A Place to Go When a Child Really Refuses Food

Some years ago, a couple came to Ramasamy Manikam with a disturbing problem. Their 8-year-old daughter, who had suffered a brain injury, refused to eat despite countless hours of pleading and bribery. One thing worked: If they left the room, she would fling the food to the floor, get down from her chair, crawl into it and eat.

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Dr. Manikam, a clinical psychologist who has been treating feeding disorders for 19 years, listens to such stories with a gentle neutrality. He remembers the girl’s mother weeping as she explained what this strange ritual was doing to their family; if she or her husband ventured into the room, even enough to cast a shadow, the girl would stop eating, so they would wait, frozen, outside. The three of them — mother, father and child — were trapped in a “real triad problem,” he said, but “they were really good people, for all that.”

There are only nine programs in the country designed to treat young children who will not eat. Dr. Manikam runs one of them, in a ward at St. Mary’s Hospital for Children in Bayside, Queens, that can house six inpatients. Inside a row of small rooms at the Center for Pediatric Feeding Disorders, therapists do the slow, careful work of breaking down children’s resistance to eating. They act as detectives, tracing the behavior backward to the experience that may have shaped it.

Underlying the work is the notion that eating is a learned behavior, not an instinctive one. Babies fed by tube after birth may never learn to associate the sensation of hunger with the act of eating; babies who do not move to solid food by the age of 8 months may not learn to breathe, chew and swallow without choking. When those learning opportunities are missed, children can develop a deep anxiety that defies logic, something that Dr. Manikam compares to a fear of flying.

He has spent a career trying to break down that fear, most often in children with disabilities who become accustomed to tube-feeding early in life.

“I am a firm believer that learning never ends,” he said. “If you are living, you can learn.”

There was, years ago, the case of an 11-year-old boy with Asperger’s syndrome. The boy had a high I.Q.; he could play the trombone and deliver a lecture on sharks “better than Jacques Cousteau,” Dr. Manikam recalls. But he was stick-thin. He barely ate and survived by hiding in a closet and inserting a feeding tube in his abdominal incision, something he desperately wanted to keep secret. The boy’s mother, depressed and anxious, had given in to his wishes.

Dr. Manikam, then treating patients at the Kennedy Krieger Institute in Baltimore, managed the 11-year-old’s case for two months. At first he just built a relationship: He invited the boy to lecture medical students about sharks, which flattered the boy deeply. Ultimately, the doctor appealed to the boy’s ego, asking him to teach younger children about the importance of nutrition. The task required the boy to eat on videotape, something he willingly did. Without treatment, Dr. Manikam said, “he would have starved.”

More typical are babies and toddlers who spent their early months in the hospital. Dr. Manikam recalled a 9-month-old brought from South America who would bottle-feed only under a bizarre set of circumstances. She had to be held over an adult’s shoulder, on the edge of sleep, and fed by a second adult from behind, with the sound of a vacuum cleaner in the background. The baby had lived in a neonatal intensive-care unit whose nurses had noticed that she seemed to eat more when the cleaning crews were in the area; her frantic parents made a recording and carried it around with them.

“Actually, they might have shaped the child to it,” Dr. Manikam said. “I cannot verify that the child made the association.”

With the baby, as with the 11-year-old, Dr. Manikam and his colleagues used “deconditioning,” a behavioral psychology technique that aims to extinguish a conditioned response. Therapists began by playing the sound of the vacuum cleaner, then altering it slightly until the baby’s window of acceptance grew larger. This took six weeks.

They took a similar approach with the brain-injured girl who would only eat off the floor: Therapists hid in the house and observed her while she ate alone, then played with her on the floor when her parents were not around, to “neutralize the battle of wills.” The therapists became “positive agents,” new figures in her life, and very slowly they added food to the play. Four months later, she was eating at a table.

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