More Than Picky Eating: ARFID, SPD, and Other Conditions Linked to Feeding Difficulties in Children
Picky eating is a common childhood behavior that does not always resolve with age and frequent exposure to new foods. What happens when eating and feeding difficulties persist despite best efforts by parents and caretakers? For some, food restriction and refusal may point to conditions like ADHD, SPD, autism, and/or ARFID. Learn more about these diagnoses and strategies to address the fussiest eaters.
Picky eating is a common and normal behavior, starting between ages 2 and 3, when many children refuse greens, new tastes, and practically anything non-pizza. They are at the developmental stage where they understand the connection between cause and effect, and they want to learn what they can control. For others, feeding difficulties and selective eating are not a phase but symptoms of conditions like sensory processing disorder (SPD), attention deficit hyperactivity disorder (ADHD or ADD), autism, and/or, at the extreme end, Avoidant/Restrictive Food Intake Disorder (ARFID).
To successfully address picky eating and related food issues, parents must first recognize possible underlying factors so they can seek the appropriate professional help and treatments.
Picky Eating and Feeding Difficulties: Common Causes and Related Conditions
SPD and Eating Problems
While not an official medical diagnosis, sensory processing disorder is tied to immature neurological development and characterized by faulty processing of sensory information in the brain. With SPD, the brain can misread, under-read, or be overly sensitive to sensory input. Typical symptoms include heightened or deadened sensitivity to sound and light; extreme sensitivity to clothing and fabrics; misreading social cues; and inflexibility. The stress caused by sensory dysregulation can affect attention, behavior, and mood.
Eating is a key SPD problem area, as all aspects of food – from preparation to ingestion – involve reading and organizing data from all of the senses. SPD-related eating issues include:
- Appetite: Sensory overload stimulates the release of stress hormones. Mild to moderate stress increases desire for starches and sweets but chronic or high levels of stress reduces the appetite and interferes with digestion.
- Hunger signals. Young children often miss hunger cues when they are playing. They want to stay at the park for just 10 more minutes when it is obvious that without an immediate influx of food, the afternoon will be shot. When elevated to SPD, children rarely notice they are hungry as the hunger signal is lost amidst a mass of misread and disorganized sensory data. When they do ask for food, they may refuse items that are not to their exact specifications. A small percentage misread satiety, chronically feel hunger and ask continuously for food.
- Food sensory characteristics. How the brain makes sense of smell, taste, temperature, color, texture, and more impacts the eating experience. Because food has so many sensory characteristics, there are many areas where children can get thrown off.
The most common symptom of SPD is psychological inflexibility. Individuals with SPD attempt to limit sensory discomfort by controlling their external environment in the areas where they are overloaded. With eating, this rigidity can mean only one brand of acceptable chicken nuggets (not the homemade ones), the same foods repetitively, strict rules about foods not touching, and random demands about and rejection of core favorites. (e.h. “The apple is bad because of a tiny brown spot,” or suddenly, noodles are on the “don’t like” list.)
Many people on the autism spectrum identify as having strong or diminished responses to sensory information. If delays in motor planning and oral motor issues are also present, in addition to the sensory aspects of food and eating, children on the spectrum may have trouble chewing and swallowing some foods.
ADHD symptoms and behaviors may also contribute to problems with food.
- Impulse control and self-regulation problems can cause overeating and make it difficult to notice and respond to satiety.
- Poor executive functioning can derail meal planning and preparation in adolescents and young adults who prepare their own foods.
- Distractibility and inattention can lead to missed hunger signals or even forgetting to eat.
- Stimulant medications can dull the appetite.
- Mood stabilizers can increase appetite.
Also known as “extreme picky eating,” ARFID is described in the DSM-5, the guide clinicians use to diagnose health conditions, as an eating or feeding disturbance that can include:
- Lack of interest in eating or food
- Avoiding foods based on sensory characteristics
- Avoiding foods out of concern over aversive experiences like choking or vomiting
These disturbances result in failure to meet appropriate nutritional and/or energy needs, as manifested by one of more of the following:
- Significant weight loss or faltering growth and development
- Significant nutritional deficiency
- Dependence on enteral feeding or oral nutritional supplements
- Marked interference with psychosocial functioning
To merit a diagnosis, the disturbance must not be better explained by a lack of available food or a culturally sanctioned practice, and it must not be associated with body image concerns or a concurrent medical condition/treatment (like chemotherapy).
Children with ARFID may experience certain foods, such as vegetables and fruit, as intensely unpalatable and take great care to avoid them.1 They may be fearful of trying new foods and rely on highly processed, energy-dense foods for sustenance.1 Common feeding advice like hiding and disguising vegetables in food, relying on your child to “give in” to avoid starving, or repeating requests to eat does not work with children who have ARFID. This disorder is associated with extreme nutritional and health deficiencies.
Research on the prevalence of ARFID is limited, but findings from studies on patients with eating disorders estimate ARFID rates between 5%2 and 23%.3 Notably, ARFID appears to be most common in young males and more strongly associated with co-occurring conditions than are other eating disorders. One study on young patients with ARFID, for example, found that 33% had a mood disorder; 72% had anxiety; and 13% were diagnosed with autism spectrum disorder.3
In my view, the extreme eating behaviors in ARFID are sensory processing disorder symptoms. (Maybe one manifestation of SPD is quietly in the DSM-5 after all.) If you see your child in this description, get professional help. Parents of those with ARFID are usually as frustrated and discouraged as the children they are trying to help.
Picky Eating and Feeding Difficulties: Solutions
Parents can take small daily steps to better fulfill a child’s nutritional needs and reduce stress around meals. Serious feeding difficulties and eating problems warrant professional help. Occupational therapists, speech therapists, nutritionists, GI specialists, and psychologists are several of the professionals who can help evaluate and treat youngsters that resist your best efforts.
1. Assess the Severity of Sensory and/or Behavioral Challenges
These symptoms may point to challenges that require therapeutic intervention:
- Only eating one type of texture (e.g. crunchy, mushy or foods that require limited chewing, like crackers)
- Avoiding food at certain temperatures (e.g. will only eat cold food)
- Exaggerated reactions to new food experiences. (e.g. vomiting and/or lengthy, explosive temper tantrums)
- Extreme sensitivity to smells
- Brand loyalty, only eating products made by a certain company. (Processed foods may have more sugar and salt to boost flavor, which can exacerbate feeding problems)
- Refusing to eat foods if small changes are made, including in the packaging or presentation
- Refusing to eat or excessive fussing over unpreferred foods on the same plate or table when eating
- Takes 45 minutes or more to finish a meal
- Is losing weight over several months (and is not overweight)
Physical and biological problems can also contribute to feeding difficulties, including:
- Reflux; esophagitis
- Allergies and aversive food reactions
- Poor digestion and gut issues including excessive gas, bloat, constipation, diarrhea, and abdominal pain
- Underdeveloped oral motor skills. Symptoms include frequent gagging, pocketing food, takes forever to get through a meal, difficulty transitioning from baby food to solid food, drooling.
- Chronic nasal congestion.
2. Keep Nutritious Foods at Home
Try not to keep any foods at home that you do not want your child to eat. That includes certain snack foods, which are designed to be extremely appealing to the senses, but often offer paltry nutritional value. (It’s easier to remove these foods than to introduce new ones.) Consider saving leftover lunch or dinner for snacks instead.
It is also better for your child to eat the same healthy meals over and over again than to try to vary meals by filling in with snack foods or different versions of white bread (such as muffins, pancakes, bagels, noodles, rolls and crackers). Find a few good foods that your child enjoys and lean into them.
Rather than make drastic changes at once, focus on one meal or time of day, like breakfast, and start on a weekend so the initial change doesn’t interfere with school and other activities. Breakfast is a good meal to tackle, as most kids are home and this meal sets the tone for the day. These tips can help make the most of the day’s first meal:
- Limit sugary, processed items like cereal, frozen waffles, breakfast pastries, and the like. These foods fuel sudden spikes and drops in your child’s energy levels through the school day. If your child also has ADHD and takes medication for it, it’s important to serve breakfast before the medicine kicks in, as stimulants can dampen appetite.
- Focus on protein. Protein provides long-lasting energy and fullness. A protein-rich breakfast can include eggs, smoothies, paleo waffles, salmon, hummus, beans and nut butters.
- Think outside of the box. Breakfast doesn’t have to look a certain way. Leftover dinner can be an excellent meal to start the day.
3. Consider Supplements
Nutritional deficiency is a common outcome of restricted, picky eating. These deficiencies can impact appetite and mood and, in the severe cases, exact long-term consequences on development and functioning. Vitamins, minerals, and other supplements can close the gap on these deficiencies while you work with your child on eating a more varied diet.
Among the body’s many required nutrients, zinc appears to have the greatest impact on feeding difficulties, as poor appetite is a direct symptom of zinc deficiency. Insufficient zinc intake is also associated with altered taste and smell, which can impact hunger signals and how your child perceives food. Zinc is found in meat, nuts, oysters, crab, lobster, and legumes. “White” foods like milk and rice are not rich in zinc.
4. Stay Calm and Carry On
Family collaboration can play an important role in addressing picky eating and reducing stress around new foods. Even if only one person in the family has feeding difficulties, ensure that everyone is following the same plan for creating and maintaining a positive, cooperative environment at home.
How to Introduce New Foods
- Concentrate on one food at a time to reduce overwhelm. Give your child a limited set of new food options from which to choose. Consider keeping a kid-friendly food chart in the kitchen. If your child won’t choose, pick one for them.
- Introduce one bit of the same food for at least two weeks. Repetition is a sure way to turn a “new” food into a familiar one. Sensory processing issues means new things are bad things, because new means more potentially overwhelming data to read and sort.
- Do not surprise your child – make sure they know what’s coming.
- Offer choices that are similar to foods they already eat. If your child likes French fries, consider introducing sweet potato fries. If they like crunchy foods, consider freeze-dried fruits and vegetables. If they like salty and savory flavors, try preparing foods with this taste in mind.
- Set up natural consequences using when:then to increase buy-in and avoid the perception of punishment. Say, “When you finish this carrot, then you can go back to your video game.” As opposed to, “if you don’t eat your carrot, you can’t play your game.”
No matter the plan or your child’s challenges, stay calm in the process. Losing your temper can cause your child to do the same (especially if they are sensory sensitive) and create undue stress around an already tough situation:
- Start with the assumption that you and your child will be successful
- Explain expectations in simple terms
- It’s OK if your child fusses, gags, and complains about a new food in the beginning
- Give yourself time-outs when needed
- Always keep feedback positive
Picky Eating Problems: Next Steps
- Download: Best Vitamins and Supplements for People with ADHD
- Symptom Test: Sensory Processing Disorder in Children
- Read: The Parent’s Guide to Mealtime with Picky Eaters
The content for this article was derived from the ADDitude Expert Webinar Got a Picky Eater? How to Solve Unhealthy Food Challenges in Children with SPD and ADHD [podcast episode #355] with Kelly Dorfman, M.S., LND, which was broadcast live on May 18, 2021.
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1 Brigham, K. S., Manzo, L. D., Eddy, K. T., & Thomas, J. J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current pediatrics reports, 6(2), 107–113. https://doi.org/10.1007/s40124-018-0162-y
2 Norris, M. L., Robinson, A., Obeid, N., Harrison, M., Spettigue, W., & Henderson, K. (2014). Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. The International journal of eating disorders, 47(5), 495–499. https://doi.org/10.1002/eat.22217
3 Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 21. https://doi.org/10.1186/s40337-014-0021-3