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Beyond picky eating: Anxiety-based feeding disorders, selective eating and solutions
March 13, 2018
Beyond picky eating: Anxiety-based feeding disorders, selective eating and solutions

    Anxiety-based eating disorders in children: Solutions to help 

    Anorexia or bulimia may first come to mind when you hear the term “eating disorder.” However, there are other eating-related conditions parents should be aware of that can seriously affect a child’s weight gain and growth. Highlighting a recently defined trend, Feeding Program therapist Amaka Winslow explains anxiety-based feeding disorders, how these issues can severely limit what a child eats, and what can help.

    Eating disorders in children

    I’ve never heard of anxiety-based feeding disorders before. What’s this all about?

    When using the term “anxiety-based feeding issues,” our feeding specialists are specifically talking about individuals who have difficulty trying or eating certain foods due to worries about what may happen to them if they eat the food. These individuals also experience physiological symptoms that accompany these worries. Common physiological symptoms include:

    • A rapid heartbeat
    • Stomach-churning (or “butterflies in their stomach”)
    • Shakiness
    • Feeling hot and sweaty
    • Nasal blanching (flaring nostrils in response to being nervous)
    • Rapid breathing

    The worries associated with anxiety-based feeding issues typically consist of thoughts such as: “What if I can’t swallow it?” “What if it gets stuck in my throat?” or “What if I don’t like the taste or texture?” Many children with these types of feeding issues experience emotional distress due to concerns related to the way the food is delivered into their bodies, not how it is ingested (which would be more of a concern for an individual diagnosed with anorexia nervosa or bulimia).

    In essence, they’re experiencing a “false alarm” produced by their body’s fight or flight response in which they’re having a normal response to the feeling of being in danger, but are not actually in danger. These anxiety issues are often associated with a child becoming severely selective about the foods they will eat.

    What is considered “severely selective” in feeding disorders?

    Historically, severe food selectivity has been well-studied and documented in children under age 6, but very little information is known about elementary-age children and adolescents who struggle with this condition. In 2013 the American Psychiatric Association named severe food selectivity as “Avoidant/Restrictive Food Intake Disorder” or ARFID.2 Severe food selectivity is defined as avoidance or restriction of food that results in any of the following factors:

    • Substantial weight loss or failure to achieve expected weight gain
    • Substantial nutritional deficiency
    • Dependency on an artificial means of obtaining nutrition such as a feeding tube
    • Significant impairment in psychosocial functioning

    It’s important to mention that in individuals with severe food selectivity these factors are NOT the result of body image preoccupation, fear of weight gain or a drive to be thin.3 ARFID typically develops from infancy and is most commonly associated with autism spectrum disorder. It can also be due to: any disturbance in the caregiver-child relationship that affects the child’s feeding; a specific phobia, social anxiety disorder or other anxiety; or a neurological/neuromuscular, structural or congenital (present at birth) disorder that affects a child’s feeding or swallowing.

    Although this is not an in-depth list, these are the most commonly seen associated conditions that cause this disorder.

    How does severe food selectivity differ from picky eating?

    To be clear, having severe food selectivity and being a “picky eater” differ in that a picky eater is generally able to maintain a relatively healthy weight and meet growth parameters, but they do not consume an adequate variety of foods.3 Individuals with the ARFID diagnosis are unable to grow appropriately due to the severity of their food refusal. They typically rely on some level of assistance to meet their nutritional needs and often rely on the support of a multidisciplinary team to provide rehabilitation, medical management and treatment.

    Research suggests that among children ages 5 to 13 there are approximately 2.6 diagnosed cases of ARFID per 100,000 children. Research in the area of severe food selectivity in older children and teens is in its very early stages, but severe food selectivity issues are known to affect this age group as well. Most research has shown that picky eating in general (whether severe or not) occurs in 7 to 27 percent of older children. Generally, if an older kid or teen is a very selective eater, they likely had this same condition as an infant or toddler.

    What can I do about it as a parent? It’s making mealtimes miserable.

    There are things that you can do to encourage kids to eat new or non-preferred foods, but you may need professional help down the road. On your own, you can do the following:

    Expose them: It’s important to expose children and teens to new foods by simply offering (but not forcing) new options. Generally, encouraging them to try one new food every week is a reasonable goal.

    Let them explore: If it’s appropriate to a child’s skill level, anxiety level and goals, let them “explore” the food using sensory-based treatment approaches. This “exploration” generally relates to playing with the food to increase the child’s comfort level with touching, smelling or tasting it. This can help build a comfort level toward the food, which is also a helpful step toward the ultimate goal of eating the targeted food. Encourage your child to touch the food five times, tap it to their lips three times, then try a small bite. Support their efforts with verbal praise (Good job! Excellent eating!), high fives, bubbles or even a short period of fun time with you (tell them a joke, for example).

    Rotate around the plate: Arrange your child’s food in a circle on the plate with a new or non-preferred food in between two preferred foods and have your child eat what’s on the plate in a rotation. This practice is helpful because it limits “avoidance behaviors,” such as eating all the preferred foods first and then leaving the new/non-preferred food for last (which by that point they will not eat because they are full). It also teaches the child that every food has its “turn” so that all foods – whether preferred or non-preferred – get eaten during the mealtime and the rotation provides an opportunity for the child to be able to look forward to the preferred food, especially if the non-preferred food is “sandwiched” between two preferred foods.

    The one-bite rule: Instruct your child to take “just one bite” of the non-preferred food and praise them when they do. The one-bite rule is especially helpful when dealing with children who have anxiety issues that are so profound it is often difficult to do any of the aforementioned strategies. Many are more willing to try just one bite, especially if it is small!

    When should I seek professional help from a feeding therapist?

    If food refusal continues despite your at-home efforts, the assistance of a multidisciplinary feeding team may also be needed to help. Research shows that children with “severe feeding disturbances benefit most from intensive multidisciplinary treatment” and the most effective method of treatment has been to provide cognitive-behavioral therapy while simultaneously addressing contributing factors such as behavioral inflexibility, gastrointestinal problems and sensory processing impairments.

    Cognitive-behavioral therapy includes approaches such as “repeated exposure” which is a method of treatment that involves teaching the child or teen how to think through their emotions (the feelings caused by their anxiety or “worries”) then learn to overcome them. Essentially, they are learning to be confident and brave – just like a superhero!

    Severe food selectivity is often a very daunting issue for many families because eating is ingrained into all aspects of each of our lives. In addition, it can affect many areas of a child’s life. Be encouraged to know that there are local supports, such as feeding programs, available to help identify specific problems and offer real-life solutions.

    By Amaka Winslow, speech-language pathologist, Feeding Program, with contributions from Dr. Priscilla Powell, a licensed clinical psychologist, Feeding Program

    About CHoR’s feeding program

    Our pediatric feeding program is designed to help children who have medical conditions that affect their feeding and growth. A multidisciplinary team of specialists works with each child and family to address the multiple factors involved with eating. The program takes a comprehensive approach that incorporates a child’s medical and developmental needs and addresses both behavioral and oral-motor feeding issues.


    • Pitt, Paulette D., et al. “A focus on Behavioral Management of Avoidant/Restrictive Food Intake Disorder (ARFID): A Case Series.” Clinical Pediatrics. (2017): 1-3. Print.
    • Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington: American Psychiatric Association, 2013. 334-338.
    • Norris, Mark L., et al. “Update on Eating Disorders: Current Perspectives on Avoidant/Restrictive Food Intake Disorder in Children and Youth”. Neuropsychiatric Disease and Treatment 12 (2016): 213-217. Print.
    • Ornstein, Rollyn M., MD, et al. “Treatment of Avoidant/Restrictive Food Intake Disorder in a Cohort of Young Patients in a Partial Hospitalization Program for Eating Disorders.” International Journal of Eating Disorders. 2017; 50: 1067-1074. https://doi/org/10.1002/eat.22737

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