Paediatrics / ARFID: food selectivity or avoidance in children

By Cristiano Antonino Last updated Dec 5, 2022

Avoidant/Restrictive Food Intake Disorder (ARFID) is included in the DSM-5 under the category of Nutrition and Eating Disorders

It replaces the diagnosis of Childhood or Early Adolescent Nutrition Disorder contained in DSM-IV-TR.

Formalised as a diagnosis in the DSM-5 (2013), ARFID has also recently been included in the ICD-11 (2018).

But what is meant when we talk about ARFID?

If we think of children, it is very common to find little ones who are very selective in their food choices.

They are labelled as ‘picky’, introduce the same (few) foods and seem to have no interest in food.

This attitude is often a source of great concern for parents who turn to their paediatrician for advice and guidance.

Of course, these children are not all affected by ARFID. In order to diagnose such a restriction of food choice, a significant impairment in health, development or general functioning must be associated with it.

What is ARFID

ARFID is a nutrition and eating disorder characterised by a persistent inability to meet adequate nutritional and/or energy needs leading to clinically significant consequences.

These consequences may include:

Significant weight loss or inability to achieve expected weight gain (normal developmental weight gain)
Significant nutritional deficiency
Dependence on enteral feeding or oral nutritional supplements to maintain weight or nutritional status
Marked interference with psychosocial functioning

Dietary restriction is not related to concern for weight or body shape and this distinguishes ARFID from Anorexia Nervosa.

It is a diagnosis that encompasses a great variability of clinical manifestations.

In the current state of research, we do not know what exactly drives the person to have such problematic behaviour.

In fact, no specific psychopathology has been identified.

However, three profiles have been identified that explain the reason for energy and/or nutritional deficiency:

Apparent lack of interest in eating or food. Emotional difficulties such as worry, anxiety or sadness are often present that interfere with eating and produce a lack of interest in food.
Avoidance based on the sensory characteristics of food. Some people, for example, only eat foods with certain textures, colours, temperatures or are very sensitive to taste variations. They therefore avoid certain foods because, in advance, they think they cannot tolerate certain characteristics of that food.
Concern about the negative consequences of eating. The reduction in food intake is due to certain fears such as:

– Choking

– Vomiting

– Not being able to swallow

– Causing diarrhoea

– Causing allergic reactions

– Causing abdominal or chest pains

The three profiles may vary in severity, but are not mutually exclusive.

Avoidant/restrictive food intake disorder (ARFID) may have onset in childhood or early adolescence, but in some cases, also in adulthood.

Prevalence data on the non-clinical population are currently not available.

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Causes and treatment of ARFID

The aetiology of this disorder is currently unknown.

However, Thomas’ (2017) three-dimensional model assumes that there is a genetic predisposition to abnormalities in taste perception and homeostatic appetite.

Emotional reactivity would also explain the three previously described profiles.

This predisposition could be triggered by traumatic food-related experiences, causing a restriction or avoidance of food intake.

This, in turn, would lead to nutritional impairment or limitation in opportunities for exploration.

The limitations of this model are related to the fact that it is based on a biological hypothesis in the absence of specific biological markers.

Although it remains an interesting theoretical model, it still lacks empirical validation.

Psychotherapy of food avoidance/restriction disorder in children and adolescents

The cognitive-behavioural treatment based on this model (CBT-AR) developed by Thomas JJ and Eddy KT (2018) is mainly based on behavioural interventions such as systematic desensitisation.

Recently, Calugi and Dalle Grave (2018) proposed an alternative model to Thomas’s three-dimensional model, which sees as the psychopathological core the over-evaluation of feeding control and/or worries about adverse feeding consequences.

Their proposed ARFID-adapted CBT-E treatment utilizes a number of specific strategies and techniques that aim to address the psychopathological core.

To date, however, no cognitive behavioral therapeutic model has scientific evidence or has been tested by clinical research.

It is also necessary to develop and elaborate specific screening and assessment measures for ARFID.

This is to quantify the extent of the problem in the general population, identify populations at risk, and support ongoing research efforts.

BIBLIOGRAPHY

Rachel Bryant-Waugh (2016) Avoidant Restrictive Food Intake Disorder In: K Brownell and T Walsh (Eds) Eating Disorders and Obesity: A Comprehensive Handbook, 3rd Edition. London: Guilford Press, 198-202

Thomas JJ and Eddy KT (2018) Cognitive-behavioral treatment of avoidant/restrictive food intake disorder. Current Opinion in Psychiatry, 31, 425-430.

Calugi, 2018, “La terapia cognitivo comportamentale adattata per l’ARFID” presentato al Congresso Nazionale AIDAP 2018. Garda, 9-10 Novembre 2018.

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