’

Avoidant/Restrictive Food Intake

Disorder (ARFID)
Jacqueline Zimmerman, MS, RDN, and Martin Fisher, MD

Avoidant/restrictive food intake disorder (ARFID) is an
entirely new diagnosis in the DSM-5. ARFID replaces “feed-
ing disorder of infancy or early childhood,” which was a
diagnosis in the DSM-IV restricted to children 6 years of age
or younger; ARFID has no such age limitations and it is
distinct from anorexia nervosa and bulimia nervosa in that
there is no body image disturbance. ARFID involves a
complex and heterogenous etiology, which is reviewed
herein. What is known to date regarding the characteristics
and medical and psychiatric comorbidities of this patient
population are described and compared to other eating
disorders. Evaluation and management strategies are also
discussed. No data yet exist regarding ARFID’s prognosis
and prevention; however, recommendations to guide parents
in establishing appropriate infant and child feeding practices
are provided.
Curr Probl Pediatr Adolesc Health Care 2017;47:95-103

Introduction DSM-5 in 2013. ARFID is an entirely new diagnosis

within the section of feeding and eating disorders in
ay 2013 marked the much-anticipated publi- the DSM-5. The DSM-5 provides diagnostic specif-
M cation of the Diagnostic and Statistical
Manual, 5th Edition1 (DSM-5) by the
icity to those patients who do not fear weight gain,
but simply cannot meet their nutritional needs for a
American Psychiatric Association (APA). The first variety of reasons. The diagnosis of ARFID in the
major update since 1994, the DSM-5 includes exten- DSM-5 does not have an age restriction; it can
sive revisions throughout, and includes the new therefore be applied to children, adolescents, and
section, “feeding and eating adults. However, since the age
disorders,” which replaces and groups in which it is most
combines two former sections, ARFID is an entirely new commonly diagnosed are
“eating disorders” and “feeding
and eating disorders of infancy
diagnosis within the section of older children and younger
adolescents, it is most often
or early childhood.” The new Feeding and Eating Disorders in pediatricians who are called
“feeding and eating disorders” the DSM-5. upon to be the first practi-
section includes expanded crite- tioners to consider the
ria for familiar diagnoses, such diagnosis.
as anorexia nervosa (AN) and bulimia nervosa (BN), as As early as 1992, Lask and Bryant-Waugh2 describe
well as several new diagnoses, including purging several childhood-onset eating disorders involving
disorder and avoidant/restrictive food intake disorder food restriction that failed to meet criteria for AN
(ARFID), the latter of which replaces “feeding disorder due to lack of body image distortion or a desire to lose
of infancy or early childhood,” which was a diagnosis weight. In 2002, Watkins and Lask3 expanded on
in the DSM-IV restricted to children 6 years or
these atypical eating disorders in children and adoles-
younger. ARFID is not genuinely a new condition,
but this restrictive eating disorder was not clearly cents and classified them as follows: food avoidance
defined and characterized until the publication of the emotional disorder, characterizing children with a
“primary emotional disorder in which food avoidance
From the Division of Adolescent Medicine, Northwell Health, Hofstra
is a prominent feature;” selective eating, describing
Northwell School of Medicine, Cohen Children's Medical Center, Hemp- children who “eat very few different foods and
stead, NY. sometimes are particular about the brand of food or
Curr Probl Pediatr Adolesc Health Care 2017;47:95-103 where the food was bought” but whose growth and
1538-5442/$ - see front matter
& 2017 Elsevier Inc. All rights reserved.
development is not negatively impacted by their
http://dx.doi.org/10.1016/j.cppeds.2017.02.005 eating patterns; functional dysphagia, which involves

Curr Probl PediatrAdolesc Health Care, April 2017 95

a “fear of swallowing, vomiting, or choking, which other eating disorders in that management involves a
makes the child anxious about and resistant to eating multidisciplinary team approach and includes medical,
normally, which results in a marked avoidance of nutritional, and psychological practitioners. However,
food,” and for which there is typically “an easily the role each discipline plays may vary to a greater
identifiable precipitant, such as having witnessed degree than for other types of eating disorders based on
someone choking while eating;” and pervasive refusal the many variants in the etiology of the ARFID
syndrome, affecting a smaller number of children, but diagnosis. As ARFID has been in existence as an
which is “a potentially life-threatening condition official diagnosis for less than four years, available
manifested by a profound and pervasive refusal to literature is primarily limited to retrospective chart
eat, drink, walk, talk, or care for themselves in any reviews and single case studies.
way over a period of several months.” None of these
disorders involve body image distortion or a desire to
lose weight, and as their descriptions indicate, there is Diagnosis
a constellation of reasons why these patients, who
would now be diagnosed with ARFID, do not meet As noted earlier, while feeding and eating disorders
their nutritional needs. of infancy and early childhood in the DSM-IV was
Indeed, ARFID may be the eating disorder with the limited to children not older than 6 years, ARFID has
most heterogenous etiology. Several subcategories no diagnostic age restrictions. ARFID distinguishes a
have emerged in the research published thus far that cohort of individuals who experience persistent diffi-
attempt to define the reasons behind restricted nutri- culty in meeting their nutritional needs despite a lack of
tional intake. In a retrospective study conducted among body image or weight concerns. The DSM-5 sets forth
seven adolescent medicine divisions, 712 patients four diagnostic criteria, titled criterion A through D,
presented for initial evaluations of eating disorders each of which must be satisfied for a diagnosis of
during a 1-year period, and 98 (13.8%) met criteria for ARFID to be made. Criterion A of the DSM-5
ARFID. According to documented symptoms, 28.7% definition states that the eating disturbance is coupled
of ARFID patients had selective eating since early with at least one of the following: significant weight
childhood, 21.4% experienced generalized anxiety, loss (or failure to meet expected weight and height
19.4% had gastrointestinal symptoms, 13.2% had a trajectories in children and adolescents); nutritional
history of vomiting or choking, 4.1% had food deficiencies (such as iron deficiency anemia); a
allergies and 13.2% had other reasons for their dependence on nutritional supplements, (i.e., oral or
4
restricted eating. Another study divided 33 ARFID enteral formulas), to meet energy requirements without
patients into the following four groups: insufficient an underlying condition necessitating this; and/or
intake/little interest in feeding (57.6%), limited significant interference with day-to-day functioning
diet due to sensory characteristics of food (21.2%), due to the inability to eat appropriately. Some individ-
aversive/traumatic experience uals with ARFID experience
(9.1%), and other reasons high levels of anxiety and dis-
(12.1%).5 ARFID is distinct from anorexia tress when near certain foods or
ARFID is distinct from ano- nervosa and bulimia nervosa in faced with particular smells and
rexia nervosa and bulimia textures, resulting in missed
nervosa in that there is no body that there is no body image school or work and social iso-
image disturbance; ARFID disturbance; ARFID patients may lation. Additionally, inadequate
patients may express a desire to express a desire to increase nutrition may contribute to irri-
increase their eating and gain their eating and gain needed tability, anxiety, and other
needed weight, but they simply changes in mood.
cannot get themselves to do it.
weight, but they simply cannot Bryant-Waugh, 20136 pre-
The reasons behind this inability get themselves to do it. sented a case study and devel-
appear to be as varied as the oped a checklist for the criteria
patients themselves. The literature to date has identi- described earlier (criterion A in the DSM-5) that
fied some common patterns, which may be used to includes seven questions to guide practitioners in
inform the course of treatment. ARFID is similar to establishing whether criterion A is fully satisfied.

96 Curr Probl PediatrAdolesc Health Care, April 2017