A Mass General expert discusses when to seek medical care for adolescents who are very picky eaters.

Picky eating is a hallmark of being a toddler. But when children are still extremely picky at age 7 or 12, it may be time to talk with your pediatrician and consider treatment, says Jennifer Thomas, PhD, co-director of the Eating Disorders Clinical Research Program at Massachusetts General Hospital.

Dr. Thomas and her colleagues suspect a biological link to picking eating.

Everyone has food preferences, Dr. Thomas explains. But extreme ones can cause medical and social problems. Kids who don’t eat fruits or vegetables can develop a vitamin C deficiency, which can affect the skin and bones. Children who don’t eat enough may not gain weight and grow taller. And kids who are afraid to eat foods that their friends eat can feel isolated, missing out on birthday parties, sleepovers and camp.

In 2013, the American Psychiatric Association officially diagnosed picky eating so extreme that it interferes with health or social functioning as avoidant/restrictive food intake (ARFID) disorder. ARFID differs from anorexia and bulimia because picky eaters do not restrict food for fear of gaining weight and altering their body shape.

A Mass General team led by Dr. Thomas and Kamryn Eddy, PhD, has developed a new treatment to help extremely picky eaters of all ages. And Dr. Thomas and Elizabeth Lawson, MD, are leading a National Institutes of Health-funded trial of young people, ages 10 to 22, to study the neurobiology of the disorder.

The reasons why some children are picky eaters are not completely known. Dr. Thomas and her team suspect a biological link.

Reasons for Extreme Picky Eating

Children with ARFID are not just being stubborn, Dr. Thomas says.

“It’s easy to blame the parents,” she adds. “Or say, ‘Don’t give the child any chicken nuggets. Give him only vegetables. And, eventually, he will get hungry and eat. ’ ”

Jennifer Thomas, PhD
Jennifer Thomas, PhD

But that approach won’t work if the child has ARFID; the child might still refuse to eat and lose more weight, Dr. Thomas says. Mass General recognizes that parents of picky eaters are doing what they think is best because they are worried, she adds.

Children with ARFID can frustrate parents because they tend to prefer non-healthy foods like chicken nuggets and macaroni and cheese or plain foods, like crackers. They might shun meat, but eat ice cream.

In a recent study conducted by Dr. Thomas and her colleagues, about 4 percent of kids who came to Mass General gastrointestinal clinics met the criteria for ARFID or showed related symptoms.

Adding the first food or two is the most difficult.

For the National Institutes of Health-funded study, Mass General researchers will study how children with ARFID react to sweet and bitter tastes while in a functional MRI, a special machine that allows researchers to observe how a patient’s brain responds as they ask the person to complete a task, like taking a taste. One theory is ARFID patients have a strong sense of taste, so bitter flavors, like broccoli or kale, are intensely unpleasant for them.

Another subtype of ARFID is being fearful of eating following a traumatic eating-related experience such as an allergic reaction to food, choking or vomiting. Researchers will show these children images of vomiting and choking to determine if their brain responds with feelings of fear.

How to Help Picky Eaters

At Mass General, Dr. Thomas’s team uses cognitive behavioral therapy to help children learn about new foods. If a child has never eaten an orange, they demonstrate how to peel it. Because everyone has food preferences, they work with the patient and family to determine specifically which new foods might help correct nutritional deficiencies or help the child socially.

“A lot of times patients are surprised at what they end up liking.”

Adding the first new food or two is the most difficult, Dr. Thomas says. After patients break that barrier, they feel encouraged.

“A lot of times patients are surprised at what they end up liking, and relieved to know that they don’t have to eat every single food. Just eating a few foods in each category — like grains, protein, dairy, fruits and vegetables — can be enough. They learn they can tolerate different foods and that foods taste different depending on how you prepare them.”

Philanthropy could help Dr. Thomas and her team add more patients to their privately funded treatment study, or add a brain imaging session at the end of treatment to determine whether cognitive behavioral therapy can alter the neurobiology that contributes to the development of ARFID. Funding could also help create a phone app to remind patients to eat, identify foods to sample and track progress.

To make a donation to help Dr. Thomas and Mass General researchers working on avoidant/restrictive food intake disorder, please contact us.

Tips for parents of picky eaters:

  1. Understand that a child may have to taste a food at least 10 times before regularly eating it. First tastes could be pea-size.
  2. Present new foods as opportunities to learn, not as must-eat mandates. Place the food on the child’s plate or table, so she can see and smell it, even if she will not eat it yet.
  3. Eat foods you want your child to eat to model openness to new foods.
  4. Plan meals and snacks on a regular schedule to help children with smaller appetites become hungry at mealtimes.
  5. Do not sneak vegetables into muffins or hide foods. That might work for babies, but for a child to choose to eat carrots, he must know that he has eaten them before without a problem.
  6. Prepare foods that have been rejected before in different ways. Even small changes, such as cutting the food differently, can make a difference for children who are extremely sensitive.
  7. If you are concerned, talk to your pediatrician. She can evaluate growth, test for nutritional deficiencies and make suggestions.