Do you ever wonder if your child’s picky eating habits are more than just intense food likes and dislikes? Do you worry that they could be causing harm to your child’s health? If so, then you may want to familiarize yourself a bit with the relatively new diagnosis of Avoidant Restrictive Food Intake Disorder, or ARFID for short. The term ARFID was introduced in 2013 when the fifth edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders) was published [This manual is the handbook used by clinicians to diagnose psychiatric disorders.].
What is ARFID?
The diagnosis of ARFID applies to individuals who experience a disturbance in eating that is restrictive in nature. It might be related to lack of interest in eating, or can involve avoiding certain foods altogether because of texture or color, or due to worry about a consequence of eating such as experiencing a choking sensation. The restrictive eating pattern characteristic of ARFID has clear consequences on nutrition and overall physical health. The intake deficit may result in significant weight problems (either losing weight or not being able to gain enough weight for normal development), nutritional deficiencies that can lead to dependence on feeding tubes or nutritional supplements, or interference with day-to-day functioning such as the ability to socialize.
Why was this diagnosis added in 2013?
The purpose of the DSM is to provide clinicians with a useful tool to diagnose and treat mental disorders. When additions or changes in the text are made, it is with the intention that the manual will become more helpful. The addition of ARFID to the Feeding and Eating Disorders section is a perfect example of this objective – it gives clinicians a new language with which to more accurately and capture a cluster of meaningful, clinical symptoms.
Using the DSM-IV, if a patient presented with the symptoms described by ARFID, that person may have been diagnosed with “Eating Disorder, Not Otherwise Specified” (otherwise known as EDNOS) or “Feeding Disorder of Infancy or Early Childhood.” EDNOS did describe a disturbance with eating, but it was a catchall category that could not provide as much guidance in terms of treatment, or prognosis. [One study found that 62.4% of children and adolescents with eating disorders were diagnosed with EDNOS using the DSM-IV, despite having very different clinical presentations.] Feeding Disorder of Infancy or Early Childhood, on the other hand, was infrequently used and limited in scope because the criteria required that onset be before the age of six. In fact, with the most recent DSM updates, this diagnosis was eliminated altogether.
ARFID “In Action”
Research is underway to better understand what ARFID really looks like in action. For now, the key feature of the clinical presentation of this disorder involves an eating problem which results in weight loss (or failure to make expected weight gains in children and adolescents) or nutritional issues, and gets in the way with developmentally expected social functioning. For a young child, this might mean having difficulty eating a snack at a friend’s house on playdate. For an adolescent, it might mean struggling with eating out with friends or when traveling away from the familiar foods at home.
One very important distinguishing aspect of ARFID from other eating disorders is that people with ARFID are not particularly “off” in how they perceive their size, either body shape or weight, and do not fear their weight or body shape changing. Appearance is basically not a factor motivating the eating behavior, though it may be part of what motivates these individuals to seek treatment (e.g., wanting to gain weight).
The eating problems seen in ARFID seem to stem from other factors, such as aversions to certain food groups or textures of foods, a lack of appetite, preferences for only specific colors of foods, or fears of vomiting or choking as a result of eating. Some of these factors are associated with other psychiatric or physical conditions – like autism spectrum disorders, emetophobia (a specific phobia of vomiting), or food allergies – but an additional diagnosis of ARFID is given if the eating behavior, in and of itself, is leading to significant problems and needs its own specialized treatment.
There are of course other problems related to eating that would not qualify as ARFID. For example, a child growing up in poverty who is not eating because he does not have adequate access to food would not be considered to have ARFID, even if his restrictive eating pattern is having consequences on his nutritional state and growth trajectory. An individual who strictly avoids certain foods or completes fasts because of religious beliefs or other cultural reasons would not be considered to have ARFID.
Who is most commonly diagnosed with ARFID?
Since the term was coined in 2013, researchers have been studying who winds up with an ARFID diagnosis. When a multi-site retrospective study considered the profiles of 712 patients previously seen by seven adolescent-medicine eating disorder programs, 98 patients (13.8%) met DSM-V criteria for ARFID. In comparing these individuals to those who met for anorexia nervosa or bulimia nervosa, patients with ARFID were found to be younger (12.9 years old on average). Additionally, a greater proportion were found to be male (29%) than in other eating disorder populations (AN – 15%; BN – 6%). Individuals diagnosed with ARFID had higher incidences of co-occurring anxiety and medical conditions, but lower incidences of mood disorders like depression, than those with AN or BN.
Looking Forward: Diagnosing, Discussing, and Treating ARFID
Altering the diagnostic language to capture these symptoms and improving awareness about this kind of eating problem is essential for accurate diagnosis and appropriate treatment.
In a 2014 survey of 2,490 Canadian pediatricians, 63% of those who responded were unfamiliar with ARFID. Additionally, of those who suspected that a previous patient had ARFID, 30% were found to have misdiagnosed that patient. Statistics like this highlight why it is so important to keep the conversation going about these lesser known disorders. While perhaps not as common as other eating disorders, it certainly seems that a diagnosis of ARFID confers a degree of potential medical danger akin to other problems in the feeding and eating disorder category. For example, for patients requiring hospitalization, one study found that those with ARFID were found to require longer hospital stays and more tube feeding than the patients with AN.
Research is still needed to explore the course of illness and most effective treatment strategies for those with ARFID. Some clinicians have posited that ARFID has many of the characteristics that put individuals at a greater risk of subsequently developing anorexia or bulimia nervosa, but there is no conclusive data available about this yet.
At this point, treatments for ARFID emphasize behavioral approaches, including for example interventions that expose patients to specific sensations or foods associated with restrictive eating, to enable nutritional rehabilitation (to correct nutritional deficiencies and restore weight) and medical stabilization. To date, no medication trials have been done specifically for the treatment of ARFID.
For a more comprehensive research update, please check out our summary of what’s been learned since the introduction of this diagnosis into the feeding and eating disorders section of the DSM.