Avoidant/restrictive food intake disorder

Avoidant/restrictive food intake disorder (ARFID) looks like anorexia on the scale but not in the mind; case questions hinge on the absence of body-image concern and on coaching families away from pressure at meals.

Criteria at exam depth (paraphrased):

• An eating or feeding disturbance, such as apparent lack of interest in eating, avoidance based on sensory characteristics of food (texture, smell, color), or concern about aversive consequences (choking, vomiting), shown by persistent failure to meet nutritional or energy needs.
• Associated with one or more of: significant weight loss or, in children, failure to achieve expected weight gain or faltering growth; significant nutritional deficiency; dependence on enteral feeding or oral nutritional supplements; marked interference with psychosocial functioning.
• Not explained by lack of available food or a culturally sanctioned practice (such as religious fasting).
• Does not occur exclusively during anorexia or bulimia, and there is no disturbance in how body weight or shape is experienced.
• Not attributable to a medical condition or better explained by another mental disorder; when it occurs alongside one, the eating problem exceeds what that condition usually brings and needs its own clinical attention.
• Onset is often in childhood, but ARFID occurs at any age.

Hinge differentials:

• Anorexia nervosa — fear of weight gain and body-image disturbance; ARFID has neither.
• Autism spectrum disorder — rigid eating may be part of ASD; ARFID is added only when the eating problem exceeds what ASD alone explains. Developmental screening helps.
• Specific phobia (choking or vomiting) — when fear generalizes to restricted eating with nutritional consequences, ARFID may fit better.
• Ordinary picky eating — no weight, nutritional, or psychosocial consequences.
• Medical conditions — GI disease, food allergy, swallowing problems.

On the NCMHCE: Refer for medical and nutritional evaluation (growth, deficiencies, swallowing) and coordinate with the pediatrician and a dietitian or feeding specialist. Screen for anxiety, which commonly co-occurs. Provide psychoeducation that sensory-based food avoidance reflects genuine sensory sensitivity and anxiety, which counters parents' belief that the child is being willfully defiant. Advise that pressuring or forcing foods may increase avoidance and distress; instead use gradual, structured exposure to new foods with low-pressure mealtimes. CBT adapted for ARFID and family involvement are commonly used. Respect cultural food practices when judging what counts as restriction.

Clinical Pearl: Restriction with nutritional or psychosocial consequences but no body-image disturbance points to ARFID. Coach families toward gradual exposure, not pressure.