In Celebration of Preferences

In Celebration of Preferences-  
The Upside to Picky Eating

It seems that over the last 10 or so years, a trend of attacking preferences in childhood has been gaining too much momentum.

Some General Thoughts on Preferences

But now, we are aware of perspectives taking hold in the arena of pre-school eating preferences.   My own perspective is that 2-5 year old children are very much like we are, many tend to like some foods, and many tend to dislike others, and I think that is wonderful.  Others are developing a perspective that would see food preferences as a worrisome thing, a sign of underlying mental health illnesses such as depression, anxiety, and even ADHD.

Before discussing food preferences, I would like to say a word about preferences over all.  I think they should be celebrated.  There is little studied or stated about the fact that every human alive, and likely every living thing, has preferences.  Making a distinction, noticing details, responding to how the world affects us, this is in many ways what it means to be alive.   I am reminded of a specific syndrome in which children tend to be extremely friendly to all they meet, everyone is their best friend, and yet these children end up socially isolated, since friends are never sure if they are special to this person--after all they like everyone the same.

I don't think you can make anything special unless you like it more.   Preferences help us decide what to do, what to say, who to be friends with, how our imaginations will burst out into the world and make an impact.

Without preferences, it is hard to see how anything of importance gets done.   How would those special relationships we cherish grow and take hold?  How would new ideas come to life?  How would music pack a punch?  And, how would a meal give us great joy?   Some people prefer garlic to onions, and some onions over garlic.  Without such preferences, how would those who love garlic enjoy that special zest they experience when they eat their favorite foods?   And, how would those who love onions enjoy their extra joy at their preferred foods?

Preferences are not only the spice of life, they are one of the great motors of life, and certainly the source of much joy in life.

The August Pediatrics article suggesting food preferences are an impairment

And so I am wary of those who would take aim at pre-schoolers who voice a preference in their foods.   I actually think it's wonderful that at such an early age, our children's minds are bubbling with excitement and thought and choice.   Another aspect of preference is that very few people can enjoy any preference without it being matched by a dislike.   If I prefer this food, it is usually in contrast to liking another food at least a little bit less.

But there are serious researchers into child behavior that are claiming that if a pre-schooler prefers some foods over others, this is likely to indicate the child is suffering from a mental illness.   This is not to say that no pre-schoolers suffer from depression, anxiety disorders, or even ADHD, of course and unfortunately, there are people in the 2-5 year old age group who do suffer from these mental health illnesses, just as there are people at nearly every age who do.   And, it is also surely true that if we look at the group of pre-schoolers who do suffer from mental health illnesses, there will be many who have preferences for specific foods, and therefore specific food dislikes as well.    But this does not mean that preferring one food or another is a mental health illness.   Or that if a child has food preferences that is a sign they have a mental health illness.


And yet, in an article released on August 3, 2015 in the journal Pediatrics, researchers from the Duke Preschool Anxiety Study, concluded, "Our findings suggest that the term SE [selective eating] (or, "picky eating") is not obsolete.  If an individual presents to primary care with the presenting problem of SE, then impairment is implied.  Such eating patterns thus may be better characterized using the diagnostic category of avoidant/restrictive food intake disorder (ARFID), an eating disorder new to the Diagnostic and Statistical Manual of Eating Disorders, Fifth Edition [the DSM-5]."   They come to this conclusion based on a study of 3,433 children.  In this study they defined a child as having selective eating if they disliked a food most kids liked.   Again, by their definition, not liking dark, green vegetables such as broccoli was not selective eating since so many kids don't like dark, green vegetables.  But even disliking one food not in that list, say oranges, qualified a 2-5 year old as having selective eating.   If the selective eating led to them having trouble even eating with others that defined their severe selective eating category.

The study itself took these 3,433 children and had their families complete questionnaires and conducted home assessments, at ages 2-5.  And, of that group, 187 children were assessed with the same techniques annually for some time after the initial evaluation.  The main results reported were the risk of having certain "psychiatric diagnoses" in the three groups of eaters- not selective, moderately selective, and severely selective eaters.

The authors found that 20.3% of the pre-schoolers were selective eaters.  But of these 222 selectively eating pre-schoolers, only 37 were severely selective.

When it came to actual "psychiatric diagnoses" found by the questionnaires, those pre-schoolers with severe selective eating were twice as likely to also have the diagnosis of depression  and almost 3 times as likely to have social anxiety.   Those young kids with moderate selective eating did not have a greater risk of such diagnoses.

When it came to symptoms, all the selective eaters, moderate and severe, had more symptoms of depression, anxiety, and ADHD than the young children who were not at all selective.  And selective eaters of all types developed more symptoms of depression and anxiety than those who were not selective.

My interpretation of the Pediatrics article 
Several observations on the paper seem important to share:
1.  This is an association article.  It notes that if you compare Group A to Group B there are some differences.  The difference in groups in how selective their food preferences are was associated with having symptoms of depression and anxiety.   Associations are weak observations.  They are always interesting, as these associations are, but they very often leave out what is causing what.  In this case, do the selective eaters come to the table more anxious, does their mood cause their eating pattern?  Or is it the other way around, does making limiting food choices cause symptoms to occur?  Or, do children who express preferences create more tension in the parents, and it's the tension that is causing the symptoms?  This study is not designed to answer any questions about how the observation happened, and does not provide any such proof of causation.
2.  The mental health of the pre-schoolers was determined primarily by questionnaire.   The flaw here is that a child could have enough symptoms to qualify for a psychiatric diagnosis, but not in fact have that psychiatric diagnosis.  It's important to know a child before making the fairly drastic determination that they have a mental health illness and are actually impaired.
3.  On the face of it, it doesn't make sense that 20% of America's pre-school children are impaired solely on the basis of not liking certain foods.   Telling all families with young children that if their child states they no longer like a food they are likely mentally ill appears to be more than excessive.  And the paper offers no proof that 1/5 of America's children are truly impaired.  There paper only presents findings on 222 children they have defined as selective eaters.   Even on this small sample, there are no observations about the children's actual lives that would prove essentially all 222 of these pre-schoolers are impaired.
4.  The definition of who is a selective eater is presented as the arbitrary opinion of the authors.
In this paper, children who don't like green, leafy vegetables and like all other foods are allowed to be considered normal and not selective.   But if any 2-5 year old dislikes any other food to the point they do not eat it, they are classified as have moderate selective eating, a category they conclude indicates impairing mental illness.   It is not clear to me, and the paper offers no clarity on the question, just how a 3 year old who won't eat an avocado is substantially different from a 3 year old who will not eat kale.

What the authors of this paper conclude
As noted above, if the authors had their way, they would have any 2-5 year old child who refuses to eat any food (except dark, green vegetables):
1.  Be deemed impaired.
2.  Be subjected to interventions for those at serious risk of mental health impairment
3.  No longer be called picky eaters, but instead be diagnosed as having a DSM-5 mental disorder, namely Avoidant/Restrictive Food Intake Disorder (ARFID).   ARFID is a relatively new concept as a diagnosis of mental disorder.  The definition is fairly vague, as it requires a person of any age to be avoiding certain foods to a degree that the person suffers significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on feeding directly into the intestine or oral supplements, or marked interference with psychosocial functioning.  That last criteria is terribly vague and broad.  What is interfered psychosocial functioning, when does it become marked?

My conclusions on thinking about this paper
Overall, I reject the notion that having a preference for foods is a sign of something wrong for the vast majority of children with a preference.  I certainly reject the notion that 20% of America's pre-schoolers have a mental health disorder, are impaired.

I take very seriously the charge that someone is impaired, and as such the burden of proof sits squarely on the shoulders of one who would say that anyone, in particular a young child, is impaired. This paper raises interesting questions of associations between food choices and various symptoms, but fails to assess any of the children in the study for actually being impaired, a claim they level against 20% of all pre-schoolers.

So, I have the following conclusions on this paper:
1.  The authors call that we suddenly say millions of happy, healthy pre-schoolers who choose to exercise their enthusiasm for one food over another have ARFID, have a psychiatric diagnosis, and are impaired, should be soundly rejected.  It simply makes no sense, and no evidence has been presented to overturn that sense.
2.  Even in the paper, the only children observed to have an increased risk of  psychiatric diagnosis (not symptom) were in the group of 22 children with severe selective eating, and not even all of them were found to have a diagnosis.
3.  The very notion of ARFID is not a very well-worked out psychiatric illness.

1.  Going back to the start of this article, I want to emphasize that preferences are not a bad thing, they are a good thing.   Having preferences isn't just sort of nice, it's essential to living in the world, to moving the world, even a little bit, in your own, inspired direction.
2.  I do agree with the authors that the phrase picky eater is not a great phrase.  But I would drop it to be more positive about young children making choices, exploring the world, accepting some things today, and some things tomorrow.   The vast majority of young childjecting ren who are called picky eaters turn out to be explorers in their world, and should not be deemed picky.  Further, most children who eat less than their parents desire are actually making a proper choice, as their need for food is actually less than expected.
3.  I soundly reject the suggestion that 20% of American pre-schoolers have a mental health impairment on the basis of disliking something other than dark green vegetables.  The authors present no evidence that this is the case, so their conclusion is not proven, and would be a very damaging stance to take in thinking about children.
4.  I accept the author's observation that some pre-schoolers have issues with depression, anxiety, and ADHD but would recommend we be concerned these mental health issues when children who have these impairments actually come to our attention.    I think it serves children and families very well to respond to times when troubles arise.  If symptoms of these disorders appear, we should see if the child is suffering from these problems.  But I think it would do far more harm than good to take all pre-schoolers who dislike foods and treat them as if all of them were impaired and in danger.  Yes, we would miss fewer children with these mental health issues, but we would be subjecting millions of perfectly healthy children to the burden of being called mentally ill, impaired, and the interventions associated with these designations.  And to even think of doing this with no attention to the harm done by calling millions of children in their formative years impaired, who are perfectly healthy, must be rejected. Keep in mind, even the group of children with no food preferences had some with mental health issues such as depression and anxiety, so even if one followed the unusual advice of the authors, one would still not be identifying and helping all the children who actually do suffer from depression and anxiety.
4.  I support children's enjoyment of food, in their way, on their terms.    On a more positive note, I have seen many, many children grow up.  And many, many of them liked certain foods, and disliked others.   By far and away, the vast majority of these children grew and developed very normally, in fact, quite well.   The only children with food preferences that descended into impairment have been children with terribly unusual and extreme food aversions that restricted eating to the point that they were no longer really nourished.  These aversions do occur, but they are very, very rare.  Given how often a young child's food preference causes no harm, no weight loss, no problem, it seems to make the most sense to let happy, playful children who are growing well have the joy of painting the world with their own thinking about their own food.

To your health,
Dr. Arthur Lavin

PS- I should also disclose that I serve on the AAP Committee on Psychosocial Aspects of Child and Family Health, and I was recently contacted by the Associated Press and What to Expect organizations for my comments on this article.  The AP interview was picked up in papers across the US on August 3, 2015, including one in Seattle, Maine, and the US News and World Report- http://www.usnews.com/news/science/news/articles/2015/08/03/most-picky-eating-harmless-but-it-can-signal-emotional-woes

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