Transcript Emotional-Social Support for Young Children with Feeding

The Feeding Relationship with
Infants and Toddlers
Kathryn Seidler, MSW, LCSW
Easter Seals Blake Foundation
[email protected]
September 29, 2009
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A baby alone does not exist.
A baby can be understood only
as part of a relationship.
D.W. Winnicott
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Periods of Development
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Prenatal: conception to birth
Infancy &Toddlerhood: birth to 2 yrs
Early Childhood: 2-6 yrs
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Definition of Early Childhood
Mental Health
Two views:
1.
2.
Individual child’s development (Zero to
Three, 2002)
Systems context (Knitzer, 2002)
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Developmental Definition of
ECMH
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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)
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Systems or Service Delivery
Definition of ECMH

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Promote the emotional and behavioral wellbeing of all young children
Strengthen the emotional and behavioral wellbeing 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)
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Systems or Service Delivery
Definition of ECMH
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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)
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Ecological Systems Theory
(Bronfenbrennar, 1979)
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CORE CONCEPTS
OF EARLY CHILDHOOD
MENTAL HEALTH
1. Early Childhood Mental Health
is first and foremost about
RELATIONSHIPS
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2. We cannot conceive or
consider infants and toddlers
outside of the relationships
they have with their
primary caregivers
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3. Mental health needs of the 0-6 age
population challenge and defy our
conventional, individual-based
thinking about providing therapy
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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
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Attachment Theory
(Cassidy and Shaver, 2008)
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ATTACHMENT: the orientation of an
infant to the person(s) who meets their
biological, emotional, and social needs
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BONDING: the ability of a parent or
caretaker to make an emotional
commitment to meet the infant’s needs
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Ainsworth’s
“Strange Situation”
Experiment
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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
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Attachment Classifications
in North American Babies
(Ainsworth, 1954; Main and Cassidy, 1988 )
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Secure (65%)
Insecure/Ambivalent (10-15%)
Insecure/Avoidant (20%)
Disorganized (5%)
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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)
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2. Avoidant Attachment (A)
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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.
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3. Ambivalent or Resistant (C)
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•
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
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4. Disorganized (D)
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•
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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.
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Variables that can impact the
attachment process
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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
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Mothers of the D babies are
reported to often have a history
of early trauma and loss in her
own life
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Attachment Stages:
birth to 36 months
1. PRE-ATTACHMENT
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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
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2. Recognition and
Discrimination: 3-8 months
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Comparison and discrimination skills
develop
stranger anxiety and “Preference for
Parent” (PFP)
Exploration of environment: distance
between infant and parent begins
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3. Active Engagement:
8-30 Months
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Separation anxiety: 7-9 months
object permanence develops
secure base behaviors 13+ months
toddler learns social rules (home,
childcare, public)
play skills develop
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4. Partnerships: 30 + months
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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
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Attachment Milestones and
Behaviors
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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+
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What does attachment have to
do with feeding?
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The Feeding Relationship
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“Feeding is a reciprocal relationship that
depends on the abilities and
characteristics of both the parent and
the child.”
(Satter, 2000)
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What is the purpose of
feeding?
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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) 29
Both the CHILD and the
PARENT bring unique
characteristics to what is known
as the
Parent-Child Relationship (PCR).
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What happens before, during,
and after a feeding will effect
the PCR.
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Therefore, the relationship
before, during, and after
the feeding/mealtime can
greatly influence:
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the intake of nourishment for the child
developing attachment relationship
between the child and caregiver
the child’s social/emotional
development
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Division of Responsibility
in Feeding
(Satter, 2000)
Parent: what, when, where
Child: how much, whether
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Influences on Mealtimes
(Morris and Klein, 2002)
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Child’s history, health, developmental skills
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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
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Distressed/Disturbed Feeding
Relationships
What can service providers do to
help?
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Multidisciplinary Team
Approach
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Child and Family/Primary Caretakers
Pediatrician/PCP
Feeding Specialist (OTR/SPL/PT)
Nutritionist
Early Childhood Mental Health Therapist
Other medical specialists
Other support providers
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Early Childhood Mental Health
Therapist
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Interview parent(s) and caretakers
Observations of parent-child
interactions
Observations of feeding (Breast, bottle,
solids)
Standardized testing
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NCAST Feeding Scale
Parent Child Relationship Inventory
Adult-Adolescent Parenting Inventory 2
Parenting Stress Index
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Child Health Assessment Model
(Barnard, 1994)
Child
Temperament
Regulation
Interaction
Caregiver
Physical Health
Mental Health
Coping
Educational Level
Environment
Resources
Inanimate
Animate
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The Barnard Model
(Barnard, 1994)
Caregiver/Parent
Characteristics
 Sensitivity to Cues
 Alleviation of
Distress
 Providing GrowthFostering Situations
Infant/Child
Characteristics
 Clarity of Cues
 Responsiveness
to Caregiver
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NCAST
Parent Child Relationship (PCI)
Feeding Scale and
Teaching Scale
(Barnard, 1994)
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Standardized, valid, reliable
Used in research extensively
Caregiver and infant learn to adapt,
modify, and change their behaviors in
response to one another
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Feeding Behavior Disorders
(Zero to Three, 2005)
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Should be considered when child has
difficulty establishing regular feeding patterns
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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
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Feeding Behavior Disorders
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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
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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
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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
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Early Childhood Mental Health
Interventions
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Developmental guidance
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Reading child’s cues
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NCAST Keys to Caregiving: Feeding is More than
Just Eating
Parent-child relationship therapy
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Psycho-education
“Ghosts in the Nursery”
Modeling
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Early Childhood Interventions
Infant Parent Dyadic Therapies
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Child-Parent Psychotherapy
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Interactive Guidance (McDonough, S. from
and Van Horn, P.)
(Lieberman, A.
Zeanah, C.)
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DIR / Floortime (Greenspan,S. and Wieder, S.)
Internal Working Models (Zeanah, C.)
Watch Wait and Wonder (Lojkasek, M.)
Circle of Security (Cooper, Hoffman, Powell,
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Play Therapy
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and Marvin)
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References
1.
2.
3.
4.
5.
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.
46
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/ParentChild Interaction Feeding Manual. Seattle: NCAST
Publications, University of Washington, School of Nursing.
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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
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