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Practicing What I Preach

**This entry is a re-post from My daughter is now almost three years old, and she continues to enjoy a wide variety of foods :-)

This post was inspired by the work that I have done with my own daughter, Adair, who is 16 months old. Even before Adair was born, I felt that I owed it to myself and the families that I work for to make sure that Adair accepts (and enjoys) a wide variety of foods.

Feeding therapy is not easy, and I expect a lot from the families that I work with. While I have always been very conscious of finding a balance between challenging a child and keeping mealtimes positive and manageable for the parents, I would be lying if I said that feeding therapy isn’t an emotional roller coaster of sorts. Many parents have said to me: “Michelle, you are so patient. I don’t know how you stay so calm throughout the tough meals.” For me, this element of feeding therapy has always come naturally. Although I build relationships with the children and parents I see, I always have the feeding goals in mind, and that is where my focus is as we work through each challenge. Since parents are dealing with all aspects of the child’s needs from sun up to sundown, it is easier for them to become frazzled, overwhelmed, and discouraged by difficult meals. While I often think of “my” kids on my off hours, ultimately I do get to leave many of the concerns of the day at the front door when I go home. Because I ask for so much dedication from my families, and because I can see and feel the challenges that they face with feeding, I wanted to experience that from my own perspective as a parent. I didn’t know how this would manifest itself, but sure enough, around 11 months of age, Adair began to show signs of picky eating.

While I try not to over think every bit of food and drink that Adair consumes throughout the day, I am conditioned to pay attention to changes in her habits, make note of the struggles that she encounters with new foods, and try to set up meals to make her as successful as possible. However, there was one problem that I faced that I hadn’t really anticipated: I don’t actually have much experience with how a typically developing child with typical eating habits turns into a picky eater. All of the children I see professionally have had some medical or developmental history that has led to their feeding challenges; this blog post is not about these kids. In my clinical experience, I am often starting with the most basic foundation of eating skills, and then working toward age-typical eating. By the time we are working on adding a wide variety of age-typical foods, we generally have a solid feeding plan in place and are met with relatively low resistance from the child. So what was I to do when my child, who had generally accepted even the more adventurous purees that I had concocted, began to reject foods based on their mere appearance?

I knew the ultimate goal that I had for Adair, and that was simple: I will not make separate meals for her; she will eat what we’re eating, end of story. The exceptions to this (given her young age) are foods that are not developmentally appropriate, or overly spicy foods (though she will eat some level of spice). However, I didn’t anticipate how easy it is to diverge from this plan, and I soon understood how so many parents end up with a picky eater situation without even realizing how it happened. This became apparent to me one evening, as I was feeding Adair and introducing some tastes of a new food. She was resistant, whining, crying, and saying “no” each time I attempted to give her a bite of the new food, and she only got more upset as I continued to withhold her preferred foods. After a few attempts on my part, she appeared to lose interest in all of the foods on her plate and just wanted out of her highchair. Screaming, squirming, and yelling ensued.

My husband, with good intentions, said: “Do you want me to just grab a yogurt so she will eat something?” Much to his surprise, I immediately shot him down, with this explanation: I would rather Adair feel hungry later if she chooses not to eat the food that we offer her, rather than presenting a highly preferred food simply to fill her up. While the yogurt would solve the immediate issue of her hunger, it presents problems in the future. Children quickly learn how to get what they want, and I knew that if I gave her yogurt in response to her refusals (spitting out food, turning her head away, crying), that it would set a precedent for doing so at future meals. This may sound like an extreme reaction, but all that I can say is that with my background in behavior analysis and my specific experience in feeding disorders, I knew this to be true.

I was aware that putting an end to Adair’s picky eating would be a challenge, even before I started. I want to explain some of the rationale that helped me to be confident as I pushed through what turned out to be about two weeks of establishing a feeding routine (aka: enduring some really, really, non-enjoyable meals). First, in most parts of the world, children eat what the rest of the family eats, no exceptions. It may be that the food presented is the only food that the family has to live on, or it may be viewed as socially unacceptable to request a separate meal. Speaking entirely for developmentally typical eaters, I am not aware of children wasting away due to picky eating in which they refuse the food presented day after day simply because they don’t like it. Children learn by example, and they adapt quickly. A second consideration is that as an adult, I generally have access to my highest preferred foods at any time that I may choose to eat them; such foods are just a grocery store trip or restaurant visit away. However, does that mean that I always indulge every craving for my most preferred foods and reject all other foods? Obviously, no. Is there any reason for me to believe that if I allow my child to eat only her most preferred foods through her early childhood, she will independently learn the importance of a varied diet as she gets older, and use moderation in dealing with highly preferred, less nutritious foods? In our American culture, I would say no, there is no guarantee of that. Lastly, I knew I had the knowledge to make her successful, now that I had been presented with a specific feeding issue. While the average parent may not know where to start, I hope that this summary of my approach may help to at least provoke some thought on what may work for your own child.

Let me first explain what I saw occurring at meals, so that if you have a young eater at home, you may be able to identify picky eating as it emerges and shape good eating habits right away. I found that my daughter, when presented with 2-3 different foods on her plate, cut into small pieces, would immediately eat all of the preferred food (generally carbs and fruit), and would leave the other food(s). If the other foods were light in color or appeared similar to her preferred foods, she may try it, but would often spit it out when it wasn’t what she was expecting. If it was green or appeared very different from her preferred foods, she wouldn’t even pick it up or taste it, and if I presented it to her, she would turn away, rejecting it without even a taste, or would accept it and immediately expel it. So pretty much, if it wasn’t one of her known and preferred foods, she wasn’t even allowing herself to try it.

Why do I think this started? Most importantly, I think that the carbs and fruits are generally easy to eat, requiring little chewing and breaking down in a consistent way. Also, these foods are generally sweet or have a bland flavor, which children often prefer. Adding to the issue is the fact that vegetables and meats are more challenging to eat, require more chewing and may have fibrous parts that can cause occasional gagging in an early eater as they learn to manage it. These foods also have less predictable flavors. For some foods, such as peas, you can’t even taste the food until you start chewing, so these bites may be expelled before even being exposed to the flavor.

Because the motivation to eat varied foods may be low for early eaters (less preferred flavor + more challenging to eat + other “better” foods available), I knew I would have to start with easy goals. However, even my easy expectations turned out to be quite a challenge to establish…fortunately the struggles were short-lived! The first thing I tackled was the expulsion of bites. I wanted to teach Adair that it is not acceptable to spit out food during meals, and that she would need to work through it*. I did this by re-presenting bites that she spit out, immediately and with as much repetition as was needed to get her to complete the bite. As soon as she spit out a bite, I picked up the bite, made an encouraging statement, like “good try, try again,” and put it right back into her mouth. I kept a calm demeanor and tried to anticipate when she was most likely to spit out the bite depending on the food I presented. I made sure I was paying attention so that I could act fast—that baby wasn’t going to get anything by me! I would try to put the bite into her cheek to encourage her to start chewing and to make it harder to spit it right back out. On the first day or two, she would spit out a single bite four or five times, so that by the time I had re-presented it on the fifth try, there was maybe a speck of food left. However, all that mattered was that she accepted it and swallowed it…I didn’t care how tiny the bite was. All the while, she was crying and looking at me like I was torturing her, all for presenting her with a 1 cm piece of sweet potato (or some other healthy, non-noodle item). I feel it’s necessary to elaborate on the “crying” that was going on, because let me tell you, it was a tantrum like I’ve never seen from my daughter. Screaming, drooling, pushing the plate, swiping at the food…all this and more was pretty much the status quo for the first few meals that we worked on her picky eating. It was overwhelming and stressful for both myself and my husband, and while I don’t like to see my child cry, I didn’t feel sad or bad for doing it. I maintained my confidence because I knew that the bites I was presenting to Adair were small and easy to eat, and tasted good too!

As soon as she swallowed (finally!) each non-preferred bite, as flustered as I may have been, I praised her and allowed her to have a bite of the preferred item on her plate or a drink of milk or water. Not all babies are into praise, but my daughter learned to expect full force applause and cheers, which we were more than happy to supply! I would present maybe five bites of non-preferred food this way at each meal so as not to overwhelm her, sometimes fewer. If she was very successful at accepting a given new food bite, I would sometimes just end on a positive note rather than pushing her further. While I will admit that the process was emotionally draining for the first couple of days, the immediate decrease in expulsion that I began to see was extremely encouraging, and when I started to see that she would accept a bite, chew it and swallow without even a flinch, I knew I was getting somewhere.

*Sometimes when self-feeding, Adair would take too large of bites and have to spit them out. This is something that I would encourage and even ask her to do at times, and was differentiated from expelling a non-preferred bite right away. You will have to monitor your child with this issue and establish the acceptable way of handling too-large bites.

By about 5 days in, Adair was very familiar with the “try a bite of this (new food), get a bite of this (preferred food) routine, but I would still meet some resistance depending on the food and how hungry or tired she was. However, I made sure that the bites of challenging foods were very small (to try to account for the difficulty factor), and I would offer larger bites of the preferred food as a reward, holding it up so that she could see that it was available as soon as she ate the first bite. By about a week-and-a-half in, refusals were infrequent and easily addressed with a little persistence: if she refused to take a bite of the non-preferred food, I would simply wait awhile, eat a little of my own food, and then offer it again. Eventually she would accept, and she often looked excited about it, clapping and saying “good girl!” Throughout the two weeks** that I needed to fully establish this routine, some of the non-preferred foods actually became preferred, and she would independently take bites of them without a “reward bite.” I can’t explain how happy it made me to see her enjoying the same foods that she vehemently refused just days before.

**I believe that I could have established this routine in less than two weeks, but with my work schedule, we generally only had dinner meals and some breakfast meals with Adair to work on new foods.

Now, at 16 months, Adair will try bites of anything that we are eating, and meals are calm and enjoyable. My husband and I still resist slipping into the routine of avoiding less preferred foods. Just the other night, I almost omitted mushrooms from her plate because she had refused them the last time we had them (even though she has eaten them a few times successfully as well). On second thought I included 3 little pieces, and while she didn’t pick them up independently to eat them, when I offered them on her fork along with a little piece of chicken, she accepted it and received a noodle bite as a reward. Sometimes a food will still be challenging for her to eat, and she may struggle with the skins of some fruit and vegetables, so I make the bites tiny and I only expect her to try a couple pieces. She does well with this routine, and because I have always told her exactly what I am presenting to her (rather than trying to hide it), I know that she now trusts me.

I can truly say that I have an adventurous eater, but it isn’t because her personality or tastebuds are any different from any other child. She learned to eat and enjoy a variety of foods, and it did take a concerted effort on my and my husband’s part. If we stopped all intervention at this point, I do think that she would regress into some degree of picky eating, but honestly, the effort that it takes at this point is so minimal there is no reason to consider stopping! I truly feel that I now understand how easy it is for typical children to become picky eaters, and how parents with the best intentions can easily shape picking eating behaviors without even realizing it. If I hadn’t known what to look for and how to address it, I could be in the same boat!

Obviously, the method that I used with Adair would not be appropriate for an older child who already has established picky eating habits, and who has more verbal communication skills. However, for most children, the use of immediate rewards, presented with consistent and firm criteria, works wonders to establish at least a minimal intake of new foods. I know that even though a child may be growing and thriving, many parents are not proud of the foods that they put on the table for their child (maybe it’s chicken nuggets everyday, or processed foods that are clearly not healthy…but at least they’ll eat it!). The initial effort to establish new foods is well-worth the long-term benefits you'll see. To see your child have a true enjoyment of foods that would not have existed otherwise is priceless!

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