Beyond picky eating: Understanding Avoidant/Restrictive Food Intake Disorder (ARFID)

Newly recognized category of eating disorder gives doctors tools to diagnose children who have a different motivation to limit food intake

Thomas has always been a little bit anxious. After a particularly aggressive bout of the stomach flu last year, his anxiety began to increase, especially when it came to food. Meal time is now a real struggle. He often refuses to eat what’s on his plate, and his lunch box often comes back full. When asked about why he doesn’t eat, however, Thomas’s motivation is not to be thin or to lose weight: he is scared of getting sick again.

Emma dislikes particular food textures, and has a very small appetite. While she will sometimes eat very small portions of her dinner, she started to avoid all green foods. Now she avoids red and orange foods too. Emma also has trouble digesting food from time to time. This poses a big challenge for her mom, who struggles with her at meal time to ensure she gets the nutrients she needs to grow and develop.  Emma is 10, but looks much younger because she is underweight.

Thomas and Emma have different symptoms that point to a new category of eating disorder called Avoidant/Restrictive Food Intake Disorder (otherwise known as ARFID).  This new recognition has given doctors the tools to diagnose children who restrict their food intake, but don’t have “traditional” eating disorders like anorexia or bulimia. 

Understanding ARFID

“ARFID patients are typically diagnosed younger”, says Dr. Holly Agostino, eating disorder specialist at the Montreal Children’s Hospital, “and ARFID can affect boys and girls more equally than other types of eating disorders. Often these children, who can have some degree of baseline anxiety to begin with,  develop a fear of eating after a bad gastro or an episode of choking. They stop eating out of fear that the symptoms will reoccur. A cycle begins and it can be very hard to stop, Patients diagnosed with ARFID don’t restrict their food intake because they want to be thinner, yet they have the same extreme fear of food and medical complications as those who do.” she explains.

• ARFID patients typically experience a persistent pattern of disordered eating characterized by:
• Lack of interest in food or a poor appetite
• Fears about negative consequences of eating (e.g., vomiting, choking, allergic reaction)
• Longstanding selective or picky eating (e.g. avoid certain colour foods, textures, etc.) that affects their ability to grow and thrive

Because they don’t get enough nutrition in their diet, children with ARFID lose weight, or they may not gain weight or grow as expected. “This can be particularly dangerous,” says Dr. Agostino. “When a child is underweight, this can have serious effects on the body. Malnutrition can affect the heart, as well as a child’s bone strength and growth potential. If not treated, younger children can have delayed puberty and may even miss the window for their pubertal growth spurt.”

Recognizing the signs

When it comes to recognizing the signs of ARFID in kids, Dr. Agostino says parents should keep an eye on their child’s growth and weight. “Kids can go through a period where they are more picky, and that’s normal,” she explains. “But if they are losing weight, that’s something that needs to be investigated and they should be seen by a doctor. Equally, staying the same weight is not normal in childhood and adolescence, so if the scale is not shifting, that should raise alarm bells.”

Another clue that can indicate a more serious problem is how the child is behaving around food in a number of different environments. “If the restrictive behaviours are more and more entrenched at home and they’re spreading to school and during time with friends, that’s another indication that the problem is more serious,” says Dr. Agostino. 

Getting treatment

Due to the possibly life-threatening impact of ARFID behaviours, Dr. Agostino says it’s important to see a health professional if patterns of disordered eating and restriction arise. “The treatment for ARFID is similar to that of other eating disorders in children,” explains Dr. Agostino, adding that a team of health professionals will first focus on stabilizing a patient medically. “We typically suggest Family-Based Treatment, which involves the active participation and commitment of parents to take back complete control over meal preparation and supervision with the support of a therapist. Although a big commitment, this form of therapy has shown the best results for restrictive type eating disorders in adolescents.

“There are certainly a lot more children affected by ARFID than we see in hospital that are labeled as being picky eaters but need expert help in order to address the physical and psychological issues they may face as a result of their restrictive eating,” says Dr. Agostino.  With this new categorization of ARFID as an eating disorder on its own, the hope is that more of these patients will be identified and promptly be referred to get the help they need.