Avoidant Restrictive Food Intake Disorder (ARFID) - what is it and effective treatment strategies
Avoidant/Restrictive Food Intake Disorder (ARFID) is not just about being a “picky eater” or “stubborn.” People with ARFID have underlying biological traits that initially made their eating habits a logical choice. Flavour preferences are partly genetic; some may be “supertasters” or “supersensers,” meaning they were born with a high concentration of taste buds, making them sensitive to small variations in taste and bitter foods. It is estimated that genetic factors contribute to 70-85% of the development of ARFID.
Young children naturally have an aversion to bitterness and sour flavors and can detect them more acutely than adults. They are also naturally wary of new foods. This “fussy” or “picky” eating phase is developmentally normal between the ages of 1 and 4 years old.
Children who do not go through the typical food journey might experience pain or discomfort with feeding, cry more from infancy, or lack an understanding of hunger. These experiences create neural pathways linked to unsafe food consequences, making them hardwired into their brains and challenging to undo or retrain.
ARFID affects both males and females equally, with the median age of onset being 6 years old. Once established, a pattern of food avoidance can become longstanding and highly resistant to change.
Three sub-types of ARFID
There are 3 well-established ARFID sub-types:
Lack of interest in food - the individual experiencing eating as a chore or simply not deriving pleasure or satisfaction from food. Possible causes may be:
Disrupted appetite regulation
Reduced desire to eat
Oral-motor or swallowing difficulties
Related to medical condition or illness
Related to being on certain medications
Sensory-based avoidance - taste, smell, temperature (has to be a specific temperature), appearance (if it doesn’t look right), colour (beige diet) and the noise it makes when we eat it. Texture in particular, and mixed textures can be outright refused with a high ability to detect even very slight changes in texture.
Concern about possible aversive consequences to eating, e.g. choking, nausea, vomiting, discomfort, abdominal pain or they won’t like it.
ARFID Diagnostic Criteria
Based on the DSM-5, ARFID is diagnosed when:
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with 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 nutritional supplements.
Marked interference with psychosocial functioning.
The eating/feeding disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
The eating/feeding disturbance does not occur exclusively during the course of 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/feeding disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
When the eating/feeding 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 clinical attention.
Parents are usually concerned about their child’s eating in the following areas:
The quantity of food eaten
The variety of food the child eats
The child’s dependence on supplements
The child’s lack of willingness to try new foods
The inability to eat any solid food
The quality of the child’s diet
Problems with chewing and swallowing
The child’s fear of food
Mealtime behaviour
Lack of interest in food/low appetite
How long it takes the child to eat
Common Symptoms of ARFID
Here are some potential signs you or your child has ARFID:
Avoidance of whole food groups or textures (e.g. fruit. meat, vegetables; slimy and mixed textures).
Sensitivity to aspects of some foods e.g. temperature.
Gagging or retching at the smell or sight of a particular food(s).
Difficulty being in the presence of another person eating a non-preferred food.
Having a diet that is limited to (usually less than 10) 'preferred foods' ('safe foods').
Lack of interest in eating or missing meals completely (not feeling hungry).
Attempting to avoid social events where food would be present.
Struggling to stay and/or eat at a table during family mealtimes; eats only with distraction e.g. television.
Negative impact on the individual’s social life, mood, energy levels and ability to learn at school.
Needing to take supplements to meet their nutritional needs and where energy intake is impaired.
And where energy intake is impaired:
Stunted growth in children (not growing in height as expected).
Severe lack of energy to the point of not being able to cope without a nap during the day.
Below is a table of picky eaters versus problem feeders to help you differentiate between the two.
The difference between Picky Eaters and Problem Feeders
How ARFID is Maintained
If you’ve been having a limited variety of food due to sensory avoidance, eating the same foods all the time can make new foods taste even more different and less appealing, especially if certain nutritional deficiencies are changing the way food tastes. This repetitive diet can lead to fatigue and aversion towards the usual foods, further narrowing dietary choices. A very limited diet poses serious health risks, such as an increased likelihood of diabetes and heart disease from high sugar and fat intake, and a higher risk of certain cancers from avoiding fruits and vegetables. Additionally, it may be hard to eat with others, causing missed opportunities to learn about and try new foods.
Even if you naturally have a smaller appetite, eating very little can further reduce it, especially if you limit the variety of foods you eat. This limited variety can make it hard to eat enough because you might get bored of eating the same things and end up eating less. As a result, you might experience low mood, irritability, anxiety, apathy, difficulty concentrating, or social isolation. Additionally, you may face significant weight loss, osteoporosis, loss of menstrual periods, muscle wasting, decreased heart rate, or other medical issues.
If you’ve had a traumatic incidence with food, you might be engaging in "safety behaviors" to avoid another traumatic eating experience. These can include taking tiny bites, chewing excessively, only dining at familiar places, or skipping meals entirely. These behaviours stop you from challenging your negative assumptions about eating. The more you avoid eating, the more intimidating it becomes!
Treatment for AFRID
Since ARFID doesn't occur exactly the same way for every individual, ARFID treatment is only successful when it's based on the individual problems and challenges a person is facing. There is no one-size-fits-all ARFID treatment. Depending on the severity of the disorder, the individual's state of health, and their proximity to a treatment team, ARFID treatment is almost always done in an outpatient capacity. The “best treatment” is one that targets what is driving and maintaining the eating difficulty and addressing any acute risk. Positive outcomes can be achieved by focusing on what matters most for the client and their family (as applicable) and managing expectations about achievable outcomes, for example:
Be able to eat bigger servings
To enjoy food more
To have more variety in the diet
To stop being anxious around food
To be willing to try new foods
To not need supplement drinks
To start to manage lumps and textures
To feed themselves
To eat more quickly
To be able to go out to eat as a family
To have normal family mealtimes
It is important to remember that treatment is active, which means the client will need to attend weekly sessions (parents may also be involved depending on their age), and there will be weekly tasks and goals for the client to practice at home. Changing will require persistence, consistency and conviction (also knowns as engagement and motivation). It is better to make small changes and build on these (rather than trying to implement major changes) and notice even tiny positive steps and acknowledge/let your child know what you have noticed, i.e. praise positive behaviour. You may also want to keep track of their progress with a food log/diary.
If you/your child is failing to meet nutritional needs, not gaining weight as normally expected or losing weight, has fewer than 20 foods they will eat and there is significant socio-emotional impact, you will need to see your GP and get a referral to a specialist and/or dietitian. The GP should get blood tests done to check your/the child’s Vitamin A, E, D and B12, iron, magnesium, phosphate and calcium levels.
Looking after the caregiver’s mental health
If you are the caregiver of someone with ARFID, it is just as important to look after your own mental health and get support. Caring for someone with ARFID is a demanding and often overwhelming responsibility. The emotional, physical, and mental strain can take a significant toll on the caregiver's well-being. When caregivers prioritise their own mental health, they are better equipped to provide the compassionate and effective support the child. They are at a better place to respond appropriately, manage their own anxiety and frustration (which then has a positive impact on the child’s eating), reduces the challenge on the child’s eating journey, and the whole family are less likely to become socially isolated and withdrawn.
The parent-child relationship can become strained and may put the child at more risk of negative experiences, feelings and interactions with food. Parents feel like a failure, have well-meaning friends who give “good advice”, feel judged, may feel like they are being manipulated by the child, and can become intrusive when trying to feed their child. It is difficult to find the right balance between not letting things slide back down the hill, but also giving them enough control to co-operate with treatment.
ARFID Treatment - Graded Exposure or Systematic Desensitization
Stage One
The first stage of treatment involves psychoeducation about ARFID and identifying the mechanism in which ARFID is being maintained: sensory sensitivities; fear of aversive consequences; or lack of interest in food. If there is a combination of mechanisms, treatment should address the one that is most impairing for the person first. The client is encouraged to establish a regular eating pattern and self-monitoring of preferred foods at this stage.
If the client is underweight, they are encouraged to increase their intake by at least 500 calories per day to support weight gain. The coach can work with the client on ways to increase their intake through the day or they may wish to seek nutritional counselling/dietitian for more specific input
For young people and teens, the therapist should talk to them about nutrient deficiencies based on their food diary and identify foods high in these nutrient deficiencies.
Stage Two
For stage two, clients continue to increase in volume of their food intake. The client’s food diary is reviewed to identify areas for intervention. At this stage, the therapist will work out a hierarchy of fear foods and give each one a rating for difficulty or the amount of distress it causes the client. For young people and teens, it is important to try to find some level of buy-in, e.g. missing out at birthday parties, avoiding social gatherings due to food, and talk about the pros of cons of food and exploring new foods.
Stage Three
Stage three is where the hard work begins. Start with foods that are similar to their safe foods to get some buy-in. Choose one food for the week that is achievable and doesn't provoke a strong aversive reaction. For sensory difficulties, use the Five Steps approach for desensitization when trying a new food:
What does it look like?
What does it feel like?
What does it smell like?
What does it taste like?
What is the texture like?
Start with very small amounts on a number of consecutive days. With repeated exposure, the shock factor will wear off so that they can get a better idea of whether this is something they might be able to eat. You can compare the new food to a similar know or favourite food, working through the sensory properties of the food, e.g. compare their favourite cracker with slightly different ones. Smell them, feel them, crush them, lick them and talk about how they compare with one another. The more the client practices, the easier it will get. Remember it can take 12-20 exposures to get comfortable with a new food. As the client becomes more comfortable with the food, start incorporating larger portions in their daily diet before moving onto the next food item. Select foods to practice tasting throughout the week - for younger children it might be easier to chose just one food that is more likely to succeed but still challenges them.
Tips for Introducing New Foods
Here are some tips for introducing new foods:
Fade it in: Add it to a preferred food or safe food using a small portion to start with, then gradually increase the portion of the new food until you fade out the preferred food completely
Add some spice: Preferred spices and condiments can act as a training wheel. Add spices, sauces, other condiments when trying the new food
Chain it up: Create links between a safe food and new food, e.g. instead of potato chips, try vege or cassava chips
Switch it up: Try different presentations, preparation and cooking methods of the food
Deconstruct: Try starting with one component of the food and then layer with one item at a time, until you get the full ingredients list of the whole meal, e.g. a deconstructed pizza
Add the new food to a meal that the client likes, e.g. one extra ingredient to pizza topping
Steps to Eating New Foods
Before eating a new food, there are several important steps that generally involve tolerating, interacting with, smelling, touching, tasting, and finally eating the food. Each of these stages includes multiple steps to ensure a more graded and gradual approach. Below is a diagram that outlines each of these steps, developed by the Te Whatu Ora Paediatric Feeding Team.
For younger children, try these placemat ideas, developed by Te Whatu Ora Paediatric Feeding Team. There may also be steps within each step, e.g. how long the food is held for in the mouth, a small like VS a big lick, a small bite VS a large bite, number of chews before dropping, etc.
Placemat for young children to introduce new foods
Tracking and Rewards
Tracking success and rewards are powerful tools and motivators for children and some young people with ARFID. They need some form of external motivation to face the anxiety of trying new foods (it is also important to educate them on the anxiety cycle). Think about what is good currency for the child or young person but do not use food as the reward. Here are some ideas on how to track progress. The scales can be used for young people to see how the food causes less and less distress with each exposure.
Placemat to track progress for young children, created by the Te Whatu Ora Paediatric Feeding Team
Food Thermometer Rating
Stage Four
Stage four involves creating a personalised Relapse Prevention Plan to cover the following areas:
Ways that my eating has improved since the start of treatment
Possible future triggers for relapse
Early Warning Signs (EWS) that I might be starting to relapse - things that I and others around me will notice (internal and external)
Skills I will use when I notice each EWS
CBT-ARFID techniques to continue or try on my own after treatment is completed
Ways I’d like to continue to change my eating post-treatment
Who will be my support network and how will I let them know I need support
Understanding ARFID and its treatment is crucial for both individuals and families affected by this eating disorder. By recognizing the unique challenges and symptoms associated with ARFID, early intervention and tailored treatment plans can significantly improve outcomes. With the right support and understanding, individuals with ARFID can embark on a path toward healthier eating habits and improved overall well-being.
