Characterisation of paediatric feeding disorders and the underlying factors implicated in their development and maintenance

Feeding disorders are psychological conditions that occur during infancy and early childhood, and result in insufficient intake of foods. Existing feeding disorder research identifies a raft of factors associated with predisposition, development and maintenance of feeding disorders, as well as a multitude of potential outcomes for the child and the system around them. However, neither feeding disorders nor their aetiological bases are well defined or uniformly applied in general, academic or clinical domains. Furthermore, the relationships and differences between observable characteristics, diagnostic criteria, and problem perceptions, and the bearing of these on disorder identification and treatment, are under-researched. The numerous definitions and profiles for feeding disorders make comprehension and knowledge gathering very difficult for caregivers and researchers, and thus hinder research and clinical progression in the field. The overarching aim of this thesis was to examine and characterise paediatric feeding disorders. The objective was to characterise and triangulate what feeding disorders are in terms of observable appearance, external perception, and psychometric properties, and better understand what constitutes a feeding disorder from multiple relevant perspectives. A mixed methods approach was taken to the collection and analysis of data, to obtain both depth and breadth of information. The results of the current thesis suggest that feeding disorders are characterised by a variety of behaviours and features within a biopsychosocial model. While physical models of feeding disorders are outdated, the potential for underlying physical contributing factors and resultant physical outcomes was highlighted throughout the current research and should not be ignored. However, overreliance on physicality, under-recognition of psychological processes, and consequent deficits to disorder identification within clinical settings, was also illustrated within the research. Furthermore, significant issues were raised regarding the lack of a consistent and inclusive model of feeding problems and disorders within healthcare systems. Though most clinicians saw feeding on a scale from normal to abnormal and frequently emphasised the value of early identification and treatment, the referral and treatment pathways that were discussed whereby only the most severe or physically affected children were treated, were not consistent with these models. Interviews with mothers highlighted the role of intrinsic child factors within the development of disordered feeding, including challenging behavioural characteristics, sensory sensitivities, difficult temperament, and lack of feeding motivation or avoidance of new foods. The importance of these child factors was supported by psychometric assessment, which identified distinct patterns of child characteristics associated with different types of problematic or disordered feeding, and a strong association between disordered feeding and the parent perception of having a difficult child. Furthermore, video observations of child mealtimes highlighted not only disparity in the amount of food eaten between disordered and non-disordered children, but a considerable deficit in the level of interest, motivation, and engagement with feeding shown by disordered children. Deficits to child feeding motivation pose a problem for parents that is less obvious than extreme emotional reactions, but which can be equally distressing for the parent who views nourishing their child as one of their major responsibilities. This point was reinforced across parent interviews and mealtime observations, and should be a key factor in the identification of families in need of support and intervention. Parent interviews, healthcare professional interviews, and psychometric assessment, all highlighted the considerable presence and role of parent anxiety within feeding disorder development. Parent anxiety was discussed as a potential cause and an outcome of challenging feeding behaviour, exacerbated by the perceived extent of the child s feeding condition and the dearth of support and information about dealing with significant feeding issues. Anxiety was seen by parents and healthcare professionals to influence the feeding strategies used by parents, and without intervention to contribute to a downward spiral of negative feeding interactions. Disordered feeding was also seen to interfere with social interactions, which would otherwise play an important role in the child s feeding and dietary development, and provide social support and guidance for parents. These patterns of problem and disorder perpetuation are liable to persist while general and clinical understanding of feeding disorders is minimal and inconsistent. The findings of the current thesis pose a great variety of potential influences and risk factors for feeding disorder development, supporting an individualistic approach to disorder identification and intervention, and the need for a significant change in the current systems for dealing with feeding disorders. It is essential to take each of the different components into consideration to understand the specific mechanisms underpinning the maintenance of the feeding disorder and aid selection of the most suitable and efficient approach to intervention. The pattern of factors implicated in each individual feeding disorder case will be differentiated according to the child, the parent and the child s general environment. Identification of the full range of children in need of support and intervention is reliant on recognition of the diversity in disorder type, severity and presentation.