Using Adult Learning Theory To Enhance Coaching In Pediatric Feeding And Swallowing Intervention

Editor's note: This text-based course is a transcript of the webinar, Using Adult Learning Theory To Enhance Coaching In Pediatric Feeding And Swallowing Intervention, presented by Pam Smithy, MS, OTR/L, and Rhonda Mattingly Williams, EdD, CCC-SLP.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

After the course, participants will be able to: 

• Analyze the impact of pediatric feeding and swallowing disorders (PFSD) on families and how these influence caregiver engagement in intervention.
• Analyze effective coaching strategies grounded in adult learning theory to support caregivers in implementing responsive feeding strategies.
• Differentiate between coaching and training approaches in pediatric feeding intervention, how each aligns with principles of adult learning theory, and the impact on caregiver empowerment and child outcomes.

Introduction

Pam: Hello everyone. We are pleased to be back to discuss coaching for pediatric feeding and swallowing, as Part 2 of our Adult Learning Series.

Pediatric Feeding and Swallowing Disorders (PFSD)

Prevalence

Pam: Between 25% and 80% of children with developmental disabilities experience problematic feeding. Infants born prematurely are at greater risk for feeding problems than full-term children, and the highest incidence of feeding difficulties is reported between six months and four years of age. These challenges significantly impact how we assess and manage children with pediatric feeding and swallowing disorders.

Issues Impacting Management of Infants/Children with (PFSD)

Dr. Rhonda Mattingly Williams: When I consider pediatric feeding and swallowing disorders, I realize how multifaceted they are, particularly because different healthcare providers often conceptualize them in distinct ways. For example, a physician may focus primarily on the physiological and anatomical aspects of a patient's condition. Their main concerns might be whether the child is gaining weight appropriately, maintaining adequate nutrition, and staying on the growth curve.

As an SLP, I might focus more on oral motor and swallowing skills, while also thinking about neuroprotection. I want to help create a positive feeding experience and protect the developing brain and nervous system by avoiding stressful or aversive mealtimes. I am asking not just “Can this child eat safely?” but also “How can we support a healthy, enjoyable relationship with feeding?”

Occupational therapy practitioners (OTPs) may approach pediatric feeding and swallowing from a similar neuroprotective stance, but with particular attention to sensory experiences—how the child responds to textures, smells, temperatures, and the overall sensory environment of feeding and swallowing. Psychologists might concentrate more on behavioral aspects, including learned patterns around mealtime, refusal, anxiety, or interactional dynamics.

These differences in how we conceptualize pediatric feeding feed directly into how we think about etiology. As a speech-language pathologist, I may first assess oral motor skills, the timing and coordination of swallowing, or structural and functional issues. Pam might focus on sensory processing, reactivity, or regulation. Naturally, when each of us emphasizes a slightly different lens—oral motor, sensory, behavioral, medical—we may arrive at somewhat different ideas about “what’s causing this,” unless we take the time to talk and integrate our perspectives.

We also use a different language to describe the attributes of pediatric feeding disorders. One clinician may focus on food refusal; another may emphasize selectivity or “picky eating.” Someone else may highlight aspiration or penetration, which are more dysphagia- and swallowing-related concerns. All of these are pieces of the same larger picture, but when everyone uses slightly different terms or operates from other priorities, it can feel like we are not entirely on the same page. Part of our work, then, is to recognize and respect these different perspectives and move toward a more integrated, shared understanding for the sake of the child and family.

Conceptualization of PFSD Historical Perspective

Pam: Upon examining the history of how pediatric feeding difficulties have been described, I notice numerous conceptual discrepancies that create significant gaps in our understanding and in how families are treated. Historically, children who struggled to eat well were often viewed through a very narrow and, frankly, blaming lens.

In the 1940s, the literature pointed to growth failure as being related to “maternal deprivation,” implying that mothers were primarily at fault. By the 1970s, authors were still writing about maternal deprivation, describing inadequate mothering as the symptom and the cause of impaired infant growth. In the 1980s, terms like organic and non-organic failure to thrive (FTT) became more common, and the concept of infantile anorexia was introduced. Non-organic FTT was often framed as multidimensional and linked to inadequate food provision and insufficient intake. However, there was still a strong focus on a “cycle of maladaptive behaviors” between infant and caregiver. It often felt like someone had to be blamed, and that “someone” was usually the parent.

In the 1990s, the literature expanded beyond dysphagia to include terms like feeding disorders, ARFID, feeding problems, food refusal, FTT, and selective intake. Rather than bringing clarity, this proliferation of terminology often adds to diagnostic confusion. In the 2000s, research began to reflect that families themselves perceived the FTT label as stigmatizing, which is not surprising given the long history of finger-pointing.

Dr. Rhonda Mattingly Williams: As I think about this history, I see how damaging it can be to a caregiver’s self-efficacy to feel singled out as “the problem.” When the narrative is that the parent is inadequate or at fault, it becomes tough for them to feel empowered to help their child. That is one of the reasons I feel so strongly about using a coaching and family-centered approach now. We are intentionally shifting our approach away from blame and toward partnership, recognizing the complexity of feeding difficulties and the importance of supporting, rather than shaming, the families we serve.

Parent Perceptions-NICU

Dr. Rhonda Mattingly Williams: When I am talking with families and trying to coach, collaborate, and work with them around feeding, I have to remember where they are coming from and what has happened along their journey before they arrive at early intervention. Many of them have already been through a great deal by the time they reach us, particularly if their child has spent time in a NICU.

The literature on parent perceptions in the NICU is critical because it reflects how parents feel, and those perceptions shape their involvement in later services. Parents have reported that when their infant was in the NICU, they expected to be more involved in the medical decision-making process than they actually were. Some described relational difficulties with healthcare providers and felt that they had been made to feel incompetent regarding their own child.

Other studies have shown that parents describe a shift in their sense of identity as parents. Many reported feelings of guilt, self-blame, and isolation. I can easily picture this from my own experience working in a NICU for about 15 years. Families often traveled three or four hours because we were the level IV NICU, which meant they were separated from their home, community, and typical supports. They might receive calls from family and friends, but day-to-day, they were living at the hospital, in a Ronald McDonald House, or in temporary housing. That level of isolation alone can be a massive source of stress.

Guilt and self-blame are also common: “What did I do wrong?” “Should I have done something differently?” Some parents wonder if they caused the early birth or medical issues because of something they ate or didn’t eat, or something they did or didn’t do during pregnancy. These thoughts can be incredibly heavy to carry.

It also makes complete sense to me, both as a clinician and as a parent, that maternal attachment can be delayed when a parent must ask permission to pick up their own infant. For medical reasons, they may be told they cannot hold or touch their baby in the way they imagined. That reality impacts how they attach and how confident they feel. There is often a great deal of uncertainty: “Can I pick my baby up?” “Will I hurt him?” “Is she too tiny or fragile?” Parents in these situations frequently report a profound loss of control. They are deeply grateful to the professionals who are helping their baby, but at the same time, they must ask for permission to do simple, deeply personal things with their own child.

By the time these families arrive in early intervention, and we begin working with them on feeding and swallowing, I must hold all of this in mind. These earlier experiences shape their current responses, hesitations, and emotions around feeding and caregiving. When I remember where they have been, I am better able to approach them with empathy, patience, and a genuinely collaborative, nonjudgmental stance.

Parental Perceptions – Medically Complex Children

Pam: Families of children with complex medical needs often experience significant health inequalities. Parents report overwhelming levels of physical and mental health challenges, not only because of what happens to their own child in the NICU, but also because they are exposed to other children’s medical emergencies right next door or down the hall. All of this contributes to decreased well-being and hurts their mental health.

Physiologically, the trauma of having a child with complex medical needs can result in chronic exhaustion, difficulties with anger, fear, and changes in both weight and sleep. Many mothers, in particular, may feel that they are not “supposed” to express anger or distress, which only adds another layer of pressure. Once the child is discharged, the demanding nature of delivering medical care at home can further strain parental mental health. Parents often experience trauma responses and find that their ability to engage in activities outside the house is restricted.

Dr. Rhonda Mattingly Williams: I recently read an account from a parent that really resonated with this. They said they wanted to be a parent; they did not want to be a nurse. They were very clear that their feelings were not a result of a lack of love for their child. Instead, they were describing how overwhelming it felt to shoulder such intense medical responsibilities at home—responsibilities they never imagined would be part of parenting. That sense of being overwhelmed is something I try to keep in mind whenever I work with families in early intervention, particularly when it comes to feeding and other medically complex routines.

Parental Perceptions – Children Requiring Multiple Hospitalizations

Dr. Rhonda Mattingly Williams: Parental perceptions for children who require multiple hospitalizations are fundamental for me to understand by the time families get to early intervention, because I want to support them in every possible way. The literature and caregiver reports tell us that many parents feel powerless to help their child. Yet we need them to feel powerful, because they are the ones who live with the child day in and day out. Rebuilding that sense of efficacy is absolutely critical.

Parents often describe feeling as though their lives are on hold. Plans, appointments, and everyday activities can be interrupted at any moment by a phone call stating that their child needs to return to the hospital. Hospitals—no matter how “nice”—are not places most people want to spend extended time. Families want to be home, but repeated admissions create a cycle of stress. I remember during my early intervention work seeing children whose services were repeatedly interrupted for weeks or months because of frequent hospitalizations, and each time it felt like we had to start all over again.

Financial burden is another primary source of distress. I often tell students that just because a parent is in the hospital with their baby, it does not mean the electric company, the water company, or any other creditor stops expecting payment. Bills continue to arrive, and the weight of those financial pressures sits on top of everything else the family is managing.

Parents also frequently report dissatisfaction with the amount and clarity of information they receive about their child’s illness. They may hear conflicting explanations or recommendations from different providers and end up feeling confused and overwhelmed. Many describe feeling that they must remain constantly vigilant—trying to rest when their child sleeps, yet knowing someone will be in and out of the room, and feeling the ongoing need to advocate and pay close attention to every detail.

One theme I have seen repeatedly in the literature and in practice is the erosion of trust that happens when professionals give contradictory guidance. For example, I might sit with a parent and carefully explain why I am recommending a specific bottle nipple, ask how they feel about it, and work collaboratively to try it. Then another provider might come in and say, “Oh no, they ate fine for me like this,” and recommend something completely different. From the parents’ perspective, this can feel like whiplash. They are hearing multiple, sometimes opposing messages from people who all claim expertise. Over time, this inconsistency can seriously undermine their trust in all of us.

When I keep these experiences in mind—the sense of powerlessness, life on hold, financial strain, information overload, constant vigilance, and conflicting advice—it shapes how I approach families in early intervention. I become more intentional about being consistent, transparent, collaborative, and very respectful of the emotional load they are already carrying.

Impact of Pediatric Feeding and Swallowing Disorders on the Family

Pam: We know that challenges with feeding in these little ones deeply affect the entire family unit. Children with feeding problems often have other developmental delays or diagnoses, and parents naturally prioritize ensuring their child receives adequate nutrition. That priority can amplify the impact of feeding challenges on everyone’s quality of life. Quality of life is also linked to social and family activities such as enjoying meals together, shopping for food, preparing it, and sharing it at the table.

Parents are keenly aware that a child who requires supplemental tube feeding will remain dependent on them unless effective intervention helps the child gradually transition away from that support. Parents of children with food refusal or restrictive eating often report feeling isolated or blamed because of the feeding problem. The guilt can be tremendous. I work with many competent, thoughtful parents who still feel, “I didn’t do the right thing at that critical moment,” and that is something we have to address head-on.

Dr. Rhonda Mattingly Williams: It is very common for people—family members, friends, even strangers—to say things like, “When I did this, it worked just fine,” or “If you would just do it this way, it would be better.” I find it exasperating on the parents’ behalf. I saw it often in the hospital and still see it in other settings. These comments, even when meant kindly, can compound parents’ sense of guilt and failure.

The degree of developmental delay and the intensity of negative child feeding behaviors have been shown to predict higher levels of parenting stress. That makes sense to me. A child with significant developmental delays often requires significantly more care, and from a speech and language standpoint, may have fewer ways to communicate their needs clearly. What may appear to be “negative behavior” at the table is often the only form of communication the child has available. When you add developmental delays, feeding struggles, and limited communication together, stress levels understandably rise.

On top of that, parents often receive input from Grandmas, aunts, uncles, and even strangers at the store who say, “If you just did it this way…” as if the parent has never considered any of those ideas. It is no wonder they feel overwhelmed and scrutinized.

We also observe higher rates of internalizing and externalizing behaviors in children with feeding challenges, such as withdrawing from meals altogether or engaging in behaviors like fighting, pushing away, and resisting when they are not comfortable with the food presented. Over time, parents understandably come to perceive their child as “difficult,” not just as a difficult eater but as a difficult person overall. This is not about blaming parents; it is simply the human response to chronic stress and struggle.

Research has found that parents of older children with feeding problems often report even higher levels of stress than parents of younger children. With younger children, there is sometimes more room for “explanations”—“They’re still little; they’ll grow out of it”—but as the years pass and problems persist, parents become more flustered, worried, and worn down. It is not surprising that, when compared to parents of children without pediatric feeding disorders, parents of children with feeding challenges report more caregiving-related stress. Feeding a child who enjoys eating can be a tremendous joy; feeding a child for whom every meal is a battle can feel exactly the opposite.

Pam: These difficulties are also cyclical. If children are not eating well, they often do not sleep well; if they are not sleeping or eating well, they may not play well; if they are not playing well, they may not meet developmental milestones. Everything is interconnected, and in many ways, it starts with feeding.

The impact on family life can be profound. In one study, five of seven dual-parent families reported that the presence of a child with feeding challenges resulted in the mother being unable to maintain employment because she needed to stay home and take responsibility for feeding. That speaks volumes. Parents reported feeling sad and frustrated; the limitations imposed by the child’s feeding problems affected their entire lives. They described having less time for other family activities, whether those involved siblings or the couple’s own relationship. They also reported that the child’s feeding difficulties limited their ability to participate in activities outside the home, such as attending worship services, going to siblings’ sporting events, concerts, or other community activities. As these restrictions accumulate, life becomes very isolating and all-consuming.

Dr. Rhonda Mattingly Williams: One young mother I met more than 25 years ago has stayed with me. She came back from picking up her little boy from a Mother’s Day Out program and was visibly upset. It took me a moment to understand why. Another child had been throwing a tantrum because he wanted to go to McDonald’s, which was located next to the program. She looked at me and said, “Do you know what I would give for him to throw a tantrum to go to McDonald’s?” It was heartbreaking. She had drastically limited their outings because her son was so averse to smells and foods. She would have loved to have a child who begged to go out for a burger and fries. In that moment, I felt very deeply how much feeding challenges can reshape not just a child’s life, but an entire family’s experience of what parenthood and everyday living were supposed to be.

What Matters Most to Parents?

Dr. Rhonda Mattingly Williams: In one study, researchers interviewed 30 caregivers whose children had received treatment for feeding issues at a feeding program at Mass General. When asked, “What matters most to you?” parents consistently reported that difficulties with feeding affected their children’s everyday activities, especially their ability to socialize. They worried about things like birthday parties and other typical events where food is central. They wanted their children not only to be invited, but to be able to participate and even to want to go, very much like the mother I mentioned earlier, who longed for her child to enjoy something as simple as a trip to McDonald’s.

Caregivers in this study prioritized enhancing their child’s overall well-being and health. Of course, as parents, that is what we would expect, but they also wanted to see their children genuinely enjoying life, not just surviving from a medical standpoint. They recognized that positive outcomes were supported by factors related to both the child and the caregiver. Still, they also acknowledged that challenges such as limited time, financial constraints, restricted access to services, and a lack of clear, consistent information hindered progress. In many cases, it was not just a lack of information, but also confusing or conflicting information that made things more difficult.

Not surprisingly, these parents expressed a strong preference for interventions guided by family-centered care. They saw themselves and their children as part of an interconnected family unit and wanted services that recognized and honored that reality. Their message was clear: effective intervention must be rooted in the family, with approaches that respect, include, and support everyone involved.

Stress

Impact of Stress on Learning

Pam: When I think about stress and learning, I remember professors who used to say, “My job is to stress you so you’ll learn,” and in a typical academic setting, a certain amount of pressure can push us out of our comfort zone and help us grow. However, for the families we work with, the level of stress they experience is far beyond anything that could be considered healthy or productive. Parents who are worried that their child cannot eat safely or adequately are not dealing with mild stress; they are coping with chronic, high-intensity stress that touches every part of their lives.

That kind of chronic stress limits their ability to engage in associative learning. It affects memory, higher-level thinking, and the mental space required to reflection, problem-solving, and retaining new information. Many of these parents are in a near-constant “survival mode,” focused on fundamental, urgent questions: “How am I going to get enough food into my child today?” “Will they gain any weight this week?” “Will we make progress on the growth chart?” Their mindset can feel almost instinctive or animalistic—purely about getting calories in and keeping their child stable. If we have not walked that same path, we need to recognize just how extremely difficult this is.

Dr. Rhonda Mattingly Williams: I often share with students the example of a family who drove about two hours for a fiberoptic endoscopic evaluation of swallow with their little girl. I knew their therapist and asked, “What does your day look like at home?” They said, “We wake up, and we wonder how much we can get in her today.” That is how every day begins. The sheer weight of that kind of stress is enormous.

When I hold this in mind, it changes how I approach coaching and education. I slow down. I simplify. I respect that parents may not retain everything we say in one session, not because they do not care, but because their cognitive and emotional bandwidth is already stretched thin. It also deepens my empathy, reminding me to be gentle, transparent, and collaborative as we work together to support their child’s feeding and overall development.

Impact of Stress & Anxiety 

Dr. Rhonda Mattingly Williams: When I think about the impact of stress and anxiety on the families I work with, I often try to imagine what it feels like in my own life. Increased anxiety can be both a state (what I am feeling right now) and a trait (a longer-term, chronic pattern). Both affect how we function, but chronic stress, especially, can erode our capacity to think clearly, remember information, and make decisions.

To put this into perspective, I sometimes picture a day loaded with typical adult stressors: I have an extra caseload at work, I’m covering for a colleague, there are new processes I’m trying to learn, my in-laws are coming to stay for a week, I forgot to pay the electric bill and I’m trying to keep the power from being shut off, and on top of that I’ve misplaced my credit card. Now, in that highly anxious state, I imagine running into the grocery store and trying to remember five or six items I need to buy. As I shop, I’m also mentally calculating whether I have enough cash, since I’m unable to use my card. Even in this scenario—which has nothing to do with my child’s health—the anxiety alone can make it hard to remember the list, think clearly, or do simple math.

Now I layer on what many of our families are actually facing: their child struggles to eat; weight gain is fragile; every ounce matters. They are managing appointments, insurance, medical decisions, sleep deprivation, and often financial strain. And then, as clinicians, we ask them to process new information, learn strategies, and implement interventions to help their child develop a healthier relationship with food.

When I look at it through that lens, it becomes very clear how profoundly stress and anxiety can interfere with even basic tasks, let alone complex learning. The fact that parents in these situations continue to show up, listen, try, and advocate for their children speaks volumes about their strength. It also reinforces for me how important it is that we approach them with patience, empathy, and realistic expectations about what they can absorb at any given moment.

I am grateful that we are finally seeing more literature that reflects what parents have been telling us for years: this is extraordinarily challenging. Their symptoms, their stress, their anxiety are not signs of weakness; they are understandable responses to a harsh reality. Remembering this helps me ground my coaching in compassion and keeps me from placing any additional, unnecessary burden on families who are already carrying so much.

Best Practice for Combating the Effects of Stress & Anxiety

Pam: When I think about best practices to help combat the stress and anxiety these parents are experiencing, I keep coming back to motivation as a central element. Learner motivation is one of the strongest predictors of how adults engage with different learning styles and how deeply they commit to the learning experience. That means I have to recognize its critical role and design interventions that actively maintain and support parent motivation, not undermine it.

Recent research indicates that when adults have a strong learning orientation—primarily driven by mastery goals—they are focused on genuinely understanding and developing skills, rather than merely “checking a box.” This mastery focus helps improve performance and reduce anxiety. When parents feel that what they are learning is helping them gain real, usable competence with their child, their confidence and sense of control grow, and their anxiety tends to decrease.

Effective coaching is closely linked to enhancing this kind of motivation because it places parents and caregivers in the driver’s seat rather than positioning me as the sole expert. When parents are directing the priorities—working on routines and issues that matter most to them—the learning becomes inherently more meaningful. If I imagine myself as the parent, my stress and anxiety would decrease if we were consistently focusing on what I find most important, in ways that feel doable and respectful.

Dr. Rhonda Mattingly Williams: In a coaching model, parents are not just recipients of instructions; they are members of a team. They have a clinician who treats them as a true partner, someone whose knowledge and insights are essential. That sense of partnership—“we’re in this together”—is a powerful buffer against stress and anxiety and is, in my view, at the heart of best practice for working with families of children with feeding and other developmental challenges.

Coaching

Coaching Vs. Training

Dr. Rhonda Mattingly Williams: When I consider coaching versus training, I return to the idea that, although these terms are sometimes used interchangeably, they represent distinctly different approaches to working with families. In a coaching model, I involve and support family members so they can make informed decisions. I may be the expert in my discipline, but the parent is the expert on the child, and that has to shape my stance.

In coaching, I am sharing my expertise. Still, my primary focus is on strengthening the family’s capacity—helping them build the skills, confidence, and problem-solving abilities they need to support their child in daily life. I ask questions, collaborate on goals, and help parents consider options that align with their routines, values, and priorities. The aim is not for them to copy what I would do, but to feel equipped to make decisions and adapt strategies independently.

Training, on the other hand, is more about telling and showing. I might demonstrate a specific strategy and instruct a parent exactly how to use it. While there can be moments of training within a broader coaching approach, if I stay only in training mode, I risk positioning myself as the sole expert and the parent as a passive learner. That is not what I want. I know a great deal about my field because I have worked with many families, but I do not know any one child as well as that child’s caregivers do.

For that reason, I intentionally lean into a coaching framework: I support, guide, and offer suggestions, but I always recognize and honor the parent’s expertise and central role. My goal is for them to feel, “I can do this. I know my child, and I have tools that fit our life,” rather than, “I just have to remember what the therapist said and hope I get it right.”

Coaching – Pediatric Feeding & Swallowing

Dr. Rhonda Mattingly Williams: When I consider coaching strategies in the context of feeding, I aim to be as comprehensive as possible, keeping caregiver coaching at the core. The goal is to support effective, high-quality feeding practices while recognizing that feeding is never just a technical task—it is a profoundly relational experience.

Pam: Occupational performance coaching has been shown to produce statistically significant improvements in children’s eating behaviors and to reduce the extent to which parents view those behaviors as problematic—that shift in perception matters. When a parent starts to see a behavior as a challenge they can work through, rather than as a sign that something is “wrong” with them or their child, it changes how they approach mealtimes and how confident they feel.

We also know that occupational performance coaching leads to gains in caregiver satisfaction with their roles and in the child’s engagement during mealtimes. I am always looking for that back-and-forth interaction between caregiver and child—shared eye contact, smiles, turn-taking, small cues and responses—because feeding should never be a one-way street of “shoveling” food into a child.

Dr. Rhonda Mattingly Williams: Feeding is a relational process. It is something we do with a child, not to a child. When coaching is done well, it supports that relationship, strengthens the caregiver’s confidence, and helps both the child and family experience mealtimes as more positive, connected, and manageable.

Coaching Strategies

Dr. Rhonda Mattingly Williams: When I think about coaching strategies, I often refer back to the framework developed by Rush, Shelden, and Hanft, which is particularly important to share here, especially in the context of feeding.

First, there’s joint planning. This is about understanding what the caregiver wants to work on next, based on today’s intervention. The key takeaway for me is always to prioritize what the caregiver identifies as important. We plan with them, not for them.

Next is observation. I make time to observe the child and caregiver initially, and then I follow up by asking, “What would you like help with today?” This helps me understand their current interactions and challenges in their natural environment.

Then comes action. This involves providing a review of evidence-based feeding interventions and discussing how they can encourage positive feeding relationships. This is where I share my expertise, but critically, I ask the parent how we can adapt these strategies for their child, because they are the experts on their child’s unique needs and preferences.

Reflection is about providing input on what was done without imposing my views. I use open-ended questions to encourage caregivers to think about what happened. Caregivers need options and the ability to make decisions, so we discuss techniques and strategies in a way that empowers them to choose what works best for their family.

Finally, there’s feedback. This involves sharing specific information about what the caregiver did, or didn’t do, and just as importantly, how the child responded. Providing particular examples really helps empower someone to make changes or to refine their approach. Providing this information allows the caregiver to learn, but as Pam mentioned, we also learn a tremendous amount from families. That sentence should definitely be added to this framework, because our learning is a two-way street.

Pam: Something else I do, though it’s not explicitly on these slides, is to ask permission from the family: “Would you be open to it? Would it be helpful? Would you mind if I brought you a notebook and some articles that explain these techniques?” I offer this so they have a place to store information, knowing that when they are under stress, they may not be able to absorb everything in the moment. I might say, “You’ve done a great job today, and thank you for not answering that phone, and for having the TV off, and for managing the other child who is here with us. We covered a lot of material, and if it’s helpful, I’ll give it to you in a notebook.” Then, after each session, we can jot down what was important. This helps them keep track and tangibly reinforces their learning.

Attributes Needed to Coach

Pam: As providers, there are several things we need to coach effectively, and it really starts with our attitudes. Sometimes, our attitudes need a bit of adjusting.

I have to intentionally accept and promote the idea that the family is an autonomous unit. They are not just “recipients” of services—they are a whole, functioning system. I must acknowledge the family’s knowledge and competencies, as well as my own. My focus has to stay on meaningful goals that are based on what the family needs and wants, following their lead rather than mine. And I have to remain open to changing my own behaviors and attitudes. If something in the way I’m approaching them isn’t working, the first place I look is myself.

Then there is the knowledge piece. To coach well, I need a solid understanding of family-centered practice. I need to be clear on what coaching actually is, and how it differs from other approaches—both in my own mind and when I explain my role to families. I must be able to describe and distinguish between different coaching strategies. I also need to understand adult learning theory—our old friend, andragogy—so that I can align my teaching with how adults actually learn.

Finally, there are the skills we need to bring all of this to life. I need to know how to apply family-centered practice in real time, not just in theory. That includes:

• Recognizing the needs of the family and communicating about those needs respectfully.
• Sharing relevant information and providing suggestions, not rigid directions.
• Asking open-ended and reflective questions, then truly listening to what caregivers say.
• Creating opportunities for them to practice new strategies while I’m present.
• Offering reflective feedback on their performance—specific, supportive, and focused on what went well and what could be tried next time.
• And then, importantly, reflecting on my own behavior and attitudes and making adjustments when needed.

Dr. Rhonda Mattingly Williams: All of this is high-level work. It’s a lot. However, without the right attitude—truly seeing the family as competent partners—the rest of the knowledge and skills won’t go very far.

Adult Learning Theory

Dr. Rhonda Mattingly Williams: This framework primarily focuses on how adults acquire knowledge, which differs from the way children learn. With adults, the emphasis is on the fact that they come to us with diverse needs shaped by their prior experiences, responsibilities, and motivations. All of these pieces—history, current life demands, and reasons for engaging—affect how well adult learning actually occurs.

The adults we work with are not blank slates. They arrive with a great deal of life experience, strong perceptions, and, very often, a high level of stress. When we remember that, we can use this framework to guide how we share information and build skills. It helps us support them in a way that respects what they already know and what they are carrying emotionally, while they are gaining comfort and confidence with new strategies to help their child move forward.

Adult Learning Theories

Pam: When you delve into this area, you quickly discover a tremendous amount of information. Adult learning can be expressed under various labels, including transformative learning, self-directed learning, experiential learning, project-based learning, action learning, cooperative or collaborative learning, discovery learning, elaboration learning, social learning, individualized learning, behaviorism, cognitivism, constructivism, and, of course, andragogy.

All of that tells us there are many rich perspectives on how adults learn, but from a practitioner’s standpoint, it can feel overwhelming. I know that when I think about one specific family, with their very real daily struggles, and I start mentally running through all these different adult learning theories, it can feel overwhelming. A vast amount of information is available.

Dr. Rhonda Mattingly Williams: Some of these approaches differ quite a bit from one another, and some are tailored more to particular settings, like higher education, workplace training, or group learning environments. Others overlap and share similar principles, just with different terminology. The key for me is not to master every framework, but to identify the common threads that actually help in practice: adults bring prior experience, they want relevance, they learn best when they are active and respected, and stress and context matter. If I keep those core ideas in mind, I can let the long list of labels sit in the background and stay focused on the real family before me.

Adult Learning Andragogy

Dr. Rhonda Mattingly Williams: Malcolm Shepherd Knowles is really considered the father of this particular theory. He was an American educator, often referred to as the father of adult education. He went to Harvard and later began teaching the very first course in adult education at Boston University in 1959. So when we talk about andragogy, we are standing on his work. He defined andragogy as the art and science of helping adults learn, and that framing guides much of how we think about working with parents in early intervention today.

Andragogy Vs. Pedagogy

Pam: Andragogy really emphasizes the application of knowledge. When working with adults, we focus on what they can use right now in their real lives—in this case, in their daily routines with their children. That is quite different from how most of us in the audience were taught.

Many of us grew up in a predominantly pedagogical model, which is focused on transmitting knowledge and skills that have “stood the test of time.” It is very content-driven and fact-laden. You learn sets of facts, rules, and procedures, often in contexts somewhat removed from your immediate, everyday life. What we are seeing now is a more apparent distinction between what children tend to need and how adults tend to learn best. 

Dr. Rhonda Mattingly Williams: In early intervention, we spend a lot of time discussing routines and context, using everyday moments such as mealtimes, bath time, car rides, and playtime as the foundation for learning. That aligns with andragogy, as we help adults integrate new strategies into situations that already matter to them.

When children transition into school, more content-heavy, fact-based learning becomes a focus. They start learning math concepts, theories, and historical facts—essential knowledge, but often more abstract and less directly tied to their current daily routines. Both are important, but they call for different teaching approaches. With the adults we coach in EI, our focus remains on the kind of learning that is immediately applicable, meaningful, and embedded in the real contexts of their lives.

Underlying Principles of Andragogy

Dr. Rhonda Mattingly Williams: What are the foundational principles guiding adult learning? We recognize that adults are inherently self-directed. They bring a wealth of life experience, which typically serves to facilitate new learning. However, it is also true that these prior experiences can, at times, present impediments. Recalling the literature previously discussed, when adults approach us in states of overwhelm and distress, their inherent self-direction may require significant encouragement, coaching, and support to enable them to engage in novel learning and integrate new experiences.

Adult learners, as many of us can attest, demonstrate maximal engagement when the content is directly relevant, offers hands-on application, and connects to tangible, real-world challenges. My own experience confirms that individuals often prioritize content that directly addresses their immediate concerns. Adults seek to comprehend precisely how new learning will contribute to the achievement of their personal objectives. If I am dedicating an hour of my time, I expect that investment to yield practical benefits. Consequently, intrinsic motivation and the capacity for practical application emerge as pivotal drivers in the adult learning process. The internal impetus to progress, coupled with the ability to utilize acquired knowledge immediately, is essential.

Pam: Furthermore, it is imperative to consider the diverse educational backgrounds of the individuals we serve. Reflecting on my tenure in acute care near Lexington, Kentucky, which is home to the horse industry, I frequently encountered clients for whom English literacy was a significant barrier to communication. Similarly, in my current early intervention practice, it is not uncommon to find at least one family on my caseload where a member has experienced academic challenges, including early school departure or reading difficulties. We must acknowledge that their lived experiences and the strategies they have employed to navigate their world possess immense value. These individuals often exhibit robust cognitive abilities and extensive real-world expertise, despite any potential discomfort they may have regarding their formal academic achievements.

Adult Learning Principles/Intervention

Pam: When considering the application of adult learning principles to our intervention, we recall that caregivers learn best when the material is immediately relevant to them. They want to be sure it is useful. For example, we might help a parent or caregiver reduce meltdowns over using a different cup than the one the child always drinks from. Some families opt to buy four identical cups, and this is not an issue. But most of our families have one “special cup,” and the child always wants that one. When we attempt to change it, there are challenges.

We also know caregivers learn best when new knowledge is built on their prior knowledge and experiences. That might look like helping a parent draw on past experiences with their older children to help them manage feeding protests with the current child. Caregivers need to understand what they are learning, why it is essential, and how they will use it with their own child. Every learner needs to be given the “why” of how a strategy could be used.

One example we list here is exposing a child to a food for familiarity, rather than expecting them to eat it. That allows them to learn that they are safe even while the broccoli—or whatever the food is—is on the table. Reducing the amount of food on the child’s plate can also decrease visual overload. The key is that we verbalize the strategies we often carry in our own minds. We explain the “why” of what we are recommending.

Dr. Rhonda Mattingly Williams: I also try to tag onto that by giving parents something to help them put themselves in their child’s position. For instance, I may ask them to imagine traveling to a foreign country where they do not speak the language, and having plate after plate of food brought out in front of them. I have told students that if I am sure the plate holds vegetables, I might be fine eating them. But if it is meat and I have no idea what animal it came from, and I cannot communicate or ask questions, there will probably be an argument. I am not likely to just willingly eat it. That is similar to what we are asking a child to do. We discuss exposure with parents, which involves letting the child see and experience the food, providing information, and helping them understand that the goal is not to frighten the child, but to build familiarity. I will often ask parents to stop and place themselves in that same role, so they can feel what that might be like.

Continuing with adult learning principles, caregivers learn best through active participation. When we are working on feeding, swallowing, self-feeding, and all the other pieces of this puzzle, we know that about seventy percent of learning comes from hands-on experiences. We do not want to be the ones doing the feeding; we do not live there. We want the parent to be the one doing it. About twenty percent of learning comes from social interaction, and only about ten percent from formal training.

We also know that caregivers learn and remember more when what they are learning is practiced in context and in real-time. We want parents and caregivers to have the opportunity to share their concerns with us: “This is what happens at breakfast when we have these challenges.” That way, they can really see what is going on, and we can see it too.

Caregivers also benefit from opportunities to reflect and receive feedback on their performance and their learning. Working through real-world problems—“This is what happens at breakfast,” or “This is what happens with the cup”—is critical. I once worked with a family whose child had a favorite cup that was being discontinued. They found out it would no longer be made, so they bought a case of those cups. We all learned together that the child really only wanted the one cup with his own teeth marks in it. No matter how many times the parents tried to put bite marks in the new cups, he was not fooled. That was a real-world problem, and we all learned from it together. Seeing these situations firsthand, in context, is incredibly valuable for us and for the parents.

How Can I Use Adult Learning Principles to Successfully Implement Coaching Strategies?

Pam: How can I apply adult learning principles to implement the coaching strategies we have been discussing effectively? How do we actually do this?

Dr. Rhonda Mattingly Williams: We have worked through this before, and in a previous course, someone asked, “How do you modify this for adults or for someone else?” The answer is that you can absolutely adapt it. When we refer to “caregivers,” it could be a spouse, an adult child, a sibling, or a friend. The framework is flexible; it depends on how you look at it and who is in that caregiving role.

When we examine adult learning principles alongside coaching strategies, they align very nicely. The principle that caregivers learn best when what they learn is immediately relevant fits directly with joint planning. During joint planning, we identify what the parent finds vital in the feeding world. We check in with them, listen to what matters most, and make plans around those priorities.

We also know caregivers learn best when new knowledge is built on what they already know. That only works if we are taking time to observe. Observation lets us see what the caregiver already does and understands. From there, we can sit down together, jointly plan, and decide how to build new strategies on top of what is already working, so that we are truly addressing the child's current situation.

Caregivers need to understand what they are learning, why it matters, and how they can apply it to their child's care. Again, that is where joint planning and feedback play a crucial role. Joint planning provides a collaborative space to explain the purpose behind strategies and how they relate to child development and feeding. Feedback then reinforces that understanding by linking specific actions and outcomes back to those strategies and developmental goals.

Pam: Caregivers also learn best through active participation and practice. That is the action part. During the action phase, we have to make time for caregivers to actually try out strategies within their daily routines while we, as practitioners or coaches, provide support. This hands-on practice—caregivers doing, rather than watching us do—is really the key piece of adult learning in this context.

Caregivers learn and remember best when learning is practiced in context and in real time. The action and observation periods in coaching enable us to embed strategies into real-life interactions and routines, such as mealtimes and bath time. The caregiver sees the immediate relevance to their own life and that of their child, which leads to better retention.

Caregivers benefit from opportunities to reflect and receive feedback on their performance and learning. That is where reflection and feedback are so critical. After a strategy has been tried, we pause and ask what they felt went well, what was challenging, and what changes they have noticed in their child. This becomes a quiet moment to take a deep breath and think: What worked? Where do I want to go next?

In the hectic lives of these stressed parents, who have often had a complicated medical journey with this new person in their life, that reflective moment can actually be calming. We might ask, “What do you think about that?” “Where would you like to go next?” “How can I support you?” “What do you need?” Those questions signal respect and partnership.

Dr. Rhonda Mattingly Williams: At the same time, this helps caregivers recognize that, while we are not erasing the difficult medical experiences they have had, they are no longer stuck in that place. They are now in a different model, one where they are being actively respected as central members of the team. It is not that they were never respected before, but the context and expectations are different now.

One quick example that comes to mind related to action and observation is positioning infants for feeding. I have worked with families where, even when no specialized sidelying or other medical positioning is required, you can see how tense they are as they hold the baby for bottle feeding. Their arm gradually sinks, their posture shifts, and suddenly everything looks strained. In those moments, I might say, “I’m noticing your arm is going down a little bit,” and then we start problem-solving together. We look around the room and ask, “What couch might be more comfortable?” “Is there a pillow we could put under your arm so you don’t have to hold it up the whole time?”

Those are very real-life adjustments that people appreciate. Once we support the caregiver in finding a more comfortable position, they can focus on enjoying the interaction with their infant instead of worrying, “Did I let my arm drop too far?” or dealing with neck and back knots afterwards from holding that position too long.

Case Study

Pam: We’re turning our attention now to Emma. She is three years and three months old and lives with her mother and Grandma. She was born at 32 weeks’ gestation and spent six weeks in the NICU. During that admission, she experienced respiratory distress and scarring. Bottle feeding was initiated at 33 weeks, but she had episodes of bradycardia and oxygen desaturations. She received both occupational and speech therapy during her hospital stay. By 36 weeks, according to her mother, she was able to take full oral feeds without distress.

Bottle feeding continued to go well at home, but the transition to a cup took much longer than her family expected, and the introduction of complementary foods was challenging. Emma’s current diet is severely limited.

Dr. Rhonda Mattingly Williams: Her protein sources include Pediasure, Carnation Instant Breakfast, whole milk, eggs, and crispy bacon. She takes her liquids via a straw cup, and she does self‑feed, which is a strength. Her grains, however, are primarily potato chips, Goldfish crackers, dry waffles, pretzels, and Ritz crackers. She successfully self‑feeds these finger foods.

When we look at fruits and vegetables, the picture changes. Foods like apples, bananas, and vegetables are not foods she self‑feeds. She will sometimes accept them from her mother or Grandma, but not consistently. Overall, this is a minimal diet. I have certainly seen children whose diets are even more restricted than this, which can feel overwhelming to families, but this is still not a pattern we want to sustain. We want to broaden it. Another concern is that, from time to time, children will “drop” one of their few accepted foods. When that happens, parents often find themselves wishing that food, such as Goldfish crackers, would return. It can feel terrifying.

Pam: Her family describes Emma’s appetite as poor. She is frequently constipated, which makes sense given the diet. She is receiving occupational therapy and speech therapy through early intervention, and is now also receiving both services as an outpatient. Her vocabulary currently consists of six intelligible words. She also uses gestures, eye gaze, and some vocalizations to communicate.

Both Mom and Grandma report that Emma’s restricted diet causes them significant stress. They are worried about her nutrition and want her to eat at least some of the foods the rest of the family is eating at mealtimes. In addition to encouraging her to eat more of the family foods, Mom would like Emma to begin self‑feeding with utensils and to sit at the table without constantly getting up and running around. Mealtimes can be stressful with young children under the best of circumstances, and a situation like this makes them even more challenging.

Dr. Rhonda Mattingly Williams: In the following several slides, we are going to circle back to the adult learning principles and the coaching framework, and walk through examples of what strong, effective practice can look like, as well as examples of practice that would need improvement.

Caregivers Learn Best When What Is Being Learned Is Immediately Relevant and Useful

Dr. Rhonda Mattingly Williams: Returning to the principle that caregivers learn best when what is being learned is immediately relevant, we can examine what this looks like in practice.

In a best‑practice scenario, we use joint planning between the caregiver and the coach. Together, we identify goals and strategies that address the caregiver’s specific concerns and daily routines. In this example, both Mom and Grandma want Emma to eat a broader range of foods, increase her desire to eat—which is entirely understandable, as you want to see your child show hunger—and reduce her constipation, which is a significant concern. The plan from the last session is reviewed, and we check in on how the previous week actually went. We do not simply move forward; we intentionally ask what happened.

In contrast, practice that does not work well is characterized by unilateral planning on the part of the clinician. In that situation, the clinician is the one generating the goals and strategies, based on her own perceptions of which factors matter most. For example, the clinician might say that she understands the family’s concerns about Emma’s limited diet and constipation, but then add that several non-feeding goals must be addressed so that the plan can be justified; otherwise, the child may have to be discharged or the goals may have to be modified. She may then propose moving ahead with strategies that focus on those non‑feeding goals. In doing so, she does not discuss mealtime routines, food preferences, or constipation, and there is no plan to follow up on the issues Mom and Grandma identified as most important.

You might think, “That would never happen,” but some of you may be thinking, “Oh yes, it would,” and you would be correct. I have seen these types of situations occur, often because we are busy, carrying large caseloads, and under pressure to show progress on documented outcomes. It absolutely can happen. Our aim, though, is to be on the “left side” of this slide—the side reflecting best practice—and to keep striving to do better. When we drift to the other side, we are no longer aligned with adult learning principles or with what families have told us they need.

Caregivers Learn Best When New Knowledge Is Built on Prior Knowledge and Experience

Pam: Best practice in this area primarily relies to observation, combined with joint planning. The coach first watches what the caregiver already knows and does, and then they plan together, building new strategies on top of that foundation. This honors the caregiver’s experiences and makes sure that what we’re doing is meaningful to them.

In the example here, Mom is sitting with Emma at the kitchen table and encouraging her to eat. The coach observes this interaction and, based on what she sees, asks whether giving Emma her own spoon for self‑feeding might be helpful. The coach also asks if offering water instead of Pediasure or Carnation Instant Breakfast during the meal might help Emma’s appetite, so she doesn’t fill up on those heavier, high‑protein drinks. When they discuss expanding food variety, the coach might ask Mom if she thinks using a suction divider plate and offering Emma both a preferred food and a new food would be beneficial. Mom is also invited to describe things she has tried that did not work. Most families have several of those experiences and are eager to share them.

In contrast, weaker practice skips that observation and joint planning step. Instead of watching what the caregiver already does and building from there, the clinician jumps straight into offering strategies without asking permission, without considering the family’s routines or skills, and without acknowledging past efforts. For example, Mom sits with Emma at the kitchen table and encourages her to eat. Rather than observing that interaction or asking what Mom already does, the clinician immediately instructs her to follow a rigorous mealtime schedule, use a visual timer, and implement a token reward system for every bite Emma eats. These strategies are not connected to what Mom is currently doing or what feels natural for her family. She ends up feeling overwhelmed and unsure how to apply these ideas, and from her perspective, Emma’s eating challenges remain unaddressed.

Dr. Rhonda Mattingly Williams: And, as you noted, none of that really supports the underlying goal of increasing Emma’s desire to eat.

Caregivers Need to Understand What They are Learning, Why It Is Important, and How to Use It With Their Children

Dr. Rhonda Mattingly Williams: Caregivers need to understand what they are learning and why it is crucial. Joint planning and feedback are central here. We take time to explain the purpose of each strategy and how it connects to the child’s development. Feedback then reinforces understanding by linking specific actions to specific outcomes and, in doing so, helps deepen the caregiver’s motivation. It also allows us to help the parent put themselves in the child’s place so they can better appreciate the child’s perspective.

In our example, the coach and Mom, with Grandma listening, discuss whether Emma might do better if Mom eats at the same time, bringing in the social and relational element. They also discuss what other potential target foods might be similar to Emma’s current foods, essentially asking, “What can we chain to?” in terms of color or texture. Mom then asks questions about Emma’s constipation. At that point, the coach responds with information, while staying within her scope of practice. She might, for instance, acknowledge that there is a high incidence of constipation among children with pediatric feeding problems and then help Mom think about how to ask more detailed questions of Emma’s GI provider. There are resources and ways to support parents in talking with physicians, and the coach can help them problem‑solve how to approach that conversation.

On the other hand, practices that need work skip joint planning and meaningful feedback, instead moving straight into issuing directions. The caregiver is left unsure about the purpose of the strategies. In that weaker example, the clinician tells Mom to have Emma sit at the table for ten minutes at every meal and to introduce three new foods during the week. There is no explanation of why sitting matters or how these steps relate to Emma’s development or feeding goals. When Mom asks about Emma’s constipation, the clinician replies, “Keep trying new foods,” without really addressing the question. This kind of response is likely to undermine Mom’s motivation and significantly increase her frustration. And, as you and I both know, it is doubtful that Emma will respond well in that situation.

Caregivers Learn Best Through Active Participation and Practice

Pam: Best practice for supporting caregivers, who learn best through active participation and practice, is to invite them to try strategies within their daily routines. At the same time, the coach is present to offer support. This is the hands-on portion of the visit, which helps family members learn by doing.

In our example, we use collaborative language such as “Can we practice while I’m here?” During a mealtime or snack time, Mom, Grandma, the coach, and Emma all sit at the table and have water to drink. We might use chaining to help Emma learn to take the spoon out of her mouth after she takes a bite, offer her a choice between two foods, and provide lots of reinforcement and praise after each success.

In contrast, practice that needs adjustment occurs when, instead of discussing with the caregiver how to use a strategy in a daily routine, the clinician either demonstrates the technique alone or only discusses it without giving the caregiver a chance to practice. When we do not provide families time to try strategies on their own, we limit their learning and fail to build their confidence and skills.

In the weaker example, during snack time, the clinician feeds Emma directly, demonstrating chaining, guiding spoon movements, and offering new food choices. Mom sits nearby and watche,s but is not invited to participate. The clinician explains what she is doing, but Mom never has the opportunity to try the strategies with support. By the end of the visit, Mom feels unsure about how to use these strategies on her own because she never had the chance to practice them during the session.

Caregivers Learn and Remember Best When What They Are Learning Is Practiced in Context and in Real Time

Dr. Rhonda Mattingly Williams: Caregivers learn and remember best when what they are learning is practiced in context and in real time. This is where action and observation come together. We embed strategies into real-life situations, such as mealtimes and snack times. I often prefer to work during snack time, because regular mealtimes are already hard enough for many families. In these moments, the caregiver can see the immediate relevance and effectiveness of what we are doing.

In our example, we practice chaining, offering choices, and giving positive feedback. We might add additional strategies, such as taking photos of Emma and her food, or counting sips of water, if that is something she seems to enjoy. The coach then asks Mom and Grandma if they feel comfortable using these strategies during snack time later that day or the next day. If they are not comfortable, that is a signal that we need to revise our approach to the plan.

Practice that needs work looks very different. Instead of embedding the strategies into real routines, we talk about them or hand over a worksheet that “tells” the caregiver what to do, without fitting the plan into the child’s daily schedule. During the visit, the clinician might sit at the table with Mom, avoid involving Emma, and not follow any real snack-time routine. She explains, in theory, the importance of giving choices and how that can help children, but there is no live practice. When the session ends, Mom is just as confused as in the previous “needs work” examples, because nothing was tried in real time, with her own child, in her own context.

Caregivers Benefit From Opportunities to Reflect and Receive Feedback on Their Learning and Their Performance

Pam: Caregivers benefit from opportunities to reflect and receive feedback. After trying a strategy, we really want to ask the caregiver what went well, what was challenging, and what changes they noticed. This kind of feedback reinforces practical actions, guides improvement, and supports ongoing learning.

In our example, once Emma is out of the high chair, the coach, Mom, and Grandma discuss what went well and how they might incorporate water, counting, and the divided plate into the next meal. Mom shares that she likes the idea of introducing another food that is similar to one Emma already eats, and she is excited to try it. She is also interested in having Emma try feeding herself, rather than Mom doing all the feeding.

In contrast, practice that needs work happens when, instead of pausing to discuss what worked, what was difficult, and how strategies could be adapted next time, the coach ends the session without meaningful reflection. The clinician might give some generic praise but skip the specific feedback that is needed. As a result, the caregiver does not see a clear connection between her actions and any progress.

In the weaker example, Emma finishes her meal and stands up from the high chair. The clinician says, “Great job, keep practicing,” packs up, and leaves. Grandma and Mom are left unsure about what actually went well and what felt difficult. There is no feedback on how to encourage Emma, how counting sips helped, or how the divided plate could be used in the future. Mom walks away, uncertain about which parts of the session were effective, and misses a critical chance to build her own confidence.

I also think this kind of ending can make people feel, “Were you really paying attention to me? Do I matter in this process?” Frivolous or generic praise does little to answer that question. What makes a difference is thoughtful, specific reflection that shows we saw what they did and that it matters.

References

See additional handout.