COPING WITH FEEDING PROBLEMS IN CHILDREN

Information for Parents

The purpose of this information booklet is to provide suggestions to parents on how to manage problems with feeding and difficult behaviour at the dinner table. The advice in the guide is based on the assumption that the child is physically well. Any suspicion that his or her difficulties are caused by a physical problem, should lead you to seek advice from your family doctor.

What do we mean by feeding problems?

This term covers a wide range of behaviours such as: -

Refusal to eat or eating very slowly.

Picky eaters, faddiness, eating a very limited range of foods

Refusal to sit at the table, leaving the table during a meal

Throwing tantrums at the table, crying, throwing food or other objects

How big a problem is it?

Studies have shown that this is a common problem. A large scale study of 5 year-olds showed that over one third were described by their parents as having mild or moderate appetite or eating problems, Two thirds of these were considered to be faddy eaters, while the rest were thought not to eat enough. In another study of three-year-olds in London , 16 percent were reported to have poor appetites and 12 percent were said to be faddy. There was no difference between boys or girls, but these problems were found to continue for one year in about two thirds of these children. In one third the problems continued for over 5 years.

What causes the problem?

There are a variety of explanations but often a feeding / eating problem arises out of difficulties in relationships in general. Feeding problems are often linked with general behaviour problems such as temper tantrums, as well as more specific behaviour problems such as sleep difficulties, soiling and breath holding.

 Parents often create problems at mealtimes by failing to establish a routine and this can lead to the child not knowing how to behave appropriately. Although mealtimes are a private affair, how many times have you been in someone else’s house or in a restaurant or café and seen a parent chasing after a child holding a chicken nugget. The parent’s aim is to feed the child regardless of what he or she is doing; the child is basically doing what they want. In some households this can often be the normal way of eating.

Eating should be thought of as any other behaviour. It has to be taught and the child must learn. Often there are too many distractions such as television or family arguments. Parents may also not realise how much the child’s appetite matches the helpings on the plate. There is nothing more off putting than having to eat a huge pile of food knowing that you are going to be told off if you do not “clear your plate”.

Attention

In many instances the child’s behaviour is linked to attention seeking. It is a natural desire for parent to feed their child. For mothers this starts at birth and helps establish the maternal bond. When a child starts to refuse to eat food or develops a fad, this leads to the parent spending more time thinking and talking about the problem. Soon it becomes the major topic of conversation in the household. When the child does not eat the beautifully prepared food that is given, there is likely to be some conflict. The child is shouted at, threats are made, and all the time the child is gaining attention. When the other parent or relative comes into the house, the first question is often “ Did Johnny eat his dinner tonight?” Grandparents will phone in the evening to find out if Susan ate her dinner. So who is in control of the situation? Who is the centre of attention?

Diet

Many parents are able to list the foods that they know that their child will eat. They can also give a list of foods that their child used to eat but no longer like. In many cases where the child is displaying a feeding problem there is little weight loss. For some reason the child is not losing weight and is growing normally. This suggests that the child’s calorific intake is adequate, so what are they eating. Often this is due to the child eating snacks or “junk food”. When the parent gives the child a meal and they refuse to eat it. The parent may do one of several things: -

1.      Asks the child what else they would like to eat and make it.

2.      Takes the food away and sends the child from the table but will make something else later.

3.      Bribes the child “If you eat one more nugget then you’ll get a bar of chocolate!”

4.      Allows the child to have a snack later on, such as crisps, Pringles, biscuits, sweets, fizzy juice, and milk.

Above all the parent feels guilty and worries that their child may starve. Who is in control here?

Assessment of feeding problems

Keeping a food diary

If you think your child may have feeding problems then the first step is to record what he or she eats over the course of a day, or if possible a week.  This should include details of the amount and type of food eaten, including all snacks and drinks, as well as time and place. This helps to identify how much “junk food” accounts for your child’s daily calorific intake.

Ask yourself some basic questions

Do you have rules about mealtime behaviour? What do you expect from your child at mealtime?

Are you clear about these rules? Is the child clear about the rules?

Do you and your partner agree and follow these rules?

Does your child sit at a table to eat?

Does your child eat at the same time each night?

What mealtime rules are often broken?

What do you do if your child breaks these rules? What is the consequence of rule breaking? Do all adults in the house apply these rules consistently?

What happens if the child follows the rules? Is there a positive outcome?

When, where, with whom does your child not present feeding problems?

Could you take your child out for a meal and know that they would sit at the table and eat?

Do you lose your temper at mealtimes?

Do you shout at your child at mealtimes?

Do mealtimes end up with arguments?

The child’s appetite

Children have a very different appetite from adults. Adults are used to having three meals a day, but this is not necessarily the best for young children. Most young children require four or five small meals a day, morning, mid-morning, noon, mid-afternoon and evening. The amount of food is also very important and parents must be aware that children do not have the same appetite as them. There is nothing more off-putting than facing a mountain of food on a plate. It is much better to give the child a modest portion and the opportunity to come back for more if needed.

You must also consider the amount of fluid that the child is taking. Some children may not be hungry because they have been drinking milk or juice before their meal. It is not surprising that they then do not eat their meal.

  Ideas for tackling feeding problems

Stimulus Control

Children require help in establishing setting cues associated with eating. This is a symbol or indicator that helps the child recognise that feeding / eating is required. This is the starting point for mealtime rules to apply. Setting cues may be only eating a table at meal times, having a special place mat or cutlery. If the child has a specific place to sit and eat then they are less likely to argue over where they want to go and there is likely to be fewer distractions. They are also less likely to drop food on the living room carpet.

Positive reinforcement

Most of the time we respond to negative behaviours, so the child does something wrong and we comment or react to it. When we think of positive reinforcement we have to responds to desirable behaviours and reward them. This can be quite hard to do as we are used to responding to negative behaviours and ignoring good behaviours.

How often do we praise a child for sitting at a table for a few minutes? A good slogan to help think about this is

“Catch the child in good mealtime behaviour rather than always in bad behaviour”

To have most effect, reinforcers (rewards) such as treats, praise and encouragement should follow as closely as possible upon a child’s performance of the particular desired mealtime behaviour. So if the child sits at the table then he is immediately praised. If he eats some food then he is praised.

Planned Ignoring

There is little doubt that attention, whether positive or negative, can be a very powerful reinforcer for children’s behaviour. Inappropriate eating habits in children who are able to feed themselves are often the result of the child mastering a technique in which they control mealtimes. If the child sits sulking at the table refusing to eat, the way that the parent responds is critical to the outcome. Frequently parents’ reprimands or attempts to clean up the mess on the table or clean up the child can simply reinforce the behaviour. The skill is knowing when to ignore the negative behaviour and asking yourself “If I respond to this what will be the consequence for me and my child?”

Examples of ABC Analysis

A useful way of looking at behaviour problems is using the A-B-C method. 

A –      This stands for Antecedents (what caused the tantrum?)

B -        This stands for Behaviour (what actually happened?)

C -       This stands for Consequence (What was the outcome?)

If you can identify the events that led to the tantrum then you can avoid the negative behaviour, which means there will be no unpleasant consequences!

Time –out

Time-out is a response to attention seeking behaviours that cannot be ignored. It involves removing the child from the rewarding situation related to the problem behaviour to a specific “time out” location for a defined period of time.  Alternatively the source of the provocation may be removed, for example the food that the child was throwing.

The rules of time-out are simple but must be applied correctly

Remember – Hunger is a natural consequence of not eating, so use it to your advantage. Explain to your children “if you don’t eat your lunch by the time the timer rings, then I’ll take away your plate and there won’t be any snacks until dinner!”

Strategies to help your child eat

Offer a limited choice

If your child is a faddy eater then you could consider offering a choice of 2 meals. They can either choose what everyone else is having or they can choose one type of nutritious food. The choice must be made well before each meal so that you are not forced into last minute preparations. By offering the child an alternative, you are giving them a way out of a conflict, so everyone wins. A limited choice introduces the idea of compromise and shows that you are willing to give them some control, but not all

If your child has a limited diet then try to introduce new foods with those that you know he or she likes. Give smaller portions but with a range of foods, for example a sausage, some potato shapes, some peas and a carrot.

Reward good eating and table manners

Watch your child eating and praise appropriate behaviours. If he or she is using their cutlery properly then praise them. Give positive feedback to the child so that they know that they are doing well. If there are other children at the table then use a technique called proximity narration. This involves the parent commenting on what positive behaviours the other child is doing. For example, “ Jack is using his knife and fork well!” “ Katy is eating all her peas”. This method reinforces the positive behaviours and allows those children who are eating well to be receive feedback.

Have time-limited meals

It is often the case that poor eaters will drag mealtimes out by eating slowly, complaining at every mouthful and playing with their food. This is not acceptable and results in tempers being frayed and the food being spoilt. Instead of allowing this to continue, set a reasonable amount of time, say 20 minutes and let the children know how long they have. You could even use a kitchen timer and when the bell rings then their plates will be removed.

Reward Charts

A start chart or sticker chart can be a useful aid to rewarding good eating behaviour. If a child eats all their meal or sits well at the table then a star or sticker can be given. These can be added up for a treat. Remember, children find it difficult to plan far ahead so the reward cannot be days away. It is best to reward that day or the next.Summary

Feeding and eating problems in young children are quite common and a normal aspect of learning. It is important that parents thinks about how they manage meal times and the rules that they set and apply. In most instances the child is receiving more attention for displaying inappropriate and unacceptable behaviours at meal times. By clarifying the rules and boundaries that we set and also by applying these consistently then it is possible to overcome these feeding  / eating issues.

Barry Syme