1. Feeding Disorders

2. 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

3. 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

4. Development of Feeding Behaviors 8 months: begin eating from spoon 18 months: self-feeding exclusively 24 months: learn social skills associated with eating

5. 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

6. 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

7. 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

8. Feeding problems Inappropriate mealtime behaviors Lack of self feeding Food selectivity Failure to advance texture

9. Feeding Problems Food refusal Oral-motor immaturity Frequent vomiting Aspiration or swallowing problems Gastro-intestinal reflux See page 190 of Piazza (2003) article

10. Assessment Review of medical records Clinical interview with caregivers Sample records of food intake Other measures –Developmental assessment –Child, parental, family behavior rating scales

11. 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

12. 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

13. Behavioral Framework for Feeding Two Factor Model (both classical and operant conditioning) 1.Negative feeding experience occurs 2.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)

14. 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

15. 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)

16. Behavioral Interventions Appetite manipulation –Changing feeding schedule –Controlling artificial feedings –Restricting between meal snacks

17. Behavioral Interventions Providing consistent verbal or physical prompts to eat E.g., every 30 sec Modeling Shaping

18. Treatment of Mild Feeding Problems Parent training –Short term and long term goals Nutrition education Interaction coaching Suggestions for preparing and presenting food

19. 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

20. 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

21. 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

22. Failure to Thrive Weight less than 5 th 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

23. 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