Hope for stressed-out parents of extremely picky eaters

By Dr. Liji Thomas, MDOct 22 2019

A new study published in the journal Cognitive and Behavioral Practice brings hope to parents who are at their wits’ end over their children’s refusal to eat one or more food groups. The research describes the success of a brief cognitive-behavioral group therapy program for parents only, that equips them to deal with mealtime tantrums and encourage their children to experiment with a wider range of foods. Researcher Katherine Dahlsgaard says, “Our research shows the acceptability, feasibility and positive outcomes of the Picky Eaters Clinic, a seven-session, parent-only, group-based intervention intended to train parents of children with Avoidant/Restrictive Food Intake Disorder (ARFID).”

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The need

The aim of the short intervention was to make parents themselves the interventional behavioral therapists, ensuring long-term continuing input into the children’s mealtime behavior and attitudes towards food.

The basis of the study is the recognition that parents often react to ARFID behavior counterproductively, by giving the child increased attention, reducing their expectations, or catering to the child’s demands. These, however, make it more beneficial for the child to continue food aversive behavior.

The parents reported high levels of stress due to the following factors:

• The child chooses from a range of less than 20 foods
• The child completely refuses anything from a whole food group, such as any vegetable, any fruit or any type of meat
• The parent needs to ensure a separate meal is ready for the picky child
• The family has a hard time while eating out in a restaurant, in a non-home setting, or traveling, because of the need to provide special meals for the picky child
• The child becomes upset or obstinate when a new food, or a food that is typically refused, is served
• The child does not want to, or cooperate with the parents in their attempts to, bring about a change in attitude

The study

The study was small, including only 21 children with ARFID (a fancy way to say extremely fussy about their food), and their parents. Extremely restrictive eating behavior results in poor family or personal functioning, or when the child fails to thrive, manifests nutritional deficiencies, or requires supplementary or enteral nutrition. The condition may then be called ARFID.

The first meeting took place for diagnosis and to select patients for the study. The patients had all been referred to the Clinic for Picky Eaters at the Children’s Hospital at Philadelphia. The age of the children ranged from 4 to 12 years.

This was followed by seven treatment sessions, each lasting 90 minutes, held over six months. The first four were weekly sessions, while the fifth and sixth were separated by 3-4 weeks. This longer interval was to allow enough time for the families to practice the behaviors that the parents had been instructed in, in their daily home settings. This comprised, for instance, putting a challenge before the child culminating, if successfully faced, in a parent-chosen reward.

The challenge was to chew or eat a defined portion of a new food or a food that was previously refused. The incentive was typically time to watch television or play an on-screen game. Trying the ‘challenge’ foods became more and more routine and these foods eventually became part of normal meals. At the sixth session, the researchers also tested the feeding success after therapy, and took a survey of the parents as to their satisfaction.

The seventh and last session was three months after the sixth. It was in the nature of a “catch-up” session, to allow the families to get together, share news about their children, and celebrate the progress made in each case. At this time a second post-treatment feeding assessment was repeated. Attendance at this session was optional, however.

The outcomes

There was a significant increase in the child’s enjoyment of food, and a reduced tendency to eat slowly, complain of feeling full before completing the meal, and to fuss about eating. The changes were preserved at follow-up indicating they were long-term. The percentage of children benefited by the intervention ranged from about 30% (the lowest, based on the Emotional Undereating measure), to 62% for reduced food fussiness. Parent satisfaction was extremely high and the dropout range was 12% compared to the typical 26% for group training therapy for parents of children with disruptive behavioral issues.

The advantages of this parent management training (approach) were many, according to the researchers. The parents did not have to go by trial-and-error but had a standardized course of conduct to deal with their child’s mealtime behavior, whether the child ate or refused the challenge food. The evidence-based nature of the intervention increased the chances of success. The treatment was at home, and the training administered in an outpatient, working parent-friendly manner. The PMT approach empowered parents to deal with the issue themselves, and at home, rather than delegating care to specialists. The fundamental nature of the intervention allowed it to be used in other non-feeding contexts to correct other behavioral aberrations. Multiple families were helped simultaneously, and more therapists were thus freed to help other patients in need by this model.

The future

The researchers say, “The results indicate that moderate to severe picky eating can be well treated in children in a relatively short time frame with high parent engagement, satisfaction, and effectiveness.” Prior research suggests that with otherwise normal children, this is difficult to treat. This study is unique in being a pioneering outpatient strategy to intervene in a brief, group-based, parents-only model to correct severe picky eating disorder.

Dahlsgaard now wants to do a systematic follow-up of the treatment group to report on the long-term outcomes. Two years have passed since the last session. She says with satisfaction, “I occasionally receive emails from the parents, telling me that their children are trying everything or eating in restaurants with no problem.” However, this cannot take the place of a scientific monitoring plan which will yield reliable data on the long-term success of this relatively simple intervention.