Maria, a 6 year old
recently adopted from Russia, has an aversion to eating anything - liquids
or solids. According to her parents: "She drinks water and very
little else on her own; when eating it takes perhaps 30 minutes for
breakfast and maybe 30-40 minutes for dinner; she doesn't have many
teeth in her mouth and gets very bored with eating. It's always a fight
to make her eat, and invariably we end up feeding her at dinner. If
there is no adult supervision she will not eat her school lunches and
this leads to melt downs in the afternoon".
Sounds familiar? Such problems are likely a combination
of medical and psychological issues, both rooted in pre-adoption experiences,
often facilitated by inadequate parental techniques and overall situation
in the adoptive family. The nature of such problems should be identified
ruling out varies possibilities:
Ruling out medical issues:
The first step is to rule out (or to determine the significance of)
physiological and neurological causes of Maria's feeding aversions through
a thorough medical evaluation. A number of pediatricians participating
in the AdoptMed
discussion on this subject and familiar with orphanage children
indicated that these children often have under-developed digestive systems
as part of their developmental delay. After the age of 18 months, they
are often fed with oversized spoons, the tongue is depressed forcing
the food (porridges & pureed foods) to run down the throat without
the child chewing and thus not releasing saliva and not "training"
chewing muscles. As a result, at the age of 4 and 5 a child may be "tired"
Next, it should be determined whether there are oro-motor
issues present, e.g.: swallowing mechanism integrity, dental issues.
This could be done by a qualified and experienced speech/feeding pathologist.
Ruling out sensory issues:
There is a lot of information on sensory problems of international adoptees
on the Internet. A couple of sensible articles that we referenced in
our Newsletters are:
Working on psychological approach:
Several years post adoption is a long time to be struggling with this
issue. Is your child malnourished or anemic? The child may be below
the 5th percentile for her weight and height, but it can be due to her
overall medical condition (ex.: FASD). Note also that food selectivity
or food aversion are common in post-institutionalized children of different
ages afflicted with PTSD as their hyper-arousal coping mechanism.
My understanding of the situation is that Maria definitely
benefits from this behavior: this is her way of getting an overall control
of the situation and total attention as she ends up being fed by the
parents. Assuming that there are no medical issues that may cause food
aversion and you are facing mostly psychological issue of control and
attention, I suggest a simple behavior-based "common-sense"
approach to address this problem:
- Limit time for each food intake.
- At the end of each meal food must be taken away and
is not available for Maria until next meal.
- The choice of food that is being served belongs to
the parents but the amount of food eaten is the child's choice. In
orphanage Maria was conditioned to "clean up the plate".
Put a minimum food on her plate letting her know that "addition"
is available upon asking.
- No snacks - this rule is to be firmly reinforced.
- The most important: do not make a "big deal"
out of her eating habits or manners she demonstrates during meal time.
Praise her for good eating, but ignore her "not eating".
Again, she is not an anorexic or malnourished child and if she prefers
not to eat at the moment, it should not be an upsetting or frustrating
factor for you.
- In school: in Maria's IEP a clear statement is to be
made under the section of "School and Classroom Accommodations":
A teacher aid or a teacher-in-charge is to supervise Maria's food
intake during her lunch in the common dining area. A behavior modification
plan can be written specifically for this person to implement an adequate
control over her behavior during lunch time. More information on what
and how can be done at school: Treating
Feeding Difficulties in the School Environment
Boris Gindis Ph.D.