Intervening with Pediatric Feeding Disorders:
Extreme food selectivity, extreme picky eating, special needs
Step 1: Feed based on the division of responsibility
1. Feed based on the Division of Responsibility
Even children who have medical, temperamental, and/or neurological barriers want to learn to eat the food their parents and other trusted adults eat, and push themselves along to do it to the extent of their abilities. Based on trust in the child’s drive to learn, grow, and master, the intervention is simple: parents learn to feed based on Satter’s Division of Responsibility (sDOR), which allows the child to master eating. While parents and helpers must be attentive to the child’s medical, developmental, and oral-motor issues, most feeding issues are the same as those of any other child. Stages in feeding look the same; they just come along more slowly. Challenges at each stage are the same; the child just works harder and longer to master them. Eating quirks are the same; it is just hard to sort out the “child” in these quirks from the “special needs.”
Following sDOR is so simple, in fact, that it may seem like doing nothing at all compared to conventional interventions. In reality, parents do a tremendous amount: Throughout the child’s growing-up years, parents keep up the day-in-and-day-out of pleasant and rewarding family meals and sit-down snacks and, at the same time, trust and support their child’s ability to eat. Problems arise when health advisors and parents who use conventional approaches get scared that children can’t or won’t eat and put pressure on them. In response to that pressure, children find eating so unpleasant and overwhelming that they literally go hungry rather than eat.
Consider causes. Understanding causes will restore your trust in your child to do her part with feeding. To fully understand those causes, you and your child need to have had a full assessment, including longitudinal and developmental history and growth and, most particularly, feeding dynamics past and present. Most medical and even nutritional assessments don't address feeding dynamics and history, and it leaves a gap in understanding. Medical assessments and labs are helpful with respect to indicating whether your child has recovered from early medical maladies and/or has some other malady. Swallow tests and oral-motor evaluation are helpful for the rare child who has a significant mouth, throat or esophageal problem.
Most feeding “problems” tend to be variants of normal and those that the child can work through on her own in the context of positive feeding. Some children are exquisitely sensitive to tastes and textures, have a strong gag reflex, and throw up easily. Children who are diagnosed as having sensory processing disorders (SPD), simply react negatively to certain tastes and textures and must be protected from pressured feeding so they can gradually learn to accept those tastes and textures. Some children get a late start with eating because they have medical issues and/or are fed by tube during their early lives. However, even if your child has any or all of these issues, once medical issues have stabilized, s/he can learn to eat the food you eat, provided you provide regular and unpressured opportunities to learn. That means you follow Satter’s Division of Responsibility in Feeding. You provide the food matter-of-factly again and again and eat and enjoy it yourselves, and your child joins in with family meals. Here are some typical causes of children’s food refusal:
- Misinterpretation of normal growth and attempts to compensate: Children come in all sizes. A child’s height and weight are normal as long as growth is consistent, even if it plots at the extreme lower end of the growth charts or even off the charts so they have to be plotted using z scores. Trying to get a child to eat more or grow faster backfires by increasing the child’s resistance to eating and, in the long run, slowing growth.
- Pressured feeding. Any sort of pressure—even subtle, indirect, manipulative pressure—makes feeding unpleasant for a child. Making feeding unpleasant for a child creates negative associations—fear, anxiety, revulsion—that interfere with the child’s ability to eat what and as much as s/he needs. Children who are pressured to eat lose their desire to learn and grow with eating, and give the impression that they will go hungry rather than eat unfamiliar foods. Extreme pressure from parents or therapists can make a child give in and eat, but enjoyment in feeing is sacrificed for both parent and child.
- Errors in feeding/misinterpretation of normal eating. At all stages,attempting to compensate for children’s normal extremes in eating behaviors can precipitate food refusal. From birth, some children don’t eat much, show little apparent interest in eating, or have atypical hunger cues. Even for the child who nurses well, the transition from semi-solid foods through the almost-toddler to the toddler period is full of pitfalls, any of which can concern parents, make them put pressure on feeding, and cause food refusal.
- Stress. Chaotic or under-supportive family dynamics, often manifesting as lack of structured and supportive feeding, stresses children, and they eat less well. Children who have had negative early eating experiences associate any feeding pressure with those early experiences and eat less well under stress.
Division of responsibility-based intervention. Have the right goal: your child’s developing positive eating attitudes and behaviors. S/he will relax at mealtime, enjoy being there, pick from the available food, eat or not-eat, ignore or matter-of-factly turn down food s/he doesn’t want, and ask to be excused. When your child feels positive about food and family meals and behaves well, s/he will gradually sneak up on new food and learn to eat it, eat the amount s/he needs, and grow in the way nature intended for her. S/he will look but not touch, touch but not eat, mouth food and take it out again,and s/he will do it all on his or her own.
Interventions for established food refusal and/or for special needs are identical with excellent feeding. Remember, when you apply sDOR, your goal is not to get your child to eat a certain amount or type of food, but for your child to feel good about eating and behave well at mealtime.
- Don’t over-react to a “food refusal,” “Sensory Processing Disorder,” or “food or eating disorder” diagnosis by trying to get your child to eat certain types or amounts of food. Instead, use any such diagnosis to motivate yourself to do an excellent job with feeding.
- Follow the recommendations in The picky eater and Avoid pressure. Study one of Ellyn Satter’s books. Child of Mine is best for children through preschool. Your Child’s Weight is best for school-age children and adolescents.
- Be absolutely faithful about maintaining structure. Establish regular, reliable, enjoyable, sit-down family meals that work for you and sit-down snacks at set times. Don’t allow eating or drinking (except for water) between times. Feed in a stage-appropriate way, and choose foods that are stage-appropriate.
- Be scrupulous about giving your child independence with respect to determining what and how much to eat from what you make available at meals and snacks. Avoid pressure. Be entirely neutral, both in the way you present food and in the way you react to your child’s eating and not eating.
- Once you have your structure and your child’s independence well in place, give your child time to recover her interest in eating. This can take months or even years. If you have been applying pressure with feeding, at first your child will eat less and be less interested in food.
- Focus on how your child behaves, not on what s/he eats, and recognize the small signs of progress that take place over time. Your child will become comfortable at mealtime, then begin regarding the food: looking at it, putting it on his plate, touching it, putting it in his mouth and taking it out again. (Sit beside him rather than across from him if you can’t stand to watch!)
- Be prepared for the long haul. Your child will only feel good about eating and eat the amount s/he needs to grow consistently when you continue to feed well. Like other children, your child may be a teenager before some eating problems are resolved.
Trouble-shoot with the division of responsibility. Do problem solving if your child continues to be upset and anxious about eating or if/when her eating attitudes and behavior relapse. Either structure is eroding or pressure is creeping in. Are you faithfully doing your jobs with feeding? Are you scrupulously letting your child do his jobs with eating? Are you avoiding pressure in all its sneaky, devious, insidious ways? Are both you and the other mportant peole in yoru child's liefe being consistent about following sDOR? To help you identify glitches in feeding, video yourself and watch it. You will be surprised! If problems persist, get help from someone who thoroughly understands the division of responsibility in feeding. But be careful. Most feeding clinics use behavioral interventions that cross the lines of the division of responsibility and focus on getting children to eat.
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