Sort of an ARFID-y Kid
I am Dr Katherine Dahlsgaard. I am lead psychologist of the Anxiety Behaviors Clinic in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the Children’s Hospital of Philadelphia. I am here today to talk to you about the scourge of our age—extremely picky eating—those patients of yours who eat a total of four foods and have driven their parents crazy. These are not the toddlers who are going through the “ew” phase, but those 8- to 12-year-olds who are so picky that it is causing true functional impairment.
I often refer to this as “selective eating disorder.” The technical term is avoidant/restrictive food intake disorder (ARFID). ARFID came of age with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In the DSM-IV, if a child had extreme picky eating or selective eating disorder such that it was causing functional impairment, you had to diagnose the child with “eating disorder not otherwise specified”—not that they had anorexia or bulimia, but that they had disordered eating. Now we have a word for it, and the adjective is “ARFID-y,” as in “He is sort of an AFRID-y kid.”
Blame the Food Culture
Why should we care about ARFID? The first reason is because of the prevalence. I called it the “scourge of our age.” ARFID is increasing in rate and prevalence in every single Western country that is keeping data. We don’t know why, but it has something to do with our food culture—our national eating disorder. We are a culture that has never known as much plenty in terms of food and yet the rates of food sensitivities, dietary restrictions, interest in food, and funny rules about food seem to be increasing among adults, so it shouldn’t surprise us that we are seeing more ARFID among children.
The second reason why we should care about ARFID is that it is medically compromising. These children typically eat only four foods, and usually it is carbohydrates: foods such as chicken nuggets, buttered noodles, plain bagels, and macaroni and cheese. These children eat foods that are like a bride’s dress, in shades of ivory, white, or beige. The problem is that they might be getting enough calories to be of normal or even above average weight, although many of the children that I work with are quite thin and underweight. They are often medically compromised. Eating only carbohydrates and sugars is a good way to be malnourished.
Picky Eating: Myths and Misery
These children don’t have sensory sensitivities. Many parents and healthcare professionals think that the reason they are selective is because of sensory sensitivities: They just can’t tolerate the chewiness of meat; they just can’t tolerate the crispness of vegetables. However, these kids will typically eat any kind of simple carbohydrate or junk food. They tolerate the crispness of potato chips and Doritos® and the chewiness of candy, so it really isn’t sensory sensitivity.
Another reason to care about ARFID is that many children don’t outgrow it. People think that if they just leave it alone, these kids will grow out of it. The research says that a significant minority do not outgrow it and become that man or woman who goes to dinner at someone’s house and annoys everyone.
The final reason that we should care about ARFID is the misery that it causes the family. I treat many extremely anxious kids who are incredibly compromised by their anxiety, and it has taken over the whole family. It pales in comparison to the misery caused by selective eating disorder. Every meal is a battle. Parents feel like terrible parents. Vacations are messed up because they can’t find a McDonald’s in Italy. When they finally find one, it is 90 minutes away and the McNuggets don’t taste the same as they do in the United States, and the child is falling over with hunger. It is very tough on families and kids.
What to Do: Mealtime Hygiene
What should you do about it as a physician? The first thing I suggest is that you don’t “pooh-pooh” it. That is the number-one complaint I get from the families of picky eaters: They went to the pediatrician and she said, “Eh, he will grow out of it.” Many of these children will grow out of it, but the parents could really use some quick advice from you.
I suggest the following advice. First, insist that parents have good mealtime hygiene. Children have become snackers and grazers and moms have become vending machines with their large purses. Even Home Depot sells candy in the checkout aisles. Children are snacking and grazing all day and they don’t come to the table hungry. Parents also truly don’t know that they are allowed to let their children be hungry until mealtimes and that children will eat much better if they are hungry. Let parents know that children should eat three square meals and maybe two or three snacks a day, and that there should be at least 2 hours between a snack and a meal or between meals. Many of the families of picky eaters forego snacks entirely so that their children sit down very hungry to eat. They send me emails, raving that cutting out snacks was the best thing they have ever done for their families.
You should also suggest to parents that exposure works to help their children accept new foods. By exposure, I mean putting the food in front of the child and insisting that the child chew it and swallow it, not just having in on the plate or on the table, but actually chewing and swallowing the food. Parents are loath to insist on this for various reasons. They are afraid that their child will develop an eating disorder if there are rules about eating. I tell parents—and they find this extremely helpful—that we make children do things that they don’t want to do all the time. It’s called being a good parent. We make them go to bed and we make them wear their seatbelt because we know better than they do. Food is the same thing. We know better that if you keep trying something you will eventually like it.
The other thing you should tell parents about exposure is that it is okay to insist that the child chews and swallows a food even if he or she doesn’t like it. The number of times that a food must be chewed, tasted, and swallowed before it will be accepted is eight to 15. The average parent puts the food in front of the child, and if the child rejects it three to five times, the parent tends to give up. Tell parents about the eight to 15 times minimum. Also let them know that their child does not have to like the food. The child just needs to be able to tolerate it. Eventually, with enough exposure, the child will come to like the food because that is the way our brains work. They need to keep exposing the child to food and expecting the child to eat it because the child’s palate will expand. Even if the child doesn’t grow to like the food, he or she will tolerate eating it without complaint.
Busting Bigger Myths: Reward and Punishment
You can also let parents know that they are well within their rights as parents to use contingency management procedures to encourage kids to eat these foods. In other words, parents are allowed to reward their children for trying, swallowing, chewing, and tasting new foods. Parents always say the following to me: “I had to bribe him to eat broccoli.” The answer is that rewards are not bribes. A bribe is giving someone $10,000 to throw a fight. Bribes don’t work. The bribed person already has what he or she wants. They have no reason to follow through with the behavior. A reward is when the child performs the wanted behavior and then gets the prize. A good example of a reward is a paycheck. Rewards are the way that the world works, and it is okay for parents to reward their kids with dessert for eating their broccoli. It is okay to withhold dessert if the child doesn’t eat the broccoli. That is fine. Parents are not going to give their kids eating disorders by using rewards or punishments around food. There is no good evidence for that. Contingency management procedures are well established in the literature. It is very clear that many children will eat for rewards, and it is okay to do.
With my extremely picky eaters, I find that no reward will make them eat broccoli or deli meat or, heaven forbid, a different brand of pizza. I find that with these children, parents really do need to employ a response cost, which is saying that if you don’t make this response, it will cost you this. In other words, you need to earn screen time after dinner by eating a couple of bites of this every night. The clinician can let parents know that all screen time should be earned. A great way to earn screen time after dinner is to try a new food, and this should be the new normal in this house. Every night, your child should be required to eat a bite of a new or nonpreferred food, and after a while it will become routine. It is just like brushing your teeth. It is the only way that their palates will expand.
To summarize, try not to pooh-pooh picky eating. Insist that the parents use good mealtime hygiene so that their children come to the table hungry. Give moms and dads permission to not be mobile vending machines. Let them know that there is no shame in rewarding their children for trying new things and that, in fact, repeated exposure (at least eight to 15 times) will help their children to expand their palates. Finally, be a cheerleader for parents. They are exhausted with the mealtime battles, and an optimistic “never give up” attitude is something that parents need to hear. This problem won’t resolve overnight. It won’t resolve in a couple of weeks or months. This is a years-long project, but let parents know that with a smile.