Authors Katja Rowell, MD and Jenny McGlothlin, MS, SLP joined us to discuss their book, Helping Your Child with Extreme Picky Eating: A Step-by-Step Guide for Overcoming Selective Eating, Food Aversion, and Feeding Disorders. What follows are our questions in italics, and Katja and Jenny’s thoughtful responses.
Your book, Helping Your Child with Extreme Picky Eating: A Step-by-Step Guide for Overcoming Selective Eating, Food Aversion, and Feeding Disorders, develops the STEPS+ or Supportive Treatment of Eating in PartnershipS method. What motivated you as professionals to establish this approach?
Though we work in different settings, we were hearing more and more from parents whose concerns had been ignored or who had “failed” months and even years of various feeding therapies. The idea of “First do no harm” was a big motivation. Parents are working hard trying to help their children with extreme picky eating, often with little or no support— or results. Worst was hearing from parents who had reached out to doctors and other professionals for help and received counterproductive advice. “Just starve him out”, “He’ll grow out of it”, or protocols that have the child and parent fighting through every bite, with the child often gagging and vomiting, are not helping.
We work in a relationship-focused approach, getting away from number of bites as the goal, and instead addressing anxiety, and allowing parents and children to work together rather than pitted against each other. The progress is dramatic for many families, often with minimal intervention. We created a clear format with “steps” parents can take to support a child’s internal motivation and skills, so the kitchen table can be a pleasant place to support nutrition and bring families together. We focus on partnership, that idea of parents and kids on the same side, and if needed, the partnerships of parents with feeding therapists, and children with therapists.
Our book is unique in its focus on the parent-child relationship, recognizing that it is neither sustainable nor helpful if children are dragged kicking and screaming to the table for treatment, or zoned out in front of screens for hours a day. We also help parents and professionals recognize more subtle counterproductive practices. Some children for example, strongly resist any pressure or suggestion even to “just lick” a challenging food. Sadly, doctors don’t know about feeding problems for the most part, and even some therapists with limited training can do more harm than good. We felt compelled to empower parents to advocate for their children and for their relationships with their children, and ultimately to positively shape the relationship the child will have with food and his or her body for life.
The book is primarily for parents, but also is a resource for the professionals who support parents through these challenges. It’s a thorough primer with insights into what children and families go through, how to avoid harmful interventions, as well as concrete ways to move forward.
Please provide some definitions to help our readers differentiate between “extreme picky eating (EPE)” and “typical picky eating.”
Many labels have been used including persistent picky eater, neophobic, problem eater, selective eating disorder, and ARFID (avoidant restrictive food intake disorder) in the DSM-5. Regardless of any label or diagnosis a child may or may not have, we describe picky eating as extreme, if it affects his social, emotional, or physical development and causes significant family conflict or worry. We estimate this includes about 10-15% of American children (studies range from 3% to 35%).
Does he eat enough variety and amount to meet basic nutrition and growth needs? Is he unusually upset around new foods and have difficulty calming himself? Has he always struggled eating solids? Does he avoid social situations where there may be new foods or pressure to eat? Is eating or not eating causing him, or parents, anxiety that is getting in the way of their relationship, sleep, or ability to enjoy life? Do parents spend a significant amount of energy and sanity points thinking about and enforcing ways to get children to eat more in terms of amount or variety?
In general, if a child has struggled since infancy, avoids entire food groups, eats only a handful of “safe” foods, has known oral-motor or sensory delays, is anxious or fearful around foods or situations that involve food, that is more likely to indicate extreme picky eating. It can get tricky since picky eating exists on a continuum, and a typical toddler may throw a brief tantrum if you serve something other than the current favorite, while a child with ARFID may gag or cry and shut down if pressured.
Our STEPS+ approach is an explanation of ‘responsive’ feeding, and specifically how to achieve it within these challenging situations. We hear some therapists say that you can’t use the division of responsibility (described as responsive feeding “operationalized” in 2009 and pioneered by Ellyn Satter) with children with extreme picky eating. We disagree. We explain how and why even children with challenges can be trusted, as well as outline specific therapeutic steps to address sensory and other challenges. We clearly state in the more therapeutic-leaning chapters which activities or food prep tips are not necessary (but won’t hurt) for typically picky eaters. The whole family can eat together as children are fed with the same guiding principles— and it doesn’t feel like therapy! That is a huge relief for parents.
You offer some reasons children push back against parental pressure to eat. Can you please identify and explain some of them?
Most feeding struggles start with an initial challenge. We break it down from the child’s point of view: “It hurts!”, involves pain or discomfort with eating or digesting. “I can’t!”, if there are oral motor, sensory or anatomical problems. “I’m uncomfortable”, if there are sensory or other issues. “I don’t want to!” brings the child’s temperament into the picture. Lastly, “I’m scared!”, which can result from a history of pain, choking, or an aversive experience like force-feeding or medical procedures. Not infrequently, there is more than one challenge! Parents may respond to these challenges, or their worries about weight gain, by trying to get children to eat more, inviting pressure, which invites more resistance from the child. It is a vicious cycle. Here are some reasons why children push back:
- Bodily Autonomy: everyone wants to feel in control over what happens to their body, including children. They seek comfort and a feeling of safety. If they feel like their boundaries are being crossed, they push back or zone out.
- Independence: it’s a child’s job to separate from the adults in their lives and begin to see themselves as an individual. Opposition to adults’ desires about what and how much they eat is one way children can do this.
- General Conflict: a child who has experienced trauma or conflict in his relationships may seek out conflict because it feels safe and familiar.
- Feelings of Incompetence: when eating is uncomfortable, hard or scary, and trusted adults repeatedly (if inadvertently) point out the child’s inadequacies, the child may internalize that sense of failing and disappointing adults and give up trying.
- Temperament: a generally anxious, sensitive, or particularly strong-willed child will react more negatively to suggestions to try foods than a child who is easy-going, compliant, and eager to please. They want to do it in their own way in their own time, and may feel pressure where other children don’t.
Throughout your book, you spend some time addressing sensory challenges. Can you please tell us more?
When a child is learning to eat, the brain is trying to process and integrate information from the many sensory organs while developing oral motor skills needed to manipulate food. A child’s sensory system can have ‘blips’ for many reasons, but the result is that there is a disconnect between what the child’s internal system needs and the information they are actually getting. They may have higher sensory needs, demonstrating this through seeking behaviors like wanting lots of movement, deep pressure, strong flavors, or crunchy foods. Or they may have very low tolerance for sensory input, so they appear to avoid too much stimulation, as when children hold their hands over their ears, only like bland foods, or are excessively bothered by tags in their clothes.
Food comes in vast flavor, texture, and consistency variations and combinations, and children may have a hard time navigating what they need and enjoy from a sensory standpoint. They may look for foods that fit certain criteria and stick with those safe, known choices (think of the child who only eats beige or crunchy foods). Their intake may be restricted to those foods they know will meet their sensory needs or that won’t cause discomfort.
Children’s oral motor skills (moving the tongue, jaw, lips, and cheeks to chew and swallow food) may also be affected by their sensory system differences. If you can’t feel food in your mouth because of low awareness, you may overstuff your mouth, resulting in poor chewing. Gagging often happens when a child experiences discomfort because they don’t have the skills to move food around and swallow it safely. They also might seek out only the foods they feel safe eating, and their sensory system lets them know if they can handle the food from an oral motor standpoint. These issues are more common in more medically complex cases, or for children on the autism spectrum or with developmental delays.
Unsupportive feeding can even lead to sensory challenges. For example, if a parent is excessively fearful of choking and only offers pureed baby food or pouch foods beyond when a child should be learning to eat solids foods, this can cause problems for the child who needs opportunities to learn to handle these foods. A clear example of this is seen in adopted children who may have only been fed thickened liquids from a bottle into the preschool years. Along with other challenges of institutional living, these children are at higher risk of having motor-sensory challenges and extreme picky eating.
While sensory issues may (or may not) be at play, gagging and resisting foods can also result from negative experiences or feeling pressured to eat; all gagging is not a result or sensory or motor challenges but is a complex interplay. For example, we hear from parents of children who gag simply at the site of a food, like oatmeal. The mushy food is perceived as challenging from a sensory standpoint. When all pressure is removed, and the child is reassured she won’t have to try or lick or poke the food, often within a few days, she is content sitting next to a parent eating the offending food, even passing it, where a few days earlier the child would have had a meltdown. Maybe the initial resistance was sensory, or she just didn’t like the oatmeal, but some of the resistance is a reaction to past pressure to try or eat the foods.
This is why we wrote a book! One question and we could write pages and pages…
How does a structured eating routine help a child tune into his appetite and eat well?
If you think about it, if a child has a little something in her tummy throughout the day, she doesn’t have the opportunity to develop an appetite. One of the most critical steps in helping children to self-regulate and discover appetite and hunger cues is to transition to a sit-down meal or snack routine, offering balanced foods every 2-3 hours for younger children, and every 2-4 hours once they are around kindergarten age. With a break, you allow the stomach, blood sugar and all those other complex systems a chance to signal hunger. Children then generally eat better to fullness, rather than just taking the edge off hunger, and are more open to trying new things. It’s the old expression, “Hunger is the best sauce.”
Many parents of smaller-than-average children are told to follow the child and try to make them sip (often Pediasure or other supplement) or eat whenever they seem willing. Sadly, this almost always reduces appetite and intake. Our STEPS+ approach supports healthy eating with less effort in many ways.
What are some specific suggestions for parents that can help them successfully establish family meals?
If families are struggling, just telling them to “enjoy family meals” is not helpful. We go into details like how to wean off distractions like iPads, or physically change the space to make a fresh start, but the main theme is to allow the child to participate in pleasant family meals, rather than have his or her eating be the focus. This takes the pressure off the child, as pressure can dampen appetite and make the child reach for those familiar foods. Talk about anything but what or how much children eat. Serving family-style is also a very powerful tip. If the child has some control over what goes on his plate, he is often immediately more at ease and more likely to branch out.
Consider this: if you are repulsed by say, raw oysters, but every meal you sit down to a plate with an oyster on it, and you are expected to eat one bite, or lick it every meal, what happens to your enjoyment of mealtimes? Would you look forward to coming to the table? Are you upset, angry? What’s happening to your appetite? It’s the same way for children. Making them bite or touch a food they really don’t like is not likely to make them like it more, and they are likely to start whining and battling. (This is different from providing natural opportunities to interact with foods around cooking, passing plates, serving others, play…) We often ask parents to put themselves in the child’s shoes.
What is the process of “bridging” as it applies to new foods?
Bridging is about creating a context for a child to learn about and move towards a new food. With a deeper understanding of their child’s unique preferences and sensory needs, parents can more confidently choose what foods to introduce to their children and in what ways. Bridging by chaining is choosing a new food that is similar in flavor, texture, or appearance to a favored food. Fading is described as making minute changes to an accepted food to move toward a new food (e.g., adding peach yogurt to vanilla and gradually increasing the peach). Briefly explaining how a new food is similar to an enjoyed food builds a cognitive bridge, making a connection to something he already enjoys, as in, “This has the same teriyaki sauce as the chicken we ate at Grandma’s.” Condiments can be viewed as “training wheels” for new foods; they allow a child to try a new food with a familiar flavor added to it. Having ketchup, Ranch or homemade dressing for dipping is an example. Adding a little sweetness to foods, especially more bitter vegetables, is a great way to appeal to a child’s natural preference for sweet. Using liquid as a bridge can introduce a variety of flavors without the sensory overload that eating sometimes leads to, like new juices or smoothies, or adding frozen juice ice-cubes to water. Texture bridges, like knowing a child likes more input is another example; some crunchy iceberg lettuce on a sandwich, or crushed potato chips is a way to bridge to a new food or increase the odds a child will enjoy a sandwich.
Consider each child’s preferences (salty, sweet, cold, spicy, smooth…) and oral-motor skills, and choose foods that are more likely (but not guaranteed!) to appeal and be accepted. Having hot sauce on the table, or a small bowl of crunchy wontons to sprinkle, or a familiar cracker to dip into the new soup all help and can be incorporated into mealtimes without too much effort.
About the authors –
Katja Rowell MD is a family doctor and childhood feeding specialist. Described as “academic, but warm and down to earth,” she is a popular speaker, author, and blogger, writing on the intersection of feeding and wellness, and has appeared in numerous publications. Her first book is Love Me, Feed Me: the Adoptive Parents Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More. Rowell enjoys camping with her family and cooking. For more information, visit www.thefeedingdoctor.com.
Jenny McGlothlin is a Speech-Language Pathologist working closely with families as a feeding therapist. She developed the STEPS feeding program at the UT Dallas Callier Center to support and promote feeding development in children, teaches at the graduate level, and frequently provides training for therapists, teachers, and parents. McGlothlin lives in Dallas with her husband and their three young children, and enjoys reading, spending time with friends, and rough-housing with her kids.