Most children go through a phase of picky eating. As children transition from a milk diet to solid food, they learn a great deal about eating. Children at this age typically have a natural preference for sweet and salty tastes, and a protective evolutionary dislike for things that taste sour and bitter (6). This “unlearned preference” for taste is a likely factor contributing to the success of the human race.
The appetite of the typical toddler is erratic – they eat a lot, a little, and sometimes not at all, much to the panic and worry of their parents. In the absence of illness or lethargy, typically, this is considered normal child development.
As parents, we want our children to eat a variety of healthy and nutritious foods. These foods are frequently called vegetables. Vegetables are typically bitter tasting, and the toddlers won’t eat them. This is also normal child development.
Insisting children eat certain foods before they are ready, however, is just going to cause trouble.
Approximately 20% of all children are born with a high reactive temperament. These children are, by nature, more anxious that the average, at high risk for developing anxiety related disorders (7), and are often extremely selective with food.
Some kids really do not know how to chew or manage with certain textures of food. Some kids have uncomfortable reactions to foods or to eating in general. Sometimes a professional is needed to develop skills or remove barriers required for successful eating.
Some kids have small appetites, or would just rather play instead of eat. Other kids are exceptionally sensitive to the sensory characteristics of food. Young children lack the cognitive ability to refuse to eat for the sole purpose of irritating their parents. There is always a reason why children refuse food.
Most of the time, food refusal is typical child eating behaviour. Sometimes it’s not.
Avoidant Restrictive Food Intake Disorder is food refusal due to highly selective intake, lack of interest in eating, or fear of the unpleasant effects of eating. The ‘disorder’ part of eating disorder means the behaviour around food impairs the ability to function adaptively in social situations (8). The majority of children with this type of food refusal are a normal weight, therefore doctors rarely take the accompanying parental stress and worry seriously.
Research on restrictive eating disorders in children estimate incidence at 2.6 – 3.01% per 100,000 person-years. In clinical settings, 19 – 25% of children under age 13 years meet criteria for ARFID (1-2). One study from Switzerland (3) determined ARFID was present in 3.2% of school age children (age 5-12 years) in the general population. The data, although limited, consistently shows ARFID to be 10 times more common than Type 2 diabetes mellitus (roi 0.27% in children under age 10y). The American Diabetes Association has described the latter as “an epidemic” (4-5).
All that to tell you, fellow parent, you are not alone.
After addressing any contributing medical or physical barriers to eating, ARFID is very treatable in young children, often by adopting a feeding strategy that ensures food isn’t straining the parent-child relationship. In older children, ARFID is also very treatable, also often at home. The older the child, the more healing there is to do around eating. What your child needs depends on many factors, and in some cases, it may be necessary to involve the expertise of a knowledgeable therapist.
Feeding struggles impact the entire family, not just the child. It is both unrealistic and unfair to expect the child to shoulder the entire responsibility for successful eating.
Without support for the family, ARFID can persist through childhood and into adulthood. At any age, there is always hope to repair a dysfunctional relationship with food.
This is our journey with ARFID.
Welcome to the table.
1. Leora Pinhas, MD, FRCPC; Anne Morris, MBBS, MPH, FRACP; Ross D. Crosby, PhD; Debra K. Katzman, MD, FRCPC Incidence and Age-Specific Presentation of Restrictive Eating Disorders in Children: Canadian Paediatric Surveillance Program Study Arch Pediatr Adolesc Med. 2011;165(10):895-899. doi:10.1001/archpediatrics.2011.145
2. Kurz S, van Dyck Z. Dremmel D. Munsch S. Hilbert A Early-onset restrictive eating disturbances in primary school boys and girls Eur Child Adolesc Psychiatry DOI 10.1007/s00787-014-0622-z
3. Nicholls, DE; Lynn, R; Viner, RM Childhood eating disorders: British national surveillance study Br J Psychiatry 2011;198(4):295–301 doi:10.1192/bjp.bp.110.081356
4. Kaufman, FR Type 2 diabetes mellitus in children and youth: a new epidemic J Pediatr Endocrinol Metab. 2002;15:(supp 2) 737-744
5. Vivian, EM Type 2 diabetes in children and adolescents: the next epidemic? Curr Med Res Opin. 2006;22(2):297-306
6. Birch LL, Fisher JO Development of eating behaviours among children and adolescents Pediatrics, 1998 Mar;101(3 pt 2):539-49
7. Medina, John J The Genetics of Temperament—An Update Cultural Psychiatry, Addiction, 2010, March 10, Psychiatric Times
8. Satter, E What is ARFID and What Does It Have To Do With Feeding Dynamics and Eating Competence? 2014 Feb; Family Meals Focus #89