A 12-year-old boy with autism spectrum disorder presents to your office. His mother reports that he has always been a picky eater and will only eat carbohydrate-based foods, such as plain pasta and French fries. He refuses vegetables and fruits stating he does not like the way they taste or feel. He does not eat all day at school and only eats at home with his mother’s encouragement. His mother also notes that he has been struggling with constipation and fatigue. On review of his growth charts, you note that he recently fell off his percentiles for weight, height, and BMI. Is this simply picky eating or something more?
Many children and adolescents exhibit picky eating. While picky eating is not always problematic, it may signal a more serious issue when it becomes extreme or causes health consequences. Avoidant/Restrictive Food Intake Disorder (ARFID) is a feeding and eating disorder characterized by significant weight loss, nutritional deficiencies, dependence on enteral feeding or oral nutritional supplements, and/or marked interference with psychosocial functioning.
ARFID is a relatively new diagnosis that was introduced to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. Unlike anorexia nervosa or bulimia nervosa, ARFID is not driven by concerns about body weight or shape. Instead, it is associated with one or more of the following subtypes:
1. Lack of interest in eating
2. Sensory sensitivities
3. Concern about aversive consequences of eating
Symptoms may begin after an adverse food-related event, such as choking, vomiting, or foodborne illness. For example, a child who chokes on a ham sandwich may develop a long-term aversion to cold cuts. About half of individuals with ARFID meet criteria for more than one subtype.
ARFID can affect people of all ages. Prevalence estimates in youth vary widely, ranging from 0.3% to 15.5%. The average age of onset is around 12 years, earlier than the typical onset for anorexia nervosa or bulimia nervosa. The female-to-male ratio is approximately 60:40. Children with autism spectrum disorder, attention deficit hyperactivity disorder, anxiety, depression, or obsessive compulsive disorder are at increased risk, as are those with a family history of eating disorders.
Common physical symptoms include abdominal pain, reflux, nausea, diarrhea, and constipation. Medical complications may include weight loss, low bone mineral density, amenorrhea, electrolyte abnormalities, bradycardia, and cardiac issues.
Evaluation should include a thorough medical history, physical examination, and review of growth curves. Routine laboratory testing may include a complete blood count, comprehensive metabolic panel, and thyroid studies. In some cases, an electrocardiogram may be warranted.
As with other eating disorders, ARFID treatment requires a multidisciplinary approach, beginning with weight restoration when needed. Medical providers help manage nutritional deficiencies and medical complications. They can also consider prescribing medications, such as cyproheptadine to assist with appetite stimulation, and/or selective serotonin reuptake inhibitors for comorbid anxiety or depression. Therapists help patients address thoughts and behaviors around eating. Treatment may involve Family-Based Therapy (FBT), Cognitive Behavioral Therapy (CBT), or Supportive Parenting for Anxious Childhood Emotions (SPACE). Nutritionists or registered dieticians support with meal planning. Speech-language pathologists can be enlisted to conduct swallowing studies when choking is a concern.
Caregivers also play a crucial role in their child’s recovery. They can model eating a variety of foods, encourage trying new foods, reinforce positive eating behaviors, and help their child manage stress and anxiety around meals. FBT and SPACE are two therapy modalities that rely heavily on parental involvement.
In the case of the 12-year-old described above, his significant weight loss raises concern for ARFID, likely driven by a lack of interest in eating and sensory sensitivities. His physical symptoms further support the need for medical evaluation and intervention.
References
Fisher M, Zimmerman J, Bucher C, Yadlosky L. ARFID at 10 years: a review of medical, nutritional, and psychological evaluation and management. Curr Gastroenterol Rep. 2023;25(12):421-429.
Willmott E, Dickinson R, Hall C, et al. A scoping review of psychological interventions and outcomes for avoidant and restrictive food intake disorder (ARFID). Int J Eat Disord. 2024;57(1):27-61.
AUTHOR:
Dr. Kristen Kim, MD
Child, Adolescent and Adult Psychiatrist
Vista Hill Foundation