Why is picky eater's palate so limited?

The cutest boy in the world bounded into my office, followed by his parents, who were not happy.

They described their son as a "very poor eater" since age 2. Now 6, "getting him to eat is a constant battle," and his parents worried they were losing the war. At mealtimes, he ran from the table, often screaming. When they managed to get him to sit, he often refused to swallow, or would spit food out, or gagged as it went down.

By the time he was brought to me for a psychological evaluation, there were no clear medical issues that explained his food avoidance, nor were there mechanical problems with regard to feeding himself: The boy was perfectly capable of holding silverware and bringing food to his mouth; he mostly just preferred not to.

At home, there were a few foods he would consume without complaint, and he ate those on permanent repeat. At school, he ate only Gogurts or nothing at all, saying the "smells" of the cafeteria bothered him. Restaurants were out of the question.

When children are restrictive with their eating and overly distressed around food, the first thought is anorexia. Though rare in males and even rarer in young children, this devastating illness can afflict both. But this child was not preoccupied with his body size or shape and professed no desire to lose weight.

Nor did an anxiety disorder explain his distress around food - I quickly ruled out vomit phobia, choking phobia, and post-traumatic stress disorder.

Possibly sensory sensitivities, particularly to certain smells or textures of foods, could explain part of the problem. But only part of it: The boy's preferred foods - mainly beige junk foods - came in a variety of textures.

Preferred was the operative word in determining diagnosis. It wasn't that this boy wouldn't eatany foods, he just wouldn't eat most of them. Many young children go through a vexing "picky eating phase," when their food choices become more limited. With enough parental persistence, most grow out of it.

But this boy had a bona fide eating disorder. His range of preferred foods was so narrow, and his distress at new or nonpreferred foods so intense, he met criteria for Selective Eating Disorder, also known as Avoidant/Restrictive Food Intake Disorder (ARFID).

I treat a steady diet of selective eaters. My approach is a form of behavioral therapy where I help parents implement a gradual and consistent routine of exposing their children to nonpreferred foods while making it worth their while to eat them via rewards. I also work with parents to weather their children's distress and refusals and celebrate any tiny success. With enough swallows, children gradually increase the foods they will tolerate - but it takes a lot more swallows than most parents realize.

Progress is usually slow and steady. In this boy's case, it was stunning. Within a few months, he was sitting at the table and rapidly expanding the range of foods he would accept. A few months after that, he was eager to go to restaurants. It became a point of pride for him to try an exotic new food.

His mother sends occasional e-mails updating me on his progress. The last was accompanied by a picture of her son smiling at a seafood restaurant. He had just tried frogs' legs.

The subject line of the e-mail?

"Hoppy Times!"