Feeding and eating problems
in infants and young children are in most instances, neurologically
based. 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
What does picky eating look like?
A strapping pre-school youngster demonstrates an extreme reaction to
certain foods. Unable to tolerate certain 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 is 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, as her son's height and weight are in the normal
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. A health practitioner ultimately discovered that this
child's brain had difficulty in accurately processing information
received from his five senses.
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. She goes on to say
that, "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. Yet, in her opinion, her eating preferences have
in no way compromised her daily existence or professional function. This
woman is clearly an exception to the rule.
Establishing a differential diagnosis
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. Children with feeding disorders (as well as picky
eaters to a lesser degree) tend to demonstrate clusters of traits that
indicate a broader, more pervasive, neurologically based dysfunction.
(Natenshon, 2009 P. 134) Also known as perseverant feeding problems,
selective eating, or food neo-phobia, Food Aversion or dysphagia, these
feeding problems are characterized by a strong fear of trying new foods,
leaving its victims at risk for malnutrition and failure to grow
Feeding problems in children often go undetected, and/or are sometimes
mistaken for the more benign picky (preference) eating behaviors. Adding
to the ambiguity of terms in diagnosing these problems, by the time
problem feeders reach adulthood, the diagnostic terminology describing
feeding problems is adult “picky eating." (see PickyEatingAdults.com).
Problem feeders tend to demonstrate diverse clusters of traits, covering
a spectrum of broader, more pervasive, neurologically-based dysfunctions
which compromise the person's existence; these might include sensory
integration disorder (SID), Asperger's syndrome, Non-Verbal Learning
Disability (NVLD), and/or Pervasive Developmental Disorder (PDD) and can
include such symptoms as choking, gagging, vomiting, difficulty
swallowing, etc. Individuals suffering from varying degrees of these
disturbances in early life carry varying degrees of pathology with them
into their adult years. Physiological conditions that can create or
exacerbate feeding problems 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.
That these disorders are chemically and genetically based is seen in the
phenomenon of "innately sensitive and distorted taste buds, which help
to explain why some children may be so staunchly opposed to eating
vegetables. Scientists have identified a gene (dubbed TAS2R38) that
controls a receptor for bitter flavors; those individuals with certain
variations of that gene are particularly sensitive tasters. One of my
adult eating disordered clients reports "a metallic taste in her mouth"
from eating most vegetables, a reflection of the chemical and genetic
bases of these problems." (Natenshon, 2009, P 135)
To varying degrees, children with picky eating syndrome experience
similar physical effects as do children with feeding disorders, but the
symptoms with picky eaters are often less severe and pervasive than in
children with feeding disorders, particularly at younger ages.
(Natenshon, 2009, P.134) On a spectrum of severity, picky eaters will
tolerate new foods on the plate, usually will touch or taste a new food,
and will eat at least one food from most texture groups, as compared to
feeding disordered children who will cry and act out in the face of new
foods and refusing entire categories of food textures. (Natenshon, 2009,
Harnessed with restrictions, compulsions, fears and limitations
regarding food consumption, children and adults alike feel like societal
outcasts, alone, isolated and seriously misunderstood, not only by loved
ones, but by the vast majority of health professionals who minimize
their problem and their suffering. Picky eaters are generally perceived
by others as being stubborn, inflexible, obstinate and unadventurous.
Picky eaters deny themselves more than nourishment, and self-care, as
symptoms require that they restrict opportunities for sociability,
recreation and celebration. Rigidity and the inability to adjust to new
foods generalize to anxiety and fear in the face of newness and change
in all life spheres.
Distinguishing problem feeders from picky eaters is not intended to
negate the seriousness and consequences of the picky eating syndrome,
emotionally, nutritionally and interpersonally. Though the picky eater
typically becomes conditioned to using food as a device to attract
attention and/or exert undue control in family situations, parents must
not lose sight of the primary issues giving rise to these problems and
must learn to deal simultaneously with their causes as well as their
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 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." Toomey goes on to say that "In the SOS approach, the first step
is figuring out how a child learned not to eat, be the triggers genetic
and chemical or environmental. 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."
The earlier the child is given a diagnosis and offered an opportunity to
make remedial changes, the timelier and more effective and sustainable
are the outcomes for change on the individual and within the
neuro-plastic brain. It is for the parents of picky eaters to educate
themselves first, so that they can educate, coach, and mentor their
Disordered eating v. eating or feeding disordered
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 are not
associated with distorted body image, fear of eating fat or becoming
fat, or mood, control or identity issues that characterize clinical
eating disorders. For picky eaters, the fear is of the painful sensation
of putting aversive textures, tastes and smells in their mouth. Despite
this, some picky eaters are treated inappropriately on hospital units
devoted to the care of clinical eating disorders. A similarity between
picky eating syndrome, feeding disorders and clinical eating disorders
lies in these conditions being biologically and genetically based.
Though feeding problems may have origins in "nature," treatment and
healing of these syndromes lies squarely within the bounds of "nurture,"
assuming there is sufficient motivation and incentive to stimulate
"Is there anything really wrong with sticking to a few foods that the
child likes and that nourish him?"
A commonly asked question, many parents and adult patients wonder about
the legitimacy of extreme personal preferences in choosing foods,
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?"
A food “preference” is just that. What a preference is
not is an eating lifestyle, a
fear or aversion to foods that is severe enough to compromise a healthy
diet and the ability to nourish oneself healthfully.
Though "pathologizing" a benign condition is not helpful, at the same
time, it is unwise to ignore a problem simply because you can. Research
shows that many of the children who later develop clinical eating
disorders were picky eaters from the start of life. Picky eating
problems are integrative in nature and need to be integrative in their
healing. Problem eaters tend to be genetically and neurologically wired
to eat in the way that they do. In addition, the natural progression of
behaviors associated with these problems wreaks havoc with a body and
brain, bringing on metabolic process dysfunction through an unhealthy
relationship with food and eating and emotional problems.
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.
"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 in
"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
by role models who are not afraid to be clear and direct in facing
adversity, dealing with it, and finding solutions
It is interesting to note that a child's eating routines and habits are
determined by the age of two; at the same time, it can take as many as
10 times offering a child a new food before the child will feel
comfortable eating it. By not making these efforts, the parent may
inadvertently be teaching the child an important life lesson about
not taking risks in trying
new things in enhancing his existence. People who cannot take risks and
adapt to new situations with food and eating, may find themselves unable
to face and handle all forms of life risks and transitions.
Doing What Works: An Integrative System
for the Treatment of Eating Disorders
from Diagnosis to Recovery, Abigail H.
Natenshon NASW Press, 2009 Washington,
Books and articles
1. Lask and Bryant-Waugh: Anorexia
Nervosa and Related Eating Disorders in
Childhood and Adolescence. Psychology
2. Lask and Bryant-Waugh: Eating
Disorders- A Parents Guide Psychology
3. Ernsperger and Stegen-Hanson. Just
Take a Bite: Effective Answers to Food
Aversions and Eating Challenges
Publisher Future Horizons, 2004
4. Marcontell, D.K., Laster, A.E., &
Johnson, J. (2002). Cognitive-behavioral
treatment of food neophobia in adults,
Journal of Anxiety Disorders, 16,
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.