How "Picky Eating" Could Actually Be A Sign Of A Serious Eating Disorder

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angry child with sandwich and cup on the table

Avoidant/Restrictive Food Intake Disorder, or ARFID, is a new label in the DSM-5 (the diagnostic statistical manual of psychiatric disorders.

The ARFID diagnosis replaces the previous "Selective Eating Disorder" in the DSM-IV.

As the name suggests, it’s a diagnostic label for an eating disorder. But unlike other eating disorders, this one can start in early childhood. 

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What is ARFID, exactly?

Though the name might suggest that it’s just a minor problem with "picky eating," the main difference with ARFID is that that’s it’s much more troublesome than just being frustrating for parents.

The ARFID diagnosis is offered when there are real medical risks and consequences to a highly-avoidant eating pattern such as:

Significant weight loss (or failure to gain weight appropriately).

Significant nutritional deficiencies.

Need for tube feeding or nutritional supplements to boost calories and nutrient intake.

Significant impairments in psychosocial functioning like the inability to eat with others.

ARFID food avoidance is way more than just picky eating.

Since it can begin in childhood, if untreated, ARFID can persist into adulthood with real long-term health risks and significant impacts on quality of life.

Imagine never feeling comfortable eating in the presence of others. Or not being able to go out for a meal with friends. Many social gatherings happen over food.

One thing that complicates the issue is that children who are diagnosed with ARFID often have other neurodevelopmental challenges such as autism, ADHD, and anxiety disorders.

Sensory hypersensitivity and ARFID

While the cause of ARFID is not known, there are reasons to suspect that genetics/epigenetics, psychological factors, and previous negative oral experiences may all play a role.

One aspect that can easily be overlooked is sensory hypersensitivity. 

Whether sensory preferences are a result of genetic predispositions or aversive oral experiences (like uncomfortable medical procedures around the face/mouth) sensory hypersensitivities can create increased psychological distress.

Specifically, anxiety in the presence of food-related sensory cues such as smells, tastes, textures, and even colors of foods.

To understand sensory hypersensitivities, think about wearing an uncomfortable, itchy wool sweater. Say it was a gift from your favorite aunt and you didn’t want to disappoint her, so you wore it to the big family gathering.

Not only were you focused on the fact that you had to wear it, you were probably having a hard time really enjoying your family gathering because the sweater felt uncomfortable. You may have been more irritable and easily annoyed too.

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Avoidant/Restrictive Food Intake Disorder could tie into sensations of extreme discomfort.

Now, what if that itchy sweater felt like ants crawling on your body?

This is sensory hypersensitivity. A non-toxic (though not necessarily comfortable) sensory experience feels more than a little threatening.

I have a friend who was a picky eater as a child and did not gain weight at the rate her parents would have liked. She had one negative experience with food when she was about 6 years old. 

Her parents had bought her a glass of freshly squeezed pomegranate juice from a street vendor. There was something not quite right about that juice as she threw it up within a half-hour.

It took her well into her 40s to be able to walk past a display of pomegranates in the produce aisle without having an unexpected gag response from simply glancing at them.

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This is the power of negative experiences that lead to food intake disorders.

Fortunately, that aversion did not generalize to other fruits or fruit juices. However, if she had had the same experiences with other fruits or juices, her aversive response could have easily generalized to fruits as a food group.

Now imagine if a child had a hard time chewing their food and it made them feel gag, retch, or choke, either because the texture of the food feels uncomfortable in their mouth or because they have poor oral motor control and chewing is hard.

These kinds of uncomfortable experiences can feel life-threatening and make them more likely to avoid foods that had those kinds of textures.

Who wouldn’t avoid foods that caused gagging, retching, or choking?

With these kinds of aversive experiences, hyper-sensitivity to the sensory qualities of foods can occur with foods from just about every food group.

The brain is wired to learn to keep you safe by noticing and then avoiding the things that appear to cause harm. It’s adaptive.

And if the child has communication delays (because they have another neurodevelopmental diagnosis), they won’t be able to communicate their discomfort in a way that their caregivers might understand. It could simply look like a lack of interest in food altogether. 

It’s not surprising that many children with ARFID will only eat foods that are uncomplicated in their odors, flavors, textures, and colors.

This includes things like crackers, white bread, french fries, chicken nuggets, cereals, and pasta — with nothing on them. 

Some children can be very specific in their tolerances and will only eat specific brands of the specific bland foods they are willing to eat.

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But this doesn't mean that anything that's relatively bland will be acceptable.

I've known more than one child who would have meltdowns at the sight of a banana. From across the room. 

One child could tell the moment he arrived home after school if anyone had eaten a banana in his home that day, even one that wasn’t "overly ripe." He had a hypersensitivity to the smell.

These responses are indicators of genuinely high-stress experiences — for the child and their parents.

What can you do to help your child with ARFID?

If you suspect that your child’s outlook and behaviors towards foods are more than just picky eating — that it poses a risk of developmental, medical, or psychological harm — contact your family physician or pediatrician and have an open and honest discussion.

Take the opportunity to explore ways to:

Access a nutritional assessment completed by a registered dietitian to provide appropriate supports and education for you and your child around healthy food habits and nutrition.

Get a feeding assessment completed by a speech and language therapist or occupational therapist who is knowledgeable and experienced in working with children with feeding, eating, and swallowing difficulties to rule out potential problems, especially if your child gags or has frequent respiratory illnesses or a persistently runny nose.

Address sensory sensitivities your child may have around feeding and eating by having a thorough assessment completed by a knowledgeable occupational therapist.

Work with a mental health professional who understands sensory sensitivities and ARFID to support your child in working through previous negative experiences and related anxieties with feeding and medical procedures around their mouth/face.

Decrease your own anxiety around food and your child’s food intake (possibly working with a mental health professional) so you can decrease the pressure and increase pleasure at mealtimes and improve the overall quality of your relationship with your child.

Trust your treatment team to come up with a successful ARFID treatment for your children and adolescents that will help them cope. 

ARFID is a challenging problem to have to handle — for parents and children.

Getting a better understanding of underlying causes and taking positive action to resolve them is a necessary step to support your child’s — and your family’s — health and well-being.

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Judith Pinto is a Registered Occupational Therapist (Alberta, Canada). Her practice focuses on addressing the mental health needs of neurodiverse children and adults. You can learn more about her work on her website.