ARFID: Symptoms, Causes, and Treatment

I want my son to know that food is so much more than our bodies’ fuel — it’s ritual and passion, celebration and connection. It’s how we say “I love you” without saying a word.

He’ll grow out of it. She’ll eat when she’s hungry.

Such advice is not only unhelpful to parents like me, but deeply patronizing.

At 13, my son isn’t simply a “picky eater.” His dietary aversions and restrictions are not easy to understand, much less manageable on a daily basis. Feeding him remains incredibly challenging and stressful, and it ultimately led to concerns that he could have an eating disorder.

According to Jessica Sprengle, a licensed professional counselor specializing in the care and treatment of eating disorders, picky eating strays into disordered territory when it impairs an individual’s domains of functioning.

“A child who is simply a picky eater may not be adventurous with food,” Sprengle says, “but that won’t have a significant impact on their health, growth, weight, (or) ability to attend school and social events.”

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder characterized by developing extreme food restrictions — much like the ones my son lives with.

Introduced in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 2013, ARFID is the newest eating disorder diagnostic category (1).

Unlike other eating disorders, such as anorexia nervosa (AN) and bulimia nervosa (BN), ARFID is unconnected to body image and weight (2).

Findings from a 2014 study suggest that ARFID lasts longer and affects a greater portion of males than AN or BN (3).

Additionally, it often co-occurs with other disorders, such as obsessive-compulsive disorder and — in my son’s case — attention deficit hyperactivity disorder and autism spectrum disorder (3).

The study authors note that participants who had ARFID were “significantly more likely to have an anxiety disorder than patients with AN or BN, but less likely to have depression” (3).

Other research suggests that the prevalence of ARFID in eating disorder treatment settings may range from 1.5%–23% (4).

Individuals with ARFID show a strong aversion to eating. They may experience sensory discomforts or phobias in relation to certain foods.

An individual may refuse to taste new foods or even foods they previously enjoyed based on consistency and/or color (5).

In some cases, they may also experience an underlying fear that eating will cause them to choke, vomit, or become ill.

While fussy eating is often temporary and common in 2- to 3-year-old children, ARFID is more than a passing developmental phase and can persist into adolescence and adulthood.

According to Sprengle, some potential symptoms are:

  • Difficulty maintaining a healthy weight
  • nutritional deficiencies and/or malnutrition
  • extreme anxiety or avoidance of events where food is served
  • aversion to and/or lack of interest in food
  • avoidance of certain (or all) foods due to sensory aspects (eg, texture) and/or fear of negative consequences (eg, choking)
  • gastrointestinal disorders or oral-motor delays
  • rejection of entire food groups (usually meat and/or vegetables)

“Another major indicator that a child is struggling with ARFID versus picking eating is the ‘why,’” Sprengle says. “Folks with ARFID tend to avoid certain foods due to fear [or] worried.”

In my son’s case, the self-imposed restrictions were so incremental that I failed to notice until they became a problem.

Every so often a new, once beloved, food gets cut. tuna Porridge. hummus olives grapes By 13, my son is ruthless in his culinary cull. RIP Turkey. cream cheese Raisins. melons shrimp

The rules, and exceptions to those rules, are so dizzying and arbitrary that I often struggled to keep track.

Cheese is OK on pizza, but not on anything else. Tomatoes are OK, but not in a sauce. Bread is OK, but only if devoid of seeds and grains. The mere sight of tortilla chips is enough to send him tearing out of the room like it’s on fire.

Crackers are the devil because they produce crumbs. Bread produces crumbs, too, yet those crumbs, curiously, are not problematic.

The list of foods my son will eat is steadily shrinking. I worry that one day there will be nothing left on his plate except chicken nuggets and goldfish crackers. That his gastronomic world will be stripped of all color and nutrients — the equivalent of a mouth gone blind.

Ultra-processed food may be convenient and cheap, but it lacks variety and essential nutrients, and I don’t want these foods to make up the bulk of my son’s diet.

I want him to know that food is so much more than our bodies’ fuel — it’s ritual and passion, celebration and connection. It’s how we say “I love you” without saying a word. I want my son to experience magic and potential when he lifts his fork.

It wasn’t always this way.

Some days I look over at him and see his toddler self so clearly. Chubby fingers forming pincers around a blueberry on a high chair tray. Back then, eating was a voyage of discovery, and he its intrepid and fearless explorer!

We often took him as a toddler to our favorite Italian restaurant, where he would devour a bowl of gnocchi. He looked so content and satisfied afterwards, a little Buddha with tomato sauce ringed around his smacking lips. The owner’s face lit up every time.

“Someone sure enjoys his food,” he’d say, and I’d nod, smug and grateful that my kid Wasn’t one of those picky brats who turned their heads from the choo-choo train or else spat out bites of pulverized broccoli.

Back then, my boy would eat pretty much anything. I’m not sure when that stopped being true or what I can do about it now.

Since ARFID is a relatively new disorder, there is no distinct evidence-based treatment for it. However, a novel form of therapy for ARFID is currently undergoing clinical trials.

Cognitive-behavioral therapy for ARFID may be offered across 20–30 sessions in an individual- or family-based format, together with adjunctive pharmacotherapy (6).

In one small study, children and adolescents showed a faster rate of weight gain after being prescribed the drug mirtazapine (7).

Treatment largely depends on the severity of the disorder and the impact on the individual’s body and overall health, according to Sprengle. Hospitalization may be required when there is significant malnutrition and nutritional deficiencies.

Interventions for ARFID are more individualized and exposure-based (eg, desensitization) than those for other eating disorders. Treatment options may range from inpatient care to residential eating disorder treatment to partial and intensive outpatient care.

Since ARFID is not typically connected to body weight and image, traditional interventions rarely get at the root of what is causing the disordered eating. In cases of ARFID, any treatment must address trauma and other underlying fears in order to be effective.

With an onset in children as young as 3-4 years old, Sprengle says family involvement and education are key.

“Not all pediatricians will have training or understanding around ARFID,” Sprengle says, “but they can be a first line of defense in discussing concerns.

“If your experiences with a doctor feel inadequate, finding a dietitian and/or therapist specializing in eating disorders would also help to rule ARFID out or confirm that treatment is needed.”

One thing is clear: An authoritative or punitive approach to eating almost always makes matters worse.

At times, I definitely pushed my son too hard. Then I gave in and fed him whatever he would eat.

I tried reverse psychology. I offered but never coerced. I set the buffet and let him choose what he wanted. I turned mealtime into a game. I let him play with his food — encouraged it, even.

Every day I agonized over mealtimes, resentment lodged in my chest like heartburn.

For caregivers, Sprengle has the following advice:

  • Prioritize snacks and meals at regular intervals.
  • Model eating a wide range and variety of foods.
  • Implement anxiety/stress-reduction techniques (eg, deep breathing, music, dance) around mealtimes.
  • Be consistent!
  • Give your child a voice and involve them in decision making around food.
  • Encourage your child to try new foods, but don’t force them to eat. That can sometimes look like having the child plate some of a new food, even if they’re resistant to eating it.
  • Ask for help! A number of organizations, such as the National Alliance for Eating Disorders, have free support groups for loved ones that could be helpful and supportive to family members.

Unlike most other eating disorders, ARFID isn’t characterized by body image disturbances or a fear of weight gain. Rather, it is marked by a disinterest in eating and/or fear and anxiety related to food.

As such, Sprengle says that treatment must address trauma and other underlying issues to get at “the root of why a person develops and maintains an eating disorder.”

Although ARFID is a relatively new diagnosis and a lesser-known eating disorder, it’s no less severe or significant than any other, and those affected deserve adequate, informed treatment.

Sprengle is hopeful that we will see big changes in related resources and research in years to come.

My son may never come to love or enjoy food the way I do. He may never eat the rainbow, or anything close to it, and that’s OK.

With limited or restrictive eating, a typical diet is not necessarily the end goal — as long as he remains nourished and reasonably healthy.

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