Disorders and Symptoms

What is Avoidant Restrictive Food Intake Disorder? (ARFID)

Long dismissed as just ‘picky eating’…

Avoidant Restrictive Food Intake Disorder (ARFID) was officially introduced in the Diagnostic and Statistical Manual of Mental Disorders: DSM 5, (5th edition) in 2013, replacing a diagnosis known as ‘Selective Eating Disorder’. 

The National Eating Disorders Association defines ARFID as “similar to anorexia in that both disorders involve limitations in the amount and/or types of food consumed, but unlike anorexia, ARFID does not involve any distress about body shape or size, or fears of fatness.” In children (where the behaviour is more commonly observed) this means a daily food intake that is insufficient for growth and development. In adults it can become difficult for the body to perform basic daily functions. While ARFID is often associated with significant weight loss and malnutrition due to consuming a restricted diet, it’s important to recognise that ARFID can also be associated with weight gain as a consequence of food preference. 

This animations was developed by Gemma Hayes and Emma Sinclair from Hertfordshire Children and Young Peoples Mental Health Commissioning Team on behalf of Hertfordshire County Council and Hertfordshire and West Essex ICB in partnership with an Expert by Experience from First Step ED and a local GP.

How it presents…

While everyone’s experience with ARFID will be unique, there are often similarities in presentation across individuals. Primarily, this is characterised by extreme food avoidance with a focus on sensory aversions including the texture, appearance, colour and smell of foods. Low appetite is often reported, including, a lack of interest in eating and the failure to respond to hunger cues is leading to a daily routine centred around a minimal food intake. 

In accordance with the DSM 5, a diagnosis of ARFID may be made when an individual presents with all or some of the following symptoms such as: 

  • Significant weight loss (or failure to achieve expected weight gain in children).
  • Significant nutritional deficiency.
  • The need to rely on a feeding tube or oral nutritional supplements to maintain sufficient nutrition intake.
  • Interference with social functioning (such as inability to eat with others).
  • Avoidance based on sensory characteristics of food and/or eating 

How it develops…

Research has suggested that there are three primary drivers of the development of ARFID behaviours, avoidance based on the sensory characteristics of food, an apparent lack of interest in food or eating, or concern about negative consequences of eating. 

Though the onset of ARFID may be at any stage in life, most cases can be linked back to childhood. Furthermore, development may also be noticed following a significant negative event such as an episode of illness, choking or food poisoning. This can encourage an individual to avoid specific foods or entire food groups altogether. Anxiety and trepidation about the consequences of eating, such as fear of choking, nausea, vomiting, an allergic reaction or stomach upset can also lead to ARFID. 

Due to the recent recognition of the behaviour, much of the research into ARFID is in its infancy. Early findings from PsychCentral state that “ARFID is one of the most common eating disorders diagnosed in children. One study based in Switzerland estimated that ARFID affects 3.2% of all children between 8 and 13 years old.” It is also thought to affect around 9.8% of adults presenting with an eating disorder, alongside more common disorders like bulimia, binge eating disorder and anorexia nervosa. 

There is a higher prevalence of ARFID is in individuals who also have an Autism Spectrum Disorder (ASD) diagnosis than in the general population. While the two diagnoses are not mutually exclusive, the overlap is often associated due to the presence of sensory processing difficulties in individuals with an ASD diagnosis. This can often result in the avoidance of meats, vegetables, and/or fruits due to aversions to specific tastes, textures, or smells. Dr Terence Dovey is a specialist in avoidant and restrictive eating disorders at Brunel University, London. He recently conducted a research trial into the similarities between those with research trial into the similarities between those with ASD and disordered eating of this nature, which was published by Cambridge University Press. He found a notable overlap in eating difficulties, behavioural problems and the sensory profiles of children with ARFID and ASD with more severe aberrations in ARFID (food-responsiveness) and ASD (hypersensitivity and social problems). He concluded: “This study has shown that there are more similarities than differences between children with ARFID and ASD in their eating behaviour… All children (in the study) with feeding difficulties appear to exhibit more internalised behavioural problems, especially within the emotional domain”. This suggests a link between ASD and the development of restrictive eating disorders such as ARFID. 

In adulthood, ARFID can continue to manifest if ignored at a younger age or may form as the result of a new, inciting event. The triggers for adults are often similar to those of children such as e.g. fear of vomiting or choking, trauma or sensory aversions. A change in physical health can also lead to the development of the disorder such as being diagnosed with diabetes, heart disease or gastrointestinal conditions and becoming obsessive about the types of foods that are recommended. 

How ARFID is treated…

Treatment for ARFID is usually person-centred and tailored to the needs of the individual, based on the nature of their difficulties. It is most often delivered in an outpatient setting following a GP referral and can involve an individual or family based approach.

A consideration of what is maintaining the individuals’ specific thoughts and behaviours will be taken, ahead of attempts to challenge perceived risks around food. The treatment commonly involves evidence-based methods such as family-based treatment, cognitive behavioural therapy, exposure work and anxiety management techniques. On occasion, medication may be suggested, most often to help with anxiety to encourage relaxation around food and mealtimes. The person’s physical health will also need monitoring by a GP or paediatrician, and it may be pertinent to involve nutritional support from a dietician. 

This animations was developed by Gemma Hayes and Emma Sinclair from Hertfordshire Children and Young Peoples Mental Health Commissioning Team on behalf of Hertfordshire County Council and Hertfordshire and West Essex ICB in partnership with an Expert by Experience from First Step ED and a local GP.

This information is currently under review August 2023.