Reduce stress around mealtimes and help your child be more flexible with what they eat!

Joining me today is Dr. Yaara Shimshoni, a clinical psychologist and a clinical assistant professor at the Yale School of Medicine, Child Study Center.

We’ll explore the complexities of Avoidant Restrictive Food Intake Disorder (ARFID) and its distinction from typical picky eating. Yaara will detail how this severe eating disorder impacts children’s health and social lives, and offer practical strategies for parents to reduce stress around mealtimes, encourage flexibility in eating habits, and break the cycle of accommodation that often exacerbates these issues.

Plus, we’ll help parents take the guiding principles of a therapy approach called SPACE (Supportive Parenting for Anxious Childhood Emotions), and learn how to apply it with kids who are showing more normative picky eating challenges, that are not clinical, but still can be frustrating and exasperating for parents to navigate.

Dr. Yarra (00:00):

I think for ARFID often this is a journey. Not all of it is done in treatment. In treatment, we help parents find the language that they want to use. How do they create the circumstances that will help the child to become more flexible over time. And then they have these tools and they will continue to work on it.

Dr. Sarah (00:27):

I won’t eat anything that’s green. My carrots touch, my pastas not eating that. I hate that smell. No, don’t slice the grapes. I won’t eat that. If you’ve heard phrases like that, chances are you’re the parent of a toddler. But while asserting their autonomy over food is very normal and developmentally appropriate, it can also be incredibly frustrating for parents whose job it is to make sure their child is healthy and gets enough nutrients. Joining me today is Dr. Yarra Shimshoni, a clinical psychologist and an associate research scientist at the Yale School of Medicine Child Study Center. In this episode, Yarra will share about a therapy called Supportive Parenting for Anxious Childhood Emotions, also referred to as SPACE, and how this approach to childhood anxiety has really revolutionized a lot of traditional treatment methods by focusing on the parent child interaction. She will explain how all parents can use the principles from the space approach to help their child be more flexible around food, whether they’re just a picky eater or they have a more extreme challenge around food like avoidant, restrictive food intake disorder, commonly referred to as arfid. SPACE has recently been studied as a specific treatment protocol for treating arfid and picky eating as it taps into some of the anxieties kids have around these interactions with foods. So I’m super excited for you to hear this episode.

(01:57):

Hi, I’m Dr. Sarah Bren, a clinical psychologist and mom of two. In this podcast, I’ve taken all of my clinical experience, current research on brain science and child psychology, and the insights I’ve gained on my own parenting journey and distilled everything down into easy to understand and actionable parenting insights. So you can tune out the noise and tune into your own authentic parenting voice with confidence and calm. This is Securely Attached.

(02:31):

Hello everybody. Welcome back to Securely Attached. We have Dr. Yarra Shimshoni on the show today. I am so happy you are here. I’m going to let you introduce yourself and get into your work because very fascinating. But I also just want to mention that you have been a massive mentor to me. You’ve been my supervisor for gosh, over a year now I think. And I have learned so much from you. So I’m just thrilled that everyone is going to get to hear your wisdom today. So thanks for being here.

Dr. Yarra (03:06):

Wow, thanks. I really enjoy being your friend, actually, I think and have these wonderful, wonderful conversations about child anxiety and picky eating and just parenting in general. So thanks for having me.

Dr. Sarah (03:24):

Yeah, thanks for being here. So why don’t we start off, can you share with everyone who’s listening a little bit about your work with the child study center and the space program and space? Sounds like we’re talking about nasa, but we’re really talking about Supportive Parenting For Anxious Childhood Emotions. And then we’ll talk a little bit about your specific area of research within that, which is feeding and eating issues related to pick eating and aed. So we’ll talk. So yeah, kick it off.

Dr. Yarra (03:56):

Okay, thanks. So I’m a clinical psychologist and I’ve had the pleasure of being a postdoctoral associate at the Yale Child Studies Center under the supervision of Eli Lebowitz who has also been on this podcast with you. He is the developer of SPACE, the parent based treatment for child anxiety and ocd. And I’ve been working very closely with Eli on SPACE related subjects, doing a lot of clinical work, supervision research, and teaching other clinicians how to administer space. That’s how I got to meet you, Sarah, and work with you. And while we were working on space, we were noticing that there were many children who were presenting to the anxiety program with food related anxieties, but these didn’t exactly fit the presentation of just child anxiety. And we started to think that maybe there is another issue that better fits what we are seeing clinically with these children and starting to think about a new diagnostic entity called arfid. So I don’t know if you want to get into all that now.

Dr. Sarah (05:28):

Yeah, well, before we jump into arfid, let’s just give people a quick overview of SPACE if they’re not familiar with it. I mean, if you want a really in-depth review of what space is and how it works for child anxiety and OCD and other anxiety related symptoms, I would definitely listen to my episode with Dr. Eli Lebowitz, and I’ll put a link to that in the show notes. But broad strokes, can you talk a little bit about why space is different than the historical approaches of treating child anxiety and why? And why we think it might be a nice option for a certain subset and maybe any child, but specifically really young ones or kids who have a harder time engaging with individual therapy for anxiety disorders?

Dr. Yarra (06:26):

Yeah, that’s a really important question. So space really adopt an interpersonal perspective on child anxiety, a systemic perspective, one that really highlights the interactions between parents and children and their role in the maintenance of anxiety, really looking differently at child anxiety. The more traditional approaches see anxiety as an intrapersonal phenomenon, meaning it exists within the individual. So there is that classical kind of triangle related to anxiety where a child will feel some physiological arousal will then interpret these cues and have automatic negative thoughts, kind of looking at them as clues that something is wrong or have negative biases and also have behavioral response, which is usually avoidance. And those traditional approaches then treat child anxiety directly with the child. So the child would come to therapy and work on their thought processes and on their behaviors, usually how to gradually approach the things that they’re afraid of.

(07:50):

And space takes a different look at child anxiety and again, highlights how the anxiety doesn’t exist only within the child, but also in the interaction between parents and children. And really highlights how parents are inherently involved in the child’s anxiety. They’re involved in regulating the child and helping them cope on many different levels. And one of the benefits when we understand a problem as a systemic problem is that we have different points of entry if we want to do something about it, if we understand child anxiety to also exist in the interaction between parents and child, then we can choose to treat it by working with the parents. So really in space, we choose to work with the parents and not with the child and look at how they contribute, how they respond to the child’s anxiety. And so the two main things that we try to do in the space are to increase the parent’s ability to support the child and to reduce the accommodations that they make to the anxiety.

Dr. Sarah (09:14):

Yeah, yeah. Well, I love that so much because, and the reason why when I first found out about SPACE, I was like, get me into the trainings for this because I think it gives parents a tremendous amount of agency. And I know for very, very, very firsthand from working with so many families that there’s nothing that makes you feel more helpless and out of control when you feel like you’re doing all the things that you’re supposed to do supposed to do and it’s not working. And it’s like you get these blinders, it’s very hard to see and how you’re in a dance with your child. And so I think space not only helps parents see the dance that they can get into when their child has an anxiety disorder or even just symptoms of anxiety, but it does so in a way that is so nonjudgmental. It is so supportive of parents, it helps parents to feel like they can do something but that they didn’t cause it, which I think is critical.

Dr. Yarra (10:20):

Really the goal of SPACE is that the child will internalize the message that even though they have a vulnerability or sometimes they get anxious or sometimes some things are challenging for them, that’s okay because they can handle it. They can tolerate feeling uncomfortable and they will be okay. And so in space, as we work on reducing some of the parents’ actual accommodations and behaviors, we are also really focusing on the messages because in our view, it really matters how the parents see their child and what the child sees when they are anxious and looking at their parents for help, it matters what they see reflecting back at them through the parents’ gaze. If I’m an anxious child and I’m looking at my mom, it matters what I see when she looks back at me. If I see her thinking, oh, you poor thing, you can’t handle things, life is so challenging for you, you’re not like other kids, this is too scary.

(11:31):

This is too hard. Over time, I am going to think that about myself that I can’t handle my own anxiety. On the other hand, if I’m able to see recognition, yes, I see that this is really hard for you or this is scary, I get it. I don’t expect it not to scare you, and also I see a strong young child who can handle feeling uncomfortable, then that is what I’m going to internalize. So that’s a big part of the rationale for SPACE, really wanting parents to focus on their messages and their behaviors when the child is anxious to help to indirectly shape the child’s relationship with their own anxiety, to shape how they see themselves when they are anxious, that is the change that we’re really trying to get at through the work of SPACE.

Dr. Sarah (12:34):

So obviously space was designed originally to treat anxiety and OCD, but you guys have done a ton of really interesting research and I’m going to put a link to your website, the space treatment.net in the show notes because if people are interested in reading, you guys have published articles, research publications on using space for autism spectrum disorder and for there’s, well, you can tell me all the ones, but the one that you have been doing a tremendous amount of research on is arf. And so I would love to talk to you more specifically about how, because yes, we can look at arfid and we’ll define it because it’s a weird word, it’s an acronym, but yes, there’s an overlay of anxiety, but it’s sort of something kind of different. So can we talk a little bit about what arfid is and maybe arfid versus picky eating and how we can apply this sort of space framework to working with kids who have challenges and anxiety and avoidant behaviors around food?

Dr. Yarra (13:44):

Yes, definitely. So first, yes, you’re right. After really establishing SPACE as an evidence-based treatment for child anxiety and OCD, we started to branch out and see whether we can apply this treatment model to additional child problems. We have one application of space for anxiety in autism. There’s also work being done currently around how to think about some of the SPACE concepts in the school setting where there’s a lot of anxiety, especially following covid. And that’s being done now. Another application is SPACE related or SPACE-informed ideas and intervention for a phenomenon that we call unfortunate, it’s not the best name for it, but failure to launch. Really we need to find another less judgmental term for this, but this generally means adult children who have not successfully transitioned into adulthood. So they’re not functioning as adults. They are often still at home, not working or not going to higher education, they’re not doing the daily adult functioning, and they also rely heavily on other parents’ accommodations. There’s also an application of space for unexplained somatic symptoms. The paper should be out soon. And then also, as you mentioned, space for restrictive eating, which is kind of a term that we include in it, both arfid that we’ll define in a minute. And also the less severe presentations of, we can call them picky eating.

(15:48):

And yes, please, you can add the link to the website. There’s a lot of information there. There’s also a Facebook group for parents who want to talk about SPACE related topics, and we can include that as well. Oh yeah. Okay. So what is ait? That is a mouthful, and it is an acronym. It stands for Avoidant or Restrictive Food Intake Disorder. And really it refers to individuals, it could be both children and also adults who are extremely restrictive and they’re eating either in the quantity and the amounts of food that they eat or in the variety of foods that they eat. And being picky is not enough to get a diagnosis of arfid because you need to be so restrictive in your eating that it has some meaningful impact on your growth, on your health, on nutritional deficiencies or just your ability to adjust psychosocially to your life. So those are kind of the important criteria for arfid.

(17:17):

For example, we expect children to constantly gain weight. So if a child is losing weight or maintaining the same weight for an extended period of time, we can consider that an impact on weight. Also height. So overall growth, we expect children to maintain the rate of growth on their growth curves. So that is something we can actually see nutritional deficiencies. Also, if a child is eating enough variety and quantity, they should not be nutritionally deficient. If not, we sometimes can see deficiencies in micronutrients, which are vitamins and minerals, vitamins, A, D, C, zinc, iron. Those are the things that we often see deficiencies in. Those could lead to medical problems. Sometimes children need to be fed with significant amounts of supplements like nutritional powders and things like that, psu. And in more severe cases, they might have to be fed via a feeding tube. But again, these are the more extreme cases and in many cases we see a lot of interference in the psychosocial domain.

(18:55):

So these could be children who have trouble at school with concentration, social interference, so they won’t go to playdates, they can’t go to sleepovers or birthday parties because of their restrictive eating. There could be a lot of conflict in the family domain as well between parents about what’s the best way to help the child between parents and the child. Parents try to get the child to eat more between child and siblings, family isolation, we can’t go anywhere. We don’t attend social events as a family because of the child’s restrictive eating and a lot of also trouble with mood and things like that. So really it’s important I think to understand that arfid is a feeding and eating disorder and you need to cross a threshold of severity and interference. So not every child who is a picky eater, we should consider it as a problem or the child has arfid, but really to know that this has to be serious and meaningfully interfering.

Dr. Sarah (20:08):

Yeah, I think that’s a very important point to make because I think, and we were talking about this before we hit record of really wanting to share information but also not trigger those little voices in the back of parents worried heads being like, oh no, does my child have arfid? What is happening? My kid doesn’t eat broccoli. Do we need to call the nutritionist? We want to be really clear. There’s a pretty vast spectrum of challenges around flexibility around food that kids have, and some live very squarely in typical development. Some creep up into a less typical range but still are not clinical in any way. And then you have this sort of top of the, I’m showing with hands that nobody can see, but the top of the arc is this sort of small percentage of kids who kind of tip that scale, no pun intended, of clinical severity and consequences. Those are the percentage of kids on that sort of tricky food spectrum. Just that little bit at the end are going to have arfid.

Dr. Yarra (21:22):

Right. It’s important to consider also development between ages of two and five, even six. It is very normal for kids to have preferences, very strong preferences even to be picky eaters, to not eat the green vegetables, to not eat different things. And that’s okay. It’s really in sync with what we see in other domains of development at that age. It’s okay, and please don’t get alarmed if your child is picky at that age. Usually around age six, we see very naturally that kids broaden their horizons when it comes to food. They start to attend school, they see what other children are eating. They become more independent in many areas and with food as well. So have that in mind as well. If you’re a parent of a toddler or a younger child, them being picky doesn’t automatically mean that they have a problem that you need to attend to.

Dr. Sarah (22:38):

That said, I will say we could, obviously, we could talk about how space works for a I because that’s a very clinical group, but I’ve tended your arfid and picky eating space for those things. And I think it was very, to me, it felt very helpful because yes, probably a very small percentage of the population might be criteria for arfid, but there’s a good amount of kids whose more rigid or avoidant or restrictive relationship with food starts to create this systemic family dance where there are accommodations that can inadvertently be sort of entrenching the family in these sort of food patterns. And it’s really the family. It’s not just the child, it’s the parent child interaction around food that can decrease flexibility, that can maintain rigidity, increase or maintain the anxiety around certain foods or textures, sensory stuff. We should also talk about that too, the different profiles of picky eating in. It’s not all stemming from the same issue, but I’m thinking with how to organize this. First, let’s talk maybe about that and then let’s talk about how we can look at this in terms of no matter what we’re dealing with, how do we use some of these principles of space to help support parents who want to help their children be more flexible around food?

Dr. Yarra (24:17):

So our fed, it’s important, I think that all everyone listening to this knows that it’s not very well understood by clinicians, researchers, yet Arfid as an eating and feeding disorder was defined only a little bit over 10 years ago. And it takes us time to fully understand and study a concept and definitely study effective treatments for a problem. And it is considered a very heterogeneous problem. Some refer to it as an umbrella term that there are different clinical presentations of restrictive eating that fall under this definition of having arfid. And what we understand today is that there are three different, some call them subtypes, others call ’em examples or driving factors for why a child is restricting their eating. One could be simply a child that has low interest in food, poor hunger and fullness kind of regulation systems. And so they don’t feel very hungry.

(25:45):

Eating is a chore for them. They don’t really want to eat. They get full really fast. And that is one driving factor. Another one is restricting eating based on sensory characteristics of the food or sensory sensitivity that the child might have. And so I’m restricting my eating based on the smell, the color, the texture. Sometimes the brand of the food will make a difference. So I’ll eat just one brand of chicken nuggets, but not another one. Physical proximity of different food items. Can they touch, can they not touch the environment? How much noise is there? Who is making my food? All of these things can impact whether I will eat it or not. And another presentation of restrictive eating really stems from anxiety and concern about negative consequences of eating different foods. So maybe I’m worried that I will have a stomach ache or I will choke if I eat this or I’ll throw up, or maybe it’ll just be disgusting and I won’t like it because it’s new. And these are kind of different driving forces or explanations for the restrictive eating. And it’s also important to know that a child could have more than one of these, so a child can restrict their eating because of sensory sensitivity and anxiety about different consequences of eating. But all of this is still emerging as we study this more and try to understand our fit a little bit better.

Dr. Sarah (27:32):

Yeah, I remember working with a family whose daughter really had a fear of fruits and vegetables, like a fear of them. And there was really another way to explain it. And anytime anyone else was eating these things around her, she would really be very, very, very dysregulated and uncomfortable and want to kind of flee. And the whole family kind of had to accommodate and modify their own rhythms because mealtimes were so stressful. And I know we could share lots of examples. I know we talk a lot about ways that this actually shows up. I’m wondering if you could just paint a picture of one or two examples of what this actually can look like and then ways that we can start to look at the parental accommodations and shift.

Dr. Yarra (28:26):

Yeah, definitely. So maybe we’ll continue with an example about around anxiety and fear. There’s a 12-year-old who I’m working with her family and her eating was normal until about a year ago, and she caught a stomach bug and she threw up several times and then after that she became really afraid that she will be sick again and vomit. And so very gradually she started to avoid foods that she ate that day and then anyone who seemed a little bit sick that she could get sick from and then more and more foods and ate really tiny bites and started losing weight. And the family obviously reacted to this and did everything they could to make sure that she eats until they found themselves making so many accommodations. Nobody was allowed to be on the ground floor when she was eating a meal. And parents provided a lot of reassurance and promised her again and again that she’s not going to throw up if she eats this food right now.

(29:44):

And almost every bite they had to be there. They had to be present. They had to almost spoonfeed her every bite. She stopped going to school because of this. She wouldn’t eat at school. You can see how this can become really serious problem. Other presentations around sensory sensitivities, another child who won’t eat or just has a hard time sitting with other people as they eat other foods. So you can’t have family meals, he can’t attend summer camp at school. He eats separately and alone. The kids start to tease him because he can’t be with them when there’s food. He stopped going to birthday parties because there’s so many questions about why isn’t he eating from the pizza and so on. So very briefly, this could seriously interfere even if the child isn’t underweight or isn’t nutritional. You don’t always have to be underweight to have arfid, which is I think another important thing to explain. You could see a lot of psychosocial impairment that really hinders adjustment for these kids and families.

Dr. Sarah (31:03):

And when you were talking about this, these examples, I’m thinking too how as a parent similar with anxiety, we were talking earlier about how when we see our kids in distress, it kicks up this very primal urge to soothe them and help them. There’s something even perhaps more than fear, but feeding when our kids are not eating, it kicks up this in tremendously primal part of us that’s like, I am responsible for nourishing my child. This is my job. I’ve got to dial this in. My anxiety gets kicked up, my attention on the problem gets heightened. And there’s what you often refer to as this bidirectional relationship in the stress around food when kids start to show these kinds of proclivities or worries or avoidance.

Dr. Yarra (32:00):

Yeah, absolutely. There’s something about being able to feed your child that is so fundamental to being a parent. And when there’s some trouble around that, it’s so natural to feel like you’re not good at your job, you’re not doing what you’re supposed to do, and you get really anxious. You feel bad about yourself. That often leads parents to apply a lot of pressure on the child to eat. And we know that when a child feels a lot of pressure, it’s going to be harder for them to actually venture out and eat. And this feeds a negative cycle because then the child doesn’t eat very well and then parents feel even worse and they feel helpless. What am I going to do? The only thing I know to do is to apply more pressure, so I’m going to do that. And again, the child is more stressed and doesn’t eat well.

(32:54):

And so that is one of the things that in space for our fit, we try to work on with the parents. So I’m thinking maybe this is a good segue to just talking broadly about the goals of this intervention and treatment that hopefully could be helpful for parents even if your child doesn’t have arfid, but you are noticing some interfering picky eating and thinking about what can you do. And so in space for our fit in the same and following the same rationale as we apply in SPACE, really focusing on the parents and we’re asking a very broad question, which is how are you the parents adding to this tendency to this picky eating and what can you do around your own messages, your own behaviors to create the optimal circumstances that will allow your child to feel differently about food, to improve their associations with food and hopefully to expand.

(34:06):

And so really the goal of this treatment is to increase the child’s flexibility around food and food related situations and improve their adjustment to a day-to-day life. And one of the things that we try to do is to look at the stress. How are parents applying some stress in addition to what the child already experiences in many of these families? Parents tell us. It’s mealtime has become the most stressful time of the day. We don’t know what’s going to happen. We get really nervous around it, everyone’s on edge and it’s a really tough event of the day. Or maybe we’ve just stopped eating together because it’s so stressful. There’s so much conflict that we just each eat separately in our own spaces or our own time. And we don’t have family meals anymore. We don’t go out to restaurants anymore. We don’t invite extended family for meals anymore. And so overall, we try to help parents look at how they contribute to the problem and what we would like to change in that.

Dr. Sarah (35:27):

Yeah, I like too how SPACE is because it can feel overwhelming when I work with families with SPACE at first and I explain accommodations and we always map ’em all out and we have this big map of all the, and it can feel super overwhelming like, oh my God, I do so many more accommodations than I realized I did. And now, oh God. So what? I just have to start taking them all away. And I’m always like the best thing about space, my opinion is you pick one thing at a time and you create a very detailed, thoughtful plan around how you’re going to modify this one thing and you don’t touch anything else. Because that is where I think parents have the hardest time when they start to realize they’re accommodating. We very often they’ll just like, okay, we we’re going to pull ’em all and you can’t maintain it.

(36:16):

There’s fights and meltdowns left and right, it’s untenable and unsustainable. And then we stop altogether and then we kind of entrench ourselves even worse because we have to go back to what we were doing. And then a kid isn’t going to really believe us when we say we’re not going to do something anymore. So I like that space kind of simplifies it by saying, let’s pick one sort of optimal thing to remove or to modify and share that with the kid and then you follow through. It’s a lot more manageable to deal with the inevitable distress that comes when you don’t do the thing that this child has expected you to do because you’ve always done it for them and they have to feel the anxiety or the frustration or the distress. And they do often meltdown while this is happening. And it’s just that one thing, which I think is so much more manageable for the family system to tackle one thing at a time.

Dr. Yarra (37:19):

Yeah, I think there are many advantages and things that we love about space and that is definitely one of them. We work in a very clear and systematic way. We not only pick one thing, but we also make a very clear and detailed plan around it so that parents approach the change that they’re about to make with a lot of confidence because they’ve thought through how might this go? How might the child respond to this? What does this response mean and how should I cope with this and respond to it? And so really they’re very well equipped when they start to remove an accommodation in space. And the same goes for space. And before we even get there, we really want to look at the stress levels and help parents reduce the stress levels during meals. We want to help them increase their supportive responses to think about how can they validate that this situation is challenging for the child and that they can cope with this challenge and only then we move on to actually making a change in the accommodations and working through all these steps in a very clear and systematic way helps parents approach the actual change from a different perspective in a different way.

(38:49):

They are better regulated and they have more tolerance for the child’s distress and that often sets the tone and allows them to send this message with a lot of confidence. You can handle difficult eating situations.

Dr. Sarah (39:05):

Yeah. Can you maybe share, I’m thinking of maybe a few examples of types of accommodations that you might have a family pull because then we could, I just want to paint a little picture of what this might actually look like in real life.

Dr. Yarra (39:23):

Yeah, definitely. So many accommodations that parents do for child eating. So often buying specific foods for the child, presenting the child only with the very specific foods that they like. Preparing separate meals so the child eats one thing and the rest of the family eats something else. Not going out to restaurants, making sure there’s always enough of the child’s preferred foods, maybe taking special trips, driving around different places just to make sure we have the specific items that the child wants. Some families, we will not allow siblings to eat their foods, the foods that they like in front of the child, sending the child to other people’s houses with special foods and so on. Really it could be endless. This list of accommodations we should finding new ones and new ones.

Dr. Sarah (40:34):

And a common theme of all those things is it’s all parents’ behavior. And that’s the critical hallmark of an accommodation. It’s not about the child’s behavior, it’s about the parents’ behavior. So I am buying a particular food. I’m preparing food a certain way. I am helping my child avoid this, I am doing this or that. For example, if you are going to pull an accommodation where I’m preparing a specific meal for my child and everyone else in the family is going to get what, we’re having the menu, but my child always gets a specific thing for dinner every single night, I need to know they’re going to eat. How might you modify that in a space protocol?

Dr. Yarra (41:19):

Yeah, so really I think the first step would be to understand in more detail where is the child’s rigidity around food? What areas would we like to see more flexibility? Is it the specific brands that we’re buying? Is it a specific pasta shape? Is it a specific place at the table that they want to eat specific? Do they need to eat alone? Are they expecting other people not to eat what they’re eating, what they like to eat in front of them because they don’t like the smell of other people’s foods and so on? Or parents and just working with the parents who they eat outside because the child is aversive to the smell and the noise of them eating. So if the child is sitting in the living room and they want to eat something, then the child says, Ew, that’s gross. Take it away.

(42:20):

And then they will take their food and go outside and sit in the patio even when it’s really cold because this is hard for or the child. So in each kind of family, we want to look at those areas and together with the parents, think about what it would be meaningful for them, what would be a change that could be maybe modest at first, but also meaningful for them that will improve the adjustment that will improve their lives or the child’s life. And so thinking about those things in a case where maybe we’re preparing different meals, perhaps we’d like to make a change in one of the things that the child is eating so that it can become a little bit closer to what the parents are eating or the other family members are eating. Or if a child, let’s say, due to sensory sensitivities and sensory, very strong preferences wants the food to be exactly.

(43:30):

So let’s say the omelet has to be completely flat. The cucumbers have to be sliced in a specific shape. Everything needs to be very precise. We might make a plan where we tell the child every day when we serve dinner, one of the things that we serve will not be exactly the way that you expect it to be. There’s going to be a small change in it, and we understand this could be hard and we know you can handle it, and we’re not telling them whether they have to eat it or don’t have to eat it. We’re just explaining our position, our rationale for making this change. And from now on, there’s going to be some shifts and changes in that, or maybe another brand. We’re not always going to buy the same brand of chicken nuggets or pasta, things like that. And we’re going to make small changes in that.

(44:26):

Or in the case of the child with a lot of anxiety around vomiting, the plan could be we will no longer promise you that you will not throw up when you eat and so on. So really it is very personalized the plan, and it is done in collaboration with the parents and sometimes with the child if they’re willing and interested, giving their input about what kind of change they would like to see, not about whether or not we are making a change, but if they can give us some of their input, if they want to influence some of these things, then we welcome them to join in the planning phase of this.

Dr. Sarah (45:10):

I like that it’s very collaborative and includes the child in a lot of ways, but also there’s a real ownership of the parents of like, we are going to do this thing and we are communicating it to you because we know it’s going to help and it might be hard and we know you can handle it and this is what you can expect. And here we go. But again, it’s just one thing at a time, so it’s a lot more manageable. But the idea is if you can do this once and it gets, the child starts to adjust to this new thing and you’re consistent with it and then you pull another accommodation, we usually pull about three accommodations in a space protocol. And the idea is you don’t have to pull every single accommodation for this to be beneficial, which is another reason why I like this.

(45:59):

It’s a short-term treatment, you just having the child experience the thing they thought they couldn’t handle and getting through to the other side and having that shift, their internal narrative of what they can tolerate and what they can handle. The whole idea is that it gets generalized. It increases flexibility in other situations and around other things that aren’t specifically being addressed by the accommodation, which I think is helpful because I don’t want parents thinking like, okay, I have 50 accommodations and I have to systematically work my way through all of them. That’s not realistic. And this doesn’t have to be that way, which is nice too. A couple does the trick.

Dr. Yarra (46:44):

Right. Exactly. No, we’re not going to go through all of the accommodations. We’re really aiming for the child, internalizing that perception of themselves. I can handle things even if it’s not exactly the way I expect it. I will be okay, I will find something to eat in most situations and I can handle it. I can handle life. I can go to a birthday party, even if they serve pizza. I can sit next to someone if they’re eating something I don’t like, I can still meet up with my friends and go to a restaurant even if I don’t like most of what’s on the menu. And really thinking of the child’s and flexibility in this way, which is really how do we respond to changing situations? How do we adjust our thoughts, feelings, behavior, when things change around us, can we still be a part of our life?

(47:44):

And I think for a often, this is a journey. Not all of it is done in treatment. In treatment. We help parents find the language that they want to use. How do they create the circumstances that will help the child to become more flexible over time? And then they have these tools and they will continue to work on it moving forward. So it’s not all kind of done. And the child doesn’t leave space a fed eating everything. By the way, none of us do. Most of us, I don’t know, maybe some people eat everything, but it’s okay, normal to have preferences, that’s fine. That’s not what arfid is.

Dr. Sarah (48:31):

Right. I think ultimately, and this is why I think it’s helpful to think about this in terms of whether we’re dealing with arfid or just picky eating. It’s like we’re really focusing is on the quality of the relationship to eating, not necessarily increasing their range of food. I mean, obviously that tends to be a byproduct when you can increase the flexibility, but the goal isn’t specifically to increase the amount of food. I think where previous treatments have kind of gotten stuck is they do sort of this exposure therapy or exposure response prevention or just these behavioral plans that kind of force the kid to keep eating things, to try to expand what they’re doing and what their menu is. But what this is, again, shifting the focus entirely to increasing flexibility in that internal narrative that I can handle things that are hard. I can handle the fears around this.

(49:22):

These feelings come and go in focusing on the flexibility first. Often the expanded palate follows the more risk taking, the more openness follows. But that’s not what we’re focusing on in the treatment in and of itself, which I think is a total, again, aha moment paradigm shift. It takes a lot of the onus off of the parent to try to control what the child eats, which anyone has a kid who’s listening knows it’s very hard to do that can’t. There’s certain things that you just don’t get to control. You can’t make your kid eat, you can’t make your kid sleep, you can’t make your kid go to the bathroom. You can’t make them stop screaming. There’s certain things, it’s futile. So putting all of our energy into trying to control what we don’t actually have control over is very frustrating for our parent and frustrating for the child.

(50:14):

It can actually entrench that dynamic more. So this to me is a perfect antidote to that. It focuses on flexibility and the parent-child relationship around food and eating times, reducing stress, reducing pressure, helping the child tolerate distress and increase flexibility. That is the goal. So I love this. I hope people found this to be helpful. Whether you have a child who might have AIT or you just have a kid who’s a little picky or rigid around food and you’re noticing that you’re getting entrenched in these patterns. A lot of this can be useful. You don’t have to do a full therapy protocol to apply a lot of these strategies though if you want to. It’s available. We do it at my group practice. We see a lot of SPACE in my group practice.

Dr. Yarra (51:05):

Yeah.

Dr. Sarah (51:07):

So if people want to learn more about this, if they want to connect with you or your research, where can we send them?

Dr. Yarra (51:15):

Yeah, so the space website has two publications (SPACE-ARFID and Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach) on SPACE arfid one is actually a case description where I think as parents you can go ahead and read what we did with this one case and follow the steps. And currently we are working on a book for parents in an effort to kind of help manage these challenging situations. It’ll take probably some time for it to, until it comes out hopefully early 2025. And it really will be a step-by-step kind of guide to how to manage these difficult eating situations from a systemic and space perspective. And Sarah’s practice of course.

Dr. Sarah (52:10):

Yeah, go to upshurbren.com if you need to do therapy for it.

Dr. Yarra (52:13):

Exactly.

Dr. Sarah (52:13):

We actually do SPACE groups too, which is nice because it’s like a little four week kind of primer instead of having to do the full thing because a lot of parents can take four weeks of a group and apply it all by themselves. It’s a really self-driven thing. So there’s a way to do this in kind of just a little taste of it and then keep going on your own, which is helpful. It makes it more accessible.

Dr. Yarra (52:40):

Can I respond to something that you said a little bit earlier that I think is really important? So I think when a child wants to get help around their eating habits, it’s great to do the exposures. It’s great to do these kind of direct child work, CBT for Arfid, for example, but when they don’t, and that is often the case, so many children who are picky eaters or have a diagnosis of arfid are not interested in changing anything in how they eat. Many of them don’t think they have an issue around food. It’s the world. Their environment should just give them the five that they want to eat. They don’t really have a problem that needs to be helped. And many interventions, like you said, Sarah, send parents home with these tasks and expectations like you need to get your child to eat this or that.

(53:44):

And we know that we can’t do that. If a child doesn’t want to eat something, it’s going to be virtually impossible to get them to eat it. And so when parents are sent home with these expectations, they’re really set up for failure, for feeling bad, for feeling like they’re inadequate. As parents, they weren’t able to do what they were asked to do. And so really, space tries to avoid all of that by not getting into a struggle where we’re definitely going to lose and everybody’s going to feel frustrated and bad. But that doesn’t mean that we are helpless. We still have some tools that we can use. And the main one is control over our own behavior, our messages to our child, how do we arrange the home, the food, and so on. And that is the focus of what we try to do and through that see change. Yeah.

Dr. Sarah (54:43):

I think that’s so important and so empowering for parents. Thank you so much for being here. I am really grateful for all of your knowledge and your mentorship. I am excited to keep our friendship going long, long after space certification.

Dr. Yarra (55:02):

That will definitely happen. And thank you for having me, and maybe we can continue this conversation as things develop in the world.

Dr. Sarah (55:11):

Oh, yes. Thank you.

Dr. Yarra (55:13):

Okay, thanks.

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