What is ARFID?
ARFID is a relatively new term, which stands for avoidant restrictive food intake disorder, now officially recognised and described in diagnostic criteria.
It involves the avoidance of a large number of foods to the extent that there is nutritional deficiency and health impairment. There is an intense fear of many foods and this usually results in social disturbances, such as being unable to join friends for school dinners or meals out.
The symptoms of avoidant restrictive food intake disorder, can seem very similar to a better-known eating disorder, anorexia; notably low body weight, weight loss and emotional disturbance. However, there is a critical difference: unlike anorexia, the driver of the disorder is not anxiety about body weight, shape and image. The three main causes of ARFID are low interest, sensory difficulties, and fear/trauma. These are explored in the next section.
The positive news is that now avoidant restrictive food intake disorder is firmly established as a diagnosis (included in the 5th edition of the American Psychiatric Association’s classification of disorders, called DSM-5 or DSM-V), it is increasingly better recognised and understood. With this improved awareness and diagnosis, those affected are more likely to benefit from targeted and effective therapy and support.
The first causal category in ARFID is very low interest/poor responsiveness to food. This can be something which is evident from a very young age (some specialists will give a diagnosis from the age of two, others younger).
The second cause is sensory based food avoidance, which might refer to a strong aversion to particular colours and textures of food or being unable to eat properly because of wider sensory disturbance (noise, light, difficulty sitting). There is a close correlation between ARFID and other disorders such as the autistic spectrum disorder, attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Some studies suggest that a majority of people with ARFID have another sensory or neurological disorders. Difficulties with eating may be the first symptoms to appear, or may emerge after other issues have been identified.
The third main cause is extreme fear/trauma, for example, an intense belief that eating will cause choking, vomiting or abdominal pain.
Although difficulties usually become apparent in childhood, specialists emphasise it is not a disorder exclusively of childhood and that adults can be affected too. Boys are slightly more at risk than girls, probably due to its correlation to disorders like ASD and ADHD, which more often affects boys.
The Warning Signs
In truth, the majority of parents might describe their children as fussy or picky eaters at some stage and this may cause real concern for them. But can we differentiate between normal patterns of choosy eating (which are usually temporary and do not impair health) and a defined eating disorder? There are two markers which help distinguish someone who is simply a fussy eater from an individual with a serious eating disorder:
- The individual fails to eat an adequate diet which leads to a nutritional deficiency.
- There is a clear impairment to their health, well-being and development.
Fussy eating is very difficult for parents to deal with and many children eat a much narrower range of foods than their parents would like. But the threshold for having a nutritional deficiency and a resulting impairment to health is high: patients seen in ARFID clinics might only eat five foods or less, together with rigid brand requirements (only a certain type of chocolate spread, for example).
In terms of the warning signs, it is important to consider social disturbance as a key symptom: is a child withdrawing socially, because of fear of meals at friend’s houses, at school and therefore avoiding social interaction and normal, enjoyable activities?
How Best to Diagnose ARFID
These are the criteria set out in the DSM-5/DSM-V:
- Significant weight loss (or failure to gain weight or faltering growth in children);
- Significant nutritional deficiency;
- Dependence on oral nutritional supplements;
- Interference with psychosocial functioning (fear of food leading to social withdrawal and isolation).
It is important to gain a really full picture of the patient, considering their development and feeding history, for example, if they have always eaten poorly, any sensory difficulties they may have, family context (consider dieting and cultural practices like fasting), their temperament and social functioning. Consider whether there are any other reasons for their avoidance of food. Are there any body image issues? Are there any medical conditions or medication which might affect their eating?
Although some individuals may have very low body weight, like those with anorexia, it is also possible for affected individuals to be a normal weight or overweight.
Treatment and Support
It is really important to properly diagnose ARFID and then to provide treatment and support that is specific for the condition. Because of the way child and adolescent eating disorders services have developed (particularly inpatient units), many young people with the avoidant disorder have ended up in units originally designed for the treatment of anorexia. However, treating someone with ARFID as if they have anorexia is likely to make their condition worse and certainly not better.
Another challenge in terms of designing therapy and support is that because this is a recently classified eating disorder, there is a lack of evidence base for treatment. Certainly, there are plenty of ‘tools’ which can be used: behavioural approaches such as food exposure and de-sensitisation, parent and family work, cognitive behavioural therapy, nutritional and medical interventions and approaches to support patients by addressing sensory difficulties.
However, specialists in this field emphasise: define the aims of treatment and target your interventions. Realistically, a person with the avoidant disorder who had a limited diet since infancy is not going to progress to a very broad and adventurous diet. The aim might be to achieve a diet which is nutritionally sufficient (sometimes including a supplement) and some alleviation of the social disturbance caused by the disorder.
If you, or someone know needs help with an eating disorder like avoidant restrictive food intake disorder, please get in touch with Newbridge House.