this presentation talks about the basic difficulties a mother faces for feeding a child . its more about the feeder and the food

1. FEEDING PROBLEMS IN
CHILDREN-”ROLE OF CLINICAL
PSYCHOLOGY”
Ms. SMARANIKA
TRIPATHY
CLINICAL
PSYCHOLOGIST

2. Feeding difficulties
•Feeding difficulties may potentially
interfere with the parent-child feeding
relationship
•Children who accept very few foods
may be at risk for nutrient deficiencies
•Feeding difficulties have the potential
to compromise nutrition, growth, and
cognitive development
•Causes vary widely and feeding
difficulties require tailored therapy to
address this variation

3. Contributing Factors
• Organic, developmental,
psychological, and
behavioral issues
• Family dynamics
• Social and cultural
influences

4. Addressing feeding problems
Picky
eating
Feeding Feeding
disorders
problems
Feeding
difficulties

5. Poor appetite
The food:
• Quantity appropriate?
• Developmentally
appropriate?
• Nutritionally balanced?
• Influenced by cultural
norms?

6. Poor appetite
The child:
• Evident appetite?
• Difficult temperament?
• Sensory difficulties?
• Oral-motor dysfunction?
• Acute or chronic illness?

7. Food(contributing to feeding problems and
poor appetite )
• Nature of the child
• Food likes and dislikes
• Preferring outside food
• Very choosy
• Improper presentation
• Food timing
• Type of food
• Preoccupation during meal time

8. Poor appetite
The feeders:
• Creating an appropriate feeding
environment?
• Sensitive to the child's hunger and
satiety cues?
• Overly controlling or too
uninvolved?
• Misinformed about nutrition?
• Working mother
• Mood/attitude/health
• Preoccupation during meal time
• Knowledge about food and nutrition

9. The feeder
• Method/time of feeding
• Interaction with the child
• Poor judgment about child’s
hunger
• Dissatisfaction about child’s
appetite
• Weight and growth concern
• Influenced by others
• Fear (falling sick/being
compared/criticized)
• Proper time interval
• Un tasted food
• Misconceptions about
food(egg/bitter gaurd /neem
leaves)
• No. of children

10. The feeder-Role of care giver or Ayahs
• Age/experience
• Nature (sympathetic/not
sympathetic)
• Wrong method of feeding
• Lack of knowledge and
interaction
• Patience and irritability
• Monotonous and repeated
meals
• Food served (too hot/too cold)
• No innovation or
improvisation in food

11. Family and cultural influence
• Type of
family(joint/nuclear)
• Traditions
• Economic status
• Poor living
conditions

12. Media influence
• Role models(promoting zero
figure)
• Taboos and stigma
• More propaganda on junk
food (Mc Donald/Pizza Hurt )
• Conceptualizing “fit and fine”
• Turning vegetarians
• Importance on “X-factor/body
image and personality)
• Following food which is
popular

13. Prevalence
• Estimates in physically normal children
– 50% to 60% for parent-reported feeding difficulty
– 25% to 35% for specific difficulties (e.g., food refusal, selective
eating)
– 1% to 2% for severe and prolonged difficulties
• Estimates in children with neurological and developmental
disorders/delays
– > 80% in some studies
– Swallowing disorders are especially common

14. Issues of Concern
• Chronic aversion with socially
stigmatizing meal behavior
• Some children do have growth
limitations
• Some have suboptimal
consumption of nutrients
• Serious organic and nonorganic
causes exist
• Impaired parent-child
interactions indicated by
touching behavior

15. Parent-child relations
• Maternal education
• Parent-child conflict during
feeding
• Parent intrusiveness during
play
• Parental pressure to eat
appears to increase feeding
resistance
• feeding resistance
associated decelerating
weight gain

16. Type of feeding difficulties
• Fear of Eating
• Highly Selective Intake
• Vigorous Child
• Organic Disease
• Apathy
• Concerned parents

17. Features demonstrated in feeding
difficulties
• Child may cry at the sight of food or the bottle or resist
feeding by crying, arching, or refusing to open his/her mouth
• May occur in a child who has experienced a frightening
feeding experience (e.g., choking) or in a child who has been
tube fed
• consistently refuses specific foods because of taste, texture,
smell, or appearance.
• Child may become visibly anxious if asked to eat aversive
foods
• Additional sensory difficulties are often present; e.g., the
child may be upset by loud noises or the sensation of sand or
grass under his/her feet
• Child is more interested in playing and interacting with
people than in feeding
• Child may take only 1 or 2 bites and be finished with eating

18. Features demonstrated in feeding
difficulties
• Child is easily distracted from feeding; may be
difficult to keep at table or in high chair during
meals
• Limited verbal and nonverbal communication (e.g.,
smiling, babbling, eye contact) between child and
caregiver
• Possible evidence of neglect and/or signs of abuse
• Child is small but achieving satisfactory growth based
on mid-parental height
• Excessive parental concern may lead to coercive
feeding methods that adversely affect the child

19. systematic approach to the identification
and management of feeding difficulties
• Acknowledge
• Investigate
• Identify
• Manage

20. Assessment of
Feeding Behavior
• Background history • History of prenatal,
birth, hospitalizations
• Observation and • Early feeding history
Assessment of
Child’s Feeding • Developmental
Behavior milestones
• Temperament
• Assessment of • Regulation: sleeping,
Caregiver Feeding soothing, toileting
Behavior
• Previous evaluations

21. Assessment of
Feeding Behavior
• Background history • Cooperates with setup
• Sits appropriately
• Observation and • + interaction with feeder (e.g.,
Assessment of smiles, claps)
Child’s Feeding • positive comments about food
• Opens mouth, anticipates food
Behavior
• Feeds self
• Assessment of • Responds to prompts to
Caregiver Feeding continue
• Requests food
Behavior

22. Assessment of
Feeding Behavior
• Background • Refuses to sit in chair
history • Cries
• Spits food out of mouth
• Observation and • Gags, vomits
Assessment of • Verbally says “no “ to food
Child’s Feeding • Moves head away from spoon
Behavior • Refuses to open mouth
•
• Assessment of Puts hands in front of mouth
• Throws food or utensils
Caregiver Feeding • Gags before food is introduced
Behavior

23. Assessment of
Feeding Behavior
• Background history • Eye contact with child
• Positions child appropriately
• Observation and • Presents appropriate food,
Assessment of utensils
Child’s Feeding • Prompts child verbally and non-
Behavior verbally
• Pays attention to child during
• Assessment of meal
Caregiver Feeding • Models appropriate eating
Behavior

24. Assessmet of
Feeding Behavior
• Background history • Reminds child to swallow
completely
• Observation and • Paces child at reasonable pace
Assessment of • Interacts positively during
meals
Child’s Feeding
• Praises child for appropriate
Behavior behavior
• Assessment of • Sets limits on throwing food,
leaving table
Caregiver Feeding • Persists
Behavior

25. Chronic Underlying Pathology(organic)
• Dysphasia
• In coordinate swallowing suggested
by cough, choking, or recurrent
pneumonia/chest phenomena
• Failure to thrive
• Feeding interrupted by pain
• Regurgitation/chronic vomiting
• Diarrhea or blood in stool
• Neurodevelopment abnormalities
• Atopic and eczema
• Chronic cardio respiratory disease
• Signs of neglect

26. Non-organic pathology
Psychological disorders/conditions
• Fear of feeding
• Poor appetite
• child who is fundamentally vigorous
• child who is apathetic and
withdrawn
• parental misperception
• Colic that interferes with feeding
(< 3 months of age)
• Developmental delays
• MR and PDD
• ADHD(attention deficit and hyper
active)
• Problem behavior
• Autism
• Somatoform disorder

27. General complaints(outcomes)
• Feeding problem in both poor and rich.
• ‘My child eats nothing’,
• ‘My child eats like a bird’
• ‘I have tried everything’
• Meal times are virtual mini-wars
• Child is coaxed, cajoled, forced, bribed
• Story, showing a picture book, T.V.,
• Mother chasing the child with plate
• The whole family revolves around child
• Meal time becomes unpleasant,
emotionally surcharged and stressful
• Morale of the child is high while the
family is gloomy.

28. General complaints(outcomes)
• Child is the usual winner.
• Worst is forcing food after
restraining child.
• Spits or vomits.
• Low growth rate
• Loss of appetite
• Physical illness/constipation
• Fear/phobia
• Irritability/excessive crying
• Is there any food supplements

29. Addressing eating disorders-
role of clinical psychologist
• More than just eating disorders
– it is psychological
• Consult with dietitian,
psychologist or medical doctor
to come up with an effective
treatment plan
• Parents should give comfort and
support during treatment
• Give love, compassion,
appreciation and quality time

30. Addressing eating disorders
An initial evaluation should focus:
• feeding history- detailed
information on type and timing
of food intake
• feeding position
• meal duration
• energy and nutrient intake
• behavioral and parental factors

31. Treatments and interventions
• Behavioral therapy can help the
parent and child overcome
conditioned feeding problems and
food aversions.
• Parents must be educated to
recognize their child's hunger and
satiety cues accurately and to
promote a pleasant, positive feeding
environment.
• Changing the texture of foods
• the pace and timing of feedings
• the position of the body
• even feeding utensils
• forcing a child to eat or punishing a
child for not eating should be
avoided

32. Addressing eating disorders
• Cognitive behavioral therapy :(CBT)
– Acceptance and commitment therapy
– Dialectical behavior therapy
– Cognitive Remediation Therapy
• Family therapy
• Behavioral therapy : focuses on gaining
control and changing unwanted
behaviors.
• Interpersonal psychotherapy :(IPT)
• Music Therapy :
• Recreation Therapy
• Art therapy

33. How to tackle?
Rule out serious illness
• Prevention is easier than
treatment.
• Avoid over indulgence not
paying excessive attention and
concern to child’s food.
• Honor the likes and dislikes.
• Offer variety to break
monotony.
• Best way is “not to try”
• Relaxed attitude at meal time.
• Enjoy.

34. How to tackle?
• “Intelligent neglect”.
• More attention and pleasure
when eats.
• Ignore when does not eat or
fiddles.
• Self feed, even if creates mess.
• Most like to eat when others
are eating.
• After reasonable time remove
plate quietly without any
concern or anxiety.
• Negative statement may help

35. How to tackle?
• The whole family to participate in
training including grand parents.
• It is a behavior disorder.
• No loss of appetite or ‘sluggish liver’
• No role of tonics and appetizers.
Placebo? Iron/multivitamin.
• Understand the family dynamics of
fussiness. Needs change in attitude
and approach in feeding the child.
• May take long time - Patience.
• Do not talk of his food habits in front
of him
• Do not lecture or find faults during
mealtime.
• Give less than what he normally
takes.

36. How to tackle?
• Meals with more eye appeal,
shapes/size.
• Let him help in preparing meal.
• Never bribe for a few more spoons
• In the beginning do not offer food
which child does not like.
• Cut down between meal snacks/drinks
• Look at the bigger picture
• Adopt a relaxed and common sense
approach without any sense of
frustration.
• Be aware of other influences such as
peer pressure and advertising
• Individualize the approach

37. Refuses vegetables
• Serve and eat a variety of vegetables.
Parents eating habits influence the
children
• Prepare vegetable to retain its eye
appeal and vitamins.
• Many like to eat raw.
• Vegetable shapes. Carrot coins, flowers
• Add cheese, sauce etc
• Gradually reintroduce vegetables
• Mix with paranthas, pizzas.
• Make soup.
• Extra fruits.
• Visit farms and gardens.
• Help him to plant seeds, watch them
grow into something to eat.

38. Refuses milk
• Drink milk yourself along
with child
• Substitute e.g. curd, butter,
cheese etc.
• Serve in small colorful glass
which child can hold.
• Straw can be used.
• Small quantity to be served
frequently
• No problem even if does not
take.

39. Conclusion
When I was growing up, I would
hear people say, "You can lead a
horse to water but you can't make
him drink." That saying reminds
me of children's eating habits. You
can slave for hours in the kitchen,
use your finest place settings,
even dine by candlelight but if
your child isn't hungry or doesn't
like the cuisine, you can't, using
reasonable methods, make them
eat it.

40. Thank You