From ED review 10/3/18
Jenny McGlothlin, MS, SLP and Katja Rowell, MD, joined us for an interview on their book, Conquer Picky Eating for Teens and Adults: Activities and Strategies for Selective Eaters. What follows are our questions in italics and their thoughtful responses.
You previously published Helping Your Child with Extreme Picky Eating. Your new book, Conquer Picky Eating for Teens and Adults: Activities and Strategies for Selective Eaters, is a workbook targeted for teens and adults. What has your research shown that led you to develop a tool for this age group?
We’ve been pleased that our first book has helped tens of thousands of families dealing with extreme picky eating. Clinicians working in pediatric feeding clinics, eating disorder programs, and GI clinics also use it. We wrote this new book for teens and adults because many children grow up without having found proper help or support, and continue to struggle.
We were hearing from many teens and their parents who had essentially given up, many having “failed” pediatric feeding therapies (explored in our first book). There is more attention in the media around ARFID, but often the only resource presented is intensive day treatment programs. With our clients, we have seen incredible gains. We think many selective teens and adults, even with ARFID diagnoses, don’t necessarily need intensive treatment.
With the new ARFID diagnosis, there is more research on adolescents but no one therapy has emerged as superior to another (Forman 2014). ARFID appears to have higher treatment dropout rates versus other restrictive eating disorders, and potentially lower rates of weight restoration.
When Katja has done outreach and training on a responsive approach to ARFID for eating disorder treatment professionals,she has heard repeatedly that treating ARFID is challenging and outcomes need improvement. These conversations with eating disorder professionals treating ARFID helped shape the book.
Most teens and adults we have worked with have struggled since early childhood (Nicely 2014, Fisher 2014), and adolescents with ARFID are sicker longer than adolescents with other eating disorders. Most have likely experienced years of coercion or pressure around eating. Therapies that pressure teens and adults with ARFID to eat often backfire. Even subtle prompts and tasks (including exposure exercises) can incite powerful and automatic resistance in a client primed by years of attempts to “get” them to eat. Our book offers a different approach. *
The key points we include in our approach with teens and adults are: autonomy, support and encouragement, anxiety reduction, psychoeducation, exposures at the reader’s pace, relaxation, cognitive reframing and frustration tolerance. The format progresses from exploring and understanding why the reader may have started down the road to selective eating, includes reflective questions, and builds skills with worksheets and exercises.
Developmentally, teens yearn for control and independence. We hope to empower teens and adults to tap into their own motivations for addressing their eating challenges. We offer suggestions and information for parents as appropriate. Sadly, some teens don’t have supportive parents, and we wanted a resource they could access as well.
We’ve heard from several eating disorder professionals that they are using the book with clients as part of their treatment. One uses the book hand in hand with the Intuitive Eating Workbook for selective clients. Another shared how she shopped for ingredients with a client in his mid-twenties who then made a homemade pizza and ate most of a slice. Prior to the workbook, he had only eaten one brand of plain cheese pizza for over a decade. His enthusiasm and ownership for the process, via filling in the food preferences list and other exercises helped him feel empowered to choose the next step. This early feedback is encouraging.
You encourage your readers to have patience and to be kind to themselves. Why are these reminders important for this population?
With picky and selective eating, kindness and patience have usually been missing for many teens and adults. There is constant attention and pressure around eating, from parents, teachers, friends and social media! With the attention and pressure there often comes a deep sense of shame and embarrassment.
We want to banish shame and empower individuals. We hope to be a kind and accepting voice in their heads as they read. We include the principle of acceptance from motivational interviewing and ACT (acceptance commitment therapy). As Miller and Rollnick write in Motivational Interviewing,“Paradoxically, this kind of acceptance of people as they are seems to free them for change, whereas insistent nonacceptance (“You’re not okay; you have to be different”) immobilizes the change process.” We have found this to be true with our clients.
“Accept how you eat now” doesn’t mean “give up,” and we explore that nuance. As readers work to change their relationship with food, we also help them explore ways to improve nutrition (chapter 16).
We incorporate technology familiar to teens and adults, suggesting several apps that can help support appetite and wellness with calendar and reminder features. Stress-reducing apps are also recommended. We include real-world examples and have readers brainstorm opportunities in their own lives on how to fit in regular mealtimes and snacks, supporting appetite and sleep as well. We tackle common obstacles such as the time-crunch, or lack of cooking skills as they begin to consider shopping and menu planning. Kindness in this sense includes embracing and caring for themselves regardless of how they eat at the moment. Being “healthy” and thriving is about so much more than food.
In most cases, extreme picky eating is not an emergency. Readers have likely been selective for as long as they can remember. The journey of supporting appetite and increasing variety can take time. They might also see progress in some areas, and experience “setbacks” during times of stress. We normalize this experience. We also provide clear red flags for readers for when the best avenue may be to seek professional help.
Often your exercises are designed to place the eater in control, to be reflective, to be curious. How does understanding one’s experience with picky eating help the individual with change?
This relates back to the last question. Many factors influence the development of a reluctance to eat (2015 Gurze-Salucore interview for more). We essentially say, “It’s not your fault.” So often, selective eaters are told they are being “picky” or stubborn and to just “get over it!“
This understanding leads to acceptance, and often even an appreciation of why they didn’t eat well as children. For many children who had a difficult or painful beginning around food (medical issues, reflux, tongue tie, sensory or oral motor challenges) it was protective and absolutely expected for them to avoid eating. With that acceptance and addressing shame, the reader can shift to curiosity. Curiosity and discovery are recurring themes as well. We were very intentional about the language we used to not add to the sense of pressure, and to present and invite readers to adapt what works for them.
Critically, understanding opens opportunities to support appetite and curiosity around more challenging foods. If readers identify anxiety as a primary stumbling block, they explore the source of the worry and learn tools to identify anxiety in their bodies and to reduce stress and anxiety. If they worry about health, they can explore ways to support health that have nothing to do with food. If their lives are chaotic and not supportive of internal hunger cues, they can work on routines and menu planning. If there are sensory challenges, they can learn ways to have controlled, non-threatening exposures; beginning with paying attention to the language on cooking shows or looking at recipes, and progressing to food explorations.
This is a gradual approach based on what feels best to them at their pace. We offer many different ways to sneak up on different foods, none are better, worse, right or wrong. The reader is in control.
Another area you explore with the reader is anxiety. What are some skills you suggest to help manage anxiety surrounding food?
Addressing anxiety is a theme woven throughout the book. We explore issues from understanding and acceptance as discussed above, to dealing with social isolation, worries about wasting food, health, disappointing family etc. There are many, many worries a client might have. We don’t assume to know what that may be, but help them explore with reflective questions and tuning in to their bodies.
We know that anxiety and ARFID go hand in hand, more so than with other eating disorders. Anxiety also impacts appetite and gastrointestinal function. Step one is to help readers determine the source of the anxiety if they can, and then empower them to address or change how they view things through psychoeducation, acceptance, and embodied techniques such as various breathing exercises, enjoyable movement, singing etc. We offer many suggestions and resources for addressing anxiety, and frequent reminders to check in, as well as when to seek help from a professional.
Inadequate sleep and hunger can also worsen anxiety, so we include chapters on getting into a routine and into the habit of offering themselves an opportunity to eat at regular intervals. Eating opportunities always include a preferred food so they know that their hunger will be addressed. For readers who have trouble identifying hunger cues, they work on those skills.
The book offers scripts and ideas on how to talk to family or friends who may tease or pressure around eating, and how to elicit support; maybe even finding a person or two to eat out with or to explore new foods. Readers will identify what supports and what sabotages their appetite, what increases or soothes anxiety.
There is a chapter on eating out, which can be particularly challenging. We offer understanding and support for the times when things don’t go the way the reader would like. For example, if they try an eating exploration and didn’t “like” the food or the way it was prepared, that’s not a “failure” but useful information for next time.
There is a lot around reframing language and expectations to address anxiety. For example, with explorations or exposure around food, changing the language from “I have to eat a bite of this” to “I wonder what will happen if I _________?” can make a huge difference.
“Rehabilitating your relationship with food” is one of the themes in your book. It’s a richly informed phrase. Why did you choose it?
The relationship an individual has with food is built upon years and years of experience and outside influence, much of which has been negative for those who struggle with selective eating or low appetite. Determining where things went wrong, and then gaining a new perspective on eating can be healing and allow for growth. “Rehabilitation” involves restoring what has been damaged — in this case, the relationship — to acceptance, positive experiences (even enjoyment and pleasure), and establishment of a foundation for moving forward.
Addressing these complex issues is about far more than getting in a few bites of vegetables or only addressing the sensory side of the reluctance to eat. This is good news because the transformation that can come from moving towards eating competence is about more than food. We’ve seen overall anxiety decrease, sleep improve, a sense of confidence and mastery develop, as well as improved relationships with family and significant others. The human experience of eating is about more than what we chew and swallow. This notion of “rehabilitating” captures that and blows open the possibilities for readers; eating out with joy, being okay with what they eat even if they never become “foodies,” and caring for their health and wellness in a myriad of ways.
Can you please explain the term, “bridge,” in the context of eating new foods?
Understanding what characteristics of a food makes it pleasurable can help a selective eater explore what other foods might be acceptable through finding similarities or “bridges” to a new experience. This can be in the form of taste, texture, temperature, or food combinations, and also might be by determining how to change a food through preparation techniques to better match a person’s preferences. This can also be called “linking,” “chaining,” or “stretching” to a new food from a familiar one.
What we offer in our “bridging” chapters are many ways to bridge or stretch to different foods. You can bridge to new flavors in drinks, smoothies or popsicles. You can also use “thinking” bridges to realize that a food may be familiar to something you like. A favorite sauce, spice, or sprinkles can bridge.
Readers explore if they tend to be sensory “seekers” or “avoiders,” and gain ideas for how to expand variety. For sensory seekers, hot sauce or crunchy texture may be a bridge. If a reader prefers crunchy and salty foods, they may go from a potato chip to a veggie straw, and may crush freeze-fried sugar snap peas and adapt a “crumbing” technique used by pediatric feeding therapists. We offer lots of ideas to empower the reader to choose and expand the foods they enjoy (or can tolerate if that is where they are.)
The reader experiences food in different ways. They might start with an accepted food and explore smaller or bigger bites, then place the food directly on their tongue or on their molars. If they tend to gag they might pay attention to whenthis happens. We share how one client realized that she preferred larger bites of food than the tiny bites she had been advised to eat in therapy. She felt more aware of the food and didn’t worry it might get “lost” and choke her. For her, a “bridge” opportunity was the size of the bite. We want to help readers question and be curious about their typical patterns and look to replace them with new, more productive ones.
The book incorporates and adapts strategies that come from the pediatric therapy world. One of our goals as we write and lead workshops is to see more collaboration and sharing of ideas between providers for children, adolescents, and adults, working from a lifespan understanding.
Please share your message of hope and success for those who identify as selective eaters.
We were seeing articles that painted such a hopeless picture for teens and adults with selective eating. The idea that this is a ‘disease’ they would struggle with for the rest of their lives, or that every bite of veggie would have to be chased with soda or choked down felt overly pessimistic. We wrote this book partly as a response to this notion.
We believe the majority of teen and adult selective eaters can expect to do better than that. This is a process of discovery and curiosity. Working with teens and adults is inspiring; when they have those “A-Ha” moments and discover they do like apples —thinly sliced and without the peel for now — it’s really joyful.
To the teen and adult we would say: It’s never too late. There is always room for change if you want it. This book can offer a new perspective and roadmap. Viewing your eating differently helps reshape your expectations for yourself and frees you from the anxiety and hopelessness that may have held you back in the past.
*The book is aimed primarily at the ARFID subtypes characterized by low appetite and sensory preferences or who have had negative experiences around food, not necessarily ARFID clients who are acutely losing weight after an aversive event such as choking or vomiting.
