Psychiatry and the Pharmaceutical Companies

A patient of mine recently asked if all doctors are as gullible to the pharmaceutical companies’ marketing tricks as it appears. I was immediately transported to my days working in an academic hospital. At the time, the "drug reps," as they are called, used to have much more leeway to befriend and bribe exhausted and overstressed trainees eager for free food and a friendly smile. The companies knew better than we that our future prescribing practices were at stake. Falsely armed with  a lethal combination of arrogance and naïveté, we medical residents assumed that we could toe the line as excellent clinicians while exploiting big pharma largesse. Even our respected mentors encouraged us to at least listen to the pharmaceutical information--advertisements disguised as clinical trials--while eating our free lunch. According to the hospital's motto, we were the "Best of the West" and that meant being fully capable of prescribing all of the newest medications, even if the only supporting data were generated by the drug company itself.

In the ten years that have passed, I have worked primarily in private practice. One of my first decisions was to eliminate all pharmaceutical company influence. I rebuff phone calls from reps every week, occasionally escort the brazen marketer, who appears unsolicited in the waiting room, to the door and regularly ignore invitations to dinners at some of New York's posh restaurants. In the meanwhile, I have also disregarded the bulk of clinical trials studying the newest drugs, even in the prestigious journals, since most of the funding for this research continues to come from the pharmaceutical companies themselves.

During my training, I believed I was simply acting according to my beliefs. Unlike many of my colleagues, I never believed I was immune to these sophisticated marketing techniques, and I wanted to practice apart from from these influences. What has surprised me through this past decade is the transformation of my prescribing practices. First, I have raised my threshold as to whether or not to prescribe medication at all. In an age when medication is supposed to cure all our ills, the default decision of a psychiatrist is to medicate and always medicate. It is liberating to know that prescribing is a clinical decision, not an automatic action. I also take into account variables never mentioned by a pharmaceutical rep: long-term safety data, years of efficacy with substantial independent research, and, finally, price.

Accordingly, I face the challenges of practicing psychiatry in a very different way. I have gravitated to routinely using medications that came on the market over 20 years ago because the safety record is proven and therefore puts patients and me at ease. I avoid new medication combinations and instead choose older, more thoroughly studied options, such as thyroid medication for depression--a treatment which has safety and efficacy data starting from the 1950s. I also weigh price into the equation both for my patient's pocketbook and to measure my small footprint on the explosion of health care costs.

The uneasy marriage between academic medicine and big business has had significant costs to medicine as well as to society at large. Physicians, by nature, are not business people. In recent years, several highly-esteemed physicians have been caught lining their pockets with pharmaceutical payouts while using their reputations to successfully sway doctors' prescribing practices. Clearly, no one is immune to such cutthroat and well-practiced marketing schemes. Left to their own devices, insulated from sales pitches cynically disguised as education, doctors might find alternate ways to differentiate between the true goals of a healing profession and the hidden influences of the marketplace. Protecting young doctors from powerful marketing influences early in their careers could have long-term safety benefits and help rescue the medical profession from the aura of skepticism and distrust that has come to surround it.

The Recovered Treating the Ill: Why so many Clinicians had Eating Disorders Themselves

The clinicians who treat people with eating disorders have often themselves suffered from anorexia or bulimia. Little has been written about having the recovered treat the ill, but informal conversations quickly reveal strong reactions from patients and clinicians alike. In fact, many programs and individuals fall in one of two camps: those who think only someone who had an eating disorder can be an effective therapist and those who think that this creates a community of people who never get well.

Although everyone's goal is successful treatment, there is something about eating disorders that generates emotional and even political factions. The confusion only grows deeper as these illnesses burrow further into the modern ethos. The multiple possible causes, limited therapeutic options and endless debate of disease vs. lifestyle choice opens the door for multiple, unsubstantiated and fractious theories.

The movement for the recovered to treat the ill has a clear precedent. Addiction treatment has been notoriously challenging and largely unsuccessful. Alcoholics Anonymous, a peer sponsored, ongoing support network with a clear program and 24 hour system provides what no treatment option can. The components include a group of people like-minded in the desire for recovery with similar experiences and a formula for success. Most important, when an addict feels the craving, there are many people only a phone call away.

Similar to addiction, it remains very difficult for people without eating disorders to understand and have compassion for the incessant mental torture of these diseases. Trying to live in the world while struggling to eat at every meal creates a very isolating existence. The deep sense of loneliness and separateness of the recovery process experience remains a barrier to getting well. The psychological and emotional pain often makes the potential relief of the eating disorder symptoms irresistible.

Understanding why eating disorder recovery is such a lonely experience is very hard. However, everyone can identify with the actual feeling of being alone. One irony of the human condition is that the feeling of being alone in the world is universal. How can we all share together the reality of being so alone? Although feeling part of a group always alleviates this ill, the relief is always fleeting.

In the eating disorder community, the banding together of the recovered and the ill creates just such solidarity. A group of people whose experience runs the gamut from very sick to fully healed can embody the entire scope of the process in one room and generate hope in a way that is at the core of any successful treatment. Seeing a therapist who communicates hope just by being there and saying "I am well" can change the tenor of recovery. In the throes of the daily struggle to eat and get well, a daily reminder of hope is invaluable.

There is one critical, potential pitfall. In any group with people still quite sick with an eating disorder, the internal drive back to starving or binging remains strong. In the face of powerful forces that everyone in this group has experienced, there has to be a constant, overt undercurrent that recovery is the goal. This may seem obvious but many well-intentioned groups have succumbed to the power of relapse. The fundamental notion, borne out of AA, is to respect the disease. As long as even the members with the longest recovery acknowledge the risk of relapse, the group as a whole will remain on track.

What clinicians without an eating disorder provide is perspective. Treatment acts as a bridge from sick to well and from isolation to connectivity. To exist in a therapeutic environment simultaneously without judgment and with the luxury to be fully honest liberates a patient from the prison of an eating disorder. Nestled solely in the arms of the recovered, a patient will remain scared to be in the world. A clinician from the outside can help that person learn how, even with the history of an eating disorder, to be in the wider world.

The community of practitioners--the recovered and the outsiders--need to stay together. The treatment of eating disorders need not be a political battleground between the afflicted and the perpetrators. It need not foster the endless debates of illness or imposed prison. Yes, the social forces behind the steep rise in eating disorders in recent decades are polarizing, but it is the clinician's job to heal. Let's put aside the disparate motives and agree that there are many, many sick people in need of help to get well.

Talking Fat and Thin with your Kids, Part II

It's a parent's job to translate a child's words and behaviors and then figure out how best to respond. Without the benefit of clear language and emotional regulation, children make basic comprehension of their actions difficult. In this day and age, a child's statement of "I feel fat" is just such a challenge.

Parents tend to interpret children largely based on the prevailing life philosophy. Following the most popular parenting books through successive generations is a great way to learn about the evolution of kids' expected roles in society. Parents, more often than not, will gladly accept any advice offered, so parenting guide books tend to be popular. Raising children is too daunting a task to leave parents with much energy to argue with the supposed experts. As the philosophy seeps into a generation, kids are gradually assimilated into their culture.

The current mode of healing in any day and age strongly influences the approach parents use to comprehend a child's baffling reactions to daily life. Often the most trusted member of the community is the designated healer. 

The concept of therapist as healer--an ignominious status passed down from shaman to minister to psychoanalyst and now to therapist--has had a profound effect on how we live our lives today and, in communities focused on youth, how parents treat children.

Therapy, taken as a whole, presents many theories that can be used to understand children. There is a vast therapy literature that explores a child's use of play and transitional objects and another that focuses on the conflicts that arise in each stage of maturation, but the lay person's current takeaway message from a world of therapy is very different.

The current parenting book is now an adult-centered self-help paperback. A quick and easy read with a few throwaway lines you forget within an hour or two. Rather than interpreting a child's behavior as a clue to their current needs, the premise of these books is to wonder what might be going on in their little minds, as if they are just small adults.

Children no longer have the free pass of just being kids. The endless stream of self-help mantras and boiled-down therapy nuggets has led parents to apply adult advice to a growing child. Kids are now mistakenly seen as little grown-ups with mature motivations and emotions and are regularly misunderstood.

The over-analyzing and rationalizing of a child's behavior leads parents to ascribe sophisticated motives to the haphazard flailing of an animal that is all id. The bygone world less preoccupied with a child's inner workings left kids to their own devices to sort through personal development and hoped for the best. Now, watched at every turn, kids have each moment scripted practically from birth.

The end result is little freedom to engage in play and experiential learning and little time for a key part of childhood, self-exploration. At activity after activity, kids perform a task and search an adult's knowing gaze for approval. Kids don't flounder in the feeling of insecurity and confusion; there is no time or reason for that. They have been trained to look to the adults in their lives for signs not only of how they're doing, but of who they ought to be.

Treated as mini-adults and left little space for development of an identity, kids have resorted to adult language--such as "I feel fat"-- to try to express any sense of unhappiness. Because kids are seen as little people, parents and clinicians alike are apt to treat a child's comment about feeling fat at face value. The two possible interpretations undoubtedly magnify and sometimes even create a problem that was never there.

One option is to actually believe the child and put her on a diet. This step, meant, in therapist lingo, to validate the child's worry, only confirms that she is fat and encourages the descent into an eating disorder.

The second is to be the proactive parent and treat this comment as if the child already has an eating disorder. Unbeknownst to the worried adult, children have little ability to distinguish between looking for a problem and having one. Thus, the child will now believe that, magically, one statement itself is enough to constitute an eating disorder.

Just as the eating disorder treatment adage "It's not about the food" explains, this isolated comment is not about feeling fat. One of the biggest challenges with children is that they don't have the ability to express what's going on inside them. It is the privilege of adolescence and young adulthood to learn how to meld our emotional and rational worlds. And the truth is that doing it well is a life's work.

Often, in children, emotions come out in physical ways, like a headache or stomach ache, tantrums or, as in this case, copying the expressions of adults around them. So a parent, spooked by this comment, has to table the initial fear. Any emotional reaction by an adult will spark the child's interest, the opposite of the desired response. Just asking the child what's wrong will get you nowhere. Saying "I feel fat" was all the child knew how to say. This is a situation for the parent to do a bit of sleuthing to understand what's going on.

The first thing to look at is the child's behavior. Kids really at risk will be restricting food, secretly binging or obsessively checking their bodies, even as young as age five or six. If the only red flag is "I feel fat," without any eating disorder behaviors, then this comment is very unlikely to represent the start of an illness.

After dismissing the worst case scenario, however, this isn't the moment to ignore the comment. Any child aware of the adults and media around them knows that feeling fat is a way to express that something is wrong. Without another way to say it, this child is using sophisticated adult shorthand to get someone to understand. This is an opportunity to poke around at school about academics or friendships, to talk to teachers or other parents and suss out what might be going on. That way, the child will see that you know there is a problem, even if feeling fat has nothing to do with it.

Talking Fat and Thin with your Kids, Part I

Although body shape and weight have long been a human preoccupation, things have changed since today's current parents were children. Yes, kids back then knew about thin and fat, but only when they saw it right in front of their eyes: a bullied peer or a body image-obsessed parent. These days, the abundance of processed food, the adoration of thinness and the explosion of eating disorders have created a world in which kids are aware of the many meanings of thin and fat at much younger ages.

The chasm between parents' memories of blissful ignorance and a child's premature exposure to the idea of weight creates a confusing scenario for families with young kids. Scared and perplexed parents seek out my advice when their young daughter starts to talk about feeling fat. Although children routinely mimic the adults in their lives, and the result is often amusing, this example stirs fear in any parent.

Sadly, there is nowhere to turn for reliable guidance. Most reassurance from friends or a pediatrician blends platitudes with unfounded opinion. Often, the advice given to parents is to put the kid on a diet, or at least restrict certain foods. I can't  count the number of patients I've seen who say that it was the first diet that started their eating disorder.

In order to guide these parents, I have found that the best approach is to place their worries within the wider public health problem of eating disorders. This step acknowledges the fears are real while pointing out that one comment doesn't constitute an eating disorder.

Their child is just playing with the adult concept of weight, something innocuous on its own, when taken out of context. And a child won't really understand the context. Once familiar with the scope of eating disorders, parents can return to their own child's behavior with some perspective and, consequentially, develop concrete, practical ideas to steer their child clear of a worrisome illness.

When I describe my practice, to clinicians and laypeople alike, the choice to treat adults with eating disorders, but not adolescents, perplexes even the most knowledgeable and open-minded. The first eating disorder image that comes to everyone's mind is the emaciated teenager, lost and alone. Surely, that's who I must be treating. The existence of a practice treating exclusively adults with these illnesses implies a much larger problem than most people could imagine.

Binging, restricting and purging remain a by product of adolescence to most adults, symptoms of a bygone age of inner turmoil and impulsivity, quickly outgrown with the maturity of early adulthood. The few who aware of an eating disorder's wider reach have generally been touched by the illnesses directly. The rest, without cause to understand further, just see the chronically ill as a group of misguided women without the will or desire to eat.

A new subspecialty, which has emerged only in the past decade, further reveals how widespread the problem has become. The incidence of children ten and younger diagnosed with eating disorders has skyrocketed, now at about ten percent of all cases. Hospital units designed for eating disorder treatment report rising numbers of young children as patients, and the clinical community is scrambling to provide adequate services.

This phenomenon generates sympathy and horror, but, from a clinical vantage point, these are new illnesses which clinicians are only starting to learn how to treat.

As I have written, the longer the course of the illness, the more difficult the recovery. The behavioral eating symptoms, the most obvious and most disturbing, are the mainstay of diagnosis and priority of treatment. All children must start the road to recovery with weight restoration and normal eating.

But the path after that is unclear. What precipitates a young child to develop an eating disorder? How is relapse prevented? These are the obvious first questions to ask and the ones critical to parents wondering what to do about the young child who feels fat. 

Any clinician would agree that protecting these children vulnerable to an early diagnosis of an eating disorder is a priority. Exposure to our culture's weight obsession is unavoidable. Objectification of even a young child's body begins with idle adult comments or a first wearing of Gap skinny jeans, even for pre-pubescent kids. This is the world we live in.

Every child will grapple to make sense of the miasma of information and feedback that comes their way, but where is the line between normal psychological development and a problem? Keeping the broader context of eating disorders in mind, I'll try to answer that question in the next post, part two of talking fat and thin with your kids.

Dessert and Children: The Final Frontier of Food

Few issues generate more confusion and disagreement among parents than dessert. That extra little piece of chocolate or candy is the bane of many a parent's existence, and the true moment of success for a child.

These kids know how to get what they want. Adept at reading their parents' cues, they will home in on any ambivalence about dessert to cash in on the reward. In that moment ripe for exploitation, kids will pounce on the adult who, unaware of the ambush, soon relents and allows the desired treat. And why not? The pestering inevitably gets kids more sweets and they love it.

So it's no coincidence that nothing elicits more whining and crying than being denied dessert. Every meal, snack or even moment of downtime is a child's opportunity to scavenge for ice cream or a lollipop. A day with children can often feel like fending off one sweet entreaty after another until you've been worn down to a nub of fury. The final capitulation is all too familiar: "Fine! Do what you want! Eat every piece of candy in the house!" To a purely literal child, this is a simple, if angry, invitation.

An adult, after enduring this argument countless times, will sit down, rationally, and hammer out a dessert treaty. The results are predictable: a certain number of desserts is allowed per day or per week; perhaps one type of dessert is favored over others; and often the treat is linked to finishing a meal or completing a particularly onerous chore.

If only logic had a chance! Children can dismantle the best-laid dessert plan in minutes. Their relentless attack and single-minded goal undo a parent's good intentions almost instantaneously.

Just as with choosing a healthy family diet, a logical plan is only half the battle. Reaching an acceptable approach to dessert in the household may look like the solution, but, as children are well aware, every sweet rule is made to be broken.

The conflict between a child's developmental drive for autonomy and the equally strong need for security runs rampant in the daily dessert fight. It's the older kid's version of push me-pull me growing up.

The mind of a child hellbent on the prize represents nothing more than burgeoning independence. Something clearly deemed a treat, which also elicits an array of powerful feelings in an adult, is an irresistible hot button to a child testing the limits of parental patience. The wistful apology that follows the gorge is the requisite search for reassurance, saying, in essence: "Do you still love me Mommy?"

So the second half of the battle has to address the emotional conflict children see both in their parents' struggle with dessert and in their own developmental challenges. There are two critical steps to defuse the timeless family argument, which, although simple, are not particularly obvious to the frustrated parent.

The first step for parents is to tame their own dessert demons. Dessert is not evil or bad. It isn't something to be avoided like the plague. It need not trigger a level of guilt and shame that demands a weeklong diet or even a juice cleanse.

It is best to remember that the varied, healthful diet of an omnivore includes dessert. Like everything in this meal plan, dessert comes in moderation. No one thinks a nutritious meal is comprised of solely chocolate cake. Dessert, broadly defined, is a reasonably sized sweet after a meal or perhaps an afternoon snack.

The most powerful way for children to understand this concept is through action. What a parent does communicates much more to a child than what a parent says. In this case, that means sitting down to enjoy dessert with the children.

When a child sees you happily eat a piece of cake too, dessert starts to transform from daily family squabble to part of the routine. That undoubtedly takes away much of a child's ammunition. Without a parent's weakness to attack, the heightened emotions dissipate and the child loses interest. In today's world of food, one true gift from parent to child is to wrest dessert from its powerful perch as the ultimate sin and make it just another food.

However, children still do need dessert rules, even though they will immediately try to break them. As any law-abiding society can attest, rule enforcement is infinitely more challenging than rule creation. That leads to the second step to defuse the dessert battle: once parents create the rules, stick by the rules, most of the time.

Dessert has been the reward for childhood successes and the go to punishment for bad behavior for time immemorial. Kids live and breathe ice cream, candy and cake as the barometer of a good or bad day, and not only because dessert tastes good. The joy of pushing a parent to the breaking point and reveling in the extra treat is the real goal. Children get enormous gratification from pushing the rules until the parent breaks them.

In futile retaliation, the parent will then modify the rules to cover for their abject failure. In that moment of panic, dessert can magically be linked to any parental demand just so the adult can blindly reassert some power. Once the rules have changed, all children know the game is over. They have won.

Parents don't need to change the rules. They need to change the game. The answer is to approach dessert rules as a wise and thoughtful judge, not a hardened cop.

If the family dessert is laden with guilt and shame, thoughtless cop parenting is the only way out, but children know blind rule following when they see it. When dessert has become just another type of food, separate from punishment, reward or conflict, shifting the rules means something very different.

In the adult world, kids know that dessert can be a pastry for breakfast, something after lunch, midday or after dinner. The actual rules are arbitrary. They are guidelines to give children a way to learn how to eat.

The cop parent will follow the hard line: these are the rules and don't break them. A child finds that approach irresistible and will inevitably find a way to flout the rules. The wise judge parent will, unemotionally, follow the rules but can offer moments when the unexpected dessert becomes a regular part of life. That may involve stopping for dessert on a whim one afternoon or a special family dessert one evening. If these treats are emotion-free, the rules transform into guidelines, and the occasional deviation becomes a way to share something fun together.

An image that brings joy and a burst of nostalgia to many adults is the gleeful child, drenched in melting chocolate, licking an ice cream cone in summer. It is the rare adult who is able to replicate the same experience. Finding a place of sanity with dessert in the family can preserve these moments every child deserves.

The next and last post in this series will address how to discuss weight with children.

Healthy Food/Healthy Family?

Anyone who has attempted to define healthy food knows how difficult a task it is. It's obviously better to choose vegetables over potato chips or grilled chicken over a Big Mac. But what about organic vs. conventional? How much meat is the right amount? What about fish, eggs, chicken? Is pasta a healthy choice?

Even after considering the endless questions, the prospect of planning a healthy diet (not to be confused with a weight-loss diet) is much more challenging when faced with the obstacles of daily life. Convenience outweighs healthfulness at every corner. It takes a surprising amount of attention and diligence to sustain a healthy meal plan.

Then, applying the healthy diet to a child or family vastly increases the level of complexity and the number of variables.  As I discussed in the previous post, add in the child apt to reject food on a regular basis, and healthy food choice becomes, at best, secondary.

The underlying truth is that a healthy food plan is more a philosophy than anything else, and it has to be simple, convenient and easy if it's going to work every day. The best way to start is with a definition followed by a dose of practicality.

As the new FDA food plate suggests, a healthy diet starts with variety. Humans are omnivores which implies certain basic facts about our biological needs. There are many essential nutrients we must ingest since our bodies cannot synthesize them. We need certain building blocks such as the components of protein (amino acids) and fats (fatty acids) to maintain body function. We also need minerals and vitamins in small but finite quantities. In order to satisfy these requirements, a diet needs to be nutritious and varied. Filling your body with less valuable sources of energy such as candy, fast food or snacks neglects our basic biological needs.

Practically, this means that a healthy diet is one that fits our needs both in terms of calories and the building blocks of good health. It is too easy to get caught up in the maelstrom of assessing every morsel of food we eat. The daily chore of weighing the pros and cons of each item of food quickly becomes onerous. Either this approach becomes an obsession or is discarded. Instead, the healthy diet can't hinge on every food choice every day but comprises the entirety of what we eat over weeks and months.

These suggestions stray from the central theme of any popular diet advice: avoid a certain food group combined with calorie restriction. The goal of this type of diet is short-term weight loss. The goal of a healthy meal plan is a balanced, sane approach to food.

Similarly, parents encounter completely impractical ideas such as only organic food or wildly adventurous meals few kids will even tolerate on their plate. Any parent is aware of how impossible these suggestions are, but that doesn't stop the idealistic ones from trying. Even the most ambitious and best intentioned will falter regularly when faced with a hungry, demanding child and an evening schedule gone awry. The end result is a parent making the best choices in the moment but wracked with guilt.

The often ignored but essential piece of a family’s diet is the parent's sanity. The satisfaction of a day of organic, healthy, well-balanced meals is usually commensurate with a day of endless battles about food. But a day with more realistic food choices is generally a copacetic one. This is a perfect moment to use the wise adage, "pick your battles."

The most important concept to remember is that there is no perfect meal plan. Children will eat pizza, chicken fingers and fish sticks for dinner. They will eat chips and french fries and dessert. It isn't ideal to eat these foods constantly, but it's equally problematic to ban them from the family diet. Even if buying organic food is important, no child can possibly eat only organic food in this world. Each food decision is not critical. It is the overall meal plan that adds up to a healthy diet.

And parents have to remember that our own food choices reflect the world we live in, whether we like it or not. This means supermarkets selling products of large food companies, agribusiness and false marketing of food with dubious nutritional value to children. Not only do kids need a healthy diet, but they need to learn how to live in our current world of food.

Armed with the general concepts of variety and practicality, a parent faced with the daily chore of feeding children can keep in mind the bigger picture. A balanced approach to food choice in this cultural climate will both keep children healthy and teach them what they need to know.

The next post will discuss perhaps the question I'm asked most frequently: what do you think about dessert?

The Timeless Struggle with Picky Eaters

Most parents would, ideally, say that one goal of raising a family is to know your child in the deepest and most profound of ways. It seems both cliche in an age of obsessive parenting and patently obvious that there is no other choice.

Yet many parents would also accede that, for years, nuance and complexity of the child are summarily ignored. Instead, the database about said child grows from endless comparison with other children. So a parent accumulates information in binary form: good sleeper/bad sleeper, obedient/oppositional, engaging/shy. That paradigm extends to food: good eater/picky eater.

As the data grows, any curious adult wonders what it all means. It's easy to accept and revel in the positive checkmark, but what about the less desirable chits? Should a parent accept these as a child's traits, work hard to eradicate impending faults, or assume personal responsibility for faulty parenting? 

The recent trend in the psychological literature takes parents off the hook. The increasing weight on the nature component of the nature/nurture debate means adults aren't responsible for everything anymore. What a relief? Perhaps, except that this shift doesn't seem to apply to food.

Parents do have to teach kids how to eat and the role of food in our lives, but kids aren't a blank slate when it comes to eating either. Even though nature plays a role here too, that's not yet common knowledge. We still live in a world where a picky eater is undoubtedly the parent's fault. It's a lot easier to attribute delayed milestones like walking or talking to a pre-programmed developmental clock than to avoid self-reproach for a child only willing to eat cheerios, plain pasta and white bread.

In addition, there is nothing to dissuade lucky parents from taking full ownership over a child's accomplishments. And there is little more discouraging that the parent endlessly bragging about a child's accomplishments.

It's one thing if this is a nine month old who walks or the three year old reader. The the "each in his own time" theory can assuage the creeping worry.

But what about the three year old who eats sushi? Parents of picky eaters are going to have a much harder time absolving themselves of responsibility. Maybe the child needed exposure to whole grains earlier? Maybe the parent was too lenient about giving the same dinner every night, for a year? Precocious eating is practically a new developmental milestone, and picky eating a harbinger of that dreaded codeword: delay.

But, as I wrote in the last post, refusing food is a child's prerogative. It's how kids express themselves and fight to get heard. Obedience and a varied palate in a child says a lot about personality, preference and the adult-child relationship, but is certainly no sign of brilliance. One way to repackage the information is that all children are picky about something, and food, for many reasons, is an obvious and powerful option.

There are a few ways to approach picky eating. First, resist the daily fight! Nothing will entrench parent and child more than the expected duel at each meal. The child has the ultimate power to allow the food in or not. Any parent will be extremely frustrated by the regular food refusal and has to work hard to avoid forcing food or regular punishment. While repeating the mantra "no child will starve," the parent can place the plate in front of the child and just observe what happens. Yes, easier said than done but still the most effective strategy.

Some children may lose interest when denied the satisfaction of adult anger and just abandon the picky eater track. One possible result, though, of a more passive approach is a child pegged for many years as a picky eater. Considering that even limited diets in the Western world are more than sufficient to have a healthy child, family peace and normal development are much more likely if the child is allowed to assume that identity. Given some freedom to assert independence and exert choice on a regular basis gives many children peace of mind and allows family life to run more smoothly. Even these children gradually incorporate more food into their diet.

The most difficult picky eater emails I receive from families concern a child above age ten who eats perhaps three or four foods. The underlying fear is that these behaviors are the start of an eating disorder. There is no clear correlation between picky eating and eating disorders such as anorexia and bulimia. Any early warning of an eating disorder always comes with other psychological and emotional signs of distress that drive the eating behaviors.

The very rare case of a chronic, adult picky eater appears to stem from a physiological cause. Some variant of taste and preference leads these children to only be able to tolerate very limited foods. Although those foods may expand some into adulthood, a few of these children may maintain a fairly limited diet into adulthood.

For a child at risk, it's important for a pediatrician to be sure the child is healthy and rule out any underlying medical cause. Judicious use of vitamin and dietary supplements in addition to the limited but sufficient diet can keep the child healthy in the long run. Rather than creating a family crisis, parents are better off working within the limitations. As long as parents continue to gently offer new options and provide adequate food at mealtime, the child will be healthy, the ultimate goal.

As mentioned, the next post will address the tricky subject of healthy foods.