Although pickiness is stable from preschool to school age, children who are more sensory sensitive are at higher risk for pickiness two years later, as are children whose parents display relatively higher levels of sensitivity and lower levels of structuring.
The unwillingness to eat certain familiar or unfamiliar types of food, known as picky eating [1], is most prevalent in early childhood, with rates ranging from 5.6 to 59.3% depending on the definition and assessment methods used [2]. Pickiness is of great concern for parents [3]. Although knowledge of the health-related outcomes of picky eating is limited due to a lack of longitudinal studies [2], research suggests that picky eating is associated with nutrient deficiency [4], underweight [5], behavioral problems [6] and symptoms of anxiety and depression [7]. Even though pickiness may decrease somewhat during the late preschool and early school years [2], evidence suggests a substantial number of children continue to be picky into school age [3], whereas others first display picky eating after starting school [8]. Further, pickiness also seems to be more persistent with later onset, while early onset cases recover more quickly [3]. Therefore, identifying the predictors of pickiness in the period of transition from preschool to school would be especially valuable.
Two longitudinal studies have examined socio-demographic predictors of picky eating [8, 9], and one investigation focused on parental negativity [10]. However, research into modifiable risk factors (e.g., breastfeeding, parenting) has been cross sectional, limiting the possibility of causal inferences between those risk factors and picky eating [11]. Children’s eating is influenced by their dispositional qualities such as temperament [12,13,14], but also by parenting practices and the way parents feed and react to their child’s eating [15, 16]. We therefore propose an etiological model of picky eating involving child temperament, sensory sensitivity and parent-child interaction. We test this model in a large and representative sample of Norwegian children followed from 4 to 6 years of age.
Temperament, sensory sensitivity and pickiness
Individual differences in temperament may explain why some children develop eating problems whereas others do not [12, 17]. According to Rothbart’s work, three overarching factors of temperament can be found: Surgency/extraversion, negative affectivity and effortful control [18]. Surgency, the tendency to be approached-oriented and sensation-seeking, may cause children to be more open to new food experiences. Studies conducted with adults show sensation seeking to be negatively associated with food neophobia, i.e. the avoidance of novel foods, which is closely related to pickiness [19,20,21]. Notably though, Hafstad et al. [10] did not find that level of sociability (akin to surgency) predicted decreased pickiness in very young children (1.5 to 4.5 years of age), but it is not known whether this also applies to older children. Negative affectivity, which is characterized by mood instability, angry reactivity and dysregulated negative emotions [22, 23], is also associated with picky eating in cross-sectional [9, 12], and prospective studies [10]. We therefore examine both surgency and negative affectivity as predictors of pickiness from preschool to school age.
Effortful control, the third overarching temperamental dimension comprising inhibition and planning [18], does not intuitively appear relevant to picky eating. However, perceptual sensitivity, one of its sub dimensions may be pertinent. Perceptual or sensory sensitivity is conceptualized as low neurological thresholds for responding to sensory events and passive response strategies [24]. Individuals high in sensory sensitivity not only notice more sensory events (from taste, touch, vision, and smell) than others, but they notice sensory stimuli, such as food textures, more rapidly [24]. As the sensory properties of foods vary, it is reasonable to assume that sensory sensitivity will affect food acceptance [25]. In fact, sensory sensitive children have been found to be more reluctant to try new foods (food neophobia), eat fewer fruits and vegetables [26], and display higher levels of pickiness in cross-sectional studies [7, 27]. However, it is not yet clear whether sensory sensitivity prospectively predicts picky eating.
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Simply stated, picky eating is characterized by one defining behavior; avoidance of food. Thus, picky eating manifests itself through avoidant behavior, as in anxiety disorders, and may similarly persist by means of negative reinforcement. Parents are concerned about picky eating [3] but may respond to this behavior differently. We propose two parenting pathways that potentially drive pickiness in early childhood, described below.
Protective pathway: parental structuring
Parents who adopt a structuring/scaffolding parenting style, who teach and help the child while acknowledging the child’s autonomy [28], may offer their child unfamiliar or disliked foods in a gentle, yet firm way, encouraging the child to try. This parental approach is comparable to an authoritative feeding style, characterized by emotional warmth and responsiveness as well as high dietary expectations [29]. Indeed, authoritative parenting (i.e. high involvement and high control) is associated with healthy eating behavior [16], including higher fruit and vegetable consumption [29], and has been shown to reduce the negative association between pickiness and fruit intake [30]. Parenting behavior characterized by non-aversive, reinforcing parent-child-interactions, the caregiver being proactive and structuring, has further shown to prospectively predict children’s dietary quality [31]. In sum, research supports a link between general parenting and dietary practices [32, 33], structuring and autonomy support being considered two of the most important parenting constructs as regards parent’s impact on children’s diet and eating habits [34]. Although relatively little is known about the management of pickiness [11], repeated exposure to a novel and/or disliked food has been shown to increase children’s acceptance of the food [35]. However, in order for exposure interventions to be effective, caregivers have to be systematic in their effort to familiarize their child with foods, for instance, by repeatedly and methodically offering certain rejected foods on multiple occasions and praising or rewarding the child for tasting [36, 37]. Such behavior requires structuring of the child’s environment and scaffolding the child’s learning. We therefore expect high parental structuring/scaffolding to reduce the risk of the child becoming a picky eater, whereas little or no structure and scaffolding is expected to increase the risk of prospective pickiness.
Risk pathway: parental sensitivity
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A child’s negative response to food can be distressing for parents [3]; however, some parents may be more distressed than others. Parental sensitivity, defined as awareness and appropriate responsiveness to children’s verbal and nonverbal cues, is generally thought to be psychologically beneficial [38]. However, high sensitivity may have its drawbacks. Because the picky child needs to endure uneasiness, or even anxiety to try a rejected food, the parent similarly needs to endure their child’s uneasiness. Highly sensitive parents may be more affected by their child’s distress and therefore more inclined to avoid confrontation or to abort efforts to encourage their child to try new foods when s/he protests or becomes distressed. This is the proposed sensitive pathway to picky eating, whereby high parental sensitivity leads to decreased food exposure, and thereby negatively reinforces the child’s avoidance. Of note, highly sensitive parents also tend to be structuring [39]. Therefore, we do not expect structuring and sensitivity, which we hypothesize to work in opposite ways, to be bivariately associated with pickiness, because these opposite effects may cancel each other out. However, when adjusted for each other, the ‘true colors’ of structuring and sensitivity may appear.
Current study
Pickiness is associated with several negative physical and psychological health outcomes and can cause parental distress. Identification of predictors is pertinent to inform interventions aimed at reducing picky eating in childhood. We aim to extend existing research by examining child- and parenting factors as predictors of pickiness from age 4 to 6. Specifically, we will explore child temperament, sensory sensitivity, parenting sensitivity and structuring as predictors of pickiness. This study extends earlier findings by applying a psychiatric interview to capture pickiness rather than single items or questionnaires used in earlier cross-sectional [2] and longitudinal studies [8, 10]. We hypothesize that pickiness at age 6, adjusted for pickiness at age 4, would be predicted by: 1) higher levels of child negative affectivity and lower levels of surgency; 2) higher levels of sensory sensitivity; and 3) greater parental sensitivity (i.e., the ability to effectively read and act upon the child’s cues) and lower levels of parental structuring. Gender differences are also explored.
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