Feeding Disorder of Poor Care Giver–Infant Reciprocity

Feeding Disorder of Poor Care Giver–Infant Reciprocity

Diagnostic Criteria

·     Shows a lack of developmentally appropriate signs of social reciprocity (e.g., visual engagement, smiling, or babbling) with the primary caregiver during feeding.

·    Onset under 1 year of age.

·           Shows significant growth deficiency.

·    The growth deficiency and lack of engagement with the pri-mary caregiver are not due solely to a physical disorder, or a pervasive developmental disorder.

This feeding disorder has been referred to in the early literature as maternal deprivation, deprivation dwarfism and psychosocial deprivation. The growth failure and developmental delay of these infants were considered a consequence of a continuum of neglect and/or maltreatment of the child leading to insecure attachment to the caregiver.

Epidemiology

It is difficult to assess how commonly this feeding disorder oc-curs. However, there appears to be an increased prevalence of cases in the lower socioeconomic classes, as noted by Chatoor and colleagues (1997).

Etiology

Much has been written about mothers whose infants fail to thrive and appear to have a disorder of reciprocity. They are frequently described as suffering from character disorder, affective illness, alcohol abuse and drug abuse. Early research suggested that the highest risk exists when the mother’s needs take precedence over those of the infant, and that difficulties of these mothers in nur-turing their infants stem from the unmet needs of the mothers during their own childhood.

Family problems and distressed marital relationships have been reported in a number of noncontrolled and controlled stud-ies of failure to thrive. In addition, socially adverse living condi-tions, poverty and unemployment are reported to be more preva-lent in these families of infants with failure to thrive.

Between 45 to 93% of the infants with failure to thrive are insecurely attached. Mothers of infants with failure to thrive are more likely to be classified as insecurely attached to their own parents, as measured by the Adult Attachment Interview (Main and Goldwyn, 1991).

The growth failure of these infants with poor caregiver– infant reciprocity appears to be a critical manifestation of a failed relationship between a mother and her infant during the first year of life, when the foundation for mutual engagement and attach-ment is usually laid. A transgenerational pattern of insecure at-tachment appears to be at the root of the mother’s difficulty to engage with her infant and leads to a lack of emotional and physi-cal nurturance of the infant.

Diagnosis

Most of these infants are not brought for pediatric well-baby care but present to the emergency department because of an acute illness, when their poor nutritional state draws the attention of pediatricians. Because of their severe failure to thrive, these infants frequently require hospitalization. During the hospitalization, the psychiatric consultant is usually called in to assist in the diagnosis and treatment of the infant’s growth and developmental problems. The evaluation should include an assessment of the infant’s feeding, developmental and health history, including any changes in the infant’s behavior during the hospitalization. In addition, the mother’s pregnancy, delivery, family situation and social support need to be thoroughly explored. A mental status examination of the mother should be per-formed to rule out severe psychiatric illness, particularly whether she suffers from depression or is abusing alcohol or drugs.

Many of these mothers are elusive and avoidant of any contact with professionals. Consequently, the observation of mother–infant interactions may have to be obtained indirectly, through the report of other professionals who admitted the infant to the hospital.

Infants with feeding disorders of poor mother–infant reci-procity characteristically feed poorly, avoid eye contact and are weak in the first few days of hospitalization. When picked up, they might scissor their legs and hold up their arms in a surrender posture to balance their heads, which seem too heavy for their lit-tle weak bodies. They usually do not cuddle like healthy well-fed infants, rather they keep their legs drawn up or appear hypotonic, like rag dolls. However, these infants appear to blossom under the tender care of a primary care nurse who engages with them during feeding and plays with them. They become increasingly responsive, begin to smile, feed hungrily and gain weight. These striking changes in behavior of these young infants when they are fed and attended to by a nurturing caretaker are characteristic of a feeding disorder of poor mother–infant reciprocity and dif-ferentiate these infants from infants with organic problems that have resulted in growth failure and developmental delays.

Course and Natural History

Because of an inconsistent definition of failure to thrive, it is not clear whether all of these infants suffered from a feeding disorder of poor mother–infant reciprocity. In general, nonorganic failure to thrive during infancy has been associated with later cognitive and behavioral problems. Hufton and Oates (1977) reported that of 21 children who had been diagnosed with nonorganic failure to thrive during infancy, at the age of 6 years, half of the children had abnormal personalities and two-thirds had a delayed reading age.

Treatment

Various treatment approaches have been proposed, ranging from home-based interventions to hospitalization in severe cases Be-cause of the complexity of the issues involved in the etiology of nonorganic failure to thrive, most psychiatrists and researchers suggest that multiple and case-specific interventions may be re-quired. An outpatient approach appears to be safe in cases of mild neglect when there is no evidence of deprivational behavior on the part of the mother, the infant is older than 12 months, and the par-ents have a support system and have sought medical care for pre-vious sickness. Immediate hospitalization of young infants with neglectful failure to thrive is indicated if it is associated with non-accidental trauma; if the degree of failure to thrive is considered severe; if there is serious hygiene neglect; if the mother appears severely disturbed, abusing drugs or alcohol; if the mother lives in a chaotic lifestyle and appears overwhelmed with stresses; or if the mother–infant interaction appears angry and uncaring.

During the hospitalization it is most important to assign a primary care nurse who can be warm and nurturing to woo the infant into a mutual relationship. Improvement of the infant’s health and affective availability can then be used to engage the mother with her infant and in the treatment process. Recovery from growth failure does not indicate that the parent–child re-lationship is adequate. The mother’s ability to engage her infant and to participate in the treatment process has to be at the core of the treatment plan. The degree of parental awareness and coop-eration is predictive of outcome for failure to thrive.

Because these mothers frequently present with a variety of psychological and social disturbances, their problems need to be explored while nutritional, emotional and developmental re-habilitation goes on with the infant. It is important to look for and identify any positive behavior a mother shows toward her infant and to use it as a building block to bolster her competence and interest in her infant. Nurturance of the mother is the first critical step in the treatment to facilitate her potential to nurture her infant. Moreover, the family can serve as a stress-buffering or stress-producing system. The hospitalization of the infant provides a critical time to assess whether the infant needs to be placed in alternative care. In some situations of severe neglect or associated abuse, the case needs to be reported to protective services, which at times can be instrumental in mobilizing the family or in finding foster care.

Discharge from the hospital is a critical time when all serv-ices need to be in place to ensure appropriate follow-through of the treatment plan for these vulnerable infants. For some infants, daycare in a nurturing environment will give the mother an op-portunity to pursue some of her own interests and needs as well as to make the time with her infant more special and enjoyable. Visits by a home care nurse or regular treatment sessions in the home by a social worker are some of the alternatives to consider because many of these mothers struggle with coming to therapy in an office setting. Because of the complexity of the problems in-volved in the etiology of this feeding disorder, a flexible multidis-ciplinary approach that is coordinated by the primary therapist is usually most effective.