Clinicians' Corner / Journal Club

Selective Eating in Early Childhood

Do you have a hard time getting your child to try new foods?  Have you ever wondered whether he or she would be considered a picky eater by experts? Do you worry about the implications of your child’s selective eating behavior? If so, you are not alone.

recently published study in the academic journal Pediatrics has received loads of attention from several media outlets including the parenting blog of The New York Times. The study, titled Psychological and Psychosocial Impairment in Preschoolers with Selective Eating, offers an important glimpse into the range of psychological problems that may be associated with picky eating.

Study Specifics

This study was conducted by Nancy Zucker, Ph.D. and colleagues. The study team examined data from a large group of children, ages 2 through 5, and their parents. Families were recruited from primary care pediatrics clinics.  Because the participants were originally recruited for a study about anxiety in preschool-aged children, children with known autism or pervasive developmental delay were excluded from the study, which is relevant because these children are already known to struggle with selective eating and sensory sensitivity at times, so including them may have provided more information about selective eating, but confounded the results.

The researchers used a questionnaire that reviewed demographic information and included questions about common childhood psychiatrist symptoms, eating behavior, and sensitivity to sensory issues (e.g., needing tags cut out of clothing).  These questions were directed to parents of 917 children; the children were not directly interviewed.

One year later, the questionnaire was repeated with parents of 187 of the children.  Data from the follow-up interview were used to look at associations between selective eating (moderate versus severe) and psychiatric symptoms, as well as the relationship between selective eating and problems like weight loss, impaired growth, food refusal, and difficulty swallowing.

Study Results

Twenty percent of parents reported that their child exhibited some type of selective eating behavior: 17.7% reported moderately selective eating (defined as restricted eating within the range of his/her preferred foods) and 3.0% reported severely selective eating (defined as keeping a restricted diet that limited the ability for the child to eat with others). Any degree of selective eating was associated with food aversion and enhanced sensitivity to texture, smell, visual cues and motion.

Children with severely selective eating were more than twice as likely to have a co-occurring diagnosis of depression or social anxiety.  Moderate and severe selective eating was associated with symptoms of depression, social anxiety and generalized anxiety. Moderate selective eating was also associated with the presence of attention deficit hyperactivity disorder (ADHD) symptoms.

What does it all mean?

To start, what doesn’t it all mean?

No conclusions about the cause of selective eating can be drawn from this study—parenting style is not to be blamed or exonerated.

More importantly, findings from this study do not mean that picky eating causes mood, anxiety, or ADHD symptoms. The correlation offers no indication of causality or directionality. That is to say, it remains unclear if low mood and/or anxiety manifests as increased selective eating behavior in young kids, or if these states result in picky eating. Equally uncertain is whether or not picky eating results in changes in mood or anxiety in kids. In adults, when eating becomes so restrictive that significant weight loss occurs, worsening mood and anxiety are common. To determine the nature of the association found in this study, longitudinal research is needed.

This study’s findings also do not mean that all selective eaters will land with a mood or anxiety diagnosis. It means that there is increased likelihood of any of a number of symptoms. A symptom of depression, for example, is low mood or loss of interest in previously enjoyed activities.  Symptoms of social anxiety in kids include difficulty meeting new friends, talking at party with big groups or speaking in front of the classroom. Frequent “what if” questions about safety or well-being are a common feature of generalized anxiety disorder in young kids.

Findings from this study, however, do offer several important take-away messages and highlight important information for parents to consider:

– A subset of picky eaters – the most severe – are at increased risk for a full-blown mood or anxiety disorder. Signs of severe eating restrictions in a child include: consistent inability to eat with others at school or at parties, weight loss, stunted growth of height, and reliance on food supplementation   (e.g. nutritional shakes) for adequate nutrition, or inability to participate in age-appropriate activities due to lack of energy.

– The common vulnerability between food avoidance and problems with mood, anxiety, and hyperactivity may have to do with difficulty modulating certain aspects of intense experiences. This means that just as an anxious child may exhibit high sensitivity to certain transitions, like being left at day care or starting a new school, a selective eater may be overly attuned to the aroma or texture of a food, or the environment in which it is being presented. Future research may help guide parents to focus on this common vulnerability to help children become more adaptive in a wide range of activities. With this in mind, parents of selective  eaters can look for patterns in sensitivity outside of the context of eating and try to address them by gradually exposing the child to different experiences that are challenging for him or her.  For example, if your child is highly reactive to loud noises, you might coach them through listening to a series of new or unusual sounds. Once your child has learned how to regulate a  reaction to noise, he or she may be in a better position to work on flexibility and regulation at meals.

Next Steps

Avoidant Restrictive Food Intake Disorder (ARFID) is a feeding disorder diagnosis newly added to DSM-5 (the reference manual used by mental health providers to make a diagnosis of any psychiatric condition). Its main feature is avoidant and restrictive eating that causes significant problems like nutritional deficiencies, weight loss or, in kids, insufficient growth/weight gain. Unlike other restrictive eating problems, like anorexia nervosa, individuals with ARFID are not overly concerned about their weight or body shape.  As the investigators of the current study indicate, developing an improved screening process to detect children that may be vulnerable to develop ARFID and interventions for caregivers to manage the behavior is vital to improve the health care of children.

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