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The SPD Companion, Issue #015-- Picky Eaters And Resistant Eaters
June 07, 2007

Truly, there are picky eaters and there are PICKY EATERS! I do believe there is a difference... the difference being the intensity, frequency, and duration. The “pickiest” of eaters are called “resistant eaters” (as described by Ernsperger and Stegen-Hanson, 2004). The types of eaters are, of course, on a continuum... the same way SPD is. From normal, on the far left, to picky eaters in the middle, and resistant eaters to the far right.

Tidbit #1: Did you know that it is part of normal development for children ages 2 to 3 to go through a “picky eater” stage?

As toddlers gradually become introduced to new, “regular” foods, they will resist and they will experience some fear of trying something new. With this normal developmental stage, fear is eventually overcome and the picky eater will add an increasing variety of foods and maintain normal nutritional standards. This is the normal process which takes place in almost all children.

BUT, for our SPD kiddos, when the sensory messages in their mouths, nose, eyes, ears, or to the muscles and joints are not perceived or interpreted correctly, the “simple” (actually eating is not simple, but rather, quite complex) task of eating can become a major battle filled with pain, criticism, tears, forced rules and expectations, punishments, and/or a lack of proper nutrition. Mealtimes may be dreaded, filled with tension, a major project consisting of different meals being cooked for different individuals, and a lack of structure or family mealtimes. The picky or resistant eater may become isolated from both family and friends, and normal social skills revolved around eating times may not develop properly.

Tidbit #2: Did you know that there is a name for the fear of new foods? It is called Neophobia. Wow, it even has an official name?

Yes! THAT is what my daughter definitely has!! You should SEE the anxiety in her when you attempt to introduce a new food... yikes! Poor thing. Have you read my I've Been There page? If you have, you'll see what I mean!

So... What Is The Difference Between A Picky Eater
And a Resistant Eater?

One of the many things I like about Lori Ernsperger and Tania Stegen-Hanson's book, Just Take A Bite is the terminology they use. A picky eater, the ones I am referring to, are really called resistant eaters. Remember I said it is a continuum? Picky eaters are in the middle, and resistant eaters are at the far end of this continuum... into dysfunction. I think this distinction is indeed important. Picky eaters and resistant eaters look different. And, in talking about the affects of SPD, the resistant eater is really the one we are focused on and concerned about.

A picky eater is less intense about their food issues and food choices. They may refuse to eat certain things for a certain time, but they do have enough foods in their diet over time to qualify as getting proper nutrition. They don't eliminate ENTIRE food groups for months and years, the way a resistant eater does. They may not like many foods, may prefer cookies over eggs, but don't we all have preferences?

The bottom line? The picky eater doesn't have the same kind of fear, discomfort and anxiety that a resistant eater shows. The picky eater will survive and thrive nutritionally, eventually. They may drive you crazy sometimes with their preferences, but they will be able to “overcome” their fears and apprehensions. The picky eater should be completely out of their phase by age 5, according to Ernsperger and Stegen-Hanson.

On the other hand, resistant eaters will definitely need to supplement their diets with nutritional drinks, vitamins, etc. just to keep them healthy, often for years. The family dynamics will also be different between a picky eater's family and a resistant eater's family. Dinnertime will be different. Difficulties regarding food, the resistant eater, and his family will be more intense, last longer, and happen more frequently.

Gagging, true anxiety/phobic responses, and vomiting are the BIGGEST clues! Please pay attention to this... force feeding a resistant eater WILL NOT work, and, in fact, will probably make the situation even worse!

Ernsperger and Stegen-Hanson (2004) point out; “Resistant eaters with sensory-based feeding problems experience difficulty eating because their sensory systems do not support the eating and drinking process... resistant eaters typically have an extreme reaction when presented with new or novel foods that continues even as they grow older. Resistant eaters may exhibit their fears through anxiety, tantrums, and/or gagging when presented with a new food.”

They continue to define resistant eaters as having one or more of the following characteristics:

1. Limited food selection. Total of 10-15 foods or less.

2. Limited food groups. Refuses one or more food groups.

3. Anxiety and/or tantrums when presented with new foods. Gag or become ill when presented with new foods.

4. Experiencing "food jags". Require one or more foods be present at every meal prepared in the same manner.

5. Diagnosed with a developmental delay such as Autism, Asperger's Syndrome or Pervasive Developmental Disorders- Not Otherwise Specified. May also have a diagnosis of mental retardation.

Ernsperger and Stegen-Hanson (2004)

The resistant eater may have anywhere from 3-20 different foods they will eat. Obviously, the less variety they have the worse their nutrition will be. They also tend to stick to foods with similar qualities and/or characteristics. They are notorious for liking carbohydrates in particular (pizza, mac 'n cheese, french fries, etc.) and eliminating the meat, fruit, and/or vegetable group altogether. They may prefer foods of all the same color, texture, or bland taste. They also tend to prefer foods that are easiest to chew.

The resistant eater, as caused from oral-motor dysfunction and/or sensory processing issues will NOT get “better” without a thorough evaluation and targeted treatment at the true underlying cause. If YOU have a resistant eater, as defined above, PLEASE get an evaluation done by either a Speech Pathologist, Occupational Therapist, or a Feeding Specialist. Your children will definitely need extra help!

And, here's why... resistant eaters are that way for a variety of reasons, all of which need to be identified or ruled out. Resistant eating for an SPD child may be caused by any of the following:

  • sensitivities to smell
  • sensitivity to taste or texture
  • poor muscle tone
  • poor jaw and/or tongue control
  • decreased oral motor skills
  • under-responsivity or over-responsivity to gustatory input
  • visual processing issues
  • vestibular processing difficulties
  • difficulty perceiving and interpreting proprioceptive input
  • auditory processing issues
  • swollen tonsils and/or adenoids

  • Kind of surprising that there are this many potential influential factors, isn't it? Eating is actually a much more complex task than people realize. It is NOT a simple process of put the food in your mouth, chew, and swallow. There are many possible disruptions in this process and oral-motor skills required are quite complex! (That is a discussion to be had at another time with a qualified Speech Pathologist or Feeding Specialist!)

    Why Resistant Eaters Are Resistant

    Tidbit #3: Did you know, according to Ernsperger and Stegen-Hanson (2004), 75% of our taste perceptions are dependent on proper perception and interpretation of smell?

    75%! That, to me, says one of the FIRST questions we should be asking ourselves, if our child is having difficulty accepting or eating new foods and/or different types of foods is... “Is my child over-responsive or under-responsive to smells?”

    Since smell and taste are so closely related, we must look at how our children may be interpreting olfactory input. Are they chronically congested? Do they have allergies? Do they have difficulty breathing through their nose? Are they mouth breathers? If so, any/all of these will impact how much of their food they actually smell, feel, and taste. Equally as important, are they sensitive to smells, bothered by smells not normally noticed by others, do certain smells make them nauseous or gag? If so, any/all of these will impact how intensely they will smell and taste their food... or how quickly they RUN away from it!! ;0)

    Tidbits #4 and #5: First, did you know we lose taste buds as we age, therefore OUR sense of taste WILL be different than our child's.

    And, second, smells are directly connected to memory, pleasant OR unpleasant and will cause an emotional reaction.

    “Smells are picked up in the nasal cavity and interpreted in the brain. When we smell something, the olfactory stimulus goes directly to the limbic system. The limbic system is the section of the brain that is primarily involved with one's emotions and inner drive. For this reason, smell has a strong emotional component and a strong association with memory storage.” (Ernsperger and Stegen-Hanson, 2004)

    Therefore, we have to remember that any smells associated with a particular food, particular experience, or a particular environment in which the child is attempting to eat may be a contributing factor to mealtime battles and picky or resistant eating. It may even be a one time nauseating experience that is stored in their memory in which a particular smell brings on, that is impacting the current experience.

    Do we even have to wonder why the school cafeteria is a problem for our kids? The cleaning and cooking smells, the smell of rotting food garbage, and the smells of hundreds of kids all in one room! Is there any doubt that lunch is not the best of times for our kids (and we haven't even considered the noises, lights, movement, visual stimuli, etc. yet!) There is so much more going on in these little sensory systems than we can even imagine. Careful assessment, planning, and detective work may be the best solution we can offer our picky eaters!

    Now, let's briefly talk about the many other factors listed above that can contribute to a child's poor eating skills, motivation to eat and/or try new foods. Many children with SPD have poor postural control and muscle tone. It will be more difficult for these kids to focus on eating when they are having trouble maintaining an upright posture, controlling their mouth, jaw, and tongue movements because of low muscle tone. Their little bodies just don't have the energy to pay attention to eating too. It may almost be “painful” for them to do so.

    Along those same lines, if they have poor proprioception, body awareness, and/or coordination, it may be difficult to eat as they may spill much of their food, have difficulty holding and using utensils, and/or staying seated properly on their chair. You may see spilled drinks, frequently dropped objects, falling off of their chair, goofing around to disguise their poor motor skills, and frustration when they can not decide how tight their grip should be on their food, utensils, drink box, etc. causing things to break, spill, or drop. Sometimes, they may not even eat a particular food in their lunch box or drink their milk because they can not get it open by themselves... many being too embarrassed or too shy to ask for help

    Visual, vestibular, and auditory processing issues will also interfere with mealtime. The child may not see what they need to see, be able to sit still long enough to focus on eating, may react to bright lights, and/or the noises that accompany a school lunchroom, restaurant, or family dinner table. Additionally, they may have poor oral motor skills leading to difficulty chewing and swallowing. Who wants to eat when it makes you choke, gag, cough or vomit?

    Sidenote: My daughter has refused to eat certain foods EVER again because she choked once on them... lettuce, popcorn; or got sick from it... Chinese food, fettuccine alfredo. These memories are permanently etched in her mind, and the sight or smell of them will easily bring on the anxiety. Yet, because she liked those foods, it makes her sad too.

    Tidbit #6: Did you know that studies and statistics report that almost 80% of children with severe mental retardation have feeding difficulties (William, Coe, & Snyder, 1998), and that 75% of children who have an autistic spectrum diagnosis have atypical feeding patterns and limited food preferences. Additionally, 50% of the autism population are hypersensitive to textures and lumps in their food (Mayes and Calhoun, 1999)?

    The bottom line? The sights, sounds, smells, taste, feel of everything may just be too much for the child to handle which makes eating difficult or even painful.

    Other Factors To Consider For The Picky Eater

    Another important factor to consider is the possibility of Gastroesophageal Reflux or other gastrointestinal disorders. If a child is uncomfortable during and after eating, they will choose not to eat... wouldn't you? Therefore, it is important that additional medical issues also be ruled out and/or assessed as part of a complete evaluation and treatment plan.

    Some of the signs of reflux in children include:

  • Looking/feeling uncomfortable while swallowing
  • Frequent vomiting and/or gagging during or after eating
  • Either eating constantly or not eating more than a few bites at a time(even if hungry)
  • Difficulty staying asleep at night
  • Frequent sore throats, upper respiratory problems, or drooling
  • Chronic bad breath
  • Hoarse voice
  • Poor weight gain
  • Frequent coughing and hiccups
  • (Ernsperger and Stegen-Hanson, 2004)

    Is it any surprise that children with low muscle tone also have a lower esophageal sphincter muscle that is weak, causing stomach contents and acid to come back up? So, although they are “separate” issues, it is not surprising that there may be overlap.

    Oral-motor concerns are a large part of an assessment for picky or resistant eaters. When the normal suck, swallow, breathe, mouth and tongue movements are not working properly it may be uncomfortable and “dangerous” for a child to eat. They can sense this, thus refusing to eat. We need to know that oral-motor function is working properly, and if not, what needs to be worked on. If the child's issues are indeed related to oral-motor function, an assessment by a Speech Pathologist, Occupational Therapist, or Feeding Specialist should be completed and treatment developed accordingly. Until the underlying difficulties are addressed, the picky/resistant eating will continue.

    Let me also emphasize that ANY of the oral-motor issues could be the direct result of Sensory Processing Disorders. If they are not getting enough, or too much, feedback from the gustatory sense, or the input is not modulated or discriminated well, there will be consequences while eating. Most of us notice the hyper-sensitivities that lead to gagging and vomiting, but I challenge you to be aware of the subtler symptoms. For example, there are the under-responders who do not interpret feedback from their mouths properly causing a “dulled” response. This will lead to a desire for very strong flavors, over-stuffing their mouths, eating quickly, loving extra salt/pepper/condiments, and can also lead to choking.

    Lastly, resistant eating may be the result of purely physical causes, and those will need to be assessed and addressed by a Speech Pathologist, medical doctor, Occupational Therapist, or a Feeding Specialist. (That is a topic for another newsletter! It is too involved to address here.) BUT, what I want you to know is if you suspect there may be more going on than sensory discrimination and modulation, PLEASE have your child evaluated by one of the above mentioned disciplines.

    Some of the signs you would see which indicate a physical/medical problem are:

  • abnormal sucking pattern
  • aspiration
  • gagging
  • drooling
  • tooth grinding
  • limited upper-lip movement
  • immature spoon feeding, cup drinking, or biting skills
  • The bottom line? Eating can be a difficult, scary, and unpleasant task!

    Now that I have shared with you WHY picky eating and resistant eating may be occurring, I want you to know what to do about it... how to help your child! So... I have three suggestions for you.

    The first suggestion is to make sure you have looked at the SPD Symptom Checklist to see if a child you know is showing signs of SPD. This checklist can be viewed by clicking here . If you are concerned about potential symptoms of a picky or resistant eater in your family please get them an evaluation as soon as possible! Without the proper evaluation and treatment, this will NOT go away.

    The second suggestion is to read through my other picky eaters pages on my site, which will direct you to tips and resources that may be helpful to as well. You will find tips and recipes from me and sources such as “Help There Is A Picky Eater In The House” and “Munchkin Menus”. Click here for the main picky eaters page on my site (also a button on the navigation bar).

    The third, and most important suggestion is to get a copy of the book that the information throughout this newsletter is based on. It is Lori Ernsperger and Tania Stegen-Hanson's 2004 book entitled “Just Take A Bite” (see link below). It is a one-of-a-kind, brilliant book written by an Occupational Therapist AND Speech Pathologist together. This combination of disciplines and the information they present in their book specifically targets the picky eater issues our SPD kiddos face... the resistant eaters. There are thorough explanations, personal stories, assessments, normal development by ages and stages, and countless suggestions, including games, treatment plans and printable cue cards that will help these children with eating challenges and food aversions.

    I could NEVER give you all the information they present in such an easy to read and understand, yet clinically based way. It WILL change you and your child's lives, for the better. If you are concerned about a picky eater, their book is THE first resource I would pick up!! I can't thank them enough for writing this amazing and much needed resource! If you click on the book below (or copy and paste the link, if you receive the text only version of this newsletter), you will find out more about their book and how to purchase it, if you are interested.

    It is an AMAZING book for parents AND professionals seeking diagnosis and treatment for a resistant eater! I give it five stars!

    (If you are an OT working with a child who is a picky eater... this book will be one of the best resources you could own to help the child you are treating!)

    Here is what you can look forward to in this book. The following chapters are included:

    Chapter 1: Who Are Resistant Eaters?

    Chapter 2: Oral Motor Development

    Chapter 3: Environmental And Behavioral Factors Contributing To Problems With Eating

    Chapter 4: Sensory-Based And Motor-Based Problems Affecting The Resistant Eater

    Chapter 5: Motor-Based Eating Problems Vs. Sensory-Based Eating Problems

    Chapter 6: Designing And Implementing A Comprehensive Treatment Plan

    Chapter 7: Environmental Controls

    Chapter 8: Gastrointestinal, Physical And Oral-Motor Development

    Chapter 9: Stages Of Sensory Development For Eating

    Chapter 10: A Recipe For Success

    Thank you for spending your precious time with me this month. I truly appreciate it!

    Until next time my friends... take good care.


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