What Is ARFID?

When we think of eating disorders, we think first of young women who are obsessed with losing weight, and go to unhealthy extremes of diet and exercise to do it.  But in the case of an eating disorder called ARFID (avoidant restrictive food intake disorder), the picture looks very different.

ARFID stands for “avoidant restrictive food intake disorder,” and it became a clinical diagnosis in 2013 with the release of the DSM-5. Because it’s a relatively new diagnosis, clinicians are still learning about the disorder and how to treat it. But a few key features set it apart from other eating disorders.

“Kids with ARFID don’t particularly care about weight or shape, definitely not in the way that young people with bulimia nervosa, typical anorexia nervosa or atypical anorexia nervosa do,” says Daniel Le Grange, PhD, director of the Eating Disorders Program at the University of California, San Francisco. “What distinguishes ARFID from those three eating disorder diagnoses is their worry about the taste, texture, color or even ‘movement’ (such as Jell-O) of food.” Kids with ARFID may or may not be underweight, but losing weight isn’t the motivation behind their eating habits. Instead, they avoid certain foods or groups of foods for a wide variety of reasons — which are often mystifying to their families.

Additionally, ARFID typically shows up in much younger kids than other eating disorders do. Signs can become clear by the time a child is six or seven, but because it can be hard to tell ARFID apart from normal picky eating, they may not get a diagnosis right away. And boys are diagnosed with ARFID about as often as girls are — unlike other eating disorders, where girls are much more likely to be diagnosed.

Lots of kids are picky eaters. So how is ARFID different?

The hallmark of ARFID (avoidant restrictive food intake disorder) is restriction or avoidance of certain foods or groups of foods in a way that is so extreme that it interferes with the child’s daily life and physical health. The specifics can look very different for different children.

Many kids with ARFID avoid foods that have a certain taste, texture, color or some other specific quality. For example, they might refuse to eat anything green or anything crunchy. They often have a very limited set of foods that they like and get intensely upset or even nauseated if they have to eat something else. This is often called “avoidant” ARFID.

Other kids with ARFID restrict their eating due to a fear of choking, vomiting or otherwise getting ill. They may have vomited or choked on a certain food before (or seen it happen to someone else) and developed extreme anxiety about having it happen again. For example, if they once got a piece of tomato stuck in their throat, they might refuse to eat not only tomatoes but all red things or things with a similar smell. This form of fear-based ARFID is sometimes called “aversive.”

Finally, some kids with ARFID simply have little interest in food or eating. They might forget to eat, get distracted easily during meals, or eat extremely slowly. They also tend to like only a narrow set of foods. This is often called “restrictive” ARFID.

It’s common for kids with all types of ARFID to have rigid habits or rituals around eating. For example, they might insist on eating things in a certain order or keeping foods they don’t like away from their plates.

For a child with any of these eating patterns to be diagnosed with ARFID, their eating habits must have a significant negative impact on their physical and/or mental health. Often, kids with ARFID lose an unhealthy amount of weight, or they fail to gain weight and grow as they get older. About 50 percent of kids with ARFID are underweight for their age. They may also have significant nutritional deficits, which means that they don’t get enough calories or a wide enough variety of nutrients for their bodies to function normally.

The social impacts of ARFID are profound as well. “You don’t go out with your family to a restaurant,” says Dr. Le Grange. “You don’t accept invitations from your friends if it involves eating. It can even get in the way of going to school.”

In general, early symptoms of ARFID (avoidant restrictive food intake disorder) look like extreme forms of picky eating. Some behaviors to look out for in young children include:

• Liking very few foods
• Avoiding specific foods or groups of foods based on qualities like texture or color
• Pickiness that gets worse over time, including refusing to eat foods that they once liked
• Anxiety at mealtimes
• Intense fear of choking or vomiting
• Eating very slowly
• Lack of appetite or getting full quickly
• Complaints of feeling sick after eating

Because kids with ARFID are often malnourished, there may be physiological warning signs as well. These signs can also be indicators of other eating disorders, especially anorexia nervosa, and it’s important to seek medical treatment if your child shows any of them. Physiological warning signs include:

• Weight loss, or failure to gain weight and grow as expected for their age
• Digestive problems that don’t have another medical explanation
• Trouble concentrating
• Dizziness or fainting
• Sleep issues or feeling tired all the time
• Feeling cold
• Dry skin, brittle nails or hair loss
• Missing menstrual periods
• Weakened immune system

One of the things that can make ARFID (avoidant restrictive food intake disorder) difficult to diagnose is that its symptoms often overlap with other eating disorders (most likely anorexia nervosa) or another disorder altogether — and many kids have both ARFID and another disorder.

Attention and anxiety disorders can show up in ways that look like ARFID. Kids with ADHD might show less interest in food or eat slowly because they’re easily distracted. Or a child with social anxiety might be too scared to eat lunch at school in front of their classmates.

Moreover, ARFID can be confused with, and overlap with, autism. Like kids with ARFID, kids on the autism spectrum are often very sensitive to the sensory experience of eating. For instance, they might refuse to eat anything too mushy or too crunchy.  

Finally, because kids with ARFID often have ritualized behaviors and rigid habits around eating, their behavior can look like — and overlap with — obsessive-compulsive disorder (OCD). “Emetophobia, or fear of vomiting, is the main condition under OCD that might be confused with ARFID,” says Jerry Bubrick, PhD, director of the Obsessive-Compulsive Disorder Service at the Child Mind Institute. He gives the example of a child who eats too much at Thanksgiving and vomits, and then develops an intense fear of vomiting and everything else that reminds them of that incident. “They might throw away that outfit, refuse to sit at the same place at the table, and refuse to eat any Thanksgiving foods,” Dr. Bubrick explains.

Because this child’s fear of vomiting is causing them to compulsively avoid so many different things — not just foods — their diagnosis would more likely be OCD, even though their eating is restricted. “The nutritional deficits are often the thing that sets ARFID apart,” says Dr. Bubrick. “If that same child were eating far less overall and not taking in enough calories because of that experience, and they’re starting to suffer from a nutritional perspective, then the diagnosis would tend more toward ARFID.” It’s also possible for a child to be diagnosed with both OCD and ARFID.

Because possible signs of ARFID (avoidant restrictive food intake disorder) can be so hard to interpret, it’s important to get a thorough evaluation from an experienced professional if you think your child might have it. It’s best to start with an eating disorder specialist if possible, though other clinicians (such as those who work with kids with autism or gastrointestinal issues) may also pick up on signs on ARFID in kids who initially seem to have a different problem. And if you think that your child may have another diagnosis as well, such as OCD, it’s helpful work with a specialist in that field too, particularly during evaluation.

Because ARFID is a relatively new diagnosis, researchers are still exploring the best ways to treat it, and there’s not yet a clear evidence-based treatment model. “There are a couple of pilot studies, treatment development studies, but there are no randomized clinical trials,” says Dr. Le Grange. “So we can’t say with any certainty. But there are a couple of treatment candidates that are pretty promising.”

For cases where a child with ARFID is underweight or malnourished, a big part of treatment (as with other eating disorders) is helping them regain weight and maintain medical stability. This might involve working with nutritionists and endocrinologists, while occupational therapists can help children overcome sensory challenges related to eating.

Treatment for ARFID also has a lot in common with treatment for OCD and other anxiety disorders, especially in cases where the child is not underweight. There are several promising initiatives underway to adapt cognitive-behavioral therapy (CBT) for use in kids with ARFID. These include a model called CBT-AR, as well as one that combines family-based treatment for eating disorders and an anxiety treatment model called the Unified Protocol (FBT-UP).

Dr. Bubrick notes that kids with ARFID often believe very strongly that their irrational fears are true — that is, they believe that they really will vomit if they eat something green, rather than being able to acknowledge that that outcome is unlikely. For that reason, it can be difficult to use exposure therapy for these children, since even the smallest exposure to the thing they fear triggers too much anxiety. Accordingly, Dr. Bubrick says that it’s often helpful for ARFID treatment to start with cognitive work to help kids view their fears in a more rational way. Then, they can proceed with exposure therapy knowing that the foods that make them anxious aren’t actually dangerous.

Despite the complexities, Dr. Le Grange emphasizes that whatever treatment children get, involvement of parents and support at home are key. And it’s clear that early intervention is important. While kids who are picky eaters usually outgrow their fussiness, kids with ARFID who don’t get treatment often continue to experience symptoms as adults (although ARFID rarely begins in adulthood). 

“When you look at the few studies that are available for ARFID, there are a significant number of young persons who, when they were six or seven, were already showing clear symptoms and signs, but the parents just thought they were picky eaters or awkward eaters,” he says. Because it can be so hard to pinpoint what’s ARFID and what’s not, it’s important to reach out for help if your child’s picky eating is having a negative impact on their physical, social or emotional well-being.