Every family has a kid that won’t eat. – quote from the movie A Christmas Story
Ever since food has become easily available for most fortunate families, parents have been vexed and exasperated by children who often refuse to eat or tolerate only a very narrow range of foods. Medical professionals who work with children quite commonly try to offer reassurance to worried mothers and fathers of “picky eaters” who are growing and otherwise healthy, under that idea most children will grow out of this behavior and eventually expand their food repertoire. Most do, but for some, the problem does not self-correct and additional problems can develop.
The current list of psychiatric disorders in DSM-5 now includes the term Avoidant/Restrictive Food Intake Disorder (ARFID). The diagnosis replaced Feeding Disorder of Infancy and Early Childhood which was rarely used and not well researched. Despite the fact that the diagnosis requires the “persistent failure to meet appropriate nutritional and/or energy needs,” this new diagnosis is an easy target for those inclined towards the view that way too much typical human behavior has been classified as a psychiatric disorder.
To get a better sense as to whether or not highly selective eating (SE) is related to more significant emotional-behavioral problems, researchers from the Duke Preschool Anxiety Study examined over 900 kids who on average were about 4 years old. In addition to assessing the degree of selective eating through an interview, the children’s quantitative level of emotional-behavioral problems were measured with rating scales and families were also interviewed to see if the children met actual criteria for a psychiatric disorder. Three groups were created for the study based on “normal,” “moderate,” and “severe” levels of selective eating.
Overall, at least moderate selective eating was present in 20.3% of the sample, while 3% were found to be in the severe range. Furthermore, severe selective eating was associated with higher rates of anxiety and depression both with regard to quantitative levels of symptoms and rates of some specific diagnoses (depressive disorder and social anxiety disorder). Looking at other domains, Children with selective eating also were much more likely to be hypersensitive to smells, textures or visual stimuli.
A subset of the sample was followed over time and the high levels of anxiety were found to continue for many children when they were up to 8 years old.
The authors concluded that especially more severe levels of selective eating were related to other types of emotional-behavioral problems. They speculated that the link was not causal (i.e. that selective eating caused anxiety and mood problems) but rather that an enhanced sensory sensitivity may underlie both the food selectivity and some of the associated emotional behavioral problems.
Like all studies, this one has some problems, many of them stemming from the fact that this particular issue does not seem like the primary interest of the study. While the authors do suggest that their data are relevant to the new ARFID diagnosis, they don’t directly assess ARFID in their study. Weight and weight trajectory were also not a focus of the study and indeed, the number of children with weight loss was not found to differ between the three groups of children (although 45% of the severe SE group had low growth). Finally, the number of 4-year-old children meeting DSM criteria for psychiatric illness in this study will strike many people as quite high. For example, 6% and 33% of the severe SE group met criteria for a depressive disorder and social anxiety disorder, respectively.
It is also worth noting that this is one of those studies where statistically significant associations can make things sound more dramatic than they actually are. For example, among the much larger group of children with “moderate” selective eating, the vast majority of children did not meet criteria for any psychiatric disorder.
To read another take on this study and hear about some strategies for selective eaters, please see another PT blog on the subject by Dr. Mitchell Gaynor here.
The bottom line to all this is probably two-fold. First, selective eating is quite common and often gets better on its own with the continued efforts and tireless encouragement of parents. At the same time, parents and clinicians alike need to be mindful of a smaller group of kids whose behaviors are more extreme and deserving of more focused intervention. It's not uncommon for these kids to struggle with other behavioral problems, all of which may be related to a general hypersensitivity not just to food but also types of sensory experiences.
@copyright by David Rettew, MD
David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.