Transcript document

Feeding Disorders
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
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
Development of Feeding
Behaviors
• 8 months: begin eating from spoon
• 18 months: self-feeding exclusively
• 24 months: learn social skills associated
with eating
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
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
Classification of Causes of
Feeding Problems
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Medical basis
Oral-motor delay or dysfunction
Behavioral mismanagement
Or…a combination of some or all
See page 190 of Piazza (2003) article
Feeding problems
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Inappropriate mealtime behaviors
Lack of self feeding
Food selectivity
Failure to advance texture
Feeding Problems
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Food refusal
Oral-motor immaturity
Frequent vomiting
Aspiration or swallowing problems
Gastro-intestinal reflux
See page 190 of Piazza (2003) article
Assessment
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Review of medical records
Clinical interview with caregivers
Sample records of food intake
Other measures
– Developmental assessment
– Child, parental, family behavior rating
scales
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
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
Behavioral Framework for
Feeding
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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)
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
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)
Behavioral Interventions
• Appetite manipulation
– Changing feeding schedule
– Controlling artificial feedings
– Restricting between meal snacks
Behavioral Interventions
• Providing consistent verbal or physical
prompts to eat
• E.g., every 30 sec
• Modeling
• Shaping
Treatment of Mild Feeding
Problems
• Parent training
– Short term and long term goals
• Nutrition education
• Interaction coaching
• Suggestions for preparing and
presenting food
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
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
Inpatient vs Outpatient
Treatment
• Advantages of inpatient treatment
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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
Failure to Thrive
• Weight less than 5th 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
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