Feeding developmentally delayed or premature infants and children can be complicated. Some reasons for complications can be the gap that arises from the bonding time lost to the NICU, or communication challenges related to delays that confound even the best parents. The emotional and physical bonding is often more challenging.

Premature birth or delays intertwined with concerns about feeding and weight gain can mark the life of child and parent. Daily feeding problems disrupt family life. The idea that children will not starve themselves is hardly consoling. In extreme cases, this comment is not even true. In most cases, the most bedeviling feature is the busy child engaged with everything except food.

The mother of one my current patients missed that time as she watched her busy son have trouble eating and gaining weight. She called it “lost time.” It that made her feel distant from her child when it came to feeding. Her son was born about 1 month early and, one year later, mom still missed that time. Little children often experience the same disconnect as the parent, and this disconnect further decreases their interest in food. More bonding was needed to interest her son in more calories.

The child’s development also presented challenges. By this child’s sixth and seventh adjusted months, he did not meet the developmental milestones of cup use and finger feeding associated with that age, despite the absence of any fine motor problems. The speech therapist and I made some progress with the feeding and offered nutritional information and developmental guidance. The guidance consisted of ways to help mom, dad, and baby connect with games and modeling, to helping their son eat in an age appropriate way. Mom began to feel more connected, more food went in, and the rate of weight gain increased.

A crisis arose when an old ulcer acted up. Stomach pain dulled the child’s appetite. Medications quickly resolved the ulcer but two mild illnesses occurred, one right after the other. As expected, the illnesses kept his appetite depressed and months of gain vanished in 4 weeks. Mom knew she could not force feed but her sense of failure as a mother made her very sad and increased her sense of disconnection. Her grief was exacerbated by the advice of the pediatrician, speech therapist and me that she wait out the illness. At this point, mom verbalized her sense of alienation, which she dated to that “lost time.” We therapists were worried, because as parents become distressed, children often respond with a depressed appetite. They feel the loss of connection when the parent’s feelings turn inward instead of outward towards them. Meanwhile, her son was on the mend and began to return to bottle feeding, but it was unclear about mom’s response to the recuperation.

I suggested she place him on her lap against her belly while humming as he was bottle fed. She had already moved from using television to recorded music as a distraction. I felt that now, with humming, she and her son could begin to reconnect and gain back some of that lost time. The physical connection soothed mom and baby. Perhaps, redressing some of that lost time by helping him grow while enveloped in her lap, returned him to the muffled sounds heard inside the amniotic ocean. With that, the session ended. A few weeks later, mom was happy. Her son’s weight was up and I am looking forward to the next steps.

Richard is a Registered Dietitian offering nutritional services for children between 6 months and 5 years of age. His interests are feeding problems in typical and atypically developing children experiencing pickiness, refusals, failure to thrive or other weight gain concerns. His work is based using developmental, play and family strategies to address eating problems in families with young children and children with developmental delays. He is currently researching a method to help parents wean their children off the bottle. He can be reached at: richard@brooklynlearning.com and by phone at 917-232-5373. www.brooklynlearning.com

If you are a Park Slope or Windsor Terrace parent concerned about your young child’s speech, language, and/or communication development, you have come to the right place! Brooklyn Letters is proud to announce its newest member- Dr. Michelle MacRoy-Higgins, Assistant Professor at Hunter College and South Slope resident.

Michelle MacRoy-Higgins, PhD CCC-SLP, TSHH, Speech Language Pathologist

Dr. Michelle MacRoy-Higgins has worked as a Speech-Language Pathologist for nearly 15 years. She holds her Certificate of Clinical Competence (CCCs) from the American Speech-Language-Hearing Association (ASHA), her New York State Speech-Language Pathology license and is certified as a Teacher of the Speech and Hearing Handicapped (TSHH). She received her B.S. in Communication Sciences and Disorders from the State University of New York (SUNY) College at Geneseo, her M.S. in Communication Sciences and Disorders from Adelphi University and her PhD in Speech-Language-Hearing Sciences from the City University of New York (CUNY) Graduate Center. In addition to being a private practitioner, Michelle is an Assistant Professor in the Communication Sciences program at Hunter College (CUNY) and teaches graduate students in the areas of language development, language, phonological, articulation, motor speech and swallowing disorders in children. Michelle has worked clinically in a variety of settings including home-based, preschool, elementary school and private practice clinics; and has enjoyed working with a variety of children presenting with language, phonological, articulation, and feeding disorders ranging in age from birth through adolescents. Michelle’s clinical and research expertise is with children who are late talkers. She enjoys working with children and their families to develop individualized and evidenced-based treatment, while having fun and encouraging communication success.

HOURS: Available weekends and Tuesdays and Wednesday mornings

LOCATION: Park Slope and Windsor Terrace
TYPE OF SERVICES: Individual therapy, group (2-3 children), speech-language evaluations, parent consultation

EXPERTISE: Speech-language delays, autism spectrum disorders, feeding and swallowing disorders
AGES: birth through elementary school

PAYMENT: Private Pay, Out-of-Network

CONTACT: michelle@brooklynlearning.com

Jai has been receiving intensive and individualized speech-language services 15 hours per week since 10/11/10. Long term goal areas include: receptive and expressive language skills (grammar, vocabulary, basic concepts, following directions, asking and answering questions), literacy skills, feeding skills, and social language skills.

Here are two video clips of Jai learning literacy skills:
1) http://www.youtube.com/watch?v=VSn2qaU86Dc
2) http://www.youtube.com/watch?v=4J2PTcH02Ms

Here are video clips of Jai’s mother explaining the homework binders:
1) http://www.youtube.com/watch?v=Va6sC7cwWpM
2) http://www.youtube.com/watch?v=6jtFsts8K4g

Initial summary of skills (10/11/10)

When Jai first began receiving services, he presented with significant delays in receptive and expressive language skills, literacy, and feeding skills. He also demonstrated limited attention to structured tasks and table-top activities. Jai spoke in short sentences (often 1-2 words), demonstrated grammatical and word-order errors. He had difficulty using language to request, protest, and ask for help. Jai did not independently use language to comment on objects or action during play. He answered “what” and “what happening” questions with approximately 70% accuracy. He had more difficulty with response to “who”, “when”, “where”, and “why” questions. Jai demonstrated delays in understanding of concepts (spatial, number, time) and followed 1-step directions approximately 50-60% of the time. Jai was at the pre-literacy stage of reading development and recognized 8/26 letters in the alphabet and 4 sound/symbol combinations. He had difficulty with auditory discrimination of sounds (e.g. /p/ vs /b/, /m/ vs /n/).

Progress (11/10/10)

Jai has made steady and significant progress on his speech-language, literacy, and feeding goals since he began therapy. Jai learns best given repetition of information, opportunities for practice, and through the use of hands-on materials and visual prompts. Jai demonstrates good retention of information once he has learned it. He responds well to verbal models and prompts.

Receptive/Expressive Language: In terms of receptive and expressive language skills, Jai now speaks in sentences up to 5-6 words in length with varying levels of complexity. He continues to produce grammatical errors, but responds well to verbal prompts to correct error sentences and retains information/skills gained during structured tasks that target appropriate grammatical usage. Grammatical skills targeted include regular and irregular past tense verbs, plurals, and subject+verb agreement (“He is writing”; “They are running”). Jai uses appropriate question forms to request activities, objects, or toys. He is working to use appropriate phrases and sentences to protest or indicate that he does not like something. Jai asks for help 8/10 opportunities and he is working to use more specific language when asking for help e.g. rather than saying, “Help me please,” Jai instead will say, “Please help me move these books to the table”. Jai now uses language to comment during play. He has increased the scope, complexity, and flexibility of play schemes and engages in age-appropriate pretend play. He enjoys playing with pirates, legos, play-doh, turn-taking games, and computer or ipod games. Jai has increased his understanding of spatial concepts during structured tasks and identifies in, out, under, on, next to/beside, behind, and in front with 90-100% accuracy. He continues to work on expressively using these locatives. He also continues to work on increasing his knowledge of opposites, number concepts, and temporal concepts. Jai follows 1-step directions with 100% accuracy and 2-step directions with 70-75% accuracy. Jai’s vocabulary continues to increase on a daily basis. He has been and continues to be exposed to new, different, and exciting culture, people, and experiences here in New York. He has learned about the changing seasons, weather, Halloween, Thanksgiving, ice skating, etc. Jai has increased his categorization skills and can identify and talk about how/why pictures, objects, and/or words can go together. Categories include: food, colors, shapes, numbers, vehicles, tools, animals, and furniture. Jai has increased his ability to accurately answer a variety of “wh” question forms. During structured activities and when given verbal and visual prompts, Jai answers “what” questions with 90% accuracy, “where” questions with 80% accuracy, “who” and “when” questions with 70% accuracy, and “why” and “how” questions with approximately 50-60% accuracy. He has increased his ability to answer all question forms with more accuracy during less structured activities and conversational exchanges.

Literacy: Jai now identifies 21/26 letters of the alphabet (all except h, w, g, q, y) and demonstrates knowledge of sound/symbol awareness of these letters. He auditorily discriminates between /p/-/b/ and /m/-/n/ with 90-100% accuracy. Jai has been introduced to rhyming words: cat, hat, fat, sat, mat, bat, pat, rat and can, fan, man, pan, tan, van. He is able to read these words with 80% accuracy and spell them with 70% accuracy during structured tasks. Jai enjoys books and shows a desire to read and learn new information through reading. He appears to have acquired a good foundation and knowledge base to develop literacy skills. He makes attempts to sound out new words and is more confident in his skills. Each week Jai shows significant improvement in this area.

Impressions and Recommendations

Jai has made amazing gains since beginning therapy 1 month ago. He has set the foundation for learning and literacy development. He has increased his abilities in the following areas: attention for structured tasks and for sustained focus, e.g. to discriminate sounds, confidence, willingness to try new and/or difficult tasks, retention of information, retrieval of information, carryover of skills, and independence in demonstration of knowledge and skills. He responds well to the clinician’s models and prompts. He shows excellent potential for continued learning and skill development.

Suggested goals at this time include:

1) Emerging literacy skills.
a) Jai will sound out letters
b) Jai will identify letters in words in short phrases
c) Jai will identify rhyming words
d) Jai will discriminate sounds l, h, w, g, q, y
e) Jai will identify sight words
f) Jai will read sight words
g) Jai will write short words and sentences, given prompts.

2) Expressive language
a) Social language
b) Jai will use his words to ask questions, request, comment, protest etc
c) Jai will use words to answer questions

3) Sentence formulation
a) In the appropriate context, Jai will use simple complete sentences (noun and verb phrase) to to request, protest, comment, and ask for help.
b) Jai will increase his vocabulary, including acquiring more verbs
c) Jai will appropriately use negations
d) Jai will appropriately use spatial concepts
e) Jai will use words to answer “why” questions
f) Jai will use age-appropriate syntactic/grammatical forms (plurals, regular and irregular past tense verbs).

4) Receptive language
a) Increase accuracy of comprehension and use of spatial concepts and prepositions (in, out, on, under, next to, behind, in front)
b) Increase accuracy of following 2 directions.
c) Increase accuracy of 1 step 2 unit directions (e.g. “Find the big white dog”) and 2-step directions

5) Concepts
a) Jai will learn basic opposites
b) Jai will learn all four seasons

6) Attention and Behavior
a) During focused academic activities, Jai will sustain attention for 30-40 minutes before needing a break.
b) Jai will speak to his mother in English during meals
c) Jai will learn to wait 5 minutes before he can interrupt his mother while she is engaged in a conversation

7) Feeding
a) Jai will eat thicker pieces of food in his current diet, he will eat a larger variety of foods, and he will practice eating solid snacks to facilitate his chewing skills.

Sarah Stuntebeck, M.S. CCC-SLP
Craig Selinger, M.S. CCC-SLP

Sarah is a Speech-Language Pathologist who provides home-based assessment and therapy services in the Park Slope and Carroll Gardens neighborhoods of Brooklyn, NY. She specializes in working with children and adolescents who have difficulty with articulation, phonology, language, fluency/stuttering, literacy skill development, pragmatics, and social language. Sarah develops individualized and evidence-based therapy plans that include frequent and ongoing collaboration with parents, caregivers, teachers, and educators in order to maximize the potential of each child. She can be reached at sarah@brooklynletters.com or www.brooklynletters.com