Article: Understanding Why Children Won’t Eat and How to Help
Author: Kay Toonmey, Ph.D.
When children won’t eat, parents and professionals are often tempted to classify them in one of two categories: those who have “physical” problems and those who have “behavioral” problems. These kinds of labels are not particularly helpful. First, because there is an implication of blame in this system, which is neither very accurate nor useful when trying to help children with feeding problems. Second, children with physical difficulties often develop behavioral problems after their attempts to eat don’t go well, and children with behavioral eating difficulties develop physical disorders after having poor nutrition for a period of time. So, there isn’t a clear-cut distinction between the two.
Rather than force children into categories where they don’t belong, we need to think about children who won’t eat as having had poor learning experience with food. In other word, just as children learn to eat, they can also be taught not to eat by the circumstances in their lives.
Research shows that learning about food occurs in two main ways. The first is when a connection is made between one stimulus (a natural event, behavior, or object) and a second neutral stimulus. For example, we know that feeling sick to your stomach causes the physical reaction of appetite suppression. If feeling nauseous (a natural event) is consistently paired with a specific food (previously a neutral thing), eventually the food itself will cause nausea. Another example would be when pain is paired over time with food, as occurs with Gastroesophageal reflux (GER). When that happens a person learns to avoid or escape from situations that involve eating.
The second way that we learn is through reinforcement and punishment. Eating followed by praise or imitation (positive reinforcement) leads to more eating. Similarly, refusing food followed by lots of attention/interaction (also positive reinforcement) leads to more food refusal. So, in addition to increasing desired behaviors, positive reinforcement can cause more of an undesired behavior as well.
Punishment around food is also very powerful. Booth showed that if the learning about food is unpleasant, our bodies turn off our appetites. Weingarten and Martin showed that if negative connections are made to the cues of eating (e.g., sitting down at the table, the utensils used, the people present, the room where meals are eating), a child learns to avoid the feeding situation completely.
The overall goal of all treatment with children who won’t eat is to create a situation that positively reinforces normal, healthy eating patterns through:
Structure- Have a routine for mealtimes, eating in the same room, at the same table, with the same utensils, which capitalizes on the need for repetition in learning.
Social modeling- Allow children to learn through the observation of good mealtime role models. Parents who are poor or picky eaters will have a difficult time helping their children.
Positive reinforcement- Meals need to be pleasant and enjoyable, and any interaction with food should be rewarded. Verbal praise, a smile, a touch, a cheer, and hand clapping are all great options.
Manageable foods- Foods need to be prepared in small, easily chewable bites, or in long, thin strips that a child can easily hold.
Learning about “the physics” of food- The mouth and teeth will need to use hard pressure to break apart a carrot stick. Wiggly, squishy string cheese is chewy in the mouth. Yogurt, which is cold, wet and smooth, can just be sucked down.
When parents understand that eating is a learned behavior, in which there is an interplay between their child’s physical capabilities and his experiences with food, they can take on a positive teaching role with their children rather than a negative/forcing or no-limits approach to feeding. It clarifies for parents that there are things they can do to make the feeding situation better, and gives them hope. The approach also teaches parents, and reminds us professionals, that there are things we can do that may make the situation worse and reminds us how to avoid the pitfalls of working with children who won’t eat.