Home Speech-Language Pathology Swallowing and Feeding Issues with Internationally Adopted Children

Swallowing and Feeding Issues with Internationally Adopted Children

by Deborah Hwa-Froelich

Vegetables in Whole Foods Market

Photo by Masahiro Ihara

My children were “picky eaters.” One would only eat peanut butter and jelly, frozen pizza, chicken nuggets or macaroni and cheese. The other one would only eat frozen pizza and hot dogs. Neither of them would eat any vegetables. If it was green, it was considered inedible! Needless to say, cooking for them was a challenge. Somehow they survived and are both healthy adults who eat more variety than I ever thought they would.

Many of our food preferences are based on our food experiences. Children residing in orphanages have feeding experiences that are affected by the number of staff available to feed large groups of infants and toddlers. Parents have reported observing children left in their cribs with bottles propped up to allow self-feeding, given plates of food too hot to eat without utensils to feed themselves, and children fed pureed instead of solid foods. These experiences may not only affect physical growth and nutrition but also adversely affect eating and swallowing development. Some researchers have reported a wide range of eating and swallowing problems from clinical samples including (a) chewing problems, (b) preoccupation with food availability, (c) gorging and (d) sometimes becoming omnivorous (Johnson & Dole, 1999). Others found that 15% (21 of 144 children adopted from Romania) continued to have chewing and swallowing problems at 6 years old, 2 to 5 years following adoption (Beckett, et al., 2002). Beckett and colleagues also found that if solid food was not introduced before the age of 1 year, more of these children had continued eating and swallowing problems. Many of the children seen at the Saint Louis University International Adoption Clinic present with eating and swallowing difficulty or unusual oral motor problems such as facial tics or intermittent velopharyngeal closure during speech and swallow.

Children adopted from abroad are at risk of having eating and swallowing problems. Practitioners are advised to explore the presence of oral motor sensitivity, eating and swallowing problems with the client or client’s family. If problems were observed or continue to occur, a thorough assessment of oral motor structures and function and possibly an assessment of eating and swallowing behaviors may be needed. If children demonstrate eating disorders related to mental health issues such as bulimia or anorexia, it is important to refer them to clinical psychologists or counseling and family therapists.


Beckett, C. M., Bredenkamp, D., Castle, J., Groothues, C., O’Connor T. G., Rutter, M., & the
English and Romanian Adoptees (ERA) Study Team. (2002). Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. Journal of Developmental and Behavioral Pediatrics, 23(5), 297-303. http://journals.lww.com/jrnldbp/pages/default.aspx

Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early
intervention. Infants and Young Children, 11, 34-45. Retrieved from:

Deborah Hwa-Froelich, Ph.D., CCC-SLP, is a Saint Louis University professor and Director of the International Adoption Clinic with interests in social effects on communication such as culture, poverty, parent-child interaction, maternal/child health, and disrupted development.


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Tatyana Elleseff July 27, 2011 - 9:36 pm

Dr. Hwa-Froelich,
I think your post is very relevant for all professionals who work with internationally adopted children, but especially for EI providers who are frequently the first therapists who are asked to perform the early speech/language screenings and assessments of children adopted under 3 years of age. I specialize in working with internationally adopted Eastern European children (e.g., Russian Federation), and I noticed that there’s great variation in nutritional care between regional orphanages. Namely specific areas of the Russian Federation are much poorer than others and as a result children adopted from the orphanages located in the poorer areas present with greater nutritional/feeding/swallowing deficits (poor overall oral motor function for feeding tasks, poor chewing abilities, previously undiagnosed swallowing difficulties, etc). I think it’s very important for assessing SLP’s to collect as much background information as it is feasible given the obvious situational constraints and include thorough feeding and basic swallowing assessments when assessing the overall speech and language abilities of these children. I think it is especially important because many first time parents may not be as cognizant of certain feeding/swallowing difficulties and as a result may inadvertently minimize the issue.

Deborah Hwa-Froelich July 28, 2011 - 10:36 am

Thank you for adding your comment. I could not agree more. These feeding/swallowing differences and difficulties are often missed or misunderstood and can be highly variable as you well know. Thank you for adding your voice to alerting early interventionists to complete a thorough history of feeding/swallowing behaviors, examination of the oral mechanism as well as checking feeding/oral motor skills as part of their assessment. My experience has been with children adopted from Eastern Europe, Asia, Guatemala, and Africa who have had many different profiles so it is important to screen/assess these skills in all internationally adopted children.

Deb Hwa-Froelich

Susan Wilkins July 13, 2012 - 11:25 am

Our adopted son from Russia has exactly these challenhes mentioned. He is 2 and has serious challenges chewing, swallowing- gagging on any solid food. We’ve had the swallow study done-all normal-we’ve had eating therapy-he only regresses. Any suggesstions of how we overcome this and get our little guy to eat solid foods and feed himself? Any help is appreciated!

Deborah Hwa-Froelich July 14, 2012 - 1:13 pm

Dear Susan,
First let me say that I think you can help your son develop chewing and swallowing of solid foods. However, as you have discovered, the problem and hence the solution may be more complicated than what most clinicians are used to treating. In some children choking and gagging may not be related to the actual motor movements needed to swallow or chew but are more related to past experiences with food resulting in possibly a sensory, psychological and behavioral response. That being said, I recommend that you seek an evaluation from SLPs or Occupational therapists with experience with internationally adopted children. Both professionals often work with feeding issues but few have experiences with the wide range of problems we see in children who have experienced life in orphanages. I would recommend that the professional gather detailed information from you regarding your son’s history prior to and following adoption to create a profile of eating behaviors and associated foods. From this information, the professional should be able to discern a pattern to his gagging and begin work on desensitizing him to those types of foods and changing his gagging behavior. Part of his behavior may be associated with fears of choking which also need to be addressed in a way to help him feel safe in eating foods that previously were associated with choking or gagging. This takes more than just telling the child it is ok to eat certain foods. Finding the most appropriate professional to help you is the key. I hope this information helps you.

Susan Wilkins July 14, 2012 - 3:19 pm

Thank you this is helpful. We are in the process of being referred to a specialist as you mention. My problem with gathering our son;s history of foods he ate while in the orphange is that the information we were given is false, so we really don;t know what he was given to eat. So, to create a pattern of foods that trigger his gagging will be tricky. I guess we will just go from what we fed him since the day we got him. Which is another part of this mystery…when we first got him and for the following month or so…he never gagged or had any problems whatsoever…? We can’t seem to figure that one out. Secondly, we feel that OT may not be the way to go right now as their practices may be too agressive for our very sensitive eater. Would you agree?

Deborah Hwa-Froelich July 15, 2012 - 11:49 am

Hi Susan,
I am glad the information was somewhat helpful. Your son’s case sounds particularly unusual which is why it is really important to gather a detailed history of what he ate at the orphanage, immediately after adoption and then when and what seemed to precede his gagging. Some parents have told me the orphanage primarily fed children liquids up to age 18 months while others reported that they would hide chunks of meat in soft foods which triggered gagging. Perhaps you had the opportunity to observe children eating at the orphanage and this information may be helpful to the professionals working with your son.

As for your question about OTs vs. SLPs, I am recommending a professional who understands the kinds of variability often found in internationally adopted children and someone who tries to provide individually appropriate services based on the current knowledge about internationally adopted children. Either one may be more or less informed and more or less “aggressive” as you have described. Finding the best match in services can be challenging but when you do find someone to help your son, the search is well worth it.

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