I regularly receive questions from worried parents about their children's “picky eating”, “food
refusal” or “food/meal tantrums”.
The general consensus is that it is normal
for children to go through phases when they only want to eat some foods, or refuse to eat certain foods, often using food as a means of drawing attention to
underlying psychological problems, or exerting control over parents and siblings.
However, the results of a new study conducted at the Department of
Psychiatry and Behavioural Sciences, Duke University School of Medicine, North
Carolina, suggest that “selective eating (SE)”, the term used to describe
“extremely picky eating” in young children between the ages of 2 and 5 years, may well be an indication of deeper
trouble, such as anxiety disorders and depression.
Although I have always felt
that it is important for doctors and dieticians to keep psychological factors
in mind when consulted by parents who are worried about picky eating in their
children, this study indicates that we may need to pay greater attention to possible underlying psychological problems in some of these children.
The 'Selective Eating Study'
Dr Nancy Zucker and her team screened 3,433 children between the ages of
2 and 6 years at risk of anxiety who were being treated at the Duke Children’s
Primary Care clinics. Eventually the researchers enrolled 180 children
suffering from anxiety for follow-up, as well as control children who did not
Read: Anxiety disorders
Parents were asked to complete an assessment of their child’s
psychopathology and levels of Selective Eating. If the child was so selective
in their eating habits that this prevented them having meals with other people, they were classified as “SE 2" or severe level SE.
The researchers found that children classified as moderate or severe SE
subjects were more inclined to have increased symptoms of anxiety or
depression, suffer from hypersensitivity to the taste and texture of food. They were found to
have mothers who also suffered from increased anxiety, with conflicts centring
Dr Zucker and her co-workers recommended that because the
severity of the psychological symptoms increased as the severity of SE
increased in these children, healthcare providers should "intervene at even
moderate levels of SE". They also suggest that once SE is linked to problematic
psychosocial functioning (anxiety, depression, ADHD etc.) in young children,
coupled to a breakdown in family functioning, the young patient should be
diagnosed as suffering from “avoidant/restrictive food intake disorder" (ARFID),
an eating disorder that encapsulates maladaptive food restriction” (a new
category in psychological classification).
In view of the fact that 14 to 20% of parents report that their toddlers
and preschool children are picky eaters and that many parents are frustrated by
their perception that healthcare practitioners do not take them seriously or
provide relevant assistance, the new classification of severe SE as an actual
psychological disorder may be helpful in future to improve identification and
treatment of these young patients.
Children with severe levels of SE may continue to exhibit selective and
restrictive eating patterns in their teenage years and some may go on to
develop eating disorders in adulthood. Early diagnosis and treatment may,
therefore, help to prevent such long-term problems.
Factors affecting food intake
To grow and be healthy, toddlers and preschool children need to eat a
healthy, varied diet. The findings of the present study indicated that selective
or restrictive eating in young children led to food aversions, reduced growth,
and increased sensitivity to the textures, smell and appearance of foods.
Children with severe SE also frequently had physical problems with swallowing.
Read: Is it possible to reverse an aversion to milk and dairy?
A child that refuses to eat, or eats only selected foods, or eats
minimal quantities of food, will probably struggle to grown normally. Depending
on which types of food a child avoids, their mental growth may also be
What parents can do
In view of the above, it is always important to monitor a child’s food
intake, both in quality and quantity. If you as a parent are worried that your
child is eating too little or only eating a limited variety of foods, then
please engage expert help to have the child assessed.
Get a dietician to
evaluate your child’s eating behaviour and food and nutrient intake. Also
consult a medical doctor to rule out underlying physical problems such as
difficulties with swallowing or sensory fall-out (a child who cannot smell
food for example, may not be interested in eating). Discuss the possibility of
severe selective eating (SE) or even avoidant/restrictive food intake disorder
(ARFID) with your doctor or dietician and, if necessary, ask them to refer you
to a child psychologist who specialises in childhood eating problems.
With the correct treatment and support, young problem eaters may be
helped to overcome their eating aversions and selective eating behaviour – helping to create a harmonious home environment.
Watch out for these tantrums
Daily temper tantrums not the norm for preschoolers
- Henderson, D (2015). Overly pick eating could be a sign of deeper
trouble in kids. Medscape, Aug 03, 2015.
- Zucker N et al (2015). Psychological and psychosocial impairment in
preschoolers with selective eating. Pediatrics, 126(3)e 582-590.
Dr Ingrid van Heerden is a registered dietician and holds a doctoral degree in Nutrition and Biochemistry. She believes that "we are what we eat" and offers free nutrition and weight loss advice via her DietDoc service on Health24.com. Read more of her articles.