Name: Poor Eaters
ISBN: 9780786730773

By Joel Macht, PhD

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Finally a comprehensive guide has arrived for frustrated parents who have trouble feeding their children. Dr. Macht, a respected educational psychologist, has originated strategies that have achieved remarkable results in getting children to eat right. Dr. Macht cuts to the root of the dilemma and emphasizes the relationship between a child’s total family environment and his eating disorder. The individuality of each child is an important factor in assessing the most suitable approach for dealing with food refusal. This valuable book constitutes a major breakthrough for parents, physicians, and educators alike. It offers parents a hoped-for reprieve from the battle that often takes place at the kitchen table, But most of all, it will change the lives of countless children who will finally learn to appreciate and enjoy the benefits of healthy eating.

Poor Eaters

Helping Children
Who Refuse to Eat

Poor Eaters

Helping Children
Who Refuse to Eat

Joel Macht, Ph.D.

Foreword by
Edward Goldson, M.D.
and
Sharon Felber Taylor, M.D.

Many of the designations used by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book and Da Capo Press was aware of a trademark claim, the designations have been printed in initial capital letters.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Printed in the United States of America.

Library of Congress Cataloging-in-Publication Data is available.

ISBN-10: 0-7382-0826-4 ISBN-13: 978-0-7382-0826-8

eBook ISBN: 9780786730773

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First paperback printing, August 2002

For Don Wallin (aka Uncle Otto), who got all of this started,
and
Jack Burton, who was the first to say “Yes”

Foreword

Food refusal on the part of children has been an issue that has bothered parents and clinicians for generations. How often has one heard, “Why won’t Johnny eat and gain weight?” Similarly, “Why won’t he try something new without creating such a fuss?” The factors contributing to food refusal are often complicated, often difficult to understand; the answers to such frustrating questions often difficult to come by. What is clear, however, is that on occasion, children’s food refusal can have many profound effects, including failure to gain weight and to thrive. It is somewhat unclear how prevalent food refusal is. We do know that approximately 1 to 5% of admissions to hospital pediatric wards are for the evaluation and treatment of failure to thrive. Food refusal as a contributing factor leading to failure to thrive, inadequate weight gain, and nutritional imbalance must be included in these figures. Food refusal, total or partial, can become an unpleasant focal point for family dynamics, assuming a disproportionate role in terms of both interactive time and energy.

General food refusal and failure to thrive as a clinical entity has been of concern to child-care providers for centuries. It was described among the poor in New York City in the 1890s, as well as in infants in foreign institutions, and then again in orphanages in the United States. Failure to thrive specifically, often presenting itself acutely, has been associated with extreme social deprivation, with underlying organic pathology, and with individual childhood characteristics and developmental stages. Conversely, food refusal in general, progressing gradually, often appears unassociated with anything out of the ordinary.

As is likely apparent, children’s growth and weight gain are dependent on the amount and type of nutritional intake, how much of the nutrients they are able to absorb, and how much they lose. If the demand for nutrients exceeds the supply, the child will not gain weight. Thus, when a child refuses to eat, he may not meet his metabolic requirements and so will not gain weight. The absence of weight gain can be of concern for the premature infant as well as the full-term child who has long since taken his first step. Regarding the former infants, as our medical technology advances, we are becoming increasingly expert at guaranteeing the survival and growth of tiny, premature newborns and children who show a multitude of intestinal problems. With the more frequent use of subsidized feedings (intravenous nutritional support and specialized tube feedings), we are able to bypass temporarily many problems involving weight-related difficulties. However, the use of these subsidized feeding programs often has created its own set of problems: we have seen the rise of significant feeding behavior difficulties and food refusal based on delayed oral feedings, and alteration in the natural learning processes surrounding eating by mouth. At the same time, the full-term, normally developing child can manifest food-refusal problems that can be as disconcerting to parent and professional alike. As a result of our heightened emphasis on nutrition early in childhood with all its impact on health and development in years to come, it is becoming increasingly common for physicians and nutritionists to meet highly verbal children who have developed their own set of eating quirks that can often push parental patience to its limits. It appears that food refusal has spread its presence across many ages and social and educational boundaries.

Dr. Macht, in this delightful and informative book, has focused on the child who either refuses to eat or eats only the most limited of foods. He presents in a very forthright, practical manner an approach to addressing the problems of food refusal. Each child is different and, therefore, must be approached individually. But central to Dr. Macht’s approach, and thus relevant for all food-refusal children, are the questions, “What is the meaning of the child’s food-refusal behavior?” “What is the child trying to tell us through her refusal to eat?” He presents a structured, logical approach to identifying the problem and thereby treating it. Dr. Macht’s evaluation and treatment of these children with eating problems have been developed through the application of child psychology techniques as well as keen insight into the triggers for the child’s undesired feeding behaviors. He works closely with other members of the child’s medical team; indeed, Dr. Macht emphasizes the importance of a thorough evaluation for medical or organic causes of food refusal prior to initiation of this or any feeding behavior program.

At our institution, this team approach may involve not only the child’s primary physician but also may include more specific evaluation by a pediatric gastroenterologist or developmental specialist. Strict attention must be paid to the child’s ability to swallow food without risk of causing choking or passage of food into the airways. Often the speech and/or occupational therapist will perform a formal evaluation of the child’s swallowing mechanism utilizing radiologic techniques. Other suspected anatomical or metabolic abnormalities may require X-ray or laboratory studies. Dr. Macht always institutes his eating behavioral programs only after medical clearance from these health care providers. His success frequently hinges on the flexibility of feeding schedules often necessary in the children, with attention not only to their nutritional needs but also to their fluid requirements and to the child’s individual ability to succeed at her own pace.

In this book, Dr. Macht addresses a multiplicity of issues in dealing with food refusal, including understanding and coping with avoidance behaviors, dealing with noncompliance, and, finally, trust. Ways of brainstorming problems are presented and the entire book is laced with relevant case histories. This work does not purport to provide the answers for all food-refusing children, but it serves as an excellent introduction and guide to approaching this difficult issue. The management of such children is really an art. In our experience, Dr. Macht has mastered the art, and in this provocative book he is attempting to pass on some of his knowledge. This book is well worth our attention.

Edward Goldson, M.D.
Child Developmentalist
Associate Professor
Department of Pediatrics
University of Colorado Health and Sciences Center
and The Children’s Hospital
Denver, Colorado

Sharon Felber Taylor, M.D.
Pediatric Gastroenterology and Nutrition
Associate Professor
Department of Pediatrics
University of Colorado Health and Sciences Center
and The Children’s Hospital
Denver, Colorado

Preface

This book was designed to serve as a reference source for parents who are experiencing difficulties with their children’s eating behaviors, as well as for professionals who have assumed the responsibility for guiding those children toward more healthy eating habits.

Before looking directly at the process that will hopefully offer successful solutions to the problems you are facing, I have chosen first to discuss why something so apparently natural as a child’s eating might abruptly stop or radically change. To that end, the initial chapters, in addition to offering some needed precautions, will show you how a child’s total environment (including the child’s unique physiology, as well as family dynamics) has the power to influence eating behaviors. The early discussion and its continuation throughout the manuscript will help you understand what factors may be responsible for the child’s eating difficulties. At the same time, and very importantly, the book does not concentrate solely on the issue of speculating “why” a child’s eating has become unsatisfactory. The book is highly practical. From its earliest words, it builds upon what may be responsible for the child’s behavior and moves swiftly toward the major concern of dealing with helping the child eat more successfully.

Perhaps the book’s most helpful component rests within its provided cases. The cases lead you through various subtleties of the process that yield alternative ways of working with your child. As you read the cases, notice that despite the described uniqueness of each circumstance, there exist many commonalities relating to the children’s behaviors, as well as the actions and interactions of their environments. These similarities have allowed me to format the book in such a fashion as to provide ideas for remediation regardless of the child’s age or verbal skills.

The book’s “attitude” is purposely positive. I recognize there is an excellent chance that you have experienced considerable stress associated with your child’s eating behaviors. With that understanding, allow me to share the following. Eating, fortunately, is a behavior that can carry its own rewards. Children, fortunately, are adaptive individuals who can learn how to gain access to those rewards. Those two facts, and the successes that will be described, are sufficient grounds for you to allow yourself a sense of optimism.

While my name appears as author, please recognize that the present book came about as a result of many people’s efforts. I would have accomplished little without the assistance, support, and brains of the nurses, physicians, and therapists at The Children’s Hospital in Denver. The book would not have been as readable without the assistance, support, and brains of Plenum’s Linda Greenspan Regan and my own “Schluzers.” And the joy that comes from spending megahours doing precisely what you want to do would not have been possible without the beautiful children and their families. A warm hug to you all.

Joel Macht

CHAPTER ONE

Special Little Kids,
Special Big Eating Problems

Parents face many perplexing difficulties as they set about to nurture and guide their newborn toward all the promises life has to offer. Most of us with children are fortunate in that the problems we encounter are quickly remediated, quickly forgotten. They are problems that occupy the smallest percentage of daily time; problems that, upon surfacing, do produce their share of anxiety and apprehension, but problems, nonetheless, that rarely record lasting impressions. Some parents, conversely, are faced with an issue often overwhelming, often unwilling to quietly slip away: they have a child who, for any number of reasons, either fails to consume enough calories and/or liquids to sustain health, eats so selectively that concerns over nutrition are constantly raised, or fights vociferously to avoid new foods or finish some of the food provided before raiding the cookie jar. Feeding, which should be a pleasant, loving interchange between parent and child, becomes a constant source of stress for both parties involved. The impressions experienced by both parent and child, fueled by daily, perhaps hourly, confrontations, can begin to weaken the strongest of family bonds.

Introduction

Over the past several years, I have worked with over 200 children designated as partial or total food refusers, many carrying the descriptive label of “failure to thrive,” others simply “picky” eaters, ranging from near birth to 8 years of age and predominantly from the Denver metropolitan area. I am an educational psychologist at the University of Denver. I have served (and presently serve) as a consultant to a wide variety of educational systems, sheltered workshops, community living facilities, and hospitals that have accepted responsibility for an equally varied group of individuals. Admittedly, 4 years prior to this writing, I had little knowledge of young children who rejected food. That children refused to eat, or ate so sparingly that their lives were in danger, was foreign to me. I had worked with many very difficult children over the years, but none that persistently thrashed and threw tantrums, clenched teeth, or volitionally gagged or vomited when faced with the prospects of eating or drinking. My baptism into the world of these children came quite unexpectedly. It occurred late one spring day.

I had just completed an informal behavior management inservice to teachers and parents of handicapped children who were being assisted by a special school that was funded and staffed cooperatively by several local school districts. The small audience was gradually dispersing when a young woman approached me. I greeted her with an outstretched hand that ended hanging in midair. She had something on her mind besides a reciprocal greeting. With a look suggesting her patience had run out, that she was disappointed in my presentation, she said simply, pointedly, “You guys talk a lot, but you don’t do nothing.” Taken somewhat off guard, I fumbled with an apology in behalf of myself and my colleagues and asked her to describe the problem she was facing. “I have a child who won’t eat,” she answered dispassionately. While I do not recall my precise words, I indicated, supportively, that such was not possible. “He doesn’t eat,” she repeated dryly.

“Not at all?” I asked with disbelief, my eyebrows raising with the tone of my voice.

“No.”

“But he must eat something,” I answered naively.

“He’s had a gastrostomy.”

“Oh,” I said, having no idea what she meant and trying desperately to etch the term in my head so I could find it in the dictionary when I returned to my office. “Does he attend this school?” I asked, pointing in the air.

“He’s in the next room,” she answered. I was led into a large, brightly lit classroom; the child’s mother nodded in the direction of her son who was sitting in a chair looking away from us. A teacher sat in front of him with an opened picture book of animals. While she described the pictures, another professional sat directly behind the child, holding a spoon filled with pureed food. When the teacher indicated, by a slight movement of her head, that the seated child’s mouth was open, the second woman brought the filled spoon from around the back of the child and, with lightning speed, shoved the utensil into his mouth. I watched the child for several minutes as he endured the feeding procedures. Sometimes he would spit the food from his mouth, sometimes thrash his arms as though fighting an invisible enemy, and sometimes swallow, reluctantly, what had suddenly found its way onto his tongue. I simply stood and stared. For a few moments I was uncharacteristically speechless. When the session ended, the child was handed the book, and the teacher made her way over to where Mom and I were standing. “How’d he do?” the mother asked.

“Fine,” the teacher answered with some enthusiasm. She turned to me: “Would you like to meet him?” I nodded, still numb.

I met him, of course, but I also met, for the first time, the narrow tube that seemed to be growing from his stomach. I stared at the cylindrical, flexible pipe, quietly wondering how anyone could stuff food into its small opening. Without asking any questions, thus nakedly exposing my gross ignorance, I knew I had much homework to do. When I returned to the child’s mother, I offered my assistance, somehow believing that helping a child eat shouldn’t be too difficult. (I also knew I could develop a better program than what I had just witnessed.) A day was established where I would meet with this child in his home.

After spending some 4 hours spaced over a consecutive 2-day period, working with the child mostly in his home’s kitchen and living room, the youngster gradually responded to what I was doing and became more receptive to the pureed food I presented him. His mother was ecstatic, sharing emotions that had remained protectively hidden just below the level of her expression. I accepted her appreciation while being thankful that she hadn’t pushed me to describe precisely what I had done. In general terms, I shared some suggestions about maintaining his behavior and asked her to call me after the dinner feeding. The evening phone call indicated that the child had continued eating successfully. Toward the end of our conversation, she asked if I would be willing to meet with a few of her friends from a support group to discuss my approach. I agreed to do so, acknowledging to myself alone that I had no approach. A week later, I drove to the designated address and was led through the house toward a backyard where I was introduced to the woman’s “few’ friends. Some 40 adults were seated in a semicircle. Many held children in their laps. Other children were playing near a swing set. A few of the adults were trying to feed their very young children. I sat for a moment to catch both my breath and thoughts. A pretty, blonde-haired child, about 6 years old, strode toward me, carrying a vanilla ice-cream cone in her hand. She stared at me while quietly licking the ice cream. I gaped at the visible tube that hung from her stomach. After a few moments of silence, during which I tried to reconcile the proximity of the ice cream cone and pendulous rubber piping, I pointed toward the cylinder and politely asked her, “What’s that?”

“That’s my stomach tube,” she replied.

“What do you do with it?” I softly questioned, as though I were still ignorant of its use.

She looked at me as if I had lived my life in a far-off cave. “That’s where I eat, you silly,” she replied with a roller coaster intonation that ran the length of two octaves. Then, after a sizable lick of ice cream and just before ambling away to join some of the other children, she expelled a puff of air through her nostrils as a supreme sign of exasperation. I smiled, shook my head, and knew my professional world would never be quite the same.

Based upon the number of calls and contacts I’ve received from outside the state of Colorado, it is evident that problems associated with feeding the young child are indeed widespread. Remediating the difficulties has drawn the attention of a wide variety of professionals, including speech and language therapists, occupational therapists, nurses, physicians, and psychologists, like myself. As most of us have discovered, each child seen has provided more ideas about how best to deal with the pressing problem of helping youngsters acquire, or once again manifest, acceptable eating behavior. To that end, I have tried to place on paper the experiences I have encountered, along with the lessons the very special children have taught me.

Reference versus Recipe

From the beginning, I must express some apprehension about sharing my observations, thoughts, and ideas about how to assist the child who is either not eating or eating insufficiently. A visit to any bookstore will verify that “How-To” manuals, covering the most diverse areas, are among the most popularly read works. Having written a few myself and having been engaged in an occasionally heated discussion about the relevance and worth of the printed material, I recognize how easy it is for suggestions to be interpreted as simple recipes for fixing inordinately complex issues. The previous subject areas that garnered my attention and writing, however, represented theoretical or practical issues that in themselves were not capable of placing anyone, including the reader, in jeopardy. The topics and subsequent interpretations and suggestions reflected positions of a practicing consultant (zealously presented I might add), but positions that regardless of the reader’s adherence or opposition to were not capable of making matters worse. Such a luxury allowed for an admitted enjoyable sense of casualness as those topics were broached.

An Honest Sense of Caution

But there is nothing even remotely resembling such casualness with this present topic. Suggestions offered to remediate the difficulties associated with insufficient eating, misused or misinterpreted, can take an already fragile child and threaten his very safety. Therefore, please note that much of the following material is intended to serve as reference. It is not intended as a recipe equally effective with each individual child. It is intended to offer ideas to consider during a planning phase, well before hands-on remediation has begun. Additionally, it is not intended to be used without the knowledge and supervision of your family physician. In fact, you should not undertake any remediation with your child’s feeding difficulties until your family physician has first been contacted.

The Child Establishes Remediation

An interesting note regarding my experiences with remediation associated with eating difficulties: Prior to meeting with the individual child, regardless of what history I have in hand, regardless of what information I have received about his present eating behavior, I never know precisely how I will approach the youngster until I have spent time with him, watching and noting many issues that I will soon share with you. Said succinctly, it is the child who tells me what methods to use. The child tells me which approach best suits her past history, her present experiences, and her overall uniqueness. If there is a recipe to be written, it is the child who writes and communicates it. By watching and listening carefully to what the child’s behavior is “saying,” a viable method to help her becomes more likely.

Don’t Jump at an Idea

Because no “cookbook” is available to specify the steps we should follow to help a child willingly consume more calories or try new foods, I would urge you to take note of the following request. In conjunction with having your child evaluated by the family’s physician, read the entire book before altering your present approach to feeding or initiating a new approach. It is essential that nothing different be done while you are finishing this brief book. A new program with fresh ideas and approaches, often administered in a new situation, often provided by new, neutral people, frequently holds the most promise for success. I will introduce and discuss at length the positive quality this concept of neutrality has regarding your remediation program. For the moment, know that you can quickly lose the advantage of neutrality if you start a new program prior to considering several essential ideas. If you eagerly jump at a presented idea because it sounds good, before hearing of associated qualifications and cautions, and you aren’t lucky, you will probably find yourself and your child a step below square one.

Population to Be Addressed

It is important to note that the population of children this work addresses is limited to those youngsters who, at the time a formal remedial feeding program is to be undertaken, manifest no physical problems that might interfere with oral (known as “per oral,” or “po”) feeding. Eating by mouth must not produce physical discomfort for the child. Before I begin assisting a youngster, I enlist the help of the attending physicians, nurses, speech therapists, and occupational therapists to ascertain that the youngster’s swallowing mechanisms and gastrointestinal tract are functioning within normal limits. A health and eating history are carefully documented to ascertain:

Whether the child has ever experienced choking or gagging when eating;
Whether the child has ever turned purple (as a result of oxygen loss) during eating;
Whether a suspicious number of bouts with pneumonia, sinus, or respiratory difficulties have been experienced by the youngster;