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I’m an outpatient pediatric dietitian and a strong supporter of the division of responsibility in feeding. For uncomplicated obesity, I always focus on maintaining the division of responsibility and discourage parents from any form of restriction in feeding their child. However, I also work with a large number of mental health patients who are on medications that seem to result in rapid and significant weight gain. I have had many questions from parents and health care teams regarding how to apply the division of responsibility in these cases, where medications are “known” to interfere with internal fullness cues. Parents question a child’s ability to eat the right amount in these cases, and I do find in talking with these patients that they tell me they are always hungry, and often that eating makes them even more hungry. I’m not quite sure what to advise in these cases. I am hoping for some advice that I can pass on to parents.
Carrie Abbott RD, Vancouver Island Health Authority

Consider the parents’ dilemma

You cannot give parents advice. You can give them information and let them make their own decision.

• Do you, the parent, continue to maintain a division of responsibility in feeding and keep your fingers crossed that your child’s eating and weight will equilibrate, even if at a higher level? In considering this option, be careful not to slip into the mindset that “if my child gets fat he [forgive my saying “he.” I will say “she” next time] will have poor self esteem and be even more anxious and depressed.” Children of all sizes feel good about themselves if parents feel good about them and raise them to be capable.¹
• Or, do you (again, the parent) try to restrict your child’s food intake to keep him from gaining “too much” weight? Taking that path virtually guarantees that he will become food preoccupied, put pressure on eating, and be at a high risk of gaining even more weight than he would otherwise. That choice puts you in the role of being a police officer with food rather than a nurturing parent. Your policing and his not getting enough to eat will exacerbate his anxiety and/or depression.

Do an assessment

Keep in mind that you (the professional) could be dealing with a self-fulfilling prophecy: Parents are primed by prescribers to expect overeating, they restrict the child, and sure enough, the child becomes hungry all the time, unsatisfied when he eats, and prone to overeat. While weight gain may correlate with taking psychotropic medication, “Interference with fullness cues” secondary to psychotropic medication is an urban rumor. It may be true; it has not been substantiated by studies. Don't accept such assumptions. Instead, do a careful assessment of the child’s eating and growth history.² Whether as a cause or effect of the child’s emotional problems, there have likely been and continue to be distortions in parenting and feeding. Based on your assessment, you can tell parents where they have room for improvement in feeding dynamics. You can offer to guide them in establishing positive feeding and in supporting their child in growing in a way that is right for him.³

Assess the child’s growth record from birth. Reconstruct an accurate-as-possible record of the child’s growth. Your Child’s Weight talks about this.⁴ Has the child’s growth been consistent? Or do growth inconsistencies give clues to historical disruptions with feeding and in other areas? Perhaps he is currently recovering from poor appetite and growth faltering secondary to anxiety and/or depression so would naturally eat more and gain weight rapidly for a time. Assess feeding dynamics from birth. Reconstruct an accurate-as-possible picture of feeding dynamics from birth. This also gives you clues to his psychosocial development. Child of Mine⁵ is best for this, also see this summary of the Child of Mine developmental principles. Your review will tell you the child’s developmental stage with respect to eating competence and social and emotional development. If his attitudes about eating are negative and his food acceptance, food regulation, and mealtime skills poorly developed, you have some rebuilding to do. If, for instance, a preschooler, school-age child, or even adolescent behaves like a toddler with respect to eating and in all ways, both you and the behavioral health team have rebuilding to do.

Consider the bottom line

Do not make promises to parents, other professionals, or the child himself about the child’s weight. The child’s being on medication indicates that parents and medical professionals consider it urgent and critical to treat his anxiety and/or depression and that medication is essential. That being the case, everyone may have to accept the child’s carrying a few extra pounds as the price of his emotional equilibrium.

1. Satter EM. Chapter 9, Teach your child: Be all you can be. Your Child's Weight: Helping Without Harming. Madison, WI: Kelcy Press; 2005:291-322.

2. Satter EM. Appendix E, Assessment of Feeding/Growth Problems. Your Child's Weight: Helping Without Harming. Madison, WI: Kelcy Press; 2005.

3. Satter EM. Appendix F, Treatment of Feeding/Growth Problems. Your Child's Weight: Helping Without Harming. Madison, WI: Kelcy Press; 2005.

4. Satter EM. Chapter 10, Understand Your Child's Growth. Your Child's Weight: Helping Without Harming. Madison, WI: Kelcy Press; 2005:323-380.

5. Satter EM. Child of Mine; Feeding with Love and Good Sense. In: Satter EM, ed. Chapter 2, "Your child knows how to eat and grow". Palo Alto, CA: Bull Publishing; 2000:31-76.