Table of ContentsView AllTable of ContentsARFID vs. Picky EatingDiagnosisAssessmentTypesPrevalenceTreatment

Table of ContentsView All

View All

Table of Contents

ARFID vs. Picky Eating

Diagnosis

Assessment

Types

Prevalence

Treatment

Are you or is someone you know a picky eater? Some extremely picky eaters may have aneating disorder, known as avoidant/restrictive food intake disorder (ARFID). In most cases, picky eating does not interfere with weight status, growth, or daily functioning. However, people who experience consequences such as these as a result of extremely picky eating mayneed treatment.

It may be helpful to understand the characteristics of picky eating typically seen in children at differentstages of developmentand avoidant/restrictive food intake disorder.

Picky Eating

Picky eaters are people who avoid many foods because they dislike their taste, smell, texture, or appearance. Picky eating is common in childhood, with anywhere between 13% and 22% of children between three and eleven years of age considered picky eaters at any given time.

While most young children outgrow their pickiness, between 18% and 40% continue to be picky into adolescence.

In developing children, the range of types, textures, and amount of food eaten generally progresses until age six or seven. At around this age, many school-age children become more “picky” and start to favor carbohydrates, which fuel growth.

ARFID

It can be hard for parents and health professionals to distinguish “normal pickiness” in a child from adiagnosis of ARFID. Eating behaviors and flexibility may exist on a continuum between those who are adventurous in trying new foods and those who prefer a routine diet. Most children are still able to meet their nutritional needs despite some pickiness.

In chapter 12 ofFamily Therapy for Adolescent Eating and Weight Disorders: New Applications,Dr. Kathleen Kara Fitzpatrick and her colleagues explain the condition."

Dr. Kathleen Kara Fitzpatrick

The condition can have serious consequences. Individuals with ARFID do not eat enough to meet their energy and nutritional needs. However, unlike individuals with anorexia nervosa, people with ARFID do not worry about their weight or shape or becoming fat and do not restrict their diet for this reason.

ARFID is a new diagnosis that was introduced with the publication of theDiagnostic and Statistical Manual, 5thedition (DSM-5) in 2013.Prior to this new category, individuals with ARFID would have been diagnosed aseating disorder not otherwise specified(EDNOS) or fall under the diagnosis of feeding disorder of infancy or childhood. ARFID is not as well-known asanorexia nervosaorbulimia nervosa.

ARFID also does not typically emerge after a history of more normal eating as do anorexia nervosa and bulimia nervosa. Individuals with ARFID usually have had restrictive eating all along.

Because ARFID is a less well-known disorder, health professionals may not recognize it and patients may experience delays in getting diagnosed and treated. A diagnosis of ARFID requires a thorough assessment.

Assessments should include a detailed history of feeding, development, growth charts, family history, past attempted interventions, and complete psychiatric history and assessment. Other medical reasons for the nutritional deficits need to be ruled out. Dr. Rachel Bryant-Waugh has outlined a diagnostic checklist for ARFID to facilitate gathering the appropriate information:

DSM-5 gives some examples of types of avoidance or restriction that may be present in ARFID. These include restriction related to an apparent lack of interest in eating or food, sensory-based avoidance of food (the individual rejects certain foods based on smell, color, or texture), and avoidance related to feared consequences of eating such as choking or vomiting, often based on a past negative experience.

Fisher and colleagues suggested six different types of ARFID presentation with the following prevalence rates among their sample:

We do not have good data about the prevalence rates of ARFID. It is relatively more common inchildrenand young adolescents, and less common in older adolescents and adults. Nonetheless, it does occur throughout the lifespan and affects all genders.

Onset is most often during childhood. Most adults with ARFID seem to have had similar symptoms since childhood. If ARFID onset is in adolescence or adulthood, it most often involves a negative food-related experience such as choking or vomiting.

One large study published in 2014 found that 14% of all new eating disorder patients who presented to seven adolescent-medicine eating disorder programs met criteria for ARFID. According to this study, the population of children and adolescents with ARFID:

Patients with ARFID are more likely than patients with anorexia nervosa or bulimia nervosa to have a medical condition or symptom. Fitzpatrick and colleagues note that ARFID patients are more frequently referred from gastroenterology than patients with other eating disorders. They are also likely to have an anxiety disorder, but less likely to have depression.

Individuals with autism spectrum conditions, as well as those with ADHD have been shown to be more likely to develop AFRID. Patients with ARFID on average have a lower body weight and therefore are at a similar risk for medical complications as patients with anorexia nervosa.

Children presenting with ARFID often report a high number of worries, similar to those found in children withobsessive-compulsive disorderandgeneralized anxiety disorder. They also commonly express more concerns around physical symptoms related to eating, such as an upset stomach.

For patients and families, ARFID can be extremely challenging. Families often get anxious when children are having difficulty eating and may get stuck in power struggles over food. For older adolescents and adults, ARFID can impact relationships as eating with peers can become fraught.

Left untreated, ARFID will rarely resolve itself. The goals of treatment are to increase the patient’s flexibility when presented with non-preferred foods and to help them to increase their variety and range of intake of foods to satisfy their nutritional needs.

For children and adolescents with ARFID, evidence shows thatfamily-based treatmentcan be helpful.

Residential Treatment

At present, there are no evidence-based treatment guidelines for ARFID. Depending on the severity of the malnourishment, some patients with ARFID may need higher levels of care, such as residential treatment ormedical hospitalization, sometimes with supplemental or tube feeding.

A study published in 2017 found that many patients with ARFID responded well to care in a partially hospitalized program, similar to patients with other eating disorders.

Increased Food Flexibility

Many patients with ARFID tend to eat the same food repeatedly until they tire of it and then refuse to eat it again. Thus, patients are encouraged to rotate presentations of preferred foods as well as gradually introduce new foods.

The average person typically requires several presentations before foods are no longer experienced as novel. For people with ARFID, it is often fifty times before a food is no longer experienced as unfamiliar.

Treatment Example

Next, he started to eat bigger pieces of carrots boiled in broth and eventually carrots just boiled in water. Then, he began to work on the peels of fresh carrots.

He also started to work on fruit. He began with strawberry jelly on toast, which was something he was comfortable eating. He next introduced strawberry jelly with seeds to get him used to some texture.

After that, he introduced macerated fresh strawberries (mixed with sugar to soften them). Eventually, he began to eat very small pieces of fresh strawberries. After that, other fruits and vegetables were gradually added in a similar fashion.

8 SourcesVerywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Merck Manual Professional Version.Avoidant/Restrictive Food Intake Disorder (ARFID).Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM.Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders.J Eat Disord. 2014;2(1):21. doi:10.1186/s40337-014-0021-3Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT.Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment.Curr Psychiatry Rep. 2017;19(8):54. doi:10.1007/s11920-017-0795-5Loeb KL.Family Therapy for Adolescent Eating and Weight Disorders: New Applications. New York: Routledge; 2015.American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington, DC; 2013.Bryant-Waugh R.Avoidant restrictive food intake disorder: An illustrative case example.Int J Eat Disord.2013;46(5):420-423. doi:10.1002/eat.22093Fisher MM, Rosen DS, Ornstein RM, et al.Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5.J Adolesc Health.2014;55(1):49-52. doi:10.1016/j.jadohealth.2013.11.013Ornstein RM, Essayli JH, Nicely TA, Masciulli E, Lane-loney S.Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders.Int J Eat Disord. 2017;50(9):1067-1074. doi:10.1002/eat.22737

8 Sources

Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Merck Manual Professional Version.Avoidant/Restrictive Food Intake Disorder (ARFID).Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM.Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders.J Eat Disord. 2014;2(1):21. doi:10.1186/s40337-014-0021-3Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT.Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment.Curr Psychiatry Rep. 2017;19(8):54. doi:10.1007/s11920-017-0795-5Loeb KL.Family Therapy for Adolescent Eating and Weight Disorders: New Applications. New York: Routledge; 2015.American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington, DC; 2013.Bryant-Waugh R.Avoidant restrictive food intake disorder: An illustrative case example.Int J Eat Disord.2013;46(5):420-423. doi:10.1002/eat.22093Fisher MM, Rosen DS, Ornstein RM, et al.Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5.J Adolesc Health.2014;55(1):49-52. doi:10.1016/j.jadohealth.2013.11.013Ornstein RM, Essayli JH, Nicely TA, Masciulli E, Lane-loney S.Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders.Int J Eat Disord. 2017;50(9):1067-1074. doi:10.1002/eat.22737

Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

Merck Manual Professional Version.Avoidant/Restrictive Food Intake Disorder (ARFID).Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM.Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders.J Eat Disord. 2014;2(1):21. doi:10.1186/s40337-014-0021-3Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT.Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment.Curr Psychiatry Rep. 2017;19(8):54. doi:10.1007/s11920-017-0795-5Loeb KL.Family Therapy for Adolescent Eating and Weight Disorders: New Applications. New York: Routledge; 2015.American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington, DC; 2013.Bryant-Waugh R.Avoidant restrictive food intake disorder: An illustrative case example.Int J Eat Disord.2013;46(5):420-423. doi:10.1002/eat.22093Fisher MM, Rosen DS, Ornstein RM, et al.Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5.J Adolesc Health.2014;55(1):49-52. doi:10.1016/j.jadohealth.2013.11.013Ornstein RM, Essayli JH, Nicely TA, Masciulli E, Lane-loney S.Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders.Int J Eat Disord. 2017;50(9):1067-1074. doi:10.1002/eat.22737

Merck Manual Professional Version.Avoidant/Restrictive Food Intake Disorder (ARFID).

Nicely TA, Lane-Loney S, Masciulli E, Hollenbeak CS, Ornstein RM.Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders.J Eat Disord. 2014;2(1):21. doi:10.1186/s40337-014-0021-3

Thomas JJ, Lawson EA, Micali N, Misra M, Deckersbach T, Eddy KT.Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment.Curr Psychiatry Rep. 2017;19(8):54. doi:10.1007/s11920-017-0795-5

Loeb KL.Family Therapy for Adolescent Eating and Weight Disorders: New Applications. New York: Routledge; 2015.

American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington, DC; 2013.

Bryant-Waugh R.Avoidant restrictive food intake disorder: An illustrative case example.Int J Eat Disord.2013;46(5):420-423. doi:10.1002/eat.22093

Fisher MM, Rosen DS, Ornstein RM, et al.Characteristics of Avoidant/Restrictive Food Intake Disorder in Children and Adolescents: A “New Disorder” in DSM-5.J Adolesc Health.2014;55(1):49-52. doi:10.1016/j.jadohealth.2013.11.013

Ornstein RM, Essayli JH, Nicely TA, Masciulli E, Lane-loney S.Treatment of avoidant/restrictive food intake disorder in a cohort of young patients in a partial hospitalization program for eating disorders.Int J Eat Disord. 2017;50(9):1067-1074. doi:10.1002/eat.22737

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