We examined the clinical significance of moderate and severe selective eating (SE). Two levels of SE were examined in relation to concurrent psychiatric symptoms and as a risk factor for the emergence of later psychiatric symptoms. Findings are intended to guide health care providers to recognize when SE is a problem worthy of intervention.
A population cohort sample of 917 children aged 24 to 71 months and designated caregivers were recruited via primary care practices at a major medical center in the Southeast as part of an epidemiologic study of preschool anxiety. Caregivers were administered structured diagnostic interviews (the Preschool Age Psychiatric Assessment) regarding the child’s eating and related self-regulatory capacities, psychiatric symptoms, functioning, and home environment variables. A subset of 188 dyads were assessed a second time ∼24.7 months from the initial assessment.
Both moderate and severe levels of SE were associated with psychopathological symptoms (anxiety, depression, attention-deficit/hyperactivity disorder) both concurrently and prospectively. However, the severity of psychopathological symptoms worsened as SE became more severe. Impairment in family functioning was reported at both levels of SE, as was sensory sensitivity in domains outside of food and the experience of food aversion.
Findings suggest that health care providers should intervene at even moderate levels of SE. SE associated with impairment in function should now be diagnosed as avoidant/restrictive food intake disorder, an eating disorder that encapsulates maladaptive food restriction, which is new to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.
Comments
RE: Reply to comment by Badke, Tanz, and Sanuino
Thank you for your thoughtful comments on our manuscript. We appreciate the opportunity to elaborate on some findings that may have been unclear and to correct some misunderstandings of study conclusions.
The central point expressed in your comment is that we have exaggerated the clinical significance of selective eating (SE). There were two points in support of this claim: 1) that SE does not warrant clinical concern and 2) that study conclusions were based on a biased study design. We address each in turn.
In regard to the clinical significance of SE, we wish to correct Badke et al’s presentation of our findings. We did not claim, as the authors stated, that cases of SE warrant referral to mental health professionals. We agree with Badke et al. that the vast majority of SE cases should be managed in primary care. The central purpose of the manuscript was to help improve interventions in primary care by providing further clarification and elaboration on the nature of SE. As a result of study findings, future interventions for SE will incorporate the experience of depression, disgust, and sensory sensitivities.
We also agree with the statement of Badke et al. that monitoring a child’s growth and development is an essential facet for gauging healthy development. However, we disagree with their claim that focusing on growth and development alone is a sufficient measure of healthy development on two grounds. First, Badke et al claim that SE is not associated with nutritional deficiencies. Unfortunately, they do not provide any references to support this claim. In fact, a recent review of SE by Taylor et al. 1 concluded that the nutritional status of SE was challenging to determine due to varying definitions of SE across studies. That said, Taylor et al. (1) reported that children with SE consistently had lower intakes of fruits and vegetables (2-4); repeatedly had a diet of overall lower nutritional quality than non-SE; and had lower levels of folate, fiber, vitamin C, and vitamin E.(5)
We propose that the potentially poor nutritional quality of the diets of SE may be one source of misunderstanding between parents and medical health professionals: parents perceive their child’s diet as nutritionally poor while pediatricians reassure parents that their child’s growth trajectory is normal. This miscommunication is not anecdotal as Badke et al. suggest. In a web-based survey of 482 parents with a child who was a SE, 67% reported that they were dissatisfied with the advice given to them by their medical professionals.(6) As research documenting the association between diet and the prevention of chronic disease and the promotion of healthy brain development continues to accumulate, (7-9) parents of SE have increasing information to fuel their potentially legitimate concerns about their children’s diet.
In regard to bias in our design, we employed validated, classic methods employed in epidemiological community-based studies.(10) The Duke Preschool Anxiety Study recruited its sample from specific pediatric primary care practices in the Durham, NC area with patient populations that are representative of the surrounding community. Our 2013 paper summarizes the sample and community demographics in Table 1.(11)
Finally, we wish to offer some corrections to statements made by Badke et al. Our study was designed as a planned follow-up study: a representative subset of our original sample was asked to return for more extensive follow-up testing including functional neuroimaging (see 12). Further, we are not suggesting that ARFID replace feeding disorder of infancy or early childhood (FD); that replacement occurred with the publication of the DSM-5.
We hope that our study will spur increased attention and research into the phenomenology and management of SE, which will help to improve childhood nutrition and quell parental concerns.
Sincerely and best wishes,
Nancy Zucker, Helen Egger, Lauren Franz, and William Copeland
1. Taylor, C.M., Wernimont, S.M., Northstone, K., and Emmett, P.M. (2015). Picky/fussy eating in children: Review of definitions, assessment, prevalence and dietary intakes. Appetite 95, 349-359.
2. Dubois, L., Farmer, A.P., Girard, M., and Peterson, K. (2007). Preschool children's eating behaviours are related to dietary adequacy and body weight. European Journal of Clinical Nutrition 61, 846-855.
3. Horodynski, M.A., Stommel, M., Brophy-Herb, H., Xie, Y., and Weatherspoon, L. (2010). Low-Income African American and Non-Hispanic White Mothers' Self-Efficacy, "Picky Eater" Perception, and Toddler Fruit and Vegetable Consumption. Public Health Nursing 27, 408-417.
4. Tharner, A., Jansen, P.W., Kiefte-de Jong, J.C., Moll, H.A., van der Ende, J., Jaddoe, V.W.V., Hofman, A., Tiemeier, H., and Franco, O.H. (2014). Toward an operative diagnosis of fussy/picky eating: a latent profile approach in a population-based cohort. International Journal of Behavioral Nutrition and Physical Activity 11.
5. Galloway, A.T., Fiorito, L., Lee, Y., and Birch, L.L. (2005). Parental pressure, dietary patterns, and weight status among girls who are "picky eaters". Journal of the American Dietetic Association 105, 541-548.
6. Keeling, L., Zucker, N.L., Copeland, W., Franz, L., Angold, A., and Egger, H. (2014). Psychological and Psychosocial Impairment in Preschoolers with Selective Eating. In International Conference on Eating Disorders (New York.
7. van't Veer, P., Jansen, M., Klerk, M., and Kok, F.J. (2000). Fruits and vegetables in the prevention of cancer and cardiovascular disease. Public Health Nutrition 3, 103-107.
8. Bernstein, A.M., Song, M.Y., Zhang, X.H., Pan, A., Wang, M.L., Fuchs, C.S., Le, N., Chan, A.T., Willett, W.C., Ogino, S., et al. (2015). Processed and Unprocessed Red Meat and Risk of Colorectal Cancer: Analysis by Tumor Location and Modification by Time. PloS one 10.
9. Anjos, T., Altmae, S., Emmett, P., Tiemeier, H., Closa-Monasterolo, R., Luque, V., Wiseman, S., Perez-Garcia, M., Lattka, E., Demmelmair, H., et al. (2013). Nutrition and neurodevelopment in children: focus on NUTRIMENTHE project. European Journal of Nutrition 52, 1825-1842.
10. Rothman, K.J., and Greenland, S. (1998). Modern Epidemiology.(Lippincott-Raven Publishers ).
11. Franz, L., Angold, A., Copeland, W., Costello, E.J., Towe-Goodman, N., and Egger, H. (2013). Preschool Anxiety Disorders in Pediatric Primary Care: Prevalence and Comorbidity. Journal of the American Academy of Child & Adolescent Psychiatry.
12. Franz, L., Angold, A., Copeland, W., Costello, E.J., Towe-Goodman, N., and Egger, H. (2013). Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity. J Am Acad Child Adolesc Psychiatry 52, 1294-1303 e1291.
Psychological and Psychosocial Impairment in Preschoolers with Selective Eating - A response
We thank the authors for their article 'Psychological and Psychosocial Impairment in Preschoolers with Selective Eating'.(Zucker et al.) The primary objective of the study was to examine the clinical significance of moderate and severe Selective Eating (SE), after initial screening followed by an in-home assessment. After discussing this study at our department's journal club, we would like to share the following concerns.
Defining SE: The definition of SE is not clear: the authors report that the presence or absence of SE was based on a top 20% score on the State-Trait Anxiety Scale (Table 1), but also describe structured diagnostic interviews, conducted using the Preschool Aged Psychiatric Assessment (PAPA), as well as a self-report measure used to define SE. It is also not clear whether the State-Trait Anxiety Scale which was used in this study to define SE was a validated tool or specific assessment tool (such as the State Trait Anxiety Index for Children), or forms a part of the PAPA.
Participants were screened using the Childhood Behaviour Checklist (CBCL), a well-validated parent reported questionnaire. It is not clear whether the interviewers were blinded to the participants' CBCL anxiety scores. If not, this could have contributed to bias during the subsequent interviews.
Study implications: The authors state that SE is so common in pre-school aged children, and so often associated with other symptoms such as parental mental health difficulties, that SE should be diagnosed early as a developmental disorder, rather than treated as developmentally normal. However, we feel that this conclusion cannot be drawn when we do not know: 1. the natural history of SE, 2. the sociocultural factors that influence parental report of problematic SE, and 3. what proportion of SE falls within an expected range of neurodiversity of preschool behaviour.
We agree with the authors' conclusions that parent reported SE may provide a useful marker for anxiety and vulnerability, which may assist clinicians to look for and support potential underlying mental health concerns such as anxiety disorders. We would caution, however, against clinicians using these data to screen and label young children with a diagnosis such as Avoidant/Restrictive Food Intake Disorder (ARFID), without further understanding of the natural history of this condition and knowledge regarding what evidence-based interventions may be used in the management of SE.
Ref 1. "Psychological and Psychosocial Impairment in Preschoolers With Selective Eating" Zucker, et al., 136:3 e582-e590doi:10.1542/peds.2014- 2386
Authors: Dr Rebekah Barker MBBS BMedSci1 , Dr Jonathan Kaufman MBBS1,3, Associate Professor Gehan Roberts, MBBS, MPH, PhD.1,2,3 1Centre for Community Child Health, Royal Children's Hospital, 2Population Health, Murdoch Children's Research Institute, Melbourne, and 3Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.
Corresponding author: Dr Rebekah Barker MBBS BMedSci, Centre for Community Child Health, The Royal Children's Hospital
Conflict of Interest:
None declared
Re:Psychological and psychosocial impairment in preschoolers with selective eating: concerns regarding methods and data interpretation
We are grateful for your thoughtful critiques and welcome the opportunity to clarify our research. Below, we address the concerns raised in turn.
The authors’ first contention is that our study is “not representative of most communities”. The Duke Preschool Anxiety Study recruited its sample from specific pediatric primary care practices in the Durham, NC area with patient populations that are representative of the surrounding community. Our 2013 paper summarizes the sample and community demographics in Table 11 and states that our sample demographics are similar to those of the area but not the nation. Most of the major epidemiological, longitudinal studies of child mental health of the last 30 years are community studies (e.g., Great Smoky Mountain study, Pittsburgh Youth Study, Christchurch Health and Development Study). None of these studies are nationally representative, and all have yielded significant insights about child psychopathology.2,3 We, like the authors, see the need for a nationally representative mental health study, but the absence of such does not negate the value of community studies in child psychopathology.
The authors also argued that our two-stage sampling design oversampled for children at risk for anxiety disorders and is therefore not appropriate for a study of selective eating. This is not the case. Such designs are commonly used for epidemiologic samples when the prevalence of disorder is low in the population, and a simple random sampling framework would require a very large number of subjects.4-6 All participants were given a weight inversely proportional to their probability of selection and all analyses were conducted with robust variance (sandwich type) estimates to adjust the standard errors for the stratified design effects. With such procedures, the sample can be thought of as “random sample” from the community and analyses will generate reasonably generalizable community estimates.1
The authors also expressed concern about the rates of anxiety disorders identified in this study. Indeed, the rate of preschool anxiety disorders has varied across our studies, as well as across community studies of preschoolers that use the PAPA and other measures.7-10 A review of these data can be found in our previous work.1 The degree to which these differences represent unreliability within our measures or design is reflected in our confidence intervals. As noted in our previous work,1 the overall prevalence of any anxiety disorder found in our sample (19.4% (CI 15.3-23.6) is similar to the rate found in Bufferd et al’s 2011 reported rate of 19.6% (CI 16.3-22.9) in their community study of preschoolers using the PAPA. We are pleased that multiple groups around the world are studying this important area of mental health and expect our understanding to increase over the next decade.
The authors also argue that the definition of a “Moderate Selective Eater” was unclear. To clarify, in the diagnostic interview employed, each individual symptom item has to cross a threshold of impairment across two domains to be endorsed; these determinations were made by a trained interviewer. A Moderate Selective Eater only ate within a limited range of foods and the child’s eating caused impairment in two domains (e.g., child required separately prepared meals and child would not eat food from a restaurant). To state confidently that our Moderate SE group was or was not similar to typical picky eating would imply that there is a precisely operationalized definition of picky eating, which to our knowledge is lacking.
Related to that clarification, the authors argued that our recommendation for intervention at moderate levels of SE was not commensurate with our results. Our recommendations for intervention resulted from the impairment associated with selective eating inherent in our definition. However, this interpretation was also was shaped from our clinical experiences: that current strategies for managing selective eating are inadequate and more precise tools are needed. These points are strongly supported by our data, which demonstrate that the clinical presentation of selective eating is more complex than previously thought. Prior research has established the association of anxiety with selective eating; our data highlights the role of food aversion, depressive symptoms, and sensory sensitivity as other crucial elements that need to be addressed in the clinical resources we provide to parents. Thus, we disagree with the authors’ formulation as it just focuses on the role of anxiety.
In closing, we wish to join with the authors in emphasizing the importance of the study of selective eating and in using well-designed sampling strategies to help characterize the boundary between typically development in eating behaviors and those that warrant clinical attention.
1. Franz L, Angold A, Copeland W, Costello EJ, Towe-Goodman N, Egger H. Preschool Anxiety Disorders in Pediatric Primary Care: Prevalence and Comorbidity. Journal of the American Academy of Child & Adolescent Psychiatry. 2013.
2. Costello EJ, Foley D, Angold A. 10-year research update review: The epidemiology of child and adolescent psychiatric disorders. II. Developmental epidemiology. Journal of the American Academy Child and Adolescent Psychiatry. January 2006;45(1):8-25.
3. Costello EJ, Egger HL, Angold A. 10-Year research update review: The epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. Journal of the American Academy Child and Adolescent Psychiatry. october 2005;44(10):972-986.
4. Schaubel D, Hanley J, Collet JP, Boivin JF, Sharpe C. Two-stage sampling for etiologic studies: Sample size and power. American Journal of Epidemiology. 1997;146(5):450-458.
5. Reilly M. Optimal sampling strategies for two-stage studies. American Journal of Epidemiology. 1996;143(1):92-100.
6. Pickles A, Dunn G, Vazquez-Barquero J. Screening for stratification in two-phase ('two-stage') epidemiological surveys. Statistical Methods in Medical Research. 1995;4(1):73-89.
7. Wichstrøm L, Berg‐Nielsen TS, Angold A, Egger HL, Solheim E, Sveen TH. Prevalence of psychiatric disorders in preschoolers. Journal of Child Psychology and Psychiatry. 2012;53(6):695-705.
8. Lavigne JV, LeBailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. Journal of Clinical Child & Adolescent Psychology. 2009;38(3):315-328.
9. Bufferd SJ, Dougherty LR, Carlson GA, Klein DN. Parent-reported mental health in preschoolers: findings using a diagnostic interview. Comprehensive psychiatry. 2011;52(4):359-369.
10. Costello EJ, Egger HL, Copeland W, et al. The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Anxiety disorders in children and adolescents: Research, assessment and intervention. 2011:56-75.
A Pediatric Perspective Would Have Made This Easier to Swallow
In their recent article, Zucker et al report that selective eating in preschool-age children is associated with psychopathology and impaired family functioning (1). While it may seem logical that children with severe food aversions may be at risk for developing disorders such as anxiety, we are concerned that some of the conclusions drawn in this paper may not be relevant to most picky eaters. Additionally, it is concerning that the authors recommend behavioral or psychiatric referral for all children with selective eating, as this represents 20% of the pediatric population.
The authors began with a sample of 4,520 children but only 187 participated in follow-up. Sociodemographic and family/parent functioning variables (such as poverty, single parent, maternal anxiety, and parental psychiatric help) are provided, but the authors do not describe the onset of these variables in relation to the onset of the child's selective eating behaviors. Subsequently, the nature and direction of the relationship between any of these variables and selective eating cannot be determined.
This study was performed by researchers with clinical and academic interests in abnormal and disruptive eating patterns. We believe their interests likely skewed their view of toddler eating behavior and biased the study design, interpretation of results, and discussion. Pediatricians see many children with selective eating and provide appropriate guidance to most, but the statement that parents "feel blamed by health care providers" is purely anecdotal and suggests that pediatricians routinely fail these children and families. The authors' recommendation that pediatricians should refer more patients seems unlikely to ameliorate those feelings as little guidance is provided to help pediatricians recognize which children will actually benefit from referral to centers of expertise. Moreover, the authors acknowledge "there is a need to develop interventions or provide further guidance to caregivers..." Thus, the authors describe a problem that affects 20% of children, needs referral to a mental health provider, but lacks effective interventions.
The authors propose using the DSM-V diagnosis of avoidant/restrictive food intake disorder (ARFID) rather than feeding disorder of infancy or early childhood (FD). ARFID, unlike FD, does not take weight gain and growth into account. As pediatricians, we believe that assessing weight gain, growth, and development are crucial in making a diagnosis of a pathologic eating disorder. The authors argue that children with selective eating may develop nutritional deficiencies despite sufficient weight gain, but provide no evidence for this. While children with restrictive eating patterns are common, young children with clinically significant nutritional deficiencies from selective eating are much less common. Children who are growing and developing normally should be treated as normal children, and their parents reassured. Routine referral for mental health services will overload a fragile mental health system that struggles to assist children with functionally severe psychopathology. Perhaps it would have been beneficial to balance the study design and discussion by including the perspectives of general pediatricians and nutritionists.
References 1. Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, Egger H. Psychological and psychosocial impairment in preschoolers with selective eating. Pediatrics 2015;136(3). DOI: 10.1542/peds.2014-2386
Conflict of Interest:
None declared
Psychological and psychosocial impairment in preschoolers with selective eating: concerns regarding methods and data interpretation
We read with interest the article by Zucker(1) et al, "Psychological and psychosocial impairment in preschoolers with selective eating." The authors reported that moderate and severe selective eating (SE) were associated with current and future psychological symptoms, and that "findings suggest that health care providers should intervene at even moderate levels of SE." We believe that the reported data do not support these conclusions.
The authors deem this study population to be a "community sample," but the participant selection process yielded a population not representative of most communities. After screening 3433 primary care patients, the authors selected all 943 patients deemed at high risk for anxiety disorder and a small random selection (n=189) of the remaining, low risk patients yielding a final sample where 83% were at high risk. The study sampling frame was appropriate for the authors' original study on anxiety, but not appropriate for a study of SE. Despite the authors' application of sampling weights, we remain concerned about the stability of study estimates, given the small size of their low-risk sample and the low frequency of selective eating and measured outcomes. Even with sampling weights applied, the prevalence of anxiety and other disorders presented in Table 2 is 2 to 9-fold higher than other studies using a similar primary care population and the same diagnostic tool.(2)
Moderate SE was defined as a child eating "only within the range of his/her preferred foods," without clarifying the degree of restriction or chronicity. Most children are a little hesitant to eat something they haven't eaten before. Without a precise definition of moderate SE, and no comparative "mild SE", we cannot ascertain whether moderate SE was developmentally inappropriate.
The authors' statement that their "findings suggest that health care providers should intervene at even moderate levels of SE" is not supported by their data. There were no statistically significant differences between the no SE and moderate SE groups for any psychiatric diagnosis (Table 2), and the statistically significant differences in symptom count (Figure 2) are of debatable clinical significance. If a medical condition underlies the SE, the symptoms described in Figure 2 may be a natural response that could improve with treatment of the underlying condition. Finally, the authors did not control for potential confounders such as maternal anxiety, which could influence both a child's predisposition for anxiety disorders as well as the parental report of both SE behaviors and psychiatric symptoms.
The authors assert that "the term SE (or "picky eating") is now obsolete. If an individual presents to primary care with the presenting problem of SE, then impairment is implied." Our interpretation of these data are that, among children predisposed to anxiety, selective eating may represent impairment and another manifestation of underlying psychopathology. To support the authors' assertion that all picky eaters presenting to primary care are at substantially greater risk of worrisome psychopathology requiring intervention, a cohort study that is truly representative of the general population must be conducted. We hope this study stimulates further research in this area.
References
1. Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, et al. Psychological and Psychosocial Impairment in Preschoolers With Selective Eating. Pediatrics. 2015. doi:10.1542/peds.2014-2386 2. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry. 2006;47(3-4):313-337.
Conflict of Interest:
None declared