Alan H. Silverman

Systematic Review of Psychological Interventions for Pediatric Feeding Problems

OBJECTIVE To conduct a systematic review of the research evaluating the effect of psychological interventions for pediatric feeding problems. METHODS A search was conducted to identify studies using psychological interventions for pediatric feeding problems published between 1998 and 2013. Randomized controlled trials (RCTs) and nonrandomized studies that examined aggregated outcome data were included. Primary outcomes were child mealtime behavior, nutritional status, and caregiver stress. A risk of bias assessment was conducted and the quality of the evidence rated using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS 13 studies were identified and a narrative synthesis framework was used to report findings. CONCLUSIONS The preponderance of evidence suggests positive effects of psychological intervention for the treatment of feeding problems. However, limited data and the paucity of studies using RCT methodologies limit conclusions that can be drawn regarding the efficacy of these interventions. Future studies using more rigorous research methods are needed to enhance understanding of these interventions.

A Biopsychosocial Model of Normative and Problematic Pediatric Feeding

A comprehensive model is presented that (a) highlights factors that have been implicated in the development and maintenance of feeding problems in both normal and clinical populations; and (b) provides a framework for the prevention, management, and treatment of feeding problems across the range of physically healthy children to children with acute and chronic illnesses. Relevant literatures and feeding models were synthesized to present a comprehensive unified biopsychosocial model that may aid in the prediction and synthesis of information about feeding and eating in both normal and clinical populations and provide a framework for interdisciplinary research and intervention.

Assessing Family-based Feeding Strategies, Strengths, and Mealtime Structure with the Feeding Strategies Questionnaire

OBJECTIVE Develop a questionnaire to assess family-based feeding strategies, strengths, and mealtime structure for use with children with feeding problems; validate this new instrument with caregivers of young children from the community and a specialty feeding-clinic; and examine preliminary evidence for reliability and validity. METHODS Community caregivers (n = 702) and caregivers seeking services at a pediatric feeding specialty clinic (n = 288) completed the Feeding Strategies Questionnaire (FSQ). A smaller portion of these families also completed an established feeding measure. RESULTS Exploratory and confirmatory factor analyses were conducted to develop and validate the FSQ factor structure that resulted in six scales: Mealtime Structure, Consistent Mealtime Schedule, Child Control of Intake, Parent Control of Intake, Between Meal Grazing and Encourages Clean Plate. Evidence of reliability and validity was obtained. CONCLUSION It appears the FSQ can aid the assessment of feeding strategies relevant to the prevention or treatment of pediatric feeding difficulties.

Nutritional and Psychosocial Outcomes of Gastrostomy Tube-Dependent Children Completing an Intensive Inpatient Behavioral Treatment Program

Objectives: Limited published data describe the long-term effects of behavioral strategies to wean children from gastrostomy tube (GT) feeding dependence. This study presents data relating to nutritional and psychosocial outcomes observed during a 1-year period in medically complex GT feeding–dependent patients who completed an inpatient behavioral-based tube weaning protocol. Methods: This was a retrospective study of prospectively and retrospectively collected data associated with a clinical cohort of 77 children diagnosed as having a feeding disorder, GT feeding dependence (>1 year), and an inability to maintain acceptable growth via oral feeding completing an inpatient tube weaning protocol. Nutritional data (percentage of ideal body weight, and oral energy intake as percent ofenergy goal) and psychosocial data (mealtime behavior problems, quality of caregiver and child interactions, and parenting stress) were assessed pre- and post-hospitalization. Nutritional data were also monitored longitudinally at 1, 3, 6, and 12 months postreatment. Data were grouped for retrospective analysis. Results: Mealtime environment and feeding behaviors significantly improved, and all of the patients demonstrated reductions in tube dependence aside from 1 treatment failure. Fifty-one percent of patients were fully weaned from tube feeding after 2 weeks and an additional 12% completed weaning in the outpatient follow-up clinic within 1 year. Patients maintained nutritional stability at the 1-year posttreatment follow-up appointment. Conclusions: Inpatient behavioral interventions are highly effective and safe for transitioning long-term tube feeding children to oral feeding.

Interdisciplinary Care for Feeding Problems in Children

Children with feeding disorders frequently present to primary care practitioners. The causes of these feeding disorders are often a mix of medical, developmental, and behavioral factors. Evaluation and treatment of feeding problems typically require the expertise of physicians, speech and language pathologists, registered dietitians, and psychologists. This article advocates an interdisciplinary, biobehavioral approach for the assessment and treatment of feeding disorders. First, prevalence and causes of feeding problems are discussed. Second, interdisciplinary assessment and treatment strategies are considered, including the specific roles of the interdisciplinary team members. Third, behavioral treatment strategies are described. Fourth, various treatment options are described.

Assessing Children's Mealtime Problems With the Mealtime Behavior Questionnaire

A caregiver questionnaire that assesses mealtime problems in children aged 2 to 6 years old was developed. Community caregivers (n = 712) completed the Mealtime Behavior Questionnaire (MBQ) and measures of child behavior and family mealtime behaviors and environment. Exploratory and confirmatory factor analyses revealed and validated the MBQs 4 subscales (food refusal/avoidance; food manipulation; mealtime aggression/distress; and choking/, gagging/vomiting). Mealtime problems occurred from “sometimes” to “always” for 1% to 61% of the sample. The MBQ demonstrated excellent to fair internal consistencies, and preliminary evidence for validity was found.

Cognitive-Behavioral Interventions Via Telehealth: Applications to Pediatric Functional Abdominal Pain

This integrative literature review explores the utility of telehealth, specifically videoconferencing, for the delivery of cognitive-behavioral therapy (CBT) to youth with functional abdominal pain (FAP). Children with FAP and their families encounter a number of barriers to treatment that hinder access to traditional in-clinic treatments, such as CBT. Videoconferencing may be a feasible and effective alternative to traditional services and may hold benefits such as high rates of patient satisfaction, improved access to care, improved attendance rates, and cost reductions to the family. This article concludes that videoconferencing provides a good “fit” with the delivery of CBT to children and adolescents with FAP.

A multicenter study on childhood constipation and fecal incontinence: Effects on quality of life

OBJECTIVE To describe the effects of childhood functional constipation compared with functional constipation plus fecal incontinence on quality of life, evaluating effects on physical, psychosocial, and family functioning. STUDY DESIGN This prospective, multicenter study collected data from 5 regional childrens hospitals. Children meeting Rome III criteria for functional constipation were included. Parents completed the following 5 instruments: Pediatric Quality of Life Inventory (PedsQL), PedsQL-Family Impact Module, Functional Disability Inventory-Parent Version, Pediatric Inventory for Parents (PIP), and Pediatric Symptom Checklist-Parent Report. RESULTS Families of 410 children aged 2-18 years (mean [SD], 7.8 [3.5] years; 52% male) were included. Children with functional constipation+fecal incontinence had worse quality of life than children with functional constipation alone (PedsQL Total Score, P ≤ .03). Older children with functional constipation + fecal incontinence had lower quality of life than their younger counterparts (PedsQL Total Score, P ≤ .047). Children with functional constipation+fecal incontinence had worse family functioning (PedsQL-Family Impact Module Total Score, P ≤ .012), greater parental stress (PIP-F Total Score, P ≤ .016; PIP-D Total Score, P ≤ .013), and poorer psychosocial functioning (Pediatric Symptom Checklist Total Score, P ≤ .003). There were no statistically significant between-group differences in physical functioning based on the functional Disability Inventory. CONCLUSION Fecal incontinence significantly decreases quality of life compared with functional constipation alone in children. Older children with functional constipation+fecal incontinence may be at particular risk. Strategies for early identification and treatment of constipation along with diagnosis and treatment of related adjustment difficulties may mitigate the negative impact of this highly prevalent condition.

A Cognitive Behavioral Adherence Intervention for Adolescents with Type 1 Diabetes

This study examined the impact of a cognitive behavioral intervention for nonadherent adolescents with type 1 diabetes. Six youths having problems following the diabetes regimen received training in cognitive restructuring and problem solving during individual sessions. A multiple baseline design across participants was used. Treatment effectiveness was assessed through 24-hr recall adherence interviews with adolescents and frequency of testing data was downloaded from glucose meters. Data was also collected for diabetes-specific stress. Five youths displayed improvement on at least one self-care behavior. Furthermore, the results suggest that the cognitive behavioral intervention was effective in diminishing diabetes-related stress in two participants. Cognitive behavioral interventions show promise for increasing self-care behaviors among nonadherent youths with type 1 diabetes. However, individual youths varied in their response to treatment. Further research is needed in developing procedures to better meet the needs of youths, improve youth participation, and enhance treatment effectiveness.

Excessive coupling of the salience network with intrinsic neurocognitive brain networks during rectal distension in adolescents with irritable bowel syndrome: a preliminary report.

The neural network mechanisms underlying visceral hypersensitivity in irritable bowel syndrome (IBS) are incompletely understood. It has been proposed that an intrinsic salience network plays an important role in chronic pain and IBS symptoms. Using neuroimaging, we examined brain responses to rectal distension in adolescent IBS patients, focusing on determining the alteration of salience network integrity in IBS and its functional implications in current theoretical frameworks. We hypothesized that (i) brain responses to visceral stimulation in adolescents are similar to those in adults, and (ii) IBS is associated with an altered salience network interaction with other neurocognitive networks, particularly the default mode network (DMN) and executive control network (ECN), as predicted by the theoretical models.