This clip won the America’s Funniest Home Video $10,000 prize. Is it helping her learn to like green beans?
As clinicians, parents, and experts in childhood feeding struggles, we are concerned about the one-sided nature of the online article and video War and Peace at the Dinner Table: Advising Parents of Picky Eaters, presenting advice to physicians on how to help children with extreme picky eating.
Below, we present a discussion and resources for parents and professionals who might like to learn more.
First off, we agree with the following points in the article: clinicians should take a parent’s concerns about picky eating seriously (Kerzner), and that ARFID (avoidant restrictive food intake disorder) or extreme picky eating (EPE) impacts family life and the social and emotional development of the child. We also agree that without support, a significant proportion of children will not outgrow their eating struggles and that mealtime “hygiene”, like avoiding grazing, supports appetite and curiosity around new foods.
However, we feel that several statements are not supported by the evidence, and in the absence of a widely accepted ‘best’ practice, must be examined.
1) This sweeping generalization: These children don’t have sensory sensitivities.
Many children who suffer from ARFID or EPE had medical or underlying conditions and challenges, including sensory issues, that contribute to the establishment of a feeding disorder (Arts-Rodas, Chatoor). The DSM-V ARFID diagnostic criteria recognize three subtypes of the disorder sensory (emphasis ours), associated with an aversive experience, or associated with low appetite. Sensory challenges are at least a contributing factor for many children with EPE, particularly for those on the autism spectrum, the majority of whom struggle with picky eating (Manikam). Children can tolerate different textures like crunchy or chewy, but gag or vomit with mixed textures or moist textures, or with intense smells. There is also no mention of delays or disorders in oral motor development, which can also play a role. To deny the experience of countless families and feeding professionals does not support children or parents. (Nederkoorn, Werthman, Chatoor)
2) By exposure, I mean putting the food in front of the child and insisting that the child chew it and swallow it, not just having it on the plate or on the table, but actually chewing and swallowing the food.
The number of times that a food must be chewed, tasted, and swallowed before it will be accepted is eight to 15.
There is no data to support this number for children with extreme picky eating or with ARFID diagnoses. In our experience, children may take many dozens of exposures, and by exposures, we do not mean forcing a child to chew, taste or swallow a food. Many respected clinicians in the field do not recommend forcing children to chew and swallow foods, but prefer a more gradual approach guided by the child’s comfort and response and parental facilitation.
3) I find that parents really do need to employ a response cost, which is saying that if you don’t make this response, it will cost you this. In other words, you need to earn screen time after dinner by eating a couple of bites of this every night.
No evidence is cited. We have heard from countless families using this behavioral technique that the threat of losing screen time works for chores or homework, but not eating. This tactic may work for some parents for the short-term to get a few bites in, but to present it as the solution, not taking into account the child’s reaction, does families a disservice. Most parents who seek support for extreme picky eating have tried various rewards or punishments (response costs) for months or years. What is repeatedly missing from this advice is any discussion of the child’s reaction and temperament, as well as what parents should do if they try this advice and it is not helping.
4) Every night, your child should be required to eat a bite of a new or non-preferred food, and after a while it will become routine. It is just like brushing your teeth. It is the only way that their palates will expand. (Emphasis ours.)
While some children may give in to required bites, by no means is this approach the “only” way children learn to expand palates, and some research suggests it is counterproductive (Batsell and Galloway). We have worked with families following this advice and the result was children gagging and vomiting at every dinner for months to years. This is not conducive to learning to enjoy eating or become eating competent, a hallmark of which is a positive attitude towards eating and food. And what a miserable time everyone at the table is having.
Many parents are ‘noncompliant’ with these kinds of tactics because forcing a thrashing, screaming, or vomiting child to eat several times a day is stressful (Armstrong), negatively impacts the parent-child relationship, and likely makes the extreme picky eating worse.
There are many practitioners addressing ARFID and EPE, some using a behavioral approach, as does this author, while many others do not. Each practitioner has an inherent bias that their approach is the best, but to claim it is the “only” way for children to improve is false, and misleads Medscape readers coming for information and help. The intended physician audience needs better information to truly support patients.
Marsha Dunn-Klein, PhD, OT, Get Permission Approach
Suzanne Evans-Morris PhD SLP author and international expert, New Visions
Cheri Fraker MS, SLP, Food Chaining
Ellyn Satter MS, RD, Division of Responsibility
Jenny McGlothlin, MS, SLP and Katja Rowell MD, STEPs+ approach
Nina Ayd Johanson, MS, SLP, AEIOU feeding therapy approach
Skye Van Zetten founder of Mealtime Hostage blog and parent support group
Kay Toomey, PhD, SOS approach
Feeding Matters, education, research, treatment, advocacy and support
The above list is a sampling of leaders in the field of pediatric feeding who represent a variety of approaches, while supporting children as they learn to tune in to appetite, decrease anxiety, become more comfortable around challenging foods, and expand their palates.
Jenny McGlothlin MS, SLP, Director of Feeding Therapy STEPs program at UT Dallas Callier and author
Katja Rowell MD, Relational feeding expert and author
Skye Van Zetten, Mother of a child with EPE, advocate, blogger and founder of Mealtime Hostage parents support group
Katja and Jenny’s book, Helping Your Child with Extreme Picky Eating: A Step-by-Step Guide for Overcoming Selective Eating, Food Aversion, and Feeding Disorders aims to educate and empower parents of children who struggle with picky eating, and the professionals who support them.
Armstrong C. (2008) Positive Behavior Supports and Pediatric Feeding Disorders of early Childhood: A Case Study JCEIP 4:93-109
Arts-Rodas D. (1998) “Feeding problems in infancy and early childhood: Identification and management.” Paediatr Child Health. 3(1): 21–27.
Batsell, R.W. (2002) “You Will Eat All of That!”: A Retrospective Analysis of Forced Consumption Episodes. Appetite 38 (3):211-219.
Chatoor, I. (2002) “Feeding disorders in infants and toddlers: diagnosis and treatment.” Child Adoles Psychiatr Clin N Am 11: 163-184.
Galloway, Amy et al. (2008) “‘Finish your soup’: Counterproductive effects of pressuring children to eat on intake and affect.” Appetite 50:2-3 252-259
Kerzner, B. et al. (2015) “A practical approach to classifying and managing feeding difficulties.” Pediatrics 135 (2): 344-53
Manikam, R. (2000) “Pediatric Feeding Disorders.” Journal of Clinical Gastroenterology 30(1): 34–46.
McDermott, B. (2008) “Preschool Children Perceived by Mothers as Irregular Eaters: Physical and Psychosocial Predictors from a Birth Cohort Study” J Dev Behav Pediatr 29:197–205
Nederkoorn C. (2015) Feel your food. The influence of tactile sensitivity on picky eating in children Appetite 84:7-10
Phalen, J. (2013) “Managing Feeding Problems and Feeding Disorders.” Pediatrics in Review 34, No 12: 549-557
Werthmann J. (2014) “Bits and pieces. Food texture influences food acceptance in young children” Appetite 84 C:181-187