Avoidant/Restrictive Food Intake Disorder (ARFID) is a condition that is less commonly known in comparison to other eating disorders such as anorexia and bulimia. Unlike these disorders, ARFID is not driven by concerns about body image or a desire to lose weight. Instead, it involves a disturbance in eating due to a lack of interest in eating or food avoidance based on the sensory characteristics of food, or even concern about averse consequences of eating (Zickgraf et al., 2019). Common misconceptions about ARFID include the belief that it only affects children and that it is simply a phase of picky eating that one will 'grow out' of, neither of these views captures the persistent and sometimes debilitating nature of the disorder.
Common misconceptions about ARFID include the belief that it only affects children and that it is simply a phase of picky eating that one will 'grow out' of, neither of these views captures the persistent and sometimes debilitating nature of the disorder.
The discussion of ARFID among adults, especially those who are neurodivergent, is critical. Adults with neurodivergent conditions such as autism spectrum condition (ASC) often experience overlapping challenges, including sensory sensitivities that can complicate their relationship with food (Kral et al., 2021). Addressing ARFID in this context highlights a crucial area of need that is frequently overlooked in both clinical and supportive settings.
The aim of this article is to share some insight about ARFID, to begin the conversation, and to discuss its connections with autism and other neurodiverse conditions, and to provide guidance for management and support. By increasing awareness and understanding, we can better support individuals who struggle with this eating disorder in ways that respect their neurodivergent needs and promote overall well-being. It is important to note at this time, there is limited information available on ARFID in the adult population and therefore the current guidance is limited by the evidence available for us.
A Closer Look At ARFID
Avoidant/Restrictive Food Intake Disorder (ARFID) was formerly known as Selective Eating disorder. ARFID was first identified in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). ARFID can result in a persistent failure to meet nutritional and or energy needs, which in turn may result in weight loss, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements. ARFID can also interfere with psychosocial functioning (a person’s ability to perform daily tasks and to interact with others and with society in an appropriate and productive manner) (APA, 2013).
ARFID is not associated with a distortion of body image or an intense fear of gaining weight. It is more often associated with avoidance of food based on its sensory attributes (such as texture, smell, colour), or a past negative experience with a certain type of food, which can lead to a more generalised fear of eating (Thomas et al, 2017). ARFID may also be caused by a general disinterest in eating (BEAT, 2023). The more traditional methods applied to other types of eating disorder (including focusing on body image and or weight management) are less relevant when managing ARFID cases.
Common Symptoms and Behaviour in Adults with ARFID include:
•Limited variation in type of food intake
•Sensitivity to aspects of some foods, such as texture, taste, smell or temperature
•Eating a range of foods, but overall eating much less than what is required to stay healthy.
•Missing meals completely
•Always eating the same meals
•Fear of Eating
•Being anxious at mealtimes, chewing carefully and taking small bites and sips.
•Identified by others as a ‘picky eater’
•Lack of interest in eating or of food in general
•Weight loss
•Treating eating as a chore, taking a long time to eat
•Finding it difficult to recognise when hungry
•Only eating foods of a similar colour (often beige)
•Feeling full even after consuming small amounts
•Social isolation
The above symptoms and how they manifest in ARFID are unique to every individual and therefore any intervention in response to ARFID needs to involve an individualized treatment approach (Fisher et al 2014)
ARFID in the Context of Neurodiversity
Research has shown that neurodivergent individuals, particularly those with Autism, have a higher prevalence of feeding problems and eating disorders, including ARFID. Studies indicate that up to 23% of individuals with autism are affected by ARFID, a rate that is significantly higher than the general population (Kurz et al 2015). Also, individuals with ADHD may also experience challenges related to impulsivity and inattention that can affect eating behaviours (Reynolds et al, 2019).
Autism is a condition characterised by a range of symptoms that can significantly impact social interaction, communication, and behaviours including eating habits.
A key intersection of Autism and ARFID is through sensory sensitivities. Autistic individuals often experience hyper or hypo reactivity to sensory input, which can have a profound impact on eating behaviours. As we have already discussed sensitivities may relate to texture, colour, smell or taste of food. (Ledford and Gast, 2006), however, routine also plays a critical role in the lives of autistic individuals and the need for consistency and predictability can extend to eating habits. Some individuals may only eat foods that are a certain colour or prepared in a certain way or have to eat at a certain time of day. Whilst such rigid routines can be comforting, they can also lead to nutritional deficiencies if the food eaten lacks variety (Cermak, et al, 2010).
Effective interventions for autistic individuals with ARFID require a tailored approach that considers their unique sensory profiles and need for routine. Multidisciplinary teams that include dietitians, occupational therapists, and psychologists are crucial in developing strategies that expand the diet whilst respecting the individual’s sensory preferences and need for predictability for those most severely affected by ARFID (Kuschner et al, 2015)
Managing and Supporting ARFID in Neurodiverse Adults
Our knowledge and understanding of how to treat ARFID in adults still remains quite limited, however one effective strategy identified is the implementation of gradual exposure therapy, which helps individuals slowly increase their comfort with new foods at a pace that respects their sensory sensitivities (Thomas and Eddy, 2019). Additionally, Cognitive Behavioural Therapy (CBT) that is adapted to address specific anxieties in avoidant behaviour has shown promising results (Magill et al 2019). Dietitians can also help provide personalised meal plans that accommodate an individual’s restrictions whilst ensuring balanced nutrition. They can also offer practical solutions for incorporating new foods and supplements to address deficiencies (Bandini et al 2010). Occupational therapy, with a focus on sensory integration techniques, can also play a critical role in helping individuals cope with the sensory challenges associated with eating.
The role of support networks
The role of family members and healthcare professionals is crucial in the support and management of ARFID in neurodivergent adults. Families can help by creating a supportive eating environment that reduces stress around mealtimes. This includes respecting the individual’s food preferences and gradually introducing new foods without pressure. Healthcare professionals can support by providing consistent follow-up and coordinating care across different specialties including psychology, dietetics and occupational therapy (Rhind et al, 2014).
Tips for Adults with ARFID to Navigate Daily Challenges
Understanding sensory sensitivities - recognising and acknowledging sensitivities to tastes, textures, or smells that limit dietary choices can help in finding acceptable foods and preparing them in ways which may be more palatable.
Food Journals – Keeping a diary can help track eating patterns and identify areas for improvement
Increasing Food Variety Gradually: The task involves going as slowly and not to force or to rush as this can result in increased anxiety and a deterioration in any progress made.
Meal Planning Involvement: Involving individuals with ARFID in meal planning and preparation can help to provide a sense of control over what they are eating, This engagement can also help food seem less daunting and more of an enjoyable activity.
Mindfulness Techniques – engaging in mindfulness can help reduce anxiety associated with eating and may enhance sensory processing, making meals more tolerable (Kinnaird et al, 2019). Techniques such as mindful eating can help individuals become more attuned to their hunger and fullness cues, which can often be muted in those with ARFID. This approach encourages a focus on the sensory experience of eating which can help improve the relationship to food over time.
Social Eating Strategies – developing strategies for managing social eating situations, such as pre-selecting restaurants or meals, can help individuals participate in social activities without feeling overwhelmed).
Education and Psychoeducation: Learning about ARFID and understanding its mechanisms can help reduce stigma and self-blame. Knowledge about the disorder can also equip individuals to better handle situations that might otherwise trigger anxiety around eating.
Peer and Community Support: Joining support groups where people can share experiences and strategies can provide emotional support and decrease feelings of isolation. The groups can be found online or recommended by healthcare providers (fully check out the group before participating - check the group rules and who is allowed to participate).
Resources
Books
"Eating Disorders in Boys and Men" by Jason M. Nagata, Stuart B. Murray, and Ellen S. Rome. This book provides insights into eating disorders in males, a group that includes neurodiverse individuals, with a section on ARFID.
"Just Eat It: How Intuitive Eating Can Help You" by Laura Thomas. This book offers a broader perspective on overcoming eating issues, which can be helpful for understanding the principles behind a non-restrictive approach to eating.
Websites
National Eating Disorders Association (NEDA) - www.nationaleatingdisorders.org: This site offers a wealth of information on ARFID, including symptoms, treatment options, and ways to find help.
BEAT Eating Disorders – www.beateatingdisorders.org.uk
Online Communities
Reddit Communities: Subreddits like r/ARFID and r/autism are platforms where individuals share personal experiences, advice, and support.
The Mighty - community.themighty.com: A community for people facing health challenges and the people who care for them, including eating disorders and autism.
Professional Help
International Society for Autism Research - www.autism-insar.org: Although not exclusively for ARFID, this organization provides resources and can guide you to professionals skilled in dealing with the broader aspects of autism, which may intersect with eating disorders.
Conclusion
Avoidant/Restrictive Food Intake Disorder (ARFID) represents a unique challenge within the spectrum of eating disorders. This article has explored the complex relationship between ARFID and neurodiversity.
Our discussion underlined the heightened prevalence of ARFID among neurodiverse individuals, emphasizing the importance of recognizing and addressing this condition in adults, who are often overlooked in clinical and research settings. The intersection of sensory sensitivities and the need for routine common in autism can create a unique set of challenges for managing eating behaviours. These challenges necessitate a tailored approach to treatment that considers the individual's sensory preferences and need for predictability.
By enhancing our understanding of ARFID and its links with neurodiversity, we can improve support for those affected. This involves employing specialized strategies such as gradual exposure therapy and cognitive-behavioural therapy and fostering supportive environments both at home and within healthcare settings.
Through increased awareness, education, and resource sharing, we can empower individuals with ARFID and their support networks to navigate the daily challenges posed by this disorder more effectively. The resources listed in this article serve as a starting point for those seeking further assistance and understanding of ARFID in the context of neurodiversity.
As we continue to expand our knowledge and resources, we invite readers to engage actively in this ongoing conversation. Sharing experiences, challenges, and successes can enrich our collective understanding and enhance the well-being of those living with ARFID and other neurodiverse conditions. Your insights and participation are invaluable as we work together to provide effective support and improve outcomes for adults with ARFID across the neurodiversity spectrum.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bandini, L. G., Anderson, S. E., Curtin, C., Cermak, S., Evans, E. W., Scampini, R., Maslin, M., Must, A. (2010). Food selectivity in children with autism spectrum disorders and typically developing children. Journal of Paediatrics, 157(2), 259-264.
Cermak, S. A., Curtin, C., Bandini, L. G. (2010). Food selectivity and sensory sensitivity in children with autism spectrum disorders. Journal of the American Dietetic Association, 110(2), 238-246.
Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., Callahan, S. T., Malizio, J., Kearney, S., Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a "new disorder" in DSM-5. Journal of Adolescent Health, 55(1), 49-52.
Kinnaird, E., Stewart, C., Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European Psychiatry, 55, 80-89.
Kral, T. V. E., Eriksen, W. T., Souders, M. C., Pinto-Martin, J. A. (2021). Eating behaviours and dietary changes in children with autism. Autism Research, 14(1), 214-222
Kurz, R., van Dyck, Z., Dremmel, D., Munsch, S., Hilbert, A. (2015). Early-onset restrictive eating disturbances in primary school boys and girls. European Child & Adolescent Psychiatry, 24(7), Kuschner, E. S., Eisenberg, I. W., Orionzi, B., Simmons, W. K., Kenworthy, L., Martin, A., Wallace, G. L. (2015). A preliminary study of self-reported food selectivity in adolescents and young adults with autism spectrum disorder. Research in Developmental Disabilities, 43-44, 179-187.779-785.
Reynolds, K. C., Patriquin, M. A., Alfano, C. A. (2019). Emotional dysregulation and eating disorders in children and adolescents. Eating Behaviours, 33, 17-23.
Rhind, C., Hibbs, R., Goddard, E., Micali, N., Gowers, S., Beecham, J., Schmidt, U., Macdonald, P., Treasure, J. (2014). Experienced Carers Helping Others (ECHO): protocol for a pilot randomised controlled trial to examine a psycho-educational intervention for adolescents with anorexia nervosa and their carers. European Eating Disorders Review, 22(4), 267-277.
Thomas, J. J., Lawson, E. A., Micali, N., Misra, M., Deckersbach, T., Eddy, K. T. (2017). Avoidant/Restrictive Food Intake Disorder: a three-dimensional model of neurobiology with implications for aetiology and treatment. Current Psychiatry Reports, 19(8), 54.
Zickgraf, H. F., Schepps, K. (2019). Sensorial eating problems in children with ASD. Journal of Autism and Developmental Disorders, 49(3), 1045-1057.
Disclaimer: This blog post is intended for informational purposes only and should not be considered a substitute for professional medical advice, diagnosis, or treatment. If you or someone you know is dealing with eating disorders, including ARFID, it is crucial to seek the help of a qualified healthcare provider. The strategies and tips provided here are generalized and may not be suitable for everyone; always consult a healthcare professional before making any significant changes to your diet or treatment plan. The experiences and suggestions mentioned in this post may not reflect the latest research or medical guidelines.
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