ARFID (avoidant restrictive food intake disorder) is an eating disorder in which someone eats a very narrow range of foods, or very little food, and it starts to affect their growth, their health or their everyday life. It isn’t fussy eating and poor parenting doesn’t cause it. Fear drives it (of choking or being sick, say), or strong sensory reactions to food, or a real lack of interest in eating. Often it’s more than one of these at once.
If you’re a parent or you work in a school, and a child you know eats almost nothing in the school day or lives on five beige foods, this is for you. If you’re worried, the first step is the GP.
What is ARFID, exactly?
ARFID was added to the diagnostic manual (DSM-5) in 2013, so the name is fairly new, though the problem isn’t. You may have heard older terms such as selective eating disorder or food refusal.
To count as ARFID, the eating difficulty has to cause real harm: weight loss or, in children, not growing as expected; a nutritional deficiency; reliance on supplements or tube feeding; or a big effect on daily life, like a child who can’t go to birthday parties or friends’ houses because of the food.
Two things set it apart. Unlike anorexia or bulimia, there’s no worry about body shape or weight. And it isn’t explained by a lack of food, by cultural or religious practice (fasting, being vegan) or by another condition alone. A child can be autistic and have ARFID, when the eating difficulty goes well beyond what you’d expect from the autism.
Is it ARFID or fussy eating?
Lots of children are picky for a while. ARFID goes well beyond that, and a bit of firmness won’t shift it. Some children with ARFID eat fewer than ten foods, sometimes only one or two. Others eat a wider range but in amounts too small to grow on.
The word “fussy” does damage here. Parents of children with ARFID often feel judged by other parents, by family and sometimes by professionals, and the guilt can be heavy. So if you’re school staff, start a conversation with a parent by assuming they’ve already tried everything you’re about to suggest.
What causes ARFID? The three drivers
Dr Emma Wilmot, a clinical psychologist in the feeding and eating disorder service at Great Ormond Street Hospital, describes three main drivers. Working out which applies to a child changes what helps.
Fear. A child may have been sick after a food, seen someone choke, or be frightened of pain after eating. General anxiety plays its part too: with a lump in the throat or a churning stomach, there isn’t much appetite.
Sensory sensitivity. Food is full of smells, textures, colours, sounds and shapes. Some children gag at the smell of milk being opened. Some will eat toast only in square quarters, never triangles. Mixed textures and lumps are hard for many, and the clatter of a metal spoon on a china bowl can be enough to stop a meal.
Low interest. Some children don’t get much pleasure from food, don’t notice when they’re hungry, or feel full quickly. Eating just gets in the way of what they’d rather be doing.
Most children fit more than one, so think about the particular child rather than ticking boxes.
Signs of ARFID to look out for
ARFID looks different in every child, and weight alone won’t tell you: a child with ARFID can be underweight, overweight or somewhere in between. These are among the signs Dr Wilmot sees most often:
- A preference for beige, dry, crunchy or smooth foods, and avoiding whole food groups (fruit and vegetables especially)
- Dropping foods from an already short list, and not always picking them back up
- Eating a food in one place (on holiday, at a grandparent’s, at school) but not at home
- Being tied to one brand, or rejecting a biscuit because a corner has broken off
- The same food at every meal
- Needing food kept separate on the plate, or using only their own cup or cutlery
- Eating nothing during the school day and trying to make up for it at home
It’s more common in boys, usually starts in early childhood, and is much more common in autistic children. It’s also more likely after medical difficulties such as reflux, constipation, dental problems, tonsil surgery or frequent vomiting.
How to help a child with ARFID at home
The biggest message from the course is that pressure makes it worse. If a child isn’t medically at risk (and a GP or dietitian is the person to judge that), the advice is a calm, low-pressure approach. Easier to say than to do, I know.
Always put one of their safe foods on the plate, so there’s something they know they can eat. Don’t take their main food away in the hope they’ll try something else; it rarely works and can put them off that food too. Next to it, put a small tasting bowl of something new (a few peas) that they can look at and leave.
Change things in tiny steps. Food chaining means moving from a familiar food to one that’s very like it: one breadstick to a different breadstick, not cracker to broccoli. Even children without any feeding difficulty can need 15 to 20 tries before they’ll put a new food in their mouth. For a child with ARFID, it’s many more.
Involve them in food without expecting them to eat it: shopping, scanning, cooking for a sibling, clearing the table. And on the hardest days, offer the easiest foods. One family Dr Wilmot was supporting sometimes gave their child an ice lolly for breakfast. Talk to your GP or dietitian before changing what your child eats. Healthy-eating messages don’t always fit a child with ARFID, and getting enough in comes first.
How can schools support a pupil with ARFID?
Small changes at school make a big difference, and most cost nothing.
- Let them eat somewhere quieter than the dinner hall, with friends they feel safe with and a seat they know is theirs
- Allow a packed lunch with their preferred foods, even if your policy usually says otherwise
- Let them bring their own cutlery, or use plastic if that’s what they manage at home
- Use a fridge for foods that must be cold, and keep a store of any supplements
- Offer a queue pass so they have time to eat
- Put break and lunch on their visual timetable, and warn them ahead of any lesson or trip with food in it
If a healthy snack rule means a child’s safe biscuits cause trouble with other pupils, offer a separate space rather than taking the biscuits away.
Share what you notice with parents and follow your school’s procedures; your SENCO and school nurse are good people to involve. If a child seems physically unwell at school, get medical help straight away.
Where to get help, and ARFID training
For families, start with the GP. If the GP doesn’t know much about ARFID, ask them to look into it. The usual route is on to a community paediatrician or a dietitian, sometimes a feeding clinic, and in some areas a CAMHS eating disorder team. Dr Wilmot is honest that support is patchy and that many families feel bounced around. ARFID Awareness UK is a charity worth knowing about.
If you’re in school and want more than a page of tips, our ARFID training course is a recording of Dr Wilmot’s session with a full Q&A. There’s more on children’s eating, anxiety and wellbeing on our health and wellbeing page.
Progress is slow and doesn’t go in a straight line. But children do make it, usually when the adults around them work together and go at the child’s pace.
ARFID: What It Is, How to Spot It and How to Support is led by Dr Emma Wilmot, clinical psychologist at Great Ormond Street Hospital. It covers the three drivers, how to tell ARFID from fussy eating, food chaining and the steps to eating, and what schools and families can change in practice. It’s written for parents and carers, and teachers, teaching assistants, SENCOs and school nurses will get just as much from it.