Medically reviewed by Timothy J. Legg, PhD, PsyD
Written by Jessica Caporuscio, Pharm.D.
It is not unusual for children to be picky eaters, and many grow out of this behavior. However, some children demonstrate more severe picky eating habits, such as limiting their diet to only certain textures or showing deep concern for the possible harmful effects of eating.
When these individuals stop growing, they need medical attention.
Doctors now classify a severe form of picky eating in children as avoidant/restrictive food intake disorder (ARFID). Although this disorder shares some similarities with anorexia and bulimia, children living with ARFID do not have a poor body image or desire to lose weight.
In this article, we describe ARFID and explain the treatment options. We also cover what parents and caregivers can do to help.
What is ARFID?
ARFID is a newly recognized eating disorder that features in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 defines mental disorders to help doctors and psychiatrists improve diagnosis and treatment.
Many parents and caregivers label their child as a picky eater, but sometimes, eating behaviors can become abnormal.
When a child’s eating behavior progresses to a general lack of interest in eating and starts to affect their growth and development, doctors diagnose an eating disorder, which may be ARFID.
The difference between being a picky eater and having ARFID is that children with ARFID:
- do not eat enough calories
- stop gaining weight
- stop growing
Some adults may also have ARFID, which can cause weight loss and affect normal bodily functions.
In the DSM-5, ARFID replaces an eating disorder called feeding disorder of infancy or early childhood, which doctors only diagnosed in children up to and including the age of 6 years. In contrast, ARFID has no age limitation.
The major difference between ARFID and anorexia or bulimia is that a child with ARFID does not have a problem with their body image.
Studies have shown that, compared with people with anorexia, those with ARFID are more likely to be admitted to the hospital with a lower body weight relative to their estimated healthy body weight.
Researchers also suggest that people with ARFID are more likely than those with other eating disorders to:
- have longer hospital stays
- rely more on tube feeding for nutrition
- struggle more with gaining weight during hospitalization
People with ARFID usually receive a diagnosis at a younger age than people with anorexia and bulimia, and a higher percentage of those affected are male. ARFID may also persist for longer than other eating disorders.
Doctors use the criteria in the DSM-5 to diagnose ARFID. People with ARFID typically have an eating disturbance, such as:
- lacking interest in eating or food
- avoiding food based on texture
- expressing concern about the unpleasant consequences of eating
In ARFID, the eating disturbance causes a lack of appropriate nutrition, leading to a person not meeting their energy needs. As a result, it can cause:
- significant weight loss
- nutritional deficiencies
- reliance on feeding tubes or supplements
- negative effects on psychosocial functioning
Symptoms and warning signs
ARFID has several associated warning signs that parents and caregivers may identify. These include:
- dramatic weight loss
- dressing in layers to stay warm or hide weight loss
- digestive issues, such as constipation
- restricting types or amounts of food
- only eating foods with certain textures
- feeling sick or full around mealtimes
- feeling cold
- weakness or excessive energy
- fear of choking or vomiting
- a restricted range of preferred foods that becomes more limited over time
Other symptoms of ARFID include:
- abdominal pain
- a history or fear of vomiting or choking
- gastroesophageal reflux disease (GERD), also known as acid reflux
Risk factors for developing ARFID
In comparison with other eating disorders, doctors do not know much about ARFID because it is a newly defined disorder. Still, doctors have noticed some potential risk factors for ARFID, which include temperamental, environmental, genetic, and physiological factors.
More research is necessary in this area, but it seems that autistic children and children with attention deficit hyperactivity disorder (ADHD) and intellectual disabilities are more likely to develop ARFID.
Some children with severe picky eating habits that they do not outgrow may also develop ARFID.
Children living with ARFID may also have anxiety and be at higher risk of other psychiatric disorders.
Possible health complications
Eating disorders are psychological diseases that cause physical symptoms, which can result in severe illness and death.
People with ARFID, just like those living with anorexia or bulimia, do not meet their daily nutritional needs. Some of the signs and symptoms of these eating disorders are similar, including:
- stomach cramps, constipation, heartburn
- missing periods or only having a period when on hormonal birth control
- difficulty concentrating
- low iron
- low thyroid hormone levels
- low potassium
- low blood cell counts
- slow heart rate
- constantly feeling cold
- issues with sleep
- dry skin and nails
- brittle nails
- fine hair on the body, called lanugo
- hair thinning
- dry and brittle hair
- muscle weakness
- poor healing of wounds
- decreased immune function
As the body lacks essential nutrients to keep the organs working properly in people with ARFID, bodily processes slow down to conserve energy.
The body can adapt well to stress resulting from eating disorders, so blood tests can sometimes appear normal even when someone is in danger.
Disturbances in electrolytes, such as potassium, can cause unexpected death, and people with severe nutritional deficiencies can die from a heart attack.
ARFID only received a clinical definition in the DSM-5, so doctors have not yet created guidelines for the treatment of the disorder.
However, they do recognize that people living with eating disorders such as ARFID require the care and expertise of a registered dietitian nutritionist.
Other healthcare professionals who may play a role in caring for people with ARFID include:
- occupational therapists
- developmental pediatricians
- adolescent health physicians
The involvement of so many professionals can mean that treatment plans become unclear. Some clinicians with experience in treating children with ARFID suggest that the focus of treatment will depend on what factors are causing the eating disorder.
For example, a person with ARFID who has a fear of choking and vomiting may benefit from behavioral strategies to help address those fears.
Children with ARFID need specialized and individualized treatment plans. Further studies are necessary to explore the management and treatment of ARFID.
How to help someone with ARFID
A child who is a picky eater may not need medical attention. However, if picky eating starts to affect a child’s growth and development, a parent or caregiver should take them to see a doctor. A doctor can help the family find a solution by exploring the root cause of ARFID.
With proper care, a child with ARFID can learn to accept different foods without fear and start gaining weight and growing again.
Managing ARFID requires patience because it may be challenging for a doctor to figure out the cause. As doctors do not yet have clinical guidelines to follow, it may take time to establish an effective treatment plan.
ARFID is an eating disorder that occurs in children. It is different than anorexia and bulimia because people with ARFID do not have a poor body image and are not trying to lose weight.
ARFID can affect a child’s growth and development, so it is important to seek medical attention. Doctors do not currently have any guidelines to follow for the treatment and management of ARFID.
Together with other healthcare professionals, such as a nutritionist and psychiatrist, doctors can help a child with ARFID learn to eat to support their growth and development.