Many children who are anxious eaters experience worry about varied aspects of eating. As a result, mealtimes-, generally a time for loved ones to come together to talk about their day and enjoy their meal, can become tedious and challenging for families with anxious eaters.
Some children who are anxious around mealtimes may present with diagnosed or undiagnosed conditions which can exacerbate their fear around mealtimes. Therefore, these children can become fixated about their meals and anxious about changes in their food or its presentation. It is important to promote positive mealtimes because such experiences matter in introducing new foods to anxious eaters.
WHO ARE ANXIOUS EATERS?
An anxious eater is a child who is concerned about the foods that they consume. They can appear as ‘picky’, ‘fussy’ and ‘selective’ about what they choose to eat. These children have a limited diet with very specific foods.
For example, they may only eat a particular brand of packaged foods e.g.: yoghurt brand or are fixated on consuming a particular food due to its appearance e.g.: only eat square crackers. These children may only prefer a particular texture of food like puree or crunchy foods. In addition, anxious eaters may have a preference of only eating food of a particular colour for example, beige coloured food.
Parents or careers may attempt to introduce diverse food groups such as fruits and vegetables and prepare the food in a different way like heating up the food, introduce it as raw foods so it’s crunchy, or present it in a different way (e.g.: slicing the bread in a different shape).Whichever way that the foods are introduced in a different form or visual attributes, anxious eaters may resist such changes and therefore result in tears and tantrums, making mealtimes challenging for the family.
CAUSES OF ANXIOUS EATERS
Anxious eaters may have an associated diagnosis which can contribute to their fear of mealtimes or changes in food types and preparations. The following are some possible disorders:
Food neophobia is defined as a reluctance to eat unfamiliar foods (Dovey, 2008). It is also known as ‘the fear of new foods’. It is a naturally occurring reaction in humans that protect individuals from the risk of being poisoned by consuming potentially harmful foods. There is evidence that children who present with food neophobia also have a family history or genetic component linked to their temperament and personality characteristics. Research indicates that vegetables, salads, fruit, meat, and fish are reduced in individuals with higher levels of food neophobia (Cooke, et al, 2003).
According to Pilner (1997), boys have a higher percentage of food neophobia than females. However, studies have reported that neophobic responses reduce with age. Overall, ‘picky’ eaters are likely to be food neophobic, texture resistant and eat only selected, familiar foods.
The Diagnostic and Statistical Manual for Mental Disorders (DSM) describes anxiety disorder as ‘excessive anxiety and worry about variety of events and situations for at least six months and not pertaining to another psychological disorder’. Approximately, 16% of children with ASD also have anxiety disorder (Mannion, et al., 2013). Children with anxiety disorder generally experience hypersensitivity to taste and texture and have family conflicts around food (Zucker, 2015).
Obsessive Compulsive Disorder (OCD)
OCD is a type of anxiety disorder which is neurobiological and generally runs in families- it is not a behavioural choice. Obsessions and compulsions take up more than one hour per day and increases during adolescence. OCD occurs in one in 100 children and can have significant impact on learning, routines, and transitions as well as social implications. Children with OCD may experience difficulties during mealtime routines especially if they are fixated on eating a specific type or brand of food. The way in which food is prepared and presented can also cause increase anxiety for these when mealtimes are external to the home environment.
Sensory Processing Disorder
Sensory Processing Disorder is neurological and impacts sensory information that individuals perceive which result in an abnormal response. This condition occurs when sensory input either from the environment or one’s own body is poorly detached, altered or interpreted and atypical responses are observed. Research indicates that there is a relationship between children with sensory selectivity which facilitates anxiety and selective eating. Therefore, children with greater sensitivity to sensory information are more anxious and are likely to be ‘picky’ eaters.
Autism Spectrum Disorder (ASD)
Children diagnosed with ASD have an impairment in communication, social interaction and have restrictive, repetitive, and stereotypic patterns of behaviour or interest. As a result, mealtimes with children with ASD can be inflexible rituals or routines. These children may have difficulty with transitions, rigidity in sameness and order- approximately 70% of children with ASD have eating difficulties (Zickgraft& Elkins, 2018).
Avoidant Restrictive Food Intake Disorder (AFRID)
AFRID is an eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and or energy needs associated with one of more of the follow: significant weight loss, nutritional deficiently, dependence on enteral feeding or oral supplements. There are marked interferences with psychosocial functioning around mealtimes- it is not considered bulimia or anorexia. Children diagnosed with AFRID are unable to eat certain foods and ‘safe’ foods may be limited to specific food types and brands. In severe cases, individuals may exclude whole food groups such as dairy, fruits or vegetables. Other excluded foods can be based on colour, textures and drinks/ sauces however, most individuals would change their eating habits if they could. The DSM-5 lists: avoidance of food due to sensory properties, poor appetite or limited interest, fear of negative consequences of eating as symptoms of this disorder.
Paediatric Feeding Disorder
PFD is the impaired oral intake that is not age- appropriate, and is associated with medical, nutritional, feeding skills and psychosocial dysfunction. It is classified as acute (<3months), or chronic >3 months) in duration.
SIGNS THAT YOUR CHILD IS AN ANXIOUS EATER
- They have narrow choices in food
- Imbalanced diet due to limited consumption of different food groups
- A particular sensory aspect is important e.g.: visual, appearance, smell, texture, specific brand
- Change is difficult
- Mealtimes have become highly stressful
- There is little motivation to try new foods and explore food types
The following are some “red flags” that would warrant speaking to your paediatrician or speech- language therapist about a feeding evaluation:
- If your child is having difficulty gaining weight appropriately or is losing weight
- Consistent choking, gagging, and/or coughing during meals
- Ongoing problems with vomiting
- More than one incident of gastro-nasal reflux (reflux that comes out of the nose)
- Inability to transition to baby food purees by 10-months
- Inability to accept any table food solids by 12-months
TREATMENT FOR ANXIOUS EATERS AND THEIR FAMILIES
It is best to consult an experienced speech therapist to assess the child’s condition and determine the best course of action.
The speech therapist will assess, diagnose, develop client centred goals and use evidence-based practice to provide intervention to children who present with a feeding disorder.
- Get Permission Approach – The approach is relationship based used to support families who have children with feeding challenges. The approach is rooted in the principles of responsive feeding and actively promotes a child’s autonomy whilst fostering connection, trust and consistent communication between the child and caregiver (Napa Centre, 2022)
- Sequential Oral Sensory (SOS) Feeding Approach – The SOS feeding approach combines motor, oral, behavioural, learning, sensory and nutritional factors to comprehensively evaluate and manage children with feeding and growing concerns. The approach is based on typical developmental feeding stages and skills found in children. The overall goal for therapy targeting ‘Family Meals’ is to increase the volume and consumption for children with nutritional and growth concerns (Napa Centre,2022).
At Dynamics, we have a strong team of Speech Therapists who are experienced in treating anxious eaters and fussy eaters. We are committed to providing high-quality personalised therapeutic care to each child and working closely with their parents and/or primary caregivers to ensure a more integrated and effective treatment. To facilitate development in all areas of adaptive living, we also provide holistic support through seamless and hassle-free collaborations with specialists from Dynamics’ in-house multidisciplinary team, such as Occupational Therapists, Educational Therapists, Applied Behaviour Analysis (ABA) Therapists, Psychologists and more. Our sessions can be conducted at our centre, in the comfort of your home (Therapy@Home), online (TeleHealth) or a combination (Hybrid).
Parental and caregiver’s involvement plays an important role in the success of their child’s treatment.
In addition to the professional intervention, the child’s parents and/or primary caregiver can also help their child implement appropriate exercises or set up useful reminders, whether at home or during social interactions. The child’s parents and/or caregiver should consult their child’s speech therapist on appropriate and feasible ways to reinforce the treatment outside of the therapy sessions.
TIPS TO HELP ANXIOUS EATERS
- Set up mealtimes as routine – consider the beginning to end e.g.: washing hands, serving self, passing foods, offering foods (not making demands), the child can stop when they are done eating
- Prepare the environment – Notice the child’s stress and mood level, turn off music, phones and noise distractions- can the child or sibling help prepare the meal?
- Select appropriate seating – ensure the child has supported seating where feet are touching, the child can use their hands
- Prepare the child – The child can use their hands, developmentally appropriate fingers, or utensils, ensure utensils are child sized and utensils can be used with ease. Some utensils for success include cups and straws with lids
- Use novelty utensils e.g.: straws, plates, bowls to invite the child to eat- this may take the focus away from the food
- Involve the child in the mealtime process (e.g.: helping to wash the food, plate the food)
- Having mealtimes together as a family and serving food as a ‘buffet’ style so that children are empowered to explore and choose the type and quantity of the desired food offered
- Provide opportunities for the child to watch others interact with food, ask them to pass foods, plates etc. Roles may also be included during mealtimes e.g.: salad maker, table wiper, fruit or veggie washer, food shopper and many more. Incorporate these into a daily routine.
Children need repeated exposure to learn to enjoy new foods but can only eat foods caregivers offer. Therefore, caregiver feeding decisions are vital to determine whether the child receives sufficient exposure to like new foods (S, Johnson et. al, 2019).
Increase food exposure to the child by increasing frequency to which it is exposed to them (can be away from the child or up close). Using or exposing different types of utensils, having siblings or other family members eat new foods and introducing new foods in addition to the child’s familiar foods on the plate should be encouraged.
PRACTICES TO AVOID DURING MEALTIMES FOR ANXIOUS EATERS
- Pressuring the child to eat more or try different foods e.g.: ‘I made this just for you’, ‘Why aren’t you eating this, you liked it the other day?’, ‘Eat a bite of this, eat some more, finish a bite’ etc.
- Telling children that if they want to eat, they can only consume what is offered to them. This may result in children sneaking food, negative experiences at mealtimes, caregiver resentment, tantrums etc.
- Not pressuring children to eat new foods but, limiting their preferred foods in smaller portions or frequency
Additional Information and Resources
Embodied Recovery Institute and Rachel Lewis Marlow. www.embodiedrecoveryinstitute.org
Emotionally Aware eating, Jo Cormack www.jocormack.com
Extreme Picky Eating, McGlothlin and Rowell www.extremepickyeating.com
Get Permission Institute www.getpermissioninstitute.com
Jo Cormack, www.jocormack.com
Mealtime Connections www.mealtimeconnections.com
National Traumatic Child Stress Network. www.nctsn.org
Responsive Feeding Therapy www.responsivefeedingtherapy.com
SOS Approach to Feeding, Kay Toomey www.sosapproach.com
Cooke, LJ ,et al. (2011). Eating for pleasure or profit: the effect of incentives on children’s enjoyment of food. Psychol Sci; Feb:22(2); 190-196.
Get Permission Approach. (January, 2022). Get Permission. Retrieved from Get Permission Approach: https://getpermissionapproach.com/#:~:text=The%20Get%20Permission%20Approach%20is,Ed.%2C%20FAOTA.
Dovey,T.M, Staples,P.A, Gibson E.L, and Halford , J.C., (2008). Food neophobia and picky/fussy eating in children: a review. Appetite. Mar-May; 50(2-3):181-93.
Kaar, J.L., Shapiro, A.L.B., Fell, D.M., and Johnson, S.L. ,(2016) . Parental feeding practices, food neophobia, and child food preferences: What combination of factors results in children eating a variety of foods? Food Quality and Preference; Vol 50; 57-64.
Mannion A and Leader, G., et al. (2013). An investigation of comorbid psychological disorders, sleep problems, gastrointestinal problems and epilepsy in children and adolescents with Autism Spectrum Disorder. Research in Autism Spectrum.
Napa Centre. (February, 2022). What is the SOS Feeding Therapy Approach? Retrieved from https://napacenter.org/sos-feeding-therapy/
Pliner, P., & Loewen, E. R. (1997). Temperament and food neophobia in children and their mothers. Appetite, 28(3), 239–254.
Zickgraf, H. F., & Elkins, A. (2018). Sensory sensitivity mediates the relationship between anxiety and picky eating in children/adolescents ages 8–17, and in college undergraduates: A replication and age-upward extension. Appetite, 128, 333- 339.
Zucker et al, (2015) Psychological and Psychosocial Impairment in Preschools with Selective Eating, Pediatrics. 2015; Volume 136, number 3.