Image: David Goehring (CC by 2.0)
The Mealtime Hostage Parenting Science Gang are a group of parents of children who, for various reasons, have difficulty developing an interest in eating. These children are often highly selective in the variety and quantity of food they are able to eat. Difficulty with eating can range from limited dietary variety to an inability to orally ingest sufficient calories. Some of these children have been diagnosed with the newly defined condition Avoidant/Restrictive Food Intake Disorder (ARFID), but many clinicians are not yet familiar with the term.
We discovered that there was very little research in this area and so instead of looking at successful interventions (which is what we’d have loved to do), we went back to basics and used a questionnaire to describe the characteristics of these children more accurately than had been done before. You can read more about what we decided to do in this article, but the summary is, we wanted to know whether extremely selective or avoidant eaters had similarities in their emotional behaviours and sensory sensitives.
We worked with Dr Terry Dovey (Brunel University) and Prof Jackie Blissett (Aston University) to put together the questionnaire and Terry and Jackie are now analysing the results. We gathered A LOT of data, so the work is going to carry on for some time. These are just our first findings.
About the data we collected
- “You guys have a great data set. It’s very, very good. Best one I have seen in a very long time. Better than my PhD students, but don’t tell them.”(Terry)
- “Great sample size – that gives us plenty of power for our analyses. A good solid number of clinical cases in each group, with the ability to determine which people have 1, 2 or more problems so that we can get some ‘pure’ groups for further analysis.” (Jackie)
“The most useful bit is that you managed to get so many people with clinical issues. They are hard to see.” (Terry)
- Good number of kids who suffer from reflux – sample is about 90. Neither Jackie nor Terry is aware of such a large sample in previous papers. “Seems like it’s a first.” (Terry)
- 551 usable returns including;
- 258 typically developing children
- 143 children with parent-reported feeding difficulties
- 56 children who are picky eaters and have Autism Spectrum Disorder (ASD)
- 29 children with diagnoses ARFID (Avoidant/Restrictive Food Intake Disorder)
- 17 children with ASD (but typically developing eating)
- 8 children with ARFID + ASD
What we’ve found about the questionnaire questions we used
- The Behavioural Paediatrics Feeding Assessment Scale (BPFAS) questionnaire predicted food refusal well, irrespective of ASD.
- Food responsiveness on the Child Eating Behaviour Questionnaire (CEBQ) seems to relate to just ARFID. Terry thinks that this could do with a closer look.
What we’ve found about eating behaviours
- We can see similarities between children with ARFID, ASD and reflux in terms of their eating behaviour – our sample shows peaks in food fussiness in all groups.
- Eating speed issues are seen in food refusers, but not in ASD groups compared to non-ASD typically developing children.
- Emotional undereating, drinking and conduct problems don’t show noticeable differences from typically developing children
- There doesn’t seem to be much difference between ARFID and picky eating here. “Looks to me like a spectrum. On almost every variable they are similar just ever so slightly lower. I think this data links our work perfectly. I am just dealing with extreme picky eaters.” (Terry)
What we’ve found about sensory issues
- Sensory issues are seen in all food refusal groups, increasing with fussiness and ASD. So ARFID children with ASD have the greatest sensory issues.
- ARFID children have higher environmental sensitivities (eg how they react to itchy labels, strong smells, the feeling of a toothbrush etc) but not social sensitivities (to do with interacting with people). Socially, they are more like typically developing children, while they are more like children with ASD in terms of their sensitivities to environmental stimuli. [Children with ASD tend to be both socially and environmentally sensitive]
- ARFID children tend to be sensitive in the visual but not auditory domain. We see sensitivity to lights, tactile textures and food, but not to water or loud noises. It is not global sensitivity. “You just discovered that here today with this data!” (Terry)
- Reflux and ARFID groups both show sensory sensitivity. Are they linked?
- “Looks like the data initially supports that. It’s really interesting that they are all showing the same/similar scores. You guys seem to have found it.” (Terry)
- But we can’t definitively say that they are linked. “I think if you find food aversive for pain or sensory reasons you are going to start distrusting your world. But we are going to need to dig deeper.” (Terry)
What we’ve found about emotional behaviour
- Compared to typically developing children, all our groups show higher scores for internalising difficulties (ie problems around the personal psychological environment eg anxiety, depression) and emotional problems.
- There is an increase in externalising difficulties (ie outward behaviour problems eg being disruptive, hyperactive), but it is not so marked in picky eaters/ARFID. It is greatly increased in all ASD groups.
- Picky eaters/ARFID children without ASD are similar to typically developing children in terms of conduct issues, peer problems and prosocial behaviours (eg being able to make and keep friends). This is supported by our findings of their similar levels of social sensitivities.
- This is interesting – you can see the similarities between ASD and non-ASD food refusers in the emotional problems but not in the peer or prosocial.
Terry and Jackie think that they can see four potential papers on different areas of the data. This may well change as they look more closely at the data, but at present they think that they might write these four:
The ARFID story – looking at how these children compare to the picky eaters and the typically developing children.
There has been a lot of arguments about the underlying concepts of food refusal. A good first question would be: Does emotional regulation and sensory sensitivity underpin food refusal in both ARFID and picky eaters?
A comparison between the three groups: ARFID, ASD and Neurodevelopmental disabilities.
Comparing those diagnosed groups could tell us a bit more about the key features associated with each diagnosis, even if we accept that many children aren’t diagnosed/diagnosed poorly.
Reflux. “I think that needs a dig. A really good dig. That has sparked something in my head, but i cannot link it at the moment.” (Terry)
A comparison of the two questionnaires (the Child Eating Behaviour Questionnaire (CEBQ) and Behavioural Paediatrics Feeding Assessment Scale (BPFAS)) for use as a screening measure.
What happens next?
Currently Terry and Jackie are submitting preliminary findings posters to relevant conferences. However, there is a lot of work to do looking at the data carefully to find our what it tells us about the emotional behaviours and sensory sensitivities of children who are selective eaters. Terry, Jackie and their teams will continue to work on this and let us know what they find out.
Interested in selective eating? Why not read more about the Mealtime Hostage Parenting Science Gang here: The Mealtime Hostage Story so Far.
Or check out one of our Q&As with experts in the field:
- Vexing vegetables with Dr Helen Coulthard
- Positive Feeding Relationships with Prof Jackie Blissett
- Researching Avoidant/Restrictive Food Intake Disorder (ARFID) with Dr Terry Dovey
- Extreme Picky Eating with Jenny McGlothlin
You can read all our Q&A sessions, on loads of different parenting-related subjects on the website.