Occupational therapist Pamela Modugno sat at a small table at the Bacharach Institute for Rehabilitation in Galloway Township last week, teaching three young boys how to eat.

Sebastian Coombs, 5, doesn’t like to touch food, his mother, Erica, said as she watched the session on closed-circuit TV in a room across the hall.

“He was diagnosed with autism when he was 2,” she said. “He was really limited in what he would eat: just white bread, rice and french fries.”

Most people equate eating disorders with societal factors, citing rising obesity or a teenager’s obsessive desire to be thin. But many eating disorders start much earlier and can have underlying medical, physical or developmental causes. The National Association for Eating Disorders estimates some 20 million females and 10 million males have some type of eating disorder.

Modugno became interested in the issue when she noticed that many of the children she worked with at Bacharach also had feeding issues. She got certified in the SOS, or Sequential Oral and Sensory, approach to eating and a year ago began the Pedicatric Feeding Skills Program at Bacharach for picky eaters, problem feeders and children who are afraid of food.

Currently, about 20 children ages eight months to teenagers come once a week. Each session lasts 12 weeks. Children can attend for multiple sessions. If medically indicated, the program is covered by insurance.

Modugno said there are many reasons children won’t eat. While some may be outgrown, others can grow into serious health issues. The earlier the problem is addressed, the more likely the child will be successful.

“Some children have reflux or other medical issues that make eating unpleasant,” she said. “Some spent a lot of time in neonatal intensive care with tubes down their throat. Others just have sensory integration issues. They don’t like new things in general.”

Eating may seem like a natural instinct, but some children really do need to be taught the physical process. Some don’t understand how to chew, or how much food to put in their mouth.

Coombs said Sebastian has reflux, which can cause him to vomit, so many of his experiences with food were not positive. She said he also did not know how to move food around in his mouth, chew and swallow.

“He’d gag,” she said. “He really did have to learn how to eat.”

A typical session begins with a quick period in the therapy room on motor skills, which helps relax students and set them up for the session. They will blow bubbles, an exercise that can indicate how much control they have over their mouths.

“If they can’t do it, or they’re drooling, that’s a sign of a problem,” Modugno said.

The children sit with Modugno in a small room, some in special child-size feeding chairs to support their posture. Each session includes about 14 foods, a mix of vegetables, fruits, protein and starch. Peanut butter and ketchup can be used as a dip if it helps.

The Monday group has made a lot of progress, Modugno said as the boys at least touched most items, and even tasted a few.

“Some children won’t even sit at the table,” she said. “Or they won’t touch any food with their hands, or put it on their plates.”

Modugno focuses on colors and textures, and even encourages the children to play with the food, each step bringing it closer to their mouths. The children know this behavior is only allowed at “food school,” but it has helped them be less afraid of foods at home.

Frank Gargione, of Galloway Township, said he and his wife enrolled their son, Nicholas, 6, in the program because there were so few foods he would eat, and even those, he ate very little.

“We’d go to a pizza party, and he’d just look around,” Frank said. “We had to bring a peanut-butter-and-jelly sandwich everywhere.”

Modugno introduced foods one at a time, describing them by color and texture. Carrots are orange and crunchy. Spaghetti is like a rope, or a snake. Cucumber slices are round like circles.

“Who can put teeth marks into it?” she asked as she demonstrated on a celery stick.

“We forgot napkins,” said Nicholas, who must clean his hands if he does not like a food.

Sebastian impresses Modugno with his willingness to touch and examine items, if not always eat them. He is in his fourth session, and his mother said he has made progress. She has changed her meal routine, allowing for more family-style meals and letting Sebastian pick his own foods rather than serving him a prepared plate of food he might not touch.

“He has to get more used to food,” she said.

She said he used to go in his room and cry when she cooked, because he didn’t like the smells. But he has watched what other children eat at preschool and expressed some interest in new items.

Nicholas liked to build things with his food, and his dad was impressed that he played with his spaghetti in class.

“He won’t even touch it at home,” he said.

Coombs said the class provides a safe place for her son to learn about food without any pressure to eat. Modugno said meal times can be stressful for parents worried that their children are not getting enough nutrition. Most are underweight, though some have gained weight while in the program.

Modugno said typically a food must be tried 10 times before someone can decide if they like it. She said parents of picky eaters must just keep introducing foods in different ways, and give their children the option to try them. It takes patience, and sometimes parents will use a special “learning plate” at home that mimics the session.

“There are 32 steps to eating,” Modugno said. “It takes time.”

Coombs said she her goal is to have Sebastian eat a balanced meal.

“He will eat a couple pieces of chicken now,” she said. “And he’ll eat lettuce and carrots. But it is baby steps. It’s taking forever. But then sometimes he will surprise us and ask to try something.”

Contact Diane D'Amico:

609-272-7241

More than 30 years’ experience reporting and editing for newspapers and magazines in Illinois, Colorado, Texas and New Jersey and 1985 winner of the Texas Daily Newspaper Association’s John Murphy Award for copy editing.