It is very common for kids to be slightly picky about what they eat. Finding a child who enjoys green vegetables is certainly harder than finding one who doesn’t. But some kids are more than picky eaters. Their aversion goes beyond normal choosiness and into an area where parents find they need to call for backup.

Picky eating begins to be a serious problem when kids are undernourished or eating so little that it severely limits their lives. “We typically start seeing kids who struggle with picky eating when they are 7 or 8 years old,” says Jerry Bubrick, PhD, Senior Director of the Anxiety & Mood Disorders Center at the Child Mind Institute. “That’s the age when parents begin realizing, ‘He used to be a great eater but now he won’t eat anything and it is affecting his quality of life,’ or, ‘We thought he’d grow out of it, but now we’re realizing it’s more than that.'”

Picky eating might reach a clinical level for a number of different reasons. Some kids have a heightened sense of smell that makes them taste flavors more intensely than most people. Others limit their diets because they have problems with anxiety. Whatever the reason, the longer a child is severely picky, the harder it will be for her to try new foods. Like any other bad habit, avoidance becomes ingrained in her—and her family’s—way of life.

Getting help

The first step to treating kids who seriously struggle with picky eating is to understand more about their preferences or fears. For example Dr. Bubrick says he has treated kids diagnosed with OCD who were picky eaters out of a fear of being unhealthy. “Imagine eating only extraordinarily healthy foods—all vegetables, no pasta, no pizza, no sugar, nothing. Parents might think, ‘What’s the problem?’ but when vegetables are the only things your child is eating, it isn’t good.”

Some kids avoid certain foods because they are put off by the texture or afraid of trying something new. Others control what they eat because they are afraid of choking, or think something will “go down the wrong pipe.” In this scenario treatment begins with a psychologist explaining how digestion works and dispelling any myths the child may have heard. Whatever the reason, it is important to explain to kids that unfamiliar foods aren’t bad for them, even if it seems that way.

“The treatment is fun and child-driven,” notes Dr. Bubrick. “Although parents might be focused on getting kids to eat certain things, it is more important for the kids to buy into treatment first.” Dr. Bubrick starts by making a list of foods the child wants to try and then another list of things her parents think she should try. Then he works to determine what it is she is avoiding—is it texture, taste, smell? Then they can begin exposure therapy, which means kids start working with foods they’ve been avoiding in a carefully controlled, therapeutic way.

Related: How to Help Kids Who Are Picky Eaters

“It’s about breaking down barriers,” explains Dr. Bubrick. “Sometimes exposure is just having the food on the table and being able to have a conversation in the same room. Other times it’s touching the food, smelling it, just physically interacting with it.” He also gives kids a rule—you can only say you don’t like something if you’re tried it three times. It takes some time to adjust to new flavors, so unless something immediately makes you gag, it’s important to give your taste buds a few good opportunities.

When trying new foods Dr. Bubrick has kids rate them on a scale from 0 to 10. Anything rated over five they agree to eat at home several times a week as practice. As a reward for doing their “homework” they get points for prizes. “For kids who are more open, the joy of finding new foods is the reward. But for kids who are more resistant, we factor in a reward system because trying new foods can be hard, ” explains Dr. Bubrick.

Treatment usually lasts 8 to 10 sessions. The longer a child has been a picky eater, the more sessions it tends to take to break down those avoidant food habits. But with treatment, picky eaters can make great strides. “I worked with one nine-year-old picky eater who was very skinny and drinking supplements like Ensure for his vitamins and minerals,” says Dr. Bubrick. “We started exposure therapy with cheese, which he had never tried before. After some trial and error he discovered Manchego, which he loved. He became a Manchego maniac—he went from never eating cheese before to being able to eat a whole block of it. And that opened up a lot of new things for him. From there we could try sandwiches with Manchego, and a lot of other things.”

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