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.
1. Managing the environment
The first thing that needs to be done is to think of ways in which anxiety levels around food and mealtimes can be reduced. The second action is to ensure that accepted ‘safe’ foods are always available, in all contexts.
Parents often feel guilty about their child’s eating patterns and blame themselves for the avoidant eating pattern.
Your child’s eating pattern is not your fault! It is due to many other factors, mostly genetically determined.
Parents who are anxious about their child’s limited diet often use extreme strategies to try and make their child eat.
Allow your child their preferred foods. These are not ‘junk’ foods; they provide calories enabling your child to grow. As the child develops into late childhood, so their range of foods accepted will usually increase.
Other family members need to understand that ARFID is not a choice that your child is making; so it is not something that you, or they, can control.
Talk to everyone involved in your child’s care. Make sure they understand the problem. Ask for their support, but also point out which behaviours are NOT helpful.
The child’ school also needs to know about your child’s needs. These may well conflict with the school’s healthy eating programme!
Your child’s accepted foods should be available to them in all contexts; this includes school snack and mealtimes. Those children who do not have access to their accepted foods in a stress free environment are in danger of weight loss, and poor concentration in class.
2. Is the child ready to move on?
Avoidant eating is a fear response; your child needs to be at a stage when they can cope with this fear.
To move on your child needs to be able and willing to put new foods in their mouth.
They are ready to move on when they show some interest in playing with, being around, touching or talking about new foods.
We know that children with ARFID are more likely to be sensory hypersensitive; to touch, to smell, to taste.
Before you can get a child to taste a new food they need to be able to touch different textures, to cope with different smells and get use to the way new foods look.
Children who have limited range dietary acceptance often have poorly developed oral-motor skills; this will limit the textures that they can process within the mouth.
Look at the foods that your child eats already, this will tell you what their texture preferences are. Can they move foods from side to side in the mouth, or can they only cope with liquids and purees?
Many children with ARFID like soft purees, such as smooth yogurts, or pureed baby foods.
You might need to move from smooth purees to foods that ‘dissolve’ in the mouth, such as soft crisps or soft biscuits.
When trying to move on with new foods it is important that you start from where you child is, not where you want them to be.
You might want to introduce vegetables, but your child is only ready for another type of soft crisp; go with this!
Some children are not ready to take the first steps to move on until mid- childhood, often around 8 years.
If your child is very fearful, allow yourself to wait patiently until they seem to be ready.
3. What doesn’t work!
Many parents will have tried strategies that, on reflection, they know didn’t work and possibly made things worse. Quite often these strategies have been suggested by a health professional or another member of the family. Remember, anything that increases anxiety will stop a child with ARFID from eating, so knowing what not to do is as important as knowing what to do.
Any pressure to eat, any coaxing, or forcing, will stop your child from eating the foods that they do eat, and won’t make them try anything new.
Children, who accept foods well, might try new foods if they are put on the table in front of them or put on their plate next to foods that they already eat.
A child with ARFID will find the sight of foods that they don’t accept quite disgusting. A new food put on the plate next to an accepted food will contaminate their liked food. The foods will be rejected.
It is quite often suggested that new foods should be cut up small and added to, or mixed with, foods that the child already eats. Some think it a good idea to ‘hide’ new foods.
Imagine how you would feel if someone hid a food that you really didn’t like in a food that you did like. You would reject the foods and probably never trust the provider again. Don’t hide, disguise, or ‘mix in with’, you may well lose one of your child’s accepted foods.
Parents often try to reward children for trying new foods.
Although reward programmes can work in an intervention programme designed to introduce new tastes, it does not work at mealtimes for trying new foods.
Another technique often suggested by others, is to withhold the child’s accepted safe foods and leave them to go hungry, in an attempt to force them to eat an ‘appropriate’ diet.
Children with ARFID will not eat a food that is new and therefore disgusting, even if they are starved for days. This is a dangerous strategy; the child will lose weight, may become dehydrated, and learn to be less hungry over time rather than to be more hungry.
It is often suggested that children with ARFID will ‘grow out of it’ when they go to nursery school; they will copy the other children’s eating behaviours.
Children with ARFID do not imitate other’s eating behaviour in the early years, although this might happen by the time they go to university! They will not eat what the others eat at school or at nursery; their ‘safe’ accepted foods need to be provided for them.
4. Interventions: the young child
First set your priorities; are you trying to get your child’s weight back on track, or are you trying to increase the range of foods or textures that can be accepted?
Growth must always have priority; accepted foods should be given to maintain or gain an appropriate weight, only then should you think of trying new food activities. If you think that your child’s diet might be missing essential vitamins or minerals, ask a dietitian for advice on supplements.
Children maintain appropriate growth better if they are offered frequent, small, structured meals and snacks throughout the day.
Offer three short meals and three short snacks, of food that the child accepts, throughout the day. This will reduce the child’s anxiety about mealtimes, (and yours!). It will also ‘teach’ the child to be hungry.
Children with ARFID are more likely to be sensitive to noises, sights and smells in the environment around them.
Make sure that the eating environment is calm and quiet, without other food smells; this might mean that the child needs to eat away from others, at home or at school.
Those who are sensitive to smell, to touch and to the look of messy smelly stimuli (like foods) can be gradually desensitised.
If your child will accept this, and working slowly from where they can easily cope, try gentle messy, interactive play, with both foods and non-foods
Sometimes a child might move on if a food that looks very like one that they already eat is introduced to them.
This might be a food such as another type of crisp, or another type of chocolate button. Look at their accepted foods and see if there is something you might gently introduce that looks very alike, with the same texture.
Some children will only eat food if they recognise the packet; this tells them that the food inside the packet is safe.
Try emptying the food from the packet or yoghurt pot in front of them into a bowl that they like. This will make it easier, eventually, to move to other brands of accepted foods.
Many children on the autism spectrum have ARFID, they will sometimes accept new foods in new contexts.
Try setting up a new snack time with a favourite teacher at school, or a favourite relative, when a new kind of biscuit or cake might be accepted.
5. Interventions: the older child
Older children are better able to manage their anxiety levels, and are also likely to be more motivated to move on with expanding their dietary range because they want to be like their peer group or join in with social activities.
Relaxation strategies are always a good way to help manage anxiety in any context.
Try some different relaxation techniques with your child, away from mealtimes and scheduled in regularly during the week.
To move on you must be motivated!
When your child wants to move on, talks about trying new foods, or is upset because they can’t join in some activities, then start to talk about the problem.
The acceptance of new foods is based on experience and interaction.
Look at foods your child might want to try, talk about them, describe what they taste like. But always remember to start with foods that your child wants to try, not with foods that you want them to try.
Preference for new foods has to be learned over time; and it takes more than one taste to get to like a new food.
Taste trails away from mealtimes, combined with reward, relaxation techniques and cognitive behaviour therapy, do help children who want to move on. You might need to get professional help with this, or you might be able to start the process on your own.
Moving on is a slow process to begin with.
Try just very small pieces of a few foods that you have agreed to provide. Try the foods away from mealtimes; keep a record of what has been tried. Spitting out is allowed! Remember it might take more than 10 tastes to get the food into the main diet, and the second taste is often more difficult than the first!
Practice makes perfect.
Schedule in regular tasting sessions into the week; at times that are stress free, and away from other siblings. Rewarding each taste with points that can add up to extra screen time (for example) can also be useful.
6. What else do you need to know?
Children with ARFID are more likely to have (but not necessarily):
Autism Spectrum Disorder.
Sensory Processing Disorder.
More contamination fears.
More worries about changes in their life routines which can increase anxiety and reduce appetite.
You may need to get professional help and support with these issues.