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ADHD and Picky Eating

Attention Deficit Hyperactivity Disorder (ADHD) is a very common diagnosis seen in a pediatric therapy clinic. It is not uncommon for parents to report difficulty with their child with ADHD and picky eating. The most common complaints for parents of children with ADHD who have trouble with mealtimes are distracted eaters, decreased appetites, and picky eaters.

Distracted Eaters

Distracted eaters are attending to external stimuli (e.g., TV, other conversations) or internal stimuli (e.g. lost in own thoughts) during mealtimes. Here are some strategies to help:
  • Decrease the external distractions: Eliminate other distractions like the TV or videogames playing in the background, dogs running around, telephones buzzing, etc. Have your child face other family members and face away from the busy kitchen area to encourage attention in the appropriate direction. Require your child to stay in the room and at the table for the duration of the mealtime.
  • Decrease internal distractions: Use solid placemats, plates, and utensils when eating. Colorful patterns or animated pictures can be distracting. Sometimes having a child engage in motor activities before sitting for a meal can help regulate him to be ready to sit and attend for a period.

Decreased Appetites

An almost universal side effect of stimulant medication used for ADHD is the suppression of appetite. In particular, the dextroamphetamines (e.g., Adderall, Vyvanse) seem to have the highest incidence of suppressing appetite. Here are some tips to manage decreased appetites:

  • Give the morning medication dose after breakfast to ensure an adequate meal is consumed before the side effect of decreased appetite sets in.
  • Provide proteins during lunchtime and small, healthy snacks during the day. Smaller snack-sized portions are often more visually manageable for children than an entire plate of food. Protein shakes are good options during this time.
  • Serve a larger dinner meal at the end of the day when the drug has worn off. Kids will typically make up many of the calories lost during the reduced daytime eating with a larger evening meal.
  • Consider not using the drug on weekends if your child continues to struggle with this side effect. Allowing one or two days of increased calories a week can counteract for a decreased intake during the weekdays.

Picky Eaters

Kids can be picky eaters for a variety of reasons. Evolution dictates children be wary of trying new things in order to survive. They may have a negative association with eating or have sensory issues causing anxiety with certain foods. Cognitive and developmental disorders also may impact the types of food eaten. Similarly, kids with low tone (i.e., decreased strength, coordination, and postural control) may be picky about the foods that are easier for them to eat.

Any of the above issues may co-occur with ADHD.

Here are some strategies to help your picky eaters:

  • Meal Routine: Too much grazing throughout the day may result in a lack of hunger at specific mealtimes. Three meals and two snacks should be offered per day to ensure hormonal balance triggering “hunger”. There should be a beginning, middle, and end to every meal.
  • Exposure: The best role model for food it you! Having family dinners and presenting children to a variety of foods that you, as caregivers, model eating is a critical way to expose your child to the idea that food isn’t scary.
  • Posture: Ideal eating position is hips, knees, and ankles positioned at 90 degree angles. Boosters/chairs should be utilized to ensure the child is at the appropriate table height. If your child has a hard time remaining in a chair, move-and-sit cushions can provide sensory input to help your child stay seated for a longer.
  • Desensitize: For some children, decreasing the sensitivities of the mouth may help with food intake. Using a vibrating tooth brush, a chewy tube or a washcloth tug-o-war are good options to desensitize the child.
  • Get the kids involved: Taking the kids with you when you grocery shop and letting them help pick out the foods will help with compliance. Encourage your child to help with creating the menu, choosing the foods, and preparing the meal are other ways to help your child become involved in mealtimes.

Children with ADHD may have a difficult time with mealtime. Remember to be patient and do the best you can to provide them as many healthy food options as possible. The rest is up to them. For other tips on how to parent a child with ADHD, click here.


What do Occupational Therapists Look for During your Child’s Handwriting Sample?

Handwriting is a lifelong skill. It begins as young as 3 years of age, when children start identifying shapes, letters, and numbers.  Handwriting and letter recognition are important for communicating (e.g. sending cards and emails) and for completing age-appropriate tasks (e.g. homework assignments; writing grocery lists).child pencil grasp

Below are many of the components your child’s occupational therapist looks for during a handwriting sample in order to work towards a clear and legible final product:

  • Sizing: Are the letters all relatively the same size (e.g. all upper case the same size and all lower case the same size)?
  • Spacing: Are the letters and/or words too close together?  Or is there at least a finger or pencil width between each word?
  • Mixing of upper case and lower case:  Is there inconsistency between the use of upper case and lower case letters?  Are upper case letters used correctly (e.g. start of a sentence or for a name/title)?  Mixing of upper case and lower case letters is appropriate until 6 years of age.
  • Capitalization: Are names, titles, and beginning letters of a sentence appropriately capitalized?
  • Formation of letters Does the child form each letter in the right direction?  (e.g. ‘b’, ‘d’)  Does the child use the correct number of lines and curves? (e.g. ‘m’, ‘n’)  Letter reversals are appropriate until 7 years of age.
  • Complete sentences Are there clear and complete thoughts?  Is the correct punctuation used at the end of the sentence?
  • Floating letters: Do all of the letters sit clearly on the line?
  • Pencil grasp:  Does the child hold the pencil or marker age appropriately?  The static tripod grasp is expected around 3 ½ – 4 years of age.  This is when the pencil is held between the thumb and index finger, with the pencil resting on the middle finger and the child uses and moves his wrist/arm to make movements with the pencil.  The dynamic tripod grasp is expected around 4 ½ – 6 years of age.  This is when the pencil is held between the thumb and index finger with the pencil resting on the middle finger, and the child uses and moves his fingers to make movements with the pencil.
  • Posture in chair:  Is the child slouching or falling out of the chair?  Is the child propped or leaning?  Are his feet flat on the floor?  Is the table the appropriate size?
  • Pressure used:  Is the child’s writing legible?  Or does he press down too hard or too lightly with the pencil, causing the writing to be hard to read or his hands to fatigue more easily?

This list of handwriting aspects may give you ideas of what to look for in your child’s handwriting during activities/assignments at home.   If you notice that your child is having trouble in any of these areas, encourage him to focus on one of those aspects each time he practices writing (to break down the task).  Your child will work on these aspects of handwriting during his occupational therapy sessions, but it is also very important to provide your child with similar learning opportunities and feedback at home.

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What Does my Child’s ‘Engine Level’ Refer to?

Many therapists use the term ‘Engine Level’ throughout your child’s therapy sessions, and possibly within her goals as well.  ‘Engine Level’ refers to your child’s energy level and the way her body is feeling in various environments and in various times throughout the day.  A child’s body is typically functioning at one of three ‘Engine Levels’.   Ideally, the goal is to be at the ‘just right’ level, in which your child can accomplish the most and focus on the task at hand.

Below are some explanations and examples of how your child’s engine level can be moving too fast, too slow, or just rightHappy child jumping

  • An engine level which is too fast means that you might notice rushing; distractibility; decreased body awareness; and decreased organization.  This might look like your child is running around aimlessly, touching her friends and neglecting personal space, or ignoring instructions and what her body should be doing.
  • An engine level which is too slow means that you might notice low energy and decreased endurance, inattention, and that your child is lethargic, sleepy, or unmotivated.  This might look like your child is slouching or falling out of her chair, propping herself up or leaning on a peer, not listening, or not attempting the task at hand.
  • An engine level which is just right means that you might notice that your child is refreshed and energized, that she is alert and ready to focus on the task at hand, and that she is aware of how her body is moving around her environment.  This might look like your child is maintaining an erect posture at the table to complete her homework or engage in mealtime, and she is correctly following directions and using her listening ears.

Try to use this ‘Engine Level’ lingo in a consistent manner so that your child can ideally develop increased body awareness and self-regulation.  Make sure you provide your child with examples of how your own body is feeling, or how you perceive her body to be feeling, so she can best understand what you are referring to (e.g. “It looks like your engine is moving too fast.  Your body keeps falling out of your chair.  Why don’t you stand-up and do 10 jumping jacks, and then try sitting in your chair again.”)  Stay tuned for my next blog on strategies to obtain a just right ‘Engine Level’.

Reference: Williams, Mary Sue and Shellenberger, Sherry. (1996,) “How Does Your Engine Run?”:  A Leader’s Guide to The Alert Program for Self-Regulation.  Therapy Works, Inc.

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Stability Ball Exercises

The stability ball is a simple and easy piece of equipment to work into everyday exercise for your child, ranging from infant to teenager.  Stability balls can be bought at most sports stores, cost only about 20 dollars, and last for years.

Below are some fun activities to follow along with your kiddos to see improvements in core strength, posture, and shoulder stability:

Age: Infant

  • Simply sitting your 2+ month old infant in supported sitting on the stability ball will help his posture.
  • Placing your 2-8 month old on their tummy on the ball. TLittle girl rolling on a balance ballhis is a bit more challenging then pure tummy time as they have to push up through their arms on a cushy surface, helping build strong back and shoulder muscles.
  • At 4+ months, you can lean the ball/baby to the left side and watch your infant “right” their body up toward the middle. Practice to both sides. This will help their muscles on the sides of their trunk that are important for crawling.

Age: 1 year-5 years

  • Bouncing your child up and down gently on a ball will help both their core strength and vestibular system.
  • Bouncing the ball back and forth by lifting it above your head while keeping your and your child’s tummy muscles tight helps build great core and shoulder strength.
  • 3+ years, have your child practice dribbling the ball for increased hand-eye coordination and motor planning.

Age: 5 years +

  • Sit-ups:With either
    • your child’s hips and knees at a 90 degree angle from each other or
    • holding your child’s feet down, practice crunches to build abdominal strength.
  • Push-ups: With feet on floor and child in a plank position, they can practice push-ups with their hands on the ball. An adult may need to hold the ball stable so it doesn’t move.
  • Practicing chest passes (like in basketball) is great for chest strength, motor planning and overall stability.

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Why Does My Kid Sit Like That?

You may be asking yourself the question “why does my kid sit like that?” frequently enough to drive yourself crazy.  As kids are growing, they are experimenting with their posture muscles, may be having growing pains, or are just sometimes tired after a long day. teenager sitting As adults may want to put their feet up on the couch after a long day, kids may just want to slouch in their chair when they get home from school.  Below are some common postural bad habits of children and how to correct them.

How Backpacks Affect Poor Posture:

Teenagers are the best at showing poor posture.  Between backpacks that weigh 20 plus pounds and fatigue from growth spurts, you may notice their posture ‘slacking.’  To help combat scoliosis, make sure that your child wears his backpack with both shoulder straps that should fit snuggly on the lower back.  According to the American Occupational Therapy Association, a backpack should weigh no more then 15% of the child’s body weight.  For example, a child weighing 100 pounds should not wear a backpack weighing more then 15 pounds.  Also, consider a roller-bag if your teen’s chemistry books are literally weighing him down.

The Best Position For Your Child To Sit In:

With children who are able to sit at the table, make sure that their feet are on the floor with their hips and knees at 90 degree angles.   Many children’s chairs are adjustable for this reason.  This will make sure that there is no unnecessary pressure on their lower back and leg joints.  If needed, use a stool under their feet to reach that 90 degree position.

The Affects Of W-Sitting:

W-sitting is a common way to sit for kids with low muscle tone and/or low core strength.  Instead of their legs crossed in front of them, kids with low tone or low core strength will sit with their legs splayed out to the side.  W-sitting is a way for kids to widen their base of support so they feel more stable when sitting and reaching for toys.  However, W-sitting can cause strain on the hips, knees and ankles and can also lead to in-toeing. Many children are able to correct the w-sitting habit with just a reminder to sit “pretzel” sitting or “criss-cross applesauce”.

Please refer to my backpack blog for more information on how to properly fit and wear a backpack.  If your child w-sits and you have concerns about their muscle tone or core strength, please contact a physical therapist at North Shore Pediatric Therapy.

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