by Wilson, Bee
Selective eating is first, second, and last about the food. It’s about the distress of being offered orange food when you only eat yellow. It’s about the subtle differences between the brand of yogurt you can tolerate and the one that makes you gag. Some children are so sensitized to the smell of the “wrong” foods that they cannot even sit with family members when they are eating it. Because this kind of extreme eating usually goes along with other underlying conditions, such as autism, and is often coupled with behavioral difficulties at the dinner table—terrible tantrums and rage or sadness—it is easy to assume that a failure to eat all but a narrow range of foods is primarily a way of acting out some deeper problem, and that it would be trivial to pay too much attention to the eating itself. Yet the evidence points in the opposite direction. Whatever their core condition may be, these children cannot behave at the table because the food is causing them such distress. If people kept serving you dinners that made you retch, wouldn’t you be angry, too?
The great discovery of the past twenty years in the treatment of both eating disorders and feeding disorders has been that addressing the eating head-on offers the best chance of recovery. When therapists successfully manage to train selective eaters to enjoy a wider range of food, parents report that the children’s behavior at mealtimes also dramatically improves, even for children on the autistic spectrum. Food is never just “about” food. The trials of being a selective eater—or of parenting one—bring home the ways in which food itself can represent so many other things in a person’s life: control and worry and isolation and feeling safe. If you can improve the eating, the rest of life gets a little better, too.
When you are a selective eater, your days are blighted by your need to skip situations where you might be expected to eat something that you find impossible. As you get older, you may avoid traveling, or meeting up with friends, since so many social occasions revolve around food. You make excuses about why you can’t eat: you are not hungry, you have a tummy bug, you ate already. It’s like people who grow up illiterate, who will often go to elaborate lengths to conceal that they cannot read.
For selective eaters, food can become the basis of major life decisions. A mother contacted a feeding clinic with concerns about her eighteen-year-old daughter. This girl was due to start her first year at the university. She had made her choice of college not because it offered the best academic course for her future career, or because she liked the location, but for the simple reason that the student cafeteria served pizza twice a day, at lunch and dinner. She had taken the precaution of traveling to the campus to taste the pizza, to check that it was the kind she liked: generic plain pizza, without the taint of oregano or spice.
It’s hard for others to comprehend that there are those whose diets are so restrictive they cannot even bring themselves to eat bread, or French fries, or pancakes. “It’s not unlike a phobia,” says Keith Williams, who runs the Penn State Hershey Children’s Hospital Feeding Program, which treats around 1,000 children with feeding disorders a year. Williams and his colleagues see some children with a fear of food so great that if someone enters a room carrying a plate that they know contains something they have never tasted before, they will spontaneously vomit or gag before they have had a chance to look properly at what it is.
Sometimes children have a fear of food that is linked to a specific terror of what will happen when they put the food in their mouths. They may have an irrational dread of poisons. Or there may have been a traumatic event that made them sensitive about swallowing, for fear of choking, gagging, or vomiting. It is particularly common to have anxiety about swallowing lumpy foods. Chewing skills develop most rapidly between the ages of six and ten months, but only when the child is given something substantial to chew on. With babies who are kept on smooth baby foods for too long, the chewing action is delayed, and the child may then become hypersensitive to lumps. This is called “oral defensiveness.” Experiments show that children who are only introduced to lumpy solids past the age of ten months are far more likely to show feeding difficulties as toddlers than those who are introduced to the solids earlier. It is very common for a one- or two-year-old to be wary of lumps, but for some children the fear actually intensifies with age. It is sometimes referred to as globus hystericus, or “lump in the throat.” Sufferers—who are often mistaken for anorexics because they tend to lose so much weight—perceive solid food as a foreign body and can endure terrible spasms to the esophagus when eating. This difficulty turns into a vicious circle of anxiety, where they avoid lumpy food so much that they find it even harder to deal with it when it is encountered.
An inability to swallow is relatively rare, but a general anxiety about eating anything but familiar comfort foods is very common. The majority of those who are referred to specialist feeding clinics are kids with “special needs,” especially those on the autistic spectrum or those with oral-motor problems that make it harder for them to chew and swallow. One study of seven hundred children diagnosed with feeding disorders under the age of ten found that 86 percent had an underlying medical condition, while 18 percent had a behavioral problem and 61 percent had some kind of oral dysfunction. However, you only have to look around to see that this problem is far more common in the general population than medical admissions records might suggest.
Researchers in another study asked nearly five hundred American adults who had been called for jury service about how they ate. Around 35.5 percent, over a third, described themselves as picky eaters. Before we panic unduly at this statistic, it’s worth noting that picky eating means different things to different people. Sometimes people use “picky” to mean being discerning, a quality that can serve you well. When my eating was out of control, I wasn’t picky at all. I never met a pastry I didn’t like. Now, I’ve learned to be fussy about Viennoiserie, mostly saving my appetite for those that are exceptional. Becoming a food snob has its uses.
Other forms of picky eating are not so beneficial. Among the adults called for jury service, the self-styled adult picky eaters reported much higher levels of social anxiety and distress about eating than non-picky eaters. There are clearly significant numbers of people whose diets—and lives—are restricted by very limited patterns of eating. Keith Williams from the Penn State Hershey program observes that “tons of kids are selective eaters but don’t come to a feeding clinic, because they have otherwise normal growth and development.” Parents only tend to seek specialist help for feeding if their child is already in the medical system for other problems, or if the situation is so acute that the child has become severely underweight. In Williams’s experience, the problem of selective eating in children is far from limited to his clinic patients. In some places, it is close to becoming “the norm,” because so many children are not given the opportunity to learn to like a wide range of foods. “We see families who serve pizza five or six or seven or ten times a week,” Williams says. He despairs of the attitude that it doesn’t matter if a child eats nothing but sugar-coated cereals and the occasional vitamin pill. Williams encounters this attitude in middle-class families as well as families on lower incomes. “The parents say, ‘He’ll be okay,’ but there’s just no mechanism for change. Why would a kid like that suddenly eat something else?”
We assume that over time, our tastes will gradually blossom of their own accord, but with selective eating, the pattern is for tastes to get ever more closed. Selective eating makes a mockery of the view that eating well is something instinctive, natural, or easy for humans. By the time they are seen by a feeding disorders clinic, selective eaters may be down to just a handful of foods. By far the most common safe foods chosen are carbohydrates, followed by dairy foods, meat, peanut butter, and some forms of fruit and vegetables. A typical case is of a ten-year-old girl who ate only peanut-butter sandwiches, cheese and tomato pizza, and apples. Psychiatrists working with her reported that “Tracy said she wanted to try new foods but they made her retch.” How could someo
ne’s eating reach such a state? The problem is that when parents make an intervention to widen a child’s repertoire of foods, they get punished with some strongly aversive behavior, such as screaming, gagging, or vomiting on the plate. It is agony for the parent to watch as a child retches because the parent made the mistake of serving a sandwich made from the wrong peanut butter. Next time, they make sure to buy the “right” kind, and the child’s habit gets still more entrenched. Well-meaning outsiders may advise that a child will try new foods eventually if you take their favorites away and let them go hungry; but the kind of eaters Williams sees may hold out for as long as four days without eating, at which point they are in danger of needing feeding through a tube, which can be even worse for all concerned.
Traditional treatments for selective eating have often set the bar extremely low, focusing on getting the child to eat something—anything—rather than expecting to ever achieve a full selection of normal foods. Even clinicians are often daunted by the level of resistance that some of these eaters show. These conditions are very hard to treat. The course of treatment will vary according to what other problems the child has—behavioral issues, or extreme anxiety, or an underlying physical problem with eating—but in many clinics it will take the form of some kind of psychological intervention, plus nutritional advice, plus medical monitoring. Such an approach, while better than nothing, is unlikely to yield dramatic changes, because it fails to address the eating itself.
A thirteen-year-old boy was brought by his mother to a feeding disorders clinic. He ate very little except for potato chips, dry breakfast cereal, and breadsticks, plus a single probiotic drink that his mother made him drink every day. He looked pale, tired easily, and had a very low weight and height for his age, which he was teased about at school. His mother described him as a “lazy eater” and had more or less given up on offering alternatives, since she did not want to waste money on food he would not eat. The boy was diagnosed as anxious. After a course of cognitive behavioral therapy (CBT, a talking therapy to help people change the way they behave) and some nutritional advice, he was encouraged to work on introducing “one or two” new foods. By the time he was discharged, noted the clinicians, his diet was still “far from extensive.” He would now eat yogurt, fruit smoothies, and French fries, and he would take a multivitamin. His diet was otherwise unchanged, and he remained anxious about food. He still ate no vegetables or anything resembling a proper, protein-based main course. Yet the doctors who had treated him did not seem to think that his treatment was a failure. “In many cases,” they concluded, “it will be neither realistic nor necessarily desirable [my emphasis] to achieve an eating pattern without any avoidance or restriction.”
No wonder parents and children are fatalistic about their chances of recovering from selective eating; even the doctors who treat it sometimes suggest that a cure is unattainable. Yet, in some cases, clinicians have managed to help children to overcome their selective eating more or less completely over a relatively short period of time: weeks or months, not years. Methods of treatment vary, but a common thread in the most successful interventions is that they start with the assumption that selective eating is about the food, and that it is both possible and desirable for a selective eater to find a less unhappy way of ingesting it.
One nine-year-old boy, Diego, presented for treatment at a clinic in Sydney after approximately seven years of selective eating. He would only eat chicken nuggets, potato chips, and plain bread, to the exclusion of anything else. The food had to be eaten in a certain order, and if the food appeared strange in any way—such as an unusually shaped potato chip—the whole plate of food had to be thrown out and remade from scratch. Diego often turned down birthday party invitations and avoided sporting events because he knew he just wouldn’t be able to eat the food. His eating problem was placing great strain on his parents’ marriage, as his mother and father—who both ate a wide and varied diet—could not agree about how best to entice the boy into trying new foods. Each meal might last as long as three hours, during which time Diego became increasingly distressed and would not try one single bite of new food.
Diego’s therapists realized they needed to find a new method of treatment that acknowledged just how much food scared him. They helped Diego to give a name to his anxiety: “Beaster the Worry Wart.” His parents could now tell Diego how sorry they were that Beaster was so hard for him to fight. Perhaps, they suggested, he should not try any new foods until they could “figure out a way to tame Beaster.” This form of countersuggestion is called a “therapeutic paradox.” After seven years of cajoling and tears and stress at mealtimes, this new tack must have come as a relief to Diego: now, he and his parents were on the same side in the fight against Beaster. The very next session, a week later, Diego arrived with a list of ten new foods that he had tried spontaneously, including steak and vegetables. Over a period of four months, Diego continued to try new foods, until he reached a point of full recovery. Beaster, he said, had shrunk in size and was no longer so scary.
Such an approach might not work with every selective eater. An older child might find it babyish, and a younger child might not be able to verbalize his terror about food in this way. A more obvious and universally applicable way to treat feeding disorders is to use intensive taste sessions to help change eating behavior directly. If the problem is children not eating enough different foods, the solution is getting them to eat a wider range. Given the complexity of eating disorders, this sounds too simple, but this is what Keith Williams and his colleagues have done very successfully at Penn State Hershey, where they have pioneered “taste exposure” interventions to treat selective eating. Williams was familiar with Robert Zajonc’s concept of “mere exposure” discussed in Chapter 1. He knew that if you could get someone to taste enough new foods often enough, the odds were good that they would start to like some of them. “The trick,” he says, “is getting them to taste the food.”
With standard outpatient treatment for selective eaters, parents may be advised to offer half a teaspoon of a new food at a family meal each day and ask the child to record reactions in a food diary. There are at least two reasons why this method might not work (setting aside the reluctance of small children to keep a diary). First, most parents have no training in how to offer novel foods. Quite understandably, they find it hard to ignore the tears and the rage and the throwing of spoons on the floor. When therapists observed parents who had been trying in vain for three months to treat their autistic children’s feeding disorders at home, they found that the parents were only following around half of the recommended steps. The children’s attitudes at mealtimes dramatically improved after the parents were offered intensive training in how to offer new tastes; they had to learn to ignore disruptions, and to quietly offer a new tiny bite when the first one was spat out. They were encouraged to be more ruthless about not allowing their children to snack on their own safe foods before a taste session, to give them a chance of being hungry for the tiny bite of new food. The size is very important.
When the contents of the spoon revolt you, even half a teaspoon may feel excessive. Keith Williams’s clinic has seen positive results when the novel foods are first offered in an amount as small as a pea, or even as small as a grain of rice. If the food is tiny enough, and offered in structured taste sessions, even autistic children with extreme selective eating have been able to learn to like a wide range of foods, often in less than a week. In one intervention involving pea-sized bites given on ten consecutive days of treatment, three autistic boys were able to find an unexpected liking for fifty new foods. After just four days of treatment, they had more or less stopped their “disruptive behavior” at the dinner table. Their parents were given training in how to continue the taste sessions at home.
Williams’s latest version of taste exposure for selective eaters is called “Plate A and Plate B.” First, the parent chooses twenty new foods they would like the child to try. Plate A cont
ains three or four new foods chosen from this list of twenty, in pieces no bigger than a grain of rice (maybe carrots, chicken, and oranges). Plate B contains foods that the child already eats without difficulty (let’s say Pop-Tarts, cookies, and crackers). The parent gives the child four to six “Plate A–Plate B” meals a day, each lasting ten minutes (strictly timed with a timer), and no other meals are offered. They tell the child to have one bite from Plate A and then they may have a bite from Plate B and have a drink, “ignoring crying or refusal.” The child continues to alternate between the plates until the time is up. When a child has learned to eat a food on Plate A for three consecutive meals without crying or gagging, the size is increased from a grain of rice to a pea, then to half a spoonful, and finally a spoonful. By the time a full spoonful is accepted, the child has learned to like the Plate A food. The aim is ultimately for as many as possible of the Plate A foods to become Plate B ones: something the child eats willingly and with pleasure.
The reason “Plate A–Plate B” can work so well—when strictly applied—is that it places very low demands on the child. When food is as small as a grain of rice, it is almost as if it is not there. The pressure on the child is further reduced by the fact that there are several foods on each plate. If the child really can’t stomach two of the foods on Plate A, there is always the third one. Williams says that the reason this simple intervention is successful is that it gives children who cannot bear to taste new foods an opportunity to taste them. It helps them to vault over their own wall of resistance and put the food in their mouths.