ARFID in Children

Does My Child Have Avoidant/Restrictive Food Intake Disorder (ARFID)?

For the most part, kids are pickier eaters than adults. If your child is a “picky eater” you may be wondering whether their eating is normal or not. You may have heard about Avoidant Restrictive Food Intake Disorder (ARFID) and wonder whether your child might have it. It can be hard to project whether this pickiness is a phase through which they will pass or a persistent psychological condition that warrants intervention. And the line between a “normal” picky eater and a child with ARFID may not be so clear. As with most disorders, there is a continuum.

Most children are somewhat fearful of new foods, most commonly vegetables and secondarily proteins such as meat and fish. This fear—“neophobia”—usually peaks between ages two and six. It is likely an evolutionary protection and might have developed as a way to protect the children of our ancestral foragers from toxins found in inedible plants.

So, if your child is six or younger, it is possible they may still outgrow the reluctance to try new foods.

What is ARFID?

ARFID is a type of eating disorder in which a person eats a limited variety or amount of food and it affects them negatively in terms of their health or ability to participate in life activities. The primary reason for the undereating is not because of concerns about weight or shape or not entirely due to another medical or psychological problem.

At What Age Is ARFID Diagnosed?

ARFID can be diagnosed at any age. Many children who go on to develop ARFID show signs as young as two or three. However, because kids are commonly more picky at this age, those who show signs in toddlerhood may develop into less restrictive eaters as they mature. If the symptoms seem severe at a young age and cause nutritional deficiencies or impact growth, your child may be diagnosed as young as two to four. More commonly, professionals diagnose ARFID in children ages five and up.

What are the warning signs of ARFID?

There are several potential warning signs of ARFID. These can include:

• Limited variety of foods compared to same age peers
• Weight loss or failure to gain weight
• Failure to grow in height
• Nutritional deficiencies
• Reliance on nutritional supplements such as shakes to get enough food
• Inability to eat in social settings or school
• Eating causes conflict with others
• Strong food aversions
• Reluctance to try new foods
• Sensitivity to slight variations in the presentation of food
• Strong disgust reactions to novel foods such as gagging
• Little interest in eating
• Lack of enjoyment of eating
• Expressed fear of something bad happening after eating (such as choking, pain, or vomiting)

How is a Child Diagnosed With ARFID?

If you are concerned about your child’s eating and wonder if they might have ARFID, checking with your child’s doctor is always a good first step. Because ARFID is a relatively new diagnosis, some doctors may be unfamiliar with ARFID. You can ask for a referral to a therapist or dietitian who works with children with eating disorders. If your child is under six, you may ask for a referral to a pediatric feeding clinic. These programs are usually multidisciplinary and include occupational therapists and speech therapists who can evaluate and diagnose whether there might be oral-motor problems affecting chewing and swallowing.

Who can diagnose ARFID?

A number of different professionals are able to diagnose ARFID in children. This includes medical doctors, therapists, and dietitians. Often speech and language pathologists and occupational therapists also participate in multidisciplinary evaluations of younger children.

How Do Professionals Make a Diagnosis of ARFID?

Professionals assessing for ARFID will assess eating history and patterns. They will review medical history and growth.

The psychological assessments used to diagnose anorexia, bulimia, and binge eating do not adequately assess for ARFID. Thus, specialized assessments for ARFID fill the gap. Common assessments used by professionals to diagnose ARFID include:

• The Nine Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS)
• The Pica, ARFID, and Rumination Disorder Interview (PARDI)
• The PARDI-AR-Q
• The Food Neophobia Scale (FNS)
• Eating Disturbances in Youth-Questionnaire (EDY-Q)

How is ARFID Treated in Children?

Treatment should include psychoeducation with the family about the factors that maintain ARFID. There are three primary psychological treatments for children with ARFID.

Feeling and body Investigators (FBI)-ARFID Division

Feeling and body Investigators (FBI)-ARFID Division draws from treatments for panic disorder and irritable bowel syndrome. Nancy Zucker, Ph.D. and her colleagues at Duke Center for Eating Disorders developed this therapy. This treatment uses acceptance-based interoceptive exposure activities to decrease avoidance of eating and body sensations. Children learn to engage playfully with body sensations and food through cartoons and developmentally sensitive exposures. This treatment is conducted over approximately 15 sessions and may be applied to children ages four to ten.

Cognitive-Behavioral Therapy for ARFID (CBT-AR)

Cognitive-Behavioral Therapy for ARFID (CBT-AR) was developed by Jennifer Thomas, Ph.D. and Kamryn Eddy, Ph.D. at Harvard University. This treatment is appropriate for children—as well as teens and adults—-ages ten and up. This therapy usually consists of about 20 to 30 sessions over six to 12 months. In CBT-AR for children, the provider works with the child as well as the parents. Firstly the therapist provides psychoeducation about ARFID. Next, they help the family establish a pattern of regular eating primarily using preferred foods. If the child needs to gain weight, the initial focus is on increasing the volume of food and some variety to produce weight gain. The therapist then helps the patient identify foods to introduce through exposure. Then the patient engages in exposures both in session and at home.

Family-Based Treatment (FBT) for ARFID

Family-Based Treatment (FBT) is the leading evidence-based treatment for anorexia in children and teens. It has also been applied to children and teens with ARFID. In FBT for ARFID, the parents play a central role in helping their child to eat more. Parents may use behavioral strategies to reinforce eating greater volume and variety of foods.

How to Support A Child With ARFID

We know how challenging it can be to support a child or teen with Avoidant/Restrictive Food Intake Disorder (ARFID). Mealtimes may often feel like a battle. It can be exhausting to find foods your child will eat. The worry about their health and inadequate nutrition only adds to the concern.

There are some practical strategies to help you navigate feeding difficulties and create a positive relationship with food for your child or teen with ARFID. Ensuring that your child or teen with ARFID receives adequate nutrition requires a routine of three meals and 2-3 snacks throughout the day. Discourage grazing between meals, as it can hinder their ability to recognize hunger cues and obtain necessary nutrition. At meal and snack times, prioritize serving their preferred foods, whatever these are. We have a separate page that describes in greater detail strategies for feeding children with ARFID.

Because it is so challenging we have created a support group just for parents like you–parents of people with ARFID. This group meets monthly and is open to parents in any location around the world.

Begin Treatment for Children with ARFID in California

At EDTLA, our eating disorder specialist therapists provide therapy for children with ARFID ages ten and up. We also provide a group for parents of people ages ten to twenty with ARFID. Contact us now to get help for your child with ARFID.