Not all picky eating is simple. Some children have sensory food aversions and thats why they just don’t eat and often parents are told ‘it’s just a phase’ or it’s a behavioural problem.
Well what if I were to tell you that it wasn’t.
Research tells us that the majority of children who refuse to eat either:
- can’t eat because they have a gap in their eating and drinking skills (oral motor skills)
- won’t eat because it’s thoroughly unpleasant due to how it affects their sensory system.
Essentially, what I’m saying is that it’s not them being naughty kids, it’s not a behavioural issue, it’s not ‘all in their heads’, it’s all in their bodies.
In my experience, no two picky eaters are the same, their eating habits are so individual that it can take a deep look at what’s happening to be able to start to unpick it.
In this blog I’m going to address point 2, the sensory reasons for children not eating food.
How children learn to eat
Eating is one of the most complex tasks that human beings ever need to master. We think it’s simple, we just sit down and eat. But actually it’s far more complicated than that.
It can take a typically developing child 2-3 years to learn how to eat. If your little one has difficulties along the way, this time extends significantly.
Learning to eat involves a whopping 32 step process(1) for each and every food, and that begins with the sensory system.
In addition to the sensory side of things children also learn to eat through cues in their environment and how we as parents interact around food in front of them.
How the sensory system is involved
Eating involves using all 8 (not 5) senses at the same time. These are:
- Visual (sight)
- Tactile (touch)
- gustatory (taste)
- olfactory (smell)
- auditory (hearing)
- proprioception (positioning or sense of self in space)
- vestibular (balance)
- interoception (how your body feels inside)
Eating is the only thing that children do that engages all of their senses at exactly the same time.
Children who struggle with eating may have difficulty processing what their senses are telling them.
What is sensory processing?
Sensory processing is how your child interprets the world around them through their experiences. The sensory information is processed by their brain and they respond accordingly.
Children with sensory processing difficulties are either:
- Over responsive, where there is a heightened awareness meaning they experience things more than others do.
- Under responsive, where there is a lesser awareness, your child may not notice or needs a greater sensory input to experience feeling.
Some children can have a mix of under responsiveness and over responsiveness to different senses.
Once your child has processed what they have experienced, they will respond.
Some children have a condition called sensory processing disorder and you should speak to your child’s GP if you think that your child is struggling with the way they process their senses.
Could your child have autism if they have sensory food aversions?
Children with autism spectrum disorder often display the same problematic feeding issues, such as food refusal, restrictive eating, and anxiety associated with food and eating(2).
And interestingly many autistic children also have sensory processing differences which cause sensory food aversions.
Therefore, it is important that if you are concerned that your child is displaying any of the feeding issues mentioned above, that you seek professional help so that an accurate diagnosis can be made.
It is important to note that many children with sensory food aversions do not have autism the same way that having autism doesn’t automatically mean that a child will have sensory food aversions.
What are the consequences of sensory food aversions?
I have so many parents come to me who have GP’s or Health Visitors that are not interested in helping because the child is growing but it’s about so much more than that!
If your child misses out entire food groups or eats very few foods, they may not be getting the full range of nutrients that they need leading to nutritional deficiencies.
It’s not just as simple as giving them a multivitamin, first we need to identify which nutrients their diets are falling short of and replace those. There is such a thing as having ‘ too much of a good thing’ and this is the risk when you use a generic multivitamin, too much of a nutrient can be just as harmful as too little.
You’ll need to work with a dietitian who can assess and advise appropriately.
I don’t need to tell you how hard it is, because you’re living with the struggle every single day. I just want you to know that I understand how it feels after helping my daughter, through her sensory food aversions.
The daily battles, the constant worrying if they’re eating enough of the right things, knowing what to cook for different members of the family so that no one goes hungry, the tears and the tantrums.
When I did my training in helping children with sensory food aversions, the psychologist on the team told us that the stress levels parents feel when feeding an extreme picky weather was only second to the stress they were under if they had been diagnosed with cancer.
It’s huge, I get it.
Just know that there is a way out and that you’re not alone in this.
What are the 32 steps to eating and how does this fit in?
Each of the 32 steps represents a level of tolerance for each of the 8 senses. They are grouped into 6 sensory milestones:
- Interacts with food
Children can jump through the 32 steps quickly for some foods but get stuck on a single step for weeks, months or years.
Because eating is a multi-sensory task children must be able to manage all of their sensory experiences at the same time before a food is eaten.
Let me take you through these 6 sensory milestones one by one.
Tolerates (Steps 1-5)
Just seeing your food is part of learning to like it. And that’s what this first milestone is all about, being able to visually tolerate the food.
Some visually sensitive children automatically avoid looking at the food as soon as they are in the same room as certain foods, they literally may not even be able to look at it.
Until a child can visually tolerate a food, they won’t be able to progress up the steps towards smelling or tasting the food, so this is where we start.
Interacts with (steps 6-9)
Interacting with food isn’t the same as touching the food; that comes later. In the interacting steps, your child is using objects or containers to interact with the food. If they are capable they could be helping prepare a meal in the kitchen, or helping serving themselves or others. Younger children can play dump and fill games with food or stirring the (cool) pot, washing fruits and veggies etc.
Smells (steps 10-13)
In this step your child will be working towards tolerating a stronger smell at each step. From simply being in the same room to leaning in close to take a sniff.
This stage has the most steps as texture is one of the most complex senses to master. We’re working on tolerating touching with one fingertip and gradually getting closer to their mouth.
This is the first time food is going to the mouth and it’s step no 25 of 32!
They’re starting with just a tip of the tongue, taste or a brush of the lips, without expectation to bite, chew or swallow. Spitting food out at this stage is just fine.
This is the final 2 steps where 32 is actually biting, chewing and swallowing normal mouthfuls of food.
How children learn to not eat
Children eat multiple times a day and if their sensory systems are telling them it’s unpleasant, eating is quickly learned to be a negative experience.
When negative experiences happen the body’s natural reaction is a stress response to escape the situation by either:
- fight – tantrums, kicking, hitting, arguments, throwing food, causing drama at the table
- flight – fidgeting, running away, avoiding going to school or friends houses for tea
- freeze – breath holding, child closes down, won’t talk.
On top of this they may have learned additional reasons for not-eating, read on for a mini psychology lesson on how children learn.
Classical conditioning or learning through association
Classical conditioning is also known as learning through association and was made famous by the scientist Pavlov and his dog back in 1897.
Pavlov noticed that when his dog was presented with food he started to salivate. The food was the cue that something tasty was coming and the salivation was its body’s natural response.
Pavlov introduced a bell ring at the same time as bringing out the food and repeated this over and over.
He then noticed that the dog would salivate whenever the bell rang, even if there was no food.
He concluded that the dog had become ‘conditioned’ to associate the bell with a tasty meal.
We see this in real life all the time now, from the desire to eat popcorn at the cinema (we’ve classically conditioned ourselves to associate eating with the big screen) to your child wanting an ice cream whenever you go to the park.
However, classical conditioning also plays a huge role in not eating.
If your child has had a negative experience with food, for example they are over responsive to the auditory sense (hearing) and they are being asked to eat their lunch in a noisy dining hall at school. It’s going to be really unpleasant for them and they are not going to be able to eat.
Now the lunch hall has been classically conditioned towards not eating.
Operant conditioning or learning through consequence
Operant conditioning is known as learning through consequence, almost like forming a habit.
In childhood, positive reinforcements are frequently used to encourage more of the behaviour we want to see.
For example if a child eats a new food they might get a sticker on their chart, therefore the child will eat more of that new food.
However if when your child doesn’t eat, you bring out the i-pad (in order to distract them), you have positively reinforced the not-eating and they’ll do more of that.
What are sensory food aversions?
A sensory food aversion is when a child refuses to eat certain foods because of their sensory experience of that food.
It’s often labelled fussy eating or extreme picky eating but children with sensory feeding aversions can actually stop eating because it’s so unpleasant.
Advice like “they’ll eat when they’re hungry” isn’t true of these children.
How is ARFID different from PFD?
ARFID is considered an eating disorder although there is no body image psychological involvement.
Children have a lack of interest in food or eating and so just don’t eat.
Many have sensory aversions including visual, taste, temperature, smell, sound or texture of particular foods and often can’t eat in the same room as other people or food.
Often children with ARFID are fearful about things like choking or having an allergic reaction to food and expect pain or discomfort when eating.
Paediatric Feeding Disorder(3) on the other hand is diagnosed when a child is unable to meet their nutritional requirements through eating when compared to other children of the same age and developmental stage.
It can be caused by medical issues, nutritional problems, a lack of feeding skills, sensory-motor skills or psychosocial issues and is often a combination of several of these.
Many children with ARFID or PFD will go on to require tube feeding or rely on nutritional supplements as a means for survival.
These children do not grow out of it, they need specialist feeding therapy from a multidisciplinary team of healthcare professionals in order to get better.
Are sensory food aversions all about the texture of food?
In short, no! But a tactile (texture) sensory aversion can be one of the most challenging to overcome.
Here’s what I mean:
When a child is given a plate of food, the other sensory aspects don’t change too much as they eat it.
The smell stays the same, the food looks the same, there might be a small change in temperature going from warm to cool but that’s about it.
But the big changes are in the texture.
Think about when you eat a sandwich.
Not only are there different textured foods packed into each bite – bread, lettuce, cucumber, ham etc, but with every chew, the feel of the food changes.
It goes from one soft lump, to multiple pieces of food that the tongue needs to keep track of.
As they chew more, what was once a bite of sandwich is now one wet ball rolling around their mouth!
Your child must be able to tolerate all of these different textures in order to successfully be able to eat the sandwich.
Does my child need a diagnosis?
A diagnosis can be hard to get. In the UK the NHS has very limited services, often only available in big cities and limited to children with other medical issues.
However not having a diagnosis doesn’t mean that treatment should be any different.
You can speak to a private feeding therapist if you are concerned or you can make an appointment with your child’s GP to see if they are able to refer you to a specialist service in your area.
How can I help my child if I think they have sensory issues with food?
First things first, understanding that your child is not being naughty, difficult or fussy is very important. Avoiding food is not something that they are choosing to do.
Understand that it’s their body telling them that the food isn’t right for them.
There are some key steps that you can have in place to give your child every chance of practising their sensory learning and they are all based around Positive Food Parenting which I’ve linked to here.
Next, comes individual feeding therapy. Please arrange this for your child; they won’t get better without it.
I practice SOS feeding therapy and that is where I use my knowledge of these 32 sensory steps to eating to gently advance children’s sensory preferences to help them learn to like challenging foods.
I also want to make a note here that typical fussy eating advice will not work. You may hear people tell you about Ellen Satter’s Division of Responsibility in Feeding where the parent provides the food but you leave it up to the child to decide whether to eat or not eat.
This isn’t appropriate for a child with sensory food aversions, it’s something you might come to practice later, after they have learned to eat more foods.
Play with a purpose
You can also support your child’s sensory learning through play.
This is a dialled down version of traditional messy play as a child with sensory processing issues will likely not be able to manage very messy play.
Start with dry foods that don’t stick and age appropriate games. You can choose a specific food if you have been told that your child has a particular nutritional gap in their preferred foods.
A 4 year old might enjoy making a farmyard scene with toy animals and dry weetabix as the animals feed. Can they help the horses eat their hay?
A 3 year old might enjoy playing with dry rice. Scatter rice in an oven dish and see what shapes you can draw with a spoon.
A 2 year old might drive a carrot car up Mummy’s arm? Can they drive a carrot car up their own arm?
There are endless possibilities for play with a purpose but choosing just the right entry step for your child is important. Too hard and it can have the opposite effect, too easy and they’re not going to move forwards up those 32 steps.
How to provide a balanced meal when your child has sensory food aversions
At the end of the day, you cannot make your child eat what they don’t want to eat! I think that this is often a message that gets lost when parents are trying to get help for their child. I just want to say I understand.
Depending on how restrictive their eating is, this may be very difficult to do without professional help.
You can do your best by offering a balanced plate at each meal and snack. Aim for there to be one protein food, one starchy carbohydrate rich food and a fruit or vegetable.
For children whose diets are less restrictive you can aim to provide food that provides all of the food groups across a day and the week.
Almost all children with restrictive eating will need a supplement to top them up, some will need just a multivitamin and mineral supplement, others will need something more substantial such as a supplement drink like Paediasure or Fortini.
It’s important that a dietitian recommends this for you and not just the GP, as GP’s have very little nutrition knowledge, and not all supplements contain the same nutrients. Excessive intake of some vitamins and minerals can be just as harmful as a deficiency.
When you’re dealing with a sensory food aversion your child isn’t going to grow out of it and it won’t go away on their own. Expert advice and feeding therapy will be needed.
You can absolutely try some of the ideas I have linked to here, which may move them forwards but for them to progress to normal eating they will need professional help.
If you would like professional help with your child’s extreme fussy eating, we have a team of dietitians and feeding therapists who can support you. You are welcome to book a 20 minute free discovery call to find out how we can help.