Adoptive and foster child feeding problems

by Ellyn Satter, MS, MSSW, Dietitian and Family Therapist

To address feeding problems, consider feeding from your child’s point of view. Reassure them that they will be nurtured with food by following the Satter Division of Responsibility in Feeding (sDOR). Adoptive and foster children may have learned they can’t trust their grownups to feed them. They may fear they won’t get enough to eat and are likely to hoard food if they can. Children who have been forced or pressured to eat can get so upset and turned off to food that they would rather go hungry than eat. Children who have been abused with food by being forced to eat or being starved prefer to eat in isolation.

Children’s eating behaviors tell their feeding history

Each adoptive or foster child has a unique food history that you can “read” by paying attention to how the child behaves around food.  With the young child, offering a nipple, spoon, or soft pieces of table food and observing what she does with it gives clues. With all children, observing their urgency of eating, food preoccupation, anxiety around food and eating, and growth patterns also gives clues. Observe – or ask – what foods the child eats and arrange to include some of those foods at meals and snacks so not everything is new and strange.

Annie was terrified of going hungry

Maintaining a positive feeding relationship is is the most powerful way of reaching a child who has given up on being nurtured.

Annie, a two-year-old orphan from Haiti, eats like a starving person: gobbling her food, cleaning every crumb off her plate, insisting on more and more food, and crying when she is removed from the table. Sometimes Annie eats so much she throws up. Annie is always on the lookout for food and constantly begs for food when her mother is in the kitchen. Her parents follow the division of responsibility in feeding and have given her lots of food at structured times. But they encourage her to slow down. She seems to understand and tries to cooperate.

Annie has known hunger and is terrified that she won’t get enough to eat. Her terror takes the form of embedded, non-verbal memory. She needs to know in her very being that she will get enough to eat, and that will take months and months of sDOR: absolutely reliable, every 2-or-3-hour feeding with plenty of food. These parents understand Annie’s dilemma, but their alarm about her food-gobbling and occasional vomiting has led them to try to slow her down. To Annie, being asked to slow down feels like food deprivation. Instead, Annie needs sDOR and lots of reassurance, “we are finished now but there will be another meal (snack) soon and you can have as much as you want then.” When she begs for food between times, “it will soon be time to eat, and then you can have as much as you want.” Annie will recover from her terror, she will begin eating at a more moderate pace, and she will learn to detect her fullness cues so she doesn’t overshoot and throw up. Until then, her parents can show her how to throw up without making a mess. Annie’s parents also need to avoid doing anything that seems like food restriction—such as encouraging her to slow down. While structure may seem like food restriction, it isn’t, and it is important for another reason. Letting a child graze for food puts her in charge of feeding herself. Instead, she deserves to learn to depend on her parents to take care of her. They take care of her by providing ample food at predictable times and being with her while she eats.

David took care of his little brother

Six-year-old David and 3-year-old Sean are new to foster care. Sean is David’s shadow, particularly when it comes to food. Sean begs David constantly for food and will only eat when David is there. Then he eats a great deal.

Growing out of their neglectful home environment, David has become Sean’s parent. The task is to relieve David of that job by becoming a nurturing parent to both of them. Follow sDOR. Have meals and snacks at regular times, make sure that there is plenty of food at those times, be sure David has his own plate that he doesn’t share with Sean, give lots of reassurance, and be a nurturing and non-interfering presence at both meal and snack time. Draw the boys’ attention to the leftovers at the end of the meal, and show them that there is plenty of food in the kitchen. Talk with David in front of Sean and say, “it’s all right, David, you don’t have to worry about feeding yourself and Sean. I will take care of that.” Be firm with David about this. While feeding his little brother is a too-big burden for David, he won’t give it up readily. It makes him feel important and has given him a measure of security. Letting David be a child with food is tremendously important. Maintaining a positive feeding relationship is the most powerful way to reach a child who has given up on being nurtured.

Chi-Ho knew how much to eat and how to grow

Three-month-old Chi-Ho, adopted from China, weighed at the 5th percentile. The pediatrician assumed she was undernourished and said, “do whatever you have to do to get food into her.” So Chi-Ho’s adoptive mother force-fed her. She concentrated her formula, and repeatedly put the nipple in her mouth until she ate the amount the pediatrician prescribed. The mother started solids early and did the same thing with the spoon – she held the spoon in front of Chi-Ho’s mouth until she gave in and ate. By age seven months, Chi-Ho’s weight was up to the 75th percentile.

The pediatrician assumed he knew more than Chi-Ho did about how much she needed to eat and how she needed to grow. He encouraged her parents to get her to eat more than Chi-Ho readily accepted. It would have been better to follow sDOR, respect her feeding cues and see what happened. If Chi-Ho had been truly undernourished, she would have eaten more and grown faster. His advice was tragic for both Chi-Ho and her parents. Attachment powerfully takes place around feeding. Every child is born with the longing to be understood. To feel loved and to love back, Chi-Ho needed her parents to do what she wanted and needed with feeding. Ignoring her when she indicated she was full and forcing her to eat more is the opposite of being understanding.

Alexi gained attachment through feeding

Two-year-old Alexi was adopted from an institutional setting in Russia. He was 5% for weight and 50% for height. Alexi arrived with a bottle with a cross-cut nipple to allow fluid—and perhaps solids—to come through rapidly. Alexis was anemic and wouldn’t look at his parents. Going by what he was able to do, Alexi’s adoptive parents held him close to feed him formula by bottle, cuddled, talked gently, and gazed at him while they fed. Alexi began gazing back, at first briefly, then longer. At family mealtimes, they offered him pureed and mashed table foods by spoon and formula from the cup. He gradually began feeding himself soft finger foods and over several months lost interest in the bottle. Alexi’s hematocrit improved, and after a year, his parents phased out the formula.

Following sDOR offers a powerful way of making emotional contact with a frightened and isolated child. Making emotional contact in the form of eye contact with feeding or play supports attachment, but don’t force contact. Let it happen. Look at your baby, and let him look and look away. He looks away to calm himself. When he is ready, he will look back. Continue looking so you are available when he looks back.

Your adoptive or foster child will learn to eat well

Do an excellent job with feeding, then trust that your child has within her the ability to eat as much as she needs and can find her own way with eating.

• Feed in the best way by following the Satter Division of Responsibility in Feeding. Feed in a stage-appropriate way.
• Be lovingly persistent about developing a positive feeding relationship. Hold the bottle. Maintain structure and sit down and eat with you child. Be warm and friendly.
• Be available. Offer interaction but don’t force it. Look at your child and let her look and look away. Talk with your child and let her respond – or not.
• Reassure your child in many ways that there will be enough food. Tell her: “You may eat as much as you want.“ ”That’s all for now, but there will be more at snack-time.” Make enough food to have leftovers. Show her the leftovers. Show her the food in the pantry and refrigerator.
• Solve feeding problems by following sDOR.
• Expect that at first the child’s behaviors will become more extreme; then they will moderate.