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When Picky Eating Is a Problem

What parents need to know about ARFID

Malia Jacobson

Published on: November 25, 2020

kid frowning over a bowl at the kitchen table

Editor's note: This article was sponsored by THIRA Health.

Parents raising a picky eater are in good company. According to research, about 25 percent of children and teens experience problems with feeding or eating, making pickiness one of the more prevalent complaints among parents. For most kids, pickiness is a passing childhood phase. It can even be a healthy sign that children are eating intuitively, according to their own internal cues of hunger or fullness, says Devan Weir, C.D., a registered dietitian on staff at THIRA Health, a mental health treatment center for women and girls in Bellevue, Washington.

However, in some children, picky eating is an early sign of avoidant restrictive food intake disorder (ARFID), a little-known eating disorder that can lead to severe nutritional deficiencies, developmental delays and family chaos, according to Mehri Moore, M.D., THIRA’s medical director and a nationally recognized expert in eating disorder treatment. In 1991, Moore pioneered family-based eating disorder treatment in Seattle, founding The Moore Center (later renamed the Eating Recovery Center of Washington), the Pacific Northwest’s oldest established eating disorder treatment center. 

What is ARFID?

Sometimes characterized as extreme pickiness, ARFID is an eating disorder involving an aversion to food and eating. “This isn’t just picky eating,” says Weir. “ARFID is really extreme, to the point where it’s causing malnutrition and medical consequences.”

Formerly called “selective eating disorder,” ARFID is a relatively new diagnosis defined in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

Although experts believe that ARFID is on the rise, plenty of health-care providers haven’t heard of the condition, notes Weir. “Up to 63 percent of pediatricians and subspecialists are unfamiliar with it, so parents often need to search around to find support and help.” 

The condition does occur in adults, but is more common in children, particularly in those on the autism spectrum. 

The most visible symptoms of ARFID are similar to other eating disorders and include dramatic weight loss, lethargy, cold intolerance and digestive problems such as constipation, cramps or “upset stomach.” But unlike anorexia nervosa, ARFID isn’t characterized by a distorted body image or fear of weight gain, says Moore.

Food fears

Because children with ARFID often report gastrointestinal discomfort after eating, they may begin to fear foods that might bring on symptoms and be afraid of choking or vomiting. They may have little motivation to eat and claim to be full or suffering from a stomachache when mealtimes roll around. As the disorder progresses, children may whittle down their list of acceptable foods to a single type or texture, protesting if anything else touches their plate.

Without treatment, ARFID can persist into adulthood; one study found that more than 17 percent of adult women seeking treatment for gastrointestinal problems met at least some of the diagnostic criteria for ARFID. According to the National Eating Disorders Association (NEDA), ARFID can cause neurological and growth problems in children as the body slows its metabolic process to conserve energy. In extreme cases, nutritional deficiencies can result in fatal electrolyte imbalances or cardiac arrest.

Warning signs

Stalled growth and “falling off the weight chart” can be red flags for ARFID, especially when children also exhibit low energy, difficulty in concentrating, fears about food and disinterest in eating. But caregivers won’t always notice dramatic weight loss when their child has ARFID or another eating disorder, notes Moore.

In fact, changes in eating-related behavior without any change in weight should pique a parent’s interest, says Moore. “When children and teens show either an increase or decrease in their interest in food, or do things like hide food in their bedroom, and parents don’t notice any change in weight, that’s a time to become curious.”

If picky eating doesn’t resolve by the time a child enters grade school, becomes more extreme as children get older or seems to be affecting a child’s physical or mental health, an evaluation may be in order, says Weir. “Parents can start with their pediatrician and find additional resources and support from the Ellyn Satter Institute, the National Eating Disorders Association and THIRA Health, which specializes in eating disorder recovery.”

Parents need support, too. Eating disorders like ARFID are not only developmentally dangerous for children, but extremely challenging for caregivers, says Moore. “Often, we’ll see that parents are doing a balancing act, making different meals for different family members while trying to manage extreme food preferences for one child. Because of the strain that an eating disorder places on everyone in the household, it’s important to seek out whole family healing.”

An integrated approach to treatment

THIRA Health’s therapeutic approach provides multifaceted, evidence-based and integrated treatment for eating disorders. While treatment for anxiety and depression — which are often the underlying causes for eating disorders — is rooted in Dialectical Behavior Therapy (DBT), THIRA’s comprehensive program emphasizes family therapy, nutrition rehabilitation and counseling, and family nutrition education and coaching. DBT is a proven treatment model designed to help clients learn and apply skills to manage their lives and emotional well-being more effectively. Through work in mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness, clients can achieve lasting positive change.

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