PDF Summary:Helping Your Child with Extreme Picky Eating, by Katja Rowell and Jenny McGlothlin

Mealtime doesn't have to be a battle. In Helping Your Child with Extreme Picky Eating, Katja Rowell and Jenny McGlothlin explain the multiple factors—from health issues and oral-motor delays to sensory sensitivities and temperament—that can contribute to a child's reluctance to eat. They provide a compassionate approach to help parents reduce anxiety around eating for both themselves and their children.

The authors' STEPS+ method offers strategies to create positive associations with food, develop oral and sensory skills necessary for eating diverse foods, and build independent eating habits. Their guidance helps families move away from conflicts and toward enjoyable, pressure-free mealtimes.

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Unfortunately, those with struggling children get lots of well-meaning, but incorrect, feeding advice from family, friends, teachers, and even doctors. The authors point out that most medical training doesn't even cover foundational knowledge of feeding, growth, and nutrition, so it's understandable that doctors, with the best of intentions, recommend feeding practices that are counterproductive. For example, a pediatrician might tell parents to give a bottle during the night to bolster weight gain in an infant who is smaller than average. The authors point out that this well-intentioned suggestion undermines the natural instincts of infants to regulate rest and appetite. Parents may also be told to follow their child around with food, or pressure a reluctant eater to take two bites to avoid tube-feeding, or "starve him out."

Rowell and McGlothlin caution parents to rely on their instincts when deciding whether advice is helpful or hurtful. They suggest it's okay to question any feeding approach that doesn't seem correct or support calm meals with minimal distractions. They stress that if the "solution" makes everyone miserable or causes more anxiety or conflict, it's probably the wrong approach.

Context

• Advice often assumes a one-size-fits-all solution, ignoring the individual differences in children's developmental stages, preferences, and health conditions.
• Historically, medical education has evolved with a focus on treating diseases rather than preventive health measures, which includes nutrition and feeding practices.
• Personal experiences and cultural norms can influence a doctor's recommendations, which may not always align with evidence-based practices.
• While weight gain is important, it should be balanced with overall health and development. Rapid weight gain through additional feedings might not address underlying issues such as metabolic or digestive concerns.
• This method suggests withholding food until a child is hungry enough to eat whatever is offered. It can be harmful as it ignores a child's individual needs and hunger signals, potentially leading to nutritional deficiencies and a negative relationship with food.
• Parents often know their children best and can sense when something feels off. Trusting their instincts can be crucial in making decisions that align with their child's needs and family dynamics.
• Parents may experience increased stress and guilt if feeding strategies lead to conflict, impacting their overall well-being and ability to provide supportive care.

How Pushing Kids Undermines Motivation and Food Relationships

We all like to have a sense of control, but when you exert control over your child's diet, your agenda will be met with push-back as he attempts to maintain his own sense of autonomy over his body and control. This is especially true for kids who are already more sensitive, wary, or independent. The authors offer several examples of pressure tactics and strategies that can worsen a child's diet.

How Bribes and Rewards Mislead the Child About Food

The authors remind readers that while numerous approaches targeting other behavior problems work, those same techniques, when focused on eating, often have the opposite effect in a major way. Children, like adults, should eat according to internal signals of being hungry, full, and enjoying their food. If children are taught to eat solely to please the adult or to avoid punishment, they lose touch with their innate sense of appetite and self-regulation.

Context

• Techniques like rewards and punishments are often used in behavioral psychology to encourage desired behaviors or discourage unwanted ones. These methods can be effective for tasks where external motivation is appropriate, such as completing homework or chores.
• Consistently using bribes or rewards can undermine a child's trust in caregivers, as it may signal that the caregiver's approval is conditional, affecting the child's sense of security and attachment.

Parental Anxiety Reduces Children's Enjoyment of Food and Their Appetite

As you've learned in previous chapters, feeling anxious reduces your appetite. The kid who is extremely selective about food is already anxious around it. Parental worry and pressure, in whatever form, will only compound this problem, and likely cause the child to retreat further into his "safe" eating patterns. It can be profoundly unsettling for the parent who loves exploring new foods and has a large appetite to realize that her anxiety is a major factor in her child's resistance.

Rowell and McGlothlin share numerous examples of how pressure, despite appearing positive, undermines a child's relationship with food. For example, praising kids for trying broccoli reinforces their impression that alternatives are inferior. A child who's pressured to have a couple of additional bites, or must finish their peas before they can go, learns to avoid these foods altogether. If a kid observes a parent tensing up whenever a peanut approaches his mouth, his anxieties about choking or getting sick will increase.

Practical Tips

• Engage in calming activities before meals. If you find that anxiety is affecting your appetite, try relaxation techniques such as deep breathing, meditation, or light stretching before eating to help reduce anxiety and potentially improve your appetite.
• Start a small vegetable garden with your child, even if it's just a few pots on a windowsill. Let them choose some of the plants, care for them, and eventually harvest them. The act of growing their own food can create a sense of pride and ownership, making them more likely to try and enjoy the fruits (or vegetables) of their labor.
• Create a family recipe book where each member contributes their favorite meal, focusing on the joy of cooking rather than the nutritional value. This encourages a positive relationship with food by associating it with family bonding and creativity. For example, have a monthly "recipe reveal" where a family member cooks their contribution and shares why it's special to them.

Implementing the STEPS+ Approach to Address Picky Eating

Authors Rowell and McGlothlin, based on years of experience and knowledge, have created the Supportive Treatment of Eating in PartnershipS (STEPS+) method to help parents and families overcome feeding problems in a realistic and sustainable way. This approach is based on knowing the typical way children learn to eat and how parents can support their progress, honoring the fact that individual children's requirements and rates of progress will differ.

Reducing Conflict and Relieving Stress and Pressure

The first step in STEPS+ involves addressing anxiety and stress, both in the child with extreme picky eating and in the parent. Lower anxiety will make for happier mealtimes and, more importantly, will enable your child to reconnect with his innate sense of appetite.

Managing Parental Anxiety About Your Kid's Diet

The authors recognize that reducing anxiety may feel impossible to the parent who has spent months, or even years, worrying about her child's growth and nutrition. The initial step is learning to accept your child's current eating habits. This doesn't imply you will never see a balanced meal or hear her ask for more; rather, it means that you trust her desire to learn and grow will eventually include her eating.

Remember that one child's idea of "variety" might differ from the omnivore's plate. To summarize, how your kid eats doesn't reflect your parenting skills. Rowell and McGlothlin suggest you address and combat the fear-driven messages you have been bombarded with by trusting yourself and your ability to support your child.

Context

• Acceptance allows parents to focus on long-term goals of healthy eating rather than immediate changes, understanding that developing a varied diet is a gradual process.
• The range of foods a child is exposed to can affect their perception of variety. Limited exposure might mean they find variety within a smaller selection of foods.
• Parents may not always have access to accurate nutritional information, which can affect their understanding of what is considered a balanced diet for their child. This lack of information is not a reflection of their parenting abilities.
• Engaging with support groups or communities of parents facing similar challenges can provide encouragement and practical advice, reinforcing trust in one's parenting abilities.

Reassuring Children Regarding Eating Choices

If you have been pressuring your child around food, you may need to take concrete steps to reassure her that she is safe to eat or not eat. This can be particularly challenging for a youngster who's already more cautious and fearful. For example, some kids who have EPE find it very hard to eat outside their home because of previous adverse experiences.

The authors stress the importance of allowing a child to choose whether or not to eat based on her own preferences. Reassure her that she truly has control over what goes in her mouth when it's time to eat, and remind her that there will always be something she can eat at mealtimes. If, for example, you are heading to a gathering or a restaurant, you could say, "We will find something you can eat" or "It's okay if you don't want to eat anything they offer. We can eat at home before the party or after it."

Context

• Positive reinforcement, such as praising a child for trying new foods without pressure, can encourage exploration and reduce fear. It shifts the focus from the quantity of food eaten to the experience of trying something new.
• These could include being forced to eat foods they disliked, experiencing discomfort or illness after eating certain foods, or being in environments where they felt pressured or judged.
• Extreme picky eating is often linked to sensory sensitivities, anxiety, or past negative experiences with food, making it difficult for children to try new foods or eat in unfamiliar settings.
• Parents might consider communicating with hosts or restaurant staff in advance to understand available food options, which can help in planning and providing reassurance to the child.
• In social settings, children with EPE might feel pressure or embarrassment about their eating habits. Offering alternatives can help them participate without feeling singled out or uncomfortable.

Clarifying Eating Roles and Boundaries to Reduce Conflict

Once you understand what a family meal is, and isn't, and have a strategy for how and when to serve food, the main source of mealtime anxiety for many families (particularly for children around the ages of 2 to 6) is the power struggle to make the child comply with adult requests. The authors explain how to stop these power struggles by using the DOR, a rule that involves dividing responsibility. This approach defines the roles of caregivers and kids. In a nutshell, the parent determines what, where, and when foods are offered, and the child chooses whether to eat and the quantity to consume of what's presented.

Although it may seem simple, the DOR can be difficult to implement consistently if there's a history of pressure or manipulation. For example, it will feel tempting to give in to demands for a bowl of crackers when your child rejects the dinner you've planned. However, if you stick to your role, the child learns it won't work to get a different food, and he'll have the opportunity to eat a meal with an accepted choice later on.

Context

• Different cultures have unique traditions and expectations around family meals, which can influence how boundaries are set and understood.
• Children between the ages of 2 to 6 are in a developmental stage where asserting independence is crucial. This often manifests in their eating habits as they test boundaries and explore autonomy.
• Consistently applying the DOR can lead to reduced picky eating behaviors, decreased mealtime battles, and improved family dynamics over time.
• Maintaining consistency with DOR can be difficult in social settings or when other caregivers are involved, as they may not be familiar with or supportive of the approach.
• Parents who adhere to their roles model decision-making and self-control, teaching children important life skills beyond just eating.
• The Division of Responsibility in feeding is a concept developed by nutritionist Ellyn Satter. It emphasizes that parents are responsible for the what, when, and where of feeding, while children are responsible for how much and whether they eat. This approach aims to reduce mealtime battles and encourage healthy eating habits.

Organized Schedule for Dining and Nibbles

Rowell and McGlothlin explain how routine eating opportunities help kids with EPE understand how to eat in a way that suits their hunger and appetite cues, promoting self-regulation.

Regular Meals for Hunger and Healthy Habits

This approach helps children recognize hunger signals that they may not have been able to discover due to grazing. The schedule, along with the reduction of pressure, also helps to alleviate general anxiousness. A child who is calm and able to pay attention to signals of hunger and fullness tends to have a healthy diet, just like adults!

Many children and parents are used to having at least one "eating opportunity" between meals (say, a granola bar in the car) or grazing on small amounts of less nutritious foods between meals. The authors stress that this "grazing," which sabotages appetite and the sensation of hunger and prevents learning cues, must be addressed early on in reclaiming happy mealtimes.

Context

• Shared mealtimes can foster social interaction and communication skills, contributing to emotional well-being and reducing anxiety.
• Scheduled meals encourage balanced nutrition by ensuring that children consume a variety of foods at set times, rather than filling up on less nutritious snacks.
• Snacks often consist of processed foods high in sugar and low in essential nutrients, which can displace more nutritious meals and affect overall dietary quality.
• Grazing can disrupt a child's natural ability to regulate their appetite, as constant snacking prevents them from experiencing true hunger and fullness cycles, which are essential for developing healthy eating patterns.

Easing Transitions and Minimizing Distractions at Mealtimes

The authors address the difficulty of getting a child who has EPE (and often their siblings) to sit down and stay there long enough to have a pleasant eating opportunity. Transitions often present an obstacle, and a child who doesn't yet recognize or hasn't learned how to deal with hunger may act out, resist, or have a tantrum when she's asked to stop playing.

Rowell and McGlothlin offer a variety of techniques for managing transitions and making dining more predictable, less stressful, and less chaotic. They suggest several approaches, such as using a kitchen timer to give younger children a chance to settle for five minutes while also getting used to a distraction-free table; involving your children in meal preparation and cleanup; and setting a timer for five or ten minutes before the end of a meal or snack as a warning that snacks or bedtime is coming.

Context

• The struggle to sit during meals can also be linked to broader behavioral challenges, such as difficulty with self-regulation or attention span.
• Consistent routines help children feel secure. Sudden changes or transitions without warning can disrupt their sense of stability, leading to resistance or tantrums.
• Children often seek autonomy and control over their activities. Being asked to stop playing can feel like a loss of control, prompting resistance as they assert their independence.
• The timer can act as an impartial tool that reduces power struggles between parents and children, as it externalizes the transition process.
• Involving children in meal preparation and cleanup helps them develop essential life skills, such as measuring ingredients, following instructions, and understanding kitchen safety.
• For children with sensory processing issues, auditory cues like a timer can be more effective than verbal reminders. It provides a clear, consistent signal that is easier to process.

Facilitating Pleasant Family Mealtimes

Rowell and McGlothlin point out that sitting down to a meal as a family is an almost universally recognized way to nurture children and families, though in reality it often doesn't happen as smoothly as we might hope. Bringing back a sense of connection and joy at the table is one of the long-term goals for feeding a child with EPE, but it starts with reclaiming the table as a fun, non-stressful, pressure-free place to eat and enjoy each other's company.

Creating a Comfortable, Low-Pressure Table Setting

First, the authors suggest, make sitting at the dining area a place where family members look forward to sharing a meal, without arguments, rules, pressure, or worry. This might entail a mood makeover. If the dining surface is too high or your child's feet dangle, for example, changing to a standard table and chairs will give her more stability and make her more comfortable. If your kid has sensory sensitivities, then having simple white plates, solid placemats, and dimmer lighting can improve their tolerance.

Context

• An appropriate table height reduces the risk of accidents, such as tipping over or falling, which can occur if a child is unsteady or uncomfortable.
• Properly sized furniture encourages good posture, which can aid in digestion and make eating a more pleasant experience.
• Solid placemats can help define personal space at the table, reducing anxiety by providing clear boundaries and a sense of order.
• Dimmer lighting can help minimize visual distractions, allowing children to focus more on the food and the social aspects of the meal, rather than being overstimulated by their surroundings.

Modeling Positive Attitudes and Behaviors Around Meals

The most important component of enjoyable family meals might be how you behave! Since a child learns about appropriate eating by seeing how his parents eat, relax and enjoy your meal; comment (without overselling) about the flavors and smells you enjoy; and avoid negative comments about what you don't enjoy. If you sense that you are still the focus of the child's attention in terms of his worry about whether or not you are pleased with his eating, consider giving a sibling, or your partner, extra attention at the beginning.

Context

• This psychological theory suggests that people learn from one another through observation, imitation, and modeling, which applies to eating behaviors as well.
• A calm environment can lower stress levels for both parents and children, making it easier for children to focus on eating rather than on any anxiety they might feel about the meal.
• Talking about flavors and smells can help children build descriptive language skills, enhancing their ability to articulate their own food experiences.
• Negative comments can create an emotional association with food, where meals become a source of stress rather than enjoyment, impacting a child's relationship with food long-term.

Building Child Capabilities and Determining if Treatment Would Help

This section provides you with specific tips to aid your child's advancement with eating skills by focusing on mouth movement and sensory input. In the latter part of the chapter you’ll review approaches to feeding therapy, suggestions for finding the right provider, and red flags of counterproductive therapy.

Opportunities to Practice Eating Independently and Build Oral Skills

Here, you’ll explore the many ways that you can, by changing the way you present and prepare foods, encourage your child's development of oral-motor skills and sensory awareness, along with her capacity to safely and confidently handle and explore different foods.

Support Tools and Techniques for Chewing, Drinking From Cups, and Investigating Foods

Rowell and McGlothlin offer a wealth of ideas for supporting your child’s eating, from using non-traditional dipping devices like wooden craft sticks, to adding crunch to a favorite fruit, to letting your child mash his own food. The best way to help your child develop a broader taste for different foods is to make sure you serve foods that he is capable of managing and enjoying at his current developmental level. You can use the sample list of foods and necessary oral motor skills in the seventh chapter to determine whether a food might be challenging or more readily accepted.

The authors also address the difficulty some children have with learning to drink from a cup with a straw or an open cup, particularly those who have motor or sensory challenges. These kids might have been fed thicker purees or beverages in the past, or they might have difficulty coordinating the movements of the mouth, cheeks, and tongue necessary for efficient drinking.

For some children, previous challenging feeding experiences make exploring foods scary. To support self-feeding and increase acceptance, Rowell and McGlothlin stress the importance of presenting food in ways that your child can control. This can be a difficult concept for parents who feel obligated to ensure their child consumes a specific quantity of food, at any cost. But ultimately, control belongs to the child. One idea is to take two spoons, letting your child dip and explore while you assist with eating using the other one. If messy fingers are an obstacle, keep a wet cloth within reach so she can clean her hands as needed. If a certain dish triggers anxiety, try a compartmentalized plate. Allowing a child to sip through a straw or from an open cup as she's able, perhaps at the beginning of a meal, while having a preferred cup nearby, can also encourage experimentation with new drinking skills.

Context

• Craft sticks can help manage portion sizes, allowing children to take smaller, manageable bites, which can be less intimidating for picky eaters.
• Incorporating crunchy elements like nuts or seeds can add nutritional value, such as healthy fats and proteins, to a child's diet.
• The act of mashing can keep children engaged and focused during mealtime, which can lead to a more positive eating experience.
• Ensuring that foods are safe to eat at a given developmental stage is crucial. This includes avoiding choking hazards and ensuring that the child can handle the food's size and shape.
• These are the movements and functions of the muscles in the mouth, lips, tongue, and jaw. They are crucial for chewing, swallowing, and speaking. Children develop these skills at different rates, and challenges in this area can affect their ability to handle certain textures or types of food.
• Learning to drink from a straw or open cup is a developmental milestone that typically occurs between 12 to 24 months. It involves complex coordination of muscles in the mouth and face.
• Children accustomed to thicker textures may develop habitual patterns of movement that are not suitable for handling thinner liquids, leading to difficulties when transitioning to new drinking methods.
• Conditions like gastroesophageal reflux disease (GERD) can cause pain during eating, leading to a reluctance to try new foods due to the anticipation of discomfort.
• Handling a spoon helps children develop fine motor skills and hand-eye coordination, which are crucial for self-feeding and other daily tasks.
• Having a wet cloth nearby empowers children to manage their own discomfort, promoting independence and self-regulation during meals.
• These plates provide a clear visual organization of the meal, which can be comforting for children who feel anxious about mixed or touching foods. It allows them to focus on one item at a time.
• Starting a meal with a familiar or preferred drinking method can ensure the child stays hydrated, which is important for overall health and digestion.
• Offering a choice between the new and familiar cup empowers the child, giving them a sense of control over their learning and reducing resistance.

Sensory Play to Become Comfortable With Foods

Many children who have a condition of being extremely picky eaters don’t engage with food because of sensory sensitivities or anxieties. For these children, the authors recommend giving opportunities to build familiarity in non-eating ways. Some of their suggestions include bringing kids to the grocery store, involving them in meal preparation, and encouraging fun activities with food, including creating wrapping paper using potato stamps or making "food art" with colorful condiments. The authors point out that even if a child doesn’t show interest initially, it’s important not to give up offering these opportunities to safely and playfully build food-related knowledge away from mealtimes.

Context

• Taking children to the grocery store can help them become familiar with different types of foods in a low-pressure environment. They can explore textures, colors, and smells, which can reduce anxiety and increase curiosity about trying new foods.
• Potato stamps are a simple craft activity where a potato is cut in half, and shapes are carved into the flat surface. These shapes can then be dipped in paint or food coloring and pressed onto paper to create patterns. This activity helps children explore textures and shapes, enhancing their sensory experience with food in a non-threatening way.
• Each child is unique, and what works for one may not work for another. It’s important to tailor activities to the child’s specific interests and comfort levels.

Recognizing When Counseling Benefits You and Selecting the Best Providers

If all these suggestions and the STEPS+ strategies haven't helped your child make progress, or you feel overwhelmed, then consider involving others.

Speech-Language Pathologists and Occupational Therapists for Food-Related Difficulties

Rowell and McGlothlin suggest seeking an evaluation with a qualified SLP or OT who focuses on feeding challenges. An SLP will assess oral motor skills and swallowing as well as a child’s ability to manipulate food within their mouth and move to more complex textures. Many SLPs have also obtained advanced training in sensorimotor and sense-related challenges.

An OT focuses on the small- and large-scale movements necessary for self-feeding and will help a child develop his ability to manage sensory input in a way that allows him to engage with a variety of foods and eating experiences. Since many children with feeding challenges have a combination of needs, often a coordinated approach with both SLP and OT, along with guidance from a children's dietitian, can be most effective.

Context

• Children typically progress from pureed foods to more complex textures as they develop. An SLP assesses a child's readiness to handle different textures, which is important for ensuring they receive adequate nutrition and enjoy a variety of foods.

Other Perspectives

• In areas with a shortage of SLPs or OTs who specialize in feeding challenges, long wait times for evaluation can delay intervention, suggesting a need for a broader range of professionals trained to address these issues.
• The emphasis on self-feeding and sensory management might inadvertently minimize the importance of other aspects of feeding, such as the social and cultural dimensions of eating, which OTs also consider in their practice.
• The availability and access to qualified occupational therapists may be limited in certain areas, which could affect the feasibility of this approach for some families.
• A multidisciplinary team approach can sometimes lead to conflicting advice if professionals are not well-coordinated, which can confuse families and hinder progress.