When Eating Isn’t Easy
Picky eating in kids may be associated with behavioral issues
By Nancy Maes
Many parents are familiar with children who are picky eaters. Their kids will only eat chicken nuggets day in and day out. Apples may be acceptable or an anathema, and green foods and mushy ones might be on their yucky list. Pediatricians often advise frustrated moms and dads to be patient because picky eating is just a stage the child will outgrow.
But results of recent research published in the September 2015 issue of Pediatrics, the journal of the American Academy of Pediatrics, found that picky eating, also known as selective eating, is not a passing phase in all children and may be associated with some behavioral issues.
Researchers, who screened 917 children ages 2 through 5 and interviewed their caregivers, found that moderate levels of picky eating were associated with separation anxiety and attention deficit hyperactivity disorder (ADHD) . They also noted that severe and moderate levels of selective eating were associated with high levels of anxiety, social anxiety and depression. Both levels of selective eating were associated with not only reduced growth, but also a high level of aversion to food and a hypersensitivity to the sensory aspects of food such as its texture and smell.
So how can parents of picky eaters know when to rely on the wait-and-see advice and when to be concerned that their children’s picky eating habits are an indication of something more serious?
Evora J. Brent, MD, a developmental behavioral pediatrician at NorthShore University HealthSystem, points out that selective eating is so common that about 20 percent of preschoolers are described by their mothers as picky eaters. But some warning signs may suggest that picky eating is associated with significant underlying issues, she says.
“Picky eating can be more problematic if the behavior is not just isolated to certain foods but is part of a more pervasive pattern of additional restrictions that lead to negative functional or relationship outcomes,” Brent says.
Picky eating can affect how well the parent and child get along, as well as the child’s ability to do age-appropriate self-care tasks, like sleeping or using the toilet. “Eating, like toileting and sleeping, is one of the few functions a child can control. Therefore, a picky eater may be a sign of a child who feels like they are otherwise out of control.”
Pediatricians may not think to ask about other problems evident in a picky eater’s behavior, so parents may need to bring any behavioral issues to their attention, Brent says. Then a pediatrician can help determine whether the selective eating is mood related, sensory related or suggestive of a developmental disorder such as autism or ADHD and whether a referral to a specialist is appropriate.
Parents of picky eaters who seek help at North Shore Pediatric Therapy (NSPT), which has professionals in a variety of specialties in seven locations, first speak with a family child advocate to provide background information about the child.
“Any and all concerns are helpful to know, as well as strengths and gifts,” says Zoe Sundstrom, pediatric speech/language pathologist and feeding therapist at NSPT. “Any pre- or postnatal concerns, early developmental challenges, behaviors, emotions, motor skills, sensory challenges or speech/language difficulties are [potential] factors in the child’s development of healthy eating skills.”
While picky eaters may eat only 30 or fewer foods, problem feeders are even more restrictive. “Problem feeders eat fewer than 10 foods and may knock out whole categories and may not eat any proteins or any vegetables and aren’t getting their nutrition. Many end up with failure to thrive or are underweight or anemic,” she explains.
Parents can reach the point of exasperation with their picky eaters, Sundstrom says. “When parents get anxious, so do their kids. When anxiety increases, the appetite goes down because adrenaline increases,” she explains. “Feeding is an entirely sensory experience. We look at our food, smell our food, hear our food when it’s cooking or when we’re chewing it, touch our food and taste our food.”
One part of the gradual desensitization program Sundstrom uses with children is based on Steps to Eating, developed by pediatric psychologist Kay Toomey, PhD, based in Colorado. Sundstrom has children smell a food they dislike, eventually touch it with their fingers, kiss the food with their lips, lick it, take a bite and spit it out until they’re finally chewing and swallowing it. Then the process begins again with another dreaded food and then another. The length of time to overcome the problem eating varies. “It depends on the child,” Sundstrom says. “It can take anywhere from six months for little ones to up to two years for older kids because [by then], it’s a habit with a lot more anxiety and fear.”
Sundstrom consults with pediatric nutritionists to help with malnutrition, failure to thrive, anemia and caloric intake; occupational therapists to help with sensory processing challenges that affect eating; and social workers when children are experiencing depression or anxiety. The goal is to get kids to enjoy a range of food and experiences.
“We want children to learn to enjoy mealtime because mealtimes are social in every culture. Every culture has its own food, routines, rituals and traditions, and when you’re not a part of that, it hurts.”
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