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When Mother and Child are Apart


									              Food & Trauma:
   An Infant Mental Health Perspective

         Kiti Freier Randall, PhD
Pediatric Neurodevelopmental Psychologist

           September 30th, 2010
      Children’s Network Conference
            Ontario, California
Food & Trauma: Mental Health Trajectory

  “The solution of adult problems
    tomorrow depends in large
 measure upon the way our children
         grow up today”.
             Margaret Mead
         Bonding vs Attachment
• Attachment – infant behavior is adapted to
  complement the caregiver behavior – mutual
  responsivity to cues “The tie from infant to
• Bonding – Parent’s emotional
  investment to the child
  “The tie from parent to infant”
          Feeding & Attachment

• Feeding is the first interaction where the
  parent and infant learn to work together
• It is one of the most important dyadic

     • Nancy Barnard, NCAST
   Infant Mental Health: ATTACHMENT

• It is the emotional availability of the
  caregiver in intimacy which seems to be the
  most central growth-promoting feature of the
  early rearing experience
     • Schore, 2008
                            Feeding –
                        Trauma Perspective

• Children’s Hospital
  – Feeding Problems
     • OT & SP/L – Not oral motor concerns, ability to
       swallow is adequate
     • Request Peds Psychology assistance
             Food & Trauma

• Traumatized infants/toddlers present with a
  variety of concerns that are often not
  considered from a mental health perspective
  – which do, however, impact functional status
• One very frequent concern in the traumatized
  young child relates to feeding and/or food
             Food & Trauma

• In addition to the medical and health
  consequences seen in children with food
  disorders the psychological impact is often
  even more long-term.
• Impaired self-image, anxiety and affective
  disorders, and psychosocial dysfunction may
  persist into adulthood
              Workshop Goal

• To provide information regarding the unique
  concerns related to food/feeding issues in the
  traumatized infant/toddler populations.
Food & Trauma: Mental Health Trajectory

• Well documented that persons who have
  been abused have higher risk for eating
  disorders, however, little is addressed about
  the precursors or symptomology as an infant
  or young child
 Eating Disorders & Mental Health


          Food Disorders - NOW

• At best understood as a symptom within
• Little thought to etiology and role in current
  mental health
• Not typically diagnosed – inadequate
         Food Disorders - NOW

• May be seen as a ‘behavioral’ problem
• Not specifically addressed in treatment as
  trauma symptom with etiology for eating
  – despite knowledge of high risk for eating
   disorder as an adolescent or adult
          Infant Mental Health

• Excessive crying, sleeping disorders and
  feeding problems are some of the most
  common behavioral disorders in infants and
  toddlers. Yet, treating them confounds many
  parents--and clinicians.
   Current Mental Health Diagnoses
Feeding and Eating Disorders of Infancy
          or Early Childhood

• Pica
• Rumination Disorder
• Feeding Disorder of Infancy or Early
                    307.52 Pica
• Eat 1 or more nonnutritive substances persistently
  for over 1 month
• Behavior is developmentally inappropriate
• Not part of a culturally sanctioned practice
• Typically part of MR or PDD
   – If occurring co-morbidly then diagnosis is only made
     if behavior is severe enough to warrant independent
     clinical attention
    307.53 Rumination Disorder
– Most commonly occurs in infants and young children.
– Characterized by repeated regurgitation and
  rechewing of food occurring after eating/nursing…
   • Food is brought up and into mouth without obvious nausea,
     retching, disgust, or associated gastrointestinal disorder, or
     other medical condition (Sandifer’s Syndrome or esophogeal
   • The food is either expelled from the mouth or more
     commonly rechewed and swallowed with pleasure
– After a period of normal development…
– And occurs for at least 1 month.
   Rumination: Associated Features

• Infants often present with irritable mood and
  increased hunger between episodes of
• Malnutrition occurs despite large amounts of
  food consumption
• Weight loss, failure to achieve weight
  milestones, and death can occur
  – 25% mortality rate
    Rumination: Predisposing Psychosocial
•   Lack of stimulation
•   Neglect
•   Stressful life situations
•   Problems in parent-child relationships
  307.59 Feeding Disorder of Infancy or
            Early Childhood
• Characterized by a persistent failure to eat
  adequately, failure to gain weight, or
  significant weight loss over 1 month
• No other medical conditions that could be
  source of feeding disturbance
• Onset must be before age 6 and not due to
  other mental disorder
             Associated Features
• Infants may be more irritable and difficult to console
  during feedings, apathetic, withdrawn, and may
  exhibit developmental delays
• Parental psychopathology, child abuse or neglect
  may be present
• Parent-child interaction problems: parent perceiving
  child’s refusal of food as an act of aggression or
• Inadequate caloric intake
      Associated Medical findings

• Sometimes malnutrition may be life
• This diagnosis is recommended if the
  symptoms decrease when the caregiver’s are
Post Traumatic Food Disorder of Infancy
       & Early Childhood (PTFD)
1. The infant demonstrates food refusal after a
   traumatic even or repeated traumatic
   events to the oropharynx or esophagus
   (e.g. chocking, severe gagging, vomiting,
   reflux, insertion of nasogastric or
   endotracheal tubes, suctioning, force
 Post Traumatic Food Disorder of Infancy
        & Early Childhood (PTFD)
2. The event (or events) triggered intense
    distress in the infant
3. The infant experiences distress anticipating
    feedings (e.g. when positioned for feeding,
    when shown the bottle or feeding utensils,
    and/or when approached with food)
Post Traumatic Food Disorder of Infancy
       & Early Childhood (PTFD)
4. The infant resists feedings and becomes
    increasingly distressed when force-fed

     - Chatoor,2001
• Of all pediatric hospital admissions, 1-5% are
  for Failure to Thrive, an estimated half of
  those cases are due to Feeding Disorder of
  Infancy or Early Childhood
• More understanding development of feeding
  disorders in infancy and early childhood is
  necessary to appropriately diagnose and
                    PTFD – MH
• Neglect
  – Physical
     • Starvation
  – Emotional
     • Insecure Attachment/Dysregulation
• Abuse
  – Physical
     • Physical harm oral, GI system
                   PTFD – MH
• Food behaviors in the abuse victim can
  include refusing to eat or holding food in the
  mouth but refusing to swallow, gulping down
  food, scavenging, stealing and hoarding.
  Victims of abuse commonly attach more
  emotional than physical significance to food
     • Recognition of Child abuse for the Mandated
           » Giardino et al.2002
                     PTFD – MH
• Abuse
  – Sexual
     • Oral penetration
     • Stuffing objects in mouth

  – Childhood sexual abuse is significantly related to
    adolescent and adult self-harm, including suicide
    attempts, cutting, and self-starving.
                                   Van der Kolk et al, 1991
                PTFD – MH

• Medical Conditions
  – Reflux
  – Craniofacial Anomalies
  – GI related illnesses
      Prevalence - Abuse in Infancy

• First national study of infant Abuse/Neglect
• About 1 in 50 U.S. infants are victims of
  nonfatal child abuse or neglect in a year

  –    Rebecca Leeb, Centers for Disease Control and Prevention,
 Prevalence – Infant/Toddler Abuse

• More than a quarter of a million children from
  birth to 3 years experienced substantial
  cases of abuse or neglect
  and thereby entered the
   child welfare system
                    (DHHS, 2008)
       Prevalence: Sexual Abuse

• 1/4th to 1/3rd of all children and as
  many as 42% of girls are sexually
  abused before age 18. Males are
          Saunders et al, 1992; Randall 1995
Nearly 80% of children in
     foster care have
  prenatal exposure to
   maternal substance
Zero To Three April/May 2002 Dicker, S & Gordon, E. Page 28
    Feeding & Substance Exposure

• Much concern surrounds the subsequent
  physical health of infants exposed to drugs in
• A number of studies have cited the link
  between prenatal drug use and adverse
  physiological outcomes including abnormal
  sleep-wake patterns, poor feeding, tremors,
  and hypertonia (Oro & Dixon, 1987).
     Substance abuse
  contributes to 75% of
 incidence of child abuse
and neglect of children in
        foster care
No Safe Haven: Children of Substance Abusing Parents, National
 Center on Addiction and Substance Abuse (CASA) at Columbia
                   University, January 1999
           Food & Trauma: Etiology in
• Failure to thrive
   – Organic
      • Medical condition or trauma
   – Non-organic
      • Environment
           – Caregiving
           – Physical
• Reflux
   – Higher rate of ‘bonding’ concerns
   – Higher rates among substance exposed infants
        Food & Trauma: Etiology in
• Starvation
  – Not Stealing – Hoarding
  – Eating of non-nutritive substances – e.g. feces
  – Eating out of trash can
     • Not behavioral/survival templates
• Poor nutrition
  – Attention/focus difficulties
         Food & Trauma: Etiology in
• Ingestion of toxins
   – Drink lye ( in soda
   – Eat pills (ecstasy)
   – Breastfeeding (meth)
        Food & Trauma: Etiology in
• Obesity
  – Over-feeding
     • Bottle propping
  – Emotional Eating

• Allergies
  – Stress & the adrenals
      Food & Trauma: Infant/Toddler
• Understanding the etiologies and mental
  health components of the concerns related to
  food and feeding can be of significant impact
  in intervention and outcome.
• Multi discipline efforts are best suited for
  these concerns.
    Attachment Based Co-Treatments
•   Occupational Therapy
•   Speech Therapy
•   Mental Health Therapy
•   In combination best way to address these
    complex food and trauma related concerns
    – Approach physical, motor and emotional
    – Must be done in context of caregiving
     Food/Trauma & Relationships
• Access to neuronal network change – ie
  behavior change
• Abuse destroys relationships (food trauma) –
 Healthy relationships destroy abuse (healthier
 FTT & Trauma: Attachment Intervention

• The issue of ‘neglect’ if ignored in FTT can
  result in years of medical treatment and
• After 4 years of tests, procedures, special
  diets, surgeries and tube feeding… still didn’t
  realize that the baby needed to be held,
  rocked, played with and physically
        – Based on “Laura” story Perry, The Boy who was raised as
          a dog.
    Taking care of baby means taking care of
          parent: Treat the relationship

• Teach caregiver how to interact with child
   – To encourage bonding & responsivity
   – To improve parent success in addressing child’s
     developmental level & emotional needs
• Provide positive verbal comments
   – Link mother to baby “see, s/he knows who her
     mother is”, “wow, s/he looks so comfortable with

The single most important component
of a child’s healthy development is the
presence of an enduring adult
caregiving relationship
              From Neurons to Neighborhoods
                    (Shonkoff & Phillips, 2000)
    Nursing Child Assessment Satellite
            Training (NCAST)
• NCAFS – Nursing Child Assessment Feeding
• Barnard Model – Parent Child Interaction
  – Interaction is influenced by characteristics of
    the caregiver and the infant
  Intervening with NCAST Concepts

• Contingency
  – Contingent communication
    • Speak – other listens
    • Disengage – other gives space
  – Teaching loop
    • Alert – Instruct – Performance - Feedback
  Intervening with NCAST Concepts

• Positioning
  – Sensitivity to child’s needs
     • Developmentally appropriate
  – Promotion of face to face
  Intervening with NCAST Concepts

• Verbalness
  – Talking/singing to infant
     • Influences outcomes
        – Attention
        – Social Emotional Growth
   Intervening with NCAST Concepts
• Sensitivity
   – The act of monitoring and responding
   – Watching for and appropriate changes in response to

   – Caregiver should provide the regulation for 1st 4
   – Infant/child ‘directed’ interactions/play only after 4
     months when self-regulation has occurred.
  Intervening with NCAST Concepts

• Affect
  – Expression of emotions, demeanor, feelings
     • By both mother and infant

  – Emphasizes the importance of positive affect
    interchange in health and security
  Intervening with NCAST Concepts

• Engagement/Disengagement
  – The process of regulating attention
    • Communicating comfort or distress
        Food & Trauma: Summary
• Unique features of food concerns in the traumatized
  young child not commonly found in other
  infant/toddler populations.
• The collaboration of disciplines is necessary to best
  identify and meet the needs of this population.
• With collaboration among disciplines a stronger
  focus is possible for developing & enhancing
  effective intervention and improving outcome
       Food & Trauma: Summary

• Collaborative disciplines which includes a
  mental health perspective to address the
  food related concerns in the young child with
  a trauma history offers the necessary multi-
  pronged approach to addressing the needs of
  our vulnerable children and changing the
  trajectory of their lives.

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