Children are famous for being extraordinarily choosy about the foods they eat. Everyone has known (or even been) that toddler who won’t even touch a sprig of broccoli or another vegetable. Or maybe they won’t eat one kind of food if it touches another on the plate. Although this might cause concern and consternation for parents trying to provide their kids a balanced, nutritional diet, it’s part of a natural process. As young children develop, they begin to create their tastes and discover the kinds of foods they like to eat.
However, in some cases “picky eating” in children can be a sign that there is an eating disorder present: Avoidant/Restrictive Food Intake Disorder, also known as ARFID.
What Is ARFID Exactly?
ARFID, redefined in the most recent psychiatric diagnostic guidebook, the DSM-V, is a form of a restrictive eating disorder that most often begins in childhood. People with ARFID avoid certain foods extensively, to the point that it can detrimentally affect their physical, mental, and emotional health. The DSM-V defines ARFID as:
- An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children)
- Significant nutritional deficiency.
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
There are a few possible caveats that would cause a different diagnosis from ARFID; for example, if the ARFID behaviors exclusively occur during episodes of anorexia nervosa or bulimia nervosa, the diagnosis will typically not be ARFID. Similarly, if the individual has a gastrointestinal or esophageal disease that causes discomfort when certain foods are eaten, their picky eating is not considered to be disordered. Another important distinction is that when a person has a cultural or religious injunction against eating certain foods, ARFID is usually not diagnosed. Recognizing the existence of food deserts at long last, the diagnostic criteria also include a provision for people who don’t eat certain foods because they are simply not available.
The Difference Between “Picky Eating” and ARFID
As mentioned earlier, ARFID usually begins in childhood- however, it’s not always the case. The DSM-V dropped the stipulation that the individual must be less than 6 years old at the date of onset because ARFID can develop at any time, or can go into remission can return at a later date.
Most children who are picky eaters eventually outgrow their choosy tastes, although being extremely picky can certainly persist. ARFID is a bit different. When left untreated, for example by spending time at an eating disorder treatment center that specializes in ARFID recovery, ARFID tends to become more severe and can drastically affect the person’s health and physical development. Children who eat with strong preferences normally don’t have trouble maintaining an appropriate weight or growing at a normal rate. A child with ARFID may have trouble with both.
Another difference between strong food preferences and ARFID is the reason why the individual won’t eat a certain kind of food. Religious or cultural restrictions aside, normally picky eaters just don’t like a certain food’s flavor or may avoid the food because they are on a diet (which is a slippery slope when it comes to eating disorder recovery). ARFID most normally comes from a disordered and distorted thought process that is preoccupied with “healthy eating.”
ARFID and Obsession With “Healthy” Foods
Why did we put “healthy” in quotation marks here? It’s because of the split between what the eating disorder treatment community and the general population think of as “healthy.” Many people, for good or ill, try to watch what they eat for purposes of maintaining physical health, but people with eating disorders often engage in disordered eating behaviors specifically to lose weight or prevent weight gain, although it has negative physical consequences – we’ll explore this a bit later.
People with ARFID, though, often have a different idea why their restricted foods are not “healthy.” It’s extremely common for ARFID sufferers to think that certain foods will kill them. Often, there are real or imagined allergies in play or a concept that the food is tainted or impure and can cause a disease like botulism. These fears can become obsessions – there are examples of people with ARFID whose fear of eating “dangerous” food requiring feeding tubes and supplements because they simply can’t bring themselves to eat those foods. The distorted thinking caused by ARFID causes them to think that if they eat a certain food, they will die.
Another common fear among people with ARFID is a strong fear of choking. This can lead to extreme restriction of meats, vegetables, potatoes, and so on, with a preference for soft foods taking their place. There is some evidence that childhood or even infant trauma can influence the development of ARFID; case studies indicate that choking in childhood or even having the umbilical cord wrapped around the throat during childbirth, can trigger ARFID behaviors at a later date.
People with ARFID often have “safe” foods that they will eat exclusively. These are often in line with the kind of foods we associate with picky eaters in childhood – white bread, pizza, chicken tenders, saltines, and the like. Eating only their “safe” foods can prevent normal growth during childhood and adolescence, and prevent the ability to maintain a medically acceptable body weight in adulthood. It can disrupt the person’s psychosocial development as well. It can be difficult to plan social occasions or find a suitable restaurant, and the ARFID sufferer may also face debilitating anxiety when in those situations. Without ARFID treatment, in extreme cases, this can require hospitalization.
How Is ARFID Different From Anorexia Nervosa?
Some of the symptoms of anorexia nervosa are very similar to those of ARFID. These include:
- Restricting food intake
- Inability to maintain a medically acceptable body weight
- Constant feeling of coldness; wearing layers to stay warm throughout the year
- Abdominal pain
- Loss of menstruation
- Fatigue and lethargy
Although some of the physical symptoms of ARFID can be similar to those of anorexia nervosa, the causes and psychological underpinnings of the two disorders are different. Anorexia nervosa is characterized by food restrictions, to be sure, but it usually is not limited to certain foods but rather all foods. Fear of choking, vomiting, or becoming sick is the primary root cause of ARFID, and concerns about gaining weight or being “fat” are not usually present.
People with anorexia nervosa, on the other hand, by definition have a fear of gaining weight and restrict their caloric intake to avoid it. In virtually every case of anorexia nervosa, the individual has some form of body dysmorphia, in which they have an unrealistically flawed body image and self-perception that causes them to see themselves as overweight. This form of distorted thinking is not present in people who have ARFID (although it is possible for multiple forms of eating disorders to overlap or follow each other sequentially).
Because anorexia nervosa is a more well-known disorder and more well-established in the eating disorder treatment field, laypeople may think it’s more dangerous than ARFID. However, in the extreme forms of both disorders, the dangers are roughly equivalent. Some studies show that people with ARFID were more likely to be admitted to a hospital with low body weight than people with anorexia nervosa. This goes to show that ARFID is not something to be ignored or discounted; if someone receives a diagnosis of ARFID, eating disorder treatment is always recommended.
Treatment Options for ARFID
As with other types of eating disorders like anorexia nervosa or bulimia nervosa, the priority in eating disorder treatment for ARFID is to ensure the client’s physical and psychiatric safety. If the client is suicidal, they may be placed on psychiatric watch, and if their weight is too low, medical intervention may be necessary. In less severe cases or those on an outpatient basis, talk therapy can begin from the first day.
All eating disorder treatment programs work toward understanding the underlying causes of the disorder, such as past trauma, co-occurring psychological disorders, or body dysmorphia. These can be explored through group therapy sessions as well as individual ones with a trained therapist. Further exploration of the client’s psyche and emotional state can be performed through various alternative therapies as well. These might include art or music therapy, which can help individuals access new understandings about their thoughts and feelings, journaling, or even animal-assisted therapy, in which emotional assistance animals like horses spend time with the individual. They often provide a sense of calm and loving acceptance.
At virtually every eating disorder treatment program, a team of nutritionists and dieticians are on hand to complement the psychological attempts to repair disordered eating behaviors. A weight restoration In most ARFID treatment plans, a weight restoration program is employed, and the dietician team will work with the psychiatric team to break the blocks against eating certain foods and reintroduce them to the client’s meals. This treatment plan also provides life skills for food preparation and meal planning, as well as coping skills to resist triggers to relapse. When trauma and PTSD are causative factors in an eating disorder, the disordered behaviors often act as a (detrimental) coping mechanism themselves, so it’s important to introduce healthy coping skills like meditation or journaling.
For the most complete and long-lasting recovery, family and friends can also participate as a support structure – of course, for children and adolescents with will be essential. The eating disorder treatment facility may sponsor or host alumni groups for graduates as well, where they can reconnect with their peers and continue to support each other.
ARFID is a serious mental health illness and must not be dismissed or ignored as “picky eating.” If your child or adolescent is showing the signs of Avoidant/Restrictive Food Intake Disorder, reach out for help today.