Adults and caregivers know how common picky eating can be during childhood. But what if it is more than just a phase? Approximately one in four children has a feeding disorder, and the percentage rises to four in five among children with intellectual and developmental disabilities.
Feeding and eating disorders such as avoidant/restrictive food intake disorder, or ARFID, can have several causes with serious consequences. Registered dietitian nutritionists — especially those working with pediatric patients or clients with eating disorders — should be aware of signs and symptoms of ARFID, considerations for treatment and with which health care professionals to collaborate and refer to for comprehensive care.
What Is ARFID?
ARFID occurs when there is a change in eating or feeding that makes it impossible for the person to meet their caloric and nutritional needs. A child with ARFID may not eat or drink enough calories or nutrients to grow normally, and adults may not eat or drink enough to maintain normal body functions. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, or DSM-5, this change in eating must be accompanied by one or more of the following: “significant weight loss (or failure to achieve expected weight gain or faltering growth in children), significant nutritional deficiency, dependence on enteral feeding or oral nutrition supplements or marked interference with psychosocial functioning.”
The DSM-5 also states ARFID cannot occur simultaneously with anorexia nervosa or bulimia nervosa, nor can it be better explained by an underlying medical condition or mental disorder. Additionally, it cannot be diagnosed if the condition is better attributed to food insecurity or religious practices.
Like anorexia nervosa, ARFID results in an avoidance of food; unlike anorexia nervosa, individuals with ARFID are not concerned with body shape or size. Rather, the disorder presents in three ways: a lack of interest in food or a low appetite (the restrictive subtype); cutting out certain foods due to sensory sensitivities (the aversion subtype); or a restricted intake caused by a traumatic event or fear of a traumatic event, such as choking or vomiting (the avoidant subtype).
Picky Eating vs. ARFID
- Eats from all food groups over days or weeks
- Doesn’t impact growth and weight gain
- Not associated with anxiety or extreme worry
- Avoids entire food groups
- Impacts growth and weight gain
- Exhibits anxiety, worry or obsessive-compulsive disorder tendencies
- Lack of hunger
Source: Helping Your Child with Extreme Picky Eating: A Step-by-Step Guide for Overcoming Selective Eating, Food Aversion, and Feeding (New Harbinger Publications, 2015) by Katja Rowell, MD, and Jenny McGlothlin, MS, SLP.
Making a Diagnosis
Before the addition of ARFID to the DSM-5 in 2013, children with ARFID often were described by practitioners as having “Selective Eating Disorder” or were diagnosed with “Feeding Disorder in Infancy or Early Childhood.” Only children under 6 could be diagnosed with FDIEC, whereas there is no age limit when diagnosing ARFID. This change acknowledges that, while ARFID may be more common among children and teenagers, it can persist into adulthood if left untreated.
“ARFID is a fairly new diagnosis, which was added to the eating disorders section of the DSM-5,” says Anna Lutz, MPH, RD, LDN, CEDRD-S, co-creator of Sunny Side Up Nutrition and co-owner of Lutz, Alexander and Associates Nutrition Therapy in Raleigh, N.C. “Because of this addition, more and more individuals that meet the criteria for ARFID are now being treated at higher levels of care.”
People with autism spectrum conditions, attention deficit hyperactivity disorder and intellectual disabilities, as well as children with anxiety disorders and those who do not outgrow normal picky eating, are at a higher risk of developing ARFID. People of all ages and genders are at risk of developing ARFID, though it is more common in children and young people and is thought to be more common in males.
Typically, children with picky eating will still eat foods from all food groups and their pickiness does not interfere with their growth and development. Children with ARFID, however, may avoid eating entire food groups and their extreme picky eating can stunt growth and hinder weight gain. Usually, ARFID is accompanied by anxiety and worry around eating. The disorder can disrupt family dynamics and make eating around others distressing and anxiety-provoking.
Physical signs of ARFID include stomach cramps or other gastrointestinal pain, dizziness or fainting, fatigue and sleep disturbances, difficulty concentrating, amenorrhea and the propensity to get cold easily.
Positive Feeding Dynamics
Here are some ways caregivers can create positive feeding dynamics:
- Trust and depend on information coming from the child about timing, amount, preference, pacing and eating capability.
- Support the child’s developmental tasks and help the child develop positive attitudes about self and the world.
- Help the child learn to distinguish feeding cues and respond appropriately to them.
- Enhance the child’s ability to consume a nutritionally adequate diet and to regulate appropriately the quantity eaten.
Source: Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties. FNCE® 2020.
How to Treat ARFID
Like other eating disorders, when treating patients or clients who are diagnosed with ARFID, collaboration with health care professionals in a team approach is preferred. RDNs, psychotherapists, speech language pathologists, occupational therapists and physicians may be involved.
Lutz says that because ARFID is a newer diagnosis, more research is needed to determine best treatments. Therefore, there is no definitive way a practitioner should treat a patient or client with ARFID. While many current therapies mimic traditional eating disorder treatments such as residential care and family-based treatment, many practitioners, including Lutz, have found responsive feeding therapy, or RFT, to be helpful and hope more research will be dedicated to the subject.
Rather than trying to change the behavior of the child with ARFID (for instance, trying to get them to eat more food), RFT puts more emphasis on the relationship between the caregiver or parent and the child. “Responsive feeding therapy is a treatment that takes into account the feeding relationship between the caregiver and the individual — the connection between them and collaboration between them,” Lutz says.
According to Lutz, this approach empowers the caregiver and the child and encourages caregivers to listen to what their child is telling them about what they are or aren’t eating. “A good first step is for parents and caregivers to notice how they feel when they’re feeding. Since many feeding issues come from anxiety, if a caregiver is also feeling worried and experiencing anxiety, that can be a communication to the child.”
Self-reflection from the caregiver or parent can help facilitate a calmer eating environment, which, Lutz says, RDNs should encourage before addressing more logistical questions, such as which foods parents are serving their children.
Additionally, RDNs should determine which ARFID subtype is present, since each subtype may require a different approach. For instance, Lutz says treatment of a child with avoidant ARFID who is afraid to eat because of a traumatic event such as choking may require more coaching of the parent. “A parent may feel scared to push their child who had a choking incident, or the opposite — a parent forcing too much may feed into the anxiety. It usually requires a lot of coaching for the parent to take charge and reassure their child that they’re going to be OK.”
While a standardized approach to treating ARFID may be far off, RDNs can help progress the field by being aware of the warning signs, learning more about responsive feeding therapy, encouraging caregivers and parents and learning together with their fellow practitioners.
Learn more about various treatments and approaches for each subtype of ARFID, warning signs that may indicate a referral to a speech language pathologist and which treatments may be more harmful than helpful by watching the FNCE® 2020 session Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties.
Avoidant Restrictive Food Intake Disorder (ARFID). National Eating Disorder Association website. Accessed May 21, 2021.
Balla Kohn J. What Is ARFID? J Acad Nutr Diet. 2016;116(11):1872.
Interview with Anna Lutz, MPH, RD, LDN, CEDRD-S.
Lesser J. More than picky eating—7 things to know about ARFID. National Eating Disorder Association website. Accessed June 15, 2021.
Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000;30(1):34-46.
Picky, Selective, ARFID? Assessment and Treatment of Pediatric Feeding Difficulties. Food & Nutrition Conference & Expo™ 2020 recorded session. Published October 21, 2020. Accessed May 21, 2021.
Responsive Feeding Therapy: Values and Practice. Responsive Feeding Therapy website. Published August 16, 2020. Accessed May 24, 2021.
Thomas J, Lawson E, Micali N, et al. Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Curr Psychiatry Rep. 2017;19(8):54.
What is ARFID? An Overview of the Often-Missed Eating Disorder. Central Coast Treatment Center website. Published October 2020. Accessed May 24, 2021.