AFRID: Avoidant/Restrictive Food Intake Disorder: a commentary by Ellyn Satter

Here is the definition of ARFID from the American Psychiatric Association DSM 5  Diagnostic and Statistical Manual.¹

Avoidant/Restrictive Food Intake Disorder replaces and extends the DSM-IV diagnosis of feeding disorder of infancy or early childhood. ARFID is an eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:

1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).

2. Significant nutritional deficiency.

3. Dependence on enteral feeding or oral nutritional supplements.

4. Marked interference with psychosocial functioning.

In some individuals, food avoidance or restriction may be based on the sensory characteristics or qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as ‘restrictive eating,’ ‘selective eating,’ ‘choosy eating,’ ‘perseverant eating,’ ‘chronic food refusal,’ and ‘food neophobia’ and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others.

Concerns raised by ARFID

As demonstrated by our story, the public hears about this diagnosis, which uses common language to describe eating and feeding problems, and sees the diagnosis as offering a solution to those problems. The media heightens concern with horror stories about adults who only eat French fires or waffles and children who only eat chicken nuggets or peanut butter sandwiches. How are we to interpret and work with this diagnosis?

Diagnosing may catastrophize. Diagnosing variants of normal as being pathological makes the problem seem far worse than it really is. Unfortunately, in today’s feeding and eating world, such variants are all too common. In repeated studies,^2-5 more than half of adults test low in Eating Competence,⁶ meaning they do not feel positive  about their eating, are not reliable about feeding themselves, hesitate to let themselves eat food they enjoy, and are unlikely to pay attention to their hunger and fullness in guiding how much to eat. In fact, only 40% of people admit they enjoy eating, down from 50% 20 years ago.⁷  Almost all parents of preschoolers make feeding errors, including limiting menus to foods their children readily accept, then bribing and pressuring them to eat.⁸  Despite the national hysteria about child overweight, over 90% of parents say they don't believe their children indications of fullness and encourage them to eat more.^8,9 Such pressure doesn’t work: pressured children eat less well and behave badly at mealtime.¹⁰

Inclusion in DSM implies that this is a psychiatric disorder. In most cases, problems with eating and feeding are not psychiatric disorders. They are problems, and, as such, they can be addressed by education or brief intervention conducted knowledgeably. In my view, to qualify for a psychiatric diagnosis, “marked interference with psychosocial functioning” (optional in the above definition) is essential.  For any eating malady to be a psychiatric disorder, a significant distortion in eating or feeding has to be precipitated/exacerbated/interactive with underlying psychosocial distortion. For children with feeding disorders, the underlying psychosocial distortion lies in the relationship with the parent.  

The feeding literature is not considered. The DSM states that ARFID-related problems “most commonly develop in infancy or early childhood and may persist in adulthood.” However, DSM shows no evidence of awareness of the rich feeding literature which outlines the detail of distorted parent/child feeding interactions that precipitate and/or fail to extinguish food disorders.

Disorders are considered in isolation. Child psychosocial problems are always part of a distorted relationship with parents/primary care providers. Severe feeding problems must be considered that context, and in the context of the child’s medical and developmental history.¹¹ Affected adults carry internalized distortions from those early relationships. Even when children contribute to “food intake disorders” by being irritable, having medical and/or oral-motor problems, developing atypically, or showing extreme food regulation patterns (e.g. don’t eat much or eat a great deal), the parent-child feeding relationship is paramount. 

The ARFID diagnosis implies cures that may or may not be delivered. Certainly, people need help with their feeding and eating. However, that help must be in proportion to the problem at hand, and it must be provided by people who truly understand eating and feeding. As a mental health professional myself, I have observed that, like the authors of DSM 5, mental health professionals are generally not familiar with research and optimum practice around feeding and eating. They  tend to take the sledgehammer approach advocated by the author of the Medscape article.

The take-home message: Correcting such a preponderance of problems with eating and feeding means there is plenty of work to go around. However, that work must be in proportion to the problem at hand, and it must be done by people who truly understand eating and feeding.

For more about addressing child eating problems from a Feeding Dynamics perspective, read Intervening with Pediatric Feeding Disorders. For more about addressing adult distortions in eating attitudes and behaviors, read Secrets of Feeding a Healthy Family.  

For help and direction relative to your feeding/eating problem, join us on Facebook.

References 

1. Association AP. Feeding and Eating Disorders DSM-5: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDI T ION American Psychiatric Association; 2013:329-354
2. Quick V, Byrd-Bredbenner C, White AA, et al. Eat, Sleep, Work, Play: Associations of Weight Status and Health-Related Behaviors Among Young Adult College Students. Am J Health Promot. Dec 20 2013.
3. Lohse B. Facebook is an effective strategy to recruit low-income women to online nutrition education. J Nutr Educ Behav. Jan-Feb 2013;45(1):69-76.
4. Lohse B, Bailey RL, Krall JS, Wall DE, Mitchell DC. Diet quality is related to eating competence in cross-sectional sample of low-income females surveyed in Pennsylvania. Appetite. 2011;58:645-650.
5. Lohse B, Satter E, Horacek T, Gebreselassie T, Oakland MJ. Measuring Eating Competence: psychometric properties and validity of the ecSatter Inventory. J Nutr Educ Behav. 2007;39 (suppl):S154-S166.
6. Satter EM. Eating Competence: definition and evidence for the Satter Eating Competence Model. J Nutr Educ Behav. 2007;39:S142-S153.
7. Taylor P, Funk C, Craighill P. Pew Research Center; 2006.
8. Sherry B, McDivitt J, Birch L, et al. Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers. J Am Diet Assoc. 2004;104:215-221.
9. Orrell-Valente JK, Hill LG, Brechwald WA, Dodge KA, Pettit GS, Bates JE. "Just three more bites": an observational analysis of parents' socialization of children's eating at mealtime. Appetite. 2007;48:37-45.
10. Galloway AT, Fiorito LM, Francis LA, Birch LL. 'Finish your soup': counterproductive effects of pressuring children to eat on intake and affect. Appetite. May 2006;46(3):318-323.
11. Davies WH, Satter E, Berlin KS, et al. Reconceptualizing feeding and feeding disorders in interpersonal context: The case for a relational disorder. J Fam Psychol. 2006;20:409-417.

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