When Picky Eating Isn't Just a Phase: Navigating the Challenges of Avoidant / Restrictive Food Intake Disorder

What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

As we mentioned above, these mealtime struggles are a common rite of passage in many households, as parents navigate the ever-changing tastes and preferences of their children, it's essential to distinguish between typical fussy eating and a more serious condition known as Avoidant/Restrictive Food Intake Disorder (ARFID) (American Psychiatric Association, 2022). Both typical fussy eating and ARFID involve selective eating habits and aversions to certain foods; however, they differ significantly in their severity, persistence, and impact on a child's physical and psychological well-being. Understanding these differences is crucial for parents, caregivers, and healthcare professionals to provide appropriate support and intervention tailored to each child's needs.

Amidst the diverse spectrum of eating disorders, one often overlooked yet profoundly impactful condition is ARFID. Unlike more widely recognised eating disorders such as anorexia nervosa or bulimia nervosa, ARFID manifests uniquely, characterised by a persistent rejection of certain foods or food groups, leading to significant nutritional deficiencies and impairments in daily routines.

For individuals living with ARFID, mealtimes are not simply about taste preferences or picky eating habits - they represent a battleground of anxiety, fear, and distress. Foods that may seem innocuous to others can evoke intense feelings of discomfort or even panic for those with ARFID, making every meal a daunting challenge.

While it often emerges in childhood, it can also be triggered by a traumatic experience at any time across the lifespan. It can be identified as a chronic limited diet that may be restricted in either variety or volume. For a diagnosis, it is accompanied by either significant weight loss, nutritional deficiencies (or dependence on supplements), or impairment in psychological or social functioning.

Individuals experiencing ARFID often feel anxiety, fear or disgust related to food. This can result in developing strategies to cope with these unpleasant feelings, known as avoidance behaviours. This might look like refusing to eat in public, feeling anxious about attending social-eating events or limiting the amounts of food or types they eat. Due to this, individuals may develop a range of ‘safe’ foods. These are foods that they consistently feel comfortable about eating and are usually limited to a certain texture, colour, brand or food group.

The restricted routines around food can also take a toll on the families of those diagnosed with ARFID. Parents will describe the constant stress of needing to plan ahead to ensure that they always know what food will be available. This might involve avoiding certain events or packing their own food to take to parties. It can be debilitating for the individual and their family, as they are unable to share meals, attend social events, or eat at restaurants due to the stress and fights about food.

It is predicted to occur in 1 out of 300 people in Australia (Hay et al., 2017). It is different to Eating Disorders, as concerns are not focused on weight and shape but rather related to the experience of food itself. It is typically associated with one of the following:

1. An apparent lack of interest in eating or a restricted range of preferred foods. This may be the inability to detect when they are feeling hungry or lack of enjoyment from eating
   ‍
2. An experience of anxiety or fear related to eating, which can be associated with past negative experiences with food (e.g., choking, vomiting), or concerns about the consequences of eating (e.g., allergic reactions)

Individuals with ARFID may have heightened sensory sensitivities related to taste, texture, smell, or appearance of food and may feel disgusted or stressed by the sensory experiences of eating. They may find certain food properties aversive, have difficulty tolerating them, and avoid entire food groups, textures, colours, or specific smells. Often, Individuals with ARFID prefer predictable foods, like packaged or fast foods, rather than fruits and vegetables that are inconsistent in texture and flavour! (American Psychiatric Association, 2022)

When attempting to understand the experience of ARFID, it is helpful to reflect upon either your biggest fear (e.g., spiders or something revolting like vomit). To comprehend the physiological and psychological response of an individual with ARFID, imagine being offered these items on a plate for breakfast, lunch and dinner repeatedly and pressured to consume them on the promise that you ‘will like it’. Many individuals with ARFID describe this distressing experience as how they feel when presented with food.

The treatment of ARFID

It can be overwhelming managing mealtimes with a family member with ARFID. It is important to remember that this disorder needs support and understanding, not pressure or punishment (Powell, et al., 2011). There is an underlying biological predisposition or a history of stressful experiences underlying the disorder and its associated behaviours. Those experiencing ARFID endure extreme distress and are often confused by their own reactions to food.

ARFID can have serious physical and psychological consequences if left untreated. For instance, children with ARFID may not receive adequate nutrients, leading to deficiencies. Additionally, they can develop intense distress around eating, impacting their social lives or self-esteem.

It is important to access appropriate intervention, which may include nutritional counselling, family support and therapy, to support individuals in developing a healthier relationship with food.

Next Steps for Treatment

If you suspect a child may be experiencing ARFID, seek professional help from a healthcare provider, such as a Paediatrician or mental health specialist, who can assess and provide appropriate treatment options.

Quality interventions involve a thorough assessment to identify the needs of your child, followed by individualised treatment plans. It is crucial that this includes both one-on-one support for children to build confidence to manage new foods and a parent support component. Parent support prepares families with education and skills to provide a supportive and calm mealtime environment with appropriate opportunities for success.

Experienced therapists will aim to support your child in addressing both the physical and psychological aspects of the disorder. It is also your job to provide a supportive mealtime environment as your child learns to navigate new foods! Consider which supports might be the right fit for your family. There are a range of experts that provide the following:

Dieticians

Nutritional counselling: Work with a Accredited Practising Dietitian who specialises in paediatric feeding disorders and understands ARFID. They can help your family to develop a structured and individualised meal plan. Work commences with the foods that your child already accepts, then moves towards nutritional adequacy. Dietitians can also discuss specific supplements to fill gaps while your child explores new foods. Dieticians can additionally provide education and support to parents and caregivers regarding mealtime strategies and food exposure techniques.

Psychologists

• Cognitive-behavioural therapy (CBT): CBT techniques can help children with ARFID identify and challenge their thoughts, feelings, and fears related to food and eating. This therapy can also address anxiety or other emotional factors that contribute to the avoidance or restriction of food. CBT may involve cognitive restructuring, relaxation exercises, and gradual exposure to feared situations. Finding a psychologist with an understanding and experience of working with ARFID is essential.
• Exposure therapy: Gradual exposure to new or avoided foods is central to ARFID treatment. This involves a step-by-step approach, starting with less challenging foods and gradually progressing to more difficult ones. Exposure therapy is typically done under the guidance of a mental health professional experienced in treating ARFID.
• Addressing underlying factors: In some cases, ARFID may be related to underlying factors such as anxiety, trauma, or other mental health conditions. If present, addressing these factors through appropriate therapies or interventions may be necessary to support the overall treatment of ARFID.

Occupational Therapists

• Sensory integration therapy: For children with ARFID who have sensory sensitivities or aversions, sensory-focused therapy techniques can be beneficial. This therapy aims to help the child gradually tolerate and adapt to sensory experiences associated with food. Trained professionals can provide play-based strategies to address sensory processing issues and develop sensory diets to manage sensory sensitivities.

Speech Therapists

• Oral-motor skills: For children with ARFID, they may experience difficulties related to the coordination and movement of the muscles involved in feeding and oral function. These concerns can contribute to feeding issues in infants and children. A speech therapist who has been trained in feeding therapy can guide a range of issues, including: weakness in the muscles of the lips, tongue, and jaw; poor tongue control; issues with tongue thrust or limited tongue mobility; poor lip closure; hypersensitivity; or, aversion to oral stimulation.

Parental involvement and support

Parents play a crucial role in the treatment of ARFID. They can provide a supportive and structured mealtime environment, implement strategies recommended by healthcare professionals, and help with gradual exposure to new foods. Parental education, guidance, and involvement in therapy sessions can also be beneficial.

It's important to note that treatment approaches may vary based on each child's individual needs and specific circumstances. A comprehensive evaluation by a healthcare professional experienced in treating ARFID is essential to develop an individualised treatment plan. This plan should consider the child's medical history, nutritional status, psychological factors, and any underlying conditions or comorbidities.

ARFID treatment can be gradual and long-term, requiring patience, consistency, and ongoing support. It is essential to watch the child's growth and nutritional well-being, making gentle adjustments to the treatment plan as their unique progress unfolds. In this nurturing journey, every small step forward is a victory; together, we build a brighter, healthier future.