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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 parent” • 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 (regulation) • It is one of the most important dyadic episodes • 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 concerns 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 Trajectory HISTORY NOW FUTURE Food Disorders - NOW • At best understood as a symptom within trauma • Little thought to etiology and role in current mental health • Not typically diagnosed – inadequate diagnostics Food Disorders - NOW • May be seen as a ‘behavioral’ problem • Not specifically addressed in treatment as trauma symptom with etiology for eating disorder – 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 Childhood 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 reflux) • 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 regurgitation • 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 Factors • 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 rejection • Inadequate caloric intake Associated Medical findings • Sometimes malnutrition may be life threatening • This diagnosis is recommended if the symptoms decrease when the caregiver’s are changed 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 feeding) 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 DSM-IV • 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 intervene 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 Reporter » 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, 2008. 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 underreported. Saunders et al, 1992; Randall 1995 Nearly 80% of children in foster care have prenatal exposure to maternal substance abuse. 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 utero. • 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 Infants/Toddlers • 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 Infants/Toddlers • 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 Infants/Toddlers • Ingestion of toxins – Drink lye ( in soda bottle) – Eat pills (ecstasy) – Breastfeeding (meth) Food & Trauma: Etiology in Infants/Toddlers • Obesity – Over-feeding • Bottle propping – Emotional Eating • Allergies – Stress & the adrenals Food & Trauma: Infant/Toddler Interventions • 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 factors – Must be done in context of caregiving relationship Food/Trauma & Relationships • Access to neuronal network change – ie behavior change • Abuse destroys relationships (food trauma) – Healthy relationships destroy abuse (healthier development) FTT & Trauma: Attachment Intervention • The issue of ‘neglect’ if ignored in FTT can result in years of medical treatment and assessment • 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 nurtured.. – 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 you” • 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 Scale • Barnard Model – Parent Child Interaction Model – 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 cues – Caregiver should provide the regulation for 1st 4 months… – 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 potential. 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.
"When Mother and Child are Apart"