Other examples include patients with comorbid chronic illnesses (which also increase metabolic demands) who also struggle with food indifference and low appetite. It must be noted, however, that in these cases, the comorbid medical condition does not fully account for the feeding disturbance; rather, the feeding issues drive the underlying growth concerns.
Struggles with anxiety or depression may also cause feeding issues that result in impairment and/or medical compromise; some children lose their appetite in response to feeling scared, stressed, or unhappy. Examples of stressors include anxiety associated with going to school; being bullied or rejected by peers; moving or losing a friend; parental conflict, separation or illness; or physical, sexual, or emotional abuse (all of which must be ruled out). Although children with severe school-associated anxiety often eat better on weekends and holidays, their intake does not meet their overall needs.
3) Avoidance of food based on sensory characteristics. Patients in this category struggle primarily with food variety; they are often extremely selective (picky) regarding the food that they consume. Their histories of food refusal usually date back to an early age. They often have sensory hypersensitivity that results in profound rigidity involving food (eg, can only eat foods of a certain color or texture). In many cases, the rigidity extends to the manner in which food is served (eg, different foods on a plate cannot touch; the hotdog must be cut up in equal pieces) and to details related to preparation (eg, pasta must be boiled for exactly 11 minutes). These patients often will only accept the same limited number of foods prepared in the exact same manner and served in the exact same way.
These extremely rigid picky eaters are challenging to treat, and treatment will almost always require a multidisciplinary team approach. Often, caregivers are exhausted from years of trying to meet the needs of these children. Although picky eating is common in children, and in most cases improves with age without the need for any intervention, this is not the case for children with this subtype of ARFID. Maybe not surprisingly, early research suggests that children with autism spectrum disorder are more likely to be in this category of ARFID.
It is important that health care professionals not simply dismiss parental concerns around feeding based on weight gain and growth at a rate deemed acceptable. Our early study illustrates that when patients and families with such presentations are treated with an intensive intervention, the child’s weight and growth velocity can supersede that observed before the intervention, and that this weight gain can be associated with improved physical and mental well-being.1 It is also important to recognize that these children may not be simply picky eaters but may have feeding difficulties that severely affect their functioning. For example, one 12-year-old girl would only eat baby food, while one boy with autism would only eat Cheerios and fish crackers.
Dr Spettigue is Associate Professor, Department of Psychiatry, University of Ottawa, Children’s Hospital of Ontario, Canada; Dr Norris is Associate Professor of Pediatrics, Adolescent Health Physician, Division of Adolescent Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario. The authors report no conflicts of interest concerning the subject matter of this article.
1. Norris ML, Robinson A, Obeid N, et al. Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study. Int J Eat Disord. 2014;47:495-499.
2. Nicely TA, Lane-Loney S, Masciulli E, et al. Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. J Eat Disord. 2014;2:21.
3. Norris ML, Spettigue W, Hammond NG, et al. Building evidence for the use of descriptive subtypes in youth with avoidant restrictive food intake disorder. Int J Eat Disord. 2018;51:170-173.
4. Norris M, Hiebert J, Katzman D. Determining treatment goal weights for children and adolescents with anorexia nervosa. Paediatr Child Heal. 2018.
5. Strandjord SE, Sieke EH, Richmond M, Rome ES. Avoidant/restrictive food intake disorder: illness and hospital course in patients hospitalized for nutritional insufficiency. J Adolesc Heal. 2015;57:673-678.
6. Spettigue W, Norris ML, Santos A, Obeid N. Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. J Eat Disord. 2018;6:20.
7. Brewerton TD, D’Agostino M. Adjunctive use of olanzapine in the treatment of avoidant restrictive food intake disorder in children and adolescents in an eating disorders program. J Child Adolesc Psychopharmacol. 2017;27:920-922.
8. Bryant-Waugh R, Micali N, Cooke L, et al. Development of the Pica, ARFID, and Rumination Disorder Interview, a multi-informant, semi-structured interview of feeding disorders across the lifespan: a pilot study for ages 10-22. Int J Eat Disord. 2019;52:378-387.
9. Zickgraf HF, Ellis JM. Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): a measure of three restrictive eating patterns. Appetite. 2018;123:32-42.