By STEPHANIE ZERWAS
Published: November 12, 2014
Have you ever sat across the table from an 8 year old at the dinner table and heard, “Ugh, not this again! I hate broccoli!” Parents often ask us when are kids just picky and when it is something more serious.
In the eating disorder field, we’ve heard stories from patients and families about extreme restrictive and picky eating in childhood and beyond. The college student who only ate three foods (cereal, pizza, and pasta) and was worried that her friends were starting to notice. The pre-teen who ate a restricted diet of just orange things (Cheetos, orange soda, Cheez-Its) and gagged if she tried anything else. The 9-year-old boy who only ate peanut butter and jelly sandwiches and relied on drinking Ensure to make sure he didn’t fall off of his growth curve. In the past though, we didn’t have a specific diagnostic label to give these kids, teens, and adults. Often the kids and adults struggling with extreme picky eating didn’t have the other symptoms that we associate with eating disorders like body dissatisfaction, a desire to lose weight, or the binge eating episodes that are the hallmarks of disorders like anorexia or bulimia nervosa. It was hard to tell: is this just a phase? Is it just a passing fad, or is it more serious? When should we intervene, and how should we help kids and adults who are struggling to eat a wide range of foods?
With the Diagnostic and Statistical Manual 5th edition (DSM-5), we now have a systematic way to evaluate when picky eating is a serious problem. For the first time, DSM-5 includes Avoidant/Restrictive Food Intake Disorder (ARFID) as a diagnosis. To get the diagnosis, a child or adult must have a lack of interest in eating or food, worry about the negative consequences of eating (e.g., feeling uncomfortable or bloated), or avoid food because of sensory issues (e.g., how it looks, tastes, or feels).
But the ARFID diagnosis also requires that picky eating interferes with an individual’s nutritional needs. For example, it could cause significant weight loss or lead to a child not growing and developing in the way that we would expect. It could also cause significant nutritional deficiencies like anemia and a dependence on nutritional supplements such as vitamins and liquid meals. In addition, it also could cause problems in one’s social life, such as not being able to go out to dinner with friends or requiring others to go to extremes to cater to likes and dislikes. It’s important to distinguish ARFID from other eating disorders. If someone is struggling with anorexia nervosa or bulimia nervosa or struggling with body image issues, they can’t get an ARFID diagnosis. Also, you have to ensure that there isn’t another medical condition that might be a better explanation for picky eating.
Now that we have an official diagnosis for the condition that we see in our clinics, it will be interesting to see how research on ARFID progresses. We have a lot to learn about how and when ARFID develops, how ARFID is related to other eating disorders, and which kids and adults are at risk for struggling with extremely picky eating. Recent research found that children with ARFID were typically younger than those with anorexia or bulimia when they came for treatment (13 years old vs. 16 years old). They were more likely to be male (29% vs. 15% vs. 6% for anorexia and bulimia), and to have a comorbid medical condition such as gastrointestinal symptoms (19.4%); a history of vomiting/choking on food (13.2%); or food allergies (4.1%). In addition, although treatment approaches for children and adults with ARFID have already started, many clinicians will need training on the best ways to detect and treat ARFID. Across the highway from us at Duke University, our colleague Dr. Nancy Zucker has developed an exposure treatment for children with ARFID, (see this ABC News story about her work) and she’ll also be conducting a workshop on treating ARFID at the Academy for Eating Disorders International Conference on Eating Disorders this year in Boston. Although ARFID is kind of unwieldy to say and in truth the behaviors associated with the diagnosis aren’t “new”, having ARFID in the DSM-5 means that children and adults who deal with negative nutritional and social consequences of limiting their food intake can now find treatment options.