How to Hold a Spoon and Fork

How to hold a fork and spoon

Teaching a child how to hold a spoon and scoop food requires several motor skills that must be developed before a toddler can use utensils themselves. Even older children struggle with the ADLs of holding a spoon and scooping food to feed themselves. Here, we’re covering sensory motor skills needed to hold a spoon, fork, knife, and other utensils. You’ll also find some creative activities and play ideas to develop the underlying skills that play into using utensils.

How to hold a fork and spoon
How to hold a fork and spoon with efficient grasp patterns.

Note that these strategies and skill areas are needed across the lifespan when it comes to self-feeding. Older children and even adults who may have had a physical or cognitive impairment can benefit from addressing the underlying skill areas needed for using utensils. No matter the age, noting how an individual holds a spoon and fork is part of a comprehensive feeding evaluation.

how to hold spoon and fork

Before we get to the skills in play when holding a spoon or using a fork, let’s cover the specifics on how to hold these utensils. Why? Because often, we see older children who hold a spoon with a gross grasp or hold a fork with the whole hand. These grasp patterns can impact functional performance, but can also be a cause of concern for parents.

Note that the way an individual holds a spoon or holds a fork can differ when adaptive equipment for eating is used.

How to hold a spoon
How to hold a spoon.

how to hold a spoon

To hold a spoon, one needs to grasp the utensil with their dominant hand.

  • The spoon is placed along the lateral edge of the middle finger or pad of the middle finger.
  • The pointer or index finger typically rests over the top of the neck of the spoon, and guides movements when scooping.
  • The thumb rests and stabilizes the flat handle of the spoon on the top, above the pointer finger in a modified lateral key grasp.
  • The scoop of the spoon is pointing out toward the direction the thumb points, and the handle is above the thumb web space.

In this position, one can scoop with refined movements and graded precision using the pad of the thumb on the flat part of the spoon handle. When the spoon is properly placed in the hand, the wrist is slightly pronated and slightly flexed.

You can see from the image below that there are many different grasp patterns used when holding a spoon, which progress as the child develops more refined fine motor skills. The most efficient grasp pattern is the “adult grip”, however, the other grasp patterns are typically part of a progression as the toddler or young child gains experience with eating with a spoon.

Using a spoon is likely one of the first functional tools that a small child has experience with, and while messy eating will ensue, it is important to allow the baby or toddler experience with holding and manipulating a spoon, even if they are not getting actual food into their mouth at first.

Grasp patterns for holding a spoon
Grasp patterns for holding a spoon.
No source was found for this image, may be subject to copyright

Inefficient grasp on a spoon- When the handle end of the spoon is UNDER the thumb web space, the grasp moves into a poor position for function and accuracy of scooping. In this case, the hand moves into a gross grasp pattern, and in order to gain motor control with graded precision, the elbow tends to pop out as the shoulder abducts. In this poor functional grasp pattern, you’ll see the wrist fully supinated.

Activities to move from an inefficient grasp pattern to an efficient grasp pattern include PLAY:

How to hold a fork
How to hold a fork.

how to hold a fork

Next, let’s cover the proper grasp pattern required to effectively hold a fork. Note that there are different ways to hold a fork, depending on location, no one way of these different style being better or worse for functional performance to hold and use a fork to stab and eat food.

To hold a fork, the fork is held in the dominant hand much like a pencil is held. The thumb stabilizes the narrow part of the fork handle, or the neck of the fork. This area is located above the prongs, or tines of the fork. The neck of the fork rests on the lateral side of the middle finger or the pad of the middle finger.

Like holding a spoon, the end of the fork is above the back of the hand, and not under the thumb web space into the palm.

The wrist of the hand should be slightly pronated and slightly flexed.

Note that when holding a fork to scoop food, a different grasp pattern is used than when using a fork to stab food, and still another grasp pattern is used to stabilize food when using a knife to cut.

To stab food with a fork, the fork rotates in the hand and skills of in-hand manipulation are used.

To stabilize food with a fork, in order to hold food stabile so a knife can cut the food item, the fork continues to rotate within the hand using in-hand manipulation, but the addition of finger isolation of the index finger is used to hold the fork steady.

Inefficient grasp on a fork– When the end of the fork handle is under the palm, the hand tends to pull into a gross grasp on the fork, which is a more primitive grasp pattern, and is less functional for refined and graded movements. Similar to the motions used with a spoon held in this manner, a fork held in a gross grasp will include elbow and shoulder.

Much like using a spoon, progression from inefficient grasp patterns on a fork is developmental and requires practice. Allowing kids to use and hold a fork with verbal and visual prompts is helpful. Other fine motor and eye-hand coordination tasks will support development from inefficient grasp patterns when holding a fork to more efficient and refined motor skills:

We’ve created a video that shows how different grasp patterns impact functional use in holding and using a spoon and fork. If you can’t view this video, we’ve also posted the activity ideas to help kids hold a spoon on our YouTube channel.

Prerequisites to hold a spoon and fork

Before a child can use fine motor tools such as a spoon, fork, knife and other self-care tools (hair brush, toothbrush, pencil, scissors…) independently, there are certain physical, cognitive, and emotional prerequisites that must fall into place.

These self-care skills include many of the same sensory motor components, so in this blog post, we’re covering primarily the skills needed to hold a spoon and fork.

Toddlers and young preschoolers that sit at the table, probably have taken notice of how adults and older children at the table eat. This is actually part of the developmental process. When sitting at a table, a baby and toddler is observing and noticing how older siblings and parents use forks to stab food, spoons to scoop, and knives to cut.

Toddlers often want to take part in the action!

Using a spoon and fork during the Toddler years is a natural development of self-awareness and self-control.  Using utensils is part of that progression of feeding developmental milestones that children go through. A child becomes more aware of the skills that they are developing and that they can assert their own independence. 

Likewise, using a spoon to eat at first can lead to messy eating with young children, and that’s totally normally, developmentally.

But, before these areas of independence arise, there are certain prerequisites that need to be in place. Using tools in self-feeding, brushing one’s own teeth, using a knife, crayon, pencil, or other tool requires development in a few areas. 

Speaking of using crayons to develop motor skills, these crayons for toddlers support fine motor development and coordination skills through play.

 

Prerequisites that are necessary for kids (or adults!) to effectively and efficiently use tools in fine motor and self-care tasks, like scissor use, handwriting, hair brushing, self-feeding, tooth brushing, and more.  From an Occupational Therapist.

This post contains affiliate links.

Skills Needed to Hold a spoon and fork

When you take a look at the motor breakdown of using a spoon and fork, there are several components you’ll see in action:

  • Posture
  • Grasp Development
  • Hand Preference
  • Cognition
  • Attention
  • Eye-hand coordination
  • Somatosensory experience
  • And even play!

Let’s cover each of these areas needed to hold a spoon and fork in more detail:

  • Posture- When using a tool like a fork, pencil, scissors, toothbrush, paint brush, knife…postural control is essential.  Like anything else, it all starts at the center and at the body.  You can’s use your hands in fine motor play activities if your upper body is slumped or slouched.  If postural support is the issue, work on getting into a better sitting position. Speak to an Occupational Therapist for individualized assessment and recommendations.                   
  • Grasp Development- For using tools, a child needs prehension skills and  precision skills, including grasp, release, and the ability to stabilize their arm and write while moving the hand.  Sometimes a pinch or required muscle movement is too much for an unstable arm/wrist and that required muscle effort makes the upper body slouch.  Start over with posturing is this happens.
  • Hand dominance–  A true hand dominance doesn’t typically become established until 5-6 years.  And that is a good thing!  A child’s body is developing strength, balance, muscle tone, and sensorimotor abilities at an even and symmetrical rate in the early years.  We want that to happen!  If a very strong preference of dominance is noticed at an early age, ask your pediatrician or occupational therapist for assessment of asymmetry or delay.
  • Cognitive prerequisites– Appropriate ability to follow simple directions is a must in order for use of tools in typical ways.  Sure, a fork makes a great hair brush.  A spoon is an excellent drumstick. But, inappropriate use of utensils can be dangerous.
  • Attentional Prerequisites– Appropriate attention span is needed for using tools in functional tasks. This blog post covers more on attention needed during meals.
  • Constructive play– What? A child needs functional play in order to use a pencil? Yep!  Building with blocks, combining toys, and pretending provides the base of fine motor development, skilled use, strength, imagination, and creativity that is needed to problem solve and use tools appropriately.
  • Eye Hand Coordination– More play!  Catch a ball and use crayons to establish the base of hand eye coordination needed for skilled maneuvering of tools to the mouth, paper, hair, or teeth.
  • Somatosensory Experience– Playing and experiencing the senses in typical every day activities are essential for the child to build on their awareness of textures, weights, manipulating objects, and sizes.

Given all of these areas that a child must have in place before showing success with tools in functional tasks, it’s important to work on certain areas.

Below, you’ll find a great printable resource that covers all of these skill areas that are needed for using a spoon and fork. This is a great handout to use especially when working with families of young children who are learning to hold a spoon and fork.

You can enter your email address into the form below and access this printable handout, or The OT Toolbox Member’s Club members can log into their accounts and access the handout in the Educational Handouts Toolbox area.

Prerequisites that are necessary for kids (or adults!) to effectively and efficiently use tools in fine motor and self-care tasks, like scissor use, handwriting, hair brushing, self-feeding, tooth brushing, and more.  From an Occupational Therapist.

Scooping food with a spoon

Teaching kids how to hold a spoon is the first step, but then actually scooping food, getting the food to the mouth, clearing the food from the spoon, and then repeating the process is part of the functional task of eating.

Remember that eating is a developmental process, and that this is another occupation in which practice is key to functional performance!

To improve use with a spoon and fork (and then spoon, fork, and knife!), it’s important to have various opportunities for practice.

Provide opportunities to use tools like spoons in scooping items.  You’ll find more information on the topic of scooping in our blog post on scooping and pouring.

These black beans are a great way to practice tool use and all of the skills needed in managing tools.  See the bottom of this post for more ideas.

Be sure to provide your little one with lots of opportunities to use tools in activities and play!

Related activities that you will love for teaching kids to use tools:

  • Sight Word Scoop– this scooping activity encourages users to develop the eye-hand coordination needed to use a spoon to scoop an object in a liquid, much like scooping the remaining cereals in a bowl of milk, or scooping food from a soup broth.
  • Toddler Visual Motor Scoop (Ping Pong balls)– This activity is another great way to teach toddlers to use a spoon, using a large and bright object with high visual contrast.
  • Invitation to Scoop and Pour– In this activity users can use a spoon with graded precision and refined movements to scoop grains of corn which can be a great way to practice motor skills to hold a spoon.
  • Field Corn Sensory Bin– Another activity using spoons to scoop field corn, this activity offers proprioceptive feedback through the joints and muscles of the hand, wrist, elbow, and shoulder.
  • Moon Dough Scooping– In this activity, users use a spoon to scoop and pick up a moist and dry material. This can be a great way to practice using a spoon with different materials.
  • Scooping Ice– Using a spoon to pick up ice is a fun way to practice using a spoon with a different material that also offers precision and refinement in using a spoon or scoop.
  • Relaxing Lavender Water Bin– Kids love this sensory bin, but therapists love the functionality! Use a spoon to pick up small items in a liquid, developing eye-hand coordination skills with sensory benefits.
  • Invitation to Scoop, Pour, Transfer Nuts– Use a spoon to pick up nuts with a fun sensory activity that offers feedback with movement.
  • Scooping Dyed Alphabet pasta– Kids can pick up dry pasta with a spoon and practice motor skills.
  • (Amazon affiliate link) Learning Resources Handy Scoopers are colorful and bright and a great way to practice the prerequisites for tool use in many ways.
How to hold a fork and spoon handout
Get this free handout on skills needed to hold a fork and spoon below or in The OT Toolbox Member’s Club

Free Handout- Skills Needed to Hold a Spoon and Fork

Want a printable handout of the skills kids need to hold a spoon and fork? Working with families on teaching kids how to hold a fork and spoon and need actionable tips and strategies in a handout format?

You can enter your email address into the form below and access this printable handout, or The OT Toolbox Member’s Club members can log into their accounts and access the handout in the Educational Handouts Toolbox area.

Free Handout: Using a Spoon and Fork

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    Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

    Feeding Developmental Milestones

    feeding developmental milestones

    Below, you will find resources on feeding developmental milestones and information on development of bilateral coordination that are needed for the feeding skills to use both hands together in a coordinated manner. These bilateral coordination milestones are needed for independent feeding skills, so let’s break this down.

    Development of bilateral coordination skills is necessary for improved self-feeding in toddlers and improves through the childhood years. Independence with feeding skills is an important part of child development!

    Feeding developmental milestones in kids

    Bilateral Coordination Development

    When we talk about bilateral coordination development, we can also mean bilateral integration. Typically, bilateral coordination skills refer to the physical sensory motor use of both sides of the body in a coordinated and fluid manner.

    However, bilateral coordination requires the overarching bilateral integration of the brain hemispheres and takes into consideration the ability to manage all of the functions listed above.

    In fact, there are three components of bilateral coordination and these play a role in feeding developmental milestones:

    • Symmetrical movements- picking up a bottle with both hands to drink
    • Reciprocal movements- Using one hand to pick up food and another to pick up food the next time; we see this with babies and toddlers especially
    • Dominant hand/supporting hand movements- Using a knife to stabilize the food and the knife to stab the food. Or, holding a bowl with the supporting hand and the dominant hand to scoop the food from a bowl

    Independence with feeding progresses from symmetrical movements to reciprocal movements, to dominant/supporting hand movements.

    One way to really take a look at the developmental progress of bilateral coordination skills is through the functional task of feeding using cutlery, or utensils like spoons, forks, and knives and drinking tools: cups, bottles, etc.

    When children learn to feed themselves and become more independent with self-feeding tool use with finger foods, utensils, or cups, development of bilateral coordination is one aspect that is necessary.

    When we think about self-feeding, problems can arise based on a variety of areas. Upper extremity coordination is one of those aspects that are evaluated and addressed when self-feeding difficulties are present.

    When thinking about development of self-feeding, consider the following issues related to bilateral coordination difficulty and try using some of the bilateral coordination activities based on development of bilateral coordination to improve feeding skills.

    Related: For several ideas to support bilateral coordination skills while indoors, try our list of Winter Bilateral Coordination Activities that kids will love!

    Discover typical development of bilateral coordination in feeding skills in kids, which are needed for improved independence in self-feeding.

    Bilateral Coordination Milestones

    Bilateral coordination development begins prior to birth, while in the womb with the physical movements felt by the mother. From there and immediately after birth, bilateral coordination milestones are achieved.

    Amazon affiliate links are included in this post.

    feeding developmental milestones

    Development of bilateral coordination in self-feeding depends greatly on the child’s developmental level. Below, we’ll go through feeding milestones by age.

    Development of feeding skills is just one skill that is a great way to to assess and analyze the development of bilateral coordination. Also, development of fine motor skills and visual motor skills have an impact on coordination of the hands in self-feeding.

    In one blog post, we covered the skills needed for independence with functional tools, including holding a spoon, scooping with spoons, using forks, and other tools like toothbrushes, hair brushes, etc. That is a good place to start with understanding all of the other areas of development that go into tasks like feeding.

    Throughout these ages, oral motor development plays a significant role in the manipulation of foods. Consider how these aspects of oral motor skills impact the developmental progression of feeding skills:

    • Rooting
    • Sucking
    • Swallowing
    • Gag reflex
    • Tongue movement
    • Jaw thrust
    • Jaw movements (moving jaw side to side to move food and movement of foods)
    • Lip closure during swallow phase of eating and drinking
    • Biting into foods
    • Tolerating different solid food and liquid consistencies

    Development of bilateral coordination occurs at every stage of childhood and can be observed through feeding abilities.

    Newborn Feeding Skills

    At the newborn stage, primitive reflexes dominate movements. In particular the rooting reflex supports feeding at this age.

    Babies aged 0-3 months will root, suckle, and swallow in feeding activities. This stage progresses as vision and motor control develop.

    Related to this stage is our resource on the strategies occupational therapists can address when newborns are not sleeping through the night, as sleep impacts routine and feeding schedules.

    Feeding milestones 4-6 months

    In this stage, development of coordination between the eyes and motor skills are just developing. The child explores with their eyes, hands, and mouth and will start to reach for objects purposely around four months. Accuracy of hand use is limited.

    Babies can be observed using both hands in play as they pick up objects in their line of sight. However, they typically will pick up items with the hand that is closest to the object or toy. 

    During this phase, the baby is spoon fed and when presented with a spoon, makes a suckling movement with lips and mouth. The baby will show a gag reflex at this age. With foods on a spoon, the baby will thrust their tongue out at the presence of foods and push the spoon away at times.

    Look for munching of the jaw, or movements in the jaw indicating a chewing pattern, even though the young child can not chew at this stage.

    Feeding Skills at 6-9 Months

    At this stage, the child is typically sitting up with or without support. The child’s hands are often times used in grasp with a clenched or a fist-like grasp.

    The child will begin to separate the thumb from the rest of the fingers to use a gross grasp on objects. Babies at this stage will typically place everything in their mouth, using both hands together in symmetry.

    The child will hold a bottle or cup with assistance, placing both hands on the cup/bottle, but are not able to hold the cup or bottle on their own.

    The gag reflex is still present but it is less sensitive to foods and utensils.

    The baby has a voluntary bite on soft foods, chew cookies, and baby teething foods. They will begin to hold those items independently using both hands together at their mouth.

    You will see a raking motion from the fingers, but this movement is typically not successful in picking up small foods like baby puff snacks. the baby can , however begin to pick up small food pieces using the thumb and the side of the pointer finger to grasp items (not a pincer grasp)

    Feeding Skills at 9-12 Months

    The child is able to sit upright without support and develops proximal stability, allowing for increased development of distal extremities.

    In this stage, babies are developing pincer grasp and thumb and finger opposition skills. This stage brings the ability to hold one object in each hand such as two blocks.

    The baby will be able to bring both hands together at the same time. Children will be able to begin finger feeding skills around 9 months as they bring dry cereal foods to their mouth with a scraping motion.

    Finger isolation on both hands begins as they poke foods and explore textures with their hands. Children will use both hands to smear food and bring soft foods such as wet foods like a cereal mix or applesauce to their mouth. The child will be able to hold a cup with both hands and bring it to their mouth.

    This stage is when we begin to see functional performance related to arch development. As refined motor skills continue, this base will continue to include utensil use.

    The child will start to hold a fork and spoon with a gross grasp, or a palmer grasp but without a dominant arm. At this stage, grasp of the spoon occurs with a palmer grasp. The child will not hold the bowl or plate with their non-assisting hand.

    You may see the baby begin to take longer sips from a straw while managing the liquid in their mouth to show a true drink. Similarly, with cup use, there is more drinking patterns as a result of the increased jaw control. However, at this age, these drinking skills are with an adult present to hold and remove the cup or straw. The bilateral coordination skills are not present in order to engage the hands either symmetrical coordination or as a dominant hand/supporting hand along with the drinking aspect.

    You will start to see more controlled use of the thumb and pointer finger in a true pincer grasp to pick up foods. This occurs between the tip of the thumb and the pointer fingers. The baby at this age can finger feed themselves.

    Feeding Skills at 12-15 Months

    In this stage, the child begins to dip their spoon into foods. They will have more accuracy with dipping as opposed to scooping foods.

    The spoon is held with a digital grasp and the child will likely switch hands while holding the spoon. The child will lift and drink from a cup with one hand.

    As toddlers progress in development, they will begin to establish a dominant hand and crossing midline. This ability to utilize a dominant hand and a non-dominant hand in activities indicates a maturation of the brain and lateralization in functional tasks, which is very important for motor planning, directionality, and visual motor skills

    A scooper bowl with suction base (affiliate link) can be  help with scooping development and bilateral coordination at this stage.

    The child at this age can hold a spoon with a gross grasp or palmer grasp with an inverted wrist. They will dip the spoon in food. The spoon will make it back to the mouth, but typically, the spoon is only touched to the lips. They will not likely remove all of the food from the spoon using their lips at this point. The motion of the spoon is entirely with the shoulder and elbow. The wrist is in one position so that the spoon is dipped into the food upside down. You’ll see increased shoulder abduction in order to get the spoon into the food. The spoon may be upside down in their mouth too.

    Read more in a related blog post about how to hold a spoon.

    Feeding Skills at 15-18 Months

    The child is able to support the bowl with one hand while scooping with a spoon. Children can hold a small cup and pick out pieces of dry cereal or snacks.

    Fine motor skills are developing quickly.

    Drinking from a cup can move from a sippy cup to a spouted cup. Other young toddlers can drink from a straw. Holding the cup moves from a two handed grasp to a single grasp. You’ll see grasp on the handle of a sippy cup or spouted cup begins to move from a gross grasp to a pincer grasp. This grasp pattern development occurs in this later stage of toddler range because of the weight of the cup/drink.

    By the end of this age range, the 18 month child can hold an open cup on their own to pick up, drink, and set the cup back down with just some spilling of the liquid.

    Feeding Skills at 18-24 Months

    As a child gets closer to two years of age, the variety of foods increases and this allows for greater exposure to textures of foods (mushy, crunchy, etc.) and types of foods (liquids, solid foods, mixed consistency foods).

    The child will typically be able to drink from a cup with accuracy and with one hand but with more accuracy and precision. As the child moves toward two years, you can see a desire to drink from an open cup, but the accuracy of motor control and attention skills are not there for this type of cup.

    There will be more coordination of the spouted cup or sippy cup and accuracy, with less spillage.

    At this stage, the child will use a dominant hand in self-feeding and will begin to supinate the forearm when scooping with a spoon, resulting in greater accuracy. This looks like a typical spoon motion with the wrist, however there will still be a palmer or gross grasp on the spoon.

    By two years, the toddler can use the spoon to scoop and feed themselves chunkier or thicker foods such as applesauce, mashed potatoes, etc.

    Development of bilateral coordination for feeding skills is essential for accuracy and improving independence in self-feeding in kids.

    Feeding Skills at 24-36 Months

    During this stage, the child’s dominant hand is more established and the child can support with the non-dominant hand with greater accuracy.

    There will be greater control of forearm supination so that the palm is facing upward when scooping. Typically, the child is able to self-feed without assistance.

    Around 2.5 years, the child can drink from an open cup with one hand. A small, “pixie” cup or slightly larger small cup is great for this. They can also hold the spoon with a “palm up” position on the spoon. This allows for greater accuracy and ability to self feed thinner soups or cereals with milk.

    By the end of this stage, around 3 years, the child can use a fork to pierce soft foods and they can brink the fork to their mouth and remove the food using their teeth and lips.

    Feeding Skills at 3-4 Years

    The child will begin to use a fork with improving accuracy. They can use a straw and hold the cup with one or both hands. They can also hold a cup while drinking from a straw on their own, and without assistance.

    The child can use a pitcher to pour water into a cup, demonstrating bilateral coordination with advancement to the dominant hand/assisting hand stage.

    The child will use both hands together with improving coordination in self-feeding. At this age, it’s a great time to get kids involved in helping to cook recipes. This experience in the kitchen along with an adult supports development of fine motor, sensory motor, and visual motor skills. Check out these cooking with kids recipes to support these areas.

    Feeding Skills at 4-5 Years

    Children will be able to use a knife to spread butter or peanut butter with the dominant hand while holding the plate or bread with their non-dominant hand.

    Beginning use of child-friendly knives is appropriate. They will press with the knife rather than chopping or slicing.

    In this stage, you’ll see a coordinated use of hands, in most cases. At this age, it’s important to expose the preschool child to lots of fine motor play and sensory motor play experiences to support development and exposure to motor activities. These promote development needed for fine motor skills and success in later years in the classroom.

    Feeding Skills at 5-6 Years

    Children will use a fork and spoon accurately. They will be able to scoop, poke, and stab with a fork using appropriate positioning and without use of the non-dominant hand to support the plate.

    The child will begin to use a knife to cut foods.

    Feeding Skills 6+ Years

    The child will be able to cut meat with a knife with increasing accuracy and ability. As they develop, the child will increase coordination with knife and fork use in a coordinated manner.

    Spilling of cups and foods decreases with age and development.

    Attention in feeding tasks develops as children progress through the various stages, too. This makes a big difference in accuracy as well.

    The video below shows how grasp patterns impact holding a spoon and fork in feeding tasks. This is important because we can promote more independence with self-feeding by implementing simple activities and specific cues to promote a functional grasp on the fork or spoon. If you can’t view this video, check out our video on YouTube: Using a Spoon-3 Activities to Target Grasp Patterns.

    Trouble with Feeding Development

    It’s important to remember that all children are different and the developmental milestones for feeding tasks listed above are not set in stone. There is always fluidity with development and feeding skills are no different.

    If there are skills that seem to be delayed, be sure to reach out to the child’s pediatrician and a pediatric occupational therapist for individualized feeding evaluation and assessment as well as a specific treatment plan based on the individual’s needs.

    Some things to consider that may be impacting feeding development include oral motor problems, determining if the feeding development issues are a result of sensory vs. oral motor considerations, or there is a need for specific adaptive feeding equipment.

    Development of bilateral coordination skills in feeding occurs throughout childhood.

    5 Tips for Completing a Feeding Evaluation

    feeding evaluation

    An integral part of an occupational therapy feeding evaluation is the food questionnaire or checklist. This is the foundation for building your learner’s food repertoire based on their likes and dislikes. When discussing preferences with the parent and child, the more details they are able to provide, the smoother the sessions will go.

    Feeding evaluation tips

    How to Do a Feeding Evaluation

    The first step to a feeding evaluation is often a comprehensive Food Inventory Questionnaire. By understanding what a child is and is not eating helps the therapist to better understand food preferences in the way of food texture issues, flavors, colors, tec. The food inventory is a great tool for consistent data collection. Accurate data collection will helpful be able to provide a just right challenge. Before beginning any feeding program, it is important to become educated on feeding therapy, treatment, and problem areas in a thorough feeding assessment. This guide will provide a basic understanding of sensory versus oral motor feeding concerns.

    Check out the tips below to help guide your discussion.

    Tip #1: When Planning a Feeding Evaluation, Provide Questionnaires Ahead of Time 

    If at all possible, try to provide a feeding assessment checklist or questionnaire ahead of time, or ask the parent to come prepared with a list of foods that their child does or does not like. This is SUPER important, because asking a parent during the feeding evaluation, does not typically go well.

    It is likely that you will not get a complete picture, or the parent will forget some key pieces of information–such as what brand of cereal their child eats or be so overwhelmed they claim their child eats “nothing”.

    Not all of the problems presented will be sensory food issue related. There are times when they stem from an oral motor deficiency. It is important to be able to spot the difference before beginning treatment.

    Tip #2 During a Feeding Evaluation: Ask About Food Jags 

    What is a Food Jag?

    The term “food jag” is fairly new term referring to a preference toward a couple of foods, eating them all of the time; suddenly stopping eating a once highly preferred food, refusing to add it back into their repertoire. A food jag refers to the case of children only eating one type of food or a small number of food items. Some common food jags include:

    • The child that only eats chicken nuggets, crackers, and French fries (all foods are consistent in taste and texture.
    • The child that only eats Goldfish crackers, dry cereal, and crackers (all foods are bland, have some crunch, but are thin in width
    • The child only eats yogurt tubes or yogurt smoothie drinks (the consistency and sweetness of the yogurt flavors are satisfying)

    Food jags include any small group of limited food selections. These food limitations can change over time.

    You’re looking to see if this has happened over the course of the child’s feeding history as it may be indicative of trauma (i.e.-choking), emergence of sensory processing difficulties, and feeding developmental milestones that occur in leaps and stages.

    This is also common in people who do not eat a variety of foods. They get tired of eating the same three foods over and over. Food jags can happen to people who eat a variety of foods also, but generally people have other foods to put in its place.

    For instance, I may eat peanut butter and jelly sandwich every day for three weeks, then get tired of it. That is fine because I can switch to yogurt, or ham, or turkey. A person with limited food choices loses a preferred food and does not have anything to replace it with.

    If you notice a trend of food jags in the child’s history, make sure that you provide education on how food jags occur and how to prevent food them, before they leave the evaluation. 

    Tip #3: Complete a Sensory Evaluation of Food- Review Each Food Category 

    Even if the parent fills out a feeding assessment checklist/questionnaire and hits all the food categories, fruits, vegetables, starches, dairy, protein (meat, eggs, nuts) and other (snack foods), make sure that you go through the list with the family.

    When you review each category, even briefly, it may spark the parent to remember something regarding the child’s eating patterns. 

    Consider the sensory evaluation of food including differences in types of food categories, and how there can be minute or vast sensory differences in foods based on preparation (cooked in the oven or cooked in the microwave, different brands (drier consistency vs. saltier flavor), or types of foods (spaghetti pasta vs. smaller elbow noodles).

    A food evaluation should take the sensory evaluation of foods into consideration for each meal.

    Questions to ask regarding food preferences:

    For example, if the parent reports that their child eats noodles, you might want to ask what kind of noodles.

    • Do they eat only elbow noodles?
    • All types of noodles?
    • And all varieties of noodles-egg noodles, veggie noodles, rice noodles? 

    Another example of food variables is seen in fruit.

    • Fruit can be whole, peeled, fresh or comes in a container.
    • Apples can be peeled, sliced, or presented whole.
    • How does the child eat them?
    • Mandarin oranges come in syrup or can be freshly peeled. Which does your learner prefer?

    If the parent reports that their child is very specific or limited on how they will eat their food, this is a starting place for pushing their food limits and boundaries in the first couple of sessions.

    Tip #4: Ask About Brands 

    This tip ties into Tip #3 when discussing the categories of foods. You want to know if the child will only eat a specific brand of food. This is common with cereal, snack foods, pizza, and pastas such as macaroni and cheese. It can happen with all foods, so it’s good to ask.

    This may indicate that the child has challenges with processing novel experiences and may be easily distressed by change, from a sensory perspective. It also indicates that the child is very rigid in their thinking and expectations for mealtimes.

    You will need to build confidence and trust, as something as small as changing brand of cereal might be a big leap.

    Tip #5 during feeding evaluation: Ask About Temperature 

    Another aspect to the sensory evaluation of food is the temperature of preferred foods. Ask how the child likes their food served–hot, cold or room temperature. While this may not seem like a big deal, but it can be for a child who is already struggling with introducing new foods and experiences into mealtimes.

    It’s also a very personal preference, and by knowing that preference, you have an increased understanding of the child which leads to trust, and eventually a broadened food repertoire.

    Sometimes the issue at hand is not the food at all. It is the learner’s difficulty getting it into the mouth. There are many choices when it comes to spoons, bowls, plates, cups, and serving ideas.

    Check out some of these ideas to see if these may help your learner with self feeding or trying new food challenges.

    Feeding therapy is complicated

    Feeding therapy is complicated. Without the right knowledge and tools, therapist/parents can make the problems worse. Take time to get educated on correct feeding therapy techniques. In the meantime, feel free to engage your learner in messy play. This is a great first step to understanding and tolerating new foods.

    Other areas to consider in a feeding assessment include:

    • Anatomical considerations of the mouth and tongue
    • Mobility of the jaw, tongue, lips, and cheeks
    • Positioning and body posture
    • Body awareness
    • Developmental progression of oral motor skills
    • Muscle considerations and issues that impact musculature (digit sucking, extended use of bottle or pacifier, reverse swallow/tongue trust, tongue, chewing habits, lip closure, vertical chewing during food prep stage,
    • Structural abnormalities (teeth alignment, tongue tie, palate, tonsils, lip symmetry, etc.)
    • Movements and range of motion in mouth, cheeks, lips, jaw: Jaw Thrust, Exaggerated Jaw Movements, Jaw Instability, Jaw Clenching, Tonic Bite, Jaw Retraction, Tongue Retraction, Tongue Protrusion, Stability Bite
    • Alignment of teeth
    • Presence of gagging or choking on foods
    • Speech skills
    • Sleep habits (sleeping through the night, snoring, light sleeper/heavy sleeper) Support sleep hygiene and even addressing newborns not sleeping through the night as sleep has a role in feeding routine and schedules.
    • Tooth Grinding
    • Phases of food swallow- Oral preparation, Oral Propulsion, Pharyngeal phase, Esophageal phase
    • Vision and Visual motor skills
    • Tone and musculature of the body-impacting range of motion, posture, etc.
    • Fine motor skills

    You’ll want to contact a pediatric occupational therapist who is experienced in feeding evaluations, including the oral motor aspect of food assessments.

    Use the Food Inventory Tool- A Parent Report Screening Tool to incorporate into feeding evaluations to ensure successful feeding therapy.

    This tool provides the therapist with a data sheet for a child’s repertoire allowing for consistent data collection over the course of feeding treatment. It also provides the therapist with a professional looking tool and talking point during the initial feeding evaluation to ensure that a comprehensive list of foods the child eats is gathered to support successful feeding therapy.

    Click here to get a copy of the Food Inventory Tool- A Parent Report Screening Tool.

    Contributor: Kaylee is a pediatric occupational therapist with a bachelors in Health Science from Syracuse University at Utica College, and a Masters in Occupational Therapy from Utica College. Kaylee has been working with children with special needs for 8 years, and practicing occupational therapy for 4 years, primarily in a private clinic, but has home health experience as well. Kaylee has a passion for working with the areas of feeding, visual development, and motor integration.

    *The term, “learner” is used throughout this post for readability, however this information is relevant for students, patients, clients, children of all ages and stages or whomever could benefit from these resources. The term “they” is used instead of he/she to be inclusive.

     

    Oral Motor Problems and Feeding

    oral motor problems

    Many times, OT professionals receive referrals for oral motor problems and feeding. It’s through oral motor occupational therapy interventions that kids can move from challenges biting, chewing, and moving food around inside the mouth, to success with eating and trying new foods. Let’s get started!

    Oral motor problems lead to difficulty biting, chewing, and manipulating foods. They can cause difficulties with textures of foods, and can be a cause of extremely picky eating! A good place to start is with understanding the development of oral motor skills.

    Oral Motor problems

    One thing is for sure; individuals can have a huge spectrum of considerations when it comes to oral motor issues. No two kiddos will be alike. That’s why it’s so important to discuss oral motor issues with a professional.

    The process of eating is a complex collection of movements patterns with physical and sensory components.

    When feeding is a challenge, many times individual oral structures and sensory-motor patterns are a cause. 

    If you are questioning whether an eating issue is sensory or oral motor, be sure to take time to explore each consideration. There can be different interventions and strategies depending on the underlying cause of eating difficulties. For example, there are specifics when it comes to issues with sensory food aversions and sensory food issues.

    What are Oral Motor Problems Occupational Therapy Addresses?

    The oral motor problems listed below are just some of the issues that can impact function in feeding.  

    In a small series of blog posts, I have broken down each oral motor problem that occupational therapists typically address. Each blog post includes information about the specific oral motor concern, the reasoning or underlying influences that relate to each oral motor issue, and feeding issues related to the specific oral motor problem.   

    This series of blog posts should be a resource for you to find more information relating to how feeding issues are related to specific oral motor problems and how these feeding issues can be addressed in treatment.   

    Click on the links below for more information on each oral motor problem area as they relate to feeding. 

    • Mouth Clamped Shut when eating- Consider the child who clamps their mouth shut during meals.  This is usually the biggest sign to a parent that the child is all done eating, is full, or is refusing to eat.  However, it might be an oral motor problem that is actually the cause of the clamped shut mouth.  The child falls back on this technique because it’s worked for them in the past in some way to provide stability, move out of the difficult oral motor exercises, or has resulted in a response from the parent.   

    Other oral motor problems include:

    • Tooth Grinding
    • Tonic Bite
    • Jaw Retraction
    • Tongue Retraction  
    • Tongue Protrusion
    • Tongue Thrust      

    Kids can have trouble with picky eating and difficultities in feeding when there are oral motor problems. Different types of oral motor problems.

    Occupational Therapy for Oral Motor

    Oral motor interventions in occupational therapy can cover a variety of intervention techniques. It is essential to begin with an evaluation and individualized assessment by a feeding professional. Occupational therapists are trained in this area, but some OTs have additional certifications.

    The list of occupational therapy oral motor strategies listed below is for educational purposes only and not a replacement for therapy of any kind.

    Some occupational therapy oral motor strategies that can be used are:

    1. Oral motor assessment- It is essential to start with the assessment process for safety of the individual. Addressed in more detail below.
    2. Oral motor stimulation- In occupational therapy, strategies include brushing to the lips or cheeks, towel stimulation, feeding swab, tongue mobility exercises, etc. These are explained in greater detail below.
    3. Oral Motor Exercises– We’ve listed a larger list of specific exercises to use in play and in therapy sessions.
    4. Oral motor coordination exercises– Use the oral motor cards in the deep breathing kit to improve oral motor coordination skills. Try mimicking the movements by using a mirror and visual modeling.

    Oral Motor Assessment Occupational Therapy

    Assessment occurs by a pediatric occupational therapist, but there are many things to be considered.

    Feeding is developmental and it’s essential to consider the level, age, and abilities of the individual as this will impact all aspects of feeding and oral motor considerations.

    Oral motor assessment and infants-

    In infancy, oral motor skills are both a means for self-regulation (nurturing through sucking) and nutritive. Things to consider in an occupational therapy oral motor assessment for infants and babies at this age and stage:

    • Is the infant able to suck in exploration for nipple of bottle or breast?
    • Does the infant suck in bursts and have pauses to allow for breathing while eating?
    • Assessment of the physical mechanics of swallow
    • Timing of sucking and pauses- sucking should occur at a rate of about one suck per second with pausing to swallow the liquid and breathing. This should occur in a coordinated manner.
    • Lip closure
    • Jaw movements to draw liquid into the mouth and to swallow (infants)
    • Anterior tongue movement during the sucking, along with cheek movement and jaw movement as the tongue draws milk or formula to the rear of the mouth to swallow (older babies)
    • Oral reflexes and whole body primitive reflexes (root reflex, a suck reflex, a swallow reflex and then protective reflexes like gag and coughing)
    • Liquid leaking from the mouth during eating
    • Anatomy of the mouth, tongue, lips, neck, etc.
    • Positioning during feeding
    • Family educational needs
    • Sleep and timing considerations

    Oral motor assessment in babies

    In older babies, you begin to see certain developments. Missing these milestones can indicate oral motor problems. These considerations should be addressed in occupational therapy oral motor assessments as babies grow:

    • Hands in the mouth in exploration and play- this is normal part of exploration and supports development of tongue, lips, cheek mobility
    • Positioning and seating (high chair positioning)
    • Neck, head, and upper body control against gravity
    • Motor coordination at age appropriate levels
    • Bite reflex
    • Mouthing toys, teethers, etc.
    • Making sounds with a variety of oral motor movements
    • Mimic facial expressions (open mouth, tongue out, etc.)
    • Gag reflex present
    • Accepting variety of baby food textures, flavors
    • Accepts foods from a baby spoon
    • Lip closure
    • Tongue mobility (thrusting tongue after initial spoon offerings is normal)
    • Transverse tongue reflex- The baby/child feels stimulation on the side that tongue and the tongue moves in that lateral direction- needed for swiping foods
    • Attempts or tries a variety of flavors, textures, and softer, larger foods

    Oral motor assessment in toddlers-

    During the toddler years, oral motor issues can present in drinking, feeding, and other areas. Consider these aspects in OT assessments:

    • Drinking from sippy cup/open cup
    • Drinking from a straw
    • Drinking a variety of textures and thicknesses (water, juice, thick or thin smoothies
    • Eating a variety of textures and thicknesses
    • Eating fluids mixed with solids (cereal, soups)
    • Biting foods from a larger piece of food
    • Moving food around within the mouth
    • Swiping the mouth with the tongue to clear the mouth
    • Chewing with rotational movements of the jaw
    • Begins to remove food from the lips with the tongue

    Oral motor stimulation

    We cover specific oral motor exercises designed to support the oral motor stimulation to move the lips, tongue, and jaw to bite, move, swipe, clear the mouth of food, and swallow food in our resource on oral motor exercises. However, below you will find strategies to provide oral motor stimulation to the mouth, lips, gums, and tongue.

    Oral motor stimulation in occupational therapy centers around play in order to enable function. This focuses on independence with feeding with safe ability to bite food, clear food from the mouth with the tongue so that food can be swallowed.

    Tongue Stimulation-

    • Use a mouth swab– to touch, swipe, tap and swab the tongue on the sides, at the tip, and along the length, avoiding the back of the tongue to avoid activating a gag reflex.
    • Use a vibrating toothbrush- to stimulate tongue movement on the sides. This can help the tongue with lateral movements.
    • Use a gloved finger- Put on a latex or non-latex glove and use a finger to tap the sides of the tongue. The glove can be worn by either the occupational therapist or the individual themselves.
    • Use a mirror- Move the tongue by mimicking movements and watching them in a mirror. You can even have the individual touch their tongue to a clean mirror surface. Play in front of a mirror alongside the child or in front of the child above the mirror so the child can look at the therapist’s face and check their movements in the mirror at the same time.
    • Tongue movement exercises- Use the tongue and mouth exercises included in our Deep Breathing Exercise pack for ideas.
    • Tongue sounds- Make clicking sounds with the tongue on the roof of the mouth. As the child/individual to copy the sounds.
    • Push the tongue into the cheeks of the mouth to copy motions. This can help with lateral sweep of the tongue to clear foods by increasing tongue range of motion.

    Lip and Cheek Stimulation

    • Washcloth oral motor simulation- this occurs with a dry wash cloth and then a wet wash cloth by rubbing the lips and cheeks. Each area can be separated so they are addressed in isolation. Use a dry washcloth or wet washcloth to wipe the face, without food use. Use a warm or cold washcloth to wipe the face.
    • Making faces- Cheeks and lips can obtain heavy work, or proprioception by puffing up the cheeks, making fish lips, sealing the lips and blowing, blowing raspberries, copying facial expressions, etc. Play “Simon Says” with facial expressions. We have oral motor Simon Says Commands to share!
    • Food stimulation- Some foods (sweet, sour) are very alerting. These can be used as a frozen pop in the form of a lemonade pop, smoothie, or popsicle. Or, add fruits and frozen foods to a mesh bag that is sucked on.
    • Ice pops- Freeze an ice cube on a popsicle stick and use it as an alerting and stimulating tool to “wake up” the lips and cheeks.
    • Vibrating tools- Play with vibrating mouth toys and touch the face, mouth, lips, teeth in the way of a vibrating toothbrush (offering input through the jaw).
    • Wilbarger Brushing Protocol– Use prior to eating foods (contact a trained therapy professional)

    Jaw Stimulation-

    • Vibrating toys- vibrating toys, chewing tools, or a vibrating toothbrush can offer oral motor stimulation through the jaw. This can be very alerting, so use with caution.
    • Chewing tools- biting on “chew toys” (described as heavy chewing therapy tools) or chewing tools that add heavy work through the teeth and jaws. This offers feedback to “wake up” the jaws.
    Oral motor issues related to feeding in kids

        As you can see there is a lot of different areas that need to be assessed and addressed when it comes to oral motor concerns related to eating and drinking.       

      

     
     
     
     
     
     
     

    Colleen Beck, OTR/L has been an occupational therapist since 2000, working in school-based, hand therapy, outpatient peds, EI, and SNF. Colleen created The OT Toolbox to inspire therapists, teachers, and parents with easy and fun tools to help children thrive. Read her story about going from an OT making $3/hour (after paying for kids’ childcare) to a full-time OT resource creator for millions of readers. Want to collaborate? Send an email to contact@theottoolbox.com.

    Pediatric Feeding: Is it Sensory, Oral Motor or Both?

    Below, you will find a blog post on pediatric feeding therapy and answers to initial questions about feeding therapy such as “Are pediatric feeding issues related to sensory needs, oral motor problems or both?” and thoughts about where to begin with pediatric feeding therapy techniques. A question of sensory or oral motor concerns should be taken into consideration when feeding developmental milestones aren’t being achieved on target.

    Occupational therapists and parents often wonder if feeding problems are related to sensory issues or oral motor skills. This article on pediatric therapy addresses that question.

    Pediatric Feeding: Is it Sensory, Oral Motor or Both?

    When I was in grad school, we had one, three hour lab on feeding, and were told, Speech would handle feeding, so don’t worry.  Little did I know that what I thought was going to happen, was very far from reality.

    Feeding Therapy Evaluation

    When a child enters a therapy clinic for an OT feeding evaluation, we are prepared for sensory deficits to be present. What we are not prepared for in school, is the potential, and probable oral motor component. This is a skill that most of us learn on the job, in trial by fire, with limited guidance. Or, so was my experience.

    Due to the high level of overlap between Speech and OT when it comes to feeding, this often is a problem that OT’s face. Depending on the setting, and even the facility you are in, can determine whose job it is to handle feeding clients.

    A majority of professionals maintain that if it appears sensory based and the child has a limited diet, eats only certain textures or colors, it is for OT. If it appears oral motor in nature and the child cannot chew or manage a bolus well, it is for Speech to handle.

    Herein lies the problem and common misconception about problematic feeders. Feeding challenges are more than just sensory, or just oral motor.

    It is both sensory and oral motor based. This can lead to a very challenging, and complex situation for an OT who is new to feeding.

    Oral Motor Skills and Sensory Challenges in Feeding Therapy

    When a child limits the textures and variety of foods they eat, they limit the growth and development of their oral motor skills.

    Let’s take a child who eats only pureed foods, and refuses solids of any kind for an example.

    Oral motor skills needed to eat a thin puree off a spoon and to eat a carrot stick are vastly different.

    Puréed foods require minimal bolus management of a thin food that quickly runs down the esophagus with minimal effort. The puree is also smooth, eliminating any scary “texture” for the child to manage.

    The carrot stick, on the other hand requires the child to have awareness of his mouth, tongue, and bite pressure before even creating a bolus with the bite of carrot. The child also has to manage the bolus and break down of carrot efficiently while chewing and then swallowing.

    Add in the sensory component of crunchy, wet and constantly changing size of the pieces of the carrot, and the child can become easily overwhelmed.

    And so, the vicious cycle of a limited diet begins. Lack of confidence with oral motor skills and sensory deficits can lead to problematic feeders.

    Feeding Therapy Goals

    The above example is a frequent experience that many OT’s have faced when completing a therapy feeding session. With lack of exposure and continued refusal to attempt new foods, the child’s oral motor skills are never able to develop to support the trial of new foods continuing the cycle.

    As occupational therapists, it is our job to help these children become functional eaters through the use of sensory desensitization and remediation of delayed oral motor skills.

    Oral Motor Development in Feeding Therapy

    As oral motor development is a lengthy topic, the next post will address oral motor development and food pairings to determine gaps in skills and provide effective remediation of delayed skills.

    Check out the handout below to show parents and help explain the overlap of sensory processing and oral motor skills in problematic feeders.

    Would you like to print this visual guide? Click here to access the printable pdf in our free resources library. You will also receive weekly newsletters full of therapy resources, tips, strategies, and information. The OT Toolbox newsletter is perfect for therapists and those working with occupational therapists.

    Disclaimer: Feeding difficulties stem from a variety of difficulties including medical, structural, sensory deficits and skill deficits. The main discussion of this post is to examine the crossover of sensory and oral motor skills. Medical and structural concerns will be addressed in future posts.

    A little about Kaylee: 
    Hi Everyone! I am originally from Upstate N.Y., but now live in
    Texas, and am the Lead OTR in a pediatric clinic. I have a bachelors in Health Science from Syracuse University at
    Utica College, and a Masters in Occupational Therapy from Utica College. I have been working with children with special needs for 8 years,
    and practicing occupational therapy for 4 years. I practice primarily in a
    private clinic, but have experience with Medicaid and home health settings
    also. Feeding is a skill that I learned by default in my current
    position and have come to love and be knowledgeable in. Visual development and
    motor integration is another area of practice that I frequently address and see
    with my current population. Looking forward to sharing my knowledge with you all! ~Kaylee Goodrich, OTR

    Click on the images below to check out these related articles: 

    Jaw instability is an oral motor problem that results in impaired eating and drinking skills.  Exaggerated jaw movements are an oral motor problem that interfere with feeding including eating and drinking. Here are reasons why this oral motor issue happen and how it relates to feeding in kids. Jaw clenching is an oral motor problem that interferes with feeding and eating. Help to understand jaw clenching and reasons it might occur. Jaw thrust is a common oral motor problem that interferes with feeding. Here are the underlying causes and how jaw thrust impacts feeding in kids.

    Ultimate Guide to Self-Feeding and Mealtimes

    This month in the Functional Skills for Kids series, we talked all about self-feeding.  Most parents have questions at one time or another when it comes to feeding their child.  From concerns about when to start solid foods to questioning whether their child is developmentally able to self-feed, there are many frequently asked questions.  Read on to find guidelines for self-feeding, ways to address picky eating, and the “why” behind why your child won’t eat.

    Parents and therapists will love this ultimate guide to self-feeding and mealtimes for kids.


    Mealtime Concerns for Parents of Small Children

     
    Fine Motor Skills For Mealtimes  | Therapy Fun Zone
     
     
     
     
     
    15 Tips for Picky Eaters | The Inspired Treehouse
     
    This post is part of the Functional Skills for Kids series by 10 Occupational Therapist and Physical Therapist bloggers.  You can find all of the topics and ultimate guides to functional skills here.
     
     
    Help kids with this guide to self-feeding and mealtimes