Eating disorders are often misunderstood. Each one of us has our own unique relationship to food, just as we have a unique relationship with each person we encounter in life.
It can be confusing to know what “normal” eating is versus what counts as disordered eating. In this piece, we discuss an eating disorder called avoidant/restrictive food intake disorder (ARFID) and how it affects teens.
What does ARFID look like in teens?
Teens with ARFID become malnourished because they:
Avoid eating specific foods
Restrict the amount of food they eat
Avoid eating altogether
If you are familiar with ARFID, you may have heard that it is related to “picky eating” -- but the truth is that ARFID is much more complex than that.
What are the signs of ARFID in teens?
ARFID signs to watch for in teens include:
Lack of interest in food
Avoidance of certain foods due to concern about their taste, texture, smell, temperature, or color
Refusing to try new foods
Requirement that that food be prepared a specific way
Choosing not to eat when preferred foods are unavailable, even when hungry
Avoiding meals or delaying them as long as possible
Frequent lack of hunger
Forgetting to eat
Going for long periods without eating
Fear of eating due to concern about possible allergic reactions, choking or vomiting
What the experts say
Ovidio Bermudez, MD, FAAP, CEDS, senior medical director of child and adolescent services and chief clinical education officer at Eating Recovery Center (ERC), discusses the early signs of ARFID. He explains,
“If a young person develops a pattern of ‘I don't like something and I'll never have it again,’ and then they say, ‘I don't like the next thing, and I'll never have it again,’ that is a sign that they are developing atypically. In this case, you may want to reach out to your health care provider for guidance.”
Clinical psychologist Michelle Jones, PhD, clinical manager at ERC, has studied ARFID since it first became a diagnosis over a decade ago. She shares,
“Signs of ARFID can show up as early as infancy or in the early toddler years. Some individuals may not show symptoms until middle childhood, adolescence or later."
Hear more from Dr. Jones on ERC's ARFID episode of the Mental Note podcast.
What types of ARFID affect teens?
There are three main types of ARFID:
Sensory sensitivity
Lack of interest in food
Fear of aversive consequences
Type 1: Sensory sensitivity
Teens who have strong sensory sensitivity may limit what they are eating based on the sensory properties of food. This could include avoiding foods based on:
Taste
Texture
Temperature
Smell
Color
Restricting food due to sensory issues means that ARFID and autism overlap, since teens with autism often have strong sensory sensitivity.
Type 2: Lack of interest in food
Sometimes young people with ARFID seem to have a complete lack of interest in eating, and they don’t seem to enjoy food the way many people do.
They may not look forward to eating and they may not feel hunger the same way other people feel it. Since food isn’t enjoyable, they don’t eat as much; eating becomes something they want to avoid.
This type of ARFID can often overlap with attention-deficit/hyperactivity disorder (ADHD). Explains Dr. Jones,
"People who have ADHD tend to be less aware of hunger signals.
A person with ADHD and ARFID may feel that eating takes a lot of work, organization and coordination. It ends up feeling like a chore.
Eating is something that is more easily forgotten, avoided or procrastinated on.”
Type 3: Fear of aversive consequences
Individuals who have experienced a trauma or perceived trauma related to eating may restrict their food intake as a way of avoiding another traumatic experience.
Teens with this type of ARFID may restrict the foods they eat due to fear of having one of the following reactions while eating:
Vomiting
Choking
Allergic reaction
Pain
In order to prevent what they fear from happening, a person with this type of ARFID will avoid eating certain types of food (food aversion) or avoid eating altogether.
This type of ARFID often overlaps with mental health conditions like anxiety disorders and obsessive-compulsive disorder (OCD). OCD is also tied with other eating disorders. For these individuals, exposure therapy for OCD may be helpful.
Is ARFID common in teens?
ARFID is most commonly diagnosed in childhood and early adolescence. How common is ARFID in teens? The research is mixed, but as many as 5% of young people –- or more -- could have ARFID.
While the true prevalence of ARFID remains to be studied, preliminary research[1] indicates that males may be more likely to present with ARFID than other eating disorders. Unlike most other eating disorders, all genders face an equal risk for developing ARFID.
When it comes to the causes of ARFID, multiple factors may be at play, including genetic, psychological, cultural and more.
How do I know if my teen needs help?
Dr. Jones shares insight regarding ARFID signs to watch for, and when to seek help.
“With ARFID, teens are not meeting appropriate nutritional needs, due to sensory sensitivity, a lack of interest in eating, or because they fear aversive consequences.
If a caregiver notices the signs listed above and unexpected weight loss, failure to gain weight, malnutrition or other physical and mental health problems, it’s advisable to seek help."
ARFID is a relatively new eating disorder, having been added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) -- a manual that helps providers make mental health diagnoses -- in 2013.
Because of its relative newness and due to surrounding myths, teens with ARFID symptoms (and their caregivers) may feel powerless or isolated at times.
If you or a loved one are struggling, we want you to know that you are not alone and there are many passionate healthcare providers who are here to help you.
How does ARFID differ from anorexia?
While ARFID symptoms, like food restriction and avoidance, may sound like symptoms of anorexia nervosa, the two diagnoses are quite different. Notably, people with ARFID are not motivated by weight loss or thinness - which is what drives anorexia nervosa. However, due to their restrictive eating habits, people with ARFID suffer from malnutrition and may be at very low body weights, which can produce some of the same physical characteristics as anorexia nervosa.
Many people associate eating disorders with concerns about weight and body image. While that’s true in some cases, ARFID is an eating disorder with unique diagnostic criteria. As a result, there is a chance that ARFID might be misdiagnosed as anorexia nervosa -- or diagnosed later than would be ideal.
Dr. Jones explains the difference between ARFID and anorexia nervosa:
“If we think about anorexia nervosa, there is a disturbance in body image or overvaluation of body shape and weight. With ARFID, there is an absence of that. Or -- the body distortions are not driving the restrictive eating habits.”
Read more about ARFID and anorexia in children with autism.
Does your loved one have ARFID?
Take this ARFID quiz to find out.
What does ARFID treatment for teens look like?
ARFID treatment for teens may include some or all of the following:
A multidisciplinary team to coordinate and provide treatment
Medical and psychiatric stabilization
Individual and group therapy
Family therapy, education and support
Collaboration with referring providers
The most important step toward starting treatment for a teen with ARFID is having an accurate diagnosis and comprehensive assessment. There is no “one size fits all” treatment approach. Dr. Bermudez offers his recommendation on how to ensure an accurate diagnosis,
“You want to be an informed consumer and ensure the diagnosis is verified by clinicians with experience, usually multidisciplinary.
If your pediatrician suspects a case of, say, restrictive ARFID, they should make a referral to a therapist and dietitian with the clinical expertise to get a consensus. Then, your child’s doctor can make a recommendation of where to find help.”
The Eating Recovery Center ARFID treatment approach
The treatment approach at ERC is tailored for each unique individual, includes all of the treatments listed in the bullet points above, and addresses the following:
The patient's developmental history
Internal and external motivators as well as goals and values
Areas in the patient’s life that are negatively impacted by ARFID symptoms (e.g., physical health, social functioning, psychological well-being)
Family dynamics and family involvement
A unique component of ARFID treatment at ERC is continuous education of patients and caregivers alike on diagnosis, interventions, treatment expectations and treatment goals. Dr. Jones shares some insight into how the providers at ERC work at our teen residential programs and other levels of care.
“We are not forcing anyone with an ARFID diagnosis into our expectations of recovery.
This is really about their life and their functioning and how can we help them function in a way that is going to better their life and not cause adverse experiences.
For teens, we might identify foods they can take to school for lunch, because they won't eat anything in the school cafeteria.
If they don’t eat lunch, they're going all day at school without eating anything at all.
And that's not good for their health or their growth or their development or socialization or anything like that.
We may even have them set alarms on their phone every day at certain times to remind them to eat.”
Discover ERC Baltimore, the nation's most specialized program for teens with ARFID.
What are the goals of ARFID treatment?
Eating disorder treatment for ARFID works to fill the teen’s nutritional gaps.
At ERC, registered dietitians work individually with each teen to increase the variety of foods they will eat and help them eat on a routine schedule. The goal is to help them function better with a focus on their physical and emotional health.
As an example, fast food, prepackaged foods, convenience foods and frozen foods can all be normative for teens with the lack of interest subtype of ARFID.
These are young people that probably will not stick to an organic, cooked-from-scratch meal plan on a long-term basis.
Shares Dr. Jones,
“Once the teen is eating more regularly in a routine, their body starts to feel better, their brain starts to function better and recovery starts to kick in.”
Read our interview with Dr. Jones for a full discussion on our ARFID podcast and learn about our nutrition program for ARFID here.
Get help for ARFID today
Eating Recovery Center is the nation's only health care system dedicated to the treatment of ARFID at all levels of care, including:
If you believe you or your loved one may have ARFID, we’re here to support you on your recovery journey. Give us a call at 866-622-5914 or send us a quick note. We’d be happy to discuss the symptoms you are observing and explore your treatment options.