ARFID — Avoidant/Restrictive Food Intake Disorder

Picky eating in children

Young children are often selective about food, especially between the ages of 2 and 6. Many of them struggle with particular foods such as vegetables, meat or fish. A child may be especially demanding about how food looks and smells, and how it feels in the mouth.

Most of the time this kind of selectivity passes on its own as the child grows, but in some cases it becomes more entrenched and the range of foods gradually narrows. Sometimes a paediatrician will tell you that your child has a paediatric eating disorder, or ARFID.

Let's work out together what this is (a medical diagnosis), how to live with it, what parents can do, how to support the child and which specialists to turn to for help.

Types of feeding difficulties in children

Studies carried out around the world show that, on average, roughly 25% to 35% of children face some kind of feeding and/or growth problem during their first 10 years of life.

Feeding difficulties can be roughly divided into the following categories:

• Food neophobia — refusing unfamiliar or unknown foods. This is a normal stage of development, which usually peaks between the ages of 2 and 6 (Cole NC, An R et al, 2017).
• Feeding problems and difficulties, disturbances of eating and eating behaviour — a fairly large group of children often called “picky eaters”. They usually eat less than children do on average.
• Feeding disorders in children (ARFID) — only 1–3% of all children whose parents report feeding difficulties.

As a rule, most children with feeding difficulties belong to the first and second groups.

Based on materials from Alexandra Mikhailidis (Slautina)'s programme “Counselling and feeding therapy for feeding difficulties and disorders in children”.

What is ARFID?

ARFID (Avoidant/Restrictive Food Intake Disorder) is a disorder characterised by selective eating that is not related to a lack of available food or to cultural preferences. People with ARFID (most often children — and since I work with children, this page is mostly about them) may refuse certain foods because of their texture, smell or taste, or even because of traumatic experiences involving food. The main problem is the restricted diet, which can lead to nutrient deficiencies and physical or psychological problems.

There are eating disorders — the well-known anorexia, bulimia, binge eating and others — which are mental illnesses rooted in a disturbed body image. ARFID is a feeding disorder that is partly similar to anorexia, in that there is a restriction in the amount and/or types of food eaten, but unlike anorexia, ARFID does not involve any concerns about body image.

Effects on social life

Children and adults with ARFID quite often struggle in situations that involve food:

• being around food that other people are eating — some foods can cause disgust, even to the point of gagging;
• eating their own “safe” food when other people are around.

Such children may avoid meals at nursery and school or eat very little.

What causes it?

Genetic factors. Some children may have an inherited predisposition to heightened sensitivity around food, which shows up as a stronger reaction to food stimuli such as taste, texture or smell. If parents or grandparents had feeding difficulties or emotional reactions to certain foods, this may be reflected in the child.

Sensory sensitivity. Children with sensory differences often become selective eaters. This is especially typical of children with sensory processing difficulties or neurodevelopmental conditions such as autism or ADHD. They may feel strong discomfort because of a certain food consistency: for example, soft textures (purées, yoghurts) may either attract them or, on the contrary, cause disgust.

Traumatic experiences. A negative experience with eating can become one of the key factors in developing ARFID. For example:

• fear of choking: if a child once choked on food, this may become fixed as a frightening experience and lead to refusing new or “suspicious” foods;
• allergic reactions: even a single severe allergic reaction to a food can lead to long-term avoidance of similar foods.

Psychological factors. Children with anxiety disorders, phobias or high levels of stress may be prone to developing ARFID. Often the fear of new food or changes to the diet is too strong for the child to overcome on their own. In some cases this anxiety is linked to a need for control: familiar food is seen as “safe” and any change as a threat.

Physical illness. Some physical conditions can affect how a child perceives food and eating. These include:

• gastrointestinal conditions (reflux, gastritis);
• chronic illnesses that cause nausea or pain;
• reduced appetite due to general illness.

In such cases the association between food and unpleasant sensations becomes fixed and can turn into a behavioural problem.

Social influence and habits. Sometimes selectivity stems from early experiences with food in the family. If a child watches parents or other family members avoid certain foods, they may come to see this behaviour as normal. Peers who judge someone's diet can also play an important role in shaping eating habits.

The main types of ARFID

Avoidance based on the sensory characteristics of food. Children with this type often have heightened sensitivity, which leads to strict preferences. They may eat only foods of a certain colour, texture or shape. The restrictions also extend to how dishes are prepared and served, for example:

• foods on the plate must not touch;
• a meatball has to be cut into exactly equal pieces;
• only one specific kind of pasta.

As a result, the child eats only a limited range of foods that meet their specific requirements for preparation and presentation.

Lack of interest in food. The child may have no appetite, get full too quickly or eat on an irregular schedule. These children often forget to eat or eat tiny amounts, as if “snacking”. At mealtimes they may be distracted, which makes eating harder.

Food refusal after a negative experience. This type is linked to anxiety caused by an unpleasant experience around food. For example, fear of choking, vomiting or pain, or difficulty swallowing, can make a child avoid certain foods or meals altogether.

These types are not mutually exclusive. A mixed form of two or even three types of ARFID is common. What's more, even within one type ARFID can look completely different from one child to another, so diagnosis and treatment need an individual approach.

Source: the Russian website “Selective Eating Disorder” (arfid.ru).

Treating ARFID

Because ARFID is a fairly new diagnosis (it was added to medical classifications in 2019), little is known about how best to treat it. At present there is no evidence-based psychological therapy that suits all forms of ARFID (that is, not enough research has been carried out and documented on any specific treatment programme to establish a “recipe for success”), but this does not mean nothing can be done.

Older children and adults with ARFID have improved their health and quality of life thanks to some of the same cognitive and behavioural interventions used to treat anorexia nervosa, adapted for ARFID. The most promising is a new form of CBT specific to ARFID (CBT-AR), which has been published for use by both professionals and parents.

Any form of ARFID treatment should be supervised by a specialist team experienced in treating this disorder. Such a team is usually multidisciplinary and includes a paediatrician, a gastroenterologist, a dietitian and nutrition specialist, a psychologist and a psychiatrist, a sensory therapist and a speech therapist. This team can design a programme to meet the person's many unique difficulties and needs.

Because ARFID does not look the same in everyone, treatment only succeeds when it is based on the individual problems and challenges the person faces. There is no one-size-fits-all treatment for ARFID.

Treatment goals

ARFID treatment always starts with the patient and their care team setting goals related to eating. Goals may include:

• correcting faltering growth and micronutrient deficiencies;
• eating a wider range of foods;
• taking steps to eat comfortably in front of other people;
• reducing the fear of choking or vomiting;
• bringing back interest in food;
• reducing anxiety around eating.

Desensitisation therapy

One of the most effective types of ARFID therapy for children is desensitisation (or exposure) therapy. It is a method used to help the child overcome anxiety and fear of particular foods or eating situations.

The main principles of desensitisation therapy for ARFID:

• Gradual exposure. Therapy begins with minimal exposure to trigger foods or situations. Tasks start with the most acceptable foods or textures and gradually move on to more difficult ones.
• Focus on sensory aspects. Many people with ARFID have difficulties with the texture, smell or colour of foods. Desensitisation may involve getting to know foods step by step: first by looking, then by touching (for example, holding the food), and then moving on to tasting.
• Support and building confidence. During therapy it is important to support the child and recognise their efforts at every stage. Each completed step is reinforced with positive feedback, which builds self-confidence.
• Practice in real life. Encouraging tries of new foods or situations not only in the therapy setting but also in everyday life. This helps consolidate the skills learned and adapt them to real situations.
• Cognitive behavioural therapy (CBT) techniques. A CBT therapist helps the person with ARFID identify and challenge irrational beliefs about food (for example, “this food will make me sick”). Relaxation and anxiety-management techniques are used to reduce the emotional load.
• Building a fear hierarchy. A list is made of foods or situations that cause different levels of anxiety. Therapy starts with those causing the least anxiety and progresses to more difficult ones.

Results of therapy and additional methods

Results of desensitisation therapy:

• a gradual reduction in anxiety and fear around food;
• a wider range of foods eaten;
• better overall health thanks to a more balanced diet;
• a better quality of life and less social isolation.

Additional methods:

• working with the family: involving the family in therapy helps create a supportive environment;
• food play: a playful approach to getting to know new foods can be especially helpful for children;
• sensory integration: for marked sensitivity to textures and smells.

Desensitisation therapy is a long process that requires patience and consistency, but it is highly effective, especially when combined with other forms of psychotherapy and support.

Group therapy for parents

Group therapy for parents is often offered by ARFID specialists as an important part of treatment, because the effects of this way of eating are usually felt by the whole family.

Parent therapy is a great way to learn more about ARFID while picking up practical tools to use at home. It can also give parents a sense of belonging and a chance to hear the stories and struggles of other parents in similar situations — and to realise that they are not alone with these problems.

How my team and I can help: TASTE GAMES sessions in Kaliningrad

“TASTE GAMES: sensory therapy for picky eaters” is a brand-new and unique programme. We invite you to sessions devoted to feeding therapy for children aged 3 to 7. If your child has a limited diet or excludes whole food groups, our sessions will help overcome these difficulties.

Our sessions are a fun and useful time in which children learn to see food in a new way. We have created a programme that includes a thorough exploration of the properties, textures and consistencies of different foods. Children get to touch food, smell it and even experiment with it!

The sessions run at the same time as sessions for mums, who learn the basics of healthy eating behaviour in children and receive recommendations on adjusting their child's sensory profile, plus a plan for working with the child at home.

These sessions are unique for our city: we have combined a gentle, responsive approach to feeding, exposure therapy to expand the diet and sensory activities to tackle selective eating more effectively.

Quiz: does my child have feeding difficulties? (ages 2 to 10)

Take this short quiz to see whether your child has feeding difficulties. Each answer shows how many points to give it.

• Does your child show or tell you when they are hungry? Yes — 0; no — 2.
• Does your child show or tell you when they are full? Yes — 0; no — 2.
• Does your child eat enough? Yes, I think it's enough — 0; sometimes I think it's not enough — 1; no, I think it's not enough — 2.
• Has your child lost weight recently? Yes, their weight has gone down — 2; no, their weight is going up — 0.
• How long does it take you to feed your child? Up to 5 minutes — 2; 5–20 minutes — 0; more than 20 minutes — 1.
• Does your child's diet include more than 10 different foods? Fewer than 10 foods — 2; more than 10 foods — 0.
• Does your child eat (are they offered) the same food as the rest of the family or group, for example at nursery? Yes, we all eat the same — 0; no, their food is different — 2.
• Has your child added at least one new food to their diet in the last 3 months? Yes — 0; no — 2.
• Does your child cry when put at the table to eat, or refuse to sit down, and changing the place of the meal doesn't help or change anything? Yes, they refuse, and changing the place and conditions doesn't help — 2; yes, they refuse, but changing the place of the meal helps — 1; no, they don't refuse — 0.
• Will your child refuse to eat unless cartoons are on, a particular toy is there, or some other condition is met? Yes, they only eat under these conditions — 2; it varies, they may eat with or without cartoons, I don't see a difference — 1; we don't put cartoons on at the table — 0.
• Does your child refuse to touch unfamiliar food, or refuse even a favourite food if it is next to or touching an unfamiliar one? Yes, they refuse and won't eat — 2; yes, they refuse, but if the conditions change, for example the unfamiliar food is removed from the plate, they will eat — 1; no, they won't refuse — 0.
• Does your child eat only under particular conditions, for example only one brand of cheese or a drink with a specific picture on it? Yes, we have to choose specific brands — 2; no, my child doesn't mind — 0.
• Do you have to coax, force or keep reminding your child to eat, because otherwise they won't eat anything? Yes, I coax or force them and keep reminding them — 2; no, I don't do anything like that — 0.
• Does your child's eating worry you? Yes, I feel anxious before every meal — 2; yes, I sometimes worry about what and how much my child will eat — 1; no, I don't worry about it — 0.

* This quiz is not a diagnostic tool and cannot be interpreted as a diagnosis. A final diagnosis of ARFID is made by a psychiatrist based on the child's history and an in-person examination.

Quiz results

• 0–6 points — your child's eating is fine. There are minor difficulties, but they pose no serious threat or reason for concern.
• 7–12 points — children in this group are usually “picky eaters”: they often have a reduced number of foods in their diet (10–30 foods) and usually find it hard to accept new foods. Exposure therapy suits this group, and parents should stop putting pressure on the child at mealtimes. Focus on exploring new foods, cook together and share meals.
• 13–28 points — there are significant feeding difficulties; with high scores (above 20) there is a risk of a feeding disorder (a final diagnosis is made by a psychiatrist based on the child's history and an assessment of the situation). As a rule, the situation doesn't resolve on its own, and it's worth seeking help from feeding specialists for further assessment and to choose a way of addressing the difficulties.

Where to get help

If you are facing difficulties with your child's eating, you can come to me for an in-person or online consultation, or sign up for the group sessions “TASTE GAMES: sensory therapy for picky eaters”.

Colleagues of mine who work with a range of feeding difficulties (in person and online):

• Alexandra Mikhailidis (Slautina), Moscow — psychologist (children of all ages and adults). Selective eating, ARFID, infant feeding disorders: https://rebenokdoma.com/feeding-therapy
• Yulia Valliulina, Kazan — child nutrition and eating behaviour consultant (ages 0 to 12), works in person and online. Selective eating, ARFID: https://lunnayaumka.ru/

The most complete list of specialists is on https://arfid.ru/

Useful resources

• https://arfid.ru/ — the Russian website “Selective Eating Disorder” (materials on ARFID and a large directory of specialists)
• https://www.feedingmatters.org/ — the website of the international organisation Feeding Matters
• https://www.arfidawarenessuk.org/ — the website of the charity ARFID Awareness UK
• https://sosapproachtofeeding.com/ — a website created by a team of specialists working with the SOS Approach (led by Kay Toomey), with resources for both parents and professionals
• https://childfeeding.org/ — a website created to support families of children with a wide range of feeding difficulties; it was created by a team of doctors, families and scientists from Australia, Supporting Children with Complex Feeding Difficulties (SuCCEED)