Understanding avoidant eating. Part One: Tips and points for parents, carers & medical professionals
During one of the conferences we attended last year, Dr. Gillian Harris received a request from a parent to publish the summary chapters of the book that she co-authored with Dr. Elizabeth Shea: "Food Refusal and Avoidant Eating in Children; a practical guide for parents and professionals." What follows is a summary of the 'tips and points' section of their book as re-written by Gillian Harris for ARFID Awareness UK. We'd like to thank both Gillian and Liz for their ongoing support.
STARTING POINT – How and why does avoidant eating develop?
1. The First Years: What should happen in the beginning, and what probably didn’t!
It is much easier to get new foods tastes and textures accepted in the first year of life than it is in later years. In the first months of the introduction of complementary foods, it takes fewer tastes to get a preference established than it does in later childhood.
So with a new baby get as many tastes in as quickly as possible and remember that an older child will need to taste a new food more than once to get to like it.
Some tastes, such as bitter, are always going to be more difficult, and some children and adults are more responsive to certain tastes than are others.
Even if your baby seems a bit wary to begin with, keep offering very small tastes of new foods. Remember though, some children and adults will always have problems accepting certain tastes – such as the taste of Brussels sprouts.
Babies, children and adults all learn to like foods that they have been able to smell, taste and see; these senses are important right from the beginning.
Make sure that your baby gets used to the smell and sight of the food that you want to feed them, home cooked food is usually best for this. Older children too are more likely to eat a food if they get used to the smell and the sight of the food, and if they see other people eating it.
From six to ten months is the best time to get solid/ lumpy textured foods into a baby’s diet. At this age they learn the oral –motor skills needed to process textured foods in and around the mouth.
When the introduction of lumpy solids is delayed, babies are more likely to refuse them; they become ‘orally defensive’, they don’t like foods touching the insides of the mouth.
Get the textures in as soon as possible after six months, and remember that some older children who are texture sensitive will only want to take pureed foods, or foods that ‘dissolve’ on the tongue.
Babies who have most difficulty with solid textures are those who are sensory hyper-sensitive.
Let your baby get messy, don’t be quick to ‘wipe’. Let them touch and hold food, and get their fingers into whatever you are feeding them. Older children can be encouraging to touch new and different textured foods through play.
Children who develop avoidant eating are more likely to have been sensory hypersensitive in the mouth as babies; they react strongly to the feel of food in the sides of the mouth
This is why avoidant children quite often keep to easy textured foods, or smooth purees; because of the ‘mouth feel’. Quite often they will not move food from side to side in the mouth to chew it, but will try to swallow it whole.
2. The Neophobic Response
This response, a fear of new foods starts in most infants at about two years. It is an age related response in all children.
Even foods that have been accepted before might well be rejected, especially if they are prepared in a slightly different way.
Don’t prompt, persuade, bribe or hide foods; the foods won’t be accepted and this will make your child more anxious around mealtimes.
Foods are rejected on sight without tasting; a sensible response to avoid being poisoned!
Allow your child the foods that they will eat; try not to get cross about wasted food!
The neophobic response starts as children begin to learn about foods and match new foods to a stored ‘visual prototype’.
So toast has to be exactly the ‘right’ colour!
The neophobic response to foods begins to wane from about four years when children once again begin to copy what friends and family members are eating. However, very avoidant children do not develop out of the neophobic response; they become gradually more reluctant to try new or different foods.
Their limited diet might not be as bad as you think, many foods accepted will be fortified with necessary vitamins and minerals.
Avoidant children are very aware to little changes in the food that they eat and the packaging of the food that they eat. They will only accept food that is exactly the same as they expect, down to the smallest detail.
They might well be ‘brand’ loyal and only accept one kind of bread or one flavour of yoghurt.
Avoidant children don’t want to copy others eating habits, they are too anxious about the foods that they have to eat.
But you can still model eating new foods at mealtimes with your child, and involve them wherever possible in touching, seeing and smelling foods.
3. Sensory Issues
Sensory hypersensitivity is an overreaction to sensory input from the world around us.
Check whether or not your child seems to be very sensitive to mess, smell, touch noise, light levels, crowded places.
To begin with, the most important of our seven senses, in terms of food acceptance are smell, taste and touch. If your baby is hyper-sensitive to taste, smell and touch then they will not easily accept new foods when these are first introduced; they might overreact to the sensory input.
This is why it is important to get your child accustomed to the smell and feel of foods-
wherever possible – even if they can’t put the food in their mouth. We have to desensitise a sensory sensitive child.
Some children are also not aware of internal states like hunger and pain; it is suggested that this is linked to an eighth sense, that of interception.
Many children with avoidant eating have multiple sensory processing issues and a lack of awareness of hunger might be one of them.
As hypersensitive children get older and begin to be aware of how foods look, they become hyper-vigilant to small irrelevant details. They match foods very carefully to their internal ‘visual prototype’.
This is why food is rejected on sight – and why it is never a good idea to try to ‘hide and disguise’.
Sensory sensitivity, the neophobia response and anxiety are linked. The more anxious your child gets the more hyper-vigilant they become, and the more likely they are to refuse foods.
4. The Disgust Response
Most disgust responses are learned in later life – but not all of them. Some babies will show disgust/ distaste responses to extreme tastes and textures, but slimy and smelly foods are more likely to trigger a disgust response in everyone.
Don’t ever try to persuade a baby or child to eat a food that they find disgusting. But you can eat the food yourself to show them that it is safe to eat.
Sensory hypersensitive babies and avoidant children are more likely to show more extreme, and more frequent, disgust/distaste responses.
Gagging, retching and vomiting responses can be triggered by extreme disgust/distaste.
The more anxious the child, the more likely they are to show a disgust response
Anxious, stressful mealtimes make it all much worse!
Some foods are more disgusting than others; there are foods that most adults will avoid even though they have never eaten them. The look of them is enough!
Think how you feel when faced with your disgust food!
Anything, or any food, that we find disgusting can contaminate anything that it touches.
A disliked food on the plate touching a liked food will contaminate the liked food; it won’t be eaten.
The smell and sight of a food, the sound of someone eating, can all trigger the disgust response. It is even difficult to eat a liked food when you feel disgust.
Some children find it uncomfortable being in the same room as others eating food that they themselves cannot eat; they can’t cope with school dining halls or family meals.
5. Appetite Regulation
In the early years children can regulate their food intake and take in the ‘right’ amount of food for their energy and growth needs.
So don’t prompt children to finish up what is on their plate, let them decide how much they need to eat.
But these growth and energy needs may differ from one child to another; taller children will need less food than do shorter children of the same age
If your child seems to be eating less than another child of the same age this often isn’t a cause for concern. Look at their height and weight lines on a 'centile' chart, you will probably find that they are growing as they should be.
If we miss a usual meal then we ‘compensate’ for this by eating more later on in the day.
An avoidant child might eat a large meal when they come home from school because they haven’t been able to eat at lunch time. Make sure that avoidant children have access to small frequent meals and snacks throughout the day.
Children can only regulate their energy intake, not the different types of foods that they might eat; they cannot automatically eat more or less of certain foods to keep to a good dietary balance.
Check with a dietitian to see if your child is getting the main vitamins and minerals that they need from their diet.
However, if we eat the same food over and over again we are likely to lose our appetite for it.
This often happens with avoidant children, they may suddenly refuse to eat one of their usual foods.
If children are fed milk via a bottle or tube, or given supplement drinks, and their weight is right for their height, then they will have no appetite for food. The milk feeds will give them the energy that they need.
It can be difficult to wean an avoidant child from a milk feed; it should be attempted very gradually!
Unfortunately many factors reduce a child’s appetite for food. Stress, illness, anaemia and constipation can all contribute to appetite loss.
Get help with your child’s constipation; expect them to eat less when they are ill or anxious about school. Try to keep mealtime stress to a minimum.
If avoidant children are given foods that they can and will eat, then they usually grow along their expected centile lines.
Always allow avoidant children their usual ‘safe’ foods, never withhold them; growth is more important in childhood than a balanced diet.
6. Defining ARFID (Avoidant Restrictive Food Intake Disorder)?
Avoidant eating behaviour is seen in every one to some extent. The behaviour is on a continuum, from those who will eat anything and everything, to those who have strong disgust and neophobic responses. These responses are linked to sensory hyper-reactivity to sensory stimuli. Those who have problems with tastes, smells and the feel of things are more likely to be avoidant eaters.
Some children will be mildly avoidant – usually described as ‘fussy eaters’; some children will eat anything, (their parents are described as ‘lucky’!). Avoidant eating, linked as it is to sensory hypersensitivity, is largely genetically determined; it has little to do with what parents do or don’t do at mealtimes. Some mealtime strategies can, however, make things worse.
This is a relatively new diagnostic term devised by the American Psychiatric Association (DSM 5, 2013) to describe children who are difficult to feed because of the small number of foods they will accept. The main characteristics are:
A diet made up of very few foods - often as few as 5-20 food items, usually dry, beige carbohydrates. An accepted food may have to be a specific brand, flavour or type. Bread, for example, may have to be soft and white, with no crusts and of a particular brand.
Foods are refused because of their sensory properties. This may include the look, taste, feel in the mouth, and smell of food.
An extreme fear of new food (the neophobic response). There is an extreme disgust response to foods that are not normally accepted. This may include gagging or vomiting, even at the sight of the food.
A seeming lack of interest in eating or lack of appetite. Children will go without food rather than eat foods that are unacceptable to them.
A limited dietary range which might mean that the diet doesn’t include enough vitamins, minerals or fibre for optimum health and well being.
Restrictions on the social aspects of eating. The restricted diet and fear of food may lead to problems with the child’s ability to cope with school mealtimes and take part in social functions.
Managing avoidant eating is not always easy, especially as it often, but not always, occurs in children on the autism spectrum. The usual strategies that parents and carers might be advised to use to get their child to eat will not work, and may even make the problem worse.