Are you or is someone you know a picky eater? Some extremely picky eaters may have an eating disorder, known as avoidant/restrictive food intake disorder (ARFID). In most cases, picky eating does not interfere with weight status, growth, or daily functioning. However, people who experience consequences such as these as a result of extremely picky eating may need treatment.
ARFID vs. Picky Eating
It may be helpful to understand the characteristics of picky eating typically seen in children at different stages of development and avoidant/restrictive food intake disorder.
Picky Eating
Picky eaters are people who avoid many foods because they dislike their taste, smell, texture, or appearance. Picky eating is common in childhood, with anywhere between 13% and 22% of children between three and eleven years of age considered picky eaters at any given time.
While most young children outgrow their pickiness, between 18% and 40% continue to be picky into adolescence.
In developing children, the range of types, textures, and amount of food eaten generally progresses until age six or seven. At around this age, many school-age children become more “picky” and start to favor carbohydrates, which fuel growth.
Usually by puberty, both appetite and eating flexibility increase, accompanied by a return to a wider range of intake and greater balance within and across meals. Many parents report concern around their child’s eating at a young age, but are told by others it is “normal” and not to worry about it.
ARFID
Parents of children with ARFID often notice challenges in their child’s range of intake as early as one year of age. These children may show a strong preference for a narrow range of foods and may refuse to eat anything outside this range. ARFID is described by some as “food neophobia,” where difficulty with novelty leads to a limited diet.
Parents often report that their children with ARFID had trouble transitioning to mixed foods from single baby foods. They also often report they had a specific sensitivity to textures such as “mushy” or “crunchy.”
It can be hard for parents and health professionals to distinguish “normal pickiness” in a child from a diagnosis of ARFID. Eating behaviors and flexibility may exist on a continuum between those who are adventurous in trying new foods and those who prefer a routine diet. Most children are still able to meet their nutritional needs despite some pickiness.
In chapter 12 of Family Therapy for Adolescent Eating and Weight Disorders: New Applications, Dr. Kathleen Kara Fitzpatrick and her colleagues explain the condition.”
Dr. Kathleen Kara Fitzpatrick
While many children do express food preferences and many will have strong aversions to certain foods, ARFID is distinguished by the global and pervasive nature of food refusal.
— Dr. Kathleen Kara Fitzpatrick
The condition can have serious consequences. Individuals with ARFID do not eat enough to meet their energy and nutritional needs. However, unlike individuals with anorexia nervosa, people with ARFID do not worry about their weight or shape or becoming fat and do not restrict their diet for this reason.
Diagnosis
ARFID is a new diagnosis that was introduced with the publication of the Diagnostic and Statistical Manual, 5th edition (DSM-5) in 2013. Prior to this new category, individuals with ARFID would have been diagnosed as eating disorder not otherwise specified (EDNOS) or fall under the diagnosis of feeding disorder of infancy or childhood. ARFID is not as well-known as anorexia nervosa or bulimia nervosa.
ARFID also does not typically emerge after a history of more normal eating as do anorexia nervosa and bulimia nervosa. Individuals with ARFID usually have had restrictive eating all along.
To meet the criteria for ARFID, the food restriction cannot be explained by lack of food, a culturally sanctioned practice (such as a religious reason for dietary restriction), or another medical problem that if treated would solve the eating problem. Furthermore, it must lead to one of the following:
Dependence on tube feeding or oral nutritional supplementsDifficulty engaging in daily life due to shame, anxiety or inconvenienceSignificant nutritional deficiencySignificant weight loss (or failure to make expected weight gain in children)
Assessment
Because ARFID is a less well-known disorder, health professionals may not recognize it and patients may experience delays in getting diagnosed and treated. A diagnosis of ARFID requires a thorough assessment.
Assessments should include a detailed history of feeding, development, growth charts, family history, past attempted interventions, and complete psychiatric history and assessment. Other medical reasons for the nutritional deficits need to be ruled out. Dr. Rachel Bryant-Waugh has outlined a diagnostic checklist for ARFID to facilitate gathering the appropriate information:
Are there signs and symptoms of nutritional deficiency or malnutrition?How long has the avoidance of certain foods or the restriction in intake been occurring?Is intake supplemented in any way to ensure adequate intake?Is there any distress or interference with day to day functioning related to the current eating pattern?What is current food intake (amount)?What is current food intake (range)?What is current weight and height and has there been a drop in weight and growth percentiles?
Types
DSM-5 gives some examples of types of avoidance or restriction that may be present in ARFID. These include restriction related to an apparent lack of interest in eating or food, sensory-based avoidance of food (the individual rejects certain foods based on smell, color, or texture), and avoidance related to feared consequences of eating such as choking or vomiting, often based on a past negative experience.
Fisher and colleagues suggested six different types of ARFID presentation with the following prevalence rates among their sample:
Fears of eating due to fears of choking or vomiting (13.1%)Having food allergies (4.1%)Having generalized anxiety disorder (21.4%)Having gastrointestinal symptoms (19.4%)Picky eating since childhood (28.7%)Restrictive eating for “other reasons” (13.2%)
Prevalence
We do not have good data about the prevalence rates of ARFID. It is relatively more common in children and young adolescents, and less common in older adolescents and adults. Nonetheless, it does occur throughout the lifespan and affects all genders.
Onset is most often during childhood. Most adults with ARFID seem to have had similar symptoms since childhood. If ARFID onset is in adolescence or adulthood, it most often involves a negative food-related experience such as choking or vomiting.
One large study published in 2014 found that 14% of all new eating disorder patients who presented to seven adolescent-medicine eating disorder programs met criteria for ARFID. According to this study, the population of children and adolescents with ARFID:
Is often youngerMay include a greater number of males than the population of patients with anorexia nervosa or bulimia nervosaOften has a longer duration of illness prior to diagnosis
Patients with ARFID are more likely than patients with anorexia nervosa or bulimia nervosa to have a medical condition or symptom. Fitzpatrick and colleagues note that ARFID patients are more frequently referred from gastroenterology than patients with other eating disorders. They are also likely to have an anxiety disorder, but less likely to have depression.
Individuals with autism spectrum conditions, as well as those with ADHD have been shown to be more likely to develop AFRID. Patients with ARFID on average have a lower body weight and therefore are at a similar risk for medical complications as patients with anorexia nervosa.
Treatment
For patients and families, ARFID can be extremely challenging. Families often get anxious when children are having difficulty eating and may get stuck in power struggles over food. For older adolescents and adults, ARFID can impact relationships as eating with peers can become fraught.
Left untreated, ARFID will rarely resolve itself. The goals of treatment are to increase the patient’s flexibility when presented with non-preferred foods and to help them to increase their variety and range of intake of foods to satisfy their nutritional needs.
Residential Treatment
At present, there are no evidence-based treatment guidelines for ARFID. Depending on the severity of the malnourishment, some patients with ARFID may need higher levels of care, such as residential treatment or medical hospitalization, sometimes with supplemental or tube feeding.
A study published in 2017 found that many patients with ARFID responded well to care in a partially hospitalized program, similar to patients with other eating disorders.
After the patient has been medically stabilized, treatment for ARFID often includes teaching anxiety management skills accompanied by the gradual introduction of new foods through “food chaining”: starting with foods that are very similar to foods that they already eat and progressing slowly towards more dissimilar foods.
Increased Food Flexibility
Many patients with ARFID tend to eat the same food repeatedly until they tire of it and then refuse to eat it again. Thus, patients are encouraged to rotate presentations of preferred foods as well as gradually introduce new foods.
The average person typically requires several presentations before foods are no longer experienced as novel. For people with ARFID, it is often fifty times before a food is no longer experienced as unfamiliar.
Treatment Example
One adult patient with ARFID ate no raw vegetables and no fruit. His goals were to increase his ability to eat fruit and vegetables. He ate carrots when they were in soup. Thus, treatment began by his boiling carrots in chicken broth and cutting them into extremely small pieces and eating those.
Next, he started to eat bigger pieces of carrots boiled in broth and eventually carrots just boiled in water. Then, he began to work on the peels of fresh carrots.
He also started to work on fruit. He began with strawberry jelly on toast, which was something he was comfortable eating. He next introduced strawberry jelly with seeds to get him used to some texture.
After that, he introduced macerated fresh strawberries (mixed with sugar to soften them). Eventually, he began to eat very small pieces of fresh strawberries. After that, other fruits and vegetables were gradually added in a similar fashion.
