The Feeding Relationship with Infants and Toddlers

1. The Feeding Relationship with Infants and Toddlers Kathryn Seidler, MSW, LCSW Easter Seals Blake Foundation kseidler@blakefoundation.org September 29, 2009

2. A baby alone does not exist. A baby can be understood only as part of a relationship.D.W. Winnicott

3. Periods of Development • Prenatal: conception to birth • Infancy &Toddlerhood: birth to 2 yrs • Early Childhood: 2-6 yrs

4. Definition of Early Childhood Mental Health Two views: • Individual child’s development (Zero to Three, 2002) • Systems context (Knitzer, 2002)

5. Developmental Definition of ECMH • The social, emotional and behavioral well being of infants, toddlers, young children, and their families • The developing capacity to experience, regulate, and express emotion • The ability to form close secure relationships • The capacity to explore the environment and learn (Zero to Three, 2002)

6. Systems or Service Delivery Definition of ECMH • Promote the emotional and behavioral well-being of all young children • Strengthen the emotional and behavioral well-being of children whose development is compromised by environmental or biological risk in order to minimize risks and enhance the likelihood that they will enter school with appropriate skills • Help families of young children address whatever barriers they face to ensure that their children’s emotional development is not compromised (Perry, Kaufmann, & Knitzer, 2007)

7. Systems or Service Delivery Definition of ECMH • Expand the competencies of nonfamilial caregivers and others to promote the well being of young children and families, especially those at risk by virtue of environmental or biological factors • Ensure that young children experiencing clearing atypical emotional and behavioral development and their families have access to needed services and supports (Perry, Kaufmann, &Knitzer, 2007)

8. Ecological Systems Theory(Bronfenbrennar, 1979)

9. CORE CONCEPTSOF EARLY CHILDHOOD MENTAL HEALTH 1. Early Childhood Mental Health is first and foremost about RELATIONSHIPS

10. 2. We cannot conceive or consider infants and toddlers outside of the relationships they have with their primary caregivers

11. 3. Mental health needs of the 0-6 age population challenge and defy our conventional, individual-based thinking about providing therapy

12. 4. internalization of the caregiver occurs within the child’s psyche as a mental representation about self and caregiver, based on the relationship and interactions that occur -Mahler’s Object Relations Theory 5. Early childhood mental health is understood as a model that is developmental

13. Attachment Theory (Cassidy and Shaver, 2008) • ATTACHMENT: the orientation of an infant to the person(s) who meets their biological, emotional, and social needs • BONDING: the ability of a parent or caretaker to make an emotional commitment to meet the infant’s needs

14. Ainsworth’s “Strange Situation” Experiment • Separation/Reunion of primary caregiver and child (12 months or older) • From careful analysis of the reunion behaviors of the infant when the mother enters the room four kinds of attachment patterns have been noted

15. Attachment Classificationsin North American Babies(Ainsworth, 1954; Main and Cassidy, 1988 ) • Secure (65%) • Insecure/Ambivalent (10-15%) • Insecure/Avoidant (20%) • Disorganized (5%)

16. What do these Attachment Relationships look like? 1. Secure (B) • Infant uses parent as a secure base to explore environment and re-engages the parent upon reunion (separation/reunion task)

17. 2. Avoidant Attachment (A) • Infant does NOT use the parent as a secure base; displays little affect • explores the environment, but does not seek parent upon reunion • Under stress, infant does not seek out parent for contact-comfort to reduce stress.

18. 3. Ambivalent or Resistant (C) • Infant is in a state of distress and fails to explore the environment • Infant will alternate between seeking contact with the parent and rejecting the parent • Infant is under high states of stress on a continuous basis

19. 4. Disorganized (D) • Infant behavior lacks an observable goal, intention, or explanation in the presence of the parent. • Infant exhibits interrupted movement, stereotypies (repetitive behaviors), freezing/smiling, falling, and odd postures upon reunion with the parent. • no coherent strategy to re-engage the parent. • Parent is considered, at times, to be frightening toward the infant, and parent frequently has a history of abuse of unresolved loss.

20. Variables that can impact the attachment process • Postpartum emotional health of the mother • Prior mental health history, esp. in the areas of mood disorders • Lack of social support in the home • Unlimited emotional parenting skills by the parent • Infant development status (delays) and/or prematurity or medical problems of the infant • Changes in the parents’ relationship • Other losses experienced by the mother/major caregivers

21. Mothers of the D babies are reported to often have a history of early trauma and loss in her own life

22. Attachment Stages:birth to 36 months 1. PRE-ATTACHMENT • early orientation toward voice, smell, and self-regulation from major caregiver • predictability and consistency to strengthen attachment relationship • Initial development of the Arousal/Relaxation Cycle

23. 2. Recognition and Discrimination: 3-8 months • Comparison and discrimination skills develop • stranger anxiety and “Preference for Parent” (PFP) • Exploration of environment: distance between infant and parent begins

24. 3. Active Engagement: 8-30 Months • Separation anxiety: 7-9 months • object permanence develops • secure base behaviors 13+ months • toddler learns social rules (home, childcare, public) • play skills develop

25. 4. Partnerships: 30 + months • Emotional Object Constancy develops around 36 months • Attachment to adults solidify • communication, bartering, and compromise between parent and child • attachment gives emotional foundation to explore the world in greater depth

26. Attachment Milestones and Behaviors • Eye contact/social smile • cuddle/molding • reciprocity between infant/parent • Following/searching • reaching • signaling/calling to • holding/clinging/sitting with • seeking to be picked up • stranger anxiety 5-8 months • separation anxiety 7-9 months • secure base/safe haven 9+ months • Preference for parent 7+ : Internal Working Model • Partnership 30+

27. What does attachment have to do with feeding?

28. The Feeding Relationship • “Feeding is a reciprocal relationship that depends on the abilities and characteristics of both the parent and the child.” (Satter, 2000)

29. What is the purpose of feeding? • Physical nourishment (growth and health) • Communication • Socialization • Sharing of values • Sense of family, culture, community • Celebration • Sensory Exploration • Relaxation, habit, break in routine (Morris & Klein, 2002)

30. Both the CHILD and the PARENT bring unique characteristics to what is known as the Parent-Child Relationship (PCR).

31. What happens before, during, and after a feeding will effect the PCR.

32. Therefore, the relationship before, during, and after the feeding/mealtime can greatly influence: • the intake of nourishment for the child • developing attachment relationship between the child and caregiver • the child’s social/emotional development

33. Division of Responsibility in Feeding (Satter, 2000) Parent: what, when, where Child: how much, whether

34. Influences on Mealtimes(Morris and Klein, 2002) • Child’s history, health, developmental skills • Feeding skills, oral motor, fine motor, sensory • Culture • Parental history • Parental relationship with food • Beliefs and interpretation • Family dynamics • Socioeconomic factors • Child’s emotional state • Parent’s emotional state

35. Distressed/Disturbed Feeding Relationships What can service providers do to help?

36. Multidisciplinary Team Approach • Child and Family/Primary Caretakers • Pediatrician/PCP • Feeding Specialist (OTR/SPL/PT) • Nutritionist • Early Childhood Mental Health Therapist • Other medical specialists • Other support providers

37. Early Childhood Mental Health Therapist • Interview parent(s) and caretakers • Observations of parent-child interactions • Observations of feeding (Breast, bottle, solids) • Standardized testing • NCAST Feeding Scale • Parent Child Relationship Inventory • Adult-Adolescent Parenting Inventory 2 • Parenting Stress Index

38. Child Health Assessment Model(Barnard, 1994) Interaction

39. Caregiver/Parent Characteristics Sensitivity to Cues Alleviation of Distress Providing Growth-Fostering Situations Infant/Child Characteristics Clarity of Cues Responsiveness to Caregiver The Barnard Model(Barnard, 1994)

40. NCAST Parent Child Relationship (PCI) Feeding Scale and Teaching Scale(Barnard, 1994) • Standardized, valid, reliable • Used in research extensively • Caregiver and infant learn to adapt, modify, and change their behaviors in response to one another

41. Feeding Behavior Disorders(Zero to Three, 2005) • Should be considered when child has difficulty establishing regular feeding patterns • when the child does not regulate his feeding in accordance w/physiological feelings of hunger or fullness • If these difficulties occur in the absence of hunger and/or interpersonal issues such as separation or trauma, the clinician should consider a primary feeding disorder dx

42. Feeding Behavior Disorders • diagnosis should not be used when feeding problem is primarily due to Disorders of Affect, Adjustment Disorder, or a Relationship Disorder • If organic or structural problems are present, do not use this diagnosis • Indicate the proper medical diagnosis in Axis III • However, if feeding problems persist after the organic or structural problem has been resolved FBD may be appropriate

43. Feeding Behavior Disorders 6 sub-categories 601. Feeding Disorder of State Regulation 602. Feeding disorder of Caregiver-Infant Reciprocity 603. Infantile Anorexia 604. Sensory Food Aversions 605. Feeding Disorder Associated with Concurrent Medical Condition 606. Feeding Disorder Associated with Insults to the Gastrointestinal Tract

44. Early Childhood Mental Health Interventions • Developmental guidance • Reading child’s cues • NCAST Keys to Caregiving: Feeding is More than Just Eating • Parent-child relationship therapy • Psycho-education • “Ghosts in the Nursery” • Modeling

45. Early Childhood InterventionsInfant Parent Dyadic Therapies • Child-Parent Psychotherapy (Lieberman, A. and Van Horn, P.) • Interactive Guidance (McDonough, S. from Zeanah, C.) • DIR / Floortime (Greenspan,S. and Wieder, S.) • Internal Working Models (Zeanah, C.) • Watch Wait and Wonder (Lojkasek, M.) • Circle of Security (Cooper, Hoffman, Powell, and Marvin) • Play Therapy

46. References • Barnard, K. (1994). NCAST Feeding Scale. Seattle: NCAST Publications, University of Washington, School of Nursing. • Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press. • Cassidy, J. and Shaver, P. (2008). Handbook of attachment. New York, N.Y.: Guilford Press. • Knitzer, J. (2000) Early childhood mental health services: A policy and systems perspective. In J.P. Shonkoff & S.J. Meisels (eds.), Handbook of early childhood intervention (pp 416-438). Cambridge, England: Cambridge University Press. • Morris, S. and Klein, M. (1987). Prefeeding Skills. Tucson, AZ: Communication Skill Builders.

47. 6. Perry, D., Kaufmann, R., and Knitzer, J. (2007). Social and emotional health in early childhood: building bridges between services and systems. Baltimore: Brookes.7. Satter, E. (2000). Child of mine: feeding with love and good sense. Palo Alto: Bull Publishing Company.8. Speitz, A., Johnson-Crowley, N., Sumner, G., and Barnard, K. (1990). NCAST: Keys to Caregiving. Seattle: NCAST-AVENUW.9. Sumner, G. and Spietz, A. (1994). Nursing Child Assessment Satellite Training (NCAST): Caregiver/Parent-Child Interaction Feeding Manual. Seattle: NCAST Publications, University of Washington, School of Nursing.

48. 10. ZERO TO THREE Infant Mental Health Task Force. (2002, May). Definition of infant mental health disorder. Unpublished manuscript.11. ZERO TO THREE (2005). Diganostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (Revised Ed.). Washington, D.C.: Zero to Three