It’s perfectly normal for toddlers to refuse to eat or even taste new foods, with most children naturally outgrowing the picky eating phase around the age of six. However, extreme fussy eating behaviors could also be a sign of Avoidant Restrictive Food Intake Disorder (ARFID), previously referred to as Selective Eating Disorder.
“ARFID is when someone avoids certain foods or limits how much they eat,” explains Dr Amit Mistry, consultant psychiatrist in eating disorders at Cygnet Health Care (opens in new tab). “This is not driven by an organic, medical illness or motivated by distorted cognitions related to body weight or shape such as anorexia nervosa. However, this can have a detrimental impact on daily social function, physical safety and can still lead to severe malnutrition too.”
Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new diagnosis. Not much is known about the exact origins of this eating disorder, or the best available treatments. It may also be tricky to recognize the early signs of this dangerous mental health condition.
In this article, we discuss the symptoms, diagnostic criteria and potential causes of ARFID. We’ve also spoken to mental health experts to get their take on this novel eating disorder. If you’re worried about your child’s eating behaviors, however, it’s always advisable to consult a medical professional first.
What is avoidant restrictive food intake disorder (ARFID)?
According to the National Eating Disorders Association (opens in new tab), a person with ARFID does not consume enough calories to maintain their basic body functions. In children, this results in stalled weight gain, developmental problems and stunted growth. In adults, it can lead to severe weight loss and malnutrition.
Despite the similarities, ARFID is not the same as anorexia nervosa. ARFID sufferers are not concerned about their body shape and do not have an intense fear of gaining weight. They also are more likely to suffer from gastrointestinal problems.
“ARFID tends to present with extreme food sensitivity (e.g. the appearance, smell, taste and texture of food), fear of negative consequences related to consumption (e.g. choking and emetophobia) and lack of interest in food. This may lead to a vicious cycle of fear, anxiety and avoidance of food,” says Dr Amit Mistry.
“Individuals with ARFID tend to avoid certain foods or may have a lack of interest in food overall,” agrees Dr Kim Anderson, clinical psychologist and the executive director at East Region for Eating Recovery Center. “This restrictive eating pattern can lead to medical, psychological, and interpersonal complications. ARFID is often associated with co-existing psychiatric diagnoses, especially anxiety, obsessive-compulsive disorder, and autism,” she says.
Dr. Amrit D Mistry is a dual consultant specialist in General Adult and Old Age Psychiatry. Dr Mistry holds additional clinical expertise in treating eating disorders and exercise addiction. He is the Responsible Clinician (RC) to a central London specialist inpatient unit and has previously worked as a community consultant for Oxford Health NHS Foundation trust. He is also the chair of the Royal College of Psychiatrists' Sport & Exercise Psychiatry Group.
Dr. Anderson is a licensed clinical psychologist who has focused her career on treatment for individuals with eating disorders. She developed and directed the Cognitive-Behavioral Therapy Program at the Center for Eating Disorders at Sheppard Pratt, before joining Eating Recovery Center in 2019. She has been treating patients with eating disorders in the Baltimore area for over 25 years.
According to a review published in the Neuropsychiatric Disease and Treatment (opens in new tab) journal, ARFID is most common in infants and children, with some cases persisting into adulthood. It’s estimated that ARFID affects 3.2% of the general population, with boys being at much greater risk for developing this disorder.
ARFID: Warning signs and symptoms
According to the National Eating Disorders Association (opens in new tab), signs and symptoms of ARFID include:
Behavioral and psychological
- Dressing in layers to hide weight loss or stay warm
- Severe restriction in types or amount of food eaten
- Strong preference for certain flavors or textures of food
- Fears of choking or vomiting
- Lack of appetite or interest in food
- No body image issues or intense fear of weight gain
- Rapid, unexplained weight loss
- Constipation, acid reflux, abdominal pain, ‘upset stomach’ and other gastrointestinal issues, usually reported around mealtimes
- Cold intolerance, lethargy, and/or excess energy
- Irregular periods, or lack off
- Difficulties concentrating
- Clinical signs of malnutrition, such as anemia, low thyroid and hormone levels, low potassium and low blood cell counts
- Dizziness, fainting and slow heart rate
- Sleep problems
- Dry and brittle skin, hair and nails
- Fine hair on body (lanugo)
- Muscle weakness
- Cold, mottled hands and feet or swelling of feet
- Poor wound healing and immune health
The exact causes of ARFID are not fully understood, and may differ from person to person. Research indicates that, as with all eating disorders, ARFID may result from a specific combination of biological, psychological and environmental factors.
“Most children outgrow the common phase of ‘picky eating’ that often occurs in the toddler years,” says Anderson. “Those who continue to eat from a small range of foods beyond this period are at a higher risk for developing ARFID. However, not all individuals with ARFID start out as selective eaters. Sometimes, a negative experience with food such as choking, vomiting, gastrointestinal discomfort, or an allergic reaction creates fear of certain foods or even eating in general, which may lead to the development of ARFID as well.”
Several studies (opens in new tab) were conducted to identify any potential genetic components that could play a role in developing this condition. However, ARFID does not seem to be rooted in a person’s genetic make-up.
On the other hand, the vast majority of children with ARFID suffer from gastrointestinal problems. According to a study published in the International Journal of Eating Disorders (opens in new tab), 83% of ARFID patients had been diagnosed with one or more digestive conditions — mostly constipation and gastroesophageal reflux disease (GERD).
Certain mental health disorders appear to be closely linked to the development of ARFID. According to a review published in the Developmental Medicine and Child Neurology (opens in new tab), one of the biggest predictors is Autistic Spectrum Disorder (ASC).
“It is well documented that people with a diagnosis of ASC could struggle with sensory sensitivities, which could include sensitivity to food (color, texture, smell etc.) which could then lead to having rigid rules and being selective about food,” says Dr Jeri Tikare, clinical psychologist at Kooth (opens in new tab). “For these individuals, certain specific foods’ characteristics could pose a threat and become a source of distress. Therefore, to protect themselves they develop coping mechanisms. These coping methods relieve their distress and provide them with a feeling of safety. However, these feelings are only experienced for a short period and are not sustainable.”
Individuals with ARFID are often diagnosed with depression, anxiety, and obsessive compulsive disorder, as reported in the Journal of Eating Disorders (opens in new tab). More recently, scientists from the Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (opens in new tab) journal made a connection between ARFID and Internet Gaming Disorder. Both disorders may be used as maladaptive coping strategies in efforts to avoid emotional distress. However, more research is needed to confirm these findings.
There’s also a growing amount of evidence that certain early childhood experiences significantly increase the risk of developing ARFID. According to the Appetite (opens in new tab) journal, parental pressure to eat and coercive feeding control may be important factors.
ARFID vs anorexia nervosa
ARFID shares many common features with another eating disorder — anorexia nervosa. People who suffer from these mental health issues significantly limit the amount or type of food they consume. They both may develop severe malnutrition and behavioral problems. But as opposed to anorexics, ARFID sufferers usually do not have a distorted body image or intense fear of gaining weight. They also tend to have a higher self-esteem and report fewer symptoms of depression, anxiety, perfectionism and clinical impairment, according to the Journal of Eating Disorders (opens in new tab).
The demographics of these two groups don’t tend to overlap either. ARFID affects significantly younger populations, with a much greater proportion of males. It tends to be diagnosed much earlier in life and it may take way longer to develop. Patients with ARFID may struggle more with physical health, phobias, and attention problems than those with anorexia too.
How is ARFID diagnosed?
“ARFID can be diagnosed through a clinical assessment by a doctor or mental health professional,” says Martha Williams, a senior clinical advice coordinator at Beat Eating Disorders (opens in new tab) charity. “This is done via diagnostic criteria found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A physical health assessment may also be necessary to assess for malnutrition, low weight, or growth delay in children.”
According to the DSM-5, ARFID is diagnosed when the following criteria are met:
- An eating disturbance (for example, apparent lack of interest in food or avoidance based on the sensory characteristics of particular food) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
1) Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
2) Significant nutritional deficiency
3) Dependence on enteral feeding or oral nutritional supplements.
4) Marked interference with psychosocial functioning
- The eating disturbance does not occur alongside anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
- The eating disturbance is not a result of other medical conditions or mental disorders
- When the eating disturbance occurs in the context of another condition or disorder, the severity of the disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention
“Whilst the diagnostic categories discussed can be helpful on the one hand; they can also be limiting and exclude people who might be struggling with some of the symptoms but are not underweight,” points out Dr Tikare. “Hence, getting a holistic picture of the person’s presentation and general difficulties can be helpful. Some of the symptoms associated with people struggling with ARFIDs are similar to those associated with other EDs, such as physical health difficulties like severe weight loss, difficulty with concentration, dizziness, coldness, muscle weakness, dizziness and others. Other symptoms include psychosocial difficulties such as problems with eating socially, anxiety, low mood, and others.
“Some people struggle with going on holidays, miss out on parties and events and become increasingly isolated.”
How is ARFID treated?
According to Dr Mistry, the prevalence and complexity of ARFID is increasingly recognised by eating disorder services. But despite being recognised in the latest ICD-11 classification system, they still do not have specific NICE guidance on its management.
“However, treatment principles remain the same in that both physical and mental health needs must be equally managed,” he says. “Patients with ARFID will still benefit from the whole multi-disciplinary team (MDT) expertise as per any form of eating disorder.”
ARFID tends to be treated by a team of medical professionals, dieticians and therapists, who will collectively aim to help ARFID sufferers achieve a healthier weight, develop a healthy eating routine, increase the variety of foods eaten and improve their perceptions of food.
The treatment may include nutrition coaching, psychological counseling, appetite-stimulating medications, anxiolytics (anti-anxiety drugs) and additional medical care.
“Given the potential physical complications of restrictive eating, such as weight loss and malnutrition, a thorough medical evaluation is required for all patients,” says Dr Anderson. “In severe cases, hospitalization or residential treatment may be warranted.”
If they’re not severely malnourished, children and adolescents with ARFID tend to be treated at home. According to the Journal of Cognitive Psychotherapy (opens in new tab), they appear to benefit the most from family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches.
Researchers are particularly hopeful about a novel parent-based approach called SPACE-ARFID, which is centered around changing parental responses and promoting flexibility in food related situations.
“A family-based approach has been shown to be helpful with a focus on helping parents and the families understand the condition better and, after that, help them to support the person with the condition,” says Tikare. “For example, the support could involve helping them to try to eat three meals and three snacks to counteract starvation effects, which we know can exacerbate the symptoms. Parents and families can also help by changing the culture around mealtimes, ensuring that they are regular and there is an effort to try to eat a variety of meals and some encouragement to try new foods.
“It can also be useful to promote new learning by positively reinforcing helpful eating behaviors when possible. Parents and families can also help normalize the experience, which can help people with a diagnosis of ARFID deal with an aspect of the shame associated with the condition.”
This article is for informational purposes only and is not meant to offer medical advice.