When I first started working with Max (not his real name) and his parents, I knew it was not going to be easy. Max was 3 years old, was not gaining weight well, and was developmentally a little delayed. His parents had sought help from their pediatrician, who had referred them to a dietician and early intervention services. They were later referred to an Ear, Nose, & Throat doctor and a Gastroenterologist. Many tests had been run with no significant findings other than the fact that Max seemed healthy and on track. He was ultimately referred to me for feeding therapy and by that time, mealtimes were a battle.
When I evaluated Max I was struck by how impressive he was. He had typical oral motor skills and his sensory processing tested as within normal limits. When I met with and interviewed the parents, they were clearly scared, stressed, and anxious about helping Max gain weight. Mom didn't out right say this but I could tell she especially had a LOT of self-blame, which seemed to translate into defensiveness. In my initial interview and assessment, mom frequently said things like, "we've tried everything and nothing works." When I asked about certain tools or strategies they might use mom's frequent response was, "that won't work with Max because..." In my efforts to gather more information I spoke with other team members. Both the Physical Therapist and the dietician warned me that the parents did not follow through with recommendations. I knew I had a challenging case on my hands.
Why is it so challenging to change parent's habits?
When it comes to feeding therapy, often we must help a family unlearn feeding practices and habits currently in daily use that are sustaining the child's picky eating or possibly making it worse. But letting go of these habits and strategies is a huge challenge for most families for a few reasons:
Families developed those strategies because they were trying to solve a problem and the strategy they landed on worked or at least seemed to work for a time.
Families who have a child who won't eat are generally VERY anxious and stressed by the situation. Stressed people have a very hard time being flexible and creative, and they often have a hard time letting go of habits that aren't serving them.
Families worry that the new strategy (unless it shows immediate results) might actually be wrong or set them back so they either won't try it or lose heart way too quickly.
Families may be additionally stressed by other life factors (financial strain, health issues of other family members, food insecurity, domestic violence) all of which make it nearly impossible to focus on making the changes your suggesting (again because people who are stressed, anxious, fearful have a hard time being flexible, consistent, creative, etc.)
Cases like Max (or Ella from out last few posts) can be extremely challenging for feeding therapists. We want to help and we may even feel like we can see exactly how to do it, but our client is not just the child. We have to have full buy-in and collaboration from the parent because the parent is the one that must enact each recommendation we make. When the parent seems ambivalent about participating in therapy, or when the family seems down right resistant to your therapy recommendations, even arguing with you about why certain recommendations won't work for their child, it can be very tempting to dig your own heels in and point fingers back at the parent. Maybe we label them as "non-compliant."
Both the Physical Therapist and the dietician warned me that the parents did not follow through with recommendations.
Maybe they are being "non-compliant" but the truth is that just like a parent can't make a child eat, a feeding therapist can't make a parent do anything, even if we know it would help. As the saying goes, we can lead a horse to water but we can't make it drink." If the parent is being "non-compliant" there is nearly always a reason (a few common ones are listed above) and it indicates that we as feeding therapists must better listen to the parents' experiences, beliefs, observations in order to modify our plan, AND we must find another way to motivate, convince, support the parent with making necessary changes in order to move forward.
I think it's important to really pause here for a minute because again, this mirrors the exact issue that we often get SO frustrated about with our families. We often have a lot of trouble getting parents to STOP pushing kids to eat and instead letting the child make his/her own choices (with some guidance and support from the parent that should be SO enticing that the child can't help but take the support and eat). The irony however, is that as feeding therapists we often don't recognize the exact same interplay between us and parents- we try to push, encourage, force our parents to change how they interact with their child and meals, when the reality is that we must let parents make their own choices (with some guidance and support from us that should be SO enticing that the parent can't help but take it).
Just like a parent can't make a child eat, a feeding therapist can't make a parent do anything, even if we know it would help
Once we believe this, we need to help the parent do 2 things-
See that new/different strategies are available
Convince themselves that they want to try those new strategies, make a change & do things differently
Our favorite strategy for this, hands down, is Motivation Interviewing (MI). Motivational Interviewing is an evidenced based collaborative approach created by Miller & Rollnick, which is used to help people express why they want to make a change and then move towards that change.
Why we love using motivation interviewing as part of our feeding therapy
We love this tool primarily because it's highly respectful and highly effective. But why else should you use MI in your feeding therapy tool box:
It's evidence based. There is strong research to support its effectiveness with helping people change across a wide variety of settings and issues. There is even a study that looks specifically at MI and picky eating.
MI is conversational and is an excellent way to practice actively listening, which can sometimes be challenging for feeding therapists (all medical professionals really) because we're used to talking and giving advice.
Using MI is a great way to build rapport with your parents and helps you show them that you really care about what they are feeling, seeing, and experiencing.
MI pushes you to make sure you're tapping into the parents' goals/hopes/needs, rather than putting your priorities front and center.
MI allows you to set a strong collaborative relationship with the family from the start, which is truly essential for all pediatric therapy, especially feeding therapy.
Using motivational interviewing as part of feeding therapy is not rocket science but it does take some creativity and LOTS of practice. We explore the how to of MI more in this post.