ARFID

Avoidant/Restrictive Food Intake Disorder (ARFID)

Background

  • First published as a diagnosis in 2013, by the American Psychiatric Association (APA)
  • May be informally known as Selective Eating Disorder (SED)

Myths and misconceptions

  • ARFID is a children’s problem
  • People with ARFID are underweight
  • ARFID is a fancy way of describing a fussy eater

What happens?

In ARFID, a person may experience food disturbances to the point that they do not meet their appropriate nutritional and/or energy needs.

There are three primary components to ARFID:

  1. Avoidance due to the sensory characteristics of food (sensory food aversions, extreme picky eating)
  2. A lack of interest in eating or food (food avoidance, low food responsivity)
  3. Worries about the consequences of eating (phobia affecting food intake, fear of choking)
  • ARFID may occur during childhood, but it can also develop in adults.
  • In some instances, children affected by autism spectrum disorder may experience ARFID.

Unknown factors

Currently, little is known about effective treatments and interventions and the course of illness for individuals who develop ARFID. There is limited research on the how and whether picky eating contributes to ARFID. There is a lack of systematic data on the dietary characteristics of the disorder. Other unknown factors include the age at which ARFID develops and whether or not it presents as a risk factor for later-onset eating disorders. There is little is known about ARFID in adults. There is not enough research to determine the extent to which ‘picky eating’ may play a role in the experiences of children or adults with ARFID.

Consequences of ARFID: Impaired health and development

  • Clinically significant restrictive eating leading to weight loss, or a lack of weight gain
  • Nutritional deficiencies and related complications, electrolyte imbalances, vitamin deficiencies
  • Reliance on tube feeding and oral nutritional supplements
  • Disturbances in psychosocial functioning

Research has also identified behaviours and difficulties such as:

  • Food avoidance
  • Restrictive eating
  • Selective eating since childhood
  • Decreased appetite
  • Abdominal pain
  • A heightened fear of vomiting and/or choking
  • Possible food texture issues
  • Generalised anxiety
  • Gastrointestinal symptoms

There may be some body image concerns, though different to those seen in cases of anorexia and bulimia. In children, there may be a fear of physical illness related to shape/weight for example, high cholesterol and/or obesity leading to heart disease. Research has noted that some children were underweight due to feeding and eating disturbances had reported teasing from peers. Those with ARFID may be less likely to report typical eating disorder behaviours such as purging and excessive exercise.

Diagnosis and treatment: Key factors

  • Current eating behaviour
  • Persistence of the problem
  • Interest in food and eating
  • Sensory issues
  • Fear/aversion related to eating behaviour
  • Nutritional adequacy of intake/ consequences
  • Oral supplement or tube feed dependency
  • Social and emotional functioning
  • Personal circumstances and context
  • Whether primary eating disorders and weight/shape concerns are a factor
  • Presence of other medical or psychological disorder

A diagnosis of ARFID would not be given if the nutritional problems are better explained by a lack of available food or a cultural practice/tradition (such as religious fasting), or if the person has substantial and profound dissatisfaction with body shape or weight (such as in anorexia nervosa, or bulimia nervosa, or if the clinical problem is better accounted for by an existing medical condition or another mental disorder.

Treatment approaches

As with all eating disorders, there is no know one size fits all treatment. Please see the Bodywhys Treatment Guide for information on treatment pathways. Sourcing a dietitian with knowledge of sensory issues around food and with knowledge of ARFID may be helpful.

Recent studies have highlighted:*

  • Cognitive Behavioural Therapy for ARFID (CBT-AR)
  • Family-Based Therapy (FBT) – modified for ARFID
  • Parent-Facilitated Behavioural Treatment (PBT-ARFID)

*Note – these therapeutic treatments are relatively new and may not be widely available yet.

References:

Brown, M. & Hildebrandt, T. (2019) Parent-facilitated behavioral treatment for avoidant/restrictive food intake disorder: A case report. Cognitive and Behavioral Practice,

Eddy, K.T. et al. (2014) Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network. International Journal of Eating Disorders, doi: 10.1002/eat.22350

Fisher, M.M. et al. (2014) Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55, 49-52.

Harshman, S.G. et al. (2019) A diet high in processed foods, total carbohydrates and added sugars, and low in vegetables and protein is characteristic of youth with avoidant/restrictive food intake disorder. Nutrients, 11(9), doi: 10.3390/nu11092013.

Kenney, L. & Walsh, B. T. (2013) Avoidant/Restrictive Food Intake Disorder (ARFID). Eating Disorders Review, 24(3). Accessed 23 September 2014. Available from: http://eatingdisordersreview.com/print/nl_edr_24_3print.html

Kurz, S. et al. (2014) Early-onset restrictive eating disturbances in primary school boys and girls. European Child & Adolescent Psychiatry,

Nicely, T.A. et al. (2014) Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of Eating Disorders, 2(21).

Norris, M. L. et al. (2013) Exploring avoidant/restrictive food intake disorder in eating disordered patients: A descriptive study. International Journal of Eating Disorders, 47(5), 495-499.

Spettigue, W., Norris, M.L., Santos, A. & Obeid, N. (2018) Treatment of children and adolescents with avoidant/restrictive food intake disorder: A case series examining the feasibility of family therapy and adjunctive treatments. Journal of Eating Disorders, 6: 20

Thomas, J.J., Wons, O.B., Eddy, K.T. (2018) Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Current Opinion in Psychiatry, 31(6), 425-430.

Wildes, J.E., Zucker, N.L. & Marcus, M.D. (2012) Picky eating in adults: Results of a web-based survey. International Journal of Eating Disorders, 45(4), 575-582.

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