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A THERAPEUTIC FEEDING PROGRAMME.
1: THEORY AND PRACTICE OF FEEDING
Katrin Stroh
Thelma Robinson
George Stroh
THIS MATERIAL IS PROVIDED IN
ACCORDANCE WITH COPYRIGHT LAW
(US CODE TITLE 17)
C. 0. BAX
RY W. BAIRD
G. MITCHELL
'IN
From 1957 to 1979 Dr. George Stroh was
Psychiatrist-in-Charge of High Wick
Hospital, St. Albans, where he and his
colleagues worked with severely disturbed
children. The hospital was perhaps unique
because of the particular attention given to
feeding disorders. Unfortunately, Dr.
Stroh's untimely death in 1979 meant that
he could not present the material he was
gathering in a systematic paper of his own.
Our purpose is to present some of his
results and conclusions, as well as further
findings we have made in the intervening
years in our practice in London.
Over a period of nine years we explored
the use of feeding as a therapeutic measure
for severely disturbed children at High
Wick Hospital. Originally we had intended
to make a particular study of psychotic
children, but as our work progressed we
realized that the ideas were relevant to all
disturbed children, and that the basic
principles could be generalized and were
beneficial when feeding normal infants.
Our main purpose is to describe a
technique which may help a wide range of
children, so we will not discuss terms such
as autism or psychosis. We choose to use
the broad term 'severely disturbed
children', and a few of the children
involved in the feeding programme are
described.
Theoretical perspectives
The importance of treating feeding
difficulties was emphasized by Clancy and
her colleagues in Australia (Clancy and
McBride 1969, Clancy et a/. 1969). They
described a feeding programme for autistic
children and noted that, with improvement
in eating, 'significant changes also occur in
other facets of behaviour'. Our feeding
programme was based on Clancy's work,
and was first used at High Wick in a pilot
study with one child (Stroh 1974).
There have been programmes for
helping physically handicapped children to
feed, for example those of Harkness and
Sandys (1970), Morris (1977) and Warner
( 1981 ), but for the most part they deal with
the 'mechanics' of eating, very little
consideration being given to the emotional
aspects or the relationship between child
and feeder. Peculiar eating habits are
referred to in the literature. Tustin ( 1983)
found ' ... early difficulties in sucking to be
characteristic of all the autistic children I
have seen ... weaning difficulties [are] also
characteristic . . . time and again the
parents of an autistic child have told me
such things as "he will only eat soft food
and rejects hard lumps" or that "he will
only eat semi-liquid food"'. Rimland ( 1962)
mentioned feeding problems in his
description of specific problems and
3
behaviours of autistic children: 'Feeding
problems are almost the rule. Some
children have ravenous appetites; others
eat very little. Almost all have odd eating
habits and preferences, however'. Wing
and Wing (1971) talked of the multiple
impairments m childhood autism but
made no specific mention of eating
disturbance. Presumably they, with many
others, regarded feeding problems as
secondary manifestations which were nonspecific and not significant (indeed, a
computer search of the literature seems to
confirm this).
Two accounts of 'normal' feeding are
worth mentioning. R. Thomas writes: 'Of
all the strange things a child will do, the
strangest and incidentally the commonest
must surely be this refusal to eat some
things, more rarely a pretty general refusal
to do more than pick at food'. Ainsworth
and Bell ( 1969) looked very closely at the
feeding patterns of 26 normal babies: their
table of patterns of mother-infant
interaction during feeding showed that
there were problems with almost all of the
infants, e.g. colic, spitting up, gastric
distress, unhappy feedings.
It is our impression that most severely
disturbed children show significant eating
abnormalities, though some may be
disguised or not be regarded as significant.
Among the most common types we have
noted are: (1) automatic, mechanical
eating; (2) shovelling food, gulping,
stuffing; (3) not chewing; (4) avoiding
touching food with the lips, not looking at
food; (5) spitting or regurgitating; (6)
throwing food; (7) scavenging, grabbing
food from other people's plates; (8)
excessive fads or refusals; (9) patterning of
food; and ( IO) holding food in the mouth
for long periods.
4
With regard to the importance of early
feeding experience m general, Kanner
( 1973) has stated that 'Food is the earliest
intrusion that is brought to the child from
the environment. It ts the basis of
judgement, of deciding: is this good or
bad? The judgement is 'I should like to eat
this' or 'I should like to spit this out'
(Freud 1925). Furthermore, the early
feeding experience, that is the giving and
taking of food, IS probably the most
important aspect of that intimate
interaction betwen mother and baby we
call mothering.
We think that early feeding difficulties
give rise to the faulty development of the
disturbed child. If in infancy eating is
unpleasurable, it does not change
discomfort into comfort, but tends to
increase discomfort. Eating then becomes
a threatening experience, and a vicious
circle is set up so that fundamental conflict
exists between the basic need to eat and the
intense fear of doing so. The conflict is
resolved by the process of 'non-eating
eating' (Stroh 1977), which allows food to
be taken in in an affectless way, in a state of
relative unawareness.
The feeding programme
Our feeding programme provides a
situation in which a child, on his own
initiative, breaks through his basic feelings
of mistrust. By subsequent pleasurable
feeding interaction with a 'feeder', he is
then able to make a more normal
adjustment to his environment.
High Wick Hospital is a small
residential psychiatric unit for up to 18
children ranging in age from three to 13
years. Their length of stay was from one to
several years, depending on the severity of
the disturbance. The day-to-day care of the
children was undertaken by lO child-care
workers. The children were divided into
groups of between three and five, each
group being under the care of two childcare workers. Within each group, one
child-care worker was responsible for
between one and three children. In this way
a high degree of consistency and continuity
of care was achieved.
The buildings in which the children lived
and engaged in school and other activities
were part of a large Victorian country
house m four acres of ground. The
accommodation for the child-care workers
was a similar house across the road, which
also contained an attic flat used for the
individual feeding sessions. The Flat
contained a kitchen, bedroom, playroom,
bathroom and dining room with video
equipment and a one-way screen.
The school was an integral part of the
unit, and there was a daily programme of
structured activity for which the children
were divided into school, nursery or prenursery groups, each run by a teacher
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assisted by child-care workers. The
teaching programme provided for the
individual needs of each child and was
based on what we came to call the
'functional learning' technique*. Some
children had individual psychotherapy and
speech therapy. The Psychiatrist-inCharge (G.S.) was responsible for the
administration of the unit and for its
planning, after dis~ussion wi_th all the staff.
A social worker dtd the maJor part of the
counselling, support and treatment of
parents.
A feature of the unit was the attempt to
integrate social, therapeutic and educational aspects of care with the day-today care of the child. Factors which helped
were the participation of child-care
workers tn the teaching and activity
groups, regular meetings to discuss the
children involving all members of staff,
and an in-service training programme for
child-care staff.
During the first phase of the feeding
programme the child lived in the attic flat,
and treatment began after the child had
settled into the new environment. All
meals were taken in the dining room there,
which contained a small table and two
chairs. The walls were covered with
acoustic tiles to reduce noise. At the three
usual meal-times each day the child came
into the dining room and sat at the table
near the feeder (K.s.), who was known to
the child. At this stage only a plate of food,
a spoon and occasionally a glass of juice or
water were on the table. The food, which
was kept to a single course, was always
bland and easily digestible, e.g. mashed
potatoes or minced meat, and only small
amounts were presented at each meal. The
food was offered on the spoon, with the
feeder watching for any cues the child
might give, however minimal. There was
no persuasion or cajoling at any stage,
since the initial aim was for the child to
accept food from the feeder. The feeder
always remained relaxed and friendly,
while making minimal verbal contact with
the child. If the child continued to refuse
the food after 10 .to 15 minutes the plate
*This technique was developed over a number of
years in collaboration with Dr. Geoffrey Waldon. It
tries to provide the conditions in which the normally
deyeloping young child learns, and to help our
children acquire the tools to learn about the world
around them. A variety of procedures and techniques
are described in Part II of this study.
was taken out of the room without
comment. This procedure was repeated at
each meal-time. Only water or juice were
allowed between meals, when the child had
the use of the flat and was looked after by a
parent or child-care worker. Sometimes
there were walks; at other times the child
remained in the playroom. No child ever
looked for or asked for food between
meals.
The child might refuse food for some
days, and the conflict between accepting or
rejecting it became intense. Two of the
three children discussed later lost weight
slightly but the third did not. Eventually
each child did accept food, and with this
came a closer relationship with the feeder
and increased awareness of the surroundings. The child gradually came to
feeding himself and the bland food was
replaced by a more varied diet. After two
to four weeks the child returned to the
mam building, where the prolonged
second phase of treatment began (this is
discussed in Part II of this study).
In all cases the feeding programme
began only after full discussion with the
parents, who were made aware of the
stresses and tensions that could arise
during the non-eating period. Whenever
possible both parents were encouraged to
become fully involved, preferably living in
the flat over this period. If this was not
possible the 'mothering' role was taken by
a child-care worker.
The one-way screen in the dining room
was used for observation and videorecording, so films of each meal were
available for the feeder, parents and childcare staff to discuss. Throughout the
treatment the children were monitored by
a paediatrician and electrolyte balance was
checked daily.
Case reports
All three children described here were
seven years old when they began the
feeding programme. Before coming to
High Wick they had been seen by many
agencies and had been subjected to various
methods of treatment. All three children
came from families who remained caring,
despite years of frustration. However, their
behaviour finally made it impossible for
them to remain at home. Progress tn
language and learning were minimal, and
5
one boy had no language progress at all.
They all had feeding problems, which had
become gross by the time they were
admitted to the unit.
After admission the children settled and
made social gains. Treatment included the
two essentially different procedures, the
brief feeding programme and the slow and
painstaking building on the results of that
to deal with educational, language and
emotional problems (Stroh eta/. 1985).
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MARK
Early his10ry
Mark had been born at term and delivery was normal.
His mother was a medical student from Austria, in
her final year. His father, a teacher, was English. He
had been breast-fed on demand and supplementary
feeding was started at six weeks. Weaning began at 3'/,
months and was completed at 4'/, months, when he
suffered the first of two major separations from his
mother, who returned to Austria for five months to
complete her medical studies. Mark was looked after
by foster parents, and he seemed to accept his mother
when she returned. During the second separation
lasting for two months, at the age of 13 months, Mark
was looked after by his paternal grandmother in his
own home. When his mother returned he did not
recognize her. He regressed, stopped babbling,
screamed a lot and became faddy about his food.
After the birth of each of his two brothers he
behaviour deteriorated even more: he started to spin
objects, and temper tantrums and feeding problems
increased. At five years he was admitted to High Wick
when his family could no longer cope.
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6
Response to inpatient care
Mark settled gradually and recognized his child-care
workers but avoided contact with other children. His
understanding and language were severely limited
and he did little during the time outside school except
jumping, spinning objects and toe-walking in his bare
feet. His rituals and obsessive behaviour limited
learning in school. His sleep and toilet-training
improved, but his eating habits remained a problem.
He ate a limited range of food, shovelling and gulping
it, accompanied by noisy, defensive behaviour. His
screams often could be heard throughout the unit:
they were prolonged and savage. He would attack
himself by biting and banging, or attack an adult
restraining him. He was inconsolable.
In trying to anticipate and avoid situations that
might cause Mark to explode, we unwittingly
reinforced the controlling behaviour that he used with
such devastating success. After two years at High
Wick, since gains were minimal and all agreed that
Mark needed more intensive help, we offered the
parents opportunity to participate in the feeding
programme. They accepted, but preferred that the
staff at High Wick carry out the day-to-day
treatment. Mark had a special helper who sat beside
him at meal-times, and his parents agreed to visit him
and to look at and discuss the video-recordings.
Feeding
Mark accepted food throughout the first meal: he was
quiet, passive and at times hesitant. He tended to
'swoop' over the spoon. He used defensive
manoeuvres*: he !lapped and clapped his hands,
opened his mouth wide while shutting his eyes,
crossed his arms over his chest, tapped his fingers and
tried to touch the plate. Towards the end of his second
meal he became more noisy, giggling and laughing in
a bizarre way. He grinned in a babyish, seductive way
and his 'non-eating eating' mannerisms increased
before his rather ambiguous 'No-No' and final refusal
of food. He refused to eat for the next six days.
Days two, three and four showed increasing
conflict as he looked at the food. Once he tried to
'feed' himself by blowing on his little finger and
sucking it like a nipple. He resorted to primitive
raging and howling, twisting and turning his body
until, physically exhausted, he turned for comfort to
his child-care worker, burying his head in her lap.
This was Mark's first attempt to seek help from an
adult.
During the fifth to seventh days the videorecordings showed his increasingly heart-rending
facial anguish and distress. His noisiness decreased
and he became hopeless and helpless, but was
exquisitely sensitive to the sound of the spoon on the
plate. There was now a real pull towards the food as
he made prolonged, silent contact with his lingers on
the edge of the plate.
Mark chose to eat on the seventh day, taking tiny
bites of food and spitting some out. His distress
returned, but the meal ended with a warm verbal
communication between Mark and the feeder.
Acceptance of food did not become established for a
few more days, but after this he fed himself, learning
to trust, taste and enjoy a wide range of foods, both at
High Wick and during weekend visits to his home .
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ZEEVI
Early history
Zeevi was born in South Africa of Israeli parents, who
came to England when he was two. He had a younger
brother, who was a bright normal boy. Zeevi's birth
had been normal and he was breast-fed for three
months-'a hungry, greedy baby who sucked very
hard'. There were no indications of delay in physical
development, but he became an irritable, crying,
*G.S. on Mark: 'The defensive armour is the essential
part of his disturbance which prevents him from
adapting and adjusting in anywhere near a normal
way. The defensive armour is the autism, it is selfdefeating in that it prevents adjustment. In
behaviouristic terms it is self-perpetuating, a faulty
learned behaviour pattern; in psychoanalytic terms
there is no libidinal development, except perhaps
primary narcissism. He projects onto the food, or the
food becomes, the totality of the hostile world or
hostile feelings, against which his autistic defence is
directed. It ceases to be a gesture of apparent defiance
(which it never quite was); rather, it could be
understood as a need to preserve the fantasy, to be in
complete control-what he cannot control he
excludes, and therefore it does not exist. This is a
primitive mechanism used when confronted with
situations which are not understood or do not make
sense. There can be many reasons why situations are
incomprehensible, for example when his omnipotence is challenged, or when he can no longer
exclude the experiences that maintain the fantasies.
Only by mobilizing some of his libido, moving from
primary narcissism onto the food (outside) will he be
able to develop object relationships and all that grows
from this'.
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unresponsive child who soiled and wet and refused to
sit down for meals. His mother followed him around
with two bottles of juice, putting the full one into his
mouth when he dropped the empty one on the floor.
At three years of age he was diagnosed as autistic and
at five years he came to High Wick.
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Response to inpatient care
Zeevi moved about bent double, almost on all fours,
scavenging everything so that his fists were full of
dust, dirt and tiny objects which he might cram into
his mouth. He was always active, but his activities
were limited, non-integrated and self-perpetuating.
Most of his attention was given to objects: he ignored
the other children and made only minimal contact
with adults. He became toilet-trained and started to
use a spoon and to sit at the table, but his food fads
continued. He had no speech sounds, but his previous
noisy distress sounds were replaced by good-natured
laughing and giggling, particularly when he was
tickled. However, his behaviour patterns were
absolutely rigid and he was unable to tolerate change
in them, or indeed any kind of change.
During the early months at High Wick Zeevi's
mother visited weekly, but these visits stopped when
the family settled in America. The parents did visit
once or twice a year, and during one of these visits,
when Zeevi was seven, we discussed the feeding
programme. They agreed, though obviously the
absence abroad meant they were unable to
participate. A research worker was assigned to
'special' Zeevi throughout the day, apart from mealtimes, when he would be with the feeder. He spent the
day in the attic flat, but returned to the main building
to his usual bedroom at night.
Feeding
During the first two days Zeevi sat at the table and
took minute bits of food after 'modifying' it in various
ways. He did not allow the spoon to enter his mouth;
instead he used his fingers to take food off the spoon,
then smearing, moulding or patterning it on the table
or on the sleeve of his sweater. Some burlesque
'defence' and bizarre facial movements accompanied
this food 'play', hut he became distressed, shut his
eyes, buried his head on the table and refused more
food.
His refusal lasted for another 12 days, during which
he drank water or juice and suffered little weight-loss.
There was never any catastrophic distress or loss of
control. However, h1s mood ·and behaviour changed
dramatically from day to day as he varied his defensive manoeuvres, to such an extent that often only
in retrospect were we able to make some sense of his
confusing signals or cues.
On days three and four Zeevi became increasingly
aggressive, attacking the feeder's hand and trying to
force-feed her-now the food was more clearly a
threat. On other days he wept, grizzled and screamed.
On day seven he made his first real speech-sounds
when he pushed the plate away with 'go-go-go'. At
times there was a growing awareness of the feeder as a
person, as he left his chair and sidled up to her,
holding his plate. Some of his noises began to sound
like a normal baby's distress sounds.
The most difficult behaviour to cope with was his
ultimate retreat into a kind of chanted singing, which
he could maintain for a whole feeding session. This
led us to change our procedure in an attempt to make
contact with Zeevi. On day six he was offered food on
the feeder's finger to help him overcome his aversion
to the spoon. However, this only seemed to increase
his confusion and he retreated to earlier defensive
behaviour. On day 11 we modified the situation so
that Zeevi could take part in preparation of the food:
he grabbed, bit and scavenged, and the food seemed
to become more rather than less threatening.
We wondered whether this behaviour could be
linked to earlier difficulties with weaning and decided
to offer him fluid and solids separately. This time the
response was dramatic, as he allowed sufficient milk
to come in contact with his teeth to blow or spit it out
onto the table. The feeder allowed this 'in and out' as
an acceptable rhythmic pattern. The session ended
with Zeevi picking up the cloth and wiping the table
and his mouth with it before handing the cloth to the
feeder-an ambivalent response to the food, but a
pleasurable interaction. Despite our willingness to
join in with the spitting response, we were not aware
at the time that in fact this was the breakthrough we
had been working towards. Slowly and hesitantly,
Zeevi began to eat a variety of food and to take part in
its preparation and cooking. Recognizing his real
aversion to milk, by using preferred food we slowly
weaned him onto it, so that by day 39 he was pouring
milk and drinking it from a glass, accompanied by a
wordlike sound 'more-milk'. Zeevi's practice and use
of language associated with pleasurable food laid the
foundation for his emerging language.
-....,
0
I
STEFANO
Early history
Stefano was born in Italy, the only child of an English
mother and an Italian father, both of whom were civil
servants. From the beginning there were feeding
difficulties: he sucked slowly, ate very little and
needed cajoling. Stefano's mother felt inadequate and
unsure of her mothering role. She returned to parttime work when he- was two months old and he was
looked after by an Italian-speaking nanny. There was
much mistrust and friction between the two women
and eventually his mother took full charge of him
again when he was two years old. He had started to
walk, but made no effort to explore his surroundings.
He cried a lot, used gestures, and had a variety of
confusing speech-like sounds. From the age of three
his parents tried to find help in Italy but were
unsuccessful. When he was seven his mother brought
him to England and he was admitted to High Wick.
Response to inpatient care
Stefano was a well-built, not unattractive boy with a
fatuous, empty lop-sided grin. He was clumsy and he
toe-walked and flapped his hands. He could do very
little for himself in the way of washing and dressing,
nor could he open a door. He tended to cling to adults
seductively but avoided other children. He used a few
poorly articulated words, which became incessant
chatter when he was anxious. At times he showed an
endearing sense of fun, but mainly his behaviour
fluctuated between passivity-almost a frozen state,
when he would look endlessly out of the
window-and aggression, when he seemed 'all over
the place'.
Meal-times were very difficult at first, but after
about eight months Stefano could be contained in the
7
dining room, where he gulped and shovelled his few
preferred foods but showed some enjoyment in them.
In school he lacked any fundamental learning and he
made no progress with intensive language work.
During weekends when he visited his mother in
London he remained much as before. There was a
strong bond between Stefano and his mother but it
was difficult to define, being ambivalent and
contradictory. His mother seemed to be unable to
alter the way she handled him, which meant
confusion and conflict for Stefano since he was
having one type of management at High Wick and
another at home. At this point we thought that a
modified feeding programme offered the best
potential for change and growth for Stefano and his
mother, since feeding had been associated with
disappointment and frustration in the early years. His
mother agreed to participate in the feeding three times
a week, after the initial difficulties had been
overcome.
Stefano left the main building twice a day for meals
in the attic flat, but otherwise continued his daily
routine as far as possible-breakfast with his family
group, school morning and afternoon, and sleeping in
his usual bedroom.
8
Feeding
During the first 16 days Stefano accepted simple food
(eggs, toast, potatoes, milk) from the feeder. His
initial frozen body-posture alerted us to the
possibility that he had been force-fed in his early
years, and his mother was able to confirm this. We
began to understand the parasitic rather than
symbiotic nature of the mother/son relationship:
their interactions perpetuated a state of fusion and
total dependency, preventing Stefano's growth of
initiative or assertion of independence. The feeder
learnt not to collude with or reinforce either of his
extremes of passivity or destructive, manipulative
behaviour. After 16 days Stefano had hesitantly
begun to feed himself and was showing more
appropriate affect and increased understanding.
On day 17 his mother became the feeder for the first
time, although she had been in the room several times
before then. Stefano acted as he did to any new
experience, accepting the food passively and without
pleasure: it became a 'non-eating eating' experience
with his mother in control. The mother continued to
feed him three times a week for six weeks, then once a
week for four months. Time and again Stefano and
his mother faced the type of trauma reminiscent of his
early years-missed or misunderstood cues, tensions
and mood changes, control and confrontation.
One of the critical feeds was when Stefano was
given a new food, stewed apple. He did not seem to
like it, though he accepted it passively at first. At the
next meal he was more hesistant and by the third meal
he showed definite anxiety, which was reinforced by
his mother's obvious anxiety. She would have
preferred to avoid this slight displeasure (and other
sources of tension) rather than helping him overcome
it.
Another feed started with brief spells of eating,
then exploded into a battle of attrition as Stefano's
flailing arms and relentless screeching reduced his
mother to perplexed, angry hopelessness. Her words,
aimed at regaining control, only escalated the
confusion: 'Go and pick it up ... Stefano, sit down
and don't move'. During the video replay the mother
said 'What's the use of going on, nothing is ever going
to change. It's all hopeless, just like the past'.
Stefano's mother did become more conscious of
her own moods and attitudes as the feeding sessions
progressed. Her confidence increased, her timing
became more sensitive to Stefano's cues, and her
ability to share rather than take over produced
pleasurable interaction. Stefano also initiated a
feeding game. It started when he blew through a
straw, bubbling the milk he was drinking. After
looking a little apprehensively at his mother, he
offered her the glass with the sounds 'Ma-ma oo-oo'.
She responded playfully and this 'game' was repeated
over the last few weeks of the feeding programme. It
was the first real sign of intimacy, which lead to
'chatter' of a far different kind than we had heard
from Stefano before. He began to tell his mother
about daily activities, accompanied by searching
visual contact with her.
Associated responses and follow-up
The feeding programme brought about a .
number of changes common to all three
children. They were able to return to their
'family' groups in the main hospital for
meal-times without disruption; they began
to eat a wide variety of foods; and they
enjoyed food. They all showed increased
understanding, were able to start learning,
and had immediate changes in behaviour.
They showed more appropriate affect,
more social awareness, and were less·
overtly aggressive. They responded more
appropriately and adequately to simple
requests and began to enjoy a variety of
activities. Their verbal language increased·
(in the case of Zeevi, from none to some
300 words in the first three months), and
they slept better. They were no longer a
problem to handle at High Wick or at
home. All the children continued to make
slow progress over a follow-up period of
eight years.
There was one major difference between
the children in their response to the feeding
programme. Mark and Zeevi went through
a period of not eating*, but Stefano did not
refuse food. There seemed to be no obvious
*The anxiety associated with such refusal had been
likened to that of the anorexic. However, the anorexic
patient chooses not to eat for psychologically
different reasons. Crisp ( 1973) states that the latter
disorder 'is primarily one of the psychological
meaning of bodyweight with reference to puberty'.
Some aspects of our feeding treatment and the
treatment of anorexia are similar-the early relative
isolation, the 'unequivocal' (Kalucy 1973) offering of
small amounts of food, and the need to maintain
positive transference and therapeutic counselling for
the family. Unlike anorexic patients, our children's
refusal was short-lived and did not recur.
f
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b
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rr
rr
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tt
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replay the mother
1thing is ever going
<e the past'.
nore conscious of
te feeding sessions
:ased, her timing
Cl's cues, and her
e over produced
also initiated a
: blew through a
s drinking. After
t his mother, he
:Is 'Ma-ma oo-oo'.
arne' was repeated
ng programme. It
;y, which lead to
tan we had heard
o tell his mother
ied by searching
reason for this difference. Stefano's
psychopathology was different from the
other two children, his level of
understanding was greater, and his early
experience made modification more likely.
Also his mother was available to take over
the feeding, and our focus in this case was
to help both mother and child-to
concentrate on their interaction in the
hope of modifying her handling and
control.
~·
low-up
ought about a
m to all three
return to their
n hospital for
Jn; they began
ods; and they
wed increased
start learning,
in behaviour.
•priate affect,
nd were less
;ponded more
ely to simple
y a variety of
~age increased
none to some
months), and .
e no longer a
1 Wick or at
nued to make
·-up period of ·
renee between
to the feeding
went through
tefano did not
be no obvious
refusal had been
ever, the anorexic ·
psychologically
es that the latter
1e psychological
:nee to puberty'.
atment and the
-the early relative
1973) offering of
teed to maintain
tc counselling for
:s, our children's
recur.
Discussion
We learned certain basic things from the
feeding programme with these three
children, and with others not described
here. The feeding technique must be
flexible for each child: while there are
general guidelines they should be modified
when necessary. We found it best to offer
small amounts of simple food on a small
spoon near the child's mouth-but not too
near-so the child had to make only a
minimal effort to take the food. If the food
was accepted, the spoon was withdrawn
smoothly and held on the plate until the
child showed readiness for more.
The feeder should watch for minimal
approach behaviour from the child before
offering food, and should always be wary
of the 'gaping hole'-the meaningless
wide-open mouth. We learned that this
minimal contact is not necessarily
associated with eye contact: many other
body cues are available. The feeder may
use appropriate verbal responses such as
the child's name or naming the food, but
must always be attentive or cues from the
child may be lost. There is no need to
cajole, divert or be punitive. The feeder's
face should be gentle, not overtly smiling,
but relaxed and accepting. Once the child
shows interest in touching the spoon there
can be sharing rather than handing over,
for example the child feeds himself a
mouthful and the feeder gives him the next
mouthful, then gradually relinquishes the
spoon as appropriate for the particular
child.
When the child responds with pleasure
the feeder can respond in kind, but even
then it must be done in a quiet and
facilitating way-and always in readiness
for further cues. Ending a meal may
distress a child, in which case it might help
to share scraping the plate and removing it
for washing.
We found the video invaluable for both
learning and teaching for the feeder, other
workers and parents. It allows subtle cues
to be identified which are difficult to see
during the actual feeding. It also provides
the opportunity for free associations and
spontaneous recall of earlier events
associated with feeding, particularly by the
parents. It also is an invaluable
preparation for others who are going to
take over the feeding*.
The initial feedings are done by one
feeder, but once feeding is established or
refusal is overcome it is possible-indeed
desirable-for others to help. Bonds can be
transferred from feeder to caretaker. The
interplay between feeder and fed is a
shared experience requiring intuition, as
well as knowledge and skill. Like all skills,
it can only be acquired by doing it, just as
the emotional part of the experience can
only be had by 'feeling' it.
Feeding is a fundamental language
known to all: we have all had the
experience of being fed and we all have to
eat. Once the bond is established,
continuity becomes possible because the
feeding periods occur three times a day,
which greatly enhances the likelihood of
consistency of handling and integration of
the experience.
• All of the work described remains recorded on
video-cassette. It is our experience that watching
these tapes arouses deep feelings, often not very
comfortable ones. However, these feelings must be
confronted, not avoided. Once people have
conceptualized the ideas it is possible for them to
apply techniques of feeding with a whole range of
children.
Accepted for publication 6th August /985.
Authors' Appointments
Katrin Stroh and Thelma Robinson were both
involved with the feeding programme as feeder/
therapist and psychologist/teacher, respectively, and
with the subsequent language and learning work
described in Part II of this study. Although no longer
at High Wick, they are continuing the work. Reprints
and information about video material can be
obtained from Mrs. Katrin Stroh, 112 Southwood
Lane, London N6 5SY.
SUMMARY
Feeding problems are often commented on in the literature, but very little has been reported on the
systematic examination of these problems. In the present study feeding disturbances were treated as part of a
full diagnostic and treatment programme for disturbed children in a small residential psychiatric unit. The
9
feeding programme was based on the early work of Clancy and colleagues in Australia, and consisted of
offering the child food in a set situation by the same 'feeder'. A one-way screen was used for observation and
video-recording. Three children are described in detail, and a striking effect was the immediacy of change in
their feeding disturbances. It is stressed that early feeding difficulties of disturbed children can give rise or
contribute to ever-widening faulty development.
RESUME
Un programme therapeutique d'alimentation. 1: Theorie et pratique de /'alimentation
Les probH:mes d'alimentation sont souvent commentes dans Ia litterature mais tres peu de chose a ete publie
sur un examen systematique de ces problemes. Dans cette etude, les perturbations de )'alimentation ont ete
traitees comme une partie d'un programme complet de diagnostic et traitement pour des enfants perturbes,
dans une petite unite de placement psychiatrique. Le programme d'alimentation a ete base sur les travaux
anterieurs de Clancy et collaborateurs, en Australie, et a consiste a offr;r une nourriture a I'enfant dans un
ensemble de situations dis tincts mais par le me me 'nourricier'. Un miroir semi-transparent a ete utilise pour
)'observation et )'enregistrement video. Trois enfants sont etudies en detail, et le changement immediat de
leurs perturbations d'alimentation a ete tres frappant. Les auteurs insistent sur le fait que des difficultes
precoces d'alimentation chez des enfants perturbes peut donner lieu ou contribuer a accentuer des defauts de
developpement.
ZUSAMMENFASSUNG
Ein therapeutisches Fiitterungsprogramm. 1: Theorie und Praxis des Fiitterns
Fiitterungsprobleme sind oft in der Literatur kommentiert worden, aber es ist sehr wenig tiber systematische
Untersuchungen dieser Probleme berichtet worden. In der vorliegenden Studie wurden
Fiitterungsschwierigkeiten im Rahmen eines ganzen Diagnostik- und Behandlungsprogramms fiir gestorte
Kinder in einer kleinen psychiatrischen Abteilung mitbehandelt. Das Fiitterungsprogramm basierte auf den
ersten Arbeiten von Clancy und Mitarbeitern in Australien und hestand darin, dem Kind in einer bestimmten
Situation von derselben Person Essen anzubieten. Zur Beobachtung und fiir Videoaufnahmen wurde ein
Einwegspiegel benutzt. Drei Kinder werden sehr genau beschrieben und ein auffiilliger Befund war die
sofortige Veriinderung ihrer Fiitterungschwierigkeiten. Es wird mit Nachdruck darauf hingewiesen, daB friihe
Fiitterungsprobleme bei gestorten Kindem eine immer starker werdende Fehlentwicklung verursachen oder
dazu beitragen konnen.
RESUMEN
Un programa de terapeutica alimentaria. 1: Teorfa y practica de Ia alimentaci6n
Los problemas de Ia alimentacion son comentados a menudo en Ia literatura, pero se ha aportado muy poco
sobre el examnes sistematico del problema. En el presente estudio, las alteraciones de Ia alimentacion fueron
tratados como una parte de un diagnostico completo y de un programa de tratamiento para nifios con
alteraciones mentales en una pequefia residencia psiquiatrica. El programa de alimentaci6n se bas6 en un primer
trabajo de Clancy y colaboradores en Australia y consistia en ofrecer el alimento infantil en una situacion
determinada por el mismo 'donador del alimento'. Se uso un espejo unidireccional para Ia observacion, asi
como una grabacion en video. Tres nifios son descritos en detalle, y un efecto sorprendente fue un cambio
inmediato en sus problemas alimentarios. Se pone de relieve que las dificultades precoces en Ia alimentacion
de nifios con alteraciones mentales pueden ocasionar o contribuir a un fallo en el desarrollo cada vez mayor.
10
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