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.
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.
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
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.
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
Melanie Potock’s My Munch Bug
Jennifer Hatfield’s Therapy and Learning Services
Marsha Dunn Klein at Mealtime Notions
More Reading on Resistant Eaters
Fearless Feeding (Chapter 7)
Love Me, Feed Me (Chapters 3 & 4)