Month: March 2021

  • Supporting Feeding Challenges in Young Children through Occupational Therapy and Infant Mental Health Interventions

    Supporting Feeding Challenges in Young Children through Occupational Therapy and Infant Mental Health Interventions

     

    In the 10 years I’ve been an Infant Mental Health clinician, picky eating habits in children top the list of things families come looking for support in. “My kid only eats mac and cheese” or “He won’t eat a vegetable” are common phrases heard at an initial intake appointment. I’ve often wondered:  What is picky eating? Is it behavioral/emotional, relational, medical, sensory or environmental? The answer I’ve discovered upon working with an Occupational Therapist (OT) for the past five years: All of the above. 

    Research has shown that children with feeding challenges generally have more difficult temperaments, which leads to relationship conflicts and a lack of maternal confidence and competence in addressing these difficulties (Aviram et al., 2015). Through infant mental health services, a clinician can support children and families through navigating these difficult interactions, which can also address the children’s feeding challenges.  However, psychological support is just one of the many important pieces that goes into addressing this complex issue. 

    In the field of mental health, we are well aware of the ‘anger iceberg,’ the idea that anger is an emotion that tends to be easy to see — the tip of the iceberg — but with many other emotions and experiences hidden below the surface. The field of occupational therapy has a similar metaphor around feeding.

    For feeding therapy to be effective, the OT needs to take into consideration three overarching areas: the 1) psychological experiences with eating, 2) previous experiences with food/eating, and relationships with people around eating, and 3) oral motor skills and abilities to manage foods.  One or a combination of these can be the reason the child is having difficulties.  Due to the complexity of feeding, a team approach is required to have the highest level of success for overcoming challenges.

    As Infant Mental Health clinicians, it is important to understand when it is problem feeding, not just picky eating.

    As part of developmental guidance, and to be generally supportive, we may normalize picky eating, but we must also do our due diligence to help families discern when picky eating rounds the corner into problem feeding and when to refer to appropriate specialists.

    So when would it be considered problem eating? It is not uncommon for toddlers to display preferences for specific foods or refuse to try new things that are introduced. By the age of three, children should have consumed at least 20 foods, with two to three items in each food group, on a consistent basis. Below are red flags for problem feeding; it is recommended that a child be referred to an OT, or other appropriate specialists, if at least two are present. 

    • Restricted diet with little variety  
    • Cries and falls apart when presented with new foods; complete refusal 
    • Refuses entire categories of food textures or nutritional food groups 
    • Almost always eats different foods at a meal than rest of the family; often doesn’t eat with the family 
    • More than 25 steps of the 32 on the Steps to Eating Hierarchy** 
    • Consistently reported by a parent as “picky eater” across multiple well child checkups. 
    • Significant loss of previously eaten foods (as some loss can be considered typical)
    • Signs of aspiration: wet sounding voice after and during eating, sweating, sneezing, coughing, excessive amounts of saliva, etc. If any of these are present, seek medical assistance from a physician.

    If a child is exhibiting any of the above, as well as the signs/symptoms below, a referral to a speech-language pathologist or medical specialist is likely needed. 

    • Ongoing poor weight gain 
    • Ongoing choking, gagging, or coughing during meals 
    • Problems with vomiting 
    • History of traumatic choking incident 
    • Inability to transition to baby food purees by 10 months of age 
    • Inability to accept any table food solids by 12 months of age 
    • Inability to transition from breast/bottle to a cup by 16 months 
    • Has not weaned off baby foods by 16 months 
    • An infant who cries and/or arches at most meals 
    • Family is fighting about food and feeding (i.e. meals are battles)
    • Parent reports repeatedly that the child is difficult for everyone to feed 
    • Parental history of eating disorder, with a child not meeting weight goals 

    We are focusing on occupational therapy interventions for the purpose of this article; however, it is also common for speech-language pathologists to address feeding concerns, specifically as it relates to swallowing/choking/aspirating behaviors. It is important to coordinate with the child’s pediatrician to make sure referrals are made to appropriate specialists. Choking, gagging, vomiting, food coming out their nose, and aspiration during and after eating are very serious concerns and the child may need a swallow study or other assessment to check for anomalies. 

    The following case study highlights how Infant Mental Health and Occupational Therapy disciplines can work together to support the complex needs of infants and toddlers associated with picky and problem eating.  That relationships are the foundation for all successful interventions was apparent through our work together.

    Building an Alliance and Settling In

    Lindsey — Infant mental health clinician

    My work with Chloe and her family began when she was 10 months old, but the family had been involved with my organization for many years before that. Chloe lived with her mother, Sarah; father, Michael, and older brother. Chloe’s brother had been involved in the parent-infant program as a toddler and at age 5 had been diagnosed with autism. Because of that, Sarah was anxious about Chloe’s development  and she was often very uncertain of her parenting skills. Sarah told me at our initial intake, “I don’t trust myself to know what is typical for kids anymore. How could I have missed the signs with her brother for so long?” The grief that comes with an autism diagnosis is often heavy and complex, and I often found myself supporting them during my four years of work with them.  This was not the child she dreamed of having, and I needed to create space to validate her grief and to talk about the guilt she was feeling before she could move forward with possible interventions with Chloe.

    The first two years of work with the family focused a lot on developmental guidance. Sarah and Michael looked forward to the completion of Ages and Stages Questionnaires to monitor Chloe’s development. Sarah continued to be anxious about Chloe, often worried that she would also be diagnosed with autism. For much of the first year of our work together, Chloe’s development was on track. It was into the second year that I began to notice that her language skills were mildly delayed, and our interventions and parent-child focused activities became geared toward supporting her language skills. Sarah and Michael were always very open to learning new ways to support her and would eagerly try to continue the activities outside of our sessions. 

    Along with developmental guidance, emotional support was a predominant core strategy used with Chloe’s parents to encourage their confidence and competence in raising their two children. During my weekly sessions, I would frequently observe the strengths they possessed as a family and notice them out loud. It was important to point out the moments of connection, as they were often difficult for Michael and Sarah to see. I wanted them to know how important they were to their children. Along with in-the-moment commenting, I would frequently use video in our sessions to observe strengths together and build upon them. 

    Sarah especially enjoyed doing art projects with the kids, and we would often videotape these delightful moments. Both Sarah and Michael had good insights into their children’s challenges, but they often felt frustrated and sad over not being sure how to help them. I often noted out loud how much I appreciated their willingness to be vulnerable. Sarah was very playful with her children and loved going out into the community and offering them experiences she did not have growing up. Both of Chloe’s parents had complex trauma histories, and as we got into the second year of our work together, we were able to explore more of the impact those histories had on their relationship with their children, each other, and their home environment.

    The home environment was often very chaotic with little structure. The children did not have a consistent meal and bedtime routine, and we frequently focused on that during our sessions in those first two years. From the time Chloe started becoming independent in her feeding/eating, she would sit in a highchair on the floor in front of the TV. Additionally, because of her mild speech delay and observance of her brother’s challenging behavior, she frequently screamed to get her needs met. Chloe did not have a consistent meal schedule, which resulted in grazing; her family would feed her whenever she screamed. The family also did not typically eat a wide variety of foods, which limited what Chloe was offered. 

    Observation and Further Assessment

    Lindsey

    Around Chloe’s third birthday, Sarah and I started to become increasingly concerned about some of Chloe’s sensory processing issues and picky eating habits. It was something Sarah had brought to the attention of Chloe’s pediatrician on multiple occasions. Chloe frequently would scream when water was splashed in her face; she would not let her hair be brushed or washed so it was constantly matted, and she often refused to wear clothes. She had only 10 foods that she would eat, refusing to try anything new. Her food repertoire consisted of predominantly softer foods, with little variety. She would not eat foods of mixed textures (such as noodles with a meat sauce, instead the sauce had to be a plain marinara), she was very particular about meats (only cheeseburgers from McDonald’s, bologna and hot dogs), yogurt, one fruit and one vegetable. We would expect some pickiness or refusal to try some new items by the time a child is three, but we were not seeing Chloe eat many typical kid foods such as pizza, chicken nuggets, French fries, mac and cheese, etc. While she appeared to be a healthy weight (and trips to the pediatrician confirmed this), I was concerned that this would not be the case for much longer if her diet continued to be so limited. Mealtimes had consistently been a point of stress within the family at this point; Chloe frequently would have tantrums while Sarah would scream at the kids to just eat the food that was given to them. 

    Around this same time, I had hired an OT through a grant, which allowed both an OT and IMH clinician to go on home visits to work together.

    I understood many of the behavioral and relational interventions that would support Chloe’s picky eating, but I began to realize that her needs were outside of my scope of practice and that she needed more intensive intervention from a specialist.  

    I referred Chloe and family to Deb for occupational therapy. 

    I was able to be present during Deb’s initial evaluation, as well as subsequent sessions, which allowed me to gain further understanding on how treatment would look. My initial reaction while observing the evaluation was feeling almost surprised by how much Deb was aware of, and in tune with, Sarah and Chloe’s relationship. I was struck by Deb’s ability to wonder about the parent-child relationship dynamics as she explored what the family’s relationship with food itself was like. 

    Through my work with Deb, I learned ways in which I could enhance what I already knew to support Chloe and her family. Deb and I quickly collaborated on how to support making mealtimes more enjoyable for Chloe and Sarah. Once again, we were able to successfully use videotaping to observe interactions and support these everyday routines. Deb helped me think about how the stress response system and appetite are directly linked together, which we were able to bring to Sarah and Michael during our sessions. The family was receptive to the information and the perspectives Deb and I brought them. Slowly, we began to see subtle improvements and more delight during meals. 

    Collaboration and Occupational Therapy Intervention 

    Deb

    When I first met Chloe and Sarah, I noticed how Chloe was connected to and looked for her mother.  In addition, I noticed how she called for her help when Sarah left the room and not as often with her father.  During the evaluation, her mother was a strong participant and was encouraging to Chloe.  Sarah had insights into the challenges her daughter was having but did not know how to help her.  Their house had many activities and items that could support treatment, and Sarah was a willing participant in evaluation and subsequent treatment sessions. 

    When working with Chloe, it became evident quickly that she had not fully integrated her nervous system.  This was evident by how she was still having difficulties engaging with activities and tasks of a variety of textures through her hands, without having negative reactions or atypical play with them.  For example, Chloe was able to play with water through her hands but could not tolerate it splashing on her face.  Also, she was slow to play with sand and paint.  Initially, she would engage with one or two fingers for a few seconds and then over time she would add more fingers and play for longer periods.  However, even between periods of play, she would wipe her hand or hands off.  Most children at the age of three would dive in with both hands to get messy.  They would not worry about cleaning their hands or be slow to touch either sand or paint textures.  This type of engagement and play that Chloe demonstrated through her hands indicated that they were not integrated from a sensory perspective, which also meant her head and face were not as well, since the nervous system develops from feet to head.  This meant we had to focus on integrating her nervous system before we were going to see change within the areas of grooming/hygiene, bathing, and feeding.  I also had to change the environment and how some of these activities were being performed to create a new pattern since the current patterns were creating a stress response and negative reactions.  This included changing the places activities occurred, who completed them, the tools used during the activity, and interactions/relationship between the parent and child.  It also took recognizing sensory cues and learning to accept when a therapeutic break was required to then allow the task to be completed instead of just pushing through it.

    This model assists across all areas of activities of daily living.  A child will relax when you can create a secure and safe environment, which can then allow for growth and change.  In addition,

    we needed to try and create routine and expectations, which also create security and safety during tasks that children perceive as scary or that create a sense/state of anxiety.

    This was the model used for Chloe’s feeding therapy, which combined sensory integration, transcending the food hierarchy model (Steps to Eating Hierarchy) with a variety of foods, modeling, environmental modification, and parent-child interaction modification.  The sensory integration approach involved increasing exposure and tolerance to a variety of textures through her hands and slowly moving it up her arms toward her head and face, all while monitoring and respecting her interactions and need to clean up.  A play approach was used for adding foods to her very limited repertoire by first increasing tolerance for being in the environment, to breaking it up and playing with it with tools, toys, and hands, then allowing foods to progress up her body till we could get it to her mouth, and then possibly taking a bite and spitting it out.  These are activities we use to progress up the Steps to Eating Hierarchy.  It is a therapeutic approach that allows for exposure to foods at a level of tolerance that a child can manage while learning about the properties of foods without the pressure of eating while working and addressing the different properties of new foods.  It then progresses up to the mouth and eventually to eating a bit of a new food.  

    The education process around feeding is multifaceted and has many layers to create overall changes in feeding, the relationship between food and the person, the person and the environment, and the person and others within the environment, as well as changing current patterns, behaviors, and routines. For this client and her family, there was education about presentation of new foods even at the level of tolerating them in the environment or on her plate, creating a new routine around mealtimes. We worked with the family on establishing consistent times of day for eating because grazing behaviors do not promote a sense of hunger. We also wanted to encourage that at least one meal a day take place as a family. I noticed Lindsey exploring barriers to these two routines with Sarah and Michael, wanting to make sure they were as successful as possible. I could see how understood they felt by her, which led to more success and confidence in their ability to make these changes. 

    One of my top priorities was to move Chloe away from the TV, and instead to a table, in order to make food the most interesting thing happening at mealtimes.  By decreasing distractions, we were able to promote the increased speed of eating, plus being around other people eating allowed for modeling and socialization of mealtime and eating behaviors. It also gave her the opportunity to be around new foods even if they were not on her plate.  

    There was a high degree of education, as well as emotional support provided by Lindsey and me, for Sarah to try and not worry during mealtimes. Often, Sarah was so concerned about what and how much Chloe was eating that Chloe’s stress rose during meals. Ultimately, we just needed her to eat.  Kids pick up their parent’s stress and when the stress response rises it decreases appetite.  This inadvertently creates a power struggle between the parent and child because the parent becomes focused on the child’s eating and then the child just exerts more control over the situation by not eating.

    Lindsey’s knowledge of the family was integral in the development and implementation of all strategies and progress throughout the subsequent treatment sessions.  Her in-depth knowledge of the family allowed for more realistic goals to be determined and for me to gain all relevant client factors that could help and impact progress.  In addition, the relationship she had with both Chloe and Sarah created a sense of safety that allowed the client and her mother to be open to me and create progress within a very difficult area of feeding.  Feeding is so multifaceted that it took the combined skills of Lindsey and me to make a true difference.  I can impact the sensory processing, progress feeding, and create some environment and parent/child modifications, but Lindsey’s knowledge of the parent-child relationship was integral in changing those relationships to then allow the families to be available for my interventions.

    “We don’t have to do it all alone. We were never meant to.” — Brene Brown

    Lindsey

    We wish we could say that all of Chloe’s feeding concerns were addressed by the time we finished working with this family, but just as parent-child relationship work takes time, so does occupational therapy and feeding treatment. Chloe made tremendous progress from a sensory integration standpoint, and she gained three new foods that she would consistently eat, and seven foods that she progressed up the Steps to Eating Hierarchy. Depending on when children ‘fall off’ the normal developmental feeding trajectory, it can take just as long to get back on track. Our work with this family highlighted the importance of professionals working together in collaboration and that we can’t do this work alone. Deb was able to support the family, and myself, in establishing new routines and attitudes around food, which created a building block, or planting of seeds, for us to take with us into our work long after she was gone. 

    References and Resources: 

    1. Aviram et al (2015) Mealtime Dynamics in Child Feeding Disorder: The Role of Child Temperament, Parental Sense of Competence and Paternal Involvement. Journal of Pediatric Psychology, 40(1). Pp. 45-54.
    2. Growing hands-on kids. (n.d.). Retrieved from https://www.growinghandsonkids.com
    3. Kranowitz, Carol Stock. The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder. New York: A Skylight Press Book/A Perigee Book, 2005.
    4. STAR Institute (n.d.) Retrieved from https://www.spdstar.org/
    5. Toomey, Kay & Ross, Erin. (2011). SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 20. 82. 10.1044/sasd20.3.82.

    **Steps to Feeding Hierarchy:   This hierarchy represents the 32 steps it can take a person to eat one bite of a new food.  It is a sequential desensitization approach created by Dr. Kay Toomey and is an evidenced-based approach to feeding therapy. It was established with a copy-write in 1995 (and updated in 2010).  A person moves through the steps with interventions that provide them a safe environment along with the addition of other treatment strategies and theories.  The major steps within the hierarchy are as follows: tolerates, interacts with, smells, touches, tastes, and eating. There are smaller steps within those larger steps, which progress upward from “tolerates” toward “eating,” and a person can start at any level for any food.  After eating a single bite of a food, it can take up to about 30 trials of that food to determine if you like or dislike that food. 

     

  • Risk and resiliency: Failure to Thrive in the First Year of Life

    Reprinted from July-September 1997 issue

    Carol Oleksiak, Thomas M. Horner, Ph.D.

    Intervention: Carol Oleksiak

    Terry was referred to an infant mental health program located in an urban community because a children’s hospital social worker was concerned about his poor weight gain. Although he weighed 6 pounds, 7 ounces when he was born at 33 weeks, he had gained only 5 pounds during the next six months.  Terry was Jane’s fifth child. She reported that she had previously come to the hospital twice because her baby was throwing up after each feeding, and eventually had stopped eating. She tried a third time to get help for her baby at her local medical clinic, which responded by having Terry hospitalized. During his hospital stay he began to eat and gain, and he had hernia surgery. He was discharged after one week and the hospital social worker referred him to our program for home-based services. 

    As I entered this family’s home a few days after Terry was released from the hospital, I reminded myself of this mother’s many attempts to get help for her baby. It helped me to remember the IMH assumption that even in the face of difficulty the family is struggling toward health. The family was large: a single mother and her five children under the age of eight. 

    A slight, timid mother opened the door to the home, a lower flat near a busy airport. The rooms were sparsely furnished. Terry’s next sibling, a two-year-old boy, was not wearing diapers even though he was not yet potty-trained. There were only two beds; Terry’s mother, Jane, stated that she and Terry slept on the couch. There was very little evidence of books or toys. The baby appeared very thin and fragile, his belly distended. He was hypervigilant and watchful. He did not sit alone and often slid to one side when he was propped in a sitting position. However, he seemed curious about a toy that I had brought with me and, when his mother offered it to him, he reached for it, transferring it from one hand to the other. His 25-year-old mother quietly sat on the couch. 

    As I watched them, I wondered how I could begin to help them. She was so shut down and he was so frail. She finally spoke and said, “I think he has a fever.” She was worried because he had just had surgery; I was worried, too. There was no thermometer or Tylenol, so I went to the corner store and purchased some infant Tylenol drops for her. When I returned, she was giving her baby water to keep him from dehydrating. When it was time for me to go, I said, “I’ll be back tomorrow at noon to see how you and the baby are doing.”

    When I arrived the next day, Jane was waiting for me at the window. I understood her wish to have things be better for her baby and her other children, but it was clear that she would need a great deal of support. Jane was unable to accomplish the most basic caregiving tasks.

    I talked with her about becoming a team, that together we would try to understand why her baby was having trouble gaining weight.

    She was able to manage a slight smile and nodded her head. 

    The next day I took the whole family to WIC to get formula for Terry. It was a difficult visit. The appointment took a long time; the children had not eaten breakfast and were hungry. I went next door to the grocery store and bought a bag of apples. It was at this appointment that I noticed that Terry seemed to avert his gaze when I tried to talk to him. I thought it was important to ask Jane if this was something that she had also noticed. She nodded her head in agreement. As a team, we would try to understand Terry’s cues and behaviors. She smiled but said very little. 

    I felt worried about Terry’s health and scared about being able to really help this family. I watched Jane tease Terry with his bottle — offering it and then pulling it away — understanding how difficult it was for her to give him what he needed at that moment. I acknowledged her struggle, saying, “This must be so hard for you.” I repeated this many times during our work together. With recognition of her struggles, Jane began to respond more consistently to her baby.

    Two months later, at eight months old, Terry weighed 14 pounds, 6 ounces, a gain of three pounds! During this time I transported Jane and her children to all their pediatric appointments. I advocated for Jane and her children to be seen by the same pediatrician every time. We added Dr. B. to our “team.” Together, we provided the family with consistent medical care. 

    I struggled. I had so many questions. What got in the way of Jane feeding her baby? What made this baby unable to keep his formula down? Why did he vomit after almost every feeding? I observed Jane teasing the baby with the bottle and withholding his toys during play. When Terry and his mother were together, he often seemed more interested in other things. It was hard at times for Jane to get her baby to play with her. We used videotapes to understand how she and Terry were interacting with each other. 

    In the time that we worked together, I spoke often for the baby as well as for Jane and her other children. I gave support for the concrete needs of the family, e.g. diapers and formula for the baby, clothes for the children and food when they ran out. I visited at least twice per week, and more often if Jane needed to go to the clinic, WIC, the grocery store, or to visit her family. Jane began to listen to me as I talked about Terry’s development and his cues and his behaviors.

    Together we discussed what she thought her baby might be thinking or needing when we observed him. As Jane felt supported and came to trust me, she could respond to her baby’s needs. 

    At 10 months, Terry was a stronger baby. He crawled, pulled himself up on furniture, and could feed himself. He now weighed 15 pounds and showed interest in playing patty cake, could find hidden objects and liked dropping toys as a game. When Terry’s weight gain slowed, Jane agreed to keep a food chart. After eating, Terry would often cry for more food even though his belly looked very distended. We concluded that he couldn’t tell his mother when he was full. I wondered aloud that if she slowed the pace of his feedings it might allow him to feel full. She gave this a try, with positive results. 

    By Terry’s first birthday there were still concerns but also some celebrations and pleasures. He was a much happier baby. He began to communicate, using gestures and simple words. He was getting ready to walk, a much sturdier baby who now weighed 17 pounds and 2 ounces!

    One hot summer day as we sat on the porch watching the children play and eating the popsicles I had brought, Jane revealed that she had once thought Terry was going to be “slow” and only recently did she feel hopeful about him being “OK.” She felt better because he was beginning to do more things and was more responsive to her. Her baby continued to gain weight and enjoyed eating. As Terry grew more healthy and competent, Jane realized that he would survive and was in turn able to be more affectionate and attentive toward him. 

    Jane and I worked together on behalf of Terry and her other children for four years. She continues to keep in contact with me. She calls when she has questions and during Terry’s birthday month. Today he is seven years old and doing well in school. There are no significant developmental delays. After a difficult beginning, Jane and Terry have an enduring relationship with one another. 

     

    Discussion, Thomas M. Horner, Ph.D.

    Terry was referred for infant mental health services when he was 6 months old, an age at which a typical infant weighs 14-15 pounds. The presumption underlying the development of such “typical” infants, though, is that they have lived in ordinary circumstances that are conducive to their physical growth, including weight acquisition. Weight acquisition is a widely used marker of how well physical growth is proceeding in an infant. 

    At the time of the referral, however, Terry’s circumstances were not ordinary. Experienced practitioners are accustomed to the fact that many preterm infants who are born with low (but not extremely low) gestational weight “catch up.”  The point by which the actual “catch-up” will have occurred is usually in the early half of the first year following the expected full-term date. Born significantly preterm, Terry’s weight acquisition had clearly stalled. He entered the hospital, where his eating led to weight gain, and where he also underwent surgery to repair a hernia. Clearly the discharging staff at the hospital were concerned that his gains might not be sustained, and the services of the infant mental health were appropriately sought. Enter Ms. Oleksiak. 

    Ms. Oleksiak’s depiction of Terry’s living circumstances are familiar enough to those who work with slow weight acquisition in infants. Limited material means, a mother who shoulders alone the care of her children, and who is distracted by so many sociofamilial exigencies, and in whom exists a basic cautiousness about the infant mental health provider’s presence and intentions — all are evident as Ms. Oleksiak makes her initial contact. Yet the story of what follows in Ms. Oleksiak’s brief narrative is also a familiar one: the therapist’s pattern of patient observation and listening, her faith in the mother’s drive to be whole (or well, as one might put it), her implicit recognition in her approach that there is much, much more that is operating in the case than simple “failure to thrive” dynamics, and her impulse to help and assist from a perspective of partnership and alliance (Ms. Oleksiak’s “team” approach) — all are the familiar (though sometimes faith challenging!) elements of effective intervention on behalf of nutritionally compromised infants. She knows that Terry has an eating disorder, which may be only partly related to the possibility that there exists a feeding disorder as well. 

    Ms. Oleksiak’s entrance into Terry’s and his mother’s lives transformed itself from the start into a growth-augmenting process; operating from within the subjective domains of her clients, she was able to assist, advise, advocate and guide — all in the service of enhanced eating and growth. She aligned her observational stance with Terry’s in order to convey to his mother ideas as to how she might approach his troublesome eating behavior — his tendency to distract himself during eating, his reaction to her seemingly innocent but frustrating teasing with the bottle, and his general tendency to avert his gaze. Such infants frequently defeat their nutritional needs, particularly when their appetitional dynamics have been suppressed by depression, or when they are insufficient to impel nutritionally secure eating. 

    Ms. Oleksiak’s holistic approach — one that entailed involvement with the family and acting within and throughout the large sphere of events and circumstances surrounding Terry’s eating and weight acquisitions, e.g. visits with the pediatrician to recruit him to the “team” — was essential to his ability to recapture a positively accelerating weight trajectory. Her use of videotapes to bring perspectives to the eating and interactive situation was, perhaps, certainly important to the mother’s permitting Terry a greater share of the lead-taking in eating. It also contributed greatly to the mother’s being able to develop a communication/feeding framework that was more nutrition-augmenting and enhancing than existed at the outset of their work together. 

    By one year of age, Terry’s weight is said to be still quite low relative to his age-mates, but he is growing and his abilities and interests in social communication are emerging. Ms. Oleksiak is the truly wonderful facilitator of this, being the skilled accompanist, rather than the conductor, of Terry’s developmental performances and his mother’s caretaking performances. She has not taken Terry’s weight alone as an index of her, or his, or his mother’s success at life. She has dealt with an eating disorder of infancy, but she has also enhanced a realm of communicative and psychologically significant contacts he has with his mother and others. She has worked with the relationship not to undo causes of the eating disorder but to assist in their joint dealing with it and to foster its life-enhancing functions. 

    Ms. Oleksiak remained at or near their sides for four years, a continuity of care that is not only remarkable but truly exemplary. Nearly seven years after entering his life she is aware that Terry is on a secure developmental track. His weight as such is no longer the issue. He has achieved an adjustment and ability to accept life’s challenges, including those that come with being who he is, physically and otherwise. 

     

    General comments: a more general consideration on non-organic failure to thrive

    Terry is like so many infants who are born into circumstances in which their parents are distracted by many exigencies or collateral demands. These circumstances are so familiar that they frequently form the basis of an intervention that implicitly holds the mother responsible for the infant’s failure to gain weight. No doubt, there are mothers who are neglectful. But there are circumstances where the mother, distracted as she was in Terry’s case, is not responsible for her infant’s failures to gain weight adequately or at a pace that is even roughly commensurate with comparably aged infants. Such mothers often “seem” neglectful, and they are often, due to expediency, classified as such.

    As infant mental health specialists we must discipline ourselves not only to set aside presumptions as to the causes of infant failure to thrive, but also to recognize that eating in infancy is not solely a matter of someone’s simply feeding her/him. 

               I have, over the years, developed a differentiated approach to infant failure to thrive, one that distinguishes between eating and feeding. A truly infant-centered point of view requires that the infant mental health specialist acknowledge that as much as anyone feeds infants, infants eat. From the outset of their lives, eating is an active process governed not only by the appetitional dynamics of the infant, but also by the eating repertoires of behavior infants possess. This repertoire may be “skilled” insofar as the infant has the behavioral capacities to orient to and to “connect with” food, or it may be comparatively “unskilled” insofar as the infant either lacks these capacities or possesses capacities that are impaired either by circumstances or by intrinsic defect. 

    Although no one would avoid trying to link together the seeming “causes” and “effects” in an infant’s behavioral and affective adjustment, the natural tendency on our parts to construct just such linkages frequently results in our forming premature (and sometimes erroneous) judgments as to what has “gone wrong” when we encounter infants classifiable as failing to thrive. Terry’s aversion to the bottle could have been brought about by early patterns of maternal intrusiveness that “caused” him to learn to avoid the bottle, to avoid eye contact, to avoid social exchange, and the like. But it is also possible (and more likely in my experience) that Terry himself possessed inherent patterns of gaze and social communication that made him less likely to effectively organize his food orienting and food seeking behavior around and within the food-presenting contexts created by his mother.

    Why would Terry not eat when food was presented? Is it simply depression, which we know can alter appetitional urges, satisfactions, and mechanics. Or is it the condition that is causing his fever, which we know can alter appetite. Is it perhaps that the food itself is not interesting to him? Is this his mother’s “fault?” Perhaps a case can be made (whether or not correct) that Terry’s mother lacks the ability or disposition to excite his interests, or to present food in ways that satisfy his appetitional (and ultimately, his nutritional) needs. There are such parents. But is it also possible that Terry’s appetitional dynamics are intrinsically different from what we ordinarily encounter in infants who are obviously hungry and who “know what to do” to be fed. It may be that he does not feel the urgencies of hunger in a way that we quite naturally expect them to be in an infant. We are not prepared — until we have allowed such possibilities to exist — to recognize that such infants lack, or seem to lack, part or all of a hunger drive. They do not clamor for, nor do they directly seek, food, sometimes even after rather strikingly long periods of not eating. If such an infant happens to seek food when s/he is hungry, s/he may demonstrate what appears to be a very low threshold of satiety, that is, having only just begun to eat s/he may close off eating as though s/he were now “full.”

    At the core of Ms. Olkesiak’s approach to Terry was at least a tacit recognition and acceptance that Terry’s eating was just that, Terry’s eating. In other words, she allowed Terry to be Terry, while offering advice and guidance to his mother that defined her not as the cause of the eating disorder but as the one and only figure who would be instrumental in his thriving — emotionally and nutritionally — the best that he could. Ms. Oleksiak’s approach sought to bring the best from Terry’s mother without ascribing the worst in her. That Ms. Oleksiak’s assistance in these regards led to changes in how Terry’s mother presented food to him, and to changes as to how Terry’s eating was to be augmented, in no way “confirms” that the mother was the “cause” of 1) the eating dynamics themselves, or 2) Terry’s inability to gain weight at a pace commensurate with the growth charts. 

    In truth, the fact that things improved in the affective-interactive sphere, while Terry continued to gain weight at a pace far below his agemates suggests that the eating/nutritional dynamics that were operative were originally as disconnected from the affective-emotional sphere as they were connected to it. 

    This is, of course, a point that many infant mental health specialists, and many Protective Services case workers, fail to consider when dealing with infants in nutritional distress associated with failure to gain weight. Fortunately Ms. Oleksiak did not fail to consider it. 

    This is not to say that there are not instances in which maternal neglect, willful deprivation, or simple incompetent provisions of food, are operative. But it is to say that there are infants whose intrinsic patterns of eating foster an illusion that a given mother — who herself may be depressed, distracted, burdened heavily, or otherwise non-optimal in her interactive and emotionally communicative dynamics — is at fault in the matter of her infant’s failure to gain weight. Recognition of the fact that infants do have unique styles and dynamics of eating, which are in turn connected to their respective and unique appetitional-behavioral dynamics, has caused some in the field to reconsider the use of the term “feeding disorder” to describe such conditions. Increasingly clear is the fact that they are dealing in such cases with eating disorders. 

    Eating disorders are, after all, disorders of eating, and we must be careful not to quickly ascribe their roots to psychoaffective and socioaffective domains that, while crucially relevant to amelioration, are not necessarily causal. 

    In most instances, problematic eating is a transient thing, perhaps an offshoot of a serious illness or surgery, or an accompaniment of an illness, say, or the pain of an ear infection, etc. In some instances, however, problematic eating belongs to the endowed behavioral repertoire of the infant. In any of these instances, chronic problematic eating is demoralizing, and the behaviors of parenteral demoralization then arise. When the latter are first encountered by the infant mental health specialist, they form an illusion that the parent is somehow causally inattentive, or causally disruptive, to a point that she is at fault rather than at a loss as to how to overcome the impasse of the infant’s failure to gain weight. Ms. Oleksiak’s case report is a splendid example of where this illusion was not peremptory of her therapeutic assessment, planning, and intervention. 

    Failure to thrive in infancy is more than simply a challenging disorder. In the past decades, the increased rates of survivorship of extreme preterm birth generally entail to the infant not only an altered course of emerging behavioral dynamics associated with coping with impositions of early extrauterine, but adjustments associated with any number of mechanical and surgical procedures imposed in the service of keeping her/him alive. In these cases infant mental health specialists are increasingly having to confront conditions, including medical, that far exceed the knowledge traditionally directed to determining simply whether or not a given parent is “fit” enough to care for an infant. Moreover, with the widening knowledge that has accumulated in regard to the early primary ego repertoire of infants — including aspects of what is widely called temperament, but including as well aspects of infant-directed attention, social interest, and social communication — infant mental health specialists are faced with having to account more fully and in more detailed fashion for the infant’s own contribution to problems of development or adjustment. 

    But this is what makes infant mental health truly infant mental health: taking the infant’s point of view, allowing for individual and sometimes perplexing differences between infants, and, in the end, coming to the infant’s assistance in helping a given parent make things go better. 

    Can there have been a better example of this than Ms. Oleksiak’s account of her work with Terry and his mother?