发件人: Babble and Munch Learning

发送时间: 2023 年 7 月 31 日 18:32

收件人: hillarysong2019@gmail.com
主题: [A-Z Feeding] D is for Division of Responsibility

Hi Hillary,

Welcome to a new email in our A-Z of Feeding Therapy series, where you receive
a weekly email on a feeding therapy topic, one for each letter of the alphabet!

I’ve had one of those weeks (or two!) where things have not gone to plan. That
means I’m dropping into your inbox a few days later.

This week we’re covering a key foundational principle in feeding, ‘D is for Division
of Responsibility’.

Have you heard of the Division of Responsibility in Feeding?

Even if you’re not familiar with the term, you may have come across some
principles from the Division of Responsibility (or ‘DoR’ for short) in public health
messaging e.g. “Parent provides, child decides”. That’s not exactly the Division of
Responsibility (and can be misrepresented!), but it’s close to some of the principles.

The Division of Responsibility was developed many decades ago by Ellyn Satter (a
well-known Dietitian and Family Therapist) and is based on responsive parenting
and feeding practices. Responsive feeding is considered best practice for childhood
feeding by institutions such as the World Health Organisation and the American
Academy of Pediatrics.

What is the Division of Responsibility?

The Division of Responsibility in feeding is a set of principles for feeding children

from birth through to adolescence. It is based on the premise that children are born
with an innate ability with eating, that (when all is going well…we’ll come back to
this) they can eat what they need to meet their body’s individual nutritional and
growth needs, and learn to eat the foods their parents eat over time.

The Division of Responsibility is basically about a set of feeding “jobs” or roles in

feeding that both parents and children take part in, in order for feeding to be
successful and for children to learn to grow up feeling good about eating. It’s all
about the feeding relationship between the parent and the child.
It basically boils down to the parent providing structure for the child, while the
child needs autonomy in the feeding situation.

If you are familiar with the Division of Responsibility, did you know that there are
some age-based differences to how it’s applied?

Here is a quick summary...

The Division of Responsibility for infants:

 The parent is responsible for one part of the mealtime structure – the
‘what’.
 The infant is responsible for ‘how much’ (and everything else).

This means that the parent decides if the baby will be fed via breast or bottle,
breastmilk or formula (the ‘what’). At this stage it isn’t the parent’s job to decide
when their baby will feed or how much they will take at a feed – that is the baby’s
job, based on their hunger cues and appetite. That means feeding on demand,
rather than a set schedule determined by the parent.

The Division of Responsibility for older infants making the transition to

solids and family food:

 The parent is still responsible for the ‘what’ and is starting to be

responsible for the ‘when’ and ‘where’ of feeding (the structure).
 The infant is still (and always!) responsible for ‘how much’ and ‘whether
to’ eat the food/fluid offered by the parent (the autonomy).

This means that parents are starting to bring their child to the table to share in
family meals and slowly transitioning them from a milk feeding on-demand
schedule, to more of the solids meals/family meals schedule.

The Division of Responsibility for toddlers through adolescence:

 The parent is responsible for the ‘what’, ‘when’ and ‘where’ (the
structure).
 The child is responsible for ‘how much’ and ‘whether’ (the autonomy).

This is what is most commonly referred to as the Division of Responsibility – the full
principles in practice. It is where the parent chooses the food they will provide, sets
a mealtime routine of meals and snacks (without grazing in between), and decides
where the child/family will eat. These decisions are all individualised to the child and
family’s needs, so that they are supporting the child to do their best with eating.

Why do we need to know about the Division of Responsibility?

Besides being best practice in childhood feeding, the Division of Responsibility
helps parents and children to work towards that child’s later eating competence.
The learning that takes place in childhood underpins their adult attitudes towards
eating, food, appetite and enjoyment of meals.

The Division of Responsibility also supports the relationship between the parent and
child in mealtimes (the ‘feeding relationship’).

Problems in feeding and the feeding relationship can happen when we’re not
following a Division of Responsibility.

When we try to ‘get’ children to eat a certain amount or certain types of food, we’re
basically crossing that line of the Division of Responsibility and trying to do the
child’s feeding job for them, taking away their autonomy and control.

This is felt by the child as pressure (a topic we covered last series) and can lead to
the child pushing back and refusing or developing a dislike for the pushed food.
This is where mealtime battles can sometimes begin or become more significant.

On the flip-side, if we don’t provide structure for a child, and instead let them
wander around and graze through the day whenever they want, then we’re letting
the child try to do the parent’s job and instead compromising their appetite, interest
and attention to eating.

In our feeding therapy, the Division of Responsibility also gives us an ‘ideal’ to base
our feeding principles on. It forms the basis of responsive feeding and can therefore
also form the basis of our Responsive Feeding Therapy. It gives us something to
share with families and work towards, based on the child and family’s own needs.
And it’s done without judgement or blame – feeding kids can be hard work (and
issues crop up so easily)!

Does the Division of Responsibility apply to children with significant

feeding difficulties?

I have heard some therapists argue that the Division of Responsibility is not
applicable or not helpful for children with significant feeding difficulties or aversions
or neurodevelopmental differences.

That their feeding difficulties are so significant or the feeding relationship so

impaired, that the Division of Responsibility is not applicable to them in a
therapeutic setting. That it’s a nice principle, but not one that we can apply with
more entrenched feeding disorders, when a child may not be able to listen to their
own internal cues of hunger and fullness.
Is that a view you can relate to?

I want to make a counterargument and say that these children also deserve our
belief in their innate competence, the structure we can provide them, and the
autonomy they need to grow in independence.

Does this mean that we can fully implement the Division of Responsibility straight
away with all our kids (and families) with significant paediatric feeding disorders?

No! We’re not being black and white, one-size-fits-all here!

We may have a child in discomfort due to reflux, allergies, nausea, aspiration, a

nasogastric tube, or any other underlying medical or developmental challenge that
leads to significant discomfort around eating or drinking. If a child refuses to eat in
this situation, that is actually a protective response to try to prevent this discomfort
from occurring or reoccurring.

Or we may have a child with a history of discomfort or trauma around eating who
has now developed a feed aversion (where protective withdrawal moves to learned
withdrawal).

We might have a child who is tube dependent, who has been fully tube fed from
very early and does not have a schema for hunger and fullness, and how this may
relate to eating and drinking, or even how they may go about eating or drinking.

Or we might have a parent who is so worried about the child’s nutrition and slow
growth that they can’t help but pressure, force or coerce their child to eat,
because they love them so much and just want them to eat and be healthy.

We can’t expect all of these children to be tuning into hunger and fullness cues or
even know what these are (i.e. reflux can be uncomfortable or painful, as can
hunger. It’s no wonder these signals could get mixed up!).

And we can’t expect all these parents to be able to immediately shift from doing the
child’s jobs (taking over the autonomy) to stepping back and trusting the child to do
the eating.

So how do we bring the Division of Responsibility into these situations?

Firstly, we need to make sure we complete a super, extra thorough assessment of

the child’s feeding and medical history (I cannot ever state this enough!). We
need to be constantly screening for red flags of underlying issues (more in other
topics and in my teaching), working with the medical team and referring on when
we have concerns that have not been addressed for the child.

If we miss a current and ongoing issue that is impacting feeding, we’re not
going to be able to make much progress in therapy without addressing or
accounting for the underlying cause or contributor. I’m particularly thinking of
gastrointestinal discomfort (as one example), as it’s just so pervasive and important
in paediatric feeding disorders.

Secondly, we can prioritise the feeding relationship as one of the central, most
important aspects of the child (and parent’s) development around feeding.

Sometimes we can’t do this first if we need to work with the family to make small
wins in other areas, work with the child’s strengths and build trust with the
family and child. But we do need to keep it there central to our approach and long-
term goal for the family.

We could help the child and family find ways of connecting around food or
mealtimes…working towards some form of shared experience that is not traumatic
but lays the foundation for steps towards positive moments of engagement and
enjoyment.

We could perhaps find just one meal or snack time in the day, where we can work
with the family to come up with a plan where we put aside pressure and allow the
child more autonomy in making a decision around how much or whether they eat.
Where we can start to shift the focus from ‘getting’ the child to eat, to supporting the
child to start to tune into their own internal cues, perhaps for the first time.

Or we could work towards more mealtime structure over time, with less grazing
through the day and more appetite for mealtimes.

We could bring a tube-fed child to the table to participate in family meals for the
first time, while the family provides a lived example of other reasons that we eat
besides appetite (i.e. social connection, curiosity etc).

We can find ways to look for competence and strengths in the child and their
eating and celebrate these.

Let’s work towards building connection at mealtimes, while the caregiver builds
structure and the child experiences autonomy for feeding. Sometimes we can do
this more quickly with big changes. Sometimes with just tiny, tiny, ‘pebbles’ of
change in the extended path towards learning to feel good about eating.
Let me know, is the Division of Responsibility something you use in feeding or
feeding therapy? I’d love to hear.

Yours in feeding,

Carly Veness
Speech Pathologist & IBCLC
Babble & Munch Learning

p.s. Want to share this with a colleague? Feel free to forward it on and ask them to
sign-up for future emails HERE.

p.p.s. We cover the Division of Responsibility in our upcoming Infant Feeding

Foundations Workshop. Registrations open in a month! You can also find Ellyn
Satter’s Division of Responsibility handout HERE - an extra resource for you!

The A-Z of Feeding Therapy email series is designed for therapists working in feeding,
written from the point of view of a Speech Pathologist. Please consider your own
professional Scope of Practice and experience in the application of any information
provided. This email series is not considered to be providing clinical or professional
advice and is provided for informational purposes only. You are responsible for your
own interpretation and application of the information provided.

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