Feeding Disorders

Feeding

• Complex, dynamic process• Continuous sequence of hierarchical steps• Results in adequate growth in weight,

height, and head circumference• Feeding problems are common

– 25-35% overall– Found more commonly in children with

medical conditions and developmental delays– Over 60% of parents of toddlers reported

more than one eating concern

Stages of Feeding

• Nursing period (newborn – 4 months)– Breast milk or formula

• Transitional period (4-6 months)– Semisolid foods are added

• Modified adult period (1-2 years on)– Solid foods– Food preferences

Development of Feeding Behaviors

• 8 months: begin eating from spoon• 18 months: self-feeding exclusively• 24 months: learn social skills

associated with eating

Development of Feeding Behaviors

• Toddlers– Assert self and quest for autonomy

• Noncompliant behaviors can emerge

– Onset of self-feeding– Establishment of food preferences– Shift from parental control to shared

control

Variables affecting parent’s response

• Importance attached to feeding– CF child needing to consume 150%

RDA

• Feelings of success as a parent through the child’s eating

• Tolerance and patience

Classification of Causes of Feeding Problems

• Medical basis• Oral-motor delay or dysfunction• Behavioral mismanagement• Or…a combination of some or all• See page 190 of Piazza (2003)

article

Feeding problems

• Inappropriate mealtime behaviors• Lack of self feeding• Food selectivity • Failure to advance texture

Feeding Problems

• Food refusal• Oral-motor immaturity• Frequent vomiting• Aspiration or swallowing problems• Gastro-intestinal reflux• See page 190 of Piazza (2003)

article

Assessment

• Review of medical records• Clinical interview with caregivers• Sample records of food intake• Other measures

– Developmental assessment– Child, parental, family behavior rating

scales

Assessment

• Direct observation of feeder-child interactions during a simulated or actual meal– Piazza (2003) article discussion– Study 1: Observed…

• Escape: removal of food• Attention: reprimands, coaxing, redirection• Tangible item: gave preferred food, toy• Page 192

Assessment

• Study 2: Functional Analysis– Baseline control – free access to attention and

preferred items– Escape– Attention– Tangible– Purpose: to simulate situations– High levels of inappropriate behavior in each

condition would suggest that child’s behavior was sensitive to the experimental condition

– Results: Environmental variables play a role in the occurrence of feeding disorders

Behavioral Framework for Feeding

• Two Factor Model (both classical and operant conditioning)1. Negative feeding experience occurs2. Child associates other feeding stimuli with

this negative experience (classical conditioning)

3. Anxiety regarding negative experience leads to avoidance behaviors

4. Avoidance behaviors result in removal of food (negative reinforcement)

Behavioral Interventions

• Contingent differential social attention– Positive attention to appropriate behavior

• Opening mouth• Closing lips• Chewing

– Planned ignoring of inappropriate behavior• Throwing• Hitting• Clenched teeth

– Brief time out for inappropriate behavior• E.g., turn child’s high chair to face wall

Behavioral Interventions

• Positive tangible consequences– Offering bites of preferred food– Providing access to television, toy play,

sensory reinforcement, or tokens

• Negative tangible consequences– Removal of favored items– *Escape extinction

• E.g., hold spoon at child’s lips until food is accepted

– Physical guidance (rarely used)

Behavioral Interventions

• Appetite manipulation– Changing feeding schedule– Controlling artificial feedings– Restricting between meal snacks

Behavioral Interventions

• Providing consistent verbal or physical prompts to eat

• E.g., every 30 sec

• Modeling• Shaping

Treatment of Mild Feeding Problems

• Parent training– Short term and long term goals

• Nutrition education• Interaction coaching• Suggestions for preparing and

presenting food

Severe Feeding Problems

• Experienced by 3-10% of children• Tend to persist and worsen with

time• More prevalent in children with

– Physical disabilities– Mental retardation– Medical illness– Prematurity– Low birth weight

Inpatient vs Outpatient Treatment

• Prerequisites for outpatient treatment– Child’s medical status is stable– One or more caregivers is available to

participate in treatment– Recommended treatment is

acceptable to all caregivers

Inpatient vs Outpatient Treatment

• Advantages of inpatient treatment– Can control and measure child’s intake– Medical coverage is immediately available– Medical monitoring– Permits consistency of trainers– Easier to restrict access to food to induce hunger

• Disadvantages– High cost– Substantial professional time requirements (3-4

feeding sessions per day)– Possible problems of generalization of treatment

effects to home after discharge

Failure to Thrive

• Weight less than 5th percentile for age and sex OR downward trend in weight

• Distinguished from “feeding problems”

• Often accompanied by physical and psychological problems

• Not a diagnosis, but an outcome resulting from various etiologies

Failure to Thrive

• Parental influences– Limited food availability– Feeding patterns and relations– Maternal psychological status

• Child influences– Physical and medical problems– Behavioral difficulties

• Parent-child risk factors– Quality of home environment– Security of attachment