The short answer is that ARFID stands for Avoidant / Restrictive Food Intake Disorder. It is a clinical diagnosis that may be given to children (and adults) whose eating is extremely limited.
Now for the long answer: The journey towards the development of a diagnosis for severe picky eating has been full of twists and turns - and it is not over yet. Childhood eating problems have been called all sorts of things: infantile anorexia; selective eating disorder (SED); sensory food aversions; food avoidance emotional disorder (FAED); functional dysphagia… the list goes on.
These labels have various conceptual underpinnings and distinct characteristics. They have been developed by leading researchers and clinicians and yet somehow, this plethora of terminology results in a potentially confusing picture.
Let’s take a step back and consider how clinical diagnoses are arrived at. There are two main diagnostic manuals which are recognised internationally. They are the ICD and the DSM. The ICD is produced by the World Health Organisation and the DSM is produced by the American Psychiatric Association.
The idea behind both the ICD and the DSM, is that there needs to be some kind of central reference point for clinicians where they can use agreed criteria when they assess a patient. These manuals are constantly being reviewed and developed and are updated every so often. At the time of writing, we are up to the ICD-10* and the DSM-5**.
In the DSM-4, (the previous version of the DSM, which was published in 1994) there were some vague umbrella terms under which very limited eating would fall. ‘Eating disorder not otherwise specified’ (EDNOS) meant an eating problem that merited a diagnosis but didn’t fit the description of anorexia nervosa or bulimia nervosa. ‘Feeding disorder of Infancy and early childhood’ was similarly vague and required children to be underweight, thus missing a huge group of children whose eating may have been problematic enough to require a clinical diagnosis but who were not underweight***.
When the DSM-5 came out in 2013, a new disorder - ARFID - was included to reflect what researchers knew about childhood eating problems. It is also probable that it will be in the next version of the ICD (ICD-11)**** due to come out this year.
How is ARFID diagnosed?
There are many different causes of ARFID, such as sensory food aversions or a fear of choking. Sometimes, there may be multiple factors affecting a person's ability to eat a varied diet. In the future, more work may be done to further distinguish sub-categories of ARFID.
Here are the key features of ARFID:
Remember, a trained professional like a psychiatrist or clinical psychologist would need to diagnose ARFID. Please also note that the following information is not exhaustive and is just an attempt to provide an overview of this disorder:
A person (they can be an adult or teen, not just a child) can be diagnosed with ARFID if they are a very limited eater and don’t have other reasons for their restricted eating, such as a lack of access to a varied diet, cultural reasons to go without food or the kind of body dissatisfaction that is associated with anorexia.
A person must be getting insufficient energy or nutrition (or both) from their diet because it is so limited - although importantly, they do not necessarily have to be underweight or lacking in nutrients. This point may seem contradictory, but the distinction is a subtle one: it is possible not to be meeting the recommended intake of calories and/or nutrients without being significantly nutritionally deficient or underweight.
At least one of the following must be discernable:
- Weight or growth problems (although this would need to be significant)
- A lack of nutrients in the diet (again, this would need to be significant)
- A reliance on tube feeding or supplements taken by mouth
- The eating problem cannot be explained by another diagnosis (like digestive issues)
- ‘Marked interference with psychosocial functioning’
I have put this bullet point in bold because I feel that this aspect of ARFID is really important. It recognises just how debilitating serious eating problems can be - they can have a significant impact on a person’s day to day functioning and sense of wellbeing. They can affect a person’s interactions with others and their ability to take part in social situations.
What does all of this mean for parents?
If you suspect that your child may meet the diagnostic criteria for ARFID, is this something you should pursue? Like any question about diagnosis, this is a very personal decision. Depending on where you are and how you access healthcare, a diagnosis may be hard to come by. In the UK where I am, many GPs (doctors) don’t know about ARFID and getting the right referral for an assessment could be challenging. It is not included on the NHS Choices website (UK government health information site) and is clearly not on many people’s radars.
Having said that, a diagnosis of ARFID could open doors in terms of access to professional support for your child. It could also help them (and the adults in their life) understand that their eating is a genuine challenge that needs to be taken seriously. Regarding how you support your child, if their eating was very limited and they were extremely anxious eaters (for whatever reason) broadly the same positive feeding practices would be supportive, whether they had an ARFID diagnosis or not. So it wouldn’t necessarily change what they need, but it might change the help they can get and how they are perceived.
* World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.
** American Psychiatric Association., & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association.
*** Chatoor, I. (2002). Feeding disorders in infants and toddlers: diagnosis and treatment. Child and adolescent psychiatric clinics of North America, 11(2), 163-183.
**** Bryant‐Waugh, R. (2013). Avoidant restrictive food intake disorder: An illustrative case example. International Journal of Eating Disorders, 46(5), 420-423.