Parents of toddlers and preschoolers are familiar with picky eating: an insistence on eating the same foods over and over and a refusal to try new ones. Most children start to outgrow this pickiness by the time they start elementary school, and while they may still have a strong preference for favorites like chicken nuggets, peanut butter and jelly, and macaroni and cheese, it should be possible to get them to try a bite of a vegetable or share in the family meal.
If your child continues to be extremely selective about the foods they eat, shows panic or distress about trying something new, or isn’t gaining enough weight for their height, ask their doctor about avoidant/restrictive food intake disorder, or ARFID.
ARFID is a relatively new diagnosis, first appearing in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013.
We spoke to Rollyn Ornstein, MD, a UNC Health pediatrician who specializes in adolescent medicine and eating disorders, about this eating disorder. She served on the work group that defined the condition for the DSM-5.
What is ARFID?
ARFID is marked by one or more of the following criteria:
- The person has significant weight loss or a child fails to gain weight appropriate for their height.
- The person shows signs of nutritional deficiency, such as anemia.
- The person has to rely on oral nutritional supplements (such as PediaSure or Boost) or a feeding tube to get enough calories or nutrients.
- The person’s food requirements interfere with daily living or their ability to socialize. They may eat enough to maintain weight, but can’t fully participate in activities without the desired food, which could inhibit a family’s ability to take a vacation or a child’s ability to go to camp or a sleepover.
Importantly, “a person with ARFID is not trying to lose weight and doesn’t have any of the weight or shape concerns associated with other eating disorders,” Dr. Ornstein says. “They can recognize that it’s a problem that they’re losing weight—as opposed to a patient with anorexia, for example—but not be able to fix the situation.”
Because ARFID is a newer diagnosis, it’s unclear how common it is; current estimates suggest that it affects between 0.5 and 5 percent of the population, both children and adults.
Three Types of ARFID That Can Affect How Someone Eats
ARFID can present very differently from person to person, but there are currently three general types. A person may show signs of one or all of them at various times, Dr. Ornstein says.
First, the individual will eat only a few foods.
“I want to highlight that ARFID is not just picky eating, and not all picky eating is ARFID,” Dr. Ornstein says. “These are kids who are seriously selective, who may only want one brand of bread or peanut butter or will eat nuggets only from a specific restaurant. It’s really granular with how picky they are, and there can be fear or distress about a different brand of food looking or tasting different.”
Dr. Ornstein says these individuals may have significant fear about trying new foods (food neophobia) or be very finicky over very small differences in food. They may have extreme sensory responses to the taste, texture, smell or appearance of food.
Second, the person may show low interest in food or a poor appetite in general.
“There are people who can be food avoidant, who may always say they’re not hungry or that their stomach hurts at mealtimes,” Dr. Ornstein says. “Food is not interesting to them and almost seems like a chore. There may be an association of sadness or anxiety with a physical complaint, like belly pain, that can lead to food avoidance.”
Third, there are people who become extremely fearful of food because they are scared they will choke, vomit or have some other significant physical reaction to the food.
“There may be a kid who witnesses a peer or sibling vomit or choke, or maybe they had a bad stomach bug and an episode of vomiting,” Dr. Ornstein says. “This can present in an abrupt and scary way: The child may immediately start refusing all foods and liquids and start to lose weight very quickly.”
An individual can exhibit some of these behaviors and still consume enough calories to maintain an adequate weight, meaning they might make it to adulthood without anyone identifying an issue. Other times, the weight loss and nutritional deficiencies will be apparent, or the emotional distress around food will be so overwhelming that a family seeks support.
If a child does lose weight extremely fast, ARFID can be confused with anorexia nervosa. While people with ARFID are not trying to lose weight, Dr. Ornstein says it’s important to know that children with ARFID can cross over to a diagnosis of anorexia if the child develops concerns about weight and shape. The child would then need treatment targeted toward anorexia.
Researchers are still working to understand the causes and common coexisting conditions of ARFID. Dr. Ornstein says research is being done at UNC on a possible genetic predisposition. She says that some with ARFID may also be on the autism spectrum, diagnosed with obsessive-compulsive disorder, or have symptoms of anxiety or depression, but not always.
Treatment for ARFID
Treatment for ARFID will depend on the type as well as the severity of the situation.
“A kid with acute food refusal may need to be hospitalized or have a feeding tube so that they’re medically stable,” Dr. Ornstein says. “Generally, you first try to get the kid eating or taking any form of nutrition, even supplements, if needed. Next, you make sure they’re getting an adequate amount of food. Then, you work on increasing the variety of foods.”
Food exposure therapy, in which people are slowly introduced to new or feared foods, can help, and therapists or dietitians can help family members continue to do food exposures in the home, Dr. Ornstein says. If the person has sensory issues with food, an occupational therapist can also be helpful. A person may need to work with someone to learn how to recognize or increase their hunger cues. Therapy and medication can also help if the person is experiencing symptoms of anxiety or depression as well.
These treatments also could help adults who realize that they may have had these behaviors for decades but didn’t know it was a problem.
“It’s helpful to have a name for something, and now it’s causing some adults to realize that their lives aren’t as full as they could be,” Dr. Ornstein says. “They can’t go out with people, or they’re eating a separate meal before they see their friends. But an adult has to be motivated to make a change. Some adults compensate and think their life is generally fine.”
For parents, Dr. Ornstein recommends offering young children a variety of foods and paying attention to behavior around food.
“If you don’t present kids with a variety of fruits, vegetables and different protein sources, they won’t try them,” she says. “They need to be introduced to foods multiple times. Try to offer new foods alongside foods they like. By school age, they should be able to try a bite of something.”
You may never be able to get your child to eat broccoli without complaining, and the occasional night of refusing dinner is typical. But if you notice repeated avoidant or restrictive behaviors, or if your child’s eating is affecting your family’s mealtimes or ability to go places, Dr. Ornstein encourages you to ask your child’s pediatrician about an evaluation for ARFID.
“If a child is frequently sad or anxious around food, or often says their belly is hurting at mealtime, go to your pediatrician with those concerns,” she says. “Don’t ignore those behaviors or assume they’ll outgrow it. If you’re worried, ask for help.”
If you’re concerned about your child’s eating or your own behavior around food, talk to a doctor. If you need a doctor, find one near you.