Why don’t they like eating?
ARFID is a type of pediatric eating disorder that stands for avoidant/restrictive food-intake disorder. If your child only eats between 5-10 foods, refuses any unknown brands, and shows extreme aversions to foods, or food-related situations, it could be ARFID. Many children with ARFID prefer a “beige diet” or a very limited/specific diet based on contaminated/unsafe foods or those that cause disgust. Some children rely on drinks or blended foods and avoid actual eating/chewing of food. As a result, ARFID can often serve as a barrier to nutritional or energy needs. Lacking food diversity over time can result in malnutrition, either weight loss or weight gain (depending on diet and food intake), as well as altered bowel habits and poor GI health. ARFID can either be present from a young age or arise later on in childhood/adolescence, It occurs across gender, ethnicities, and socio-economic status. Many who carry an ARFID diagnosis also have co-occurring GI, neurodevelopment, psychiatric or nutritional disorders/deficiencies. In fact, between 20-40% have co-occurring GI symptoms/disorders. Premature birth was also found to have an increased association with ARFID. Research has shown that the younger the child is when they begin experiencing ARFID, the more likely psychiatric or medical comorbidities. ARFID often co-occurs with anxiety, depression, ASD, ADHD, and OCD, also similar genetic factors/profiles. Those with ARFID tend to have more executive dysfunction than typical peers: cognitive inflexibility, working memory deficits, poor response inhibition, resulting in rigidity in food preferences, difficulty trying novel foods, hyper vigilance of feared foods, and difficulty forming new positive associations with foods. In terms of underlying causes and co-occurring conditions, those receiving care via their pediatrician tended to be younger patients with medical comorbidities, with higher rates of GI problems, ASD, and ADHD, while those receiving care via their psychiatrists tended to have increased rates of anxiety and depression, a more acute presentation, and were teens/young adults. Formal interventions for ARFID have been limited and minimal randomized controlled trials. It has also been hard to evaluate interventions because of significant heterogeneity (different ages, genders, diagnoses) within children with ARFID, and as a result, there are no empirically supported treatments at present for children.
Typically, there are certain underlying factors that result in avoidance of certain foods. Most often being, sensory sensitivity, lack of interest, and fear of aversive consequences of eating. These are not mutually exclusive and often do overlap. Some children who have sensory processing disorder are considered “super sensors” in terms of food smells, taste, textures, temperature, or appearance. Research has shown that there is often significantly atypical sensory perception in those with ASD and ADHD (up to 33% of these kids). For children with co-occurring ASD, they tend to be more sensitive to tastes and smells of food. Moreover, children may be further compounded by ritualistic and routine-based eating behaviors that they struggle to deviate from. Others may not experience the same level of hunger cues or have low interoceptive awareness of cues from their body. Moreover, some children with ASD struggles with food preferences and eating because of communication barriers. Additionally, those with ADHD may be more likely to exhibit lack of interest in eating, especially if exacerbated by stimulants. Some children avoid eating because they fear of choking, vomiting, gagging, or GI distress, and this type of ARFID usually develops at a later age and more acutely. Those with anxiety or trauma may be more likely to have fear of aversive consequences of eating. Additionally, some parents with good intent put pressure on children to eat, which can sometimes backfire and result in further avoidance and negative association.
The assessment of ARFID should always be multidisciplinary (e.g., speech/language pathologist, occupational therapist, developmental pediatrician, psychologist/neuropsychologist, nutritionist, gastroenterologist etc). It is also necessary to assess physical health and track weight/BMI, swallowing, oral-motor skills, nutritional profile. In terms of formal assessments there is the Pica ARFID and Rumination Disorder Interview, the children food neophobia scale, the child eating behavior questionnaire, the child feeding questionnaire, and The Brief Autism Mealtime Behavior Inventory (BAMBI) that can all give helpful and specific about the child’s eating behaviors in addition to diagnostic purposes.
So what should parents know about potential treatments and supports for their children? Ideally, those with ARFID will receive an appropriate and individualized combination of psychotherapy, nutritional support, occupational therapy, swallowing therapy, parent training, and other medical interventions. Both the child’s and the family’s goals are important in creating a treatment plan for a child with ARFID. Of note, ARFID treatments likely need adjustments for those who are neurodivergent and/or have medical or nutritional complications. Cognitive-behavioral therapy, or CBT, helps to create a new behavioral contingency in response to “triggering food or food characteristics”, removes negative effects from eating, and teaches both parents and the child that the avoidance of certain foods only results in temporary relief but also perpetuates fear and can be irrational (over-estimation of threats). For some children, it may be helpful to gradually remove any “safety behaviors” (e.g., checking foods repeatedly, only eating in certain settings or with certain utensils or brands) with clinician support. The most common manualized treatment for ARFID, CBT-AR, is intended for children ages 10 and up and has a parent/caregiver component, which has shown good acceptability and feasibility but not proved to be effective via RCTs yet. There is also the Supporting Parenting for Anxious Childhood Emotions (i.e., SPACE)-ARFID program, which is a manualized treatment for the whole family and help parents to prevent enabling while supporting their children, which has been shown to be effective thus far. Additionally, some behavior analysts have employed positive reinforcement for children when attempting new foods in combination with feeding programs to assist in habituating to sensory experiences. If sensory issues appears to be prominent, the child may benefit from a detailed sensory evaluation and sensory-based intervention if sensory avoidance appears part of underlying motivators. There are also potential supplements and diets that may be beneficial. For example, NAC (N-acetylcysteine) may be beneficial due to anxiolytic (support for anxiety reduction/irritability) properties and pro-GI effects, while Camel Milk or Candida Diets may potentially benefit GI symptoms independently.
Family support is critical because research has shown the most effective and long-term positive outcomes when there is strong family involvement. It is important to have feedback from children in terms of their experience with trying new foods, as well as effects of new settings, new smells, and new therapies. It can helpful to keep a food journal of what foods were presented, setting, textures, temperatures etc to identify cause of avoidance. Its helpful to understand that packaged/processed foods often feel safe because they are more homogenous in smell, taste, appearance etc, while fresh foods often look, taste, and smell differently. It is helpful to gradually expose a child to a new food by starting with a familiar food and slowly changing appearance and ingredients. When parents model eating a variety of foods, children may be more likely to try very small portions of new foods, especially if presented as optional at first. Sometimes allowing child to cook or prepare foods with you can be helpful and encouraging in trying new foods or becoming familiar with certain foods. Parents can also explain to their children that even if they don’t like a certain food YET, they may like it in the future, as this helps to curb concreteness and black/white thinking. It is also helpful make touching, smelling, or trying new foods fun and humorous by creating games, offering rewards, and making it competitive and silly. Finally, it is very important for parents not to judge themselves or their children for unusual food choices or combinations.