A Bowl of Herbs With Love in Three Acts: What Happens During Sessions

People ask me what are my sessions are like and how long it takes to get a result. Well, it depends. Here is a vignette of a three-session case that took two months from beginning to end.

Setting the stage

A father called about his 14-year-old daughter. His first stated concern was maybe his daughter had a sensory issue in her mouth. After his description, my thought was that this child might need a feeding therapist to mediate sensory issues. Father did not want a feeding therapist. He said he was not clear. The real issue, he thought, was that his daughter did not eat vegetables. I told dad that it would be a healthier practice if his daughter, Mary (not her real name), ate vegetables. Vegetables have a bitter taste, I told him, that some people simply do not like. Some of these flavors come from sulfur compounds. These compounds prevent cancer and other illnesses. Sulfur compounds, such as isothiocyanates in broccoli, are health powerhouses that taste bad to some people. I wondered, if there was an eating disorder or another problem that, for some reason, could not be disclosed over the phone. We made an appointment.

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Breaking Mealtime Rules and Mirror Neurons

There’s a practical rule for parents feeding children: Keep meals to 20 to 30 minutes. Most meals take about that amount of time. If meals are a difficult time at your house, 20 to 30 minutes is enough discomfort for everyone. There is also a time to break the 20/30 rule. Reasons for breaking the rule come from the relatively recent discovery of mirror neurons and a case history. Mirror neurons explain how we learn by copying without conscious cognition. The specialized nerves use the eye or ears to bypass the word driven teaching styles and help us with social cues. Mirror neurons help pre-verbal infants and toddlers learn by watching and listening. When you and another adult enjoy a postprandial chat, staying at table models conviviality for your child.

Beatrice Beebe, an important infant researcher, shows a video demonstrating how fast moms and their babies copy each others facial gestures. Famed child psychoanalyst Theodore Gaensbauer thinks that mirror neurons explain how infants as young as three months link gestures and emotions by copying. Enjoy family and social meals together with your child as soon as possible after the birth.

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Monkeying Around with Creative Moms

Some of my favorite professional moments are from the moments the parents get the fundamental ideas of helping their child eat. The parents have become creative and gone beyond struggle, worry about weight, calories and developmental status. The parents connected deeply with themselves and their child. This connection helps the child progress. When the parents’ creativity sparks, I also learn. Today, I am writing about a simple technique with stuffed animals that helped one mother and her child. Maybe, it will help you.

Mom, Fatima, discovered that her son’s favorite toys, stuffed monkeys keep him focused on eating. Her son, Yunus, has lots of monkeys. Fatima placed two of Yunus’ stuffed monkeys at the table to keep her son company and more. The monkey’s kept Yunus, her son, company and engaged in eating without some of the bother and worry that had been going on before. Fatima let me post two of the photographs of her idea in action. Here is the first:

monkeys and parents

Stuffed animals are what psychologists call transitional objects. Transitional objects help toddlers mediate between their inner world and the outer world. Some children prefer blankets or teddy bears. In this case, monkeys did the trick for Yunus.

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Found In Translation

One morning in New York City public clinic, a mother sits down and tells me her 4 month old son has been vomiting his formula for the past 3 months. The boy’s weight and height were adequate. Enough formula was being digested. Maybe the child needed something other than the standard formula. “What did the doctor tell you?” I asked. Mother told me she had not told any of this to her son’s pediatrician. I was concerned because chronic vomiting can corrode her child’s esophagus, throat and vocal chords.

Mother told the pediatrician nothing about the vomiting because of something going on between her husband and herself. Father, in her opinion, was chronically anxious for their first child. It appeared as if when Father thought his son needed more care, Mother reacted by thinking their child needed less. The child was caught in the crossfire with a possibly damaging condition.

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Watch, Wait and Wonder

One day, I watched a father hold the bus’ back door open for his, around, 3 year old son. He expected his son to get down from the bus to the sidewalk on his own. The boy hesitated. Rather than use words to urge the son past his hesitation, the father simply held the boy’s hand, perhaps, to help him down. The son suddenly jumped down to the street. Dad’s silent, connecting hand enabled an existing ability.

Delayed children also want their leap and use gestures, like pausing, to be understood. Kelly, for example, wanted and needed to eat more. Born at 23.5 weeks, at her 20th month the IFSP report stated she had been through seizures, bleeding in the brain, and pulmonary problems. She has hydrocephalus, vision problems, cannot sit on her own, move her left arm or hand much. Her right arm and hand could move some. When we met at her 24th month, she could intentionally move her head a bit to the right even though the IFSP stated that she had no control over her head. Her parents had trouble feeding her and were concerned with her weight. She ate barely enough of pureed food and had a feeding tube in her history. I wanted to keep tube feedings in the past. I wondered how I could help before I even met the family.

Wondering is part of a three step process for developmentally based therapy. Developmentally based therapy is about meeting the child’s needs from the child’s perspective. The other two steps are watching and waiting. Developmental therapists have to be patient and know that their particular disciplinary knowledge must fit in to the child’s desires expressed in gestures or words. Like the father on the bus, the therapist has to watch and learn about the child to help the child solve their own problem. Waiting, like quietly holding a hand, helps the child take the next step because we can see the child’s wishes.

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Walking ‘Til You Come Back to Me

When busy parents rush home and the first thing they do is rush to put dinner on the table, they are often perplexed when junior won’t eat. The same child who was cranky from hunger before the parent arrived may be much less concerned about dinner when the parent appears.

What’s going on? Parents are goal oriented, busy and scheduled. Little children are interested in the returning parent, not the schedule of chores that need doing before bedtime. They missed their mommy and daddy. Children show they want some attention and affection. In most cases, bonds restore easily with a little attention. When parents give a little time after returning from work, bonds restore easily. A little playtime before the meal makes dinner easier for everyone.

Sometimes, however, the longing for parents creates more serious eating problems. Longing is part of the picture for 2-year old Amanda, a child I am seeing for food refusals and slow weight gain. Early in the therapy, we examined Amanda’s growth chart. We realized that Amanda’s significant weight increases occurred when mom, a teacher, was home on extended holidays. Part of the problem also lay in with feeding, speech, and movement delays.  A confirming clue appeared. Despite her ability, Amanda refused to hold her own bottle. It was as if she wanted to be babied and did not want to grow up. Her stay-at-home dad helped, too. Amanda’s eating improved when we tightened up the schedule and she fed herself with less assistance. Mysteriously, she began to hold her own bottle. Amanda has been growing taller rapidly. Her rate of weight gain increases more slowly. Mealtimes became less challenging.  Then, a new problem appeared.

Amanda began to vomit her bedtime milk. She could not afford to lose the nutrients. I guessed that Amanda needed more time with her working mom. I suggested that mom and Amanda go for a little walk after dinner. An after dinner stroll fit the family schedule, improves digestion and creates unhurried time for mother and daughter to hold hands. Sometimes, dad went along. Vomiting ceased within a week.  Amanda’s parents’ attention to the interplay of emotional and eating set everyone on the right path.  We are all looking forward to more progress.

Be My Little Baby

Children grow up in body and mind even when they are affected by some kind of delay or medical conditions. When a medical or developmental problem masks signs of inner maturity, the drive to grow remains. The drive to self feed, for example, exists even when most people miss the child’s cues. In the parents’ mind, the child remains, unconsciously, immured in the NICU, the disease or the technical definition of the delay. Professionals inadvertently contribute to this feeling when they focus in on limitations.

When a growth problem hard to understand, parents and professionals often focus on food instead of the processes related to eating the food. The important adults should the child as a whole person with a desire to grow into increasing mastery.  When the child is kept from mastering of self-feeding within their limitations, feeding struggles and refusals can start because the child does not yet recognize the delay. Children, especially infants and young toddlers, only recognize their desires. When we do not recognize others’ desires, emotional disconnects develop. In the case of feeding, mealtimes can be unsuccessful nutritionally and socially. Here is what happened with Pearl, an underweight toddler with a transplanted liver.

 A long list of drugs suppressed Pearl’s immune system in order for her new liver could make itself welcome in her body. The same drugs, though, irritated her mouth, throat, intestines and suppressed her appetite. The very lifesaving medications were one reason Pearl was underweight. To make things more challenging, Mary, the mother, and, Tom, the dad, were working through a difficult divorce. Dad was out of the house. Loss of a parent and the stress of a divorce can also a make a child want to eat less. And, no one had told Pearl’s parents that keeping her from self-feeding caused Pearl to fight feedings.

Mom, a nurse, understood that drugs can lower the appetite. It was hard, at first, for her to understand that an underweight with medically-induced reasons to a poor appetite should not be force fed, let alone to self feed.  The daily feeding struggles further diminished Pearl’s appetite. Mom was inwardly experiencing the vulnerable baby and not the child strong enough to fight her way back to health and mom during feedings. Mom had to grow past the challenging baby months to become the mother of an increasingly healthy toddler capable of asserting her own desires.

Another area of infantilizing was the little child’s table. Children do better watching grown-ups Infants and young toddlers need adults or at least an older child to model self-feeding in order to eat well. That common piece of furniture had to go.

The struggles ceased. Pearl began to gain weight. Her need for medicines decreased as her body adapted to the new liver. Sessions decreased from twice a month, to monthly to every other month. I was getting ready to close the case.  A call came. Pearl’s weight plummeted. That nice healthy growth curve that took months to achieve sank like the Titanic. What was the iceberg, I wondered? I rushed up as soon as I could.

By chance, I arrived as mom was taking Pearl to the school bus in a stroller. Pearl and her mom lived in a high rise whose set-back entrance felt like a mile to the bus to mom who had to be at work on time. Pearl could do the walk, albeit at toddler pace.  At the same time, a working, single mom definitely is busy. Those few extra morning minutes provided by the stroller could make a big difference in terms of getting to work on time. Looking at the stroller, then, looking at Mary, I said, “Are you babying her again?” I saw an abashed face with an acknowledging smile. Mom had backtracked on Pearl’s self-feeding and other parenting strategies we had worked on. We all got back on track. Pearl’s weight climbed back into the healthy range.