The Nagging Question Every Parent of a Picky Eater Asks (Part 2)

by Maryann Tomovich Jacobsen, MS, RD on August 20, 2013

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This is Part 2 of the Series: What to Do When Picky Eating Doesn’t Get Better

Lindsay was enjoying parenthood like any mom when she noticed something about the way her child accepts food. “I started suspecting that my son (now 3 years old) was having atypical difficulties with feeding when he was between 12-15 months of age,” she says. “He would eat any type of smoothly puréed foods as a baby, but then really struggled with textured purées. He really wouldn’t tolerate much of anything and would spit out everything we tried giving him.”

Lindsey, who blogs about her experiences at Food for Thought, had her son diagnosed with sensory processing disorder at 21 months of age and a daughter diagnosed at 7 months.

She asked the question almost every parent of a picky eater asks at one time or another: Is my child’s picky eating normal or not? That is the question I want to help parents answer today in this second post in our What to Do When Picky Eating Doesn’t Get Better series. We covered normal picky eating in our first post so it’s time to delve into how to tell if it’s problematic.

The red flags
First off, there are different terms used to describe a child who is beyond normal picky with the most common being problem feeder, resistant eater and selective eater. Kay Toomey, pediatric psychologist and developer of the SOS Approach to Feeding, defines problem feeders as children who consume 20 or fewer foods and will reject whole texture categories. A problem feeder might yell and scream being near disliked foods, won’t graduate to new textures when young (no puréed food by 10 months or finger foods by one year) and gag or vomit after eating certain foods. See this article for more on the difference between picky eaters and problem feeders and this one for red flags.

“Meals were extremely stressful in our household,” says Lindsay. “My son would start tantruming before dinner had even begun, screaming that he wanted a preferred food rather than what was being served.”

The American Psychiatric Association recently changed the diagnostic criteria for problematic picky eating to “Avoidant/restrictive food intake disorder” (ARFID) in their Diagnostic and Statistical manual of mental disorders (DSM-5). This was changed from “feeding disorder of infancy or early childhood” because this disorder is not just for young children anymore and can occur after age 6 and in adulthood. ARFID should not be confused with eating disorders like bulimia or anorexia, because weight and shape are not driving forces behind food refusal (for more about the criteria, click here).

“While his twin sister would pick mushrooms, peppers and different meats off my plate, my son showed no interest in food or eating. He never complained of hunger. Ever.” says Skye who blogs at Mealtime Hostage. “When we insisted he try some of our meal, he would cry and hide behind his chair. Our doctor said he would grow out of it.”

Resistant eaters aren’t trying to be difficult, they are trying to let their parents know that eating hurts or is difficult for them.

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Understanding the WHY
Once the signs are there, it’s important to discover the why behind the child’s avoidance of eating, which can be done when getting help. In Lindsay’s case, her kids had sensory processing disorder which is difficulty processing the sensory properties of food’s smell, taste and texture. Skye’s son had several choking incidents that seemed to be a contributing factor, where he dropped foods after each incident.

“Problematic picky eating (AKA selective eating) is commonly caused by undiagnosed gastrointestinal issues (reflux, constipation, allergies), undiagnosed oral/motor disorder (muscle weakness or coordination issues for chewing) and sensory processing disorder, says Jennifer Hatfield, a speech and language pathologist (SLP) who works with resistant eaters. “While less common, it can be triggered by well meaning caregivers who have taken bad advice for their very cautious eater (force them to try something new, only serve “healthy” foods and they’ll eat them, refuse to give in, they’ll eventually eat etc.).”

In Chapter 7 of Fearless Feeding, we have a chart that describes all the possible causes/signs at different ages. If it’s a medical issue or a reaction to a past incident like reflux or a choking incident, the child still may be very cautious around food even when the condition is controlled. And children with autism spectrum disorder, ADHD or developmental delays are much more likely to experience difficulty eating. While the causes may be different, the key behind every resistant eater is an intense, very real fear of eating food.

What about older picky eaters?

“They are no different than younger picky eaters when it comes to reasons. The difference is that it affects them more socially because of how food-oriented our ‘social’ time is,” says Hatfield. “Think about a teen who gets invited to a party but is an extremely picky eater… how do you navigate all of those foods you don’t like AND the questions from others as to why you aren’t eating? You’ll look “different” and that is devastating to an adolescent. Same for adults.”

Getting the right help
Lindsay, also a speech-language pathologist, chose to attend the SOS Feeding Approach training and she describes it as having a “significant impact” on meals in her house. After visiting two dietitians and working with occupational therapists, and a bad flu that caused her son to dip below 5% for weight, Skye stopped therapy and embraced the trust model of feeding by following Ellyn Satter’s Division of Responsibility. Her son’s diet increased from 13 foods to 27 unique foods and his weight is now 18%.

In her book, Love Me, Feed Me, Katja Rowell writes that while therapy is often helpful, the wrong kind of therapy can backfire. Most therapists try to desensitize children to food but if the child is resisting, or pushed beyond their comfort level, problems can erupt. Rowell recommends asking the right questions when choosing a feeding therapist such as how long have they been in the field? What is their training? What type of an approach do they use? (For more questions to ask a therapist see this post).

Help can come from a pediatric dietitian, a dietitian specializing in eating disorders, a speech (SLP) or occupation therapist (OT) or a feeding team that includes various members (dietitian, OT/ST and psychologist). “If a parent has pursued intervention and has not yet had success,” adds Lindsay. “Maybe they didn’t have the right therapist, or maybe they only got a piece of the answer from the therapist they saw.” Below are links to help you find the right support/help.

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You are not alone
I wish the answers were simple and that there was one therapy that works with every resistant eater out there. But the key is to find out if you have a resistant eater in the first place, why it is occurring and trust your gut when it comes to the right type of help and support. We will discuss more about specific strategies in the next post.

I’ll end with words from one of Skye’s blog posts as she reaches out to other parents of resistant eaters who are struggling:

“Now that you’ve met another parent of a resistant eater, I would like to welcome you into the club with these two encouraging bits of advice: 1. Never accept judgment on your parenting ability based solely on the appetites of others, and 2. You are not alone.”

If you have a resistant eater, where are you on your journey?

Resources for Parents of Resistant Eaters

Parent Support
Mealtime Hostage has a closed parent-to-parent Facebook support group for parents of selective eating children who are learning about and getting started with DOR feeding.

Food for Thought on Facebook

Finding Help/Resources

Go here to find an SLP who specializes in feeding (may be listed as dysphagia)

Go here  to find an OT

Go here to find a dietitian

Find an SOS Therapist

Melanie Potock’s My Munch Bug

Jennifer Hatfield’s Therapy and Learning Services 

West Island Speech

Marsha Dunn Klein at Mealtime Notions

More Reading on Resistant Eaters

The Difference Between a Picky Eater and a Resistant Eater

Beyond Picky Eating: You Are Not Alone

The Older Picky Eater: Even Michael Pollan Has One

Feeding Therapy: Feeding the Whole Child

Is Your Child a Resistant Eater?

Books

Fearless Feeding (Chapter 7)

Love Me, Feed Me (Chapters 3 & 4)

Happy Mealtimes with Happy Kids

Food Chaining

Just Take a Bite

Just Two More Bites

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{ 10 comments… read them below or add one }

Amy August 20, 2013 at 9:22 am

Just want to say thank you for getting out information about this particular issue. As a mother of an 11-year-old that is becoming more picky instead of less, I have found that help is very hard to find, especially for older kids. My pediatrician gives the “bad advice” you listed in the article (only offer healthy foods, refuse to give in & he’ll eventually eat, etc.). My son has not gained any weight in the last 9 months & is very small for his age. He takes meds for ADHD that really curb his appitite, so waiting him out is a lost cause – he simply does not feel hungry enough to overcome the pickyness. I intend to check out all of the resources listed in your article. Thanks!

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Maryann Tomovich Jacobsen, MS, RD August 20, 2013 at 11:18 am

Thanks Amy. You might want to start with a pediatric dietitian making sure you choose one who works worked with ADHD kids. The medications can decrease appetite and the RD can help you troubleshoot meals to help. Good luck!

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Melanie Potock August 20, 2013 at 9:26 am

Thank you for including my website, articles and book as a resource! Truly appreciate it – as so many kids, from those with special needs to even garden-variety picky eaters benefit from feeding therapy!

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Maryann Tomovich Jacobsen, MS, RD August 20, 2013 at 11:16 am

Of course!! Thanks for all the work you do!

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Jennifer Hatfield (@TherapyLearnSvc) August 20, 2013 at 2:05 pm

Great article Maryann. Thank you again for providing excellent information for parents and caregivers. It is a wonderful feeling to see so many of us continuing to educate and inform. I sincerely appreciate the opportunity to comment for the article AND to be included with such wonderful professionals as you have listed. It takes a village. :)

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Bret Johnson August 20, 2013 at 6:28 pm

Really helpful post Maryann. Especially the idea that picky eaters may have an un-diagnosed internal issue.

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Maryann Tomovich Jacobsen, MS, RD August 23, 2013 at 9:29 pm

Thanks Bret. It’s so important to find the reasons even if it can’t be helped. Just knowing why seems to bring peace of mind.

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Heather August 20, 2013 at 8:49 pm

I am so grateful for this website! I can’t wait to read more comments and posts. I am the Mom of 11 year old twins – born 6 weeks premature (which I think is a factor). They were fed the same things at the same time as infants/toddlers. My daughter eats everything and my son eats exactly the same thing every day which calorically is nearly nothing. He eats no meat, beans, soy – his only protein is dairy. If I didn’t force him to sit at the table for a meal he would never say he is hungry. He is in the 10% for height and 7% for weight. She is 75% and 50%. His bones show he is the equivalent of an 8 year old (his pediatrician did an xray two years ago and does a follow up every year). Somehow with eating so little he is able to get great grades and play on sports teams at a high level. I don’t know where the energy comes from. We tried feeding therapy (expensive and no result), a hard line (eat this or else…he held out for 4 days!) and threats. You can tell he wants to be better and just can’t. I am trilled to be able to follow up with some of the websites listed. Thank you so much!

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Maryann Tomovich Jacobsen, MS, RD August 23, 2013 at 9:28 pm

Thanks Heather. How does feeding go now? Does he eat with the family or separate meals. Did you ever have him tested for gastro-intestinal issue or food allergies?

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Mandie Sellars October 24, 2013 at 2:00 pm

Hi! I’ve been reading through your posts with interest. My eldest son has what I like to call texture issues. He likes to eat, and eats plenty, but he really has a great aversion to things that aren’t a consistent texture (IE he won’t even eat chocolate that has nuts or crisped rice in it, just PLAIN chocolate). He’s almost five now, and unlike a lot of your commenters’ children, he’s a normal height/weight. My answer has been to make green smoothies every morning for him, so I don’t have to worry about vitamins/minerals if he only eats hummus, noodles or PBJs the rest of the day. He certainly does have a list of 20 items or fewer than he will eat, but it’s not a battle or anything. I make very healthy versions of what he will eat, and don’t push. Whenever he wants to try something, we encourage him, but 9 times out of 10, he spits it out because of texture. He is a gagger and choker, but also has a bad habit of shoving too much food in his mouth, which we keep trying and trying to get him to stop. I guess I’m on the fence as to whether or not to seek help, but I don’t want to him to have lifelong issues with food, either. Your articles have been helpful in thinking through these issues, so thanks!

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