The Obscure
“Eating” Disorders
Feeding Disorders and Picky Eating in Infants and Children

By Abigail Natenshon, MA, LCSW, GCFP

Feeding problems are real; they are hard-wired and neurological. Their far-reaching effects are nutritional, interpersonal, behavioral and developmental, altering the sense of self and self-esteem, family relations, sociability, as well as academic and professional performance.

Diagnosis
A strapping pre-school youngster demonstrates an extreme reaction to certain foods. Unable to tolerate certain textures in his mouth or smells in his environment, the aroma of certain foods hurts his nose and makes him so upset, he runs out of the kitchen. He spits out most foods, and typically gags, coughs or chokes during meals. Though he is growing normally, his mother fears he isn't getting adequate nutrition from the limited foods he is eating. Their pediatrician has repeatedly told this mother not to worry, that her son's height and weight are in the normal range.

An older youngster with a similar problem goes all day at school without anything to eat because he cannot tolerate the smell of food in the cafeteria at lunch time. His food intake during the school day is limited to cakes and chips that he can easily eat on the playground. This same child heaves at the beach in response to the smell of seaweed on the shore. A health practitioner ultimately discovered that this child's brain had difficulty in accurately processing information received from his five senses.

Be aware that eating dysfunction sand disorders can arise in children or adults at any age, though most often, signs of such dysfunction can be picked up early in life. Triggers in the environment and changes in body chemistry, however, make onset of such problems not unlikely at latency as well as in later life stages.

Establishing a differential diagnosis
Feeding problems in children typically go undetected, and/or are mistaken for the more benign picky (preference) eating behaviors. Adding to the ambiguity of diagnosing these problems, by the time problem feeders reach adulthood, the diagnostic terminology describing feeding problems reverts back to being called "adult picky eating." (see PickyEatingAdults.com). Problem feeders describe the one out of twenty children between the ages of birth and 10 who refuse to eat or who will only eat limited numbers of selected foods. Children with feeding disorders (as well as picky eaters to a lesser degree) tend to demonstrate clusters of traits that indicate a broader, more pervasive, neurologically based dysfunction. (Natenshon, 2009 P. 134) Also known perseverant feeding problems, or food neo-phobia, feeding problems are characterized by a strong fear of trying new foods, leaving its victims at risk for malnutrition and failure to grow normally. Problem feeders tend to demonstrate diverse clusters of traits, covering a spectrum of broader, more pervasive, neurologically-based dysfunctions which compromise the person's existence; these might include sensory integration disorder (SID), Asperger's syndrome, Non-Verbal Learning Disability (NVLD), and/or Pervasive Developmental Disorder (PDD) and include such symptoms as choking, gagging, vomiting, difficulty swallowing, etc. Individuals suffering these disturbances in early life in many instances carry varying degrees of pathology with them into their adult years.

Harnessed with restrictions, compulsions, fears and limitations regarding food consumption, children and adults alike find themselves feeling like pariahs and societal outcasts, alone, isolated and seriously misunderstood, not only by loved ones, but by the vast majority of health professionals as well. Generally perceived as being stubborn, inflexible, obstinate and unadventurous, their behaviors dictate that they deny themselves more than nourishment; adult as well as child picky eaters miss out on so many of life's pleasures…the sociability, recreation, celebration and self-care that is so much part of feeding oneself. The achievement of developmental/emotional milestones, as well as the opportunity and emotional capacity to use them to adjust to life, to newness and the anxiety of uncertainty may be forfeited as a result of these early onset problems.

That these disorders are chemically and genetically based is seen in the phenomenon of "innately sensitive and distorted taste buds, which help to explain why some children may be so staunchly opposed to eating vegetables. Scientists have identified a gene (dubbed TAS2R38) that controls a receptor for bitter flavors; those individuals with certain variations of that gene are particularly sensitive tasters. One of my adult eating disordered clients reports "a metallic taste in her mouth" from eating most vegetables, a reflection of the chemical and genetic bases of these problems." (Natenshon, 2009, P 135) Physiological conditions that can affect feeding problems include cystic fibrosis, cerebral palsy, autism, low muscle tone and allergies, as well as sensory, oral-motor, gastro, cardiac, metabolic and genetic disorders. Another condition known as "burning mouth syndrome" the result of a dental procedure, may affect a person's relationship with food, as does Arnold-Chiari Malformation, (ACM), where the brainstem, pressing on the top of the spine, compresses the nerve that regulates breathing, gagging, etc.

In considering the spectrum of behaviors that co-exist with feeding problems, Asperger's Syndrome (AS), for example, is a syndrome linked with a variety of characteristics ranging from mild to severe. Overly sensitive to tastes, sounds, smells and sights, people with AS have a normal IQ and can display obsessive routines and skills, with interest and talent in specific areas. Because of their high degree of functionality and naiveté, these individuals are often perceived as being odd and eccentric, and are often victims of teasing and bullying. The individual with AS might show marked deficiencies in social skills, (they are often extremely literal and have difficulty using language in a social context) and have difficulties with transitions or changes, preferring sameness. They have a great deal of difficulty reading non-verbal cues (body language) and difficulty determining proper body space.

To varying degrees, children with picky eating or selective eating experience similar physical effects as do children with feeding disorders, but the effects are less severe and pervasive in children with feeding disorders, particularly at younger ages. (Natenshon, 2009, P.134) On a spectrum of severity, picky eaters will tolerate new foods on the plate, usually will touch or taste a new food, and will eat at least one food from most texture groups, as compared to feeding disordered children who will cry and act out in the face of new foods and refusing entire categories of food textures. (Natenshon, 2009, P.134)

Distinguishing problem feeders from picky eaters is not intended to negate the consequences of the picky eating syndrome, emotionally, nutritionally and interpersonally. The picky eater typically becomes conditioned to using food as a device to attract undue attention and exert undue control, in some cases distracting family members from dealing with other more relevant or highly volatile issues within the family system.


Discussion
A medical doctor who is, and was, a picky eater as a child, recommends that parents of picky eaters "…do as my parents wisely did. Give the child a vitamin pill and let her grow out of it. She goes on to say that, "Too much attention could make it worse and lead to an eating disorder." Describing her continued preference today for sugary, fatty and bland foods, she still gravitates towards hotdogs, hamburgers, chicken nuggets, French fries, and ice cream and has only learned to eat vegetables as an adult. Yet, in her opinion, her eating preferences have in no way compromised her daily existence or professional function. This woman is clearly an exception to the rule.

Dr. Kay Toomey, one of the nation's leading specialists in treating problem feeders, is cofounder of Children's Hospital Oral Feeding Clinic in Denver and is director of Colorado Pediatric Therapy and Feeding Specialists, Inc; she is best known for developing the multidiscipline Sequential, Oral, Sensory (SOS) Approach to Feeding. Toomey refutes the idea that eating is completely instinctual. She says that "instincts only start the process, and only then if they are not interfered with by premature birth or a physical disorder. Eating is, in reality, a learned behavior. Just as children learn to eat, so children can be taught to not eat by the circumstances of their lives. If the smell of oatmeal hurts a child's nose, he believes that it will certainly hurt his mouth." Toomey goes on to say that "In the SOS approach, the first step is figuring out how a child learned not to eat, be the triggers genetic and chemical or environmental. If children have a sensory integration disorder, it becomes difficult for them to understand and put together all the different pieces (requirements and functions) involved with the process of eating."
(http://www.freep.com/news/health/picky11_20020611.htm).

The earlier the child is given a diagnosis and offered an opportunity to make remedial changes, the timelier and more effective and sustainable are the outcomes for change on the individual and within the neuro-plastic brain.

Disordered eating or eating disordered?
Picky eating disorders must be distinguished, too, from early childhood eating disorders (anorexia, bulimia and compulsive overeating/binge eating disorder). Unlike eating disorders, picky behaviors are not associated with distorted body image; fear of eating fat or becoming fat; or mood, control or identity issues that characterize clinical eating disorders. Despite this, some picky eaters are treated inappropriately on hospital units devoted to the care of eating disorders. A similarity between picky eating syndrome, feeding disorders and clinical eating disorders lies in research that bears out that all of these conditions are genetically based, with traits and propensities carried in the DNA. Though feeding problems may be based in "nature," treatment and cure of these syndromes lies squarely within the bounds of "nurture," assuming there is sufficient motivation and incentive to stimulate change.



Parents' Questions
"Is there anything really wrong with sticking to a few foods that the child likes and that nourishes him?"
A commonly asked question, many parents and adult patients wonder about the legitimacy of even extreme personal preferences in choosing foods, particularly when the child's weight remains in the realm of normal. This parent goes on to ask, "Does it have to be a food allergy or philosophical beliefs about eating (i.e. vegetarianism) for it to be okay to consume a limited menu?"
It is a legitimate point that to "pathologize" this condition is not helpful; at the same time, is it wise to ignore a problem simply because it lends itself to being ignored? Research shows that many of the kids who later develop clinical eating disorders were picky eaters when younger. This could be the result of a natural progression of behaviors that wreak havoc with a body and brain, of genetic predisposition, of metabolic process dysfunction brought on by an unhealthy relationship with food and eating, and/or of too much of the wrong kind of attention (power struggles) around food and eating from loved ones and care-takers.
Problem eating is a red flag, an indicator that something is amiss. A problem must be recognized and defined as such before it can be resolved. With feeding disorders, the earlier the problem is defined and addressed, the more timely and effective will be the solution….. Abigail Natenshon, MA, LCSW


"Should I start making an issue out of my child's eating patterns? Should I try to get him to try new foods? Will doing this make it more of a problem than it seems to him right now?"
It is an interesting concept that a problem is not a problem unless it is identified as such, defined, literally, through words and the expression of real feelings. By not speaking one's thoughts and observations, by not verbalizing what everyone knows and believes, parents and care takers enter an implicit contract of dishonesty in "turning the other cheek," pretending not to look at… and not to see… the "elephant under the chair."

If you knew something was good for your child, such as learning to look both ways before crossing the street, or taking antibiotics for an ear infection or strep throat, would you be asking the same question about whether of not to step up to the plate and assume your responsibility as a parent to educate your child about how to become more capable of fueling his brain and body for a healthfully functioning life?

Children are not born fully competent people prepared to take on the realities and challenges of life. Kids need to be taught, and to learn, the ways of the world and how to most effectively care for the self within that world. What is more, they need to be guided into how best to approach and solve problems, through strong and secure problem-solving role models who are not afraid to be clear and direct in facing adversity, dealing with it, and finding solutions

It is interesting to note that a child's eating routines and habits are determined by the age of two; at the same time, it can take as many as 10 times offering a child a new food before the child will feel comfortable eating it. By not making these efforts, the parent may inadvertently be teaching the child an important life lesson about not taking risks in trying new things in enhancing his existence. People who cannot take risks and adapt to new situations regarding food and eating, may find themselves unable to face and handle life itself, with all of its curve balls and transitions.
……… Abigail Natenshon, MA, LCSW


References:
Doing What Works: An Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery, Abigail H. Natenshon NASW Press, 2009 Washington, D.C.



Books and articles
1. Lask and Bryant-Waugh: Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. Psychology Press 2000.
2. Lask and Bryant-Waugh: Eating Disorders- A Parents Guide Psychology Press 2004
3. Ernsperger and Stegen-Hanson. Just Take a Bite: Effective Answers to Food Aversions and Eating Challenges Publisher Future Horizons, 2004
4. Marcontell, D.K., Laster, A.E., & Johnson, J. (2002). Cognitive-behavioral treatment of food neophobia in adults, Journal of Anxiety Disorders, 16, 341-349.
5. Nicholls, D., Christie, D., Randall, L., & Lask, B. (2001). Selective eating: symptom, disorder or normal variant? Clinical Child Psychology and Psychiatry, 6, 257-270.
6. Seminars: http://www.sensoryresources.com/conf_details2.asp?cid=915

An internationally renowned expert in the treatment of eating disorders, Abigail H. Natenshon, MA, LCSW, GCFP is a psychotherapist who has treated children, adults, couples, families and groups for past 40years. The author of When Your Child Has An Eating Disorder: A Step-by-Step Workbook for Parents and Other Caregivers (Jossey Bass, Publisher), and the book Doing What Works: An Integrative System for the Treatment of Eating Disorders from Diagnosis to Recovery Abigail is a Guild Certified Feldenkrais Practitioner who is on the cutting edge of combining traditional psychotherapy with this potent holistic adjunct body technique to enhance body- and self-image healing. Outcomes point to an enhanced awareness of self and well-being, anxiety reduction, symptom cessation, and increased options for using the self with facility and intention.

As the founder and director of "Eating Disorder Specialists of Illinois: A Clinic Without Walls."
Ms. Natenshon hosts three informational web sites, including http://www.empoweredparent.com, http://www.empoweredkidZ.com and http://www.treatingeatingdisorders.com Abigail has made numerous guest appearances on national television including The Oprah Show, The John Walsh Show, Starting Over (NBC), MSNBC News, as well as National Public Radio.
Abigail speaks widely to parent and professional audiences and maintains a private practice in Highland Park, Illinois where she resides with her husband.