Aug. 3, 2015 -- Children's picky eating, often dismissed by parents and doctors as just a phase, can sometimes signal more serious issues such as anxiety or depression.
"It's not necessarily something that goes away for all kids," says William Copeland, PhD, associate professor of psychiatry at Duke University School of Medicine. Copeland is part of a team at Duke that researched the problem. Their study found that 1 in 5 children might have a picky eating problem.
For some kids, it can be a red flag that they're "struggling in terms of emotional or behavioral functioning," Copeland says.
Here’s what parents should know.
What did the study look at?
The researchers studied 917 healthy children ages 2 to 6, who were getting routine pediatric care at Duke. Parents and caregivers answered questions about the child's eating habits and whether the child had symptoms of anxiety, depression, or other problems.
Based on the child's eating habits, the researchers labeled them as normal, moderate, or severe picky eaters, also called selective eaters.
- Normal picky eaters have typical dislikes, such as refusing to eat broccoli.
- Moderate picky eaters eat limited food. Their parents might make special meals for them.
- Severe picky eaters are so selective that eating with others is difficult. They might skip birthday parties, for instance, or bring their own food. Their eating habits interfere with family life.
"The children we’re talking about are not just misbehaving kids who refuse to eat their broccoli,” says Nancy Zucker, PhD, lead study author and director of the Duke Center for Eating Disorders, in a statement. “These are children whose eating has become so limited or selective that it’s starting to cause problems.”
What did the study find?
Eighteen percent of kids were considered moderate picky eaters, but only 3% were severe. Children with moderate and severe picky eating were more likely to show symptoms of depression and anxiety. Some symptoms of depression can be changes in patterns of eating and sleeping, as well as behavioral problems. Those with severe picky eating were more than twice as likely to have a formal diagnosis of depression or social anxiety.
A couple years later, the researchers re-assessed 180 of the children and found the distress was long-lasting. "Two years after the initial evaluation, the kids who were classified as moderate to severe for selective eating, overall, had higher levels of anxiety symptoms,'' Copeland says. This finding suggests picky eating is not a harmless phase for some children, the researchers say.
Both moderate and severe picky eating were linked with reduced growth, the researchers found. Children with severe picky eating sometimes even had problems swallowing food. Those who had the severe type were twice as likely to have behavior problems outside the home.
Aren't most children picky eaters, to some extent, at some point?
Yes, says William Muinos, MD, a director of the weight management program at Nicklaus Children's Hospital. He was not involved in the study but reviewed the findings. "From 1 year to 6 years can be the highest incidence of picky eating," he says.
Often, he finds, it's just a phase and there's nothing to it. But, he says, the new study points to the need to intervene if the selective eating becomes moderate or severe, regardless of the child's age. Children who are severe picky eaters may have ritualistic eating patterns, such as needing to eat certain foods at the same time and agreeing to eat only about three to five different foods.
The Duke researchers say that picky eating is an outdated term. They prefer selective eating.
Selective eating that interferes with a child's daily life is called avoidant/restrictive food intake disorder, or ARFID. That’s a type of eating disorder now included in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Doctors use this manual to diagnose conditions.
Besides the anxiety and depression, are nutritional deficits a concern with moderate or severe picky eating?
Yes, Muinos says. Children who refuse to eat many foods over time might have low levels of iron, vitamin D, zinc, and selenium in their bodies.
"All of that is treatable by supplements," he says.
What should parents of severely picky eaters do?
"If you are worried about it, you need to speak to your pediatrician," Muinos says. The doctor should assess the child's growth, check for nutritional deficiencies, and refer the child to a specialist if necessary.
If a child's eating patterns are interfering with family life, and he's showing symptoms of distress or anxiety, ''you want to jump in rather than taking a wait and see approach," Copeland agrees.
“There’s no question that not all children go on to have chronic selective eating in adulthood,” Zucker says. “But because these children are seeing impairment in their health and well-being now, we need to start developing ways to help these parents and doctors know when and how to intervene.”
William Sharp, PhD, director of the feeding disorders program at Marcus Autism Center in Atlanta, agrees. He says that if serious food issues have continued for a year, it's time to seek professional help -- and sooner rather than later.
Some children who refuse to eat might have heightened senses, meaning they find the smell, texture, or taste of some foods overwhelming, Zucker says. Others might have had a bad experience with a certain food and get anxiety when trying another new food or being forced to try the one he didn't like again.
Some children may benefit from therapy, but new ways are needed to help children who may have sensory sensitivities, she says. Researchers also believe treatments should be better tailored to a child’s age range.
"You want to make sure the child is medically cleared," Sharp says. Among the medical issues that can affect a child's eating, he says, are food allergies or gastroesophageal reflux disease (GERD), a condition in which stomach contents come back up the esophagus. Some children may need a swallowing test to be sure there are no problems there, he says.
Children with severe selective eating need a team of experts, he says, including a gastroenterologist, behavioral psychologist, nutritionist and others. A registered dietitian will look at overall growth and also assess which nutrients are missing from the diet, he says. A child can often be growing fine and have a normal weight, but still be lacking crucial nutrients.
Parents can take several steps to help their children develop a better relationship with food, Sharp says. Among them:
- "Recognize that for certain children, eating new and unfamiliar foods can cause distress," he says.
- Take small steps. Instead of trying to persuade your child to eat foods the rest of your family eats, focus on getting him to sit at the table and eat together with the family.
- When introducing or re-introducing a food, start with a small amount, such as one black-eyed pea on a spoon, not a bowl of them.
Diagnosing and treating depression or anxiety in kids may not make all their eating problems disappear, Sharp says. But it may make them more open to learning new habits about food.