --> 00:07:59.070 Vivian Ibanez: And on the cruise at some point the child lost the cup and the family ended up having to stay at one of the stops on the cruise because. 58 00:07:59.550 --> 00:08:14.580 Vivian Ibanez: The child stopped drinking and then they were at risk for dehydration so it can really have devastating health consequences but it's also very stressful for caregivers to have to manage that level of sort of routines when it comes to getting their kids to eat even preferred foods. 59 00:08:15.300 --> 00:08:19.770 Ann-Marie Orlando: Absolutely, and particularly when our children are young we're always thinking about. 60 00:08:20.100 --> 00:08:31.830 Ann-Marie Orlando: You know, making sure that they get all of the variety of different foods that they're getting all the nutrients that they require and it's hard to even know that as a parent is this my child to eating enough of these. 61 00:08:31.860 --> 00:08:40.800 Ann-Marie Orlando: different foods, and so what are some resources that you think might be available for families who have questions about their child nutrition. 62 00:08:41.430 --> 00:08:43.320 Vivian Ibanez: yeah so that's a great question there's. 63 00:08:43.650 --> 00:08:44.040 Vivian Ibanez: one. 64 00:08:44.310 --> 00:08:53.850 Vivian Ibanez: A couple of resources, but one that I particularly often recommend to families just given that it's a free resource and also available in numerous languages is. 65 00:08:54.210 --> 00:09:04.320 Vivian Ibanez: A my plate plan website so if caregivers kind of want an idea of perhaps how much their child should be consuming or what types of foods. 66 00:09:04.620 --> 00:09:13.110 Vivian Ibanez: This is a great resource, because you can input very specific information about your child, so it will ask you for things like age height weight. 67 00:09:13.440 --> 00:09:26.340 Vivian Ibanez: it'll even ask you to input and describe their physical activity level and so these this information allows you to then produce a very specific plan in terms of what your child should be getting on a daily basis. 69 00:09:27.210 --> 00:09:41.400 Vivian Ibanez: And I always of course remind parents that nobody truly gets that amount so perfectly every single day and so it's really just meant to be kind of a guide in terms of knowing what the child should be consuming. 70 00:09:41.970 --> 00:09:54.690 Vivian Ibanez: And how much so that's one resource that's available and the other one that I often recommend is if there are concerns, I think, doing a wellness check if it happens to be around the corner or perhaps scheduling one and starting with a. 71 00:09:56.160 --> 00:10:11.100 Vivian Ibanez: check from the child's PCP just to get an idea if, perhaps, the child's restriction in terms of number of foods is having any consequences in terms of their growth, so if they're losing weight that might be something to kind of keep an eye out for. 72 00:10:11.790 --> 00:10:23.820 Vivian Ibanez: Or if there are other you know health consequences that might be kind of manifesting from the child not eating the right kinds of foods and, of course, I think, starting with that is a great first step, because it also allows you to make. 73 00:10:23.820 --> 00:10:24.930 Vivian Ibanez: sure that you're ruling out. 74 00:10:25.080 --> 00:10:36.930 Vivian Ibanez: But there's nothing else in terms of the child's medical status that might be contributing to why they're eliminating certain foods, such as the case of intolerances and allergies, which are quite common these days. 75 00:10:38.520 --> 00:10:49.800 Ann-Marie Orlando: So that's a really great point for parents to check with their primary care physician, to make sure that there's nothing else going on, that these difficulties or challenges with. 76 00:10:50.340 --> 00:10:56.700 Ann-Marie Orlando: feeding are not associated with any other physical or anatomical type of issue. 77 00:10:57.240 --> 00:11:05.940 Ann-Marie Orlando: You referenced the my plate and we'll definitely put a link to that our website so folks listening in to cover our website and find that particular resource. 78 00:11:06.240 --> 00:11:22.350 Ann-Marie Orlando: I think too families, probably worry about where's the point at which I need to bring this up as a question to my child well visit when do I, as a parent need to start having some concerns. 79 00:11:23.070 --> 00:11:36.930 Vivian Ibanez: So that's definitely very difficult and tricky to navigate and I empathize a lot with parents, because again there's so many different types of feeding concerns that are presented that may be difficult to kind of figure out which one. 80 00:11:37.530 --> 00:11:44.640 Vivian Ibanez: may be most concerning and probably even if parents are speaking to each other, you know kids move at different paces, although we kind of have. 81 00:11:44.910 --> 00:11:57.270 Vivian Ibanez: An expected trajectory of you know, feeding milestones it's quite typical and common for a lot of kids to maybe fall off of that or maybe take a few extra months to kind of get to that next step. 82 00:11:57.840 --> 00:12:10.980 Vivian Ibanez: So one thing that I often recommend is taking a look at those milestones and asking themselves whether it has been three or more consecutive months in which that child has not made progress. 83 00:12:11.340 --> 00:12:20.490 Vivian Ibanez: At least in some capacity toward that next sort of advancement so good example, might be, if your child is perhaps having difficulty. 84 00:12:21.300 --> 00:12:33.000 Vivian Ibanez: not relying so much on liquids and consuming more variety, so if you've gone three consecutive months and your child is still on the bottle and perhaps they're at an age where maybe they should be drinking from an open cup or self-feeding. 85 00:12:33.540 --> 00:12:40.650 Vivian Ibanez: You may start to ask yourself whether it would be time to take an appointment and start just start with that wellness visit. 86 00:12:41.190 --> 00:12:50.820 Vivian Ibanez: So I think that's one sort of area to kind of take a look at is looking at those developmental milestones and seeing whether the child is making progress, or whether they're kind of at a halt. 87 00:12:51.330 --> 00:13:01.980 Vivian Ibanez: Another area that I often recommend for caregivers to think about is if there are immediate health consequences that are noticeable so you know we talked a lot about foods activity. 88 00:13:02.250 --> 00:13:09.210 Vivian Ibanez: that one can be really tricky and i'll get to that in a second, because often for that a lot of the health consequences are hidden or masked. 89 00:13:09.450 --> 00:13:16.650 Vivian Ibanez: You know those kids are eating, probably enough to continue to grow, but there's other concerns that might be going on more internally. 90 00:13:17.280 --> 00:13:24.600 Vivian Ibanez: But you know, in terms of immediate health consequences if your child is appearing to be lethargic or losing weight. 91 00:13:25.470 --> 00:13:36.150 Vivian Ibanez: Or you know, often complaining that maybe their stomach hurts after they're trying certain foods or perhaps you can't remember when the last time was it they had a bowel movement and they're experiencing constipation. 92 00:13:36.960 --> 00:13:42.150 Vivian Ibanez: I think that that would be a situation where I would probably say it would be a good time to make an appointment. 93 00:13:42.720 --> 00:13:47.460 Vivian Ibanez: For a wellness check just to kind of start to check off the boxes and make sure that perhaps. 94 00:13:47.760 --> 00:13:59.190 Vivian Ibanez: it's not time for them to see a specialist outside of a PCP like a gastroenterologist or a dietitian to do some blood work or maybe they can get a more specific sort of eye on what the child is consuming. 95 00:14:00.090 --> 00:14:05.160 Vivian Ibanez: And then shifting gears a little bit to foods selectivity which I had mentioned is a little bit more tricky to figure out. 96 00:14:05.490 --> 00:14:19.200 Vivian Ibanez: It is common at the age of two once the kids start self feeding becoming more independent trying, a lot of foods developing preferences, because you know we all have them to this day, I still don't like mushrooms or raw. 97 00:14:19.200 --> 00:14:33.480 Vivian Ibanez: tomatoes, but I can supplement that food group with a lot of other foods it's not so much a concern right so having preferences isn't necessarily a bad thing it's great to have foods that we enjoy because it has a lot of other social implications like we've talked about. 98 00:14:33.870 --> 00:14:41.550 Vivian Ibanez: But if you find yourself in a situation where they've eliminated an entire food group I might become more concerned. 99 00:14:42.300 --> 00:14:47.460 Vivian Ibanez: Also, if you just find that you're very stressed out, you know I know you, Ann-Marie, you mentioned. 100 00:14:47.790 --> 00:15:00.540 Vivian Ibanez: The chicken nuggets scenario where it has to be a specific shape and perhaps dipped with a specific brand of sauce or heated to a certain temperature and eaten in this specific room, then you might start to wonder whether. 101 00:15:01.140 --> 00:15:06.510 Vivian Ibanez: That is going to continue and whether you know you're able to manage that level of sort of routine. 102 00:15:06.810 --> 00:15:17.460 Vivian Ibanez: Or if your child is having excessive challenging behavior, to the point where you can no longer manage the behavior at the meal times and it becomes a stressful situation and sometimes unsafe. 103 00:15:18.090 --> 00:15:34.530 Vivian Ibanez: Then, that would be a situation where you might wonder whether it's time to sort of get a wellness check at least that's the first step to that, then you can get a referral to other experts within the interdisciplinary team to start to look at what else might be going on with your child. 104 00:15:35.760 --> 00:15:39.900 Ann-Marie Orlando: So those are really great points of things that parents ought to be thinking about. 105 00:15:40.140 --> 00:15:40.860 Ann-Marie Orlando: Right is. 106 00:15:40.950 --> 00:15:49.020 Ann-Marie Orlando: How much are you how much, are you as the parent anxious about when it comes time to feed your child right how much time do you invest in that and I. 107 00:15:49.530 --> 00:16:03.630 Ann-Marie Orlando: I think, too for some families, we do our needs assessments to figure out how is card going to support you, one of the things I asked families is does your child eat with you and eat the same things that you eat. 108 00:16:04.320 --> 00:16:09.000 Ann-Marie Orlando: Maybe not the exact same portion but but join you for those family mealtimes. 109 00:16:09.420 --> 00:16:20.700 Ann-Marie Orlando: Because we know that, in general, family meals meal times can be somewhat challenging and stressful but if if this child is is causing you know stressed beyond the typical. 110 00:16:21.900 --> 00:16:24.060 Ann-Marie Orlando: You know rush to get there on the table, and all that. 111 00:16:24.810 --> 00:16:39.030 Ann-Marie Orlando: Then it's time to really maybe do some further examination of what the issues are, and is it around the particular food that they're they're having or even the idea of sitting at the table yeah for some kids that can be a challenging as well. 112 00:16:39.390 --> 00:16:45.870 Vivian Ibanez: Exactly and like you said I don't mean to I think oftentimes especially foods selectivity it can be quite alarming and some parents might be wondering. 113 00:16:46.290 --> 00:16:53.160 Vivian Ibanez: Oh, my goodness, I you know my kid didn't eat vegetables all last week for dinner or it was hard to get them to finish the broccoli on their plate again. 114 00:16:54.150 --> 00:17:01.740 Vivian Ibanez: taking a look at whether it's been a consecutive you know, three months is kind of a rule of thumb that I use because again it's typical for kids. 115 00:17:02.070 --> 00:17:07.560 Vivian Ibanez: You know you maybe have to remind them, you know finish the broccoli on your plate, so that you can get dessert and maybe. 116 00:17:07.770 --> 00:17:16.110 Vivian Ibanez: You know a little bit of negotiating and things like that are quite common but, again, if you find yourself like you were saying, where you, you know you're very anxious and very stressed or. 117 00:17:16.380 --> 00:17:24.840 Vivian Ibanez: You perhaps go to bed thinking I don't know if my kid ate enough or I truly can't remember the last time they ate a vegetable then. 118 00:17:24.870 --> 00:17:26.670 Vivian Ibanez: Again, those are situations where you may. 119 00:17:26.880 --> 00:17:33.690 Vivian Ibanez: want to at least you know check off that you are going to a wellness visit just just ask those questions. 120 00:17:34.530 --> 00:17:35.610 Vivian Ibanez: that's yeah. 121 00:17:36.450 --> 00:17:50.790 Ann-Marie Orlando: So, once a parent has you know confirmed that you know, maybe my child does have you know have a feeding problem, what are some types of treatments that they might be looking for in terms of services to help with this issue. 122 00:17:51.900 --> 00:18:00.630 Vivian Ibanez: There so there's quite a vast number of treatment options, which again is great, but also can be really challenging for parents in terms of navigating and knowing. 123 00:18:00.990 --> 00:18:09.750 Vivian Ibanez: What might be the best fit for their individual child now in a moment i'll focus more so on behavior analysis, just because that's my area of expertise. 124 00:18:10.530 --> 00:18:12.030 Vivian Ibanez: As a wealth of empirical support. 125 00:18:12.150 --> 00:18:15.240 Vivian Ibanez: But it's not the only treatment modality that exists out there. 126 00:18:15.840 --> 00:18:25.230 Vivian Ibanez: In fact, probably first line clinicians before behavior analysts tend to include folks like occupational therapist, speech and language pathologist and they. 127 00:18:25.530 --> 00:18:42.960 Vivian Ibanez: offer an incredible area of expertise in terms of just the anatomy of the swallow, understanding oral motor skills and what it takes to manage certain foods and on that note I think it's important to mention, even with kids who have what might be called foods selectivity. 128 00:18:43.290 --> 00:18:49.680 Vivian Ibanez: We have found that over half of the kids that we have seen in a year's period of time who present with foods selectivity 129 00:18:50.010 --> 00:19:05.730 Vivian Ibanez: often also present with oral motor skill deficits, so this is just also something to keep in mind, even if your child is eating chicken nuggets, potato chips, French Fries is it may still mean that you might want to seek a check of where they are in terms of their. 130 00:19:05.730 --> 00:19:08.070 Vivian Ibanez: Oral motor skills if they're only practicing. 131 00:19:08.370 --> 00:19:19.890 Vivian Ibanez: Certain skills, with very specific foods and don't really have a large variety so folks like ot occupational therapist and speech language pathologist have a really good eye for figuring these pieces out. 132 00:19:20.220 --> 00:19:25.020 Vivian Ibanez: So that's one treatment option and again, those are very child directed, dynamic. 133 00:19:25.620 --> 00:19:38.190 Vivian Ibanez: they're often incorporate you know, a sensory-based sort of intervention, and if that is not you know not enough, which is the case for some kids you know just like we all have. 134 00:19:38.820 --> 00:19:45.180 Vivian Ibanez: You know, certain medication prescriptions where if we have to take a specific dose a specific type to kind of get the. 135 00:19:45.450 --> 00:19:52.830 Vivian Ibanez: effects we also see that in terms of the treatment options with feeding interventions so for some kids those treatment options may be great. 136 00:19:53.340 --> 00:19:58.980 Vivian Ibanez: But other kids might need something a little bit more intensive you know systematic. 137 00:19:59.430 --> 00:20:08.010 Vivian Ibanez: More therapists direct it with kind of a very specific structure that's protocol driven and that's kind of where behavior analysts come into the mix as well, so. 138 00:20:08.250 --> 00:20:23.880 Vivian Ibanez: Again first thing clinicians tend to be occupational therapists, speech and language pathologist and they offer a lot of great resources, but then there's also behavior analysis as well, which might be for kids who maybe need something a little bit more to make to make clinical gains. 140 00:20:25.560 --> 00:20:26.970 Ann-Marie Orlando: That sounds great sounds like a great. 141 00:20:27.990 --> 00:20:36.990 Ann-Marie Orlando: format, you know to sort of think about how intensive the treatment needs to be and start with some of those maybe less intensive types of treatments first. 142 00:20:37.410 --> 00:20:48.840 Ann-Marie Orlando: And then get to something that's more intensive and what are some things that families and strategies that families might use they have concerns about about their child's eating. 143 00:20:49.710 --> 00:20:59.640 Vivian Ibanez: So I have what I call often are like healthy contingencies that i'll recommend to any family, including my own, you know my sisters have nieces. 144 00:21:00.120 --> 00:21:11.970 Vivian Ibanez: Or have kids of their own that are my nieces and nephew and i'll often recommend some of these strategies, so I always say that my general philosophy is that to be a good eater you have to practice eating and. 145 00:21:12.510 --> 00:21:24.030 Vivian Ibanez: To be able to do that, we really need to set up the child for success by breaking it down into very small simple, easy steps, so I often recommend that the parents take a look at. 146 00:21:24.360 --> 00:21:31.260 Vivian Ibanez: kind of those what I call antecedent variables so things that happened before, and what you're doing to set up that child's mealtime. 147 00:21:31.620 --> 00:21:35.460 Vivian Ibanez: So to start, for example, I often tell parents to take a look at the schedule. 148 00:21:36.030 --> 00:21:43.620 Vivian Ibanez: You know if the child is you know grazing or eating throughout the day that might be one kind of starting point is to get the child used to. 149 00:21:44.340 --> 00:21:49.710 Vivian Ibanez: A structured schedule, so that it's not a situation where perhaps there you know eating. 150 00:21:50.010 --> 00:21:59.310 Vivian Ibanez: cheerios at 7 and then at 7:40 they're having cheeses, and then at 8:15 they're having you know eight ounces of milk and then they kind of just snack throughout the day. 151 00:21:59.550 --> 00:22:08.700 Vivian Ibanez: That often can limit kind of that association and responding to hunger cues and the way that you and I may do when we have our you know typical three meals and maybe two snacks throughout the day. 152 00:22:09.090 --> 00:22:18.540 Vivian Ibanez: So I have to start at that point, and then I think really starting really small and just kind of adding little bits of structure and so much so that you kind of. 153 00:22:18.870 --> 00:22:28.290 Vivian Ibanez: The intent really isn't to kind of evoke or cause a lot of challenging behavior that might be difficult to manage, but it may be something as simple as just starting with one bite. 154 00:22:28.680 --> 00:22:35.820 Vivian Ibanez: And then you know if the child consumes the one bite you know, a party happens and it's something great and all these great things that the child wants occurs. 155 00:22:36.090 --> 00:22:44.760 Vivian Ibanez: But if the time doesn't do it, you know you end based on time it's not really a situation where we're pushing the kid a whole lot we may try something and then, if that doesn't work. 156 00:22:45.360 --> 00:22:47.880 Vivian Ibanez: Maybe taking a look at the whole meal and figuring out. 157 00:22:48.180 --> 00:23:01.590 Vivian Ibanez: You know if they only eat yellow foods or orange foods, perhaps, starting with an orange vegetable and trying to match some of those properties that might at least increase the probability that the child might be more willing to approach a food. 158 00:23:02.520 --> 00:23:09.180 Vivian Ibanez: And then, even in terms of approaching the food, you know, maybe the goal isn't at first to eat the bite and swallow it maybe it's just. 159 00:23:09.450 --> 00:23:19.380 Vivian Ibanez: Tolerating it being on the plate for a little bit of time and if that goes well, then you know only touching it or you know minimizing kind of some of those steps and breaking it down such that. 160 00:23:19.620 --> 00:23:30.120 Vivian Ibanez: Things are really easy at the start and you're increasing the likelihood that the child will contact success and then get a lot of great things that you know, in response to them. 161 00:23:30.690 --> 00:23:33.060 Vivian Ibanez: doing the appropriate things that you're asking them to do. 162 00:23:34.260 --> 00:23:41.760 Ann-Marie Orlando: I like that, because it sounds really doable right, I think you know it's important whenever we make suggestions to families there's something that. 163 00:23:42.060 --> 00:23:52.050 Ann-Marie Orlando: families can do and so thinking about the schedule and and how much the child is eating throughout the day and then trying to just add one thing at a time. 164 00:23:52.080 --> 00:23:53.790 Ann-Marie Orlando: To their food repertoire. 165 00:23:54.810 --> 00:24:00.030 Ann-Marie Orlando: can really you know, increase the likelihood that they might eat something a little different. 166 00:24:00.660 --> 00:24:07.200 Vivian Ibanez: yeah and like you said it definitely takes time and I think that we're all even myself as a as a clinician sometimes. 167 00:24:07.650 --> 00:24:14.580 Vivian Ibanez: I want to kind of rush the kid through and meet the goal, and you know if the week has elapsed i'm wondering why are we making progress yet, but. 168 00:24:14.910 --> 00:24:27.540 Vivian Ibanez: You know, I think that, just like you said it can take time and for that reason we're very specific about you know, making sure that there's not other immediate health consequences, so I want to add the caveat that I probably wouldn't recommend. 169 00:24:27.780 --> 00:24:30.180 Vivian Ibanez: Taking a long time or taking this approach. 170 00:24:30.390 --> 00:24:35.640 Vivian Ibanez: If the child has had three consecutive months of weight loss or they're ending up in the er. 171 00:24:36.240 --> 00:24:44.490 Vivian Ibanez: hospitalized for dehydration that's kind of a different sort of category in terms of what we would want to do that would require more immediate intervention. 172 00:24:44.760 --> 00:24:51.330 Vivian Ibanez: But you know if you have a kid who perhaps you're just trying to increase the number of vegetables or the variety of their diet, then. 173 00:24:51.960 --> 00:25:01.530 Vivian Ibanez: Taking this sort of mealtime structure approach and starting very small and breaking things up into very small steps, is certainly appropriate and like you said. 174 00:25:01.830 --> 00:25:08.100 Vivian Ibanez: manageable and you know it's another way to figure out whether your child needs something more intensive if you've given this ago. 175 00:25:08.430 --> 00:25:22.590 Vivian Ibanez: And you still find that you're quite frustrated or you're not making enough gains or other health consequences emerge as you're trying this and that might be another way for you to kind of know or confirm, as a parent whether it's time to get some other help. 176 00:25:23.700 --> 00:25:35.400 Ann-Marie Orlando: Absolutely that's really great advice and I, like those you know benchmarks about take her to the er because dehydration that's that's a real red flag about needing something a little more intensive. 177 00:25:36.600 --> 00:25:49.200 Vivian Ibanez: yeah and one thing that I do want to add Ann-Marie is again, I think that the role of the caregiver cannot be overstated, so you know caregivers are a crucial and critical component of. 178 00:25:49.650 --> 00:25:54.000 Vivian Ibanez: Their child success when it comes to feeding so even in our Program. 179 00:25:54.480 --> 00:26:01.410 Vivian Ibanez: which I think we'll get to in a moment we do require a lot of the parents and have them become active participants just because. 180 00:26:01.680 --> 00:26:11.220 Vivian Ibanez: You know, they are the main supervisors of the meal their their present and, ultimately, the goal really for any kid is to join a family meal so inevitably parents are involved. 181 00:26:11.580 --> 00:26:24.180 Vivian Ibanez: To some extent, and so I really have a lot of respect and empathy for the role that caregivers play and the effort that is required of them to kind of support their child in in terms of feeding. 182 00:26:25.200 --> 00:26:25.800 Ann-Marie Orlando: Absolutely. 183 00:26:26.940 --> 00:26:29.160 Ann-Marie Orlando: vital role to this whole process. 184 00:26:30.690 --> 00:26:46.020 Ann-Marie Orlando: And so, so you mentioned working at Florida autism Center, and this is a new specialty clinic that we have here at the Center for autism and neurodevelopment, where so many autism services are co located so tell us a little bit about that. 185 00:26:46.920 --> 00:26:57.090 Vivian Ibanez: Sure, so we are really excited like you said, we now have services that are co located, which is great for clinical care, but also I imagine for parents kind of a one stop shop. 186 00:26:57.600 --> 00:27:10.800 Vivian Ibanez: sort of approach, specifically at the Florida autism Center we have opened a what we call a day treatment program so in this program really The goal is to jumpstart feeding behavior so. 187 00:27:11.370 --> 00:27:18.780 Vivian Ibanez: Part of our admission criteria in terms of who has a program is appropriate for is those kids that we talked about where perhaps. 188 00:27:19.110 --> 00:27:29.940 Vivian Ibanez: Other treatment modalities haven't been quite effective or really enough to get them going so if the child has had three months of previous therapy with another provider. 189 00:27:30.210 --> 00:27:47.010 Vivian Ibanez: Then that's kind of one of the first sort of indicators or steps that we require in terms of admission to the program and then, once they get here we'll do an initial assessment to take a look at exactly what the mealtime concerns are and then what the parents can expect is an eight. 190 00:27:47.040 --> 00:27:50.940 Vivian Ibanez: To 12 week commitment in terms of the intensive program where. 191 00:27:51.150 --> 00:28:01.860 Vivian Ibanez: they'll have a team of registered behavior technicians i'm usually a primary and a secondary therapist That then is overseen by someone like myself a BCBA at the doctoral level. 192 00:28:02.100 --> 00:28:06.000 Vivian Ibanez: And then we will work on a series of feeding goals. 193 00:28:06.210 --> 00:28:15.960 Vivian Ibanez: With the kind of goal to transition to less intensive therapy on more of an outpatient basis where we'll see them for once a week and goals you know include. 194 00:28:16.680 --> 00:28:29.010 Vivian Ibanez: meeting their nutritional needs by mouth perhaps if the child is dependent on to feedings reducing those to feeding such that they're now consuming calories by mouth, but we also work on self feeding, chewing. 195 00:28:29.610 --> 00:28:41.010 Vivian Ibanez: Really, a variety of types of goals, depending on that child's individual needs and like I said initially the team is working with the child, but then the goal is to incorporate the parent and do. 196 00:28:41.670 --> 00:28:50.820 Vivian Ibanez: Some training with the caregivers and anyone else who might be feeding the child, such as a teacher, daycare provider, grandma, grandpa anybody else in the family who would it be participating in meals. 197 00:28:51.240 --> 00:29:00.660 Vivian Ibanez: And then, of course seeing them on an outpatient basis, because the goal for any child that comes into our program is to attain age typical feeding. 198 00:29:01.260 --> 00:29:02.340 Vivian Ibanez: and so that can take. 199 00:29:03.600 --> 00:29:10.800 Vivian Ibanez: I can take quite a bit of time, so, although we jump started in the day treatment program outpatient is kind of meant to continue working towards those goals. 200 00:29:11.100 --> 00:29:19.740 Vivian Ibanez: and generally, although it's different for each kid parents might expect, you know that that can take up to two years from the time they start in this program. 201 00:29:21.450 --> 00:29:35.490 Ann-Marie Orlando: Okay, great well Thank you so much, I mean that's that's such an important service like I said in the beginning, we have so many families who are coming to us and asking for them when do they need more intense services and where do they get those more intense. 202 00:29:35.520 --> 00:29:37.890 Vivian Ibanez: Now yeah and I know. 203 00:29:38.040 --> 00:29:47.970 Vivian Ibanez: they'll be there and I know it sounds like a lot, some people may be listening to this and thinking man, you know eight to 12 weeks six hours a day that sounds like a lot. 204 00:29:48.480 --> 00:29:58.350 Vivian Ibanez: But again it's it's really kind of adding a new sort of service, because there's already a lot of existing Community based providers that provide outpatient feeding therapy. 205 00:29:58.800 --> 00:30:10.890 Vivian Ibanez: But what seemingly has been kind of missing at least from the Community is a place like this, where kids who need that extra sort of support in terms of that intensity can come. 206 00:30:11.160 --> 00:30:23.400 Vivian Ibanez: To kind of get going and then, of course, the goal would be to transition to something less intensive so they're not coming to us every single day all day but they're coming to us once a week until they graduate fully as an age typical feeder but. 207 00:30:23.490 --> 00:30:30.480 Ann-Marie Orlando: That makes sense and I like to that you do training for the caregivers and how to implement this at home and for the extended caregivers as well. 208 00:30:31.230 --> 00:30:46.350 Vivian Ibanez: yeah and I should mention if folks are interested in that program or want more information I can provide a phone number, and I imagine will probably provide a link to the website that's currently still in development but i'm happy to provide that information, if you would like, as well. 209 00:30:46.890 --> 00:30:53.520 Ann-Marie Orlando: yeah absolutely if you have a website or email or a phone number that you want to state right here, right now, that would be great. 216 00:31:23.250 --> 00:31:38.730 Vivian Ibanez: So that phone number is 352-554-9162 and when you reach and connect to that number, you can just ask for someone or information on the feeding Program. 217 00:31:39.780 --> 00:31:46.620 Ann-Marie Orlando: that's great, and this is would be considered an ABA service right using because it uses applied behavior analytics. 218 00:31:46.680 --> 00:31:47.760 Vivian Ibanez: Correct yes. 219 00:31:48.420 --> 00:31:54.510 Vivian Ibanez: i'm glad that yeah and i'm glad that you mentioned that because I do want to mention, although we partner with the Florida autism Center. 220 00:31:55.170 --> 00:32:10.470 Vivian Ibanez: We are a division of blue sprig pediatrics and what this means as that we will see kids who don't have autism as well, so it might be children with a related disorder or perhaps they've been diagnosed with avoidant restricted food intake disorder. 221 00:32:10.920 --> 00:32:21.810 Vivian Ibanez: But I do want to make it clear that we are able to see kids with autism, but also kids who perhaps do not have autism but might have a related diagnosis, or something more specific to their feeding. 222 00:32:22.770 --> 00:32:25.890 Ann-Marie Orlando: yeah that's really great because it really expands who. 223 00:32:27.330 --> 00:32:29.610 Ann-Marie Orlando: can be a candidate for this service so. 224 00:32:29.760 --> 00:32:30.540 that's exactly. 225 00:32:32.460 --> 00:32:43.410 Ann-Marie Orlando: Well gosh miss Vivian this has been so informative Thank you so much for joining us today and offering this information to our listeners will be really, really helpful. 226 00:32:43.770 --> 00:32:51.180 Vivian Ibanez: Of course, it was my pleasure, and I really appreciate you extending the invitation to talk about a topic that I care so much about so thank you. 227 00:32:51.900 --> 00:32:52.620 Ann-Marie Orlando: Well, it shows. 228 00:32:52.650 --> 00:32:54.060 Ann-Marie Orlando: And we really appreciate you. 229 00:32:54.360 --> 00:32:56.550 Ann-Marie Orlando: Being So this has been a UF. 230 00:32:56.580 --> 00:33:03.090 Ann-Marie Orlando: card casts please check out our other podcasts at card.usl.edu Thank you.