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Avoidant/Restrictive Food Intake Disorder (ARFID): Information for Families

Summary: Avoidant/restrictive food intake disorder (ARFID) is a condition that causes people to have troubles with eating enough food, and it can occur for many different reasons. A person may have one or more of the following: troubles with appetite; general disinterest in eating; sensory sensitivities that make it hard to eat; past troubling experiences that result in feeding difficulties. As a result, the person struggles to eat enough calories as well as enough nutrients, which can cause problems with poor energy, focus, concentration, stamina and growth. Unlike conditions such as anorexia nervosa, individuals with ARFID do not have body image preoccupation, nor a desire to lose weight. In fact, sometimes they may worry about being “too thin” or “unhealthy”. Treatment of ARFID is about making a customized plan based on the person’s concerns and symptoms. Are you worried about ARFID in yourself or a loved one? Start by seeing a family physician or paediatrician.
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J’s Story, Part 1

J. is a 10-yo male previously well. Unfortunately, this has been a stressful year with multiple stresses such as a) his parents separated; b) he has been bullied at school; c) he had a medical issue that required prescription medications that led to side effects of nausea. Although the medication has since finished, J. still says he feels nausea that prevents him from eating enough. As a result, he has lost a lot of weight. 

D’s Story, Part 1

D. is a 5-yo with troubles feeding since an early age. Now, she is having troubles transitioning to textured solid foods; and she avoids new foods as a result. She has less than 10 foods that she will eat and is beginning to restrict her intake more with time. Her weight has dropped so much that her parents are starting to get worried.

Who Gets It?

ARFID can happen in people of all ages, such as children, youth and adults.

Note: ARFID is not due to “bad parenting”.

What Causes ARFID? What Does ARFID Look Like?

ARFID can appear in different ways such as:

  1. Type 1: Person experiences stressful life events, which then lead to troubles eating and weight loss.
  2. Type 2: Person has had troubles with appetite regulation such as knowing when they are hungry and need to eat, or feeling full too easily (i.e. early satiety), which can lead to weight loss.
  3. Type 3: Child has sensory processing problems, which causes limited intake.

    Diagnosis

    DSM-5 Criteria

    ARFID is an eating or feeding disturbance that manifests as a chronic failure to satisfy energy or nutritional needs associated with at least one of the following:

    • A significant deficit in nutrition.
    • Significant loss of weight, not achieving expected weight gain, or the absence of normal physical development.
    • Disruption in psychosocial functioning.
    • Reliance on enteral feeding (e.g., feeding tube) or oral nutritional supplements.

    ARFID is not accompanied by a distortion of one’s weight or body shape and is not concurrent with symptoms of anorexia or bulimia.

    Exclusion criteria for ARFID

    • ARFID is not due to
      • Unavailability of food such as from poverty or famine,
      • Culturally sanctioned food observance or practice
      • A medical condition,
      • A different psychiatric disorder.

    Could the Eating Problems Be Due to Something Else? 

    There are other conditions where people may have troubles with eating such as:

    • Anorexia / Bulimia
      • Patients with anorexia/bulimia may have less intake due to their anorexia/bulimia.
      • Unlike anorexia/bulimia, patients with ARFID do not obsess about body image, and are not fearful of weight gain.
    • Emetophobia (Fear of vomiting)
      • Individual is worried about vomiting and as a result, restricts intake to avoid the potential for vomiting
    • “Picky eating”
      • ARFID is more than simply a child with “picky eating”
      • Although the term “picky eating” is often used, note that there is no standardized definition, although typically it refers to a child who
        • Consumes an inadequate variety of foods
        • Has limited variety of foods eaten
        • Rejects foods that may either be familiar or unfamiliar
        • Rejects foods of a particular texture, consistency, color, or smell
        • Has unusual eating behaviors
        • Picky eating behaviours generally peak between age 2-6, and improves gradually over time
        • Children with picky eating behaviors should have normal growth and development

    ARFID Can Occur With Other Issues 

    Problems eating can occur with other conditions as well such as: 

    • Depression: 
    		Are there problems with depressed mood?
    • Anxiety: 

    Are there problems with severe anxiety, to the point that it gets in the way of life?

      • Obsessive compulsive disorder (OCD)

      Are there problems with distressing fears and worries that come back over and over again? (e.g. fears of being contaminated)

      Are there rituals or habits that must be done otherwise the person feels anxious? (e.g. tidying, counting, cleaning, hand washing)

      • Autism spectrum disorder (ASD)
      		Are there problems with connecting and relating to other people? Does the person see only their perspective, and is unable to see other's? Are there narrow, focused interests in just one area?

      If so, it would be helpful to explore these issues further, and see if perhaps addressing those issues might be helpful. See a health care provider (e.g. primary care provider, or mental health professional) to explore further. 

      Self-Help: Strategies for Parents and Caregivers

      Treatment of ARFID involves a customized plan, based on that specific individual. There is no “one size fits all” approach.

      Tips for Mealtimes

      We don’t usually think of eating as a ‘skill’, but it is. Eating problems may begin because of physical differences that make learning to manage and enjoy food more difficult. Worse, if a child has had stressful experiences eating, this may contribute to make eating difficult.

      The good news is that there are many things parents can do to help their child learn eating skills, while also keeping the environment relaxed.

      Do’s

      • Do stick to a routine for meals and snacks. This will encourage hunger in your child. Stay with this schedule, even if your child does not eat a meal.
      • Do have your child sit at the table or in a highchair for all meals and snacks.
      • Do eat with your child. If you’re not ready for your own meal, have a small snack like carrot sticks.
      • Do notice positive mealtime behaviours, like:
        • Coming to the table;
        • Sitting at the table;
        • Taking tastes of food.
      • Do keep portions small. Always offer a small serving of a food your child likes as you introduce new foods on her plate.
      • Do schedule a time for drinks. Offer liquids during snack time or mealtime.
      • Do keep meals simple. Too many choices can be confusing for your child.
      • Do limit mealtime to 10-30 minutes. If your child is not cooperating at the table, thank him for coming to the table, and take the meal away in a gentle, calm manner without being angry or blaming. .

      Don’ts

      • Don’t express any feelings of frustration or disappointment during a meal or snack if your child doesn’t eat. This can add to your child’s stress; and your child is already having enough stress.

      Food Chaining

      Food chaining is where you start with the foods that your child is able to eat, and based on these foods, one slowly makes “links” or “chains” to similar foods, step by step (Toomey, 2002).


      For example:

      • Child is able to drink apple juice, and parents would like child to be able to drink milk.
      • Food chain:
        • Apple juice
        • Apple juice + apple sauce
        • Apple sauce plus vanilla yogurt
        • Vanilla yogurt plus milk
        • Milk

      Step-by-Step Exposure Hierarchy

      The step-by-step exposure hierarchy is where you gradually expose the person to the new food, progressively and step-by-step.

      One example might be:

      Step 1

      Start with being in the same room as the food, and gradually increase the intensity of the sensory experience.

      Step 2

      Interact with the new food, e.g. picking it up with utensils, putting it on the plate.

      Step 3

      Smell the new food.

      Step 4

      Touch the new food, with fingers, lips, teeth.

      Step 5

      Taste new food -- put it on the tongue, chew it, spit it out.

      Step 6

      Eat the new food

      Strategic Adult Attention

      Do’s

      Don’ts

      • Do pay positive attention to positive behaviours you want at meal or snack time.
      • Do consider using gratitude (rather than praise) for the sensitive kids. Praise, such as “You’re such a good child” can be too much for some kids. Although praise is positive, its still a judgment. The sensitive kids may feel that they are “bad” if they aren’t successful.
      • Examples of positive behaviours include:
        • Sitting calmly in the highchair
        • Holding a spoon
        • Picking up a piece of food.
      • Just describe what you see in a positive tone (with a smile!)
        • "I see you’re holding your spoon already!"
        • "You’ve got a piece of apple."
        • "I like it when you’re sitting in your chair." 
      • Don’t focus on negative behaviours -- because all children want attention, they may inadvertently do negative behaviours just to get more attention from parents, even if it is negative.
      • Do ignore negative food refusal behaviours.
      • Has your child done something negative such as said "yuck!" or spat or threw their food?
        • Don’t ‘accidentally’ reward him by expressing your frustration.
        • Any expression of emotion from you (worry, irritation, disgust) may cause your child to repeat these unwanted behaviours.
        • Try to stay calm and 
          • Keep your face calm;
          • Act as if the behaviour is of no interest to you;
          • Continue your meal;
          • Keep chatting with another family member.
      • Don’t pay attention to food refusal behaviours.
      • Do stay quiet when your child is not eating. It’s best not to say anything at all, because your voice carries emotion, and your words show interest.
      • While your child sits staring at her plate, try to busy yourself with something else(such as eating your meal), but be ready to show interest in eating related behaviours.
      • Example:
        • If your child picks up a spoon, you could say, "We’re using our spoons and forks".
      • Don’t coax or pressure or threaten your child to eat -- this just gives attention to not eating.
      • Do keep calm and carry on, even if your child gags or coughs. Many children will gag or cough on new textures. Your child will be looking to you for emotional guidance -- it is best for you to model calmness which then helps your child to stay calm.
      • Have a few phrases ready that you can repeat with confidence
        • "It’s okay."
        • "It’s going down."
        • "You did it"
        • "You swallowed!"
      • Don’t serve round, smooth foods like hot dogs or whole grapes, as their diameter is a choking risk. If you do serve hot dogs or grapes, cut them so that their diameter is small enough to no longer pose a choking risk.
      • Do be authoritative -- do be warm, positive and ‘in charge’.
      • Say what needs to happen in a clear, confident voice which will keep things simple, and convey your authority.
        • "Time to eat"
        • "Food first, then play"
        • "Food first, then milk"
        • Use “When … Then… ", e.g. “When you eat, THEN after you can play…”

      Where to Find Help?

      If you are concerned, then there are many ways for you to get help:

      • Dietician (Registered dietician)
      • Community-based pediatrician
      • Mental health professional to screen for other mental health issues
      • Occupational therapy (OT)

      Not sure where to find resources in your community?

      • Consider speaking to your local eating disorder program if they have any particular recommendations regular resources

      Treatment / Management

      Depending on what resources are available, ARFID may possibly be treated by:

      • Different professionals such as eating disorders specialists, ideally using a multidisciplinary approach which may include behavioural therapists; occupational therapists, social workers, psychiatrists, psychologists, paediatricians.

      Professionals may use different treatments, such as:

      • Family-based therapy
      • Behavioral training
      • Cognitive based therapy

      OT, behavioural therapists

      • Consider OT or behaviour therapy if feeding issues have been long-standing

      Professionals will usually work on the following goals:

      • Having a mealtime that works (i.e. “functional mealtime”) as opposed to focusing on weight gain per se.
        • Let the health professionals worry about the weight.
        • Allow your child’s hunger and appetite to motivate them to try the foods they find harder to eat (as opposed to just staying with preferred foods). Be aware that there might be a temporary period of less eating, but eventually it should result in more food variety and healthier eating.
      • Dealing with any mental health issues, such as depression or anxiety.
      • Behavioral therapy
        • E.g. Gradual exposure to the avoided foods

      Catching ARFID Early

      Are you a parent? Take your child for regular annual checkups, and make sure that they take your child’s height and weight to build up a growth chart. The growth chart can show early signs of ARFID.

      Family Education Resources

      “Helping Children with Feeding Challenges”, information on the CHEO website

      http://www.cheo.on.ca/en/feeding-challenges

      References

      Toomey, K. (2002). Preventing and Treating "Food Jags.” The Journal of Pediatric Nutrition and Development, 100, 2-6.

      About this Document

      Written by Dr. Mark Norris (paediatrician), Clare Roscoe (psychiatrist), Carrie Owen (OT), Children’s Hospital of Eastern Ontario (CHEO). Reviewed by members of the eMentalHealth.ca/PrimaryCare Team. Edited by Michael Cheng (psychiatrist, CHEO).

      Clare Roscoe: Nothing to disclose.

      Carrie Owen: Nothing to disclose.

      Mark Norris: Nothing to disclose.

      Disclaimer

      Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

      Creative Commons License

      You are free to copy and distribute this material in its entirety as long as 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes (non-commercial), 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

      Date Posted: Dec 17, 2020
      Date of Last Revision: Apr 26, 2021
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