Extreme Picky Eating: Is it an Eating Disorder? – Dr. Angela Derrick

You may be surprised to learn that what may look like picky eating could actually be an eating disorder. Avoidant/Restrictive Food Intake Disorder (ARFID) is not just about selective eating. In fact, ARFID can be distinguished from normal picky eating because the eating behaviors seriously impact the individual either physically or socially.
  • Why is my child not eating certain foods? 
  • Is my child’s “picky eating” a problem?
  • Could my child have an eating disorder?

It is not unusual for children to be selective eaters. Concerned parents certainly wonder about their children’s eating habits from time to time. In fact, many children go through phases where they will only eat bland foods, foods of one color or just pasta, chicken nuggets and fries. But what if a child continues to display an extreme aversion to many — or most — foods? What if that child limits their diet so much that they start to experience nutritional deficiencies? 

You may be surprised to learn that what may look like “picky eating” could actually be an eating disorder.

Avoidant/Restrictive Food Intake Disorder: more than picky eating

Avoidant/Restrictive Food Intake Disorder (ARFID) is not just about selective eating. In fact, ARFID can be distinguished from normal “picky eating” because the eating behaviors seriously impact the individual either physically or socially

If a caregiver or professional is concerned about a child’s diet and think a child could have ARFID, they should consider these questions: 

  • Do the child’s particular food practices result in nutritional deficits, weight loss, or a need for supplements?
  • Does the individual put off or avoid activities related to food?
  • Do they require significant food accommodation from others?
  • Does the child/adolescent experience conflict with others because of their food behaviors? 

If one’s eating behaviors are impaired, and the impact is similar to the above descriptors, a diagnosis of ARFID should be considered.

ARFID is different from other eating disorders

Unlike eating disorders such as Anorexia and Bulimia Nervosa, individuals with Avoidant/Restrictive Food Intake Disorder do not have what some consider classic eating disorder symptoms: specific body image dissatisfaction or fears of weight gain. 

Instead, the reason that these individuals are not eating is very different and falls into three primary categories.

  1. Lack of interest in food
  2. Desire to avoid foods with certain, often sensory, characteristics like “crunchy” or “mushy” (selective eaters)
  3. Preoccupation that one might choke or vomit after eating

One particular presentation of ARFID — Orthorexia — is when individuals restrict food due to a preoccupation with “clean eating” or the desire to be “healthy.” Many of these individuals also lack a strong drive for thinness. Similar to ARFID, and unlike normal healthy eating, those with orthorexia become so obsessed with restrictive food choices that they are significantly negatively impacted.

ARFID diagnosis

It is important to mention here that someone can have a diagnosis of ARFID and not fall into the underweight range. In fact, some individuals showing symptoms of ARFID may be of a higher body weight. Poor nutrition does not necessary mean that someone has lost weight. Also, someone without nutritional deficits can still be diagnosed with ARFID if they have social impairments. 

Parents and clinicians should avoid the trap of allowing an individual’s weight to bias their ability to catch the various ways in which ARFID can present. Instead, if parents and clinicians are concerned about a child’s eating behaviors, they should consult with an experienced eating disorder treatment provider who is trained to recognize the subtle various forms ARFID can take.

ARFID symptoms

People with Avoidant/Restrictive Food Intake Disorder experience a number of different physical and psychological symptoms.

Some sufferers of ARFID describe a feeling of constriction in their upper GI track, as though they are physically unable to chew and swallow. These individuals may be motivated to eat, yet unable to bring themselves to act. Others describe intense anxiety and feeling like they will surely die if they eat and, understandably, they are terrified of doing so. 

For caregivers of individuals with ARFID, it is important to build empathy and understanding for what their loved ones are experiencing. Those struggling with ARFID are deserving of this type of support and care; they are not trying to be “difficult” or “resistant.”

ARFID: On a spectrum

Researchers believe that ARFID can be understood on a spectrum. An extreme example was captured in a recent CNN Health article featuring the case of a young man who ate a severely limited range of foods due to textural dislikes. He suffered permanent blindness by the age of 17 due to the extent of his nutritional deficiencies. This example makes the case for how important it is to diagnose and treat eating disorders like ARFID early on so that any health-related damages can be lessened. 

Is ARFID a “new” eating disorder?

Researchers and clinicians first identified ARFID as a diagnosable eating disorder in 2013. Before this, individuals with similar symptoms were diagnosed with having a Feeding Disorder of Infancy or Early Childhood. Because ARFID is now considered an eating disorder, we include individuals who have psychosocial impairment as well as those who have physical concerns; this helps providers identify more people who could benefit from treatment. So, while the basic presentation is not new, the way we categorize the symptoms has changed.

Who is at risk for ARFID?

Here are some interesting facts about the risk factors of ARFID and key demographics:

  • Individuals with ARFID often have symptoms beginning in infancy or childhood. Adults can develop ARFID too although this is less common. In a recent study of adults with ARFID, all 22 individuals in the “selective eating” subset reported their symptoms had begun prior to age 5, and some much younger. 
  • All genders are equally impacted. 
  • Many individuals with ARFID have other psychological conditions such as depression or anxiety that occur simultaneously. 
  • Individuals with ADHD, intellectual disabilities, and those on the autistic spectrum are more likely to develop ARFID. 

Treatment for ARFID

Although the term ARFID may be relatively new, experts treat ARFID using well-established therapeutic techniques (Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), and Exposure Therapy). Additionally, some research suggests that Family-Based Therapy (FBT), which is a gold standard treatment for young adolescents with Anorexia, may be beneficial with this population because of its focus on empowering parents to take charge of refeeding their child outside of a hospital setting. 

Outpatient treatment — Individuals can receive treatment for ARFID on an outpatient basis. The healthcare provider may use an intervention called Exposure Therapy. During this therapy, patients are guided through progressively more challenging exposures to feared foods. Clinicians work to determine the specific reasons that a person with ARFID might be struggling to eat, and then target exposure interventions towards these fears directly. Patients are offered support and taught skills to help manage negative reactions. Over the course of the exposure treatment, the individual’s level of distress related to the experience of eating decreases. Family involvement is often critical, as parents and/or caregivers may be responsible for carrying out interventions at home that have been learned in treatment.

Residential or Partial Hospitalization — Patients may also seek treatment for ARFID at higher levels of care, such as Residential programs and Partial Hospitalization Programs. The treatment day is longer and is focused on restoring an individual’s nutrition and in some cases, weight, to safe levels. In these programs, the patient can be seen by multiple care providers such as therapists, psychiatrists, dietitians, and primary care doctors. Therapy and medication can be used jointly to target additional mental health concerns such as low mood or high anxiety. Again, family involvement and support can be necessary to help the patient maintain progress once they step down to a lower level of care. 

At Eating Recovery Center, our therapists are trained in these modalities and use the support of the multidisciplinary treatment team to provide a targeted approach to treating ARFID symptoms. Get information about our treatment programs for ARFID here.

Help for extreme picky eating

If you or someone you love are showing symptoms of ARFID, or if you are unsure if their “picky eating” requires treatment, give us a call at (877)711-1690. Our Master’s-level counselors are available for a free consultation where you can learn more about ARFID and the help that is available.

Angela Picot Derrick, PhD, CED-S is a clinical psychologist and Senior Clinical Advisor at Eating Recovery Center and Insight Behavioral Health Centers. Dr. Derrick is a Health System Clinician at Northwestern University Feinberg School of Medicine and an Associate Professor at Rush Medical College. She has studied and treated eating and mood disorders for over 15 years and is honored to help her clients build hope, self-compassion and resilience as they work towards recovery. 
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