Tag: Feeding

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Feeding: The Impact Parenting Style May Have

feeding
Image by yalehealth from Pixabay

Feeding therapy. I always say it’s a love-hate relationship for me. It’s love because I myself love food and eating. My Italian side of the family is big into cooking, so food definitely is a large part of our culture, and many cultures.

I love seeing kids become more confident and enjoy the process of exploring new foods and flavors. I think it’s fun to be silly with them and talk about taking shark bites vs. mouse bites, seeing who can crunch a carrot the loudest, etc.

The hate side of things isn’t so much a hate as it is a frustration that stems from my impatience. I am through and through a bottom up thinker. I have a hard time not getting to the root of an issue because I feel any progress we’ll see otherwise is likely a temporary bandaid. The struggle I have with feeding therapy is that a child can make lots of progress in the clinic, but seems to have a stand still at home.

As time has gone on, I firmly see that feeding therapy is whole family therapy. That’s not a bad thing, and really every therapy should be that way! However, there are so many emotional dynamics that go into mealtime that unlike learning to cut with scissors, if you don’t somewhat address the bigger emotional dynamic, you’ll likely see very limited progress.

This week’s article is to highlight the connection between family dynamics and feeding outcomes. So while the article doesn’t tell you what to directly do, (although I did write a review that covers that subject) I wanted to review it as a means to support the idea that addressing family dynamics is crucial in feeding therapy.

Journal Eating Behaviors (SNIP score 1.106)

Article Title Mindful Feeding: A Pathway Between Parenting Style and Child Eating Behaviors

  • 1A Systematic review of homogeneous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study) [This study was a cross-sectional study]
  • 5 Expert opinion without explicit critical appraisal

Methods Researchers recruited 496 parents from a sample of a larger study on the topic of feeding. Parents completed an online survey.

Measures

Mindful Feeding Study authors used the Present Centered Awareness subscale of the Mindful Feeding Questionnaire to determine parents’ mindful attention during the process of feeding their children.

feeding

Child Eating Behavior Study authors used subscales from the Child Eating Behavior Questionnaire as a means to measure children’s emotional over-eating and food fussiness per parent report.

Problematic Mealtime Behaviors The Problematic Child Mealtime Behaviors subscale of the Meals in Our Household questionnaire served as a tool to gather parent report on mealtime behaviors.

Parenting Style Investigators used the Parenting Practice Questionnaire to serve as a tool to classify parents’ parenting style as authoritative, authoritarian or permissive.

Findings

In general, the parents who self-reported more authoritative parenting reported higher levels of mindful feeding, while those reporting more authoritarian and permissive parenting reported less mindful feeding (Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 3). Those parents who used mindful feeding strategies more often had children who they reported were less likely to be fussy, less likely to eat in response to emotions and less likely to have problematic mealtime behaviors ((Goodman, L.C., Roberts, L.T. & Musher-Eizenman, D.R., 2020, p. 4).

Authoritative Parenting Per parents’ self-reports, authoritative parenting had a direct and indirect negative impact on children’s emotional over-eating and food fussiness. Meaning, those with an authoritative parenting style had children who were less likely to be fussy and to eat as a reaction to their emotions. This style of parenting did not demonstrate a negative direct impact on problematic mealtime behaviors.

However, when authors assessed how authoritative parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, they did find a significant effect. So, having an authoritative parenting style doesn’t directly impact mealtime behaviors. However, an authoritative style impacts a parents’ mindful feeding habits, which in turn impacts the problematic mealtime behaviors.

Authoritarian Parenting Per parents’ self-reports, authoritarian parenting had a direct and positive impact on children’s emotional over-eating. That is, parents with an authoritarian parenting style reported their children as more likely to eat in reaction to emotions. This result was not seen for food fussiness and problematic mealtime behaviors. As authors assessed how authoritarian parenting impacted mindful feeding and how that in turn impacted problematic mealtime behaviors, food fussiness, and emotional over-eating, they did find a significant effect.

Permissive Parenting Parents who self-reported permissive parenting style had both a direct and indirect positive impact on problematic mealtime behaviors, food fussiness, and emotional over-eating. This means, parents reporting this style also reported their children as presenting with more mealtime behaviors, food fussiness and emotional over-eating.

Things to Consider

The authors mention that it would be beneficial to the research to complete a longitudinal study in which they could assess these outcomes for the same group of parents and children at multiple points in time. This would allow drawing stronger conclusions about the connection between parenting style, parents’ mindful feeding habits and children’s eating behaviors.

Of note is that the sample in this study had a majority demographic of white families (79%), which may impact the ability to generalize findings to the picky eating population. I was not able to find the race demographics for picky eaters, so I can’t conclusively say one way or another.

The study authors also mention that it would be valuable to explore the bidirectional relationship between parents’ mindful eating habits and children’s challenging behaviors, as the children’s challenging behaviors may also impact the parents’ strategies. Finally, they include that exploring other factors, such as other life stressors, that may impact this relationship between parent and child dynamics during feeding would be useful.

What does this all mean for a feeding therapist?

While this data is preliminary and low level evidence, I think it is very important to acknowledge and include families in feeding therapy intervention. I think we are doing a disservice to children and their families if we expect the child’s progress in the comfort of a therapeutic feeding session to transfer over to home without directly also educating parents and caregivers on how to interact with food, respond to their children and shift a mindset of learning to learn about food.

References

Goodman, L.C., Roberts, L.T., & Musher-Eizenman, D.R. (2020). Mindful feeding: A pathway between parenting style and child eating behaviors. Eating Behaviors 36. http://doi.org/10.1016/j.eatbeh.2019.101335

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Parents as Agents of Change: A Group Behavioral Intervention for Parents of Children with Avoidant-Restrictive Food Intake Disorder

parent

Parents and therapists alike may tell you picky eating seems to have grown tremendously in recent years. While there is some amount of typical toddler fussiness, sometimes picky eating is indicative of something more.

As with anything, likely there are a wide variety of factors to include in the possible explanations. Challenges with sensory processing often contribute to difficulty with feeding. Processed food has become almost a staple in families’ homes. With this we have seen a decrease in families and children planting, growing, interacting with and preparing food in its fresh and natural form. Eating dinner together as a family is a hugely important activity. Here children observe and learn what to think about food and how to eat it from those with whom they share the dinner table. While some families returned to the dinner table due to lockdowns during COVID-19, it’s a habit that is not as often prioritized into overly packed after school and work schedules.

Picking Eating, Parents and Family Dynamics

Whatever the cause of picky eating, it can greatly impact family stress levels and dynamics. I always say I have a love/hate relationship with feeding therapy. I really think it’s fun, and I love when kids make progress and grow confident to try new foods! However, moving that progress to the family dinner table can be another story. Picky eating requires treatment of the whole family. Parents in particular need to play an active role in learning how to teach their picky eaters about new foods.

That’s why I loved the article I reviewed this week. It specifically focused on educating parents and empowering them so they can be the crucial agents of change their children need them to be! This article actually covers treatment of children who had a diagnosis of Avoidant-Restrictive Food Intake Disorder (ARFID). That is not your garden variety picky eater. The Washington Post published a story last week on the topic. In the article, the author of the study I’m reviewing today shared about her experience working with children with ARFID.

Journal Cognitive and Behavioral Practice (SNIP score 0.994)

Article Title The (Extremely) Picky Eaters Clinic: A Pilot Trial of a Seven-Session Group Behavioral Intervention for Parents of Children with Avoidant/Restrictive Food Intake Disorder

  • 1A Systematic review of homogeneous RCTs
  • 1B Well-designed individual RCT
  • 2A Systematic review of cohort studies
  • 2B Individual prospective cohort study, low quality RCT, ecological studies; and two-group, non-randomized studies
  • 3A Systematic review of case control studies
  • 3B Individual retrospective case-control studies; one-group, non-randomized pre-post test study; cohort studies
  • 4 Case series (and low-quality cohort and case control study)
  • 5 Expert opinion without explicit critical appraisal

Methods

The authors trained cohorts of parents whose children presented with criteria for avoidant/restrictive food intake disorder (ARFID). Parents of 21 children, ages 4-11 years old, participated. Cohorts had two to four families each. Seven total cohorts participated, with each cohort participating in seven sessions of the manualized group treatment for parents only.

parent training

Interventionists trained the parents in acting as coaches in presenting non-preferred foods on a daily basis in their homes. They also empowered parents on how to reduce problematic mealtime behaviors with parent management training. The participants in this study were referred to a specific provider, the clinical director of an outpatient anxiety speciality clinic which serves to evaluate and treat extremely picky eating (Dahlsgaard & Bodie 2019, p. 9).

Children met inclusion criteria if they were 4-12 years old, had a diagnosis of ARFID and their parents’ main concern was their picky eating in the event of coexisting psychiatric or medical problems. All parents completed the following standardized feeding measures at pretreatment, posttreatment and a 3-month follow-up to assess their child’s picky eating and problematic mealtime behaviors (Dahlsgaard & Bodie 2019, p. 3).

  • Behavioral Pediatric Feeding Assessment Scale
  • Child Eating Behaviors Questionnaire

Parents completed the Child Behavior Checklist during intake only as a means of collecting information on behavioral, emotional and social problems (Dahlsgaard & Bodie 2019, p. 12).

Intervention

Parents participated in seven 90 minute sessions which occurred weekly for sessions 1-4. The last two sessions occurred with a 3-4 week gap to promote families practicing the skills they had learned (Dahlsgaard & Bodie 2019, p. 14). The seventh session was an optional follow up. Interventionists educated parents on ARFID, mealtime hygiene, appetite optimization and the key behavioral principles for the program in the first session (Dahlsgaard & Bodie 2019, p. 14).

Interventionists taught parents how to implement daily exposure procedures in the second session. Following sessions focused on improving parents’ ability to follow through with promoting appropriate responses to children’s behaviors as well as implementing contingency management for food exposures and meals. Parents also learned about increasing the size of challenge food portions and incorporating them into meals.

parent training for daily exposure procedure

Findings

Behavioral Pediatric Feeding Assessment Scale

Significant reductions were reported for all four subscales of this assessment along with a large within-group effect size at posttreatment (Dahlsgaard & Bodie 2019, p. 16). At the 3-month follow-up, gains were maintained and the large within-group effect size remained.

Child Eating Behaviors Questionnaire

Parents ratings on the CEBQ demonstrated a significant increase for Enjoyment of Food as well as significant decreases for Slowness in Eating, Satiety Responsiveness and Food Fussiness from pre to post treatement (Dahlsgaard & Bodie 2019, p. 16). The author noted large within-group effect sizes in these areas at posttreatment.

No significant improvements were observed for Emotional Undereating on this assessment. Enjoyment of Food resulted with a significant increase from pre-treatment to the 3-month follow up, and significant decreases for Satiety Responsiveness, Slowness in Eating, Emotional Undereating and Food Fussiness. The author reported moderate-large within-group effect sizes. All of these gains remained at the 3-month follow up.

Parent Satisfaction

Of the parents who completed treatment satisfaction questionnaires post-treatment (71% of the total study participants) 96% of those parents rated specific elements of the Picky Eaters Clinic as Very Helpful or Extremely Helpful (Dahlsgaard & Bodie 2019, p. 17). Parents reported the support they received from the group and trainings in food exposures as well as contingency management as the most helpful elements (Dahlsgaard & Bodie 2019, p. 17).

Things to Consider

The parents in this study were highly motivated as demonstrated by 95% attendance rate and 71% of children having two parents attending treatment sessions (Dahlsgaard & Bodie 2019, p. 15). This study’s author noted that this group was fairly heterogeneous, but that previous research indicates that this is consistent for children with a picky eating subtype diagnosis of ARFID (Dahlsgaard & Bodie 2019, p. 27).

Interestingly, there are three subtypes of ARFID. These include those children with extreme picky eating, but also children whose avoidance of eating stems from a specific fear/potential negative consequences they they associate with eating. This can include things like a phobia of choking, having allergic reactions or vomiting. A third group of children who fall into the ARFID category are those who demonstrate decreased interest in eating.

This information is relevant as the treatment one selects varies depending on the subtype the child presents with. It is important to be specific and intentional with our selections of evidence based treatments to promote progress for children and their families!

The author also mentions that the data that was used was obtained in clinical procedure as opposed to following a research protocol. She noted that this type of data is often less reliable and complete (Dahlsgaard & Bodie 2019, p. 27). Finally, as there was no control group for this study, we can not compare it to the effectiveness of other common treatments for selective eating.

The More You Know…

So now that you know that involving parents only resulted in significant changes in the relationship with food for children with Avoidant-Restrictive Food Intake Disorder (ARFID), how do you plan to educate and empower parents of the children you’re treating? I highly recommend this article on How to Get Picky Eaters to Try New Foods as a starting point!

References

Dahlsgaard, K. K. & Bodie, J. (2019). The (extremely) picky eaters clinic: A pilot trial of a seven-session group behavioral intervention for parents of children with avoidant/restrictive food intake disorder. Cognitive and Behavioral Practice, 26 (3), 492-505. https://doi.org/10.1016/j.cbpra.2018.11.001