Dr Gillian Harris Understanding ARFID; diagnosis

food has not been offered or is not available
there are concerns about weight or body image
the disorder is not better explained by another eating disorder
the disorder is not fully explained by another mental health or medical condition

So - exclude: - Anorexia nervosa, depression.
And - ICD11; ‘picky eating’ without dietary deficiency or weight loss<br>

For both DSM and ICD

Medical:
reflux, allergies, gastro-intestinal disorders, metabolic disorders

Mental health/ developmental:

Autism spectrum disorder -> Due to sensory processing difficulties

A recent study (Nygren et al. 2021) shows around 30% of children with ASD meet the criteria for ARFID. In an audit of 60 children BFRS we found 45% of children receiving a diagnosis of ARFID had a diagnosis of ASD


Attention deficit hyper-activity disorder

Anxiety disorders, obsessive compulsive disorder -> Due to anxiety comorbidity

Specific phobia - emetophobia

Exclude: - Anorexia nervosa, depression

And - ICD11; ‘picky eating’ without dietary deficiency or weight loss How might these confound our diagnosis ?<br>

Won’t eat anything
different; ARFID Will eat roadkill (rather suspect?) Will eat most things you can buy from Waitrose or Lidl The normal distribution curve of food acceptance Acceptance interacts with parental strategy and age<br>

I contacted the hp again for help and she told me that she had no concerns whatsoever over **s eating because he was not classed as underweight in the NHS guidelines after me giving her many food diaries including from his nursery and raising my concerns . I was told to completely drop all of *’s foods that he would eat and not to give them no matter how upset he would get. So again, I followed her advice given to me which I have regretted ever since because he then completely stopped eating a majority of the foods that he was having at the time, and he has still never gone back to accepting them which has lead to him becoming more restricted Weight is fine ?<br>

What is ‘significant’ ? Nutritional deficiency Weight loss is not essential - if accepted foods are eaten in a stress-free environment - in fact, some children or adults may be overweight.
Nutritional deficiency is not essential – but what is a significant deficiency ? But only if accepted foods are given<br>

What is significant Psycho-social? Psycho-social – impairment in personal, family, social, educational, occupational life – due to avoidance or distress related to social eating events – how is this assessed?

Children/YP may not be able to eat with the family because of the sensory components of others’ food
They may need to use iPad or television for distraction whilst eating

Schools may refuse to allow ‘safe’ foods to be taken in for snacks and packed lunch
Children/YP may not be able to sit in the school dining hall

Away days and residential courses are a problem
The family cannot eat out in restaurants

Holidays are a ‘nightmare’ – parents must travel with suitcases full of ‘safe’ foods
Older teenagers and adults must order their lives around the availability of ‘safe’ foods<br>

growth faltering
eats four foods – crisps, biscuits, breadsticks, Haribo sweets.
cannot stay in the kitchen if food is being cooked.
cannot sit at the table with others.
shows a gag response when looking at other’s foods<br>

Two basic sub‘types’ Most common combination - onset from early childhood
lack of appetite rarely seen alone - except in older age group Least common –
onset in later childhood/ adolescence Sanchez. et al., Subtypes of avoidant/restrictive food intake disorder in children and adolescents: a latent class analysis; eClinicalMedicine; doi.org/10. 1016/j.eclinm.2024. 102440 ARFID subtypes This is usually reported as starting in infancy or from around 2 years -
the onset of the neophobic stage of food rejection -
but can last across the life span This is more usually seen in later childhood / adulthood – often because of a transition between schools or a major life change which increases anxiety Sensory reactivity
Lack of appetite



Fear of aversive consequences
vomiting, choking, swallowing somatisation Sensory properties of the food<br>

We must therefore be able to assess or diagnose:-

Nutritional deficiency
Growth
Sensory reactivities to food
Psycho–social distress
Along with :-
Neglect
Developmental disorders
Other medical conditions which might present with food avoidance.
Other eating disorders
Other mental health disorders<br>

Early onset sensory based ARFID Is an interaction between high :-
sensory reactivity
anxiety
disgust reactivity
Possibly linked to early experience ?

Confounded by :-
lack of exposure at sensory periods
fear based food refusal
exclusion diets
desire for sameness (autistic presentation) Always:-
Take the case history from infancy

Look at the sensory profile<br>

Onset -Sensory factors - relating to food these define ARFID – how are they assessed? They interact with social impairment and lead to the:-
avoidance of foods because of their sensory properties
avoidance of social events because of the sensory reactivity to others’ foods.
disgust and contamination responses (somatosensory disgust)

A child with ARFID -
“I can’t eat the pancake at the bottom of the pile – it tastes of plate” Early Onset -Sensory factors - relating to food these define ARFID – how are they assessed? This also interacts with a developmental stage -
the neophobic response<br>

Smell Texture Taste Sound Visual appearance Sensory issues and eating Contamination & disgust Food acceptance will often be brand specific ! Interoception We need a sensory profile<br>

This leads us to the beige/ brown carbohydrate ARFID diet – with chocolate and yoghurt. Nothing chewy, nothing mixed, nothing stringy, slimy or dusty ...
Any other food is disgusting, and can provoke a disgust response Smith, A. M. Roux, S., Naidoo, N.T. & Ventner, D.JL. (2005) Food choices of tactile defensive children. Nutrition, 21, 14-19. Harris,G. (2009) Food refusal and the sensory sensitive child. Paediatrics and Child Health, Sept. 19.9, 435-6<br>

For both DSM and ICD

Medical:
reflux, allergies, gastro-intestinal disorders, metabolic disorders

Mental health/ developmental:

Autism spectrum disorder -> Due to sensory processing difficulties

A recent study (Nygren et al. 2021) shows around 30% of children with ASD meet the criteria for ARFID. In an audit of 60 children BFRS we found 45% of children receiving a diagnosis of ARFID had a diagnosis of ASD


Attention deficit hyper-activity disorder

Anxiety disorders, obsessive compulsive disorder -> Due to anxiety comorbidity

Specific phobia

Exclude: - Anorexia nervosa, depression

And - ICD11; ‘picky eating’ without dietary deficiency or weight loss How might these confound our diagnosis ?<br>

Sensory reactivity v
restrictions due to allergies and intolerances ?
Child with anaphylactic response to nuts and early
cow’s milk protein intolerance
Parents very wary about foods in infancy
Child has experienced pain in association with food intake
Child is wary about trying new foods
ARFID? YES

Child with anaphylactic response to nuts and early
cow’s milk protein intolerance
Parents very wary about foods in infancy
Child has experienced pain in association with food intake
Child is wary about trying new foods
ARFID? NO He could tell the difference between accepted foods cooked in different pans
and juice that had been stored in the fridge with others’ foods
Could not engage in any messy play
Could not stay in the kitchen when other food was being cooked
Sensory processing difficulties Not specific about flavour, or brand of foods she would accept, was happy with messy play, could be around others eating food that she could not yet eat.
Avoidance due to limited exposure and family anxiety around trying new foods<br>

Two basic sub‘types’ Least common –
onset in later childhood/ adolescence Sanchez. et al., Subtypes of avoidant/restrictive food intake disorder in children and adolescents: a latent class analysis; eClinicalMedicine; doi.org/10. 1016/j.eclinm.2024. 102440 ARFID subtypes This is more usually seen in later childhood / adulthood – often because of a transition between schools or a major life change which increases anxiety Fear of aversive consequences
vomiting, choking, swallowing somatisation<br>

FOAC - Late onset ARFID
Address the anxiety – what has triggered this?
When a child is refusing to eat because of fear of vomiting or choking then the intervention should prioritize the anxiety and phobia rather than attempting to introduce new foods.
Then …
Standard CBT ?/Exposure therapy/ ACT - with some cognitive behavioural challenges, psycho education re: swallow.
Graded exposure to food related stimuli will decrease anxiety, negative cognitions and avoidance
Medication ?
EMDR? But beware CBT must be modified for autistic clients Can be difficult with emetophobia<br>

Interventions in general

Appropriate to age

Appropriate to subtype



Who should be involved ?

What you might suggest.

What we should never suggest.<br>

Copyright Gillian Greville Harris Work with the family Work with the child/yp<br>

Interventions – who should be involved? The importance of the MDT

For younger children

Prioritise growth – all medical and health professionals
Manage appetite - short frequent meals and snacks - dietitian
Ensure dietary balance – supplements – dietitian.
SALT - assess oral motor skills
Manage sensory issues - occupational therapist/ play therapist
Manage anxiety/ psycho-social distress (child and parent) - psychologist, counsellor, educational provision

For older children, adolescents & adults

All strategies + CBT + relaxation + taste trials -
Psychologist CBT therapist

Dispel any misperceptions – for example, that the child’s feeding difficulty is due to the parents’ mismanagement.
Strong genetic component !

Lisa Dinkler,et al. Etiology of the Broad Avoidant Restrictive Food Intake Disorder Phenotype in Swedish Twins Aged 6 to 12 Years. JAMA Psychiatry, 2023;<br>

Manage anxiety- Always ! I feel anxious
I do not have control I notice the things I am anxious about -
Vigilance - food monitoring This makes me more sensory sensitivity
Anxiety increases sensory reactivity Anxiety decreases appetite But always - help to decrease child’s anxiety – ensure they have control What is happening at school ?
Are their foods allowed?
Can they sit in the dining hall ?<br>

The key criteria of ARFID are:-

Avoidance of foods and unwillingness to try new foods
Sensory hyper-reactivity
Psychosocial distress when around food
Fear of swallowing, choking, or vomiting

Nutritional deficiency - usually present

Weight loss is not a necessary criteria, children/ adults who are overweight can still meet the criteria for ARFID.

ARFID most often presents from early childhood with no precipitating event – sensory subtype,
or from later childhood with a precipitating event – anxiety subtype – fear of aversive consequences.

Somatosensory disgust and anxiety both underpin ARFID and might well be defining characteristics.<br>

Interventions should be:-
age related
subtype specific
and where possible involving a multi- disciplinary team

But should never involve:-

Pressure to eat
Hiding & disguising foods
Sitting in front of new/unaccepted foods
Leaving the child or y/p to go hungry
Replacing accepted foods with new foods
Sitting with others to eat, if this gives sensory overload<br>

www.arfidawarenessuk.org Thank you for your attention.....<br>