Avoidant restrictive food intake disorder, otherwise known as ARFID, is a relatively new term for what many experts in the past called selective eating disorder. I commonly call it extreme picky eating in my practice because the typical symptoms of picky eating have gone on for a long time and have worsened over time.
A child with ARFID may be resistant to trying new foods and may have a food phobia and/or a fear of eating. Nutritionally, their diet may or may not be adequate in calories. As a result, a child’s weight may classify as underweight, overweight or normal weight.
In fact, statistics show that only 10% of kids with ARFID are underweight.
In my experience, children who are extremely picky eaters have a nutritionally inadequate diet and need help bridging their nutrient gaps, whether that come from food and/or nutrient supplementation.
If you wonder whether your child is experiencing ARFID, my article entitled Does My Child Have ARFID? will give you some clarity.
There are several treatment options for children with ARFID. From working with a pediatric nutritionist or a feeding therapist to entering a day treatment facility or a hospital, there are more and more options where kids can get the help and support they need.
The overall goal for treating ARFID is to help kids be nourished with food, enjoy eating it, and normalize their relationship with food. Many parents also want to ensure their child grows up to be a healthy eater, too.
This takes time and may involve a combination of therapies. A good treatment team experienced with children, sensitive sensory systems, emotional regulation, anxiety and more is a must.
Force feeding or other manipulative ways to get kids to eat generally make the situation worse and slow overall progress.
5 Things You Need to Know about Restrictive Food Intake Disorder
If you’re a healthcare professional, such as a pediatrician, dietitian/nutritionist, speech language pathologist or occupational therapist, there are a few things you need to keep in mind when interacting and intervening on behalf of kids with ARFID.
And if you’re a parent of a child with selective eating disorder, these pointers will help you select the right treatment team for your child.
1. Every Child is Different
Picky eating runs the gamut. From typical three year-old food jags and food refusal to an 8 year old with a short list of white foods, each child presents with a variety of characteristics.
In my experience, each child is different. That is, the underlying root of extreme picky eating is varied and often multi-faceted.
For example, a child may be a very fussy eater due to an undiagnosed medical condition like multiple food allergies or eosinophilic esophagitis. Or, a child may have choked or thrown up when younger, and that was experienced negatively, leaving the child fearful of eating.
The provoking reasons for food selectivity can be medically-based, emotionally-based, sensory-based, trauma-related, or even parenting-related, for example. More often than not, it’s layered and complex.
A child’s temperament and how he or she experiences food and the eating environment is an influence as well. All this to say, each child who presents with ARFID will look different from the next.
As a result, their care and treatment should be individualized to address the root of the challenges.
2. Every Parent is Worried
Most parents I’ve interacted with over the years are very concerned about their child’s picky eating. They’ve been concerned for quite a while and often don’t feel that their concerns have been acknowledged or taken seriously by medical professionals.
Years go by without intervention for their child. Their child’s eating problems have intensified and so have their feelings of guilt.
As practitioners, we need to be good at understanding and identifying ARFID, including when intervention would be beneficial, and who would be best to enlist for help.
3. When Does a Child with ARFID Need Treatment?
Sometimes it’s hard to know when to get help for the child with extreme picky eating, especially since body weight can be deceiving.
I see kids with extreme picky eating get ignored or brushed off as “okay” because they are normal weight or overweight.
The reality? A child can be malnourished with a normal body weight or a larger frame so we shouldn’t use weight as a marker for intervention.
In fact, kids with ARFID may have a short list of foods they will eat (20 or less), but they may eat enough to sustain normal weight and growth.
Here are the signs I look for to indicate a child with picky eating needs more help:
The child has a short list of foods he will eat (less than 20 but around 30 foods can be concerning too)
He refuses to try new foods
He avoids certain characteristics of food (color, smell, texture, appearance)
He has emotional outbursts or experiences anxiety with new food, foods touching, new eating situations
There is high stress amongst family members around the child’s food consumption and eating
The child refuses or can’t/won’t participate in social eating experiences
Picky eating is not getting better – it’s getting worse
My philosophy is to be curious about a child’s experiences with food and offer help. Many families have been told to wait out the picky eating phase, but having a professional look closely at the big picture can be helpful to everyone.
At a minimum, getting a perspective can be a sigh of relief for a family (and an opportunity to optimize food parenting and feeding). At the most, it’s an opportunity to gather support to help the child.A child with ARFID can be malnourished despite a normal body weight or a larger frame so we shouldn't use weight as a marker for intervention. #pickyeating #arfid #childnutrition Click To Tweet
4. Who Should be Part of the ARFID Treatment Team?
The most important players on the team is the family – both parents and the child. Since ARFID can seep into the family dynamic, it’s important to have a unified parental front in helping the child.
A pediatrician is needed to track any medical condition that may be underlying extreme picky eating. He or she is key in getting proper referrals and testing, if needed. The pediatrician is often on the front lines and can get the ball rolling for treatment.
A dietitian/nutritionist will help ensure a child with ARFID is growing properly and address any nutritional gaps in the diet. He or she can advise nutritious options for food exposure and feeding therapy and can help families map out a productive feeding style and strategy and food exposure plan. Find a dietitian here.
To get a sense of what this could look like, I outline my approach with very picky eaters in my book, Try New Food: How to Help Picky Eaters Taste, Eat & Like New Foods.
A feeding therapist, either an occupational therapist or speech-language therapist trained in feeding therapy, is a valuable part of the treatment team. If there are sensory challenges or mechanical issues with the mouth or chewing and swallowing, an OT or SLP who is trained in feeding can provide kids with regular therapeutic interventions in office and at home. You can find a feeding therapist here.
A mental health provider is also a good idea. Over 50% of children with ARFID have anxiety disorder. Many children experience anxiety, and some develop obsessive compulsive disorder (OCD) as a result of food phobia.
Cognitive behavioral therapy has been shown to be effective in the treatment of ARFID. Often, a mental health provider makes the diagnosis of ARFID, however, other healthcare providers can make associated diagnoses.
5. The Pros and Cons of ARFID Treatment
The pros of getting help for the extreme picky eater include improved nutritional status and growth, desensitization to offending food characteristics, overcoming fear of eating, developing coping skills for anxiety or OCD, a broader diet, and reduced stress on the child and family.
Treatment isn’t always rainbows and cupcakes, however. Progress is slow and many families lose their steam in pursuing treatment.
In some kids, treatment can make things worse, especially if food is forced or a feeding tube is used. This can cause more trauma for the child and reinforce sensitivity, disgust and fear of eating.
[Listen to my interview with mom and author, Stephanie Elliot, whose daughter overcame ARFID.]
Healthcare professionals who aren’t trained in feeding, nutrition, or therapy modalities can inadvertently cause more harm to the child with ARFID.
If you’re a potential treatment team member for children with extreme picky eating or ARFID, let your local pediatrician and other allied health professionals know and offer to collaborate.
If you’re a parent looking for help, interview and research your options. I wrote more about this here.
Written by: Jill Castle, MS, RDN
Published on: June 12, 2019
Updated on: August 26, 2019