ARFID in Adults and Children: Research, Diagnosis, and Treatment
Written by ‘Ai Pono Hawaii Staff Writer
There are probably some picky eaters in your life. You may be one of them. There are different kinds of “picky eating”: from a child who’s unwilling to try new things to an adult who gets the same thing on the menu all the time. But these things don’t severely interfere with a person’s life — until they do. At some point, an aversion to food turns into Avoidant/Restrictive Food Intake Disorder, or ARFID.
In this article you’ll learn:
The difference between picky eating and an eating/feeding disorder
The reasoning behind the development of ARFID
How ARFID is different than other eating disorders
The nine questions currently used to screen for ARFID
How ARFID can be treated
The Basics of ARFID
ARFID is categorized as “extremely picky eating.” On the surface, this may not sound like a full-blown eating disorder. This is because most people don’t know the difference between picky eating and extremely picky eating.
Picky eating does not decrease your quality of life. Extremely picky eating is problematic and negatively impacts your life.
ARFID causes an individual to become very restrictive in their food choices, which can:
Limit a person socially, as they struggle to find safe foods while in public
Cause anxiety just thinking about eating foods outside their safe zone, and when they find themselves in situations where they can’t access their safe foods
Have physical consequences, such as stunted growth, weight loss, and malnutrition
How is this different from other eating disorders? Doesn’t everyone with an eating disorder have fear foods?
Many individuals with eating disorders have fear foods, no matter what their diagnosis is. And everyone has different fear foods for different reasons. But people with ARFID do not have body image issues (for the most part.) And they do not avoid certain foods because they fear gaining weight. They know they have to eat, and at the same time, have difficulty consuming most foods.
There are three subtypes of ARFID:
Restrictive: characterized by a lack of interest in food and eating; lack of appetite
Avoidant: characterized avoidance of sensory stimulants such as: color, texture, smell, taste, temperature
Aversive: characterized by fear of negative consequences, including: choking, gagging, vomiting, extreme gastroesophageal reflux symptoms
People who find eating extremely boring, or genuinely just have no interest in eating food, may not put in the time and effort it takes to maintain a balanced diet. They may pick one thing that’s quick and easy, and stick with that.
Other people have difficulty with the sensations that come along with eating. This is especially true for individuals with co-occurring autism, as many in this group already have complex sensory issues.
Autistic individuals may also have more complex food rituals, as they have more anxiety about change. And many autistic individuals also have trouble knowing when they are hungry and full, due to a lack of internal awareness.
There are also people who very much believe that any foods outside of their handful of safe foods will harm them in some physical way.
Signs and Symptoms of ARFID:
An individual may be developing ARFID if they:
Have a short list of foods that are acceptable to eat
Avoid entire food groups (fruits, vegetables, proteins, etc.)
Eat only foods with similar characteristics (crunchy texture, easy-to-swallow, etc.)
Remove certain foods from their diet, and they are never reintroduced
Highly prefer foods be prepared in a certain way (pureed, chopped small, etc.)
Are very inflexible about food choices when their “normal” food choices are not available
Experience emotional distress when confronted with unfamiliar foods
Experience social limitations because of their inability to be flexible around food
Have a vomiting/choking phobia
Have an allergic reaction phobia, despite having no diagnosed allergies
Experience physical GI/abdominal discomfort, beyond what medically makes sense
Do not grow taller or gain weight (as a child)
Do not gain weight (as an adult)
Many people only associate extremely picky eating with children. And for a long time, research and treatment methods were heavily focused on children. But ARFID does affect adults just as much.
Proposed Changes to Diagnostic Criteria of ARFID
In the DSM-V, ARFID was differentiated from other eating and feeding disorders. It currently includes a weight loss/failure to gain weight criteria for diagnosis. But since it is a mental health disorder (just like any eating disorder), many researchers have suggested that weight loss requirements are unnecessary for making a diagnosis.
Instead, researchers believe the focus should be on psychosocial impairment. This includes:
An inability to participate in normal social activities, such as eating with others, attending school or work or sustaining relationships as a result of eating disturbances
A substantial disruption of family functioning, such as marked restriction of foods permitted in the home or inordinate accommodations to provide foods from specific grocery stores or restaurants
If there is no longer a physical requirement to be diagnosed with ARFID, many more people can be clinically diagnosed and receive treatment.
ARFID can affect anyone, no matter their weight. (This is true for every eating/feeding disorder.)
The Nine Item Avoidant/Restrictive Food Intake Disorder Screen for Children and Adults with ARFID:
The nine item ARFID screening tool focuses more on emotions and behaviors, rather than weight. It presents nine statements to the individual being tested for ARFID. They are asked how much they agree or disagree with each statement.
The nine items on the screening list are:
I am a picky eater.
I dislike most of the foods that other people eat.
The list of foods that I like and will eat is shorter than the list of foods I won't eat.
I am not very interested in eating; I seem to have a smaller appetite than other people.
I have to push myself to eat regular meals throughout the day, or to eat a large enough amount of food at meals.
Even when I am eating a food I really like, it is hard for me to eat a large enough volume at meals.
I avoid or put off eating because I am afraid of GI discomfort, choking, or vomiting.
I restrict myself to certain foods because I am afraid that other foods will cause GI discomfort, choking, or vomiting.
I eat small portions because I am afraid of GI discomfort, choking, or vomiting.
If individuals being tested highly agree with each statement, it’s a strong indicator of ARFID. This screening tool has been validated through research studies and is a reliable tool to investigate ARFID-related behaviors.
Treating ARFID
There are several forms of therapy that can be used to treat ARFID, but providers must also take into account any co-occurring conditions, such as an anxiety disorder or autism. ARFID should be treated at the same time as these conditions, as they are often related.
Exposure therapy is a common, useful therapy for many individuals with eating disorders. For individuals with ARFID, this would include challenging distorted beliefs about their fear foods. Treatment professionals work with individuals with ARFID to figure out their fear foods, and then try them in a safe environment, then work through those distressing emotions. This is done over and over, until the fear food is no longer something to be feared.
Cognitive behavioral therapy (CBT) is used for the treatment of several disorders, including ARFID. This practice involves challenging negative and distorted thoughts that a person has about food, the way food is prepared, the effect food has on them, etc. Once a person learns how to identify and disprove irrational, distorted thoughts and beliefs, it’s easier to stop listening to them, and start eating a greater variety of foods.
Many providers also use dialectical behavioral therapy (DBT) to help those with ARFID manage distress. DBT involves the teaching of distress tolerance skills that can help when challenging new foods and when experiencing anxiety in general.
Children and their families may undergo family based treatment. The idea behind this treatment practice is to have the family be intimately involved in the treatment process and support a child with ARFID as they’re challenging new foods and increasing intake.
Having ARFID does not mean you will eat the same foods for the rest of your life. If you or someone you know has ARFID, the first step is to ask for help. Once you do, you’re already one step closer to recovery.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.