Geisinger Behavioral Health Primary Care Pediatrics I Will Not Eat Green Eggs and Ham: A primary care Guide to Picky Eating Jessica Sevecke, PhD Geisinger Behavioral Health Primary Care Pediatrics February 26, 2018

Agenda Overview How do children become picky eaters? Assessment Intervention Considerations & Tips for Parents References Tools

Overview Presentation will reflect interventions and recommendations for typically developing children who do not have any known medical issues.

Research shows a wide range of prevalence. 8% to 35% of toddlers 1-2 7-8% of school-aged children 3 Highest prevalence for children diagnosed with Autism Spectrum Disorder: 46-89% 4 Peaks between ages 2 and 6

A child may be a picky eater if: Does not eat foods across food groups Does not eat fruits or vegetables Or a range of fruits of vegetables across the color spectrum Does not eat a variety of textures Continuum: Will not try a single new food to will not eat anything but a preferred food for days on end. Parents may define any child along this continuum as a “picky eater.” Intervention is an active, not a passive process. Goal should be to increase variety first, amount later (if necessary). Without active intervention, variety of food preference is not likely to change.

Parents often quit promoting a food after 1-5 taste exposures. Many selective eaters will base whether or not they like a food based on look, not taste. Food preferences are learned by tasting and increase with number of taste trials. Parents often quit promoting a food after 1-5 taste exposures. Infants require 1 to 5 taste exposures. Toddlers require 5 to 20 taste exposures. Older the child becomes, more taste exposures may be necessary. Variety of food should be a focus, not quality of food. Increase variety by trying new foods. Nutrition and weight management Allergy and food sensitivity considerations Eat what the family is eating and cultural considerations. Increase quantity. Medical considerations: GI issues like constipation or GERD. Difficulty sustaining adequate growth. Improving quantity of nutritional dense foods (e.g., fruits and vegetables) vs. empty calories from junk-food 5.

Picky eaters are often not underweight, in fact they may be more likely to be overweight. Other health implications: nutritional deficiency, constipation, growth and development Picky eating can continue into adulthood and can have long-term implications. Long term implications: Females who were picky eaters as adults were significantly more likely to experience an eating disorder as adults.

How do children become picky eaters?

Research identifies several factors that may contribute to selective eating. behaviors: Parent feeding patterns Medical issues including allergies or sensitivities Genetics Sleep Textural sensitivities Anxiety (e.g., fear of choking) Relatives (Differential Reinforcement/Modeling) Unsupervised school mealtime

Assessment

Step 1 Step 2 Step 3 Step 4 PCP Interview Behavioral Health Interview Provide Food Log Discuss basic strategies Step 3 Introduce behavioral therapy Warm Hand Off Describe additional strategies Referral (Speech, OT, intensive feeding program) Step 4 Family starts intervention Step 1: food log so parents may develop a hierarchy of foods to start with to increase variety. Step 2: make changes to increase successful tastes. Decrease snacking. Practice behavior management strategies. Develop goals and a reinforcement program. Psych involvement Step 3: Start taste trials at mealtime, starting with foods that are closest to highly preferred foods. Give your child a choice. Plate A- Plate B protocol Step 4: Implement behavior management and reinforcement strategies. Step 5: Having difficulty managing disruptive behaviors, medically complex children, choking, vomiting, gags or complete food refusal: Employ help of mental health professional.

Interview Developmental history to detect oral motor, fine motor, or significant health history. History of feeding difficulties. Typical food preferences across meals and snacks. Discuss quantity. Presence of disruptive behaviors at meal times. Frequency of grazing. Gagging, choking, expels, or vomiting when presented with foods. Current sleep problems. Typical food preferences for breakfast, lunch, dinner, and snacks. Asking child about favorite foods, least favorite foods. Discuss quantity at mealtims. Presence of disruptive behaviors at meal times. Grazing. Gagging, choking, expels, or vomiting when presented with foods. Provide food log handout.

Role of Behavioral Health Provider Conduct additional assessment. Assess for developmental concerns. Identify family goals. Intervention. Help family problem solve and support. Monitor progress. Assess when referral to more intensive program is necessary. Facilitate communication between providers. Developmental concerns: oral-motor, fine motor- discuss referral if necessary Intervention: exposure and feeding in session- provide modeling/ coaching for family, strategies to manage mealtime battles, development of positive reinforcement programs like a token economy.

Intervention

Exposure Systematic presentation of non-preferred food to increase taste trials and decrease disruptive behaviors. Plate A- Plate B Protocol (See Broccoli Bootcamp). Fading Create a hierarchy. Little tastes are better than spoonfuls. Incorporate behavior management strategies. Set goals. Hierarchy: Based on color, texture, taste. Start with foods similar to preferred foods then gradually work toward more difficult foods.

Exposure interventions may look different depending on age. Younger children will need fewer taste exposures than older children. It can be a challenge to get a child to taste a new food or a non-preferred food. Parents may decrease exposure with increase in disruptive mealtime behaviors. Decreased exposure if child expels, gags, or vomits when presented with non-preferred food. Do not start with licks because it can be difficult to transition from licks to bites. If necessary step back down to licks. Side by side presentation. Paired or mixed presentation. Gradually fade larger, preferred food and gradually increase non-preferred food. This is different from simply “disguising food” (e.g., Kale in a fruit smoothie or brownies).

Practice At Home Picky Palate Passport Picky Eating Bingo Good first step for parents to try, even before having their first appt. with the behavioral health provider. Can help parents identify food hierarchy. Teaches children that tasting foods can be tied to positives. Success tied to reward or privilege

Mealtime Battles Crying, whining, tantrums, aggression, destruction, self-injury. Trying new foods can be stressful. Disruptive behaviors may result in avoidance or escape contingent reinforcement. Decrease future success with tasting new foods. Feeding interventions are an active process. Requires time, energy, and effort. Praise, Differential Attention, and Token Economy Systems.

Token Economy Systems Child can earn a sticker, token, or behavior buck for every taste. Set goal in advance. Goals should be easily attainable. Provide access to reward upon reaching goal. Include child in developing reinforcement menu and grab-bag. Explain rules before starting meal. Do not negotiate goal throughout trials. Stay firm.

Considerations & Tips for Parents

Time to commit to intervention. Cost of food. Parental eating patterns and habits. Willingness to model eating behaviors. Frustration and stress that goes along with picky eating. Parents have probably tried strategies in the past. Health considerations. Cultural considerations. Eating schedules. Meet the family where they are at and employ the help of a behavioral health professional any step along the way.

Model preferred eating habits. Enhance appetite by decreasing grazing and increase water intake instead of calorie rich beverages. Present a small amount of non-preferred food with larger portion of preferred food. Provide choices of foods you want your child to eat more.

Present new foods or non-preferred foods in a neutral and calm manner. Catch’em being good! Use consistent differential attention. Minimize distractions. Destructive behavior: throwing food, tossing utensils, breaking plates. Limit food on plate. Have a “reserve plate.” Replace with another bite. Have child pick up after the meal. Remind about extinction bursts when using differential attention strategies End a meal on a success.

References

1. Wright, C. M. , Parkinson, K. N. , Shipton, D. , & Drewett, R. F 1.Wright, C.M., Parkinson, K. N., Shipton, D., & Drewett, R. F. (2007). How do toddler eating problems relate to their eating behavior, food preferences, and growth? Pediatrics 120(4), e1069-e1075. 2. Reau, N. R., Senturia, Y. D., Lebailly, S. A., & Christoffel, K. K. (1996). Infant and toddler feeding patterns and problems: Normative data and a new direction. Journal of Developmental & Behavioral Pediatrics, 17(3), 149-153. 3. Rydell, A.M., Dahl, M., & Sundelin, C. (1995). Characteristics of school children who are choosy eaters. The Journal of Genetic Psychology, 156(2), 217-229. 4. Ledford, J. R. & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders a review. Focus on Autism and Other Developmental Disabilties, 21(3), 153- 166. 5. Williams, K. & Seiverling, L. (2016). Broccoli Boot Camp.