Colman Noctor: Looking at the differences between fussy eating and eating disorders

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Colman Noctor

CHILD PSYCHOTHERAPIST

Fussy eaters exist in most families, whether it involves a six-year-old who won’t eat any vegetables or a 15-year-old who survives on a diet of waffles and plain pasta. Despite being commonplace, we have yet to find a solution to this parenting conundrum.

I avoid the terms ‘fussy’ or ‘picky’ when describing dietary intake as they suggest the child is intentionally difficult when the reason can be far more than preference. Of course, there are children who naturally have narrow food preferences just like adults. (I will always go for the plainest option on the menu and struggle with anything that involves strong flavours or is considered ‘hot’ when it comes to taste.)

Some children assume they don’t like certain foods even though they have never ever tried them. This scenario is common to many families. Neophobia is a term used to describe a fear of new or unfamiliar things and is developmentally normal during childhood. Most parents will be familiar with the child who ate everything until two years of age and then suddenly became more selective. Children around this age become big fans of the words ‘no’ or ‘never’ and tend to overuse them to demonstrate newly acquired independence. Food becomes one of the few areas in their lives over which they can exert control. This behaviour is normal and usually requires nothing more than patience and creativity on behalf of parents to resolve.

I would avoid creating battles around food and mealtimes. If the child has enough options to maintain a balanced diet, it may be best to use a ‘less is more’ approach when it comes to mealtime battles. It is vital not to create a dynamic where food becomes a source of power and control between parent and child. Most children with a narrow range of food preferences broaden their food choices as they get older and adolescent peer pressure can lead to them surprising you when you learn they had a deli chicken roll with friends, despite claiming never to have liked chicken before.

However, there are a small number of children who restrict their diet to one or two types of foods, which can cause parents great anxiety as they worry the child is not getting sufficient nutrients to develop and grow. Fuller exploration is required when a child’s limited dietary intake is impeding their ability to develop physically. There may be a sensory issue at play, with the child finding certain textures or smells intolerable and struggling to overcome these aversions.

Looking for signs of ARFID

I recently took part in a Safefood webinar which referred to a condition called ARFID, recently discussed on RTÉ Radio One’s Liveline. ARFID stands for avoidant restrictive food intake disorder and is characterised by an eating or feeding disturbance that manifests as a failure to meet the nutritional or energy needs of the child. The behaviour can look like picky eating, as those with ARFID have a limited range of foods they like or are willing to eat. However, there are subtle yet significant indicators to consider when deciphering if your child has ARFID.

An American nutritionist with a special interest in ARFID, Dr Jennifer Montenez, suggests the first criterion for identifying ARFID is a sudden or significant weight loss due to sensory sensitivities such as an aversion to the texture or smell of certain foods, and these aversions can lead to significant restrictive eating.

Where ordinarily picky eaters maintain weight despite their limited range of intake, for a child with ARFID, these reactions are often caused by a real or imagined adverse feeding events such as an episode of vomiting, choking or an allergic reaction, but not exclusively.

Children who struggle with ARFID may also find it difficult to eat in a variety of settings such as public places or social events. The intense anxiety experienced by the thought of having to eat can significantly limit their ability to engage in age-appropriate activities. This differs from picky eaters who generally show no distress regarding the environment and focus solely on their food preferences.

Although many children may avoid eating foods because of smell or appearance, they often can tolerate others eating these foods nearby. However, a child with ARFID will have increased anxiety being near foods with certain textures and smells and may even develop symptoms like retching or spitting out food.

Montenez concludes children with ARFID will often have a complete lack of interest in food, may say they are never hungry and can even forget to eat for long periods. In contrast, children with a narrow food range often feel hungry, but only eat preferred foods.

Unwilling or unable?

The distinction between a child with possible ARFID and one with a narrow range of food preferences comes down to the difference between being unwilling to try new foods or being unable to try new or certain foods. While neophobia and ADFID have behaviours in common, the latter is a more extreme reaction to being asked to eat certain foods. ARFID would typically affect several areas of functioning and is more common in autistic children.

If you are concerned that your child is losing a significant amount of weight and is not amenable to eating a balanced diet or has a severe aversion to certain foods following an adverse event or a morbid fear of choking or sickness, then seek advice from your GP or health professional.

However, if your child simply likes what they like and has little interest in expanding their palate, keep in mind this is typical behaviour and tends to resolve with time. Introducing new foods needs to be a slow process where you reward effort over outcome. The critical process is ‘trying’ not ‘completing’. Sometimes making more of a food issue, makes more of a food issue.

Safefood has helpful support on its website including appropriate portion sizes for children of different ages [www.safefood.net/start/kid-sized-portions]. These guidelines are useful as sometimes our expectations of our children’s hunger levels may not match their appetite or food range.

In most cases, our tastes widen as we get older and can accommodate the introduction of new foods. And even if, like me, it doesn’t, it’s unlikely a limited palette will significantly impact their lives.

• Dr Colman Noctor is a child psychotherapist