Avoidant/Restrictive Food Intake Disorder (ARFID)
In ARFID, a person may experience food disturbances to the point that they do not meet their appropriate nutritional and/or energy needs. In simple terms, the person is not eating a wholesome or well-rounded diet due to the complications of ARFID and because it forces them to have a very limited interaction with food.
A person may feel unable to eat with other people. They may prefer to avoid new foods with intense textures, tastes or smells, opting instead to stay with foods they know well. This can make trying new foods challenging. Others may not feel hungry often, or feel full quickly.
Avoidance, once established, can become longstanding and hard to change. The more a person avoids eating, the scarier it becomes.
Underlying biological factors such as a flavour preferences are partly genetic and can influence food choice.
ARFID may occur during childhood, but it can also develop in adults. Research suggests that adults affected by achalasia, celiac sprue, Coeliac disease, eosinophilic esophagitis, inflammatory bowel disease and Tourette syndrome may also experience ARFID.
People who are autistic or neurodivergent may experience ARFID.
There are three primary components to ARFID:
- Avoidance due to the sensory characteristics of food (sensory food aversions, extreme picky eating)
- A lack of interest in eating or food (food avoidance, low food responsivity)
- Worries about the consequences of eating (phobia affecting food intake, fear of choking)
Myths and misconceptions
- Low appetite
- Sensory sensitivity
- Fear and sensory sensitivity
- Fear and low appetite
- Fear, sensory sensitivity and low appetite.
- ARFID is a children’s problem
- People with ARFID are underweight
- ARFID is a fancy way of describing a fussy eater.
- Eating problems and emotional disturbances
- A person feeling frustrated at not being able to eat what they want
- 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
- Low mood, irritability, anxiety, apathy, difficulty concentrating, social isolation
- Electrolyte abnormalities and low bone mineral density
- Shorter stature
- Trouble sleeping and nightmares
Research has also identified behaviours and difficulties such as:
- Food avoidance and restrictive eating, not being able to eat solids
- Selective eating since childhood
- Decreased appetite
- Abdominal pain, constipation and gastrointestinal symptoms
- A heightened fear of vomiting and/or choking
- Possible food texture issues
- Generalised anxiety, depression, obsessive compulsive disorder (OCD), Attention Deficit Hyperactivity Disorder (ADHD)
- Difficulties with sustained attention and visual-spatial skills
- Difficulties sleeping and managing change in routine
- A nervous system sensitive to change
- Lower quality of life, avoiding social situations that involve food
- Stressful mealtimes
- Disruption to daily activities such as school, participating in social activities
There may be some body image concerns, though different to those seen in cases of anorexia nervosa and bulimia nervosa. 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.
- Current eating behaviour and 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
- Asking the person about what motivates their food avoidance
Undertaking a comprehensive developmental history of feeding and eating and possible mechanical oral motor problems can help clinicians to understand what may be happening for the person.
A diagnosis of ARFID is not 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.
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. Paediatric psychology/psychotherapy the for child and family, alongside a paediatric occupational therapist and a developmental paediatrician and speech and language therapy (SLT), are also options to consider. Most people can receive treatment on an outpatient basis.
- Learning how to cope with anxiety linked to eating or past traumatic food-related incidents
- Addressing psycho-social impairment
- Addressing nutritional imbalance, malnutrition
- Expanding the range of foods consumed, without threats or force-feeding
- Acceptance-based interoceptive/exteroceptive exposure treatment, to understand bodily sensations and needs
- Building confidence outside of hospital, for both families and the person
- Targeting the factors which maintain and drive the eating difficulty through psychological intervention, with support from medical, dietetic and other interventions tailored to address areas of impact and risk specific to the person
- Individualised interventions that consider a person’s developmental stage and treatment planning, including addressing co-occurring issues
- Food chaining strategies.
A multidisciplinary and multi-modal assessment and treatment approach may be helpful. There is a need for integrated referral and care pathways, across a network of professionals and services.
Research studies have highlighted:
- Cognitive Behavioural Therapy for ARFID (CBT-AR) – developed at Massachusetts General Hospital
- Family-Based Therapy (FBT) – modified for ARFID
- Parent-Facilitated Behavioural Treatment (PBT-ARFID)
- Supportive Parenting for Anxious Childhood Emotions adapted for avoidant/restrictive food intake disorder (SPACE-ARFID)
Currently, little is known about effective treatments and interventions and the course of illness for individuals who develop 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 not enough research to determine the extent to which ‘picky eating’ may play a role in the experiences of children or adults with ARFID.