New England Psychologist
March 2017

While it is not uncommon for children to have a limited palate when it comes to food, (heck, restaurants have special menus just for this segment of the population) when does food aversion become pathological? When does the self-restriction to certain textures, colors, tastes or smells necessitate further intervention?

In 2013, with the release of the DSM-5, the American Psychiatric Association first recognized the extreme form of picky eating that can lead to malnutrition and slower development, known as Avoidant-Restrictive Food Intake Disorder (ARFID), as an eating disorder.

New England Psychologist’s Catherine Robertson Souter spoke with Renee Nelson, Psy.D, clinical director of child and adolescent services at Walden Behavioral Care, which provides eating disorder treatment at sites through Massachusetts and Connecticut, about the diagnosis and the increase in children she has seen dealing with ARFID.

Q: How does this new diagnosis differ from other eating disorders?

A: Well, ARFID is actually repackaged from a previous diagnosis of Feeding and Eating Disorder of Infancy and Early Childhood. The American Psychiatric Association took that definition and made it more applicable to some of the kids we are seeing. It differs from traditional eating disorder in that you are not hearing the patient talk about body image concerns. Instead there is a real aversion to food whether that is due to something sensory, disgust or fear.

There are kids who never have a drive to eat, they don’t have interest in food. For some, there are significant sensory characteristics that impede their ability to be able to eat, whether that is, “I won’t eat anything green or they have to be neutral colors or the texture has to be just so.”

These are issues we tend to see happen much earlier and be more of a lifelong struggle versus the type where there is a choking or vomiting episode that triggers the onset of food avoidance.

The risk really is any malnutrition can develop into one of the other eating disorders. Any deprivation to the brain can result in using eating disorder behaviors like restricting or over exercising. Malnutrition alters the brain.

Q: This is a repackaging of an earlier diagnosis but are you seeing more of this now?

A: It is hard to know if it is because of the diagnosis changing that has brought this more to life but certainly in our centers we have seen an increase in the amount of kids struggling with ARFID over the last three or four years.

There are some preliminary estimates that suggest it may affect as many as 5 percent of children and 3.2 percent of the general population. The prevalence of ARFID is about 14-22.5 percent of children being seen for any type of eating disorder.

Q: So the primary danger is malnutrition for a child and secondary to that would be other eating disorders. Are there other concerns?

A: The first step is always targeting the malnutrition, making sure the child is getting enough calories. But that is not enough. It is a mistake to think that this is not going to impact their life in other ways. There are a lot of self-esteem and emotional struggles that come with being limited to a small range of food.

The other piece is helping a child figure out how to expand their variety so they can live a pretty normal life.

Q: Do you think that the increase in ARFID is a result of current, more permissive, parenting styles? The idea of forcing kids to eat everything put in front of them is out of style.

A: It is never the fault of the parent – that is not a helpful way to look at it – but there are always things we are doing that are helpful and unhelpful.

I think you have to know the child who is in front of you and what we actually know from these kids is that if you don’t present them with their chosen option they are not the type of children who will just eat something else.

Parents hear from their friends and family to hold out and they will be hungry enough that they will eat. Unfortunately that doesn’t work with these kids. We have to give them enough of what they will eat and then figure out a way to expand the variety.

Q: Is there a point where they end up in the hospital?

A: Absolutely. I have seen children who medically need to have tubes inserted so they can be fed directly. It can be very severe. This is not a sign that if you withheld the foods they prefer, they will come around.

Q: Many children are picky eaters. What are the signs that indicate further intervention?

A: Any medical complications or if they are not following their projected growth or weight trajectory. And really looking at how limited their food is and if the range of accepted foods continues to narrow, going from a list of 20 foods to a list of 15 and then to 10. Also, is it impacting their lives so that they can’t go out socially or are they feeling negatively towards themselves or showing more anxiety? Does this look like torture to them? It is not just what is happening behaviorally but what is happening for that child psychologically and emotionally.

Q: How is this condition treated?

A: In our clinics, we use family-based treatment which is the gold standard for anorexia and very promising for bulimia and other eating disorders.

Pull the family in to teach them how to feed their child, to give skills on how to expand their variety while working on rewarding the child for being able to try. By the time we see a family, the dinner table is one of most stressful times of day. We want to help them rework that.

As a psychologist, my first step is doing a solid developmental history to see whether some of this is normal developmental progression. You want to rule out anything medical that is getting in the way, something mechanical with being able to chew and swallow, for instance.

Is it a sensory characteristic, a fear response, disgust response or avoidance? Are there some behavioral pieces to it? Those are things you have to ask good questions around.

It is important to do a full workup. You want to be able to get a speech and language pathologist or an occupational therapist on board if there is a mechanical piece for this child. It is definitely a multidisciplinary approach. It is a real intersection of physical and psychological.

Q: What is your success rate with these children?

A: I can only speak clinically but having supervised quite a few cases, these are children who do really well in our programming. Usually by the time children are coming to a treatment center, they are pretty malnourished or unable to function in different areas of their lives or the family stress is very high around being able to feed their child and balancing everything that they need to do.

They are typically motivated despite the fact they are fearful and avoidant. Being able to get them nourished and to teach the family how to add in variety and do exposure work and how to reward and encourage and support their child through this makes a pretty amazing impact for these kids.