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Feeding Disorder of Early Childhood

Andrea Barkoukis, M.A., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

A Feeding Disorder of Early Childhood is diagnosed when a child does not eat adequately and maintain proper nutrition. This disorder, sometimes referred to as "Failure to Thrive" leads to weight loss or to difficulties maintaining normal weight. There are numerous reasons why a child might not eat properly and not all of them constitute a feeding disorder. Feeding disorders are only diagnosed when the problem is not due to a medical condition such as cleft palate, chronic lung disease, esophageal reflux (e.g., where stomach contents and acids regurgitate up into the esophagus) or to another mental disorder, such as Rumination Disorder. The problem also cannot be the result of a lack of food. To meet DSM criteria, the problem must have begun prior to the age of 6.

red no signThe causes of Feeding Disorder are unclear, but have been attributed to poverty, dysfunctional child-caregiver interactions (such as when parents use food to exert control over children), child abuse/neglect, parental misinformation about a child's nutritive needs, and to children's motor coordination difficulties. Children may also have a history of a medical condition that makes eating unpleasant. For instance, infants who were tube fed, and infants with underdeveloped stomach muscles may both experience eating as unpleasant. Food allergies and digestive system problems can also lead to feeding disorders. For instance, children with Celiac Disease, a hereditary disorder that causes an allergic reaction to wheat gluten, may find eating to be a prelude to discomfort (until their condition is properly diagnosed and their diet is modified accordingly).

Symptoms of a Feeding Disorder may include constipation, excessive crying, irritability, and apathy (showing a lack of concern) as well as low weight (for a child's age and body type). Children affected by this disorder may have problems swallowing or chewing; may be unable to feed themselves at an age where self-feeding is appropriate; may choke, gag, or vomit (sometimes intentionally); and may choose to eat only foods of a certain color or texture. Some children may refuse to eat or drink at all, turning their head, screaming, spitting, throwing food, and having major tantrums at meal times. In order to qualify as a disorder, symptoms need to be rather severe, above and beyond what might be displayed by a normal picky child who won't eat his broccoli.

According to the DSM, approximately 3% children have a Feeding Disorder. The disorder occurs more commonly among children with medical or developmental disabilities then it does among otherwise normal, healthy children. Failure to appropriately treat Feeding Disorders can create severe life-long medical problems (i.e., bone loss, growth delays).

Diagnosis of Feeding Disorder

A thorough medical examination will help rule out any medical causes of the feeding problem. A physician will also evaluate your child's growth (i.e., height, weight, and head circumference) and nutritional status (e.g., check for signs of malnutrition, dehydration, and/or nutrient deficiencies) to evaluate the extent of the problem.

Treatment of Feeding Disorder

Optimal treatment of Feeding Disorders often requires coordination between multiple professionals, including a dietitian who can consult on nutrition and diet issues, a behavioral psychologist who can design and implement a behavior modification program, and a physician who can diagnose and treat medical problems that might contribute to the feeding disorder. When children have difficulty swallowing or chewing, an occupational therapist (a health care professional who will help your child to improve their physical and motor coordination skills) can be of assistance as well.

Though a team approach yields the best results, the central pillar of treatment for a Feeding Disorder is typically a behavior modification plan that is a graduated strategy for increasing the amount of food consumed by the child across time. Each week, a slightly greater amount of food is given (and/or the meal time is increased by a few more minutes), building up to greater and greater food intake. Greater food intake helps insure that enough nutrients are present for the child's growth and development.

In general, behavior modification plans consist of methods for altering what is reinforcing/rewarding and what is discouraging about a child's environment so as to influence that child to start behaving in desirable ways. Behavior modification plans specific to feeding disorders are designed to reward desired behaviors such as eating and drinking, and to discourage unwanted behaviors such as gagging and spitting. The therapists who design such treatment plans carefully study the child's food refusal behaviors, and then customize a plan that fits that child and that family's situation. For example, if children who refuse food receive lots of subsequent parental attention, it may be the case that the children find this subsequent attention to be rewarding and that attention is, in part, maintaining the feeding disorder. Noting this, the clinician may instruct parents to not give the child attention for refusing food, but instead to give the child lots of attention only when food is accepted. In this simple example, the parents are taught to modify the child's environment to make it less likely that the child will display problematic feeding behavior in the future.

Other behavior therapy techniques such as systematic desensitization can be used to help older children who demonstrate a food aversion. In systematic desensitization, therapists pair an avoided, anxiety-provoking object (in this case, food) with a relaxation behavior. The goal is to increase the child's ability to remain relaxed in the presence of the food that he or she would otherwise avoid. The procedure starts with a therapist teaching children relaxation skills such as meditation, deep breathing, and visualization of calming scenes. Separately, the therapist and the children collaboratively construct a list of anxiety-provoking foods and food- related behavior, and arrange that list in order of the aversiveness (distress or disgust) of each food or behavior described. For example, a child who hates milk might have "holding a cup of milk" lower on her hierarchy (because this is less disgusting) than "tasting a dropperful of milk" (more disgusting) or "drinking 3 ounces of milk" (most disgusting). Children who have become good at relaxing and have completed the disgust hierarchy are taught to pair their relaxation practice with each of the food behaviors listed in their hierarchy (starting with the least disgusting item). Though the food behavior would normally provoke disgust, the relaxation practice makes it easier for the child to tolerate. The child is instructed to maintain the relaxed state while continuing to experience the food-related situation. Eventually, the child will learn to become more tolerant of the food-related situation or behavior, through a naturally occurring process known as habituation. As each level of the hierarchy becomes tolerable, the next level of the hierarchy is introduced, until all the items on the hierarchy are tolerable. Eventually, the child should be able to consume targeted foods with little or no disgust reaction.

Parent education is an important part of behavior therapy for feeding disorders. Parents are taught to recognize their child's hunger and satiety cues, and how to create a positive, pleasant feeding environment for their child. Changing the texture of foods, the timing of feedings, the position of the person who is feeding (if the child is an infant), or the type of utensil used to do the feeding can all prove helpful in modifying the child's problematic behavior.

As is the case with many child behavior disorders, feeding disorders can be, in part, a reaction to problems occurring within the home such as marital difficulties, abuse or neglect, mental illness or lack of access to resources brought on by economic hardship. As therapists assess and treat child disorders, they will also be looking for evidence of other problems, such as the above, that might benefit from assistance. To the extent that such problems are identified, the therapists will either offer to treat such problems themselves, or (more likely) will refer parents to other professionals who are better prepared to treat such problems. By helping parents to solve their own difficulties, therapists help parents to free up their attention and energy for addressing the child's needs.

For more information on feeding disorders, please visit the website of the Kennedy Krieger Institute's Feeding Disorders Clinic, the website for the Marcus Insitute's Pediatric Feeding Disorders Program, or the Cleveland Clinic Foundation's Feeding Disorders Program.