A high school boy dragged his feet into my office for a psychological evaluation. He looked skinny, pasty, and glum. His parents were more than willing to do the talking.
"He doesn't eat."
Further questioning revealed the situation wasn't quite that dire: This young man did eat, but irregularly, inadequately, and without much joy.
Breakfast consisted of two full cups of milk and maybe a breakfast bar. His typical lunch at school, when he ate it, seemed more appropriate for a much younger child: PB&J and kids' yogurt (the kind with cartoon characters on the package). Dinner was the same as lunch, and several more glasses of milk, or sometimes plain pizza or a chicken nugget or two. He drank water and sweetened iced teas throughout the day. At night, he snacked on sweets and chips.
In restaurants, he ordered nuggets and fries off the kids' menu.
Otherwise, he was developing well. He did "OK" at school, had friends, played on the soccer team, and got along with his parents. He wasn't depressed.
Anorexia was the first diagnosis to consider. Although the majority of anorexics are female, males make up 10 percent of those with this very serious disorder. But this young man had never suddenly lost an inordinate amount of weight, wasn't exercising compulsively, and believably expressed a desire to add weight to his slender frame.
Further inquiry into his early childhood revealed the problem was one of selectivity, not self-starvation.
Avoidant/Restrictive Food Intake Disorder (ARFID) is the diagnosis for those with such extreme picky eating that it causes problems. ARFID is an eating disorder, not an anxiety disorder. My patient wasn't "afraid" of food, he was just extremely rigid and selective about what he would eat, and had been since age 2. That long-standing avoidance of new or non-preferred foods was all he knew, and he understandably dreaded what the rest of us take for granted: That eating is fun and variety is the spice of life.
The other option, I suppose, is that this picky eater was "spoiled." I disagree; he described his selectivity as unwanted and his anguish about it was obvious. He was embarrassed to eat kids' yogurt and order off the children's menu. He sometimes avoiding getting together with peers simply because he knew he would be offered foods he had to turn down. Or he would force food down despite being overwhelmed with disgust because "I don't want people to think I'm some weirdo or a spoiled brat." He nervously confided that he was wondering exactly what he would eat when he started dating and was already dreading the prospect of eating at prom - still years away.
But because this young man, unlike all my younger picky eaters, was actually motivated to expand his palate, therapy was a party. Actually, more like a buffet. He picked the 10 foods he felt he was most likely to encounter when socializing with his friends - icky, horrible things like hoagies, cheeseburgers, and pepperoni pizza. He even forced himself to eat salad, knowing that he might encounter it at a family meal or on a dinner date. We methodically ate these foods in session, bite after bite, until his brain retrained itself, after years of avoidance, to accept the new, the unexpected, the previously no-way-not-evers.
Ah, the life of a child psychologist: The battles are bitter but the rewards so sweet - the high five we shared when my patient announced he'd attended a soccer banquet and ate exactly what his teammates did; his wonderment - and my joy - when he described what a relief it was to ask waiters for the regular menu. One day, I'll open my mail and find pictures of this happy, healthy, pink-cheeked young man, all dressed up and smiling on his way to prom.
Katherine Dahlsgaard is lead psychologist of the Anxiety Behaviors Clinic at Children's Hospital of Philadelphia and a contributor to the "Healthy Kids" blog at philly.com/healthykids.