Building a positive relationship with food and your body

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Parents and Carers – Selective Eating vs ARFID

Session 3

What can I do to help?

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NOT helpful things to do

Hiding foods they don’t like – they will find out and this will impact
their trust in you.

Letting them go hungry – they will enjoy not having to eat and this will impact their lack of hunger even more.

Pressure to eat or finishing on time – it will increase anxiety and it will not make them eat faster.

Not giving their preferred food - they won’t start eating other foods if you limit the amount of preferred foods.

Having the idea of 'good' and 'bad' food – food is food and if they are only managing a few foods, this is ok for now.

What can I do to help my child?

Understand that eating can be a difficult process as it includes all our senses.

Understand that there are many steps before actually eating food, e.g. tolerating food in the same room, smell, etc.

Manage my own anxiety so I am better able to handle challenging situations.

To try and have a curious approach about the difficulties my child is experiencing.
(i.e. "I can see you find eating at the table difficult, what do you think might be happening? What can we do to support you?")

Support feeding at home

Putting pressure on them can increase their adrenaline, which can suppress their appetite and make them less likely to eat. Try to remain calm and positive at mealtimes.

For example, shopping and cooking in bulk or organising food for other children. This is to help you remain as relaxed as possible and keep anxiety low.

Daily routine for feeding: try to stick to consistent times each day and if needed, create a meal plan together so your child knows what to expect.

Mealtime routines: prepare (i.e. "Lunch will be ready in 5 minutes.").

You might need to have some calming activity: wash hands together, sing song, blow bubbles, sit at the table, clean up, wash hands, finish.

Consider also using stress balls, tangle toys, weighted blankets, anything that will calm/help your child.

Avoid negative comments (avoid words like 'no', 'don’t', and 'naughty'.)

E.g. throwing, refusing, gagging. Telling a child off or making a fuss often increases that behaviour.

Instead try a sticker chart or something fun after the meal, like a favourite book. Make sure the goals you choose for your child are achievable for them.

Do not force feed them.

To 30/45 minutes and snack times to 15/20 minutes.

Make sure they have support under their feet, behind their back and they do not slip down too far in the seat – use non-slip mats if needed under feet and bottom.

Eat together as a family. Talk about the food in a positive way – make sure the food is the focus, not the child. You might want to use table cards as a way of having conversations during meals that are not related to food only. We know that eating at the table can be extremely difficult for some children, so try changing seats at the table to avoid overwhelming situations.

As well as new or less preferred foods – consider different plates or outside of their 'safe area'.

Enjoy eating and exploring your food – talk about the colours, textures, shapes, smells and sounds of the food. Encourage your child to think about these things too. Children learn by watching and copying.

For anything good they do, even if this is just touching or tasting a new food. Some children don’t like to be praised, so avoid it.

Getting food on their hands and face is good for their learning. Clean up at the end. If your child is getting distressed during the meal, provide a napkin or small towel to wipe their hands.

Remember that is a new food and it might take few days/weeks for them to get used to it.

Remember that it is an exercise and your child is not expected to eat the food, it is about engaging and desensitising them.

Strategies for treatment

There are different strategies to support individuals with ARFID. It is important to discuss these strategies with the clinician who is working with your family.

However, we know that there are important things to consider in all treatments:

A family approach is often recommended.
Keep a routine.
Have a timetable.
Motivate your child to want to change.
Working on emotions – food related and not just food related.
Understand that the eating can’t be fixed but it is a work in progress.

How to approach ARFID treatment

Pace of progress is led
by the young person.

One step at a time to avoid
overwhelming them.

Systematic desensitisation

Progressively being exposed to more anxiety-provoking food.

Working the way up the ladder, from least anxiety provoking food to most.

The young person is able to control/stop/pace progress as needed.

The goal is to create a new experience until they get used to the new food.

Flooding

Overwhelming the young person by trying too much too soon.

Pushing the young person into trying things or not allowing the young person to stop when they are uncomfortable.

This will create more fear and increase anxiety.

This moves us away from the goal to create new experiences with the food.

Food chaining

Fries to carrots

Learning to eat a new colour

French fries

Sweet potato fries - new colour

Butternut squash fries -same shape and colour

Steamed carrots - new texture

Roasted carrots - same shape and colour

Roasted butternut squash - new shape

Food chaining involves gradually and systematically diversifying the foods a person will eat.

For example:
You begin with a food that is currently accepted. You then consider what can be tolerated in relation to change i.e. colour, brand, texture, shape. You then identify a new food to try based on what can be tolerated. This new food is then introduced. This then restarts the process.

Potato chips to banana

Learning to enjoy fruit

Potato chips

Plantain chips

Banana chips

Banana

Frozen banana slices

Freeze-dried banana

Veggie straws to green beans

Veggie sticks

Green only

Snap pea crisps

Green beans

Raw green beans

Freeze-dried green beans

Image credits: @Feedingpickyeaters

Chicken to fish

Learning to enjoy more protein

Favourite nuggets

Fish nuggets

Fish sticks

Baked white fish

Fried white fish

Fish patty

Messy play

You might try experimenting with "messy play" in which:

- The child does not have to eat the foods presented to them.

- It is about exploring food with the child.

- It is about sharing an experience with the child, not teaching the child.

- Regularly reassure the child that they are 'ok'.

- It is about getting messy – wash hands at the end.

Use different food characteristics,
for example:

- Large dry foods.

- Medium dry foods.

- Fine dry foods.

- Liquid/drinks.

- Sticky foods.

6 steps to eating

There is an exercise called “6 steps to eating”, which can help expose your child to new foods. It helps to know more about the food and which aspects of it is difficult. Start with the least difficult aspect that is looking at the food and work your way to the most difficult one to the most difficult one that is eating the food.

Visual

What does it look like?

- What colour is it?

- What size is it?

- What shape is it?

Touch

What does it feel like?

- Is it wet or dry?

- Does it feel cold or hot?

- Does it feel bumpy or rough?

Smell

What does it smell like?

- Is it a weak or strong smell?

- Is it a nice smell?

Taste

What does it taste like?

- Does it have a strong taste?

- Is it sweet or salty?

- Is it spicy?

Texture/sound

What is the texture like?
What sound does it make in your mouth?

- Does it feel loud when you chew it?

- Is it crunchy?

- Does it get soft quickly?
Your child is not expected to eat the food and if they feel they can’t keep it in their mouth, it is okay to spit it out.

Swallow

Any other sensation?

- Any other sensations to think about?

Your child can start by taking a small mouthful and gradually increase quantity as they feel ready to.

- Emphasise that they are not expected to eat the food!
- Outside of mealtimes.
- To try to stick to a routine – so they know what to expect.
- Use different places to practice.

Other strategies

Fade in - adding small amounts of food they don't like into food they like.
Add some spice – ketchup, curry, salt, honey, sugar.
Food chain - try similar foods i.e. veggie chips with the same format as potato chips.
Change presentation – salted vs. unsalted.
Deconstruct – break down the food e.g. pizza – try with a piece of bread, add tomato sauce, add cheese.

They need to agree with these strategies!

Other things to consider

We know that routine works well for most children, especially for those with ARFID.
Think about a visual timetable and possibly a visual meal plan.
Think about offering 2-3 options (at most) per day so they can slowly engage with new foods.
Take them shopping and let them choose some new foods.
Having a separate cupboard with their own food and snacks can be helpful sometimes.
A reward system can be helpful for some children.
Distractions at meal times can be helpful in some cases, but ideally this should be a work in progress and these should gradually be removed so children can be present whilst they are eating.

Use a hunger chart to help them track and understand their hunger signals.
Have your child be part of the meal where possible – helping to prepare, setting the table or just bringing their own plate to the table.
Encourage them to serve others food, even if they are not serving themselves.
If possible, have a ‘learning plate’ in front of your child. They can serve a small amount of food on to this plate. There is no pressure for them to eat this food, but they can look/smell/touch/play with this food.
Have meals together as a family where possible, even if you are eating different things. This gives the child opportunities to be around different foods.
Have a familiar routine around mealtimes – washing hands, setting the table, eating food, etc.
Make sure your child is sitting in a comfortable chair (feet on the floor).