Feeding Disorders and Picky Eating in Infants and Children

By Abigail H. Natenshon, MA, LCSW, GCFP
Author of When Your Child Has An Eating Disorder, A Step-by-Step Workbook For Parents And Other Caregivers

Feeding problems are real; they are hard-wired and neurological. Their far-reaching effects are nutritional, interpersonal, behavioral and developmental, altering the sense of self and self-esteem, family relations, sociability, as well as academic and professional performance.

Identifying What You See
A strapping pre-school youngster demonstrates an extreme reaction to certain foods. Not tolerating textures in his mouth or smells in his environment, the aroma of certain foods hurts his nose and makes him so upset, he runs out of the kitchen. He spits out most foods, and typically gags, coughs or chokes during meals. Though he was growing normally, his mother fears he isn’t getting adequate nutrition from the limited foods he is eating. Their pediatrician has repeatedly told this mother not to worry, that her son’s height and weight were in the normal range. An older youngster with a similar problem goes all day at school without anything to eat because he cannot tolerate the smell of food in the cafeteria at lunch time. His food intake during the school day is limited to cakes and chips that he can easily eat on the playground. This same child heaves at the beach in response to the smell of seaweed on the shore.

Feeding problems in children typically go undetected, and/or are mistaken for the more benign picky (preference) eating behaviors. Adding to the ambiguity of diagnosing these problems, by the time problem feeders reach adulthood, the diagnostic terminology describing feeding problems reverts back to being called “adult picky eating.” (see PickyEatingAdults.com). Problem feeders describe the one out of twenty children between the ages of birth and 10 who refuse to eat or who will only eat limited numbers of selected foods. A condition that is also called selective eating, perseverant feeding problems, or food neo-phobia is characterized by a strong fear of trying new foods, leaving its victims at risk for malnutrition and failure to grow normally. Problem feeders tend to demonstrate diverse clusters of traits, covering a spectrum of broader, more pervasive, neurologically-based dysfunction which compromises the person’s existence; these might include sensory integration disorder (SID), Asperger's Disorder, Non-Verbal Learning Disability (NVLD), and/or Pervasive Developmental Disorder (PDD.) They typically demonstrate tactile and oral defensiveness and an overactive gag reflex. This is not the case with the more benign diagnosis of picky eating, refuting the notion that picky eating and problem feeders co-exist at different points along the same continuum. In the case of the pre-school child described above, a specialist ultimately discovered that this child’s brain had difficulty processing information received from his five senses.

In considering the spectrum of behaviors that co-exist with feeding problems, Asperger's Disorder (AD), for example, is a syndrome linked with a variety of characteristics ranging from mild to severe. Overly sensitive to tastes, sounds, smells and sights, people with AD have a normal IQ and can display obsessive routines and skills, with interest and talent in specific areas. Because of their high degree of functionality and naiveté, these individuals are often perceived as being odd and eccentric, and are often victims of teasing and bullying. The individual with AD might show marked deficiencies in social skills, (they are often extremely literal and have difficulty using language in a social context) and have difficulties with transitions or changes, preferring sameness. They have a great deal of difficulty reading non-verbal cues (body language) and difficulty determining proper body space.

Dr. Kay Toomey, one of the nation’s leading specialists in treating problem feeders, is cofounder of Children’s Hospital Oral Feeding Clinic in Denver and is director of Colorado Pediatric Therapy and Feeding Specialists, Inc; she is best known for developing the multidiscipline Sequential, Oral, Sensory (SOS) Approach to Feeding. Toomey refutes the idea that eating is completely instinctual. She says that “instincts only start the process, and only then if they are not interfered with by premature birth or a physical disorder. Eating is, in reality, a learned behavior. Just as children learn to eat,, so children can be taught to not eat by the circumstances of their lives.” If the smell of oatmeal hurts a child’s nose, he believes that it will certainly hurt his mouth. In the SOS approach, the first step is figuring out how a child learned not to eat. (http://www.freep.com/news/health/picky11_20020611.htm). If children have a sensory integration disorder, it becomes difficult for them to understand and put together all the different pieces (requirements and functions) involved with the process of eating.

Problem feeders will cry and act out when presented with new foods and refuse entire categories of food textures. Picky eaters, by comparison, will tolerate new foods on the plate and will usually touch or taste a new food, eating as least one food from most food texture groups. Distinguishing problem feeders from picky eaters is not intended to negate the consequences of the picky eating syndrome, emotionally, nutritionally and interpersonally. The picky eater typically becomes conditioned to using food as a device to attract undue attention and exert undue control, in some cases distracting family members from dealing with other more relevant or highly volatile issues within the family system.

Picky eating disorders must be distinguished, too, from early childhood eating disorders (anorexia, bulimia and compulsive overeating/binge eating disorder). Unlike eating disorders, picky behaviors do not arise out of anxiety, obsessive compulsive disorder, or from negative role modeling of eating and exercise; in older children, teens and young adults, picky behaviors are not associated with distorted body image, fear of eating fat or becoming fat, or identity issues that characterize clinical eating disorders.

A medical doctor who is, and was, a picky eater as a child, recommends that parents of picky eaters “…do as my parents wisely did. Give the child a vitamin pill and let her grow out of it. Too much attention could make it worse and lead to an eating disorder.” Describing her continued preference today for sugary, fatty and bland foods, she still gravitates towards hotdogs, hamburgers, chicken nuggets, French fries, and ice cream and has only learned to eat vegetables as an adult. Her eating preferences have in no way compromised her daily existence or professional function.

Research bears out that picky eating as well as feeding disorders, like clinical eating disorders, are genetically based, with traits and propensities carried in the DNA. Physiological conditions that can affect feeding include cystic fibrosis, cerebral palsy, autism, low muscle tone and allergies, as well as sensory, oral-motor, gastro, cardiac, metabolic and genetic disorders. Another condition known as “burning mouth syndrome” the result of a dental procedure, may affect a person’s relationship with food, as does Arnold-Chiari Malformation, (ACM), where the brainstem, pressing on the top of the spine, compresses the nerve that regulates breathing, gagging, etc.

Though feeding problems may be based in “nature,” treatment and cure of these syndromes lies squarely within the bounds of “nurture,” assuming there is sufficient motivation and incentive to stimulate change.

Parents’ Questions
“Is there anything really wrong with sticking to a few foods that the child likes and that nourishes him?”

A commonly asked question, many parents and adult patients wonder about the legitimacy of personal preferences, particularly when the child’s weight remains in the realm of normal. This parent goes on to ask, “Does it have to be a food allergy or philosophical beliefs about eating (i.e. vegetarianism) for it to be okay to consume a limited menu?”

It is a legitimate point that to “pathologize” this condition is not helpful; at the same time, is it wise to ignore a problem simply because it lends itself to being ignored? Research shows that many of the kids who later develop clinical eating disorders were picky eaters when younger. This could be the result of a natural progression of behaviors that wreak havoc with a body and brain, of genetic predisposition, and/or of too much of the wrong kind of attention (power struggles) to food and eating from loved ones and care-takers.
Problem eating is a red flag, an indicator that something is amiss. A problem must be recognized and defined as such before it can be resolved. With feeding disorders, the earlier the problem is defined and addressed, the more timely and effective will be the solution….. Abigail Natenshon, MA, LCSW

“Should I start making an issue out of my child’s eating patterns? Should I try to get him to try new foods? Will doing this make it more of a problem than it seems to him right now?”

It is an interesting concept that a problem is not a problem unless it is identified as such, defined, literally, through words and the expression of real feelings. By not speaking one’s thoughts and observations, by not verbalizing what everyone knows and believes, parents and care takers enter an implicit contract of dishonesty and turning the other cheek, pretending not to look at… and not to see… the “elephant under the chair.”

If you knew something was good for your child, such as learning to look both ways before crossing the street, or taking antibiotics for an ear infection or strep throat, would you be asking the same question about whether of not to step up to the plate and assume your responsibility as a parent to educate your child about how to become more capable of fueling his brain and body for a healthfully functioning life?

Children are not born fully competent people prepared to take on the realities and challenges of life. Kids need to be taught, and to learn, the ways of the world and how to most effectively care for the self within that world. What is more, they need to be guided into how best to approach and solve problems, through strong and secure problem-solving role models who are not afraid to be clear and direct in facing adversity, dealing with it, and finding solutions……… Abigail Natenshon, MA, LCSW

Picky Eating Children
Why Do You Have it?
Profile of a Picky Eating Adult
When Picky Becomes a Problem

Books and articles
1. Lask and Bryant-Waugh: Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence
2. Lask and Bryant-Waugh: Eating Disorders- A Parents Guide
3. Ernsperger and Stegen-Hanson. Just Take a Bite: Effective Answers to Food Aversions and Eating Challenge
4. Marcontell, D.K., Laster, A.E., & Johnson, J. (2002). Cognitive-behavioral treatment of food neophobia in adults, Journal of Anxiety Disorders, 16, 341-349.
5. Nicholls, D., Christie, D., Randall, L., & Lask, B. (2001). Selective eating: symptom, disorder or normal variant? Clinical Child Psychology and Psychiatry, 6, 257-270.
6. Seminars: http://www.sensoryresources.com/conf_details2.asp?cid=915

An internationally renowned expert in the treatment of eating disorders, Abigail H. Natenshon, MA, LCSW, GCFP is a psychotherapist who has treated children, adults, couples, families and groups for past 34 years. The author of When Your Child Has An Eating Disorder, A Step-by-Step Workbook For Parents And Other Caregivers, and the e-book Doing What Works: The Professional’s Guide to Treating Eating Disorders, Abigail is a Guild Certified Feldenkrais Practitioner who is on the cutting edge of combining traditional psychotherapy with this potent holistic adjunct body technique to enhance body- and self-image healing. Outcomes point to an enhanced awareness of self and well-being, anxiety reduction, symptom cessation, and increased options for using the self with facility and intention.

As the founder and director of “Eating Disorder Specialists of Illinois: A Clinic Without Walls.” Ms. Natenshon hosts three informational web sites, including www.empoweredparents.com, www.empoweredkidZ.com and www.treatingeatingdisorders.com. Abigail has made numerous guest appearances on national television including The Oprah Show, The John Walsh Show, Starting Over (NBC), Fox News (documentary: Eating Disorders; the Deadly Secret) MSNBC News, as well as National Public Radio. Abigail speaks widely to parent and professional audiences and maintains an active private practice in Highland Park, Illinois where she resides with her husband.

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