Avoidant/restrictive food intake disorder, or ARFID, is an eating disorder diagnosis that has been introduced into Diagnostic and Statistical Manual of Mental Disorders (DSM) fifth edition. Historically, this diagnostic category of avoidant eating patterns was restricted to children less than 6 years and suggested maladaptive interactions between the child and caregiver must be present. According to research led by Mark Norris, “In the years leading up to the DSM-5, it became apparent that there was a group of children, adolescents, and young adults who displayed feeding issues that did not fit into the diagnostic categories of anorexia nervosa (AN) or bulimia nervosa (BN).” As such, the DSM-5 Working Group re-articulated the diagnosis of “EDs of infancy and early childhood” and named this new ED ARFID.
ARFID As a Complex Diagnosis
ARFID is a complex diagnosis which is beginning to be more adequately understood by researchers and clinicians. The diagnostic criteria of ARFID in the DSM-5 are summarized by “restrictive or avoidant eating behaviors that result in significant weight loss, growth compromise, a reliance on nutritional supplements to meet daily energy requirements, nutritional deficiency (like iron deficiency anemia) or marked interference with the patient’s psychosocial functioning.”
With new research developments, the field is growing in its ability to differentiate ARFID from “picky eating” and other eating disorders, better estimate its prevalence among children, adolescents, and adults and determine future directions and next steps.
How Does ARFID Differ From AN and Picky Eating?
This diagnosis is differentiated from AN due to the lack of body image preoccupation or fear of weight gain and no reported drive for thinness despite the presence of substantial restriction and pronounced physiological/psychosocial distress. Additionally, an individual with ARFID does not demonstrate any of the cognitions typically associated with anorexia nervosa.
In an attempt to differentiate ARFID from picky eating, the DSM-5 Working Team has moved to define and pathologize picky eating as a psychiatric condition. Picky eating is generally defined as occurring in children who are normal weight but consume an inadequate variety of foods through rejection of foods that may either be familiar or unfamiliar to them. There is a tendency toward refusal/apprehension to try new foods, limitations in a variety of food consumed, and rejection of foods based on texture, consistency, color or smell. This behavior is known to peak between ages two and six with a reduction over time and into adolescence. However, ARFID identifies only those individuals with clinically significant restrictive eating problems that result in persistent failure to meet an individual’s nutritional and/or energy needs. This diagnostic component eliminates many patients who are labeled as picky or fussy eaters.
As the DSM-5 was released in 2013, there are few population studies on ED that have recorded that etiology and prevalence of ARFID. Few existing studies have provided comprehensive research the rates of ED in small children and even fewer studies exist that examine the ways in which ARFID presents differently in various age groups, further compounding the ability to effectively define prevalence rates.
The Dovepress study states that “the rates of ARFID have ranged from 5 percent to 14 percent among pediatric inpatient ED programs and as high as 22.5 percent in a pediatric ED day treatment program (17–21). Studies have consistently demonstrated that, compared to those with AN or BN, ARFID patients are younger, have higher proportion of males, and are commonly diagnosed with comorbid psychiatric and/or medical symptoms.”
Future Directions and Intervention
Now that ARFID has been officially identified and defined in the DSM-5, it will be up to clinicians, researchers, and medical treatment providers to educate themselves about ARFID, better define its presentation across the lifespan, determine prevalence rates, outline risk factors, compare treatments, study the effectiveness of medications, and describe factors that affect outcomes in this patient population. It will also be important that as evidence-based treatments become available, clinicians learn to apply treatments in an attempt to optimize outcomes and reduce morbidity associated with the illness.