When Picky Eating is More Than Just “Annoying”

Chuck E. Cheese serves pizza, not broccoli. The business plan developed in the late 70’s capitalizes on the fact that at a young age, many children are picky eaters. If Chuck E. Cheese developed a new plan to serve broccoli or other foods commonly refused by children, families may find themselves in a scene commonly found at homes: families gathered around a table, with the younger children loudly protesting the contents on their plate.

Many kids are picky eaters at a young age and parents frequently go through the frustration of dealing with a “picky eater.” In fact, pediatricians report that it is one of parents’ most commonly cited concerns. Picky eating is simply the norm for many children and families. While this behavior can be very frustrating for parents, it is normative for children to refuse certain groups of food or types of foods. A recent review in Current Opinions in Psychiatry estimates the prevalence of picky eating to be somewhere between 14% and 50% in early childhood. The majority of children are the pickiest around age 2, this gradually declines by their 6th birthday.

What does “normative” picky eating looking like?

Normative picky eating most commonly includes:

  • Refusal to try new foods
  • Eating a limited variety of foods
  • Less enjoyment or interest in food

In addition, parents often notice picky eaters eating more slowing and children complaining about the texture of certain foods. For example, picky eaters often prefer foods that are smooth, such as bananas, or complain about foods that are very crunchy, such as broccoli. This sensitivity to texture is referred to as tactile sensitivity.

Currently, experts are unsure what exactly causes picky eating. Parents sometimes hear that individuals may be predisposed to picky eating, indicating a potential genetic or biological risk, but the cause is likely to be a combination of both genes and the environment.

Normal development of picky eating can shift from “normative” to “concern” when children have an overall lack of interest in eating or refusing many foods. Additionally, concern may be warranted when children are hung-up on certain details of food such as the shape, texture, or taste, or when they develop fears and worries around specific foods groups.

The updated classification and diagnostic tool used across North America for the treatment of mental health, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), now recognizes clinical picky eating, and offers health care providers with clear guidelines for diagnosis. The new diagnosis, Avoidant/Restrictive Food Intake Disorder (ARFID), describes children who persistently refuse groups of foods or have very limited food choices. For example, a child may ONLY eat products with little-to-no color such as bread, pasta, or rice. In addition, to be diagnosed, this pattern of eating needs to be coupled with health consequences such as weight loss, inadequate growth, or not developing in a way that would be expected. Many children with ARFID are also diagnosed with “failure to thrive,” meaning that these children are not even on the developmental growth charts. This pattern of very limited food intake often leads to challenges outside of food as well, such as general anxiety around eating with others or discussing food with friends and family. It is important to note that picky eating and ARFID are not synonymous terms.

What does “clinically significant” picky eating look like?

Meet Sophia: Sophia is an 11-year-old girl who loves Taylor Swift, sleepovers, and anything glittery and pink. Her parents describe her as a “social butterfly;” she has lots of friends, in all different friend groups. When asked to describe herself, Sophia happily rattles off a host of positive personality traits: “I am funny, kind, pretty, smart and a good friend.” Her favorite subject is reading and her least favorite subject is lunch. Yes, unlike most kids, Sophia hates lunch. In fact, Sophia refuses to eat lunch at school because all of the foods “taste horrible.”

Sophia’s diet is limited to Goldfish, pretzels, McDonalds Chicken Nuggets and lemon hard candy. She refuses to eat any food in the presence of ketchup, which makes school lunch particularly challenging. In most situations, Sophia is described as a very outgoing and social child, except at lunch. During lunch, Sophia does not talk to her friends or eat any foods because she is so worried about the foods around her or appearing “weird” in front of her friends. In fact, Sophia has never eaten lunch at school.

Growing up, Sophia’s parents noted that she was a picky eater. She often refused milk and most baby food. She has been referred to multiple eating disorder specialists, gastroenterologists, allergists, and dietitians. Her fears surrounding food have increased over the years, and she continues to refuse new foods. She frequently complains of headaches and a lack of energy.

At 11 years old, Sophia is severely malnourished and underweight. Sophia wants to gain weight. In fact, Sophia would love to eat around her friends and family. She has no fear of weight gain and no body image disturbance, unlike most individuals with other eating disorders.

This description illustrates the behaviors described in the new diagnostic category, Avoidant and Restrictive Food Intake Disorder (ARFID). While many children may go through normative stages of picky eating, sometimes called “food tantrums,” ARFID is not just about picky eating. It is a complex pattern of picky eating that requires treatment to address both the medical and psychological aspects of the disorder. Most importantly, if left untreated, children and teens may be left with serious long-term complications.

How Parents Can Help

While picky eating can be very challenging and frustrating for parents, there are some ways parents can help.

1) Be a role model.

Children observe and notice everything, including what their parents eat. Studies have shown that the food preferences of 2 and 3 year-olds are related to foods that their mother like, dislike, or avoid. Try to express excitement around new foods or to not avoid specific food groups.

2) Exercise patience and persistence.

Giving up when a child continues to refuse a type of food may feel like a short-term solution, but studies have shown that introducing more foods takes many repeated tries. Offering new foods each night needs to be repeated, between 5 and 10 times, before a child may take the first bite. Although it may not work for all foods, studies show that children will eventually learn to like some new foods.

3) Make a wide variety of foods available.

Instead of cooking a limited variety of meals or only purchasing certain foods, provide a wide variety of foods. Be sure to make a wide variety of foods easily available for kids to try out on their own time.

4) Don’t force it.

Make sure to offer new foods, but try not to pressure your child to eat them. Forcing your child to eat certain foods will only cause more stress for you and your child. Try serving some new foods at dinner, along with foods your child enjoys. Or see if you can incorporate new ingredients into their favorite foods. Encourage your child to try everything you serve. In addition, you may want to try out a “one-bite rule;” every child must try at least one bite of the foods on their plates.

5) Offer rewards, not punishments.

Research has consistently shown that children are more likely to change or alter behavior if you offer rewards. When building rewards into trying new foods, it is important to create rules that are non-food related. Children should not view eating vegetables as a chore. For example, broccoli should not be necessary for a brownie. Rewards might be spending extra special time with mom or dad or a getting a few extra minutes playing outside.

6) Early intervention is key.

When you start to notice your child restricting certain foods or limiting food groups, early intervention is key. Early improvements have lasting consequences. On the other hand, once children become picky eaters, it is more difficult to change these patterns and behaviors.

Parents can take early steps if they are concerned that picky eating has become more than just “annoying.”

It may be scary to think that picky eating may not end, or that it could lead to other challenges such as anxiety and avoidance of social situations. However, recognizing the signs and symptoms of the disorder early is important. The new ARFID diagnosis will allow children and adults who deal with extreme anxiety around food to find treatment options. Treatment for ARFID will typically include psychological interventions, nutritional advice or intervention, and correspondence with medical experts. The goal of treatment will be to minimize any physical or nutritional complications as well as anxiety around eating and trying new foods.

While the official diagnosis for ARFID is new, the behaviors associated with the diagnosis are not. Below are a few ways to help evaluate the context surrounding your child’s picky eating to determine whether their picky eating is normative or if they could be showing signs of more troubled disordered eating:

  • Pay attention to the quality and quantity of the foods your child is eating. If you notice your child continuing to eliminate entire categories of foods for reasons other than taste (e.g., all green foods) or only eating foods based on color or texture, you may want to seek expert advice.
  • In addition, pay attention to the overall interest in food and eating your child displays. Is your child excited to go and eat with friends? Or is your child avoiding situations where food is present?
  • If you notice continued declines in your child’s weight or are concerned about their physical development, your child’s pediatrician is a great place to start with questions.

Remember that while ARFID is classified as an eating disorder, it differs from other eating disorders in that the eating difficulties are not related to concerns with body weight and shape. There is also NO evidence that parents are to blame for ARFID, or any other eating disorders for that matter. Rather, parents are often best positioned to help their children recover.

For additional information and support, contact the National Eating Disorders Association Helpline at 1.800.931.2237.

Lauren Breithaupt, M.A.
George Mason University

Lauren B.