Avoidant restrictive food intake disorder is a disorder in which food or eating is avoided to the extent that nutritional requirements are not met and a considerable amount of weight and energy is lost. This disorder is most commonly seen in children and is different from other eating disorders such as bulimia nervosa and anorexia nervosa. People with avoidant/restrictive food intake disorder have little interest in food or avoid many types of foods, which results in nutrition deficits. Several of these disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder, are characterized by serious disturbances in body image and a preoccupation with weight and shape. When these individuals stop growing, they need medical attention. Doctors now classify a severe form of picky eating in children as avoidant/restrictive food intake disorder (ARFID).

With the more well-known eating disorders gaining headlines in the mainstream, it can be easy to forget that there are several other eating and feeding disorders outside of anorexia nervosa, bulimia nervosa, and binge eating disorder. Regardless of what the disorder itself is, individuals who struggle with these types of diseases typically face enormous challenges in their daily lives and require professional help for overcoming and finding recovery.

A Closer Look at Avoidant/Restrictive Food Intake Disorder

People with avoidant/restrictive food intake disorder have little interest in food or avoid many types of foods, which results in nutrition deficits. Several of these disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder, are characterized by serious disturbances in body image and a preoccupation with weight and shape.

Perhaps one of the lesser-known feeding disorders is Avoidant Restrictive Food Intake Disorder, or ARFID. This selective eating disorder was previously classified as “Feeding Disorder of Infancy or Early Childhood” and recently changed in the the most updated revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Previously, this condition was thought to be something that exclusively developed in children and adolescents; however, ARFID has broadened the defining criteria of this condition to also include adults who limited their eating and may also be impacted by a related psychological and/or physiological issue.

ARFID is defined by the following criteria according to the DSM-5 [1]:

• Disturbance in feeding and/or eating patterns as evidenced by dependence on external feeding sources (such as a feeding tube or dietary supplements), significant weight loss or the absence of expected growth/gain in children, the presence of nutritional deficiencies, and/or significant psychosocial interferences.
• Disturbances in feeding and/or eating patterns that are not related to unavailability of food or cultural norms
• Disturbances in feeding and/or eating patterns that are not related to anorexia or bulimia nervosa
• Disturbances in feeding and/or eating patterns that are not explainable by another mental disorder or medical condition

Signs and Symptoms of Avoidant/Restrictive Food Intake Disorder

Understanding the criteria for ARFID may be helpful, but what might this actually look like in a person who is presenting with this eating disorder? Typically, in individuals with ARFID, whether child, adolescent or adult, there is an inability to eat certain foods, which is characteristic of this disorder.

This may be due to a particular taste, smell, texture, color, or temperature of the food, and sufferers may avoid certain food types or entire food groups, such as meats, fruits, and/or vegetables. Some individuals with ARFID may experience such adverse reactions to foods that gastrointestinal upsets are triggered, such as gagging, choking, or vomiting.

On the outside, ARFID may appear a case of picky eating, where individuals avoid particular foods and food groups. However, with ARFID, there is often a comorbidity, meaning that other mental or developmental disorders may develop alongside this eating disorder. Research has found that an estimated eighty percent of children with developmental disabilities also have some form of a feeding disorder [2].

ARFID is not necessarily recognizable by physical manifestations, as individuals who struggle with ARFID are usually of normal body weight. Because of the complex criteria and factors involved with ARFID, it is important to seek out professional diagnosis and assessment.

Treatment Options For ARFID

Comprehensive treatment for ARFID is important, particularly if another disorder is present, such as autism, obsessive-compulsive disorder, an anxiety disorder, or so forth. Many forms of therapy can be effective in helping individuals overcome anxiety associated with certain foods or the eating experience in general.

Working with a registered dietitian as part of treatment and alongside a therapist can also be helpful in addressing nutrient deficiencies and for meal planning purposes. Medication management may also be appropriate in some cases for treatment as well.

If you or someone you care for is dealing with ARFID, be sure to seek out the care of a specialist who can help address the complexity of issues involved with this eating disorder. Recovery is possible with appropriate treatment and care.

About the Author: Crystal is a Masters-level Registered Dietitian Nutritionist (RDN) with a specialty focus in eating disorders, maternal/child health and wellness, and intuitive eating. Combining clinical experience with a love of social media and writing.

As a Certified Intuitive Eating Counselor, Crystal has dedicated her career to helping others establish a healthy relationship with food and body through her work with EDH/AH and nutrition private practice.

References:

[1]: American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5
[2]: Chatoor,I., Hamburger, E., Fullard, R., & Fivera, Y. (1994). A survey of picky eating and pica behaviors in toddlers. Scientific Proceedings of the Annual Meeting of American Academy of Child and Adolescent Psychiatry, 10′, 50.

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Reviewed By: Jacquelyn Ekern, MS, LPC on March 23, 2016
Published on EatingDisorderHope.com

Avoidant/restrictive food intake disorder
Other names	Selective eating disorder (SED)
Specialty	Psychiatry

Avoidant/restrictive food intake disorder (ARFID), previously known as selective eating disorder (SED), is a type of eating disorder in which people eat only within an extremely narrow repertoire of foods.^[1] This avoidance may be based on appearance, smell, taste, texture, brand, presentation, or a past negative experience with the food, to a point that may lead to nutritional deficiencies or other negative health outcomes. ^[2]

Signs and symptoms[edit]

People with ARFID have an inability to eat certain foods. 'Safe' foods may be limited to certain food types and even specific brands. In some cases, individuals with the condition will exclude whole food groups, such as fruits or vegetables. Sometimes excluded foods can be refused based on color. Some may only like very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods, or avoid sauces.

Most people with ARFID will still maintain a healthy or typical body weight. There are no specific outward appearances associated with ARFID.^[3] Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting or gagging. Some studies have identified symptoms of social avoidance due to their eating habits. Most people with ARFID would change their eating habits if they could.^[3]

Associated conditions[edit]

The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed other conditions that co-occur with ARFID.

There are different kinds of 'sub-categories' identified for ARFID:^[4]

• Sensory-based avoidance, where the individual refuses food intake based on smell, texture, color, brand, presentation
• A lack of interest in consuming the food, or tolerating it nearby
• Food being associated with fear-evoking stimuli that have developed through a learned history
• Anorexia and bulimia often occur in individuals suffering from ARFID.^[5]

Autism[edit]

Symptoms of ARFID are usually found with symptoms of other disorders or with neurodivergence. Some form of feeding disorder is found in 80% of children that also have a developmental disability.^[6] Children often exhibit symptoms of obsessive-compulsive disorder and autism. Although many people with ARFID have symptoms of these disorders, they usually do not qualify for a full diagnosis. Strict behavior patterns and difficulty adjusting to new things are common symptoms in patients that are on the autistic spectrum.^[3] A study done by Schreck at Pennsylvania State University compared the eating habits of children with autism spectrum disorder (ASD) and typically developing children. After analyzing their eating patterns, they suggested that the children with some degree of ASD have a higher degree of selective eating. These children were found to have similar patterns of selective eating and favored more energy dense foods such as nuts and whole grains. Eating a diet of energy dense foods could put these children at a greater risk for health problems such as obesity and other chronic diseases due to the high fat and low fiber content of energy dense foods. Due to the tie to ASD, children are less likely to outgrow their selective eating behaviors and most likely should meet with a clinician to address their eating issues.^[7][8]

Anxiety disorder[edit]

Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar.^[3] Some people with ARFID have fears such as emetophobia (fear of vomiting) or a fear of choking, but this is not common.

Diagnosis[edit]

Diagnosis is often based on a diagnostic checklist to test whether an individual is exhibiting certain behaviors and characteristics. Clinicians will look at the variety of foods an individual consumes, as well as the portion size of accepted foods. They will also question how long the avoidance or refusal of particular foods has lasted, and if there are any associated medical concerns, such as malnutrition.^[4] Unlike most eating disorders, there may be a higher rate of ARFID in young boys than there is in young girls.^[9]

Criteria[edit]

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) renamed 'Feeding Disorder of Infancy or Early Childhood' to Avoidant/Restrictive Food Intake Disorder, and broadened the diagnostic criteria. Previously defined as a disorder exclusive to children and adolescents, the DSM-5 broadened the disorder to include adults who limit their eating and are affected by related physiological or psychological problems, but who do not fall under the definition of another eating disorder.

The DSM-5 defines the following diagnostic criteria:^[10]

• Disturbance in eating or feeding, as evidenced by one or more of:
  • Substantial weight loss (or, in children, absence of expected weight gain)
  • Nutritional deficiency
  • Dependence on a feeding tube or dietary supplements
  • Significant psychosocial interference
• Disturbance not due to unavailability of food, or to observation of cultural norms
• Disturbance not due to anorexia nervosa or bulimia nervosa, and no evidence of disturbance in experience of body shape or weight
• Disturbance not better explained by another medical condition or mental disorder, or when occurring concurrently with another condition, the disturbance exceeds what is normally caused by that condition

In previous years, the DSM was not inclusive in recognizing all of the challenges associated with feeding and eating disorders in 3 main domains:^[4]

• Eating Disorders Not Otherwise Specified (EDNOS) was an all-inclusive, placeholder group for all individuals that presented challenges with feeding
• The category of Feeding Disorder of Infancy/ Early Childhood was noted to be too broad, limiting specification when treating these behaviors
• There are children and youth who present feeding challenges but do not fit within any existing categories to date

Children are often picky eaters, but this does not necessarily mean they meet the criteria for an ARFID diagnosis.

Treatment[edit]

For adults[edit]

With time the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than symptoms may typically disappear without treatment.^[3]

There are support groups for adults with ARFID.^[11]

For children[edit]

Children can benefit from a four stage in-home treatment program based on the principles of systematic desensitization. The four stages of the treatment are record, reward, relax and review.^[3]

• In the record stage, children are encouraged to keep a log of their typical eating behaviors without attempting to change their habits as well as their cognitive feelings.
• The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
• The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Often these stories can also include the introduction of new foods with the help of a real person or fantasy person. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.^[3]
• The final stage, review, is important to keep track of the child's progress. It is important to include both one-on-one sessions with the child, as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.

It has also been suggested that making mealtimes fun is a great way to get young children to the dinner table, by helping to create positive associations with dining.^[12]

See also[edit]

References[edit]

1. ^American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 334–334. ISBN978-0-89042-555-8.
2. ^Fisher, Martin M.; Rosen, David S.; Ornstein, Rollyn M.; Mammel, Kathleen A.; Katzman, Debra K.; Rome, Ellen S.; Callahan, S. Todd; Malizio, Joan; Kearney, Sarah (2014-07-01). 'Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A 'New Disorder' in DSM-5'. Journal of Adolescent Health. 55 (1): 49–52. doi:10.1016/j.jadohealth.2013.11.013. PMID24506978.
3. ^ ^abcdefgNicholls, D., Christie, D., Randall, L. and Lask, B.. (2001). 'Selective Eating: Symptom, Disorder or Normal Variant.' Clinical Child Psychology and Psychiatry. Vol 6(2): 257–270.
4. ^ ^abcBryant-Waugh, R (2013). 'Avoidant restrictive food intake disorder: An illustrative case example'. International Journal of Eating Disorders. 46 (5): 420–423. doi:10.1002/eat.22093. PMID23658083.
5. ^'Avoidant/Restrictive Food Intake Disorder (ARFID)'. Archived from the original on 2017-01-10. Retrieved 2019-04-25.
6. ^Chatoor, I.; Hamburger, E.; Fullard, R.; Fivera, Y. (1994). 'A survey of picky eating and pica behaviors in toddlers'. Scientific Proceedings of the Annual Meeting of American Academy of Child and Adolescent Psychiatry. 10: 50.
7. ^Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without Autism' Journal of Autism and Developmental Disabilities 2004; 34: 433-438.
8. ^Evans, E. (2013). Selective Eating and Autism Spectrum Disorder. In Behavioral Health Nutrition. Retrieved April 2, 2013, from 'Archived copy'. Archived from the original on 2013-07-19. Retrieved 2013-04-16.CS1 maint: archived copy as title (link)
9. ^'Eating Disorder Statistics • National Association of Anorexia Nervosa and Associated Disorders'. National Association of Anorexia Nervosa and Associated Disorders. Retrieved 2017-12-11.
10. ^American Psychiatric Association. (2013). Highlights of Changes from DSM-IV-TR to DSM-5. Retrieved May 14, 2014, from 'Archived copy'(PDF). Archived from the original(PDF) on 2013-10-19. Retrieved 2013-10-23.CS1 maint: archived copy as title (link)
11. ^Wang, S. (2010, July 5). No Age Limit on Picky Eating. Wall Street Journal. Retrieved April 2, 2013, from https://www.wsj.com/articles/SB10001424052748704699604575343130457388718
12. ^Munchy Play - https://www.munchyplay.com/blog/top-10-tips-for-coping-with-a-fussy-eater

External links[edit]

What Is Food Intake

Classification	ICD-10: F50.8 ICD-9-CM: 307.59 MeSH: D000080146

Daily Food Intake Log