Picky Eater or Eating Disorder? Understanding ARFID in Children

Many children are picky eaters, refusing to eat things like vegetables or simply hesitant to try new foods. But when does pick eating turn into something more concerning?

Michelle Bowden, MD, medical director of the Eating Disorder Program at Le Bonheur Children's Hospital, shares important information surrounding ARFID—which stands for avoidant restrictive food intake disorder – an eating disorder characterized by extremely selective eating.

What Does ARFID Look Like?

ARFID can present in a few different ways in children, says Dr. Bowden. In some cases, a child has always been a picky eater, for various reasons, but instead of the pickiness getting better it becomes worse over time. For other children, ARFID arises due to an acute event related to food such as choking spell or vomiting.

“Then, all of a sudden, they're fearful of eating lots of different kinds of foods and become really restrictive in how they eat,” states Dr. Bowden.

A third type is when kids have no interest in food. They don’t have an appetite and eating starts to feel like a chore; they’d rather be doing something else. “Most of the time, there is some combination of those reasons when we're talking about ARFID,” she adds.

Often, an underlying issue exacerbates ARFID. Children who are on the autism spectrum, with a lot of anxiety, and in the preliminary stages of obsessive compulsive disorder (OCD) are typically more prone to developing the eating disorder.

Distinguishing ARFID vs. Picky Eating

It’s important to understand about what time ARFID might become an issue. Dr. Bowden explains that three-year-olds are the peak of picky eating. At this point, they start to exert their ability to say, "Hey, I'm a human too. I want to make my own decisions. I'm going to not eat this." Still, they are often too young for an ARFID diagnosis.

“I very rarely would diagnose a kid with ARFID at less than about age six because picky eating can be typical for kids. Even for a kid who is an extremely picky eater in those early childhood years, we're typically talking about something like oral aversion that may eventually develop into ARFID but doesn't quite meet the diagnostic criteria yet,” she notes.

A good distinction to make is whether or not anxiety accompanies the aversion to food. Meaning, the pickiness could be rooted in annoyance rather than a feeling of anxiety. For example, a kid who is merely a picky eater can go to a friend’s birthday party and eat a cupcake or snacks. A kid with ARFID experiences so much anxiety about eating in that type of social situation that they refuse to eat.

Treatment Strategies: A Multidisciplinary Approach

One key indicator of ARFID is a child’s growth pattern. Even picky eaters will generally eat enough to grow as they should to achieve an appropriate height and weight. A child might not be gaining weight, but they shouldn’t be losing weight. If kids aren’t going through puberty stages at the appropriate time,

that is also a potential ARFID indicator. An additional red flag is if children engage in fights about food or have breakdowns surrounding food (or food discussions).

If any of these signals arise, parents or caregivers should enlist the help of their child’s pediatrician—who can then refer the child to the appropriate experts, like Dr. Bowden and her team. Then, the child can be evaluated for certain criteria to determine an ARFID diagnosis. She mentions that having a psychologist or therapist on board is immensely helpful in identifying any underlying factors, such as anxiety, OCD or autism spectrum disorder.

“That will help us develop a treatment plan, which is multidisciplinary. As the medical provider, I can offer things like medication for anxiety. Alongside that, there are really good therapies available from community therapists, from our psychologists, that focus on strategies like cognitive behavioral therapy,” says Bowden.

Additional professionals that provide benefits include dietitians, occupational therapists, physical therapists and speech therapists. “They can really help us determine any sort of sensory issues we need to address so we can be more effective at aiding this child in making the progress they need to be making to be successful in the long-term.”

Looking Toward the Future with a Positive Lens

Many kids living with ARFID make progress with the right strategies in place. In addition to professional guidance, parents can also take steps to help their child with ARFID. One such approach is to make meals as low-pressure as possible. Another is to avoid labeling foods as “good” or “bad” and be a positive role model in terms of eating healthfully. Also, understand that it might take 10-20 times for a child to try a food and accept it onto their palate.

Even with these strategies in place, Dr. Bowden cautions that addressing ARFID is a “long game,” not something that will get better in weeks or even months. It may need intervention for a few years.

“It’s really about focusing on helping your child grow and thrive with the foods they're able and willing to eat,” says Bowden. “Honestly, letting them direct which foods they want to add over time and not push with specific foods becomes an important part of the treatment process. If we're willing to do that, slow down, take our time, follow our kids' lead, get them the therapies they need, I do see kids make great progress and live long, healthy, fulfilled lives with a diagnosis of ARFID.”