Unhealthy eating behaviours may include eating too much or too little or worrying about your weight or body shape. You may also not be meeting adequate nutritional needs.
Anyone can get an eating disorder, but teenagers between 13 and 17 are mostly affected. Eating disorders can affect any age, although typically ARFID has been noted to affect all ages, typically starting at a younger age than anorexia and bulimia.
ARFID- Avoidant restrictive food intake disorder
ARFID is when someone avoids certain foods, limits how much they eat or does both.
Beliefs about weight or body shape are not reasons why people develop ARFID.
Someone might be avoiding and/or restricting their intake for a number of different reasons. The most common are the following:
- They might be very sensitive to the taste, texture, smell, or appearance of certain types of food, or only able to eat foods at a certain temperature. This can lead to sensory-based avoidance or restriction of intake.
- They may have had a distressing experience with food, such as choking or vomiting, or experiencing significant abdominal pain. This can cause the person to develop feelings of fear and anxiety around food or eating, and lead to them to avoiding certain foods or textures. Some people may experience more general worries about the consequences of eating that they find hard to put into words and restrict their intake to what they regard as ‘safe’ foods. Significant levels of fear or worry can lead to avoidance based on concern about the consequences of eating.
- In some cases, the person may not recognise that they are hungry in the way that others would, or they may generally have a poor appetite. For them, eating might seem a chore and not something that is enjoyed, resulting in them struggling to eat enough. Such people may have restricted intake because of low interest in eating.
It is very important to recognise that any one person can have one or more of these reasons behind their avoidance or restriction of food and eating at any one time. In other words, these examples are not mutually exclusive. This means that ARFID might look quite different in one person compared to another. Because of this, ARFID is sometimes described as an ‘umbrella’ term – it includes a range of different types of difficulty. Nevertheless, all people who develop ARFID share the central feature of the presence of avoidance or restriction of food intake in terms of overall amount, range of foods eaten, or both.
ARFID has 3 different domains….fear of an aversive consequence in relation to food and eating or drinking, a lack of interest in food , or avoidance of food based on sensory characteristics of food. This is different to other eating disorders.
ARFID DSM-5 Criteria
The DSM-5 specifies the following criteria must be met for a diagnosis of Avoidant/Restrictive Food Intake Disorder (ARFID):
An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidant 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:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
- Significant nutritional deficiency.
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
The eating disturbance is not attributable to a concurrent medical condition or not better explained by another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
Signs of ARFID
Your child may appear to be a picky eater, but don’t worry, being a picky eater does not mean that your child has ARFID.
Some children will also show distress at mealtimes which can be age related. They may find seeing others eating or the smells and sight of food a challenge.
Because ARFID includes a range of different types of difficulty that contribute to the avoidance or restriction of food intake, there is a wide range of possible signs and symptoms, not all of which would necessarily occur in one person. Possible signs of ARFID include:
- Eating a reasonable range of foods but overall having much less food than is needed to stay healthy.
- Finding it difficult to recognise when hungry.
- Feeling full after only a few mouthfuls and struggling to eat more.
- Taking a long time over mealtimes/finding eating a ‘chore’.
- Missing meals completely, especially when busy with something else.
- Sensitivity to aspects of some foods, such as the texture, smell, or temperature.
- Appearing to be a “picky eater”.
- Always having the same meals.
- Always eating something different to everyone else.
- Only eating food of a similar colour (e.g. beige).
- Attempting to avoid social events where food would be present.
- Being very anxious at mealtimes, chewing food very carefully, taking small sips and bites, etc.
- Weight loss (or in children, not gaining weight as expected).
- Developing nutritional deficiencies, such as anaemia through not having enough iron in the diet.
- Needing to take supplements to make sure nutritional and energy needs are met.
Treatment for ARFID
Due to the varied forms ARFID may take, people may receive treatment in one or more of a number of different types of services from a range of different types of professionals. Currently, treatment for ARFID is not included in the NICE guidelines for eating disorders; however, this certainly does not mean it does not need to be taken seriously. The GP should still make a referral to the relevant service. Young people may be treated by their local community eating disorders service for children and young people, generic Child and Adolescent Mental Health Services (CAMHS), community paediatric services, in the local acute paediatric service, or by a range of private practitioners, including dietitians, speech and language therapists, psychologists and occupational therapists.
Treatment for ARFID is usually best tailored to the needs of the individual, based on the specific nature of the difficulties the person is experiencing and what is considered to be maintaining these. Most often, treatment can be delivered in an outpatient setting. Treatment commonly involves evidence-based treatments such as family-based treatment (for young people), cognitive behavioural therapy, behavioural interventions such as exposure work, and anxiety management training. Sometimes some medication may be suggested, most often to help with anxiety. The person’s physical health should also be monitored and managed, for instance by their GP or a physician or paediatrician. Treatment may also involve nutritional management through support from a dietician and help with sensory problems.
England Helpline: 0808 801 0677 | firstname.lastname@example.org
If you feel that you or your child is suffering from avoidant restrictive food intake disorder, we recommend that you also have a look at the following resources:
Avoidant restrictive food Intake disorder by Rachel Bryant-Waugh: A guide for parents
What is ARFID?
Pica – eating non-food items
Pica refers to eating or mouthing non-edible items, such as stones, dirt, metal, faeces.
The reason a person on the autism spectrum might experience pica could be medical, dietary, sensory, or behavioural and include:
- not understanding which items are edible and inedible.
- seeking out sensory input – the texture or the taste of the item
- relieving anxiety or stress
- relieving pain or discomfort
- displaying a symptom of iron deficiency
- a continuing of infant mouthing behaviour, or a later occurrence of the mouthing phase
- seeking attention
- avoiding a demand
You could try to:
- set up a sorting activity for the person to sort edible and inedible items.
- use PECS (Picture Exchange Communication System) to encourage the person to put appropriate items in their mouth and reward them.
- replace the inappropriate item with an appropriate alternative of a similar texture, e.g., a crunchy carrot stick, a chewy tube, popcorn, chewing gum.
- visit the GP or dentist to rule out any medical problems, oral pain, or nutritional deficiencies, or to seek referral to an occupational therapist.
- increase the number of structured activities in the person’s day.
- respond as neutrally as possible when the behaviour occurs, giving a firm ‘no’ with little eye contact, reinforcing it with a symbol.
- reduce demands placed on the person.
- distract and divert their attention.
You could try to use a social story to reinforce the idea about not eating faeces. Social stories are short descriptions of a particular situation, event, or activity, which include specific information about what to expect in that situation and why.
The National Autistic Society website has some useful information:
You could add pictures too if you feel this may help.
For example, a social story about not eating faeces may include:
- Don’t eat the poo.
- Poo is dirty and smells bad.
- Don’t touch the poo with my hands.
- Poo goes in the toilet.
- I sit on the toilet and poo into the toilet.
- If I want something to eat, I ask for something that I can eat.
We all have different ways of eating and many of these ‘eating styles’ allow us to remain healthy. However, some are driven by body shape and weight concerns (e.g. an intense fear of being at a healthy weight or becoming fat) and can upset body functioning and daily activities. These are called eating disorders and are often a way of coping with difficult experiences and emotions. They are described below.
Anorexia nervosa: The person is low in weight and has a fear of being a healthy weight. They restrict what they eat and may purge or use excessive exercise in the pursuit of thinness.
Signs and symptoms of anorexia include:
- if you’re under 18, your weight and height being lower than expected for your age
- missing meals, eating very little or avoiding eating any foods you see as fattening
- believing you’re fat when you’re a healthy weight or underweight
- taking medicine to reduce your hunger (appetite suppressants)
- your periods not starting (in younger women and girls)
- physical problems, such as feeling lightheaded or dizzy, hair loss or dry skin
Those under 18 should be offered family therapy. You may also be offered another type of talking therapy, such as CBT or adolescent-focused psychotherapy.
Bulimia Nervosa: The person is in a healthy weight range and frequently binge-eats. They also use harmful methods in an attempt to counter the effects of eating such as vomiting, fasting or excessive exercising.
Symptoms of bulimia include:
- eating very large amounts of food in a short time, often in an out-of-control way – this is called binge eating
- making yourself vomit, using laxatives or diuretics, fasting, or doing an extreme amount of exercise after a binge to avoid putting on weight – this is called purging
- fear of putting on weight
- being very critical about your weight and body shape
- mood changes – for example, feeling very tense or anxious
These symptoms may not be easy to spot in someone else because bulimia can make people behave very secretively.
Treatment for children and young people:
Family therapy- Children and young people will usually be offered family therapy. This involves you and your family talking to a therapist, exploring how bulimia has affected you and how your family can support you to get better. If family therapy is not suitable, you may be offered CBT, which will be similar to the CBT offered to adults.
Eating Disorder Not Otherwise Specified (EDNOS): The person has most but not all the diagnostic signs of anorexia nervosa or bulimia nervosa.
If your child is aged 8-18 you can be referred to the Children and young people’s eating disorder service
What it means to have an eating disorder NHS
Anorexia: Katie’s story | NHS
It happens to boys too…. Freddie Flintoff reveals the eating disorder he has kept secret for over 20 years – BBC https://www.youtube.com/watch?v=d7qYccObggc
Advice for parents
If your child has been diagnosed with an eating disorder, here’s what you can do to help.
Talk to them about it
If your child becomes withdrawn, touchy or moody, it might make it difficult to talk to them. It may be even more difficult if they cannot accept they have a problem.
But talking about their condition is needed for their recovery, so keep trying. They might come across as angry, even if they’re really feeling scared or insecure. It might be difficult for them to talk about their feelings, so be patient and listen to what they’re trying to say.
It can help if you:
- stay calm and prepare what you’re going to say to them – do not blame or judge them, just focus on how they’re feeling
- avoid talking about their appearance, even if you’re trying to say something nice
- try to use sentences starting with “I”, like, “I’m worried because you do not seem happy”, rather than sentences beginning with “you”
- avoid discussing people’s diets or weight problems
- try not to feel hurt if they do not open up straight away
- do not be upset if they are being secretive, because this is part of their illness, not their relationship with you
Try these mealtime tips
Mealtimes can be particularly difficult. You may find the following advice helpful:
- if your child is in treatment, ask their treatment team for advice on how to cope with mealtimes
- try to make meal plans with your child that you both agree to
- agree with the family that none of you will talk about portion sizes, calories or anything else about the meal
- avoid eating low-calorie or diet foods in front of them or having them in the house
- try to keep things light-hearted and positive throughout the meal, even if you do not feel that way on the inside
- if your child tries to get too involved in cooking the meal as a way of controlling it, gently ask them to set the table or wash up instead
- try not to focus too much on them during mealtimes – enjoy your own meal and try to make conversation
- a family activity after the meal, such as a game or watching TV, can help distract them from wanting to purge or overexercise
- do not worry if a meal goes badly, and just move on
Support for your child
If your child is being treated for an eating disorder, their treatment team will play a big part in their recovery. But do not underestimate the importance of your love and support.
It may help to:
- learn as much as possible about eating disorders, so you understand what you’re dealing with
- keep telling them that you love them and will always be there for them
- make them aware of the professional help available
- suggest activities they could do that do not involve food, such as hobbies and spending time with friends
- ask them what you can do to help
- try to be honest about your own feelings, as this will encourage them to do the same
- be a good role model by eating a balanced diet and doing a healthy amount of exercise
- try to build their confidence, for example, praise them for being thoughtful or congratulate them on something they’ve done
Get support for yourself
Ask a GP or a health professional in your child’s treatment team for advice on how to help at home.
It’s important the whole family understands the situation and has support. The following organisations offer advice online:
- Anorexia and Bulimia Care: advice for family and friends
- Beat: supporting someone
- Family Lives: eating disorder help
- Young Minds: help for parents
You can also ask your GP about support groups for parents caring for someone with an eating disorder.
Talking to your teenager
Getting teenagers to talk openly about what’s bothering them can be hard. Follow these tips to help get them talking to you about their worries.
Do not judge your teenager- Start by assuming they have a good reason for doing what they do. Show them you respect their intelligence and are curious about the choices they’ve made. If you do not pre-judge their behaviour as “stupid” or “wrong”, they’re more likely to open up and explain why their actions made sense to them.
Try not to assume you know what’s wrong- Do not assume that you know what’s wrong. Rather than asking “Are you being bullied?”, try saying “I’ve been worried about you. You do not seem your usual self, and I wondered what’s going on with you at the moment? Is there anything I can help with?”.
Be clear you want to help- If you suspect your child is using drugs or drinking excessively, be gentle but direct. Ask them and let them know that you’ll help them through any of their difficulties.
Be honest yourself- Teenagers will criticise you if you do not follow your own advice. If you drink too much alcohol yourself, for example, they’re likely to mention it (“You cannot talk!”). Make sure you’re acting responsibly yourself.
Help your teenager think for themselves- Instead of trying to be the expert on your teenager’s life, try to help them think for themselves:
- Discuss the potential implications of poor behaviour choices. For example, “How does smoking weed make you feel the next day? So, if you feel like that, how’s that going to affect you playing football?”
- Help them think critically about what they see and hear. “So Paul said X: is that what you think?”
- Help them feel that they can deal with life’s challenges. Remind them of what they’re good at and what you like about them. This will give them confidence in other areas of their lives.
Information is empowering. Point them towards websites that can give them information on drugs, sex and smoking so they can read the facts and make up their own minds. Help them think of ways they can respond and cope. “So, when you feel like that, is there anything you can do to make yourself feel better?”
Encourage them to think through the pros and cons of their behaviour.
Pick your battles with your teenager- If they only ever hear nagging from you, they’ll stop listening. Overlooking minor issues, such as the clothes they wear, may mean you’re still talking to each other when you need to negotiate – or stand firm – with them on bigger issues, such as drugs and sex.
Try not to react to angry outbursts- Teenagers often hit out at the people they most love and trust, not because they hate you, but because they feel confused. Do not think that they mean the bad things they say (“I hate you!”). They may just feel confused, angry, upset, lost or hormonal, and they do not know how to express it.
Help your teenager feel safe- Teenagers often worry that telling an adult will just make things worse. You need to be clear that you want to help them and will not do anything they do not want you to. This may be particularly important with bullying. If your child opens up to you about bullying, explain that it is unacceptable. Listen to their fears and reassure them it’s not their fault.
Help build up their confidence by reassuring them that you’ll face the problem together.
Ask your teenager the right questions- Sometimes you’ll find out more about your teenager if you ask open questions. If they have an eating disorder, for example, asking confrontational questions like “What did you eat for lunch?” or “Have you made yourself sick?” may mean you get a dishonest answer.
Sticking to open questions such as “How are you?” or “How has your day been?” helps your teenager talk to you about how they’re feeling.