Food Aversion: Next Steps for Kids with ARFID
ARFID, or Avoidant Restrictive Food Intake Disorder, is an extreme form of food aversion. Learn who can provide ARFID treatment, including options for outpatient and inpatient therapy, and what parents can do to help right now.
ARFID is a relatively new diagnosis for picky eaters with food phobia. The acronym stands for Avoidant Restrictive Food Intake Disorder. Children with ARFID avoid eating for a variety of reasons: fear of eating, a history of negative experiences with food, medical conditions, sensory interference, and more. Generally, children with ARFID aren’t trying to lose weight or change their appearance.
I’ve written two articles to help you learn more about the condition:
ARFID Treatment: What Parents and Professionals Need to Know
In this article, I’ll cover:
- What specialists do, and how they can help your child
- Treatment settings, including outpatient and inpatient options, and how to start researching the next steps
- The watch-outs for food aversion treatment
- What you can do at home, right now
- Other resources
Why It Takes So Long to Get Help for Food Aversion
I’ve been having a lot of conversations with parents recently who suspect their child has a food aversion. After doing some research online, a light bulb goes off, and they realize the picky eating mystery they’ve been living with for so long may be ARFID.
Of course, they want to help their child get better: help them try new foods, expand their food preferences, and nutritionally rehabilitate them.
But often, they don’t know what to do next.
What many of these parents tell me is they have been suspicious of something bigger all along. They knew things weren’t normal, but when they asked their health care provider, they were told not to worry.
Here are some of the common obstacles that prevent parents from getting help for their child:
- The doctor assures them their child is growing well and not to worry, so they go back to the same old routine (and continue to worry)
- They were told not to make an issue out of eating (good advice!), but remained unsure about how to interact with their child at the table, leaving things to continue as is
- They think it’s their fault and something they should know how to fix themselves, so they feel a lot of guilt and hopelessness, and nothing really changes
- They’re not sure where to go for help. If their main healthcare provider poo-poo’s their concerns, how can they go against that?
- They suspect their child needs a specialist, but they can’t easily find one in their area
- They’re not sure when to start and the idea of “treatment” is overwhelming
I know how frustrating this can be.
And scary.
While it’s freeing to finally have a name for what some parents have been struggling with for so long, it’s defeating not to know what to do next.
Professionals Who Can Help Kids with Food Aversion
There are several healthcare providers who can assist a child and family who shows signs of food phobia, or ARFID. Many of these provider roles overlap. Let’s dive into the most common ones for this condition:
Pediatric Dietitian
The role of the pediatric dietitian is to assess nutritional status, the overall diet, and come up with a nutrition plan that addresses the following:
- Goals for nutritional rehabilitation (weight gain, growth, nutrient deficiencies, etc, as needed)
- Creative food ideas and personalized goals for trying new foods
- Steps to introduce new foods, including how, when, what, how much and more
- Improving the relationship with food
- Guiding parenting interactions at the table
Doctor
The doctor keeps tabs on the medical status of the child, including blood tests, ongoing management of medical conditions, referrals to specialists, and orchestrating the team of specialists treating the child.
Occupational therapist (OT)
An OT who is trained in feeding therapy is often involved when sensory challenges are present. They are trained to desensitize the offending characteristics of food, such as texture, appearance, and temperature.
[Listen to: Alisha Grogan on The Nourished Child podcast, episode # 88: Making Sense of Sensory Issues]
Speech language therapist (SLP)
A speech language therapist (trained in feeding therapy) works on the mechanical manipulation of food in the mouth, including chewing and swallowing, but can also work on new food introduction.
[Listen to: Melanie Potock on The Nourished Child podcast, episode # 44: How to Help Extreme Picky Eaters]
Counselor/therapist
Many children with ARFID have anxiety around food, eating, and participating in meals. A psychologist or therapist can help address and minimize fears, stress, and avoidant behaviors in children.
How Do I Know Which Healthcare Professional is Right For My Child?
It’s not always clear who is the right professional to help your child. Talk with your doctor or other healthcare professional with which your child is already involved. They can help with triaging the supportive team of professionals your child might need.
Often, children with ARFID are in need of more than one professional to help them. For example, a child with sensory-based ARFID who is a slow grower and anxious may need a dietitian, occupational therapist, a counselor and their pediatrician.
Just the other day, I had a client who I suspected has some serious and long-term gastrointestinal issues contributing to ARFID. That child needs a gastroenterologist and a GI work-up.
A child with sensory sensitivities may need to work with an occupational therapist trained in feeding therapy and with a dietitian simultaneously, while one with swallowing or chewing issues may need a speech therapist to address oral-motor needs.
And, for those with ARFID who are very anxious, working with a therapist may be essential.
The potential impact on growth and development due to a narrow, limited diet makes many children with ARFID candidates for a pediatric nutritionist.
ARFID Treatment Options
When the official diagnosis came out a few years ago, there was little guidance around treatment protocols or standardized care for ARFID. Thankfully, treatment options are surfacing and research is helping us understand the effectiveness of the different therapy approaches.
From individual healthcare providers offering home-based interventions to hospitalization (and several choices in between), the options for treatment are broad.
Which one is right for your child? It depends.
Individualized Outpatient Therapy
Many individual healthcare providers are able to help children with ARFID, and they do so through regular office appointments. Therapy is provided during the appointment with guidance and exercises for the parent to continue at home.
For example, a child might see a dietitian to strategize ways to improve nutrient intake with food suggestions using a food chaining approach and through micronutrient supplementation. She may also help with parenting and monitor the child’s weight status and growth.
[A Helpful Resource: Essential Nutrient Guidebook for Kids]
That child may also see a feeding therapist and mental health counselor during the same week. Each individual provider is focusing on one aspect of treatment to help the child and family move forward.
Obviously, communication between healthcare providers is critical to keeping each other up to date and working together. This outpatient “team” is constructed based on the needs of the child.
Day Treatment/Outpatient Programs with Intensified Therapy
These programs focus on eating meals and snacks at the treatment center, including exposure to new foods and flavors, over a set period of weeks. Counseling (individual and group) with a cognitive based therapy (CBT) slant is often included.
One 2019 study in International Journal of Eating Disorders, though small, showed 10 out of 11 participants went into remission after participating in a 4 week day treatment program. Patients restored their weight, reduced their fear of food, and minimized anxious and dysfunctional thoughts about food and eating.
[Listen to: Stephanie Elliot talk about Sad Perfect: A Book about a Girl with ARFID on The Nourished Child podcast.]
Inpatient Hospitalization
Seventy-three percent of physicians medically admit ARFID patients to the hospital according to a 2018 study in Journal of Eating Disorders. More than half of these hospitalizations followed an eating disorder treatment approach, including the use of tube feedings.
Nasogastric tube feedings may cause more harm to a child with ARFID, as it may increase food aversion, especially if a child has oral sensitivities.
Do No Harm: Unexpected Consequences for the Child with Selective Eating Disorder
While you may recognize your child needs more help for his extreme picky eating, you need to know that treatment itself can be traumatizing. As mentioned above, tube feedings can introduce more trauma to the child with ARFID.
Interview potential therapists and understand the methods being used in therapy, particularly around introducing new foods. Force feeding, threats, shaming, excessive pressure or other negative techniques can make your child’s eating worse, not better, and extend the condition.
How Parents Can Help Right Now
As a parent, there are several things you can do right now to ease the environment around food and eating.
Stop talking about food and eating
Many children (even those without extreme picky eating) interpret the constant dialogue about eating and health as pressure. Pressure can reduce the desire to eat, and interfere with appetite signals.
[Read: Too Much Nutrition Talk at the Table]
Resist the urge to encourage too much
Although positive encouragement feels like it would be okay, for some children it feels the same as negative pressure. Be judicious in your encouragement – a little bit goes a long way.
Be understanding and empathetic
It’s likely your child has been picky for a long time. And it’s possible he has created an environment around food whereby he can ‘survive.’ Changing that environment (and his eating) will take time and may include some resistance from your child.
Be patient and understanding. Know that your child wants to please you, small steps equal progress, and big changes take time.
Know that your child wants to please you, small steps equal progress, and big changes take time. #pickyeaters #ARFID via@pediRD Click To TweetEach Child is Different
If there’s one thing I’ve learned over the years from working with ARFID, it’s that there is no one treatment path that serves every child. Each child needs a unique plan that works for him.
Do your research. Talk with your pediatrician about working with someone who can start to identify you child’s needs, whether it be feeding therapy, nutrition, or counseling (or a combination of some or all of these).
Interview professionals to make sure you agree with their methods and understand the investment of your time and money.
Additional Resources for the Child with Food Aversion
The following are search platforms for specific therapists. While I cannot guarantee the quality or breadth of services provided by individuals or treatment centers, my hope is that these will give you a place to begin your search for more help, if needed.
For a Dietitian/Nutritionist: https://www.eatright.org/find-an-expert
Find a Feeding Therapist: https://www.feedingmatters.org/resources-support/provider-directory/
For a Mental Health Therapist: https://www.psychologytoday.com/us/therapists
Find a Treatment Center for ARFID: https://www.edreferral.com/treatment-center/avoidantrestrictive-food-intake-disorder-arfid
Outpatient/Day Treatment Programs:
Several eating disorder treatment facilities have programs, which may or may not include treatment for ARFID. Here is a search platform from the National Eating Disorders Association (NEDA) to further identify potential treatment options: https://map.nationaleatingdisorders.org/
Duke Health: https://www.dukehealth.org/treatments/psychiatry/eating-disorders/avoidantrestrictive-food-intake-disorder-arfid
The Marcus Center for Austism: https://www.marcus.org/care-and-services/feeding-program
UC San Diego Pediatric Feeding Program: http://eatingdisorders.ucsd.edu/treatment/pediatric-programs.html
Try New Food Book
I wrote this book with the parent of picky eaters in mind. From your garden-variety, typical 2-6 year old picky kid to your older, extremely picky child, there are basic fundamentals to interacting around food and helping your child try new foods.
