Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

restriction may be relatively long-standing; however, in many cases, normal adult functioning is eventually achieved.

4-weeks-old, Jennifer’s mother had reluctantly switched her to bottle feedings because Jennifer was losing weight. Although her intake improved somewhat on bottle feedings, she gained weight very slowly and was still less than 8 pounds at 3 months of age. Since then, she had gained a minimal amount each month to main- tain a low but adequate weight. Jennifer’s mother appeared tired and described that Jennifer would drink only up to about 6 ounces at a time, or two bites of baby food, and then wiggle and cry; and refuse to continue with the feeding. But after a few hours, she might cry again as if she were hungry. However, she could not settle her into a good rhythm of feeding, and continued attempts to feed her would lead her to cry inconsolably. Jennifer’s mother described approxi- mately 10 to 15 attempts at feeding her both liquids and solids in a 24-hour period. Jennifer was reported to be an irritable and fussy infant, who cried multiple times during the day and at night, and woke her family often during the night with her crying. Jennifer’s developmental milestones such as sitting up, tracking, and making sounds were within normal limits. The observation of mother–infant interactions during feeding and play revealed that Jennifer was a very alert and wiggly baby who had difficulty sitting still. While drinking from the bottle she would kick her feet and move around, and if the bottle slipped out of her mouth, she did not try to recapture it. When eating baby foods, she was not interested and her mother had to coax her to open her mouth. This upset Jennifer, and she would start crying. Jennifer’s mother reported that she was always anxious during meals, and would try to convince Jennifer to take spoonfuls of baby food while sitting in her high chair. After repeated unsuccessful attempts of adequate feeding, Jennifer and her mother both appeared exhausted and took a break. The history and examination revealed that Jennifer was a very active and excitable baby who had difficulty keeping calm dur- ing feedings. After reviewing the videotape with the mother, the therapist explored ways in which the mother could better facilitate calming Jennifer before and during meals. Using a quiet corner in the house, and singing to Jennifer before meals resulted in Jennifer remaining more calm during meals, and she was able to drink larger amounts of milk, eat more solid foods, and waited longer between meals. This, in turn, relieved her mother’s anxiety and helped both to have calmer interactions. (Adapted by Caroly Pataki, M.D.) Treatment Most interventions for feeding disorders are aimed at optimiz- ing the interaction between the mother and infant during feed- ings and identifying any factors that can be changed to promote greater ingestion. The mother is helped to become more aware of the infant’s stamina for length of individual feedings, the infant’s biological regulation patterns, and the infant’s fatigue level with a goal of increasing the level of engagement between mother and infant during feeding. A transactional model of intervention has been proposed for infants who exhibit the “difficult” temperamental traits of emo- tional intensity, stubbornness, lack of hunger cues, and irregular eating and sleeping patterns. The treatment includes education for the parents regarding the temperamental traits of the infant, exploration of the parents’ anxieties about the infant’s nutrition, and training for the parents regarding changing their behaviors to promote internal regulation of eating in the infant. Parents are encouraged to feed the infant on a regular basis at 3- to 4-hour

Epidemiology It is estimated that between 15 percent and 35 percent of infants and young children have transient feeding difficulties. A study of restrictive eating difficulties in Swedish 9-year-olds and 12-year-olds found that restrictive eating problems were pres- ent in 0.6 percent of their sample. However, another study of avoidant eating patterns in young children in Germany, found that some degree of avoidance was present in up to 53 percent of children. Thus, avoidant eating behaviors without impairment of nutritional state or psychosocial functioning must be sepa- rated from restricted eating disturbances leading to significant functional impairment. A survey of feeding problems in nurs- ery school children revealed a prevalence of 4.8 percent with equal gender distribution. In that study, children with feeding problems exhibited more somatic complaints and mothers of affected infants exhibited increased risk of anxiety symptoms. Data from community samples estimate a prevalence of failure to thrive syndromes in approximately 3 percent of infants, with approximately half of those infants exhibiting feeding disorders. Differential Diagnosis The disorder must be differentiated from structural problems with the infants’ gastrointestinal tract that may be contribut- ing to discomfort during the feeding process. Because feeding disorders and organic causes of swallowing difficulties often coexist, it is important to rule out medical reasons for feeding difficulties. A study of videofluoroscopic evaluation of children with feeding and swallowing problems revealed that clinical evaluation was 92 percent accurate in identifying those children at increased risk of aspiration. This type of evaluation is nec- essary before psychotherapeutic interventions in cases where a medical contribution to feeding problems is suspected. Course and Prognosis Most infants with feeding disorder who are identified within the first year of life and who receive treatment do not go on to develop malnutrition, growth delay, or failure to thrive. When feeding disorders have their onset later, in children 2 to 3 years of age, growth and development can be affected when the dis- order lasts for several months. In older children, or adolescents, the feeding disorder typically interferes with social functioning, until treated. It is estimated that about 70 percent of infants who persistently refuse food in the first year of life continue to have some eating problems during childhood. Jennifer was 6 months old when she was referred for a psy- chiatric evaluation because of feeding difficulties, irritability, and poor weight gain since birth. She was small and slight, but she did not appear to be lethargic or malnourished. Her parents were college-educated, and both had pursued their professional careers until Jennifer was born. Although Jennifer was full-term and weighed 7 pounds at birth, she had been unable to be breast feed due to turning away and not ingesting enough milk. When she was