Avoidant/Restrictive Food Intake Disorder
Avoidant/Restrictive Food Intake Disorder (also known as Selective Eating Disorder (SED)) is an eating disorder that prevents the consumption of certain foods. It is often viewed as a phase of childhood that is generally overcome with age. Children may not grow out of the disorder, however, and may continue to be afflicted with ARFID throughout their adult lives.
Avoidant/Restrictive Food Intake Disorder was renamed in the Diagnostic and Statistical Manual of Mental Disorders and expanded the criteria previously used for "Feeding Disorder of Infancy and Early Childhood" in the DSM-IV. The DSM-IV disorder was rarely used, and limited information is available on the characteristics, course, and outcome of children with this disorder. Avoidant/Restrictive Food Intake Disorder is a broader category intended to capture a wider range of presentations.
Diagnostic criteria requires that sufferers have:
- An eating disturbance (lack of interest, avoidance of, or concern about the social consequences of eating) that presents a persistent failure to meet nutritional or energy needs, with at least one of; significant weight loss, significant nutritional deficiency, dependence on enteral feeding or nutritional supplements, or an interference with social functioning.
- The disturbance is not better explained by a lack of food or cultural practice.
- The disturbance does not occur exclusively as a result of anorexia nervosa or bulimia nervosa, or evidence of problems in which the body's weight or shape is experienced
- The disturbance is not attributed to another medical condition or mental disorder, unless the disturbance exceeds the severity normally associated with the condition.
Sufferers of ARFID have an inability to eat certain foods based on texture or aroma. "Safe" foods may be limited to certain food types and even specific brands. In some cases, afflicted individuals will exclude whole food groups, such as fruits or vegetables. Sometimes excluded foods can be refused based on color. Some may only like very hot or very cold foods, very crunchy or hard-to-chew foods, or very soft foods, or avoid sauces.
Most sufferers of ARFID will still maintain a healthy or normal body weight. There are no specific outward appearances associated with ARFID. Sufferers can experience physical gastrointestinal reactions to adverse foods such as retching, vomiting or gagging. Some studies have identified symptoms of social avoidance due to their eating habits. However, most do not desire to change their eating behaviors.
The determination of the cause of ARFID has been difficult due to the lack of diagnostic criteria and concrete definition. However, many have proposed likely causes for ARFID.
ARFID and Autism
Symptoms of ARFID are usually found with symptoms of other disorders. Some form of feeding disorder is found in 80% of children that also have a developmental handicap. Children often exhibit symptoms of obsessive-compulsive disorder and autism. Although many suffers of ARFID have symptoms of these disorders, they usually do not qualify for a full diagnosis. Strict behavior patterns and difficulty adjusting to new things are common symptoms in patients that suffer from some degree of autism spectrum disorder. A study done by Schreck at Pennsylvania State University compared the eating habits of children with ASD and typically developing children. After analyzing their eating patterns they suggested that the children with some degree of ASD have a higher degree of selective eating. These children were found to have similar patterns of selective eating and favored more energy dense foods such as nuts and whole grains. Eating a diet of energy dense foods could put these children at a greater risk for health problems such as obesity and other chronic diseases due to the high fat and low fiber content of energy dense foods. Due to the tie to ASD, children are less likely to outgrow their selective eating behaviors and most likely should meet with a clinician to address their eating issues.
ARFID as an anxiety disorder
Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who suffer from ARFID do not have this fear, but the psychological symptoms and anxiety created is similar.
With time the symptoms of ARFID can lessen and can eventually disappear without treatment. However, in some cases treatment will be needed as the symptoms persist into adulthood. The most common type of treatment for ARFID is some form of cognitive-behavioral therapy. Working with a clinician can help to change behaviors more quickly than symptoms may typically disappear without treatment.
- In the record stage, children are encouraged to keep a log of their typical eating behaviors without attempting to change their habits as well as their cognitive feelings.
- The reward stage involves systematic desensitization. Children create a list of foods that they might like to try eating some day. These foods may not be drastically different from their normal diet, but perhaps a familiar food prepared in a different way. Because the goal is for the children to try new foods, children are rewarded when they sample new foods.
- The relaxation stage is most important for those children that suffer severe anxiety when presented with unfavorable foods. Children learn to relax to reduce the anxiety that they feel. Children work through a list of anxiety-producing stimuli and can create a story line with relaxing imagery and scenarios. Often these stories can also include the introduction of new foods with the help of a real person or fantasy person. Children then listen to this story before eating new foods as a way to imagine themselves participating in an expanded variety of foods while relaxed.
- The final stage, review, is important to keep track of the child's progress. It is important to include both one-on-one sessions with the child, as well as with the parent in order to get a clear picture of how the child is progressing and if the relaxation techniques are working.
- Wang, S. (2010, July 5). No Age Limit on Picky Eating. Wall Street Journal. Retrieved April 2, 2013, from http://online.wsj.com/article/SB10001424052748704699604575343130457388718.html
- Nicholls, D., Christie, D., Randall, L. and Lask, B.. (2001). "Selective Eating: Symptom, Disorder or Normal Variant." Clinical Child Psychology and Psychiatry. Vol 6(2): 257-270.
- Chatoor,I., Hamburger, E., Fullard, R., & Fivera, Y. (1994). A survey of picky eating and pica behaviors in toddlers. Scientific Proceedings of the Annual Meeting of American Academy of Child and Adolescent Psychiatry, 10', 50.
- Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without Autism. Journal of Autism and Developmental Disabilities. 2004; 34: 433-438.
- Evans, E. (2013). Selective Eating and Autism Spectrum Disorder. In Behavioral Health Nutrition. Retrieved April 2, 2013, from http://www.bhndpg.org/students/selective.asp
- Avoidant/Restrictive Food Intake Disorder (ARFID), Center for Eating Disorders at Sheppard Pratt
- Overview Of Adolescent Picky Eating and Other Feeding Disorders, by the Association of Pediatric Food Refusal
- Other "Eating Disorders", by Somerset and Wessex Eating Disorders Association
- Welcome to the Eating Disorders Team, UCL Institute of Child Health
- "Something fishy about being so fussy", article at Times Online by Lucy McDonald, February 17, 2007
- "The Picky Eater Files", article at the Washington Post by Annie Groer, September 26, 2006