When the contents of the spoon revolt you, even half a teaspoon may feel excessive. Keith Williams’s clinic has seen positive results when the novel foods are first offered in an amount as small as a pea, or even as small as a grain of rice. If the food is tiny enough, and offered in structured taste sessions, even autistic children with extreme selective eating have been able to learn to like a wide range of foods, often in less than a week. In one intervention involving pea-sized bites given on ten consecutive days of treatment, three autistic boys were able to find an unexpected liking for fifty new foods. After just four days of treatment, they had more or less stopped their “disruptive behavior” at the dinner table. Their parents were given training in how to continue the taste sessions at home.
Williams’s latest version of taste exposure for selective eaters is called “Plate A and Plate B.” First, the parent chooses twenty new foods they would like the child to try. Plate A contains three or four new foods chosen from this list of twenty, in pieces no bigger than a grain of rice (maybe carrots, chicken, and oranges). Plate B contains foods that the child already eats without difficulty (let’s say Pop-Tarts, cookies, and crackers). The parent gives the child four to six “Plate A–Plate B” meals a day, each lasting ten minutes (strictly timed with a timer), and no other meals are offered. They tell the child to have one bite from Plate A and then they may have a bite from Plate B and have a drink, “ignoring crying or refusal.” The child continues to alternate between the plates until the time is up. When a child has learned to eat a food on Plate A for three consecutive meals without crying or gagging, the size is increased from a grain of rice to a pea, then to half a spoonful, and finally a spoonful. By the time a full spoonful is accepted, the child has learned to like the Plate A food. The aim is ultimately for as many as possible of the Plate A foods to become Plate B ones: something the child eats willingly and with pleasure.
The reason “Plate A–Plate B” can work so well—when strictly applied—is that it places very low demands on the child. When food is as small as a grain of rice, it is almost as if it is not there. The pressure on the child is further reduced by the fact that there are several foods on each
plate. If the child really can’t stomach two of the foods on Plate A, there is always the third one. Williams says that the reason this simple intervention is successful is that it gives children who cannot bear to taste new foods an opportunity to taste them. It helps them to vault over their own wall of resistance and put the food in their mouths.
Overcoming selective eating is even harder for older children and adults than for younger children, but it can still be done. Tyler was a sixteen-year-old boy with Asperger syndrome. His food restriction was so acute that for nine years he had been fed by gastrostomy tube. He had the height of a ten-year-old and the weight of a nine-year-old. Tyler ate just three foods: ham steak, cereal, and pasta (which had to be bowtie-shaped: farfalle). Without the tube, he would not have received enough calories to survive. Previous attempts to improve his eating had been unsuccessful. Over a two-week course of treatment, therapists at Penn State Hershey created a modified version of “Plate A–Plate B” for Tyler involving a system of token rewards that he could put toward “arcade” time on his laptop, DVD player, and game consoles. For each meal, Tyler was asked to choose six foods, some easy and some “difficult.” The more difficult Tyler considered a food to be, and the more bites he ate, the more time he could earn on his screens. The difficult foods all started off the size of a grain of rice and got gradually bigger. By the last three days of treatment, he was happily eating full-sized portions of normal meals: a main course, plus three or four side dishes.
By the end of treatment, Tyler had a repertoire of seventy-eight different foods, and several months after discharge he was willingly adding new foods to his diet. He was now free of the wretched tube-feeding. On cost grounds alone, Tyler’s cure was a triumph: a year of tube-feeding cost a minimum of $16,000 at 2007 prices, whereas his treatment cost less than $500 a day: $7,000 total. But the greatest gain was to Tyler’s health and well-being. His parents reported that family meals were now actually enjoyable, and he was gaining weight faster than he ever had on the tube. Tyler had left behind the loneliness of tube nutrition and was now enjoying the social interaction of a shared meal.
Keith Williams believes that, with the right motivation for change, it would be possible to use taste exposure to treat selective eating at any age.
The greatest obstacle is that most selective eaters—and their parents—view their condition as incurable, and therefore do not really believe there is any point in treatment. Their reluctance in the face of new food is so great that they would rather organize their lives around the disorder—like the girl who chose the college that offered pizza twice a day—than fight the disorder and try to buy themselves a new life. It is even harder to treat selective eating in adults than in children. The adults may not cry and gag and spit, but they are less open-minded than the children about their potential to learn a new trick. Most would prefer to keep their condition as an embarrassing secret rather than contact a feeding disorders clinic.
There are exceptions. Over the years, Williams has worked with several adult picky eaters who desperately wanted not to be so limited in and fearful about their eating. When the motivation to change is there, Williams finds that taste exposure works just as well on adults as on children. He was once contacted by a primary-school teacher who wanted to become a missionary in Asia, but knew she would not be able to make it in a foreign country unless she could teach herself to eat differently. At the time, she ate only ketchup sandwiches, Oreo cookies, and instant noodles. Unless something changed, she would never be able to cope with the food in the Far East: it wasn’t just the thought of the pungent flavors, such as soy sauce, ginger, scallions, and Sichuan pepper. She didn’t even eat plain white rice. Slowly and gradually, using taste exposure and tiny morsels, she built up the foods she could tolerate. That teacher is now working in the Philippines, land of vinegar and garlic.
When your beautiful baby is first handed to you by the
doctor or midwife and you see a whole future in those blurry eyes, it’s unlikely you’d imagine that he or she might become a person who ate only ketchup sandwiches, Oreos, and instant noodles. What parents do spend a lot of time pondering, particularly if the baby is a girl, is how awful it would be if their child developed anorexia. What misery: to watch this person you have fed so tenderly just waste away, rejecting your meals and, by implication, your love. You would do anything to avoid it, for your own sake as well as theirs.
Those of us who squandered too much of our youth on stupid diets may feel especially determined not to “give” our children an eating disorder. We tie ourselves in knots trying to save them from it. “There’s no such thing as perfect,” was my mantra when my daughter was little and she scrunched up a piece of her artwork. My fear was that her high artistic standards might seep dangerously into body hatred. I would then forget my own words and praise her for doing something “perfectly,” at which point she would correct me, saying it couldn’t be perfect: no such thing. I tried to promote her self-esteem by saying, “Goodnight, beautiful girl,” every night; and then I stopped, fearing that she would equate beauty with self-worth. I watched her vigilantly for signs of wariness around cake. “It’s fine to have a slice. Or two if you are hungry.” No food, I insisted, was absolutely healthy or unhealthy, not even salad. I talked a lot about how it was good to be normal-sized rather than skinny or chubby, but a bit of chubbiness was fine, too, especially in teenagers. I showed her exposés of how models in magazines were Photoshopped, so that she wouldn’t be taken in by those deceitfully lovely images.
So far (she is twelve), no eating disorder. But it’s unlikely to have been all my little preventive measures that have saved her (if, indeed, they have helped at all). It’s an extremely good thing for families to promote sanity around bodies and food, as far as they can, but in the end, our attempts to save our children from anorexia are pieces of magical thinking, like throwing salt over your shoulder to blind the devil. There is no charm that can absolutely ward off anorexia. The current evidence on this puzzling and eerie disease is that the causes are more biological than social. While there is no single anorexic gene, up to 85 percent of the risk of developing it is genetic.
There has been a real sea change in clinical thinking about anorexia over the past two decades. The prevailing view among those who treat it now is that it is a largely heritable condition of the brain rather than a symptom of having an overbearing mother or seeing too many ads featuring thin models. Scientists have identified a cluster of anorexic genes that have to do with the drive for perfection, the need for control, and low self-esteem. Research in 2013 by a team of Cambridge scientists led by Simon Baron-Cohen found that adolescent girls with anorexia
showed elevated autistic traits on cognitive tests compared to a control group. The suggestion is that the characteristic brain structure of anorexic patients (the neural phenotype) is strongly inclined toward systems, like the brains of autistic children. Many studies on anorexia have shown that sufferers display a high degree of social anxiety and difficulty interacting with others. Both autism and anorexia are associated with
social anhedonia
: an inability to find pleasure in many of the social interactions that others find enjoyable. The theory is not that anorexia and autism are the same—or that every anorexia sufferer is socially withdrawn—but that they share certain neural traits that are expressed in different ways. It is striking that whereas the male-to-female ratio is roughly 10:1 for autism, with anorexia the situation is reversed, with a male-to-female ratio of 1:9. Baron-Cohen noted that the rigid mental attitudes of anorexia mirrored the narrow and repetitive behavior of autism “but in anorexia happen to focus on food or weight.”
Patients with anorexia have brains that work slightly differently from the rest of the population, although whether the brain dysfunction is cause or consequence of starvation is not so clear. Neuroimaging has revealed various forms of cognitive impairment in anorexic patients. In particular, anorexics have a poorly functioning
insula
, a part of the brain that helps regulate anxiety. The insula is also crucial for flavor recognition. Some of this brain malfunction may be a response to a lack of food. But it seems that the insula of anorexics is still impaired after recovery, suggesting a structural flaw that predates the onset of the illness. One study measured the brain response of sixteen recovered anorexics to the pleasant taste of drinking sugar water. In contrast to a control group, these women had reduced activity in the insula when they drank the sugar water. It was as if their brains had difficulty recognizing pleasure.
As with any genetic inheritance, however, having an “anorexic brain” is not enough to give you an eating disorder. You might have anorexic genes but never get ill. Carrie Arnold, who is both a recovering anorexic and a biologist, describes the condition as arising from “a complex interaction between malfunctioning hunger signals, anxiety, depression, and difficulties with decision making.” If the causes of anorexia are more biological than social, this could be taken as good news for parents. It
absolves the families of anorexic children from the crushing sense of guilt that affects so many. Arnold notes that her own parents were relaxed around food and never counted calories or pressured her to lose weight. In most cases—though there are exceptions, where eating disorders are triggered by abuse or cruelty—parents are not “to blame” after all, except insofar as they have passed on their genes. A family history of anxiety or depression places children at a markedly higher risk of developing an eating disorder. The downside to this is that if parents are not primarily to blame, there may be little that parents can do to prevent their children from becoming ill.
One of the many scary things about anorexia is how young the sufferers sometimes are. A 2011 survey of eating disorders in Britain found that, while the incidence of the illnesses was stable overall, it was increasing in younger children. Out of all the new cases of children with eating disorders, 59 percent—whether boys or girls—were preadolescent. It was not uncommon for them to be as young as ten or eleven. Some—though this was far more unusual—were eight, or seven, or six. It scarcely seems possible that a child so young could have the distorted body image and fear of fatness of anorexia. Part of the magic of childhood for most of us, looking back, was the sensation of freedom in your own body—the feeling that these legs were made for skipping. How cruel that any seven-year-olds, who should be eating popsicles in the park without a care in the world, should be calculatedly starving themselves.
The obvious explanation for anorexia arising in children so young is that something has gone hideously wrong in our culture. There’s no doubt that anorexia and bulimia are most common in Western or Westernized societies that revere thinness, while pushing foods that make it very difficult to be thin. Anorexia usually starts with a period of dieting. Maybe a child decides to cut out dessert because she has been told at school that sugar is unhealthy, or maybe she has been teased for the way she looks in a swimsuit. The ideal female body type depicted in advertisements in glossy magazines is estimated to be possessed by just 5 percent of women, leaving the other 95 percent feeling potentially unworthy. As for boys, the ideal superhero body—quads like tree trunks, a small waist, and an ability to fly around skyscrapers—belongs to precisely no one.
Little kids hear their parents talking about how they wish they could lose weight, or calling pudding “naughty,” or using “skinny” as a compliment; and anorexia would seem to be one logical response.