You may never have heard of Avoidant/Restrictive Food Intake Disorder (ARFID) before but – if you’ve ever shared a meal with a toddler – then you know that picky eating is very common in early childhood. In fact, it is a pretty normal and even developmentally appropriate behavior. Picky eating first emerges around age one when children begin to feed themselves. During this stage, toddlers start to “individuate” from their primary caregiver and develop their own personal identity. And with that newfound sense of self comes the expression of their own food preferences. You might find your toddler only wants the yellow cheese, not the white! Or they like raisins today and hate them tomorrow. They love bread and crackers and spit out their broccoli and oranges. Or they only eat snacks but won’t eat their meals. Keeping up with a toddler’s food preferences day in and day out is enough to make your head spin. However, being in charge of feeding themselves allows your little one some degree of control over their highly scripted life, so it is important to let them be in charge of what and how much food they put in their body. This also helps them start to become “in tune” with their own hunger and fullness cues.

Photo by Karo Kujanpaa on Unsplash

Also during toddlerhood, kiddos typically become very interested in routines, predictability, and “sameness.” They may want the same snacks and meals every day and be afraid of trying new foods. Toddlers are growing and changing so much during their early years, so the predictability of and control over their food can be a real source of comfort to them. But while they may be perfectly content to exist solely on a diet of Cheerios, Mom and Dad are likely to have concerns. During this stage, parents can continue to expose their children to new foods by modeling eating it themselves, putting it on the table for their child to see, or putting it on their plate for them to touch, smell, and mouth. This is a situation where it is perfectly okay for your child to “play” with their food and explore all the sensory aspects of it! Despite their worry, parents should try hard to resist forcing a child to eat a new food but, rather, the repeated low-key exposures described above (often 10 or more) can increase a picky eater’s comfort with a new food in a way that can help them continue to feel safe and comfortable with food long into the future. Fortunately, most children go on to outgrow their picky eating behaviors by elementary school age and become teenagers and adults that can eat a wide variety of nutrient-rich foods from all the different food groups (including vegetables!). And mom and dad can help their little picky eaters get comfortable with trying new foods by following these guidelines: https://www.zerotothree.org/resources/1072-how-to-handle-picky-eaters. But what if your child doesn’t outgrow their picky eating? Or what if their picky eating develops later in life?

How do you know if it is more than just “picky eating”?

As we discussed above, picky eating is pretty normal for toddlers through the elementary years. However, “extreme picky eating” that can result in significant nutritional deficiencies, weight loss or failure to gain weight (in children), stunted growth, and interference in psychosocial functioning is problematic. Let’s take a look at the following examples:

A low-weight, small-stature 5^th grader with low appetite whose reflux during infancy limited his diet to bland white foods that don’t upset his stomach. It takes over an hour for him to finish every meal because he doesn’t feel hungry and thinks eating is a chore. He often complains of feeling too full after just a few bites. Due to his anxious parents’ insistence that he eat more food, mealtimes at home can be very tense and unpleasant!

A slim teenager with an egg allergy who, following a frightening egg-contamination episode at a restaurant, has further limited her already restrictive diet due to fear of future allergic reactions. She feels very distressed that she is unable to go out to eat with her family or spend the night at a  friend’s house due to her fear of eating anything new or “unknown.” Her restrictive diet and subsequent low weight have led to a loss of her period and concerns about her bone health.

An 11-year-old girl with autism spectrum disorder who has sensory sensitivities to taste, smell, and texture gags when eating. Over time this has led to a nutrient-deficient diet and dependence on nutritional supplements and a feeding tube. She is often excluded from social events like birthday parties due, in part, to her inability to eat solid food.

As you can see from these examples, “extreme picky eating” may be maintained by a lack of interest in food or enjoyment of eating, avoidance of food based on sensory characteristics  (e.g., texture, taste, or smell), or fear of adverse consequences of eating such as choking, vomiting, or allergic reaction. Often it is a combination of two or three of these maintaining mechanisms. However, what all of these different presentations have in common is an avoidant/restrictive pattern of eating with associated medical and psychosocial consequences. In these cases, it is not just picky eating. It is something more.

Maybe it’s ARFID

Avoidant/Restrictive Food Intake Disorder (ARFID) is defined by a pattern of eating that is limited in variety (e.g., avoidance of specific foods) and/or volume (e.g., restriction of amount) and associated with important medical and psychosocial consequences. ARFID is thought to affect about 3.2% of children (Kurz et al., 2015). Risk factors for ARFID are not yet well known but children with autism spectrum disorders, ADHD, OCD, and anxiety disorders appear much more likely to develop ARFID. To qualify for an ARFID diagnosis, a person must have one or more of the following:

• significant weight loss/growth fall-off
• nutritional deficiencies
• dependence on tube feeding or reliance on energy-dense supplements
• or psychosocial impairment

Unlike other eating disorders (e.g., anorexia or bulimia), ARFID is not motivated by weight or shape concerns. Instead, it is maintained by a lack of interest in food or eating, a fear of aversive consequences of eating such as choking or vomiting, or concerns with the sensory characteristics of food. People with ARFID tend to eat a lot of carbs and dairy and very little protein, vegetables, and fruit. Early research suggests that some people with ARFID may be supertasters! That is, many ARFID cases exhibiting sensory sensitivities to food seem to experience bitter flavors much more intensely than the average person.

How is ARFID treated?

ARFID is a relatively new diagnosis, first conceptualized in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5) that was published in 2013. Until recently, there has been very little guidance around evidence-based treatments for ARFID. However, psychological treatments for ARFID are emerging. At Massachusetts General Hospital/Harvard Medical School, the Eating Disorders Clinical and Research Program team has developed a cognitive-behavioral therapy for ARFID (CBT-AR) to treat individuals ages 10 and older with all presentations of ARFID who are medically stable and not reliant on tube feeding.

“This structured time-limited outpatient intervention can be delivered in an individual or family-supported format depending on the patient’s age, and lasts between 20 to 30 sessions depending on the degree of nutritional compromise. The treatment operates using the principle of volume before variety to support nutritional rehabilitation (i.e., weight restoration, correction of deficiencies). Specifically, patients who are underweight are encouraged to eat larger volumes of preferred food in the early stages of treatment, before increasing dietary variety in later stages. The key intervention is structured in-session exposure to systematically address the maintaining mechanisms most relevant for the patient, including sensory sensitivity, fear of aversive consequences, and lack of interest in food and eating” (Brigham et al., 2018).

I recently attended an excellent 2-day treatment dissemination workshop led by eating disorder expert Dr. Lauren Breithaupt (member of the above-mentioned team) to gain additional skills in providing this new evidence-based treatment for ARFID. CBT-AR shares much in common with the CBT-based treatments I currently provide for other eating disorders and obsessive-compulsive disorder (OCD) but has some treatment elements unique to ARFID. Following this training, I am excited to begin offering CBT-AR to families struggling with non-weight or shape motivated avoidant/restrictive eating problems in Northern Michigan. If you would like to learn more about ARFID or CBT-AR, I encourage you to reach out today.

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Dr. Rebecca Swenson is a licensed clinical psychologist and parent coach who works with children, adolescents, young adults, and families in Northern Michigan. If someone in your family is struggling with an eating disorder, OCD, anxiety, or other emotional/behavioral health issues, contact Dr. Swenson today to learn more about evidence-based treatments that can help.

Sources:

1. https://www.zerotothree.org/resources/1072-how-to-handle-picky-eaters
2. https://www.nationaleatingdisorders.org/learn/by-eating-disorder/arfid
3. Kurz, S., van Dyck, Z., Dremmel, D., Munsch, S., & Hilbert, A. (2015). Early-onset restrictive eating disturbances in primary school boys and girls. European Child and Adolescent Psychiatry,24, 779–785.
4. https://www.smithsonianmag.com/science-nature/why-are-you-picky-eater-blame-genes-brains-and-breast-milk-180953456/
5. Brigham, K.S., Manzo, L.D., Eddy, K.T., & Thomas, J.J. (2018). Evaluation and Treatment of Avoidant/Restrictive Food Intake Disorder (ARFID) in Adolescents. Current Pediatrics Reports, 6 (2): 107-113. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534269
6. Thomas J.J., & Eddy K.T. (2019). Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults. Cambridge, UK: Cambridge University Press.
7. Thomas JJ, et al. (2020). Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (CBT-AR): Feasibility, acceptability, and proof-of-concept for children and adolescents. International Journal of Eating Disorders, 53 (10): 1636-1646. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719612/