Chances are you know someone, whether it's a friend, family member, or child, who could be considered a picky eater. But when a person’s range of acceptable foods becomes very narrow and specific—to the point where, for example, they’ll only eat one brand of chicken nuggets and only if Dad makes them,—and this persists for some time, there might be a bigger issue at play.

Avoidant/restrictive food intake disorder (ARFID) is a relatively new diagnosis that can sometimes seem like an extreme form of picky eating, but it’s actually a serious eating disorder that can have significant negative consequences. Luckily, evidence-based treatment can effectively address the different forms of ARFID disorder, prevent any negative mental or physical consequences, and help those struggling develop a healthier, more positive relationship with food.

Read on to learn more about ARFID, its signs and symptoms, treatment options, and more.

What is ARFID?

Avoidant/restrictive food intake disorder is defined as a disturbance in eating or feeding behaviors that's not driven by the fear of weight gain or body image concerns that accompany other eating disorders.

In simpler terms, this means that people with ARFID disorder eat very little food, a very small variety of food, or both, but this isn’t due to any feelings about body image or a desire to lose weight. The diagnosis captures a wide variety of feeding and eating challenges related to limiting food intake, and while it’s often associated with young people, ARFID also affects adults.

ARFID is less commonly known than other eating disorders. This is likely in part because it was only introduced into the Diagnostic and Statistical Manual of Mental Disorders in 2013, and partly due to the fact that it doesn’t fit the mold of more stereotypical eating disorders.

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ARFID vs. picky eating: what’s the difference?

“This is the number one question I get from parents and other providers,” says Jessie Menzel, PhD, VP of Clinical Programs for Equip. So let’s break down what is ARFID vs. what is picky eating.

“Picky eating is a developmental phase that's very much common for children to go through,” Menzel says. And while many children outgrow picky eating, it can also persist through teenage years and adulthood. Menzel explains that, at any age, someone with picky eating may refuse to eat certain foods and be particular about:

• Which brands of foods they eat
• How the foods they eat are packaged
• How the foods they eat are prepared

On the surface, these types of eating preferences might resemble ARFID (and vice versa). After all, people with ARFID are selective about what they eat. However, differentiating between the two is all about degree: “the extent to which they narrow what they eat and the persistence with which they narrow is what differentiates picky eating from ARFID,” Menzel explains.

With ARFID, the person limits the amount and variety of food they’ll eat to the point where:

• They are nutritionally deficient or are at risk of being nutritionally deficient
• It affects their day-to-day life (and the life of their loved ones)
• In children, their growth (height and weight) has started to flatten

“When someone has ARFID, they’re not only limited in terms of what they eat, but also in the number of circumstances and situations in which they'll eat or accept food,” Menzel explains. “All of a sudden, they will only eat boxed Kraft macaroni and cheese—they won’t eat macaroni and cheese served in the cafeteria at school or at a restaurant. Or they only like how they or their mom makes it, and not how dad or their grandparents make it.”

The three subtypes of ARFID

ARFID is generally understood as having three main types, which are clinically referred to as ARFID “presentations.” People affected by ARFID can experience symptoms or behaviors of just one presentation, or several. The three ARFID presentations are:

• Lack of interest in food and low appetite. People with this presentation of ARFID find little pleasure—or even discomfort—in eating due to low appetite or a lack of interest in food. Many of these folk may have struggled with feeding from birth, sometimes being designated as having a “failure to thrive” by their pediatrician. They may lack hunger cues or get full easily, and tend to avoid eating. Sometimes (but certainly not always) this low appetite stems from another medical condition or medication—for instance, having ADHD can make it hard to stay in tune with hunger cues, and stimulant medications to treat ADHD can blunt appetite.
• Selective eating due to sensory sensitivity. This presentation is driven by intense aversions to or strong preferences for certain textures, colors, smells, and tastes. This high level of sensitivity is common among individuals who are on the autism spectrum, but can also be present in those who are not. People with this ARFID presentation have a very limited number of foods they feel safe eating. Often, pre-packaged foods from a specific brand or items from a particular fast food restaurant are the only acceptable foods, as they tend to be consistent, predictable, and easy to eat.
• Avoiding eating due to fear of an adverse outcome. With this presentation of ARFID, people avoid eating out of an unfounded fear that something bad will happen. Common food-related phobias include fears of vomiting, choking, allergic reaction, illness, or pain. Symptoms of this presentation may suddenly appear after a traumatic eating-related event (like choking or getting food poisoning), or the fear may grow slowly over time after experiencing multiple upsetting events. This presentation is most often associated with a sudden and significant drop in weight that may lead to hospitalization.

Symptoms of ARFID

It can be tough to tell when picky eating behaviors cross the line from "normal" to being signs of an eating disorder. A general rule is that if someone's eating habits start to affect their physical or mental health, they may be dealing with something serious. Below are some more specific ARFID symptoms to look out for.

Physical symptoms

• Low weight or noticeable weight loss
• In children or teens, faltering growth
• Nutritional deficiencies
• Dizziness/lightheadedness
• Stomach cramps
• Constipation
• Irregular menstrual cycles
• Delayed puberty in preteens

Behavioral symptoms

• Difficulty concentrating
• Sleep problems
• Lethargy
• Impaired social functioning
• Irritability

Food-related symptoms

• A general lack of interest in food and eating
• Being disgusted by specific characteristics of foods (texture, smell, etc.) and avoiding foods with these characteristics
• A small list of "acceptable" foods that grows smaller over time
• Fear of something bad happening after eating (vomiting, choking, allergic reaction)
• Rigid habits or rituals around eating (for instance, eating foods in a certain order, keeping foods a certain distance from one another, etc.)
• Lack of appetite
• Anxiety around mealtimes

Anxiety and fear in particular play a significant role in ARFID. Someone with ARFID might be nervous to eat and become extremely upset or worked up around mealtimes, especially if new or challenging foods are on the table. “This might look like anything from a lot of arguing with their loved one to having a full-blown tantrum,” Menzel says.

Identifying ARFID in a loved one

Even if you familiarize yourself with the symptoms of ARFID disorder, it’s challenging to determine if your loved one’s eating habits are “normal” or not. In general, if intense food preferences, loss of appetite, aversions, or fears start to interfere with a person's health or their ability to live life fully, that means it’s time to get help.

Here are specific warning signs to look for:

• Your child’s growth. Every child grows at a different rate. Ordinarily, kids should continue to become taller and gain weight as they mature. If your child’s growth curves have flattened out, talk to their pediatrician.
• The situations in which your loved one will accept food. Are they able to eat out at restaurants? Can they eat at others’ houses and attend social events, or do their eating restrictions cause them to stay home? If they become increasingly rigid about where and how they’ll eat, it’s a red flag.
• What foods your loved one eats. Do they only eat certain brands of foods, prepared specific ways, or only by one person? Have they cut out entire food groups? For example, even if someone doesn’t eat vegetables, they often enjoy French fries (which are made from a vegetable)—but many people with ARFID wouldn’t.
• Your child’s developmental stage. If your child is under five and their eating challenges seem to stem from developmental challenges, rather than psychological ones (for instance, they haven’t yet developed appropriate motor skills necessary for eating), they may have pediatric feeding disorder (PFD), not ARFID. PFD is a feeding disorder that can be treated by working with different specialists.

Menzel emphasizes the importance of trusting your gut. “You know if something feels like it's harder than it should be and if eating in general is harder than it should be for your loved one,” she says.

Causes and risk factors of ARFID

At this time, we still don’t fully understand what causes avoidant/restrictive food intake disorder. Like all eating disorders, ARFID rarely has one single cause, but rather emerges out of a complex mix of different factors, and these factors can vary slightly depending on whether you’re talking about ARFID in young people or ARFID in adults. Some factors that could contribute to the development of ARFID include:

• A family history of eating disorders
• Differences in sensitivity and perception of taste
• Differences in brain regions that regulate appetite
• A traumatic experience, such as choking, vomiting, or having a bad allergic reaction to a food

Treatment for ARFID

As with other eating disorders, treatment for ARFID disorder typically takes a multidisciplinary approach. This way, you address all components of the eating disorder—the nutritional, physiological, behavioral, and psychological—which gives you the best chance of achieving sustainable, lasting recovery. This means working with a team of specialists who understand the nuances of each aspect of ARFID, usually a medical provider, dietitian, and therapist.

Medical care

ARFID patients often work with a medical provider to track weight gain (if necessary), identify nutrient deficiencies, monitor co-occurring medical conditions, and manage any medications.

Many times, the first goal of treatment is weight restoration. Even though people living with ARFID often don't want to lose weight, their restrictive behaviors can lead to weight loss, in which case treatment begins with weight restoration. But regardless of whether or not weight gain is necessary, addressing any nutritional deficiencies is essential, since a limited diet makes it more likely that a person lacks all the nutrients their body needs to function properly.

In addition to working with a pediatrician or physician, many patients also see specialized medical providers, such as GI doctors, allergists, neurologists, or psychiatrists. These professionals can help treat conditions that can contribute to ARFID symptoms (such as sensory processing disorders, food sensitivities and allergies, and gastrointestinal disorders) and that can co-occur with ARFID (such as autism and ADHD).

Nutritional counseling

Registered dietitians with experience treating ARFID can help patients create balanced meal plans and normalize eating habits. By providing nutrition education, teaching skills to help manage anxiety around eating, and using practices like food bridging (starting with an acceptable food and then making small, incremental changes to gradually expand food variety), dietitians help to increase the amount and variety of food a person will eat. They can also help ARFID patients face specific fear foods, like those with challenging textures or those linked to a traumatic event.

Therapy

Food fears don't come out of nowhere—psychological or emotional concerns or past food-related trauma can lead to ARFID behaviors. Therapists help patients unearth the root cause of their eating disorder and then learn to identify triggers and thought patterns and establish healthy ways to face their food-related anxieties.

To accomplish this, providers may use different treatment modalities, including family-based treatment for ARFID (FBT-ARFID), cognitive behavioral therapy for ARFID (CBT-AR), and exposure and response prevention (ERP). Learn more about the evidence-based treatment approaches used at Equip.

• FBT-ARFID: Considered the gold standard of care for young people with eating disorders, FBT empowers family members—who know their child best—to take a central role in treatment, helping to stop disordered behaviors and renourish their child. FBT-ARFID is a specialized version of FBT built for the nuances and specific challenges of ARFID.
• CBT-AR: Mostly used in adults, this specialized type of CBT involves several phases. First, it focuses on teaching the patient about ARFID and how it manifests. Then, it uses prescribed interventions to help patients notice and challenge the thoughts and behaviors of ARFID. There are different modules to address the various presentations of ARFID, including picky eating driven by sensory sensitivity, food-based fears, and problems with appetite and enjoyment of food.
• ERP: Exposure is a central component of ARFID treatment, and this method has been shown to be highly effective. ARFID is rooted in fear, sensitivity to, and avoidance of certain foods. ERP provides a safe, supportive space for the patient to face challenging or anxiety-provoking foods and experiences. Over time, they gradually become accustomed to and more comfortable with those thoughts and foods.

At Equip, our multidisciplinary treatment team also includes mentors. Patients have access to a peer mentor, who has recovered from an eating disorder, and loved ones have access to a family mentor, who has helped a loved one recover from an eating disorder. Mentorship is a less common but extremely powerful component of treatment, as it provides support, empathy, and guidance from people who know just what you’re going through.

How to find professional help

ARFID is fully treatable, but it requires working with a team of eating disorder experts who are knowledgeable about ARFID disorder. Your pediatrician or physician can be a great support in finding ARFID treatment, or you can schedule a consultation with our team to discuss your concerns and possible next steps. Equip is the leading ARFID treatment provider in the United States, and our providers have deep experience treating ARFID patients of all ages.

It can also be helpful to learn more about ARFID so that you feel prepared to discuss what you’re noticing, what you think may be going on, and what your goals are with treatment. There are a number of online resources— like Equip, Feeding Matters, F.E.A.S.T., and the National Eating Disorders Association—that can provide more in-depth education about ARFID.

Supporting your loved one through recovery

If someone you know has ARFID symptoms, understand that ARFID is not your fault, nor is it your loved one’s fault. Eating disorders are not a choice, and a support team is central to recovery. Finding professionals who understand ARFID and how to treat it is the first step toward helping your loved one get better.

Once your loved one begins treatment with a team of knowledgable ARFID professionals, you can further support their recovery by keeping in mind these tips:

• Be patient: “ARFID can be really slow moving to recover. It can feel like you’re doing a lot of work for very little gain at the start of treatment,” Menzel says. So celebrate the smallest wins, and understand it might take a while to change behaviors—but it will happen.
• Remain open: It’s very difficult for someone who eats only 10 to 15 foods to turn into a foodie. However, you have no idea what this journey and the outcome may look like for your loved one—move forward without specific expectations, and notice every bit of progress your loved one makes.
• Foster a non-judgmental environment: Your loved one’s experience with food is probably very different from your experience with food, Menzel says. Just because you enjoy apple pie doesn’t mean everyone does—and expressing surprise, disappointment, or any other form of judgment when your loved one doesn’t have your desired reaction to a certain food can backfire. Your best plan? Help them be willing to explore new foods, rather than being invested in them liking foods.
• Build a support system: Because ARFID is so little-known, dealing with it can be very isolating—you may never have heard of ARFID yourself until you started being concerned about your loved one’s eating. Luckily, peer support groups exist and can help you feel less alone. There are a number of free, online support groups you can join today. And if you pursue treatment at Equip, both you and your loved one will be matched with mentors who have made it through eating disorder recovery themselves.

The Equip takeaway: Moving forward with hope

Avoidant/restrictive food intake disorder is more than picky eating—it is a diagnosable eating disorder that requires professional help to overcome.

This type of restrictive eating impacts a person’s ability to function and enjoy their daily life, and it can impair a child’s growth. So if you suspect you or someone else’s picky eating is more than that, don’t ignore it or wait for them to grow out of it. Talk about your concerns with your physician, your pediatrician, or your loved one, or seek out an experienced eating disorder expert.

With the right professional and peer support, recovery from ARFID is possible—and worth it.

FAQ

What is ARFID?

Avoidant/restrictive food intake disorder (ARFID) is an eating disorder where someone doesn’t eat enough food, enough different types of food, or both. Unlike other eating disorders, however, ARFID isn’t driven by body image concerns or a desire to lose weight. Instead, challenges with food are caused by extreme sensory sensitivities, fear of negative outcomes from eating, or lack of interest in eating. ARFID can harm a person’s physical and mental health, and interfere with day-to-day life.

What is the difference between ARFID and picky eating?

ARFID is when a person eats very little food, a small variety of food, or both, without any body image issues or desire to lose weight. These eating behaviors persist for a long time and impair a person’s growth and ability to take part in everyday life. On the other hand, someone who is a picky eater may only eat certain foods or foods prepared in certain ways, but this doesn’t affect their social life or growth (in children).

What are the health risks of ARFID?

ARFID poses several health risks. These include:

• Nutritional deficiencies
• Constipation
• Bloating
• Abnormal cycles or amenorrhea
• Poor concentration
• Weakened bones
• Languo (fine hair all over the body)
• Slow pulse
• Dizziness, fainting
• Stunted growth
• Delayed puberty (in children)

What are the signs of ARFID?

ARFID symptoms include:

• A small list of "acceptable" foods that grows smaller over time
• Rigid habits or rituals around eating
• Anxiety around mealtimes
• In children, a plateau in growth
• A general lack of interest in food and eating
• Avoiding specific food groups
• Being repulsed by specific aspects of foods
• Fear of something bad happening when eating
• Impaired social functioning due to food fears or preferences

How is ARFID treated?

If appropriate, the initial focus of ARFID treatment is weight restoration and addressing any nutritional deficiencies. The next phase of treatment helps the patient learn skills and tools to normalize eating habits, decrease and manage anxiety, cope with uncomfortable physical sensations, and increase variety in their diet.

Treatment providers may use different modalities, including family-based treatment for ARFID (FBT-ARFID), cognitive behavioral therapy for ARFID (CBT-AR), and exposure and response prevention (ERP), to accomplish these goals.

Can adults have ARFID?

Although it’s more commonly diagnosed in children, adults can have ARFID. In fact, one study reported that up to about 9 percent of adults with an eating disorder meet the criteria for ARFID. Some of these people may have developed ARFID symptoms as a child but never received treatment, while others may have developed ARFID disorder after a traumatic food-related event that occurred later in life, such as choking, an allergic reaction, or severe vomiting.